Kidney Transplantation: Single-Center Experience.

OBJECTIVES: This study aims to present our cadaveric and living related donor kidney transplantation experience. METHODS: Between September 2009 to February 2015, renal transplantations were performed to 417 patients in Medicana International Ankara Hospital organ transplantation center. RESULTS: Of the patients, 231 were male, and 186 were female. Of the transplantations, 385 came from a living donor, and 32 came from a cadaver donor. The degree of kinship; 324 (77.7%) transplants were received from relatives, 5 (14.1%) with approval by the ethical committee, 32 (7.7%) from cadavers and two (0.5%) with cross-matching. Post-Operative Complications in recipients; lymphocele was found within the graft in two cases, urinary anastomosis leakage was detected in two cases, wound infection was detected in four cases, and hematoma in one case. We had no mortality in post operative or early follow up periods. CONCLUSION: The morbidity and mortality rates in our organ transplantation center, regarding renal transplantations, are consistent with the literature.

Long-Term Success with Adhesiolysis in Post-Transplant Encapsulating Peritoneal Sclerosis: A Retrospective Case Series of 4 Patients and Review of the Literature.

Encapsulating peritoneal sclerosis (EPS) is an occasional and serious complication for peritoneal dialysis (PD) patients for whom no evidence-based management strategies have yet been established. Encapsulating peritoneal sclerosis could appear after kidney transplantation in patients who previously underwent long-term PD. In this report, we present our experience in four PD patients diagnosed with EPS after kidney transplantation. Adhesiolysis provided improvement in their acute clinical conditions and allograft functions, despite the long-term follow-up. Surgical intervention may be a safe modality for this specific group of patients.

A giant left atrial myxoma neovascularized from the right coronary artery.

Myxomas are benign and the most common tumors of the cardiac muscle (Reynen, 1995). They are predominantly located in the left atrium. Clinical manifestations may vary according to the localization and the size of the myxoma. On the other hand, imaging of a myxoma by contrast dye during coronary angiography is a rare sign, which displays the vascular supply of the tumor. Here, we report the case of a 51-year-old man presenting with presyncope and palpitations due to a giant left atrial myxoma having its vascular supply from the right coronary artery (RCA).

Five right hepatic vein reconstructions using the autologous saphenous vein in the right lobe living-donor liver transplant: a case report.

In living-donor liver transplant, hepatic venous anomalies are not rare. Despite numerous techniques developed over the years, the best way of establishing a patent and durable hepatic drainage system remains controversial. We present a case where we successfully reconstructed 5 hepatic venous structures with a combination of direct anastomosis and saphenous vein interposition. Careful planning before surgery, and a customized approach for the patient on the back table, brought about successful results.

Aflatoxin exposure in viral hepatitis patients in Turkey.

BACKGROUND/AIMS: Hepatocellular carcinoma is the fifth most common cancer and a major public health problem worldwide. Differences in distribution of hepatocellular carcinoma incidence are probably due to different levels of exposure to hepatocellular carcinoma risk factors: chronic infections with hepatitis B virus (HBV) and aflatoxin exposure in developing countries, and smoking and alcohol abuse in developed countries. Aflatoxin is one of the most important of the environmental toxins that contribute to the pathogenesis of hepatocellular carcinoma, especially in the regions where dietary foodstuffs (peanuts, corn, Brazil nuts, pistachios, spices and figs) are highly contaminated. High aflatoxin levels have been shown in the foodstuffs that are produced in our country. The specific aim of this study was to assess the rate of aflatoxin exposure and to determine some clues about aflatoxin metabolism by measuring and comparing the levels of carcinogenic forms in healthy subjects, in different stages of viral disease, and in different viral hepatitis types. METHODS: This was a cross-sectional observational, single-center study. A total of 203 (male/female: 119/84) viral hepatitis patients who were consecutively admitted to Ankara University, School of Medicine, Gastroenterology Clinic, between January 2006 and June 2007 were enrolled into the study. Sixty-two healthy subjects (male/female: 33/29) with normal blood chemistry and negative viral serology served as controls. Chemical forms AFB1, AFB2, AFG1, and AFG2 were assessed in plasma of study participants by high-performance liquid chromatography. RESULTS: AFB1, AFB2, AFG1, and AFG2 were detected in 24.6%, 17.2%, 22.7%, 18.2% of the 203 patients, respectively, and were significantly higher than in the control group for all chemical forms. Percentage of AFB1-positive patients was significantly higher than in the control group irrespective of disease stage. There was no significant difference between chronic infected patients, cirrhotic patients and patients with Hepatocellular carcinoma with respect to percentage of aflatoxin-positive individuals. CONCLUSIONS: With this study, we have documented that in viral hepatitis patients, aflatoxin exposure is significantly higher than in healthy subjects in Turkey and it may play an important role in the development of hepatocellular carcinoma. Thus, large studies exploring the relation between aflatoxin exposure, viral hepatitis status, and risk of hepatocellular carcinoma development are needed.

