Unusual variability of the superficial venous system of the upper limb and its consequences for deep venous system.

In our report we would like to present a variation of the two main superficial veins of the upper limb. In 21 (88%) explored upper limbs, the venous system showed a pattern similar to that presented in the anatomical textbook. However, in 4 (12%) others venous patterns differed from those already described. Especially in one of them the variant of the veins of the upper limb distinctly contrasted with the others. In that case, the basilic and cephalic vein, instead of the normal course to the arm where they should bypass the elbow pit, unexpectedly merged into one and formed one of the two brachial veins. Towards the axillary cavity it ran laterally over the entire arm regardless of the second brachial vein. In the armpit cavity, instead of connecting with the second one, it gave rise to an independent second vein - the accessory axillary vein. This uniqueness was based on that, independently from deep venous system, the superficial one formed their own net. The accessory axillary vein and the second brachial vein were completely formed by two main superficial veins: the basilic and cephalic vein. By describing this case we wanted to emphasize that in any surgical procedure on the upper limbs, especially on the venous system, there is a certain probability of encountering this anatomical variation. Another conclusion is that the catalogue of patterns of the venous system of the upper limb seems to be endless.

Anatomical traps for arteriovenous fistula creation.

BACKGROUND: The risk of complications in undisclosed vascular variability appears relatively likely. Therefore, it is important to assess the probability of encountering anatomical-topographic variability in the venous system of the upper limb. The catalogue of patterns of the upper limb venous system seems to be unlimited and should therefore be constantly updated. The aim of the study was to explore the venous system of upper extremity and discuss some problems that would be encountered with the formation of an arteriovenous fistula. RESULTS: In 17 (85%) explored upper limbs, the venous system showed a pattern similar to the reports already described. But in (15%) 3 of them, the venous system showed certain differences in relation to the accepted anatomical textbooks. Especially in one of them the anatomical variant of basilic and cephalic vein contrasted distinctly with the other veins. Based on the revealed anomalies, a statistical analysis of the probability of occurrence of any anatomical variant and the risk of complications associated with fistula creation was conducted. Even on such small group an assessed probability of anatomical variability of the upper limb venous system was statistically significant at p < 0.0244 (odds ratio 0.0828; 95% confidence interval 0.0095-0.7252). CONCLUSIONS: The probability of any anatomical-topographic variability in the venous system of the upper limb should be considered as statistically significant. Only intense anatomical dissections would undoubtedly help to avoid some anatomical traps and then minimise some complications in the creation of arteriovenous fistulas.

Experience with autosomal dominant polycystic kidney disease in patients before and after renal transplantation: a 7-year observation.

OBJECTIVE: Autosomal dominant polycystic kidney disease (ADPKD) is characterized by the presence of multiple cysts in both kidneys. Symptoms of the disease may arise either from the presence of cysts or from increasing loss of kidney function. First symptoms usually appear in the third decade of life: lumbar pain, urinary tract infections, arterial hypertension, or renal colic due to cyst rupture or coexistent nephrolithiasis. An early diagnosis, male gender, large kidneys by sonography, arterial hypertension, hematuria, and urinary tract infections are predictive factors of a faster progression of the disease. Our aim was to establish the indications for nephrectomy among symptomatic ADPKD patients before kidney transplantation and to assess the risks of posttransplantation complications among ADPKD patients without nephrectomy. PATIENTS AND METHODS: The observed group consisted of 183 patients with ADPKD among whom 50 (27.3%) underwent kidney transplantation during a 7-year observation period (2000-2007). Among those subjects were 3 groups: (I) nephrectomy preceding transplantation; (II) nephrectomy during kidney transplantation; and (III) without nephrectomy. RESULTS: Among group I before transplantation we observed: arterial hemorrhage, wound infections, and splenectomy 4 weeks after ADPKD nephrectomy; afterward we observed: urinary tract infections and contralateral cyst infection. Among group II we only observed 1 case of wound infection. Among group III we observed: ascending urinary tract infections, cyst infections, and cyst hemorrhage. Cyst hemorrhage and cyst infections led mainly to ADPKD kidney nephrectomy. During the observation time, 80.95% of grafts were functioning. CONCLUSIONS: Unilateral nephrectomy is a well-founded preliminary surgical treatment before kidney transplantation. Bilateral nephrectomy before or during transplantation eliminates ADPKD complications and does not significantly increase general complications. The greatest numbers of complications and of graft losses were observed among the group without pretransplantation nephrectomy.

