Effects of hepatitis B surface antigen (HBsAg) positivity of donors in HBsAg(+) renal transplant recipients: comparison of outcomes with HBsAg(+) and HBsAg(-) donors.

AIM: The aim of this study was to determine the effects of hepatitis B surface antigen (HBsAg) positivity of the donors on graft survival and liver complications in HBsAg(+) renal transplant recipients. PATIENTS AND METHOD: A group of 55 patients who underwent renal transplantation (RTx) in our hospital between 2001 and 2012 were included in the study. Patients were divided into 2 groups. Group 1 (n = 50) consisted of HBsAg(+) renal transplant recipients (RTR) whose donors were HBsAg(-). In Group 2 (n = 5), RTR and donors were both HBsAg(+). Lymphocyte cross matches, number of mismatches, donor types, renal replacement treatment modalities, drugs of induction treatment, and preoperative hepatitis B virus DNA titers of the groups were similar. In Group 1, 42 patients were taking lamivudine, 3 patients were taking entecavir, and 5 patients were taking tenofovir. All of the patients in Group 2 were taking lamivudine. Patient and graft survival rates, graft functions, acute hepatitis rates, acute rejection rates, and other clinical outcomes of the groups were compared. RESULTS: Demographic data of the groups were similar. Acute rejection rates (P = 0.458), graft survival rates (P = 0.515), and patient survival rates (P = 0.803) were also similar. No significant difference was found between the groups in terms of acute hepatitis rate (P = 0.511), glomerular filtration rate (calculated by Modification of Diet in Renal Disease formula) in the last follow-up (P = 0.988), alanine aminotransferase levels (P = 0.069), or delayed graft function rate (P = 0.973). Rates of chronic allograft dysfunction and new onset diabetes mellitus after transplantation were similar. CONCLUSION: Our study revealed that, RTx from HBsAg(+) donors to HBsAg(+) recipients is safe with antiviral treatment.

Oxidative stress and asymmetric dimethylarginine is independently associated with carotid intima media thickness in peritoneal dialysis patients.

BACKGROUND: Oxidative stress (OS) and asymmetric dimethylarginine (ADMA) are accepted as nonclassical cardiovascular risk factors in end-stage renal disease patients. To clarify the role of these factors in the atherosclerotic process, we investigated if OS and ADMA are associated with common carotid artery intima media thickness (CIMT) in peritoneal dialysis (PD) patients. METHODS: Thirty PD patients without known atherosclerotic disease and classical cardiovascular risk factors as well as age- and gender-matched 30 healthy individuals were included. We measured serum thiobarbituric acid-reactive substances (TBARS), malondialdehyde (MDA), advanced glycation end product (AGE), pentosidine, advanced oxidation protein products (AOPP), ADMA and CIMT in each subjects. RESULTS: TBARS, MDA, AOPP, AGE, pentosidine and ADMA levels were significantly higher in PD patients than in controls (p < 0.001). CIMT in patients was higher than in the control group (0.83 +/- 0.09 vs. 0.77 +/- 0.06 mm; p < 0.01). CIMT was independently correlated with TBARS (beta = 0.33, p < 0.01), MDA (beta = 0.27, p < 0.01), AOPP (beta = 0.22, p < 0.02), AGE (beta = 0.45, p < 0.01), pentosidine (beta = 0.56, p < 0.01) and ADMA (beta = 0.54, p < 0.01). CONCLUSIONS: OS markers and serum ADMA levels independently predict the CIMT level in PD patients.

Phosphorus control in peritoneal dialysis patients.