PPAR-alpha L162V polymorphism in human hepatocellular carcinoma.

BACKGROUND/AIMS: Several lines of evidence suggest that peroxisome proliferator-activated receptor alpha may be involved in hepatocarcinogenesis. L162V polymorphism of the peroxisome proliferator-activated receptor alpha gene enhances the transactivation activity of this transcription factor. The aim of this study was to determine the frequency and clinical correlates of peroxisome proliferator-activated receptor alpha L162V polymorphism in hepatitis virus-induced hepatocellular carcinoma. METHODS: 90 hepatocellular carcinoma patients diagnosed at Ankara University Gastroenterology Clinic between January 2002 and July 2003 and 80 healthy controls with normal body mass index, blood chemistry and with negative viral serology were included. peroxisome proliferator-activated receptor alpha L162V polymorphism was determined by PCR-RFLP. RESULTS: hepatocellular carcinoma etiologies were as follows: 56 HBV, 12 HBV+HDV, 22 HCV. Eighty-seven patients (97%) were cirrhotic, and 60 patients (67.5%) had advanced tumors. In 83 (92%) of 90 hepatocellular carcinoma patients, gene segment including polymorphic region could be amplified by PCR (50 HBV, 12 HBV+HDV, 21 HCV) and 6 of them (7.2%, all infected with HBV) had L162V polymorphism, while 2 (2.5%) of 80 controls had this polymorphism (p=0.162). This trend became more remarkable when only HBV (HBV+HDV)-infected patients were compared with controls (6/62, 9.7% vs. 2/80, 2.5%, respectively, p=0.071). Five of 6 patients with L162V had advanced disease. CONCLUSIONS: Peroxisome proliferator-activated receptor alpha L162V polymorphism tends to occur in HBV-induced hepatocellular carcinoma and is absent in HCV-related hepatocellular carcinoma. These findings may show clues for the existence of different carcinogenesis mechanisms in these two common etiologies. Frequent occurrence of advanced disease in patients with L162V polymorphism suggests a role for this polymorphism in tumor progression.

The fate of recipient-derived hepatocytes in sex-mismatched liver allograft following liver transplantation.