Does calcium channel blocker improvement of perfusion impact the functioning of kidney graft in early period after transplantation?

The aim of the study was to evaluate the influence of reduced vascular resistance following calcium channel blocker verapamil administration on kidney function at 3 months after transplantation. A group of 48 kidneys received 100 microg verapamil by injection directly into renal artery before starting perfusion. The control group included 48 paired kidneys without verapamil addition. Calcium channel blocker therapy with verapamil greatly decreased renal vascular resistance but it did not affect graft function. Administration of calcium channel blockers improved kidney function in the early period after transplantation. A better-functioning graft seems to be based more on metabolic than hemodynamic effects.

Lymphocele after kidney transplantation.

BACKGROUND: One of the most often occurring complications after a kidney transplantation is a lymphocele. MATERIALS: The examined group consisted of 118 patients (70 males and 48 females) with end-stage renal disease (ESRD). RESULTS: Fourteen patients (12%) developed symptoms of lymphocele within an average time of 34 weeks. The clinical symptoms included the following: decreased 24-hour urine collection and increased creatinine level, abdominal discomfort, lymphorrhoea with surgical wound dehiscence, urgency, vesical tenesmus, and/or fever. Increased appearance of lymphocele was noticed in patients with diabetic nephropathy, congenital malformations of the urinary tract, and inflammatory diseases, including glomerulopathy and extraglomerular ones, after high-voltage radiotherapy and after removal of the renal graft. The methods of treatment and their efficacy were as follows: percutaneous aspiration with the ratio of recurrence 100%; ultrasound guided percutaneous drainage 50%; laparoscopic intraabdominal marsupialization 75%; and surgical intervention with favorable results. CONCLUSIONS: Ultrasound-guided percutaneous drainage with a success rate greater than 50% should be recommended as the first line of treatment. As a minimal invasive surgery this kind of treatment does not interfere with subsequent internal drainage through an open or a laparoscopic surgery. Laparoscopy, a feasible, safe technique with a success rate of more than 80%, should be used routinely after unsuccessful percutaneous drainage.

Histopathologic evaluation of pretransplant biopsy as a factor influencing graft function after kidney transplantation: a 1-year observation.

INTRODUCTION: Many factors affect long-term results in kidney transplantation including histologic damage as a independent predictor, such as chronic allograft/nephropathy in protocol biopsies and age-dependent lesions. Histopathologic findings correlate with the incidence of delayed graft function, renal function, and allograft survival, allowing a rather precise prediction of graft outcome. MATERIALS AND METHODS: We analyzed 92 renal thick needle preimplantation and 29 postexplantation biopsies. Biopsies were preserved in 4% formalin and immersed in paraffin. Optimal biopsies contained at least 10 glomeruli and at least 2 cross-sections of arteries. We analyzed tubulitis, intensity of acute tubular necrosis, inflammatory infiltration, glomerulonephritis, arterial hyalinization, arteritis, fibrosis, tubular atrophy, arterial intimal fibrosis, increase of mesangial matrix, and percentage of glomerulosclerosis. During the postoperative course we analyzed patients condition, exigency of postoperative dialysis, urine output, as well as serum concentrations of creatinine, urea, uric acid, and ions. During a 1-year observation period, we analyzed living recipients, graft loss, death with a functioning graft, incidence of nephropathy (CAN), and acute rejection episodes (ARE). RESULTS: We observed a significant correlation between immediate graft function (IGF) and lack of ATN in the pre-0 biopsy. We observed no correlation between renal function and arterial hyalinization and fibrosis, inflammatory infiltration, tubular atrophy. In the postoperative period, we observed a significant correlation between IGF and lack of interstitial fibrosis with significantly lower levels of creatinine, urea, and potassium and higher urine output early after transplantation. IGF and better function of the right kidney was correlated with shorter time to reach a creatinine level of 2 mg%. In the postoperative periods, we also observed a difference between renal function depending on gender. The presence of acute tubular necrosis, arterial fibrosis, lack of inflammatory infiltration in the pre-0 biopsy correlated with worse late renal function. Among explantation biopsies 65.5% showed signs of CAN, and 37.93%, histologic marks of ARE.

