Comparison of Bipolar vascular sealing and conventional back-table dissection in terms of post-renal transplant drainage and back-table preparation times.

OBJECTIVE: The usage of vessel sealing devices has been gaining popularity in all surgical specialties. Post-renal transplant drain placement is a common practice among transplant surgeons. However, prolonged drainage accompanied by surgical wound complications and perirenal fluid collections is a frequent complication experienced by the recipients. This study aimed to compare Bipolar vascular sealing with conventional back-table dissection in terms of post-renal transplant drainage duration, amount, surgical wound complication, and back-table preparation time. PATIENTS AND METHODS: A double-blind clinical study randomizes recipients into 2 groups, using Bipolar vascular sealing (Group 1) and conventional ligation (Group 2) back-table dissection. Variables such as recipient age, gender, body mass index (BMI), cause of end-stage renal disease, amount and duration of surgical drainage, back-table time, and cold ischemia time (CIT) were collected prospectively. RESULTS: Ninety-eight consecutive living donor (M/F: 69/29) renal transplant recipients were enrolled in this prospective randomized clinical trial. There were 49 patients in each group. The mean BMI was 26.76±4.57. There was no difference among the groups regarding recipient age, BMI, total drainage, and surgical drainage duration. The surgical site infection rate was not different between the two groups. Group 1 had significantly shorter back-table time, with mean back-table time being 15.26±2.51 minutes in Group 1 and 28.83±6.27 minutes in Group 2 (p<0.001). The CIT was also significantly different between the 2 groups (p<0.001). In Group 1, the recorded CIT was 43.3±11.4, and in Group 2, 57.1±13.3 minutes. CONCLUSIONS: The use of Bipolar vascular sealing to seal lymphatic vessels at the back-table is feasible, safe, and easy to perform. It also expedites the dissection and shortens the time required for back-table graft preparation.

A single-center kidney transplantation experience in children with low weight: is low weight a contraindication?

OBJECTIVE: Kidney transplantation (KT) might be difficult for underweight kids (under 15 kg). Our goal was to convey information on KT in underweight children. PATIENTS AND METHODS: The study's target population consisted of children (age 18) weighing 15 kg or fewer who received KT at our facility between January 2018 and June 2021. A retrospective analysis was performed on demographic and clinical data, including age, gender, primary disease, pretransplant dialysis status, recipient weight, recipient body mass index (BMI), surgical approach type (intraperitoneal/extraperitoneal), complications, graft status (functioning/failed), patient survival, and immunological data. RESULTS: There were 94 pediatric KTs completed. Thirty-three patients were included when the selection criteria were applied. The mean recipient weight was 11.45 [6.7-15] kg, and the average patient age was 3.36 [1-7]. Three (9.9%) patients had kidney transplants from dead adult donors, whereas thirty (90.1%) patients underwent live donor kidney transplantation (LDKT). While the intraperitoneal (IPA) technique was used in 19 cases, the extraperitoneal (KT) strategy was used on 14 patients (EPA). The donor BMI was 28.24 [19.6-42] kg/m2, and the mean donor weight was 78.13 [55-109] kg. Bridectomy was necessary because five individuals experienced ileus. IPA was performed in each of these patients during LDKT. Following IPA, a 2-year-old patient with a BMI of 16 kg/m2 had renal allograft compartment syndrome and required graft nephrectomy. CONCLUSIONS: Pediatric patients weighing 15 kg or fewer can get kidney transplants successfully. Gastrointestinal problems are relatively uncommon with EPA, even though there is no agreement on the best surgical strategy.

Expression Profile of MicroRNA Biogenesis Components in Renal Transplant Patients.