Hyperphosphatemia is independently associated with an increased risk of death among dialysis patients. In this study, we have assessed the status of phosphate control and its clinical and laboratory associations in a large international group of patients on chronic peritoneal dialysis (PD) treatment. This cross-sectional multicenter study was carried out in 24 centers in three different countries (Canada, Greece, and Turkey) among 530 PD patients (235 women, 295 men) with a mean+/-s.d. age of 55+/-16 years and mean duration of PD of 33+/-25 months. Serum calcium (Ca(2+)), ionized Ca(2+), phosphate, intact parathyroid hormone (iPTH), 25-hydroxy vitamin D(3), 1,25-dihydroxy vitamin D(3), total alkaline phosphatase, and bone alkaline phosphatase concentrations were investigated, along with adequacy parameters such as Kt/V, weekly creatinine clearance, and daily urine output. Mean Kt/V was 2.3+/-0.65, weekly creatinine clearance 78.5+/-76.6 l, and daily urine output 550+/-603 ml day(-1). Fifty-five percent of patients had a urine volume of <400 ml day(-1). Mean serum phosphorus level was 4.9+/-1.3 mg per 100 ml, serum Ca(2+) 9.4+/-1.07 mg per 100 ml, iPTH 267+/-356 pg ml(-1), ionized Ca(2+) 1.08+/-0.32 mg per 100 ml, calcium phosphorus (Ca x P) product 39+/-19 mg(2)dl(-2), 25(OH)D(3) 8.3+/-9.3 ng ml(-1), 1,25(OH)(2)D(3) 9.7+/-6.7 pg ml(-1), total alkaline phosphatase 170+/-178 U l(-1), and bone alkaline phosphatase 71+/-108 U l(-1). While 14% of patients were hypophosphatemic, with a serum phosphorus level lower than 3.5 mg per 100 ml, most patients (307 patients, 58%) had a serum phosphate level between 3.5 and 5.5 mg per 100 ml. Serum phosphorus level was 5.5 mg per 100 ml or greater in 28% (149) of patients. Serum Ca(2+) level was > or =9.5 mg per 100 ml in 250 patients (49%), between 8.5 and 9.5 mg per 100 ml in 214 patients (40%), and lower than 8.5 mg per 100 ml in 66 patients (12%). Ca x P product was >55 mg(2)dl(-2) in 136 patients (26%) and lower than 55 mg(2)dl(-2) in 394 patients (74%). Serum phosphorus levels were positively correlated with serum albumin (P<0.027) and iPTH (P=0.001), and negatively correlated with age (P<0.033). Serum phosphorus was also statistically different (P = 0.013) in the older age group (>65 years) compared to younger patients; mean levels were 5.1+/-1.4 and 4.5+/-1.1 mg per 100 ml, respectively, in the two groups. In our study, among 530 PD patients, accepted uremic-normal limits of serum phosphorus control was achieved in 58%, Ca x P in 73%, serum Ca(2+) in 53%, and iPTH levels in 24% of subjects. Our results show that chronic PD, when combined with dietary measures and use of phosphate binders, is associated with satisfactory serum phosphorus control in the majority of patients.

Protein oxidation in Type 2 diabetic patients on hemodialysis.

BACKGROUND: Oxidative stress is considered to be a unifying link between diabetes mellitus (DM) and its complications, including nephropathy. There have been many reports on increased production of oxidants and decreased level of antioxidants in diabetic patients. The dialysis procedure contributes to oxidative stress. An increase in oxidative stress may contribute to the development of oxidative protein damage in diabetic patients. Our aim was to reveal the effects of diabetes and hemodialysis (HD) on oxidative modifications of plasma proteins. METHODS: We measured reactive carbonyl derivates (PCO), protein thiol (P-SH), and reduced glutathione (GSH) levels in Type 2 diabetic (DM) and diabetic hemodialysed patients (DHD) and in healthy control participants. RESULTS: Protein carbonyl (PCO) content increased significantly in all patient groups relative to the controls. The dialysis procedure caused an additional increase in PCO levels in DHD patients before and after dialysis compared with the level in DM patients. There was a significant decrease in P-SH levels in DHD patients compared with the level in healthy participants and DM patients. There was no significant difference in the whole blood GSH levels between the DM patients and control participants. It was significantly higher in DHD patients in comparison to the DM patients. CONCLUSIONS: We conclude that PCO level increases in DM patients, and this increase is more profound in DHD patients, indicating that both diabetes and dialysis contribute to increased protein oxidation. The low P-SH level in DHD patients, but not in DM patients, suggests that dialysis is responsible for this decrease. We propose plasma PCO derivate as a novel specific marker for oxidative protein damage.

Effect of haemodialysis on the oxidative stress and antioxidants in diabetes mellitus.

Oxidative stress has been defined as a loss of counterbalance between free radical or reactive oxygen species (ROS) production and antioxidant systems. It is involved in the pathogenesis of different chronic diseases. High levels of ROS production via different biochemical mechanisms accompany diseases like type 2 diabetes mellitus (DM) and end-stage renal disease (ESRD). Elevated oxidative status and reduced antioxidant defence systems in patients with DM and ESRD accelerate the prevalence of atherosclerosis and other chronic complications. Our aim was to reveal the effects of diabetes and haemodialysis (HD) separately and together on oxidative stress. In our study, we included 20 diabetic (DM) patients with no renal disease, 20 non-diabetic haemodialysis (HD), 20 diabetic haemodialysis (DHD) patients and 20 healthy volunteers. We have determined the levels of lipid peroxidation expressed as thiobarbituric acid-reactive substances (TBARS), oxidative protein damage as indicated by protein carbonyl (PCO) content and activities of antioxidant enzymes including superoxide dismutase (SOD), catalase (CAT) and glutathione peroxidase (GSHPx) in all patient groups and healthy subjects. We found enhanced oxidative stress in all patient groups due to an increase in lipid peroxidation (TBARS) and increased oxidative protein damage in terms of PCO content and reduced activities of SOD, CAT and GSH-Px. Oxidative stress was more profound in diabetic patients undergoing haemodialysis. We conclude that both diabetes and dialysis increase oxidative stress and their combined effect on oxidative stress is the highest in magnitude as observed in diabetic patients undergoing haemodialysis.