Laparoscopic removal of renal cysts in patients with ADPKD as an alternative method of treatment and patient preparation for kidney transplantation: preliminary results.

BACKGROUND: The most frequent genetic disease of the kidneys occurring in 1 of 1000 inhabitants is autosomal-dominant polycystic kidney disease (ADPKD). Growing renal cysts compress the kidney resulting in damage to parenchyma and functional disorders. Around 10% of these patients are dialyzed due to terminal renal insufficiency. With the advent of laparoscopic techniques, the idea of laparoscopic excision of cysts seemed a tempting alternative to nephrectomy. We assessed the preliminary results of laparoscopic treatment of polycystic kidneys compared with open nephrectomy for patients with ADPKD. MATERIALS AND METHODS: Thirty ADPKD patients were treated between 2000 and 2004. Eleven procedures in five men and six women of mean age 51 years included laparoscopic cyst excisions. In the remaining 19 patients (six men and 13 women) of mean age 54 years, nephrectomy was done. Indications for surgery included pain due to compression by large cysts and cyst contamination. Patients after nephrectomy were prepared for renal transplantation when necessary. RESULTS: Laparoscopic polycyst removal produced better effects than nephrectomy. Mean operative time was significantly shorter (86 minutes for cyst removal vs 108 minutes for nephrectomy; P < .05). Postoperative pain measured with the VAS scale was reduced in patients after laparoscopy. Hospital stay was shorter (5 vs 9 days), as well as time to recovery. Other benefits of laparoscopic cyst removal included maintained urination in the patient and no need for erythropoietin substitution, as well as reduced risk of cyst contamination. When eligible for renal transplantation, patients after laparoscopic polycyst removal have smaller kidneys that do not interfere with the graft and the risk of infection during immunosuppression seems lower. CONCLUSION: Although larger series of patients are required in patients with ADPKD, laparoscopic polycyst removal seemed superior to early nephrectomy.

Experiences in kidney transplantation with duplicated ureters.

INTRODUCTION: The purpose of this study was to evaluate the complications of duplicated ureters in renal transplant recipients. METHODS: Between 1983 and 2004, 12 patients (median age 34 years) received renal transplants from donors with duplicated ureters. In four patients the ureter to bladder anastomoses were performed separately according to the method described by MacKinnon, including two cases transplanted with ureteral catheters because of narrow widths. In the following cases of eight duplicated ureters an anastomosis was performed between the distal part of each ureter to form a common ureteral ostium, which was connected to the urinary bladder. A ureteral catheter was used to the splint ureterovesical anastomosis. RESULTS: No graft loss to ureteral complications was observed. There was no ureteral necrosis in the postoperative period. No clinical symptoms of ureteral junction obstruction were revealed after removing the ureteral catheter. By ultrasound examination four patients showed a slight temporary pyelocaliectasis was observed and four patients developed temporary urinary fistulas. CONCLUSION: Our ureterocystoneostomy procedures with duplicated ureters were safe and useful in kidney transplantation.

[Percutaneous drainage of recto-cecal abscess due to appendectomy]. / Drenaz przezskórny ropnia zakatniczego powstalego po appendektomii.