BACKGROUND: MicroRNAs (miRNAs) and the miRNA biogenesis components are potential biomarkers of some prevalent diseases, such as cancer and diabetes. In light of this information, we aimed to investigate the expression profiles of miRNA biogenesis components in renal transplant patients before and after transplantation and how these profiles are related to immunosuppressive treatment and clinical outcomes of these patients. METHODS: In this study, gene and protein expression profiles of Dicer, Drosha, Pasha (DGCR8), Exportin5 (XPO5), and Argonaute2 (AGO2) in peripheral blood mononuclear cells (PBMCs) of renal transplant patients were evaluated by means of real-time quantitative polymerase chain reaction and Western blot methods before and 3 months after transplantation. Patients who had transplant procedures for the first time were included in the study. RESULTS: Gene expressions were significantly reduced after transplantation. The reduction rate of expressions in 1 patient undergoing chronic rejection was higher. In addition, in patients under everolimus treatment, gene expression of Dicer did not change and gene expression of AGO2 increased. Dicer, Drosha, DGCR8, and AGO2 protein expressions were reduced in all patients, but no change was observed in XPO5 protein expression in nonrejecting patients. Interestingly, in the patient undergoing chronic rejection, protein expression profiles other than Dicer were distinctive from nonrejecting patients. However, XPO5 protein expression was higher in that patient. CONCLUSIONS: Our study shows the importance of the global effect of immunosuppressive treatment on the miRNA biogenesis pathway. miRNA biogenesis components are potential biomarkers indicative of graft outcome and pharmacologic target molecules.

Liver Transplantation for Polycystic Liver Disease Due to Huge Liver With Related Complications: A Case Report.

Polycystic liver disease is characterized by multiple cystic lesions on the liver. It is an uncommon autosomal dominant disease. The cysts' diameters range from 20 to 30 cm to small microscopic nodules. Generally, more than half of the liver parenchyma is covered. The mass effect of the liver created by the large cysts can cause life-threatening symptoms such as weight loss, reduction of oral intake, and malnutrition. Liver transplantation is the best treatment option in symptomatic patients. We present a patient who had polycystic liver and kidney disease, and we performed liver transplantation because of his life-threatening symptoms.

Renal Transplantation With Size-Matched End-to-End Venous Anastomosis in Children With Inferior Vena Cava Thrombosis.

Due to surgical technical difficulties, inferior vena cava (VCI) thrombosis is contraindicated for renal transplantation in pediatric patients. Of 287 pediatric renal transplantations, 3 patients (9, 12, and 19 kg, respectively) with end-stage renal failure, who had VCI thrombosis at the level of renal vein, underwent end-to-end anastomosis to the proximal aspect of VCI for venous drainage. The latest creatinine values of the patients, who were in the postoperative 56(th), 28(th), and 14(th) months, were 0.6, 0.4, and 0.3 mg/dL, respectively, with graft and patient survival rates of 100%. We think that end-to-end venous drainage into the proximal caval system is the most appropriate surgical approach in pediatric recipients, who have an open suprarenal VCI and a small intra-abdominal cavity, in the presence of an appropriate size-matched graft.

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.

Comparison of open and retroperitonoscopic donor nephrectomy in terms of lipid and protein peroxidation responses.

BACKGROUND: This study was designed to compare donors who underwent open (ODN) versus retroperitonoscopic nephrectomy (RDN) in terms of intra-operative oxidative stress and recipients graft function in the early postoperative period. METHODS: Among 40 patients who underwent donor nephrectomy, 23 were operated via an open method and 17 via retroperitonoscopic method. To analyze oxidative stress, we measured plasma levels of malondialdehyde (MDA), protein carbonyl, and protein sulfhydryl moieties in donor venous blood before induction of anesthesia and postoperatively at 0, 6, and 24 hours. The influence of oxidative stress on graft function was evaluated by means of the postoperative 5th day recipient creatinine and estimated glomerular filtration rate (eGFR) Modification of Diet in Renal Disease Formula (MDRD) to evaluate delayed graft function (DGF) status. RESULTS: ODN patients showed significantly higher 24-hour mean levels of MDA, (6,139 ± 1,854 vs 4,813 ± 1,771 nmol/L; P = .01), protein carbonyl (366 ± 64 vs 311 ± 62 µmol/L; P = .01) and protein sulfhydryl (468 ± 110 vs 386 ± 75 µmol/L; P = .01) moieties compared with those RDN patients. However, ODN and RDN recipients were similar in terms of 5th day mean creatinine and eGFR (1.1 ± 0.3 vs 1.4 ± 0.8 mg/dL and 69.15 ± 12.24 vs 56.31 ± 25.2, respectively) and DGF status (4.4% [1/23] vs 5.9% [1/17], respectively). CONCLUSIONS: Although ODN donors were more prone to intra-operative oxidative stress than RDN donors, based on significantly higher levels of oxidative stress markers, this difference seems to not significantly influence recipients early graft function.

