Perioperative standards for the treatment of coagulation disorders and usage of blood products in patients undergoing liver transplantation used in the Clinic for Transplant Surgery in Wroclaw.

BACKGROUND: Coagulation system disorders in liver transplantation (ltx) patients are considered a serious issue. Liver cirrhosis leads to decreased synthesis of clotting factors and decreased elimination of waste products, including coagulation proteins. Platelet sequestration and dysfunction in an enlarged spleen additionally worsen these conditions. The resulting state, the most common pathology of the coagulation system, involves the reduction of clotting potential and hyperfibrinolysis. OBJECTIVES: Tackling the problem of impaired hemostasis is a dynamic process. Throughout the whole procedure, consisting of the preanhepatic, the anhepatic and the neohepatic phases, consecutive pathomechanisms disrupt the very balance that anesthesia aims to preserve. MATERIAL AND METHODS: Rotational thromboelastometry (ROTEM), having been introduced in the Clinic of Anesthesiology and Intensive Therapy, Wroclaw Medical University, Poland, enables the efficient and early diagnosis of clotting disorders. An additional major problem which occurs during ltx, namely blood loss, could be solved using a cell separator. RESULTS: In this study, we present the standards introduced to the Transplantology Department of the Vascular Surgery Clinic, Wroclaw Medical University, Poland, that describe blood treatment during ltx procedures. CONCLUSIONS: We conclude that thromboelastometric examination and the use of a cell separator have significantly increased the safety of ltx procedures at our clinic. The introduction of thromboelastometry (TEM) and the implementation of the cell separator recovery method have enabled us to perform the dangerous and complicated surgical procedure of ltx in a much more stable and much safer manner than in the past.

Brain death-associated pathological events and therapeutic options.

BACKGROUND: At present, organ transplantation is the most efficient treatment of end-stage failure of various organs, including the heart, lungs, pancreas, intestines, kidney, and liver. Despite the efforts to use organs from living donors or from donors after circulatory death, most of the organs are recovered from brain dead (BD) donors. METHODS: The Medline and Web of Science databases were searched without time limit on November 2015 using the terms "brain dead donor" and "deceased donor" in conjunction with "transplantation", "graft", "organ", "hemodynamic", "hormonal", or "management". The search was limited to the English, Polish and Spanish literature. Articles that did not address the topics were excluded and the full text of the remaining articles was reviewed. RESULTS: It is well established that brain death is associated with a cascade of hemodynamic, inflammatory, and immunologic events that affect the outcome of transplanted organs. Proper management of the potential organ donor may help increase the supply of organs for transplantation. However, because there is a lack of good quality evidence, it is difficult to establish specific BD donor management guidelines. CONCLUSION: In this paper we present a review of studies and literature concerning the detrimental impact of donor brain death on graft function. We present pathologic changes that take place after brain death, their influence on graft quality and therapeutic solutions to enhance transplanted organ function.

The influence of warm ischemia elimination on kidney injury during transplantation - clinical and molecular study.

Kidney surface cooling was used during implantation to assess the effect of warm ischemia elimination on allograft function, histological changes and immune-related gene expression. 23 recipients were randomly assigned to a group operated on with kidney surface cooling during implantation (ice bag technique, IBT group), and the other 23 recipients receiving the contralateral kidney from the same donor were operated on with a standard technique. Three consecutive kidney core biopsies were obtained during the transplantation procedure: after organ recovery, after cold ischemia and after reperfusion. Gene expression levels were determined using low-density arrays (Format 32, TaqMan). The IBT group showed a significantly lower rate of detrimental events (delayed graft function and/or acute rejection, p = 0.015) as well as higher glomerular filtration rate on day 14 (p = 0.026). A greater decrease of MMP9 and LCN2 gene expression was seen in the IBT group during total ischemia (p = 0.003 and p = 0.018). Elimination of second warm ischemia reduced the number of detrimental events after kidney transplantation, and thus had influence on the short-term but not long-term allograft function. Surface cooling of the kidney during vascular anastomosis may reduce some detrimental effects of immune activation resulting from both brain death and ischemia-reperfusion injury.

Urological complications after renal transplantation - a single centre experience.