The authors presented 26 year old women suffered from lumbal and hypogastric pain, fever and recurrence diarrhea. She was performed appendectomy 3 years previously. From that time she has had abdominal pain, lack of appetite and moderate anemia. Based on ultrasound examination the diagnosis was established abscessus of retrocecalis. The diagnostic and therapeutic difficulties resulted from the situation of the abscessus were discussed.

[Activity of antithrombin III in the blood of patients with bladder cancer]. / Aktywnosc antytrombiny III we krwi chorych na raka pecherza moczowego.

The activity of antithrombin III (AT III) in the blood of patients with bladder carcinoma was examined. It was shown an increase of AT III activity in comparison with control group. The changes of AT III activity in the blood of patients with bladder carcinoma can be the symptoms of an increased risk of haemorrhagic or thromboembolic complications.

[Fibrinolysis process in blood of patients with bladder carcinoma]. / Proces fibrynolizy we krwi chorych na raka pecherza moczowego.

In patients with bladder carcinoma a shorter ELT, and increased concentrations of EDP and t-PA were observed. These indicate on fibrinolysis activation caused by the released of t-PA. The increased fibrinolytic activity can be a cause of hemorrhagic complication occurring sometimes in bladder carcinoma. We observed much stronger activation of fibrinolysis in patients with an advanced bladder carcinoma.

[Antithrombin III activity in blood of patients with renal cancer]. / Aktywnosc antytrombiny III we krwi chorych na raka nerki.

The activity of antithrombin III (AT III) in the blood of 20 patients with renal carcinoma was examined. An increase of AT III activity in comparison with control group was observed. The increase of AT III activity in the blood of the patients with renal carcinoma can be as a result of compensatory mechanism safing these patients before thromboembolic complication. The measurement of AT III in renal carcinoma can be a prognostic symptom of haemorrhagic and thromboembolic complications.

[The activity of alpha-2 macroglobulin in the blood of patients with prostatic carcinoma]. / Aktywnosc alpha 2-makroglobuliny we krwi chorych na raka gruczolu krokowego.

The activity of alpha 2-macroglobulin in the blood of the patients with prostatic carcinoma (PC) and benign prostatic hyperplasia (BPH) was examined. It was shown an decrease of alpha 2-macroglobulin in patients with prostatic carcinoma in comparison with control group consisted of the patients with benign prostatic hyperplasia. The low activity of alpha 2-macroglobulin in the blood od the patients with PC can be a symptom of an increase risk of haemorrhagic complications.

[Tissue type plasminogen activator antigen in urine of patients with bladder cancer]. / Antygen tkankowego aktywatora plazminogenu w moczu chorych na raka pecherza moczowego.

In urine of 25 patients with bladder carcinoma the antigen of tissue type plasminogen activator (t-PA) was assessed. The level of t-PA was much higher in patients with bladder carcinoma in comparison with a control group. We also analyzed the level of t-PA between patients with superficial and invasive bladder carcinoma the level of t-PA was higher. In conclusion, there is t-PA in urine of patients with bladder carcinoma and its level is correlated with staging of neoplasm.

[Tissue plasminogen activator in urine of patients with prostatic carcinoma and benign prostatic hyperplasia]. / Antygen tkankowego aktywatora plazminogenu w moczu chorych na raka i lagodny rozrost gruczolu krokowego.

In the 20 patients with prostatic carcinoma (PC) and the 18 with benign prostatic hyperplasia (BPH) the level of tissue type plasminogen activator (t-PA:Ag) was examined. As a compared group consisted of 24 healthy volunteers. In the urine of examined patients with PC and BPH and control the t-PA:Ag was absent or present only in trace amounts. We concluded that the t-PA:Ag in the urine of patients with PC can not be as a marker in the diagnosis of prostatic diseases especially in the prostatic carcinoma.