Paired exchange kidney transplantation experience of Turkey.

OBJECTIVE: Paired-exchange kidney transplantation (PKD) has gained in importance because of the difficulty to obtain suitable organs. The aim of this study was to compare the biochemical and clinical parameters of PKT with those of living-related kidney transplantation (LD). METHOD: We compared 272 PKD performed in 3 transplant centers with 1885 LD. The 2 groups were compared for graft and patient survivals, rejection episodes, serum creatinine levels, and other biochemical parameters. RESULTS: The median human leukocyte antigen, mismatch was similar: PKD, 4 (95% confidence interval [CI], 3-4) and LD; 3 (95% CI, 3-4; P = .1292). The mean creatinine level among the PKT group of 1.07 ± .37 was lower then the LD group 1.17 ± .56 (P = .0043), but after the second year it was lower in the LD group (1.39 ± 0.61 and 1.16 ± 0.43; P < .0001). The rates of patient death (PKT, 3.31% vs LD 3.58; P = .9603), graft loss (2.74% vs 2.71%; P = .8647) and acute rejection episodes (19.48% vs 19.36%; P = 0.9719), were similar between the 2 groups. CONCLUSIONS: Paired donation expands the living donor pool and decreases the number of waiting list patients. It is cost effective according to ABO incompetible transplantation.

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.

Combination of epidural anesthesia and general anesthesia attenuates stress response to renal transplantation surgery.

Choice of the anesthestic technique can reduce or even eliminate stress responses to surgery and decrease the incidence of complications. Our aim was to compare a combination of epidural anesthesia+general anesthesia with general anesthesia alone as regards perioperative insulin resistance and inflammatory activation among renal transplant recipients. Forty-six nondiabetic patients undergoing renal transplantation were prospectively randomized to the epidural anesthesia + general anesthesia group (n = 21), or general anesthesia alone group (n = 25). Plasma levels of glucose, insulin, interleukin (IL)-6, tumour necrosis factor (TNF)-α, resistin, and adiponectin were measured at baseline (T1), end of surgery (T2), postoperative first hour (T3), postoperative second hour (T4) and postoperative 24th hour (T5). Homeostasis model assessment-estimated insulin resistance (HOMA-IR) scores were calculated at every time point that the blood samples were collected. Glucose levels (P < .001) and insulin levels at the end of surgery (P = .048) and at postoperative first hour (P = .005) and HOMA-IR levels at the end of surgery (P = .012) and at postoperative first hour (P = .010) showed significantly higher values among the general anesthesia alone group when compared with the epidural+general anesthesia group. TNF-α levels at postoperative 2nd and at 24th hour (P = .005 and P = .004, respectively) and IL-6 levels at postoperative 1st and 2nd hours (P = .002 and P = .045, respectively) were significantly higher in the general anesthesia alone group when compared with the epidural+general anesthesia group. The TNF-α levels were significantly less at all time points when compared with baseline only in the epidural+general anesthesia group (T1, 33.36 vs 37.25; T2, 18.45 vs 76.52; T3, 15.18 vs 78.27; T4, 10.75 vs 66.64; T5, 2.98 vs 36.32) Hospital stays were significantly shorter among the epidural+general anesthesia group (P = .022). We showed partly attenuated surgical stress responses among patients undergoing renal transplantation using general anesthesia combined with epidural anesthesia compared with general anesthesia alone.