Outcomes of Renal Transplantation in Patients With Alport Syndrome.

AIM: We evaluated the outcomes of patients who underwent renal transplantation (Rtx) due to end-stage renal disease (ESRD) related to Alport syndrome in our study. MATERIALS AND METHODS: Twenty-five patients (female/male: 9 [36%]/16 [64%]) who underwent Rtx at our center between 2002 and 2014 were enrolled in the study. Mean ages of patients and donors (cadaveric/living: 8 [32%]/17 [68%]) were 28.2 ± 11.6 and 42.3 ± 15.8 years, respectively. As immunosuppressive therapy, tacrolimus plus mycophenolic acid were used for 17 (68%) patients and cyclosporin plus mycophenolic acid were used for 8 (32%) patients where induction therapy was basiliximab 20 mg (day 0 and 4) for 11 (44%) patients and anti-thymocyte globulin for 8 (32%) patients. Acute rejection was diagnosed using biopsy and evaluated with Banff classification. Analyses were performed by using SPSS 20.0 software with outcomes of mean 75.4 ± 31.4 months follow-up. Patient and graft survival were measured by using Kaplan-Meier survival curve and compared by using log-rank test. RESULTS: Graft survival rate was 89%, patient survival rate was 92.9%, and acute rejection rate was 12% (3 cases; 1 was cellular and 2 were antibody-mediated). Delayed graft function was observed in 4 (16%) cases, 1 patient (4%) had BK virus nephropathy and 2 (8%) patients required hemodialysis and had cytomegalovirus infection. At the last follow-up, mean serum creatinine level was 1.57 ± 1.23 mg/dL, spot urine protein creatinine ratio was 0.13 (0.04-1.84), and glomerular filtration rate was 71.7 ± 34.9 mL/min. CONCLUSION: Rtx is an effective and successful treatment modality for ESRD cases related to Alport syndrome.

A Successful Renal Transplantation Case After Stem Cell Transplantation.

Renal transplantation is the most effective treatment method for end-stage renal disease (ESRD). However, new treatment modalities are being investigated, such as immunotoleration, to avoid the acute and chronic side effects of immunosuppressant drugs. We report a case in which a man had undergone allogenic stem cell transplantation from his brother 16 years ago due to chronic myeloid leukemia, and who then developed ESRD due to arterial hypertension and underwent renal transplantation (Rtx) from the same brother. The patient was followed up without immunosuppression due to full chimerism.

Cigarette smoking in renal transplant recipients.

Cigarette smoking may adversely influence patient and graft survival. In Europe and the United States the prevalence of cigarette smoking in dialysis patients is 35% to 40% and 25%, respectively. In Turkey, the estimated prevalence of cigarette smoking rate in the normal population is 26%. This study evaluated the rate of smoking in 63 cadaveric, and 158 living-related renal transplant recipients including (150 men, and 76 women of 38 +/- 12 years; range, 8 to 70) who were operated between 1986 and 2001. Demographic data were collected with a questionnaire delivered to patients during their routine outpatient visits. During this time period, 8 patients had died, 4 from hemophagocytic syndrome, 2 from cardiovascular disease, 1 from Kaposi sarcoma and 1 from a cerebrovascular accident. Twenty-three patients have lost their grafts. While at the time of transplantation 97 (42%) were smoking cigarettes, only 29 (12%) continued smoke after transplantation. Male gender significantly correlated with cigarette smoking (P =.000). Twelve smokers were single but 85 out of 97 were married, a statistically significant difference (P =.010). In contrast there was no significant relationship between pretransplant smoking and educational status (P =.354); graft loss and smoking (P =.129); or mortality and smoking (P =.224). There was a significant relationship between pretransplant and posttransplant smoking (P =.000). There was no relationship between pre- and post-transplant smoking and development of diabetes mellitus or hypertension. Interestingly the posttransplant serum albumin level was lower among smokers than nonsmokers (4.44 +/- 0.02 g/dL vs 4.30 +/- 0.02 g/dL; P =.019). There was a close relationship between transplantation duration and smoking.