[The activity of protein C in the blood of patients with bladder carcinoma]. / Aktywnosc bialka C we krwi chorych na raka pecherza moczowego.

The activity of Protein C in the blood of patients with bladder carcinoma was examined. The average of Protein C activity was similar both in bladder carcinoma and in control group. The disperse of Protein C activity in bladder carcinoma was more greater than in control. In two patients with bladder carcinoma the bleeding with low activity of Protein C was observed. The low activity of Protein C in the blood of patients with bladder carcinoma can be the symptoms of an increased risk of thromboembolic complications.

The impact of interleukin 12B (1188A>C), interleukin 16 (-295T>C), and interleukin 18 (607C>A, 137G>C) gene polymorphisms on long-term renal transplant function and recipient outcomes.

BACKGROUND: Inflammatory mediators play an important role in kidney graft outcome. The cytokine and chemokine gene polymorphisms are associated with variable production, activity, expression, or ligand-receptor affinity. Genetic variation in the DNA sequence of the interleukin 12B (IL12B), interleukin 16 (IL16), and interleukin 18 (IL18) genes may lead to altered cytokine production and activity. These variations can lead to changes in individual patient outcomes after kidney transplantation. It is known that polymorphisms of interleukins have an influence on inflammatory diseases, eg, Crohn's disease, diabetes, and asthma. AIM: The aim of this study was to evaluate the correlation between IL12B, IL16, and IL18 gene polymorphisms with delayed graft function (DGF), acute rejection episodes (AR), and chronic rejection episodes (CR). MATERIALS AND METHODS: A total of 267 (38.6% women, 61.4% men) recipients were included in the study. Cadaveric kidney transplantations were performed at the Department of General Surgery and Transplantation. Polymerase chain reaction was used to determine gene polymorphisms of IL12B (rs3212227), IL16 (4778889), and IL18 (rs1946518, rs187238) in 2 mL of serum. Statistical significance (P < .05) was analyzed by logit regression, ANOVA and odds ratio (OR) of χ(2) with Yates correction (95% confidence interval). RESULTS: Regression analysis revealed no significance between AR/DGF/CR and IL-2B, IL16, IL18rs1946518, and IL18-rs187238 (P > .05). The CR group, AA vs CC genotype of IL18 (rs1946518), had an OR = 2.35 (P = .04). AR and DGF groups had no significance in OR. CONCLUSIONS: There was no statistical significance between IL12B, IL16, and IL18 (rs187238) gene polymorphisms and kidney graft outcome after transplantation. Presence of AA genotype (IL18-rs1946518) is connected with a 2.35 times higher risk of CR occurrence.

The effect of cause of cadaveric kidney donors death on fibrinolysis and blood coagulation processes.

BACKGROUND: Organ donors can be generally divided into two groups according to the cause of their death. The first group is composed of those who died because of physical injuries, especially road traffic injury, and the second group, those who died from central nervous system (CNS) stroke or bleeding. The aim of our work was to examine hemostatic processes among kidney donors. MATERIALS AND METHODS: The 38 deceased kidney donors (KD) included 11 women and 27 men of overall average age of 37±12 years. The donor group of according to the cause of death, included 14 injured donors (ID) (41%) and 24 noninjured donors (ND) donors (59%). The control group consisted of 25 healthy volunteers matched for sex and age. We determined the following concentrations: antithrombin (AT), thrombin/antithrombin complexes (TAT), and prothrombin F1+2 fragments. The fibrinolytic parameter concentrations were: plasminogen (PL), plasmin/antiplasmin complexes (PAP), and D-dimers. RESULTS: Deceased kidney donors showed an increased plasma concentrations of TAT complexes (P<.000001) and prothrombin fragments F1+2 (P<.0000001); however, the protein C concentration was decreased (P<.000001). The antithrombin activity was similar to the control group. The concentrations of PAP complexes and d-dimers were higher (both P<.000001), but the level of PL lower among KD compared with controls (P<.0000001). The higher of TAT, PAP complexes, d-dimers, and F1+2 concentrations as well and as lower plasminogen and PC concentrations were evidence for increased activation of blood coagulation and fibrinolysis in cadaveric KD. However, analysis compairing ID versus ND donors revealed increased concentrations of PAP complexes (P<.05) and decreased amounts of TAT complexes (P<.01) among ID subgroup. The positive predictive value (PPV) and negative (NPV) for PAP complexes were 75% and 68% and for TAT, 71% and 57%, respectively. On the basis of these observations, we concluded that an intensive activation of fibrinolytic process occurs among the ID. In contrast, ND show intensive activation of blood coagulation.