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.

Neurological complications after liver transplantation.

This was a single-centre, prospective study to assess the frequency of neurological complications and their impact on prolonged hospitalization in 137 liver transplant patients presenting between September 1997 and June 2010. Neurological complications were seen in 22 (16%) patients during their postoperative stay in the intensive care unit. Complications included new-onset, recurrent headache (five patients), generalized seizures (four patients), dysarthria (two patients), delirium with agitation (three patients), persistent flapping tremor (two patients), alteration in level of consciousness (three patients), central pontine myelinolysis (one patient), myopathy (one patient) and visual hallucinations (one patient). Seizures were associated with immunosuppressive drug toxicity (tacrolimus). Myopathy presenting as quadriplegia was diagnosed by muscle biopsy. The patient with central pontine myelinolysis lived in a persistent vegetative state for 2 years and died of pneumonia. In conclusion, neurological complications are frequently encountered after liver transplantation, and are an important cause of severe morbidity and prolonged intensive care unit and hospital stay.

Assessment and comparison of endothelial function between dialysis and kidney transplant patients.

Dialysis and kidney transplant patients display endothelial dysfunction. Previous studies concerning comparisons of endothelial function in dialysis and kidney transplant patients included subjects with cardiovascular risk factor(s) that alone may lead to endothelial dysfunction. In this study, we compared endothelial function between dialysis and transplant patients who did not show known cardiovascular risk factors that lead to endothelial dysfunction. We studied age- and gender-matched cohorts: 30 hemodialysis (HD), 30 peritoneal dialysis (PD), and 30 kidney transplant patients. We also included 20 age- and gender-matched healthy controls. We assessed the endothelial function of patients and controls by a noninvasive technique. Serum biochemistry profiles of patients were also similar to controls in terms of lipid profile and fasting blood glucose level. Although mean FMD% levels of HD and PD patients were similar (6.6% +/- 3.1% vs 6.8% +/- 3.0%, P > .05), the mean percent of flow-mediated endothelium-dependent dilatation (FMD%) level in transplant patients was higher than those in HD or PD patients (10.50% +/- 3.0% vs 6.6% +/- 3.1% and 6.8% +/- 3.0%, respectively; P < .01). In addition, the mean FMD% level in healthy controls was higher than those in HD, PD, and transplant patients (14.0% +/- 2.3% vs 6.6% +/- 3.1%, 6.8% +/- 3.0% and 10.50% +/- 3.0%; P < .01, respectively). In conclusion, endothelial functions in transplant patients were better than those in dialysis patients.

Mediastinal, cystic and functional parathyroid adenoma in patients with double parathyroid adenomas: a case report.

Primary hyperparathyroidism is usually caused by single adenoma. Ectopic adenomas are a frequent cause of recurrent or persistent hyperparathyroidism. Parathyroid cysts are rarely seen and most of them are non functional. This case report describes a patient with double adenoma, one is solid and cervical, the other is cystic and located in mediastinum; both of them are functional.

Simvastatin therapy in lymphocyte cross-match-positive kidney transplantation candidates.