BACKGROUND: ''Bone marrow-derived stem cells'' have attracted great attention as potential candidates for liver-directed gene therapy and as a tool for regenerative medicine. However, the fate of these cells is not well-known. The aim of this present study was to investigate the fate of ''recipient-derived repopulated hepatocytes'' in sex-mismatched liver allografts in individuals following liver transplantation during systematic longitudinally performed liver biopsies. METHODS: Paraffin-embedded sex-mismatched liver biopsy samples of nine recipients (male/female ratio 5/4; mean age: 39.7 yr) were reviewed. Double labeling with immunohistochemistry for hepatocytes and recipient-specific bone marrow-derived cells and fluorescence in-situ hybridization for visualizing X and Y chromosomes were performed. These slides were examined systematically using an image analyzer system (Olympus microscope; Cyto-Vision, Applied Imaging, Biosciences Centre, Newcastle, UK). Only cells with two nuclear spots were considered for interpretation. RESULTS: The mean times from transplantation to first biopsy and between the first and the second biopsies were 5.9 and 20.9 months respectively. The proportion of recipient-derived repopulated hepatocytes was significantly decreased in the late biopsies when compared with the early biopsies (p = 0.001). All nine samples of the first biopsies had demonstrated recipient-derived hepatocyte repopulation, with a mean of 2.0%, whereas only seven of nine samples of the second biopsies had demonstrated recipient-derived hepatocyte repopulation with a low mean of 0.5% (p = 0.001). CONCLUSION: Based on these results, we suggest that ''recipient-specific bone marrow-derived hepatocyte repopulation'' in liver allograft during tissue injury is a relatively early event.

Antituberculous therapy-induced fulminant hepatic failure: successful treatment with liver transplantation and nonstandard antituberculous therapy.

Standard antituberculous therapy including isoniazid, rifampin, ethambutol, and pyrazinamide is widely used for the treatment of active tuberculosis. Its most important side effect is hepatotoxicity, ranging from asymptomatic transaminitis to fulminant hepatic failure. A 19-year-old woman was admitted to our unit due to jaundice and unconsciousness. According to her past medical history, she was diagnosed as having extrapulmonary tuberculosis and had been prescribed standard antituberculous therapy. The patient became icteric and unconscious on the fourth day after therapy initiation. She was diagnosed with drug-induced acute fulminant hepatic failure and underwent living-related liver transplantation. Nonhepatotoxic antituberculous therapy (cycloserine, ciprofloxacin, streptomycin, and ethambutol) and low-dose immunosuppressive therapy were started after transplantation. Currently the patient is very well with normal graft function 42 months after transplantation. Here we report a case of a patient with acute fulminant hepatic failure caused by isoniazid, rifampicin, or both, who was successfully treated with living-related liver transplantation and a relatively less hepatotoxic antituberculous therapy. In conclusion, liver transplantation is a feasible therapy for individuals with standard antituberculous therapy-induced hepatic failure. Nonhepatotoxic antituberculous therapy may achieve control of active tuberculosis in such individuals after transplantation.

Multislice CT angiography in the evaluation of hepatic vascular anatomy in potential right lobe donors.

PURPOSE: To assess the role of multislice CT angiography in the evaluation of arterial, hepatic and portal venous variations in potential right lobe donors. MATERIALS AND METHODS: Fifty-two potential liver donors (28 females, 24 males), underwent CT angiography in the arterial and portal venous phases with an eight-row CT scanner. Two- and three-dimensional images were obtained from 1.25-mm-thick axial images with multiplanar reformatting, maximum intensity projection and volume rendering techniques. Both axial and two- and threedimensional images were evaluated for possible variants of hepatic vasculature. In twelve operated patients, CT angiography results were compared with the results of surgery. RESULTS: Of 52 patients, 40 had type I, five type III, two type II, three type IX, and two type V hepatic arterial anatomy. In 13 patients (25%), segment IV artery originated from the right hepatic artery. In 26 patients (50%), veins that drained segment V and/or VIII to the middle hepatic vein were larger than 5 mm. Twenty-five patients (48%) had 28 accessory hepatic veins larger than 3 mm; 23 of these drained to the inferior vena cava more than 4 cm caudal to the right hepatic vein-vena cava junction. Three patients (6%) had trifurcation and one patient (2%) had quadrifurcation of the main portal vein. In two patients (4%), the right posterior portal vein arose directly from the main portal vein before its bifurcation. CT angiography findings showed one-to-one correlation with surgery in the 12 operated patients. CONCLUSION: Multislice CT angiography can successfully show the relevant hepatic vascular variations in potential liver donors.

Recipient-derived hepatocytes in sex-mismatched liver allografts after liver transplantation: early versus late transplant biopsies.

