Increased Mortality Among Renal Transplant Patients With Invasive Pulmonary Aspergillus Infection.

INTRODUCTION: Renal transplantation is the most effective and preferred definite treatment option in patients with end-stage renal disease. Due to long-term immunesuppressive treatment, renal transplant recipients become vulnerable to opportunistic infections, especially to fungal infections. METHOD: This was a single-center, retrospective observational study of 438 patients who underwent renal transplantation between 2010 and 2016. RESULTS: Thirty-eight renal transplant recipients who had lower respiratory tract infection with median age of 41.5 years were evaluated for invasive pulmonary aspergillus (IPA). Of these, 52.6% were female and 84.2% had living donors. Eleven of 38 lower respiratory patients were found to have IPA infection, 5 with proven infection. Compared to patients who did not have fungal pulmonary infection, patients with invasive aspergillus were older and had high fever, galactomannan levels, and leukocyte counts. Mortality was also higher in those patients. Having fever at the baseline and IPA infection was significantly associated with mortality in univariate analysis and remained related in multivariate model after adjustment for age, gender, and fever. CONCLUSION: Invasive pulmonary aspergillus infection is highly associated with increased mortality rates in renal transplant patients. Fungal pulmonary infections in immune-suppressed patients should be diagnosed and treated immediately in order to avoid the life-threatening complications and may greatly improve prognosis.

Superiority of Single-Antigen Bead Study in Donor-Specific Antibodies: Determination in Highly Sensitized Patients.

OBJECTIVES: The presence of donor-specific antibodies against HLA before kidney transplant has been variably associated with decreased long-term graft survival. Data on the association between pretransplant donor-specific antibodies and rejection and cause of graft failure in recipients of donor kidneys are scarce. MATERIALS AND METHODS: For this study of HLA antibody levels, we analyzed serum samples from 76 patients (48 women and 28 men) who were prepared for kidney transplant at the Baskent University Istanbul Hospital between 2017 and 2022. Levels were determined by using Lifecodes panel reactive antibody class I and II identification kits and Lifecodes LSA class I and II identification kits by the Luminex assay method. RESULTS: Multiple antigen tests showed more than 70% sensitization detected against both class I and class II antigens in our patient group. When some samples were reevaluated with the single-antigen bead method, desensitization values were shown to be considerably reduced compared with values from multiple antigen methods. CONCLUSIONS: The single-antigen-coated bead method can be useful in determining the risk of donor-specific antibodies in highly sensitized patients.

Clinical Outcomes of Liver Transplantation for Patients Over 60 Years Old: A Single-Center Experience.

OBJECTIVES: Although advanced age is no longer considered an absolute contraindication for liver transplant, transplant in elderly patients with comorbid diseases remains debatable because of high risks with surgery. Here, we report patient outcomes in this population. MATERIALS AND METHODS: We retrospectively reviewed medical records of 276 liver transplant recipients, grouped by age. Group 1 (≤59 years old) consisted of 247 recipients, and group 2 (≥60 years old) consisted of 29 recipients. Reviewed data included age, sex, cause of liver disease, presence of hepatocellular carcinoma, Child-Pugh and Model for End-Stage Liver Disease scores, survival, and posttransplant complications. RESULTS: In both groups, most patients (n = 108) required liver transplant for hepatitis B virus. Mean age was 40 ± 12.3 and 63 ± 2.3 years in groups 1 and 2, respectively, with more men than women in both group 1 (71.7% vs 28.3%) and group 2 (75.9% vs 24.1%). No significant differences were shown between groups for patient characteristics, except group 1 had significantly higher Model for End-Stage Liver Disease score. Group 1 mean survival time was 10.2 ± 0.6 years, with patient survival rates at 1, 5, 10, and 15 years of 65.5%, 53%, 46.3%, and 40%, respectively. In group 2, respective results were 10.6 ± 1.3 years and 75.9%, 68.6%, 61%, and 48.8% (no significant difference vs group 1). CONCLUSIONS: Liver transplant recipients >60 years of age had survival rates, acute rejection rates, and complications similar to younger recipients. Liver transplant should not be withheld from older recipients on the basis of age alone. However, comprehensive screening for comorbidities should be performed.

Use of Eculizumab in Pediatric Patients with Late Antibody-Mediated Rejection After Kidney Transplantation.

Late antibody-mediated rejection triggered by donor-specific antibodies is a leading cause of kidney allograft failure. Effective treatment options for late antibody-mediated rejection are limited in renal transplant recipients. Here, we report 2 pediatric cases of severe late antibody-mediated rejection resistant to conventional immunosuppressive therapy who were successfully treated with eculizumab. Two patients who fulfilled the late antibody-mediated rejection diagnostic criteria (positive donor-specific antibodies, elevated mean fluorescence index, acute and/or chronic morphological lesions in the microvasculature, and abnormal kidney function test) were included in this study. Both patients were previously unsensitized with negative panel-reactive antibody. Case 1 was a 12-year-old male patient with kidney failure secondary to vesicoureteral reflux who underwent related-living donor kidney transplantation 2 years ago. Eleven months later, he was diagnosed with late antibody-mediated rejection. Despite an aggressive conventional immunosuppressive regimen, signs of rejection persisted. After the patient was treated with 2 doses of eculizumab, his mean fluorescence index dropped and serum creatinine decreased from 3.8 to 1.5 mg/dL. Case 2 was an unsensitized 16-year-old male patient with kidney failure secondary posterior urethral valve who underwent related-living donor kidney transplantation 4 years ago. Two years later, he was diagnosed with late antibody-mediated rejection. Despite an aggressive conventional immunosuppressive regimen, signs of rejection persisted. After treatment with 2 doses of eculizumab, his mean fluorescence index dropped and serum creatinine decreased from 2.1 to 1.01 mg/dL. In both patients, eculizumab therapy effectively reduced the markers of late antibody-mediated rejection and improved the kidney function.