INTRODUCTION: Urological complications after renal transplantation occur in between 2.5% and 30% of all graft recipients. The aim of the study was to present 7 years of experience in urological treatment of patients with a transplanted kidney. We aimed to identify retrospectively late urological complications in renal transplant recipients at a single center and analyze the treatment modalities and their outcome. MATERIAL AND METHODS: Between January 2008 and December 2014, a total of 58 patients after KTX were treated in the Department of Urology because of post-transplant urological complications that occurred during follow-up at the Transplant Outpatient Department. Retrieved data were analysed in retrospectively. RESULTS: In the group of 38 patients with ureteral stenosis (Clavien grade III), 29 patients underwent endoscopy, 8 open surgical procedures and one both endoscopic and open operation. Ten patients were admitted with symptomatic lymphocoele (Clavien III), of which 9 were successfully treated with drainage and one with surgical marsupialization. Because of urolithiasis in the grafted kidney (Clavien grade III), 4 patients were treated with ureterorenoscopic lithotripsy (URSL) and one only with the extracorporeal shock wave lithotripsy (ESWL) procedure. Five urethral strictures plasties and one graftectomy because of purulent pyelonephritis were also conducted. The average age in the group of recipients who experienced urologic complications was similar (46.1 vs. 47.8) to those without complications. There was no vesicoureteral reflux or ureteral necrosis requiring surgical intervention, no graft loss and death related to urological complication and treatment. CONCLUSIONS: Most complications could be successfully treated with endourological procedures. The kidney function improved in the majority of patients.

Pretransplant Immune- and Apoptosis-Related Gene Expression Is Associated with Kidney Allograft Function.

Renal transplant candidates present immune dysregulation, caused by chronic uremia. The aim of the study was to investigate whether pretransplant peripheral blood gene expression of immune factors affects clinical outcome of renal allograft recipients. Methods. In a prospective study, we analyzed pretransplant peripheral blood gene expression in87 renal transplant candidates with real-time PCR on custom-designed low density arrays (TaqMan). Results. Immediate posttransplant graft function (14-day GFR) was influenced negatively by TGFB1 (P = 0.039) and positively by IL-2 gene expression (P = 0.040). Pretransplant blood mRNA expression of apoptosis-related genes (CASP3, FAS, and IL-18) and Th1-derived cytokine gene IFNG correlated positively with short- (6-month GFR CASP3: P = 0.027, FAS: P = 0.021, and IFNG: P = 0.029) and long-term graft function (24-month GFR CASP3: P = 0.003, FAS: P = 0.033, IL-18: P = 0.044, and IFNG: P = 0.04). Conclusion. Lowered pretransplant Th1-derived cytokine and apoptosis-related gene expressions were a hallmark of subsequent worse kidney function but not of acute rejection rate. The pretransplant IFNG and CASP3 and FAS and IL-18 genes' expression in the recipients' peripheral blood is the possible candidate for novel biomarker of short- and long-term allograft function.

[Methods of Reduction of Warm Ischemic Time in Kidney Transplantation and Their Role of Early and Late Outcomes].

Kidney is the organ transplanted most often. An increase in the number of expanded criteria donors (ECD) has been observed for years, and consequently the condition of transplanted organs worsened. In recent years, the possibility to recover organs from donors after cardiac death (DCD) became legally available in Poland, which will result in the increase of donors. Every DCD donor is at the same time ECD donor. One of the most important challenges the transplantology has to face is the improvement of the quality of transplanted organs. In this study the available data on the reduction of warm ischemic time (WIT) on transplanted kidney has been presented. WIT may influence early and late outcome of kidney allograft. Long WIT increases the risk of delayed graft function (DGF). DGF occurs more often in transplanted kidneys from DCD. One of the main reasons for that is the fact that DCD have longer WIT compared to donors after brain death (DBD). So-called WIT II appearing during vascular anastomosis in kidney transplantation may be reduced by various techniques. The model of clear sterilized polyethylene bag developed by the authors has been presented. The construction of the bag, consisting of three compartments, allow to safely perform vascular anastomosis while keeping the temperature of the transplanted kidney low. The article describes as well other techniques used to decrease WIT II. The effect of anastomosis time on allograft outcome is still not well researched. The article presents the newest information regarding the influence of WIT on graft and patient survival.