BACKGROUND: The presence of microchimerism in transplanted tissues is well defined; however, the timeframe of appearance and disappearance of engraftment in liver allograft is unknown. The aims of this study were to analyze for the presence of "recipient-derived cells" in sex-mismatched individuals after liver transplantation, comparing the frequency of "recipient-derived cell repopulation" in early versus late transplant biopsies and to evaluate the relationship between "recipient-derived cell repopulation" and the severity of graft injury. METHODS: Paraffin-embedded liver biopsy samples of 18 recipients were reviewed. Sixteen of them were obtained from recipients with sex-mismatched donors. The remaining two were obtained from recipients with sex-matched donors and were used as controls. Immunohistochemistry and fluorescence in situ hybridization double-labeling method were performed on pretreated slides using anti-human hepatocyte antibody to identify hepatocytes, a mouse anti-human cytokeratin-7 to identify ductal epithelial cells, and using CEPX/Y DNA probes for visualizing X and Y chromosomes. The double-labeled slides were examined systematically using an image analyzer system. RESULTS: The mean time from transplantation to biopsy was 8.1 months. Eleven of the 16 samples obtained from recipients with sex-mismatched grafts demonstrated "recipient-derived hepatocyte repopulation," comprising a mean of 2.1% of the hepatocytes. In the control biopsies, none of the cells demonstrated different nuclear signals from the donor's sex origin. The presence and proportion of "recipient-derived hepatocyte repopulation" rate were significantly higher in early transplant biopsies than in late transplant biopsies (P < 0.05). CONCLUSION: Some hepatocytes of sex-mismatched liver grafts were replaced by "recipient-derived cells" during injury. Such repopulation is more common in the early liver-graft biopsies. The severity of acute cellular rejection appears to have no effect on the rate of recipient-derived repopulation.

Hepatic artery aneurysm.

Hepatic artery aneurysms are rare. It is also very uncommon to diagnose a hepatic artery aneurysm prior to rupture. We report a 53-year-old woman who presented with symptoms of gallstones, and was later diagnosed as having hepatic artery aneurysm. Abdominal ultrasound and computed tomography showed two cystic lesions located at the hepatoduodenal ligament. Color Doppler and arteriography identified two aneurysms situated at the common hepatic artery and at the bifurcation of gastroduodenal artery, respectively. A saphenous vein graft was interposed between the origin of the common hepatic artery and the bifurcation of the right and left hepatic arteries. The postoperative course was uneventful and the patient was discharged on the seventh postoperative day.

Hemodynamic effect of transdermal glyceryl trinitrate on newly constructed arteriovenous fistula.

Transdermal glyceryl trinitrate (GTN) administration may have a beneficial effect in the creation of an arteriovenous fistula (AVF) by increasing blood flow through the access and by inhibiting platelet aggregation. We evaluated the hemodynamic effects of transdermal GTN administration on newly constructed arteriovenous fistula. Radiocephalic fistula at the wrist (Brescia fistula) was constructed as the initial vascular access in 31 uremia patients (study = 16, control = 15). The patient demographics and the etiology of chronic renal disease were similar in the two groups. None of the patients had severe vasculitis. The mean duration of chronic renal disease was 8 months (1-24 months). The diameter, blood flow rate, and blood output at the drainage vein and the subclavian vein were measured by duplex ultrasonography 24 hours after the procedure. The measurements were performed again with transdermal GTN (10 mg/24 hours adhesive patch) administration in the study group and, without any medication, in the control group 4 hours after the initial measurements were taken. In the study group, all of the hemodynamic parameters were significantly increased over the initial measurements (p <0.05) whereas in the control group all hemodynamic parameters were unchanged, except the diameter of the subclavian vein (p <0.05). The actual change in hemodynamic parameters was significant in the study group when compared to the control group (p <0.05). Our data showed that transdermal GTN administration at the forearm increases flow through the Brescia fistula.