Transfer of native insulin through the peritoneal membrane during CAPD in non-diabetic and diabetic patients.

Because of its relatively small molecular size of 5800 daltons, insulin is a transperitoneally diffusable substance. Insulin is also known to be a mitogenic coadjuvant for mice fibroblasts, and safety of its long-term intraperitoneal use has been questioned because of the potential risk for peritoneal fibrosis. For similar reasons native insulin content of the peritoneal effluent should also not be neglected. To our knowledge, no sufficient data are available about native insulin transfer to dialysate during continuous ambulatory peritoneal dialysis (CAPD). In this study we measured plasma and dialysate immune-reactive insulin levels during a 4 hour peritoneal exchange in 9 nondiabetic and 4 type II diabetic end-stage renal disease patients on CAPD. In both plasma and dialysate, insulin levels were higher in diabetic patients. At hour 4 of dwell time, plasma insulin was 37.5 +/- 7.9 microU/mL in non-diabetics and 64.2 +/- 34.1 microU/mL in type II diabetics. In both groups, dialysate insulin was 1.5 to 2 x higher than their simultaneous peripheral vein insulin levels and was measured as 88.1 +/- 26.8 microU/mL in nondiabetic group and 101.7 +/- 52.6 microU/mL in the diabetic group at hour 4 (p < 0.005 vs 4 hour plasma level). In conclusion, in both diabetic and nondiabetic CAPD patients, native insulin was present in the dialysate in amounts exceeding simultaneous plasma levels. Equilibration with high portal vein insulin content through hepatic capsule may explain higher insulin concentrations measured in the dialysate.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of cefodizime on peritoneal mononuclear- and polymorphonuclear-cell chemotaxis.

In this study, a third-generation cephalosporin with proposed immunomodulatory properties, cefodizime, was investigated to see if it has any effect on the chemotactic activity of human peritoneal monocyte and polymorphonuclear cell populations ex vivo. Ten continuous ambulatory peritoneal dialysis patients with peritonitis were entered in the study. Monocytes and polymorphonuclear cells were isolated from the patients' peritoneal effluent prior to initiation of any antibiotic therapy. Chemotaxis was measured by the Boyden chamber method before and after 2-hour incubation with cefodizime (200 mg/2L). Following 2-hour incubation with 200 mg/2L cefodizime, monocyte chemotaxis was increased from 36.8 +/- 5.6 microns to 50.2 +/- 6.6 microns (P = 0.0005). A similar increase was observed in polymorphonuclear cells from 42.0 +/- 8.8 microns to 48.7 +/- 10.3 microns (P = 0.02). We conclude that cefodizime acts as a priming agent on peritoneal polymorphonuclear cells, particularly on monocytes, and increases their chemotactic movements.

Response to triple treatment with omeprazole, amoxicillin, and clarithromycin for Helicobacter pylori infections in continuous ambulatory peritoneal dialysis patients.

In this study, the response to triple treatment with omeprazole, amoxicillin, and clarithromycin was investigated in continuous ambulatory peritoneal dialysis (CAPD) patients with Helicobacter pylori (Hp) infections. The study enrolled 20 CAPD patients (11 male, 9 female) who had dyspeptic complaints. The mean age of the patients was 46 (range: 21-65). The study also enrolled, as a control group, 124 patients (66 male, 58 female) who had no systemic disease, but who had upper gastrointestinal endoscopy for dyspeptic complaints. The mean age of the patients in the control group was 47 years (range: 20-74 years). Upper gastrointestinal endoscopy, rapid urease test (CLO test), and direct histologic examination were carried out to detect Hp infection. Hp infection was detected in 10 cases (50%) in the CAPD group and in 53 cases (43%) in the control group. In both groups, patients with Hp infection received the triple treatment of omeprazole 20 mg twice daily for 30 days, amoxicillin 500 mg thrice daily for 15 days, and clarithromycin 500 mg thrice daily for 15 days. To assess response to treatment, upper gastrointestinal endoscopy, CLO test, and direct histologic examination were repeated 3 months after initiation of the treatment. Hp was eradicated in all of the 11 CAPD patients (100%), and in 42 of the control patients (92%). Our results suggest that the triple treatment with omeprazole, amoxicillin, and clarithromycin for Hp infection is as effective in CAPD patients as in the normal population.

[Fulminant meningococcemia]. / Fulminant meningokoksemia.