Acute appendicitis during coronavirus disease 2019 in Türkiye: Changes in clinical approach, treatment, and diagnosis modalities: A retrospective and cohort study.

BACKGROUND: The novel coronavirus disease 2019 (COVID-19) has resulted in major changes in health-care systems and emer-gency surgical interventions. Here, we examined patients with acute appendicitis who presented to emergency departments and com-pared diagnosis, treatment, and post-treatment processes before and during the pandemic period and investigated how the pandemic affected management of acute appendicitis. METHODS: A national, multicenter, and cohort study model was designed that included patients older than 18 years of age diag-nosed with acute appendicitis clinically and/or radiologically, with patients compared before (pre-pandemic period: January 1-April 30, 2019) and after (pandemic period: January 1-April 30, 2020) the pandemic. Our investigation included comparisons of pre-operative imaging methods, presence of plastron appendicitis/abscess, conservative/surgical approach, type of anesthesia given, laparoscopic/open surgical approach, bowel resection rates, drain insertion rates, and presence of post-operative complications RESULTS: For the two study groups, 8972 patients from 69 centers were examined, with 4582 patients operated in the pre-pan-demic period and 4234 patients operated in the pandemic period. During the pandemic period, 63.6% of patients underwent open surgery, whereas 34.4% had laparoscopic surgery. Although 60 patients (1.3%) requested non-operative follow-up in the pre-pandemic period, 94 patients (2.2%) requested this in the pandemic period. When conditions of patients were evaluated regardless of their own wishes, 114 patients (2.4%) before and 163 patients (3.8%) during the pandemic received non-operative follow-up. CONCLUSION: Our study did not show the direct correlation between the application of COVID-19-related restrictions and the severity of acute appendicitis. Although non-operative management rates have been increased during the COVID-19 period, the incidences of both complicated and the uncomplicated appendicitis were similar during the COVID-19 crisis period. Given this infor-mation non-operative management can be employed for patients diagnosed with appendicitis.

Concurrence of rectocoele and anal incontinence, and outcome of their simultaneous surgical correction.

Rectocoele and faecal incontinence coexist in most patients. We determined an excellent one-year outcome of simultaneous repair of the former and correction of the latter can be achieved.

Liver and Kidney Transplant During a 6-Month Period in the COVID-19 Pandemic: A Single-Center Experience.

OBJECTIVES: With the declaration of COVID-19 as a pandemic, many studies have indicated that elective surgeries should be postponed. However, postponement of transplants may cause diseases to get worse and increase the number in wait lists. We believe that, with precautions, transplant does not pose a risk during pandemic. Here, we aimed to evaluate our transplant results, which we safely performed during a 6-month pandemic period. MATERIALS AND METHODS: Until September 2020, 3140 kidney and 667 liver transplants have been performed in our centers. We evaluated 38 kidney transplants and 9 liver transplants procedures performed during the pandemic (March 1 to September 2, 2020). Recipient and donor candidates were screened for COVID-19 with polymerase chain reaction and thoracic computed tomography. All recipients had routine immunosuppressive protocol. During hospitalization at our COVID-19-free transplant facility, we restricted the interactions during multidisciplinary rounds. RESULTS: During the pandemic, 38 kidney transplants with an average length of hospital stay of 8.1 days were performed. Mean serum creatinine values of recipients were 0.91, 0.86, and 0.74 mg/dL on postoperative days 7, 30, and 90, respectively. During the pandemic, 9 living donor liver transplants (1 adult, 8 pediatric) were performed with an average length of hospital stay of 17.1 days. Mean serum total bilirubin levels were 0.9, 0.5, and 0.4 mg/dL on postoperative days 7, 30, and 90, respectively. Mean serum aspartate aminotransferase levels were 38.1, 28.3, and 22.3 U/L on postoperative days 7, 30, and 90, respectively. All recipients and donors were successfully discharged. Only 1 liver recipient died (on day 55 after discharge as a result of oxalosis-induced heart failure). CONCLUSIONS: According to our results, when precautions are taken, transplant does not pose a risk to patients during the pandemic period. We attribute the safety and success shown to our newly developed protocol in response to the COVID-19 pandemic.

Evaluation of Transplanted Kidneys and Comparison with Healthy Volunteers and Kidney Donors with Diffusion-Weighted Magnetic Resonance Imaging: Initial Experience.