Type of Renal Replacement Therapy (Hemodialysis versus Peritoneal Dialysis) Does Not Affect Cytokine Gene Expression or Clinical Parameters of Renal Transplant Candidates.

UNLABELLED: Patients with renal failure suffer from immune disturbances, caused by uremic toxins and influenced by dialysis treatment. The aim of the present study was to reveal whether type of dialysis modality (hemodialysis, HD, versus peritoneal dialysis, PD) differentially affects the immunocompetence, particularly the expression of genes involved in the immune response. MATERIAL: 87 renal transplant candidates (66 HD, 21 PD) were included in the study. METHODS: The peripheral blood RNA samples were obtained with the PAXgene Blood system just before transplantation. The gene expression of CASP3, FAS, TP53, FOXP3, IFNG, IL2, IL6, IL8, IL10, IL17, IL18, LCN2, TGFB1, and TNF was assessed with real-time PCR on custom-designed low density arrays (TaqMan). Gene expression data were analyzed in relation to pretransplant clinical parameters. RESULTS: The mean expression of examined genes showed no significant differences between PD and HD with the exception of FAS, expression of which was 30% higher in PD patients compared to the HD group. There was nonsignificantly higher expression of proinflammatory cytokines in the PD group. The clinical inflammatory parameters (CRP, albumin, cholesterol, and hemoglobin levels) did not differ between the groups. CONCLUSION: Type of renal replacement therapy exerts no differential effect on cytokine gene expression or inflammatory clinical parameters.

The influence of non-HLA antibodies directed against angiotensin II type 1 receptor (AT1R) on early renal transplant outcomes.

Non-HLA antibodies (Abs) targeting vascular receptors are thought to have an impact on renal transplant injury. Anti-angiotensin II type 1-receptor-activating antibodies (anti-AT1R) have been mentioned to stimulate a severe vascular rejection, but the pretransplant screening has not been introduced yet. The aim of our study was to assess the incidence and importance of anti-AT1R antibodies and their influence on renal transplant in the 1st year of observation. We prospectively evaluated the presence of anti-AT1R antibodies in 117 consecutive renal transplant recipients in pre- and post-transplant screening. Anti-AT1R antibodies were observed in 27/117 (23%) of the analyzed recipients already before transplantation. The function of renal transplant was considerably worse in anti-AT1R(+) group. The patients with anti-AT1R Abs >9 U/ml lost their graft more often. Biopsy-proven AR was described in 4/27 (15%) pts in the anti-AT1R(+) group and 13/90 (14.4%) in the anti-AT1R(-) group, but more severe cases of Banff IIB or antibody-mediated rejection (AMR) were more often observed in anti-AT1R (+) 4/27 (15%) vs. 1/90 (1.1%) in anti-AT1R(+) (P = 0.009). Patients with anti-AT1R Abs level >9 U/ml run a higher risk of graft failure independently of classical immunological risk factors. The recipients with anti-AT1R Abs developed more severe acute rejections described as IIB or AMR in Banff classification. More recipients among the anti-AT1R-positive ones lost the graft. Our study suggests monitoring of anti-AT1R Abs before renal transplantation for assessment of immunologic risk profiles and the identification of patients highly susceptible to immunologic events, graft failure, and graft loss.

The impact of non-HLA antibodies directed against endothelin-1 type A receptors (ETAR) on early renal transplant outcomes.