Graft infection in kidney recipients and its relation to transplanted kidney function.

INTRODUCTION: Following kidney transplantation, septic complications are the leading causes of therapeutic failure including recipient death or graft removal. The serum creatinine level is one of the earliest metrics of kidney metabolic function. We examined the influence of graft infection on serum creatinine levels in kidney recipients. STUDY DESIGN: We analyzed the function of 220 kidneys transplanted in nine centers in Poland. The kidneys were recovered from 146 multiorgan donors. Donor urea and creatinine levels were within the normal range. We investigated the influence of perioperative graft infection incidence on recipient creatinine levels at 1, 2, 3, 7, 14, 30, 90, and 180 days after kidney transplantation. The association of the serum creatinine level with categorical variables was assessed using either Student t test analysis of variance and multivariate techniques. In all analyses P<.05 indicated statistical significance. RESULTS: There were 25 graft infections revealing a significant relationship with increased recipient serum creatinine level after kidney transplantation (P=.003). Multivariate analysis confirmed the impact of infection. CONCLUSION: Perioperative kidney graft infection influenced graft funtion in the early and late periods post-transplantation.

The outcomes of treatment and the etiology of lymphoceles with a focus on hemostasis in kidney recipients: a preliminary report.

BACKGROUND: The etiopathogenesis of lymphoceles remains incompletely understood. The aim of our work was to analyze the perturbations of blood coagulation process for their possible impact on the etiology of lymphoceles. Additionally we performed an evaluation of the incidence and effectiveness of treatment methods for lymphoceles. MATERIALS AND METHODS: During 2004 to 2010, we performed 242 kidney transplantations in 92 female and 150 male patients. The hemostatic parameters included concentrations of: antithrombin, plasminogen, thrombin/antithrombin complexes (TAT), prothrombin products F1+2 (F1+2), d-dimers, and plasmin/antiplasmin complexes. RESULTS: At 7 years follow-up 27 (11%) recipients had developed symptomatic lymphoceles, namely abdominal discomfort, a palpable mess in the lower abdomen, arterial hypertension, infection of the operative site with fever, lymphorrhoea with surgical wound dehiscence, decreased diurnal urine output with an elevated plasma creatinine, voiding problems of urgency and vesical tenesmus, and/or symptoms of deep vein thrombosis. We applied the following methods of treatment aspiration alone, percutaneous drainage, laparoscopic fenestration or open surgery. In two only patients did perform open surgery. Since 2008 we have not performed an aspiration alone because of high rate of recurrence (almost 100%) and abandoned open surgery in favor of a laparoscopic approach. Our minimally invasive surgery includes percutaneous drainage guided by ultrasound and a laparoscopic procedure with 100% effectiveness. The examined hemostatic parameters revealed decreased concentrations of TAT complexes and F1+2 in subjects with lymphocele showing positive predictive values of 33% and 41% respectively. The negative predictive values for TAT complexes and F1+2 were 14% and 10%, respectively, suggesting decreased blood coagulation activity among effected recipients. Altered blood coagulation processes may explain some aspects of the disturbances of postoperative obliteration of damaged lymphatic vessels and formation of pathological lymph collection afterward. CONCLUSIONS: Perturbations of blood coagulation may be one cause for a lymphocele.