Fulminant meningococcemia is a rare clinical form of meningococcal disease which has been frequently fatal. In this case report, two patients with fulminant meningococcemia which have been cured completely were presented and the related literature was examined.

[Legionnaires' disease following kidney transplantation]. / Böbrek transplantasyonu sonrasi gelisen Lejyoner hastaligi.

Legionella pneumonia was diagnosed in two patients receiving triple immunosuppressive drug therapy after renal transplantation. High fever was the predominant symptom of these patients. Hyponatremia, leucopenia and anemia were also observed. The disease was diagnosed by immunofluorescence antigen technique and easily controlled with erythromycin therapy.

Favorable outcome of renal grafts with multiple arteries: a series of 198 patients.

OBJECTIVE: We sought to report the postoperative complications, vascular reconstruction techniques and graft outcomes among our series of renal transplantations performed using grafts with multiple renal arteries. METHODS: We reviewed retrospectively the medical records of 196 renal transplant patients of mean age 35.6 ± 13.3 years (range, 6-68) including 130 males and 66 females whose grafts from living (n = 164) or deceased (n = 32) donor with multiple arteries between 2006-2012. We noted the number of renal arteries, graft function, surgical technique, as well as vascular, urological and other complications. RESULTS: Of the 196 patients, 182 had 2 and 14 had ≥ 3 renal arteries. The surgical technique was separate anastomosis of renal arteries to the external and/or common iliac artery in the majority of patients (86.2%), while 13.8% of patients underwent anastomosis as a single renal artery after cuff reconstruction. Three patients experienced a lymphocele and only 1, a urinary leak from lower end of ureter, which was repaired surgically. Graft survival was 96.9% with losses in 6 cases due to rejection. CONCLUSIONS: Grafts bearing multiple renal arterial displayed low postoperative complication rates and good outcomes.

Patient and graft survival after pre-emptive versus non-pre-emptive kidney transplantation: a single-center experience from Turkey.

OBJECTIVE: We sought to report the graft and patients survival of pre-emptive and non-pre-emptive kidney transplantations performed in our center. METHODS: The 859 subjects showed a mean age of 36.1 years and included 64.6%; males, who received grafts from living (n = 665) or deceased (n = 194) donors between January 2008 and June 2011. We reviewed their medical records retrospectively, to separately pre-emptive versus non-pre-emptive recipients for year transplant outcomes. RESULTS: Among the 859 patients, 153 (17.8%) underwent pre-emptive and 706 (82.2%), non-pre-emptive kidney transplantations. The rate of living donors was higher in the pre-emptive group (97.4% vs 73%, respectively). The 1-year graft survivals were 99.3% and 95.8% in pre-emptive and non-pre-emptive transplantation groups, respectively (P > .05). There was no significant difference between groups with respect to patient survival at 1 year (P > .05). CONCLUSION: In conclusion, graft and patient survival rates between pre-emptive and non-pre-emptive kidney transplantation cases were comparable at 1 year. Pre-emptive kidney transplantation, which eliminates hemodialysis costs and complications, should be preferred as the optimal renal replacement therapy for end-stage renal disease patients.

Drug interaction between tacrolimus and ertapenem in renal transplantation recipients.

To show drug interactions between tacrolimus and ertapenem, we retrospectively evaluated 13 renal transplant recipients who had been treated with ertapenem for urinary tract infections during prescription of a constant dose. The mean dose of tacrolimus to achieve desired therapeutic concentrations decreased significantly after beginning ertapenem. The decrease from 0.079 mg/kg to 0.043 mg/kg occurred 2 days after initiation of ertapenem (P < .005). These results suggest that ertapenem, which is not metabolized through the cytochrome (CYP) P450 3A metabolic pathway, interacts with tacrolimus by an unknown mechanism. This report recommends tacrolimus concentration monitoring and dose reductions when the two drugs are administered in combination.

The first (double) hand transplantation in Turkey.

In September 2010, a bilateral hand allotransplantation was performed on a 28-year-old man who had suffered amputations at the level of 1/3 of the proximal forearm on the right and 1/3 of the distal forearm on the left 2 years previously. This was the first hand transplantation case in Turkey. Preoperative organization, legal difficulties, technical aspects of the operation, and immunosuppressive regimen are detailed herein. The early results of the first composite tissue allograft (CTA) transplantation are also reported. The results were encouraging for all future types of CTA transplantation, including hand and face. Following the early promising outcome of the first case of hand transplantation in Turkey, we have accelerated preparation of regulations for CTA transplantation, including hand and face allotransplantation.