BACKGROUND: Non-HLA antibodies (Abs) targeting vascular receptors are considered to have an influence on renal transplant injury. Anti-endothelin-1 type A receptor (anti-ETAR) antibodies were associated with cellular and antibody-mediated rejection and early onset of vasculopathy in heart transplant patients but their role in renal transplantation remains unclear. The aim of our study was to assess the incidence and importance of anti-ETAR antibodies and their impact on renal transplant during the first year observation. METHODS: We evaluated the presence of anti-ETAR antibodies in 116 consecutive renal transplant recipients in pre- and post-transplant screening (before and in 1st, 3rd, 6th, 12th month after transplantation). Additionally, we assessed the presence of anti-HLA antibodies. Anti-ETAR antibodies were assayed by ELISA. The diagnosis of acute rejection was based on the Banff criteria. RESULTS: Anti-ETAR antibodies were observed in 55 (47.4%) of the analyzed recipients before transplantation. The function of renal transplant was significantly worse in the anti-ETAR(+) group compared to the anti-ETAR(-) group during the first post-transplant year. One month after transplantation the serum creatinine in anti-ETAR (+) patients (pts) was 1.86±0.8mg/dl and 1.51±0.5 in anti-ETAR(-) pts (p=0.009). Twelve months after transplantation the difference between the groups was still observed 1.70±0.7 vs. 1.40±0.4 (p=0.04). Biopsy proven acute rejection was recognized in 8/55 (14.5%) in ETAR(+) and 9/61 (14.8%) in ETAR(-) patients but cases with mild to severe intimal arteritis (v1-v3) were more often observed in patients with the presence of anti-ETAR Abs 4/55 (7.2%) comparing with 1/61 (1.6%) in anti-ETAR(-) patients. The anti-ETAR antibody levels varied at different measurement intervals during the one-year follow-up. CONCLUSIONS: The presence of anti-ETAR antibodies is associated with a worse renal transplant function during the first 12months after transplantation. Including anti-ETAR antibodies in the diagnostics of renal transplant recipient immune status should be considered to provide comprehensive assessment of humoral alloimmunity.

The influence of CTLA-4 gene polymorphism on long-term kidney allograft function in Caucasian recipients.

The aim of the study was to examine whether CTLA-4 (CD152) and CD28 gene polymorphisms affect the outcome of kidney transplantation (KTx). Polymorphisms of the CTLA-4 gene (-318 C>T, +49 A>G, and the microsatellite polymorphism in the 3'UTR of exon 4 (AT)(n)) and a CD28 gene (IVS3 +17T>C) were investigated in 314 allograft recipients with a mean age of 41.9+/-12 years. The median time since KTx was 97.5 months. The genotypes of the SNPs were determined by SSP-PCR and (AT)(n) genotype by PCR and capillary electrophoresis (ABI Prism 310). In general, no relationship was found between the allele variants and acute rejection or graft function. Univariate and multivariate analyses showed no influence of CTLA-4 or CD28 polymorphism on graft/patient survival. In the individuals bearing the combination of the homozygous variant of low AT repeat number (82 bp) and the homozygous variant A (adenine) in CTLA-4 +49 A>G, higher eGFR was observed at one year after KTx, which was also maintained at 10 years. In summary, 24.2% of the studied patients carrying the "favorable" CTLA-4 genotype exhibited significantly higher allograft function than the 16.9% recipients with the "unfavorable" genotype up to 10 years post transplantation.

Cytokine gene expression in kidney allograft biopsies after donor brain death and ischemia-reperfusion injury using in situ reverse-transcription polymerase chain reaction analysis.

BACKGROUND: This study focuses on the cytokine genes expression after brain-death, ischemia-reperfusion injury, and during allograft rejection. METHODS: A total of 49 needle core biopsies from kidney transplant recipients, performed before and during transplantation procedures were studied. The first biopsy was taken during procurement of the organ, the second after cold ischemia, and the third after approximately 30 min of reperfusion. We also assessed 34 allograft biopsies obtained during acute rejection. Tubular and glomerular expression of interferon (IFN)-gamma, transforming growth factor (TGF)-beta1, platelet-desired growth factor-B (PDGF-B), interleukin (IL)-2, IL-6, IL-10 mRNA was analyzed with reverse-transcription polymerase chain reaction (RT-PCR) in situ technique, which allows to detect a few copies of the target gene without destruction of the tissue architecture. RESULTS: Compared with normal kidney tissue from living donor, high gene expression of IFN-gamma, TGF-beta1, PDGF-B, IL-2, IL-6, and IL-10 was detected in all procurement specimens. After reperfusion gene expressions of IL-2, IL-6, and IL-10 were significantly upregulated in renal tubules compared to biopsies taken after cold ischemia. The gene expression of IFN-gamma, TGF-beta1, and PDGF-B remained stable after organ procurement, during cold ischemia, and after reperfusion. Gene expression of IFN-gamma, IL-2, IL-6, IL-10, and PDGF-B in procurement biopsies, as well as in those taken after cold ischemia and reperfusion, were significantly higher than during the period of acute rejection. CONCLUSION: The data presented herein strongly point out the importance of the immunological and morphological injury that occurs before and during transplantation. The increase of inflammatory response after brain death is important for further stimulation of the immune response and long-term kidney survival.