OBJECTIVES: The aim of this study was to evaluate the feasibility of diffusion-weighted magnetic resonance, by comparing imaging in renal allograft recipients for functional assessment of kidney transplants versus imaging of these features in healthy volunteers and kidney donors with native kidneys. MATERIALS AND METHODS: Seventy renal transplant recipients (group A) with stable graft function at postoperative month 1, 40 healthy volunteers (group B), and 40 kidney donors (group C) underwent diffusion-weighted magnetic resonance imaging. An echo-planar diffusion-weighted imaging sequence was performed in coronal orientation by using 6 b values (0, 200, 400, 600, 800, 1000 s/mm²). The apparent diffusion coefficients were determined for the upper and lower poles of the kidney cortex and medulla. Relations between apparent diffusion coefficients and allograft function, determined by the estimated glomerular filtration rate (comparing rates > 60 mL/min/1.73 m² [group A1] versus < 60 mL/min/1.73 m² [group A2]), were investigated in renal transplant recipients, and apparent diffusion coefficients in groups A, B, and C were compared. RESULTS: Apparent diffusion coefficients were statistically higher in group A1 than in group A2 (P < .05) and statistically higher in group A than in groups B and C (P < .001). There were no significant differences between groups B and C (P > .05). CONCLUSIONS: We observed that apparent diffusion coefficients of transplanted kidneys at postoperative month 1 were higher than values in native kidneys of healthy volunteers and kidney donors. In addition, apparent diffusion coefficients of transplanted kidneys with estimated glomerular filtration rates > 60 mL/min/1.73 m² were higher than transplanted kidneys with rates < 60 mL/min/1.73 m².

Reconstruction of Traumatic External Iliac Artery Dissection Due to Vascular Clamping.

Traumatic external iliac artery dissection after renal transplant is a rare complication, but it should be urgently managed due to its devastating effects on graft and lower limb circulation. External iliac artery dissection is seen more in recipients with diabetes mellitus and comorbid disease. Recipients with external iliac artery dissection should be treated immediately by percutaneus angioplasty or surgical reconstruction. In this study, we reported the management of 2 kidney transplant cases with external iliac artery dissection due to vascular clamping of the artery. External iliac artery dissection was diagnosed by ultrasonography in both cases. After failed percutaneous interventional angioplasty, we reconstructed the external iliac artery dissection surgically and replaced the external iliac artery with polytetra-fluoroethylene grafts in both patients. Both patients were discharged with normal functioning grafts showing 0.9 and 0.8 mg/dL serum creatinine levels at month 3 posttransplant. Close monitoring of recipients after transplant is mandatory for early diagnosis and early management of external iliac artery dissection to prevent graft loss and preserve lower limb circulation. Routine Doppler ultrasonography is an inexpensive and useful tool for early diagnosis in cases of sudden cessation or decrease in urine. In cases of failed percutaneous interventional angioplasty, reconstruction with synthetic vascular grafts can be safely applied in external iliac artery dissection.

Surgical Complications After Kidney Transplantation.

Since the first successful organ transplant conducted between twins in 1954, kidney transplant has evolved considerably over the past 50 years. Kidney transplant plays an important role in the treatment of end-stage kidney disease to improve the quality of life and prolong the life of patients. Despite significant advances, postoperative medical and surgical complications still represent important causes of morbidity and mortality. Many problems can be avoided through prophylactic correction of abnormalities detected during the preoperative evaluation; however, it is critical that technical mishaps at all stages of the transplant process (donor nephrectomy, benchwork preparation, and implant) be prevented and that careful postoperative monitoring be carried out, including thorough examination by attending physicians. However, despite these advances, surgical complications still present serious problems in kidney transplant recipients.

Results of liver transplant in elderly patients: a single center experience.

OBJECTIVES: With the increased life span, the need for liver transplant for elderly patients also increased in the world. In this study, we reviewed our experience to determine the outcomes and problems of patients aged > 60 years who had liver transplants. MATERIALS AND METHODS: Data of recipients aged > 60 years were reviewed retrospectively. We analyzed 16 elderly patients who had liver transplant for chronic liver disease between 2001 and 2014 in our center. RESULTS: In our series, there were 5 women and 11 men between age 60 and 65 years. The mean Child-Pugh score was 7.9 ± 1.7 and Model for End-Stage Liver Disease score was 14.1 ± 5.1. Primary liver disease was hepatitis B in 9 patients (34.5%), most of them with hepatocellular carcinoma. The other causes of liver failure were hepatitis C (n = 4), alcoholic cirrhosis (n = 2), and cryptogenic cirrhosis (n = 2); 1 patient had both hepatitis B and hepatitis C virus, and 1 patient had both hepatitis B virus and alcoholic cirrhosis. There were 9 patients who had hepatocellular carcinoma. Mortality was observed in 4 patients. The reasons for mortality were sepsis (n=3) and hepatocellular carcinoma (n=1). CONCLUSIONS: Liver transplant can be safely performed and has acceptable long-term outcomes in low-risk elderly recipients. Age alone should not be a contraindication for liver transplant in elderly patients.