OBJECTIVES: Recent identification of several mechanisms by which statins decrease recruitment of monocytes and T cells into the arterial wall and inhibit both T-cell and B-cell activation and proliferation in vitro prompted us to study the immunomodulatory effects of statins. In this study, we examined the effect of simvastatin therapy on lymphocyte cross-match positivity in kidney transplantation candidates. METHODS: Simvastatin therapy (20 mg/d) was administered to 25 patients (18 men, 7 women of mean age 34 +/- 11.7 years who displayed positive lymphocyte cross-matches between July 2002 and October 2004. The etiologies of end-stage renal disease were vesicoureteral reflux (n = 5), urinary stone disease (n = 4), glomerulonephritis (n = 6), amyloidosis secondary to familial Mediterranean fever (n = 1), and unknown (n = 9). RESULTS: The lymphocyte cross-match became negative in 10 patients 4-9 months, and successful kidney transplantation was performed in 6 of them. The serum creatinine levels of these patients ranged between 0.8 and 1.4 mg/dL. Two patients required higher doses, but none suffered from adverse effects. The remaining 4 patients are still undergoing pretransplantation evaluation. CONCLUSION: Simvastatin therapy seems to be a cost-effective and useful method for lymphocyte cross-match-positive kidney transplantation candidates compared with immunoadsorption or intravenous immunoglobulin use.

Sirolimus as primary immunosuppression agent in kidney transplant recipients: Akdeniz University experience.

OBJECTIVES: Recently usage of sirolimus as the primary immunosuppressant is widening among kidney transplant recipients. We reviewed the clinical follow-up of patients transplanted at our center using sirolimus protocols. METHODS: Sirolimus including primary immunosuppressive treatment protocols were begun in February 2002. Among the 21 patients (15 men, six women) who received sirolimus, six patients were prescribed sirolimus + prednisolone; seven, sirolimus + mycophenolate mofetil + prednisolone; and eight, sirolimus + cyclosporine + prednisolone. The mean age of the patients was 32.9 +/- 7.3 years and the mean posttransplantation follow-up, 13.2 +/- 4.5 months. RESULTS: Three patients experienced acute rejection episodes, which were treated successfully with steroids. None of the patients had either hematologic or wound healing problems. Lymphoceles developed in eight patients. Serum creatinine level was 1.4 +/- 0.5 mg/dL at 12 months. There was a serious increase in serum cholesterol and triglyceride levels starting from the first month posttransplant (total cholesterol levels pretransplant and at 1 month, respectively: 159.3 +/- 29.5 and 255.7 +/- 52.3 mg/dL, P = .0001; triglycerides pretransplant and at 1 month, respectively: 146.9 +/- 89.5 and 215.1 +/- 102.5 mg/dL, P = .001). Despite routine antihyperlipemic treatment those high levels were maintained for 12 months. CONCLUSIONS: We achieved 100% graft and patient survival rates for 1 year among patients who were using sirolimus. But the most important role in defining the morbidity and mortality in this group of patients is cardiovascular events; for this reason the abnormalities in the lipid profile must be taken seriously.

Kidney-pancreas transplantation: single-center experience at a university hospital in Turkey.

INTRODUCTION: One treatment option for patients with type 1 diabetes mellitus with end-stage nephropathy is combined pancreas-kidney transplantation, which can be performed either simultaneously (SPK) or following kidney transplantation (PAK). PATIENTS AND METHODS: Between February 2003 and November 2004, 14 patients, including 10 males and 4 females of overall mean age of 31.3 +/- 6.1 years (range, 23-44 years), presented with end-stage renal disease secondary to type 1 diabetes mellitus. Five patients (35.7%) received SPK; 7 patients (50%) received PAK; and 2 patients (14.3%) received simultaneous pancreas and living-related kidney (SPLK) transplantations. RESULTS: Two among 14 pancreas grafts were lost in the early postoperative period secondary to venous thrombosis despite anticoagulation including 1 with poor portal drainage. Insulin therapy was reinitiated in 1 patient after a second rejection episode in the seventh postoperative month. By the ninth median follow-up month (range, 1-21 months), all kidney grafts were functioning. CONCLUSION: Our single-center short-term experience with 14 consecutive kidney-pancreas transplantations suggests that while the pancreas transplant is effective and safe to reestablish normoglycemia, this transplant creates additional surgical and immunosuppressive stresses on the patient.