[Gene expression of INF-gamma, IL-10, IL-2, IL-6, PDGF-B i TGF-beta in kidney tissue after renal transplantation]. / Ekspresja genów dia: IFN-gamma, IL-10, IL-2, IL-6, PDGF-B i TGF-beta w wycinkach nerek od biorców przeszczepu nerki.

UNLABELLED: The aim of the study was to evaluate the effect of brain death, ischemia-reperfusion injury and alloreactivity of some cytokines on intragraft mRNA expression. MATERIAL AND METHODS: We have examined 49 needle core biopsies of kidney allografts from cadaveric donors. Samples were taken before harvesting, after cold ischemia and approximately after 20-30 minutes of reperfusion. We have also assessed 56 allograft biopsies taken after transplantation. Tubular and glomerular expression of IL-2, IL-6, IL-10, IFN-gamma, TGF-beta 1 and PDGF-B mRNA was assessed using semiquantitative evaluation of the RT-PCR in situ on paraffin tissue sections. RESULTS: In all pre-procurement specimens high glomerular and tubular IL-2, IL-6, IL-10, TGF-beta 1, PDGF-B and IFN-gamma mRNA expression was detected. After reperfusion an increase of IL-2, IL-6, and IL-10 mRNA expression was observed in all specimens and was limited only to tubules. Biopsies samples with borderline changes exhibited the lowest levels of cytokine gene expression close to the intensity in control specimens. An intense, comparing to normal kidney, tubular and glomerular all examined cytokines gene expression was also noticed during acute rejection. No significant differences between acute cellular and vascular rejection were noticed. The mRNA expression of IFN-gamma and IL-2, IL-6, IL-10 in chronic rejection did not differ from acute rejection. The tubular expressions of mRNA for IL-6 and TGF-gamma 1 in biopsies with acute rejection obtained from patients treated with MMF were significantly lower than in biopsies obtained from patients treated with azathioprine.

Organ donor with complete situs inversus. Case report and review of the literature.

Complete situs inversus (SI) is a very rare anomaly characterized by the total inversion of all abdominal and thoracic organs. SI has been traditionally considered an absolute contraindication for liver and heart transplantation. We report a case of a donor with complete SI diagnosed at the time of organ recovery and we review the literature concerning this anomaly and organ transplantation.

Intraoperative hemostasis during kidney transplantation and the use collagen mesh dressing covered by fibrin glue (TachoComb).

In this paper we present influence of use of haemostatic dressing TachoComb, onto bleeding from surface of transplanted kidney. Kidney transplantation (KTX) seems to be main method of treatment of terminal renal failure. Enlarging number of KTX results in growing frequency of intra and postoperative complications. Hemorrhagic complications can impact clinical status of recipient and graft function. Haemostatic dressing was applied at 29 cases. Control group in which only gas compresses were used consisted of 25 patients. It was proved, that use of dressing from collagen mesh covered by fibrin glue TachoComb, after kidney transplantation diminished parenchymal bleeding and time necessary to get complete hemostasis.

The modification of renal transplantation with the usage of own polyethylene receptacle.

In this study a method of elimination of the second warm ischemia is shown. The method is based on the application of a specially constructed polyethylene bag, in which the transplanted kidney is placed in the time course from a removal from ice to the reconstruction of vessel flow. The bag is built of polyethylene foil HDPE of low density produced under high pressure. Own construction of the bag (three spaces and polyethylene) enables the storage of a transplanted organ at the stable temperature +4 Celsius degrees. Thanks to the separation of containers for melting ice and for the kidney, possible becomes unrestrained performance of both venous and arterial anastomosis independently of existing operative conditions. Due to the applied method of the elimination of the second warm ischemia with the usage of own construction of polyethylene bag HDPE, one can expect better early renal function after transplantation--decrease in the number of cases and shortening of the time of acute tubular necrosis (ATN--Acute Tubular Necrosis).