[Mechanisms influencing implantation of the embryo--the last-years' news]. / Mechanismy ovliviiující implantaci embrya--co je nového v posledních letech.

OBJECTIVE: To summarize recent knowledge concerning mechanisms which influence the implantation of embryo. DESIGN: Literature-based overview. SETTING: Institute for the Care of Mother and Child, Prague. SUBJECT OF THE STUDY: Factors influencing implantation of embryo in the uterus elicit increased interest due to study of unexplained failures of embryotransfer following the successful in vitro fertilization. Our article points to recent information about physiology and pathology of mechanisms controlling implantation, namely the factors of immunity (antibodies, cells, cytokines and other mediators) whose exact regulation on the feto-maternal interface is a crucial precondition of successful implantation. Also the genetics of early embryo, as well as the possibilities of modern endoscopic techniques offer new insight onto mechanisms of implantation. Recommendations for diagnostics and treatment of implantation failure are given in the end of the article.

[Cytomegalovirus infection in patients after kidney transplantation]. / Cytomegalovirová infekce u nemocných po transplantaci ledviny.

BACKGROUND: Cytomegalovirus disease (CMV) (active infection with various clinical and laboratory symptoms) in patients after renal transplantation (Tx) is an important diagnostic and therapeutic problem. Early CMV antigen pp65 is a structural protein of the antigenic type. It was discovered as a marker of activation of CMV infection. We decided to test the value of the method of early CMV antigen detection in the diagnosis of CMV disease in patients after renal transplantation (Tx). METHODS AND RESULTS: During a 10-month period 53 patients after Tx of the kidney were examined for the presence of early CMV antigen. Thirty-nine patients were followed up systematically, examined for the first time before Tx and then after regular one-week intervals. All patients were subjected to serological examination before Tx for the presence of antibodies against CMV, class IgG; in 41 during subsequent examinations also IgM antibodies were assessed. A method for the assessment of early CMV antigen was elaborated by cultivation of biological material in a tissue culture using monoclonal antibodies and indirect immunofluorescence. In the mentioned 53 patients a total of 363 examinations were made, mainly in blood and urine, 63 samples were positive Among the 39 patients followed up systematically early antigen was positive in 17 patients (44%). In three already before Tx. Positivity of the early antigen was first revealed on average 16 days (+/-4.2) after Tx and persisted on average for 13 days (+/-6.4). Positive early antigen was associated in the majority of patients with one or several clinical and laboratory symptoms, most frequently elevated body temperature. Comparison of early antigen and IgM anti-CMV were statistically evaluated by the chi sq. test, Fisher's test in contingency tables and by Student's non-parametric t-test. CONCLUSIONS: We assembled new experience with the method of detection of early CMV antigen in the diagnosis of activation of CMV infection. The correlation of the method with clinical and laboratory symptoms, incl. anti-CMV IGM antibodies, was statistically significant. By this method it is possible to detect CMV activation on average already on the 16th day after Tx which contributes in a significant way to the early diagnosis of the disease and facilitates the differential diagnosis of conditions during the early postoperative period.

[Kidney transplantation and tumors]. / Transplantace ledviny a nádorová onemocnení.

BACKGROUND: In conjunction with organ transplantation and subsequent treatment there is a number of influences which potentiate the development and possibly the growth of tumours. This applies naturally also to transplantations of the kidneys. The objective of the present study was to assess the frequency and type of tumours in patients after renal transplantation and compare these results with data of the at present most extensive worldwide register in Cincinnati (CTTR). METHODS AND RESULTS: The authors analyzed a group of 879 patients where within the period between March 21, 1966 and Sept. 29, 1992 a total of 989 renal transplantations were performed from dead relations-934 or from living relations (55); in 38 patients combined transplantations of kidney and pancreas were performed. The group comprised 59% men and 41% women. In the course of years the pattern of prophylactic immunosuppression changed: up to 1984 the basic drug was azathioprin combined with prednisone, during the same year cyclosporin A was introduced as a rule in a triple combination with azathioprin and prednisone; less frequent was the combination of cyclosporin A and prednisone. For antirejection treatment corticoids were used, later supplemented with polyclonal or monoclonal antibodies. During the period 1966-1992 tumourous diseases were diagnosed in 32 patients (3.64%); in two of these patients; combined transplantation of the kidney and pancreas was performed (5.3%). There was no difference in the frequency of tumours in patients with immunosuppressive medication (azathioprin with prednisone-3.80%) and cyclosporin A (3.51%). The mean age of the patients at the time of diagnosis of the tumour was 50.2 years, the interval after transplantation was 42.2 months (in patients treated with azathioprin 57 months, in the group treated with cyclosporin A 29.2 months). As far as the location of tumours is concerned, tumours of the skin predominated 25% (as compared with CTTR where it was 30%), tumours of the patient's own kidneys 21.9% and of the urinary pathways 15.6%, tumours of the gastrointestinal tract 12.5%, lymphomas in 9% (as compared with 15-20% in CTTR), tumours of the lungs 6.25% and other localizations also 6.25%. Some tumours frequently encountered in the population (lung cancer, cancer of the prostate, breast, colorectal carcinoma) are less frequent in patients after transplantation (CTTR); however, this fact was not confirmed by the authors. In renal tumours and tumours of the efferent urinary pathways data on analgetic nephropathy were encountered very frequently. CONCLUSIONS: The prevalence of tumours of various organs in patients after transplantations of the kidneys are not a frequent but a very serious complication. Its causes are multifactorial. The group after renal transplantations in the Czech Repubic has some deviations as compared with CTTR as regards affection of organs.

[Pneumocystis carinii today--40 years later]. / Pneumocystis carinii dnes--po 40 letech.

Forty years ago Czech scientists, J. Vanek and O. Jírovec, diagnosed Pneumocystis carinii as the agent of interstitial plasmocytic pneumonia in weak infants. At present it is the most frequent pulmonary pathogenic organism in patients suffering from AIDS. In the submitted paper the author summarizes experience and recent findings on the aetiopathogenesis, pathology, clinical picture, diagnosis, treatment and prevention of pneumocystis pneumonia.

[Pneumocystis carinii infection after kidney transplantation]. / Infekce pneumocystis carinii po transplantaci ledviny.

The authors demonstrate on the example of two patients after transplantation of the kidney with pneumocystis pneumonia their experience with this disease. Predisposing factors include prolonged immunosuppression, protein and energy malnutrition, chronic inflammations and large doses of methylprednisolone. In the clinical picture dominated acute dyspnoea with hypoxaemia and non-productive cough. In one patient the X-ray picture was quite atypical. The prognosis of the disease is poor, both patients died.

Pneumocystis carinii pneumonia after 40 years.

Forty years ago, Pneumocystis carinii was identified by Czech researchers J. Vanek and O. Jírovec as the causative agent of interstitial plasma cell pneumonia in infants. At present, it is the commonest pulmonary pathogen in AIDS patients. This review summarizes the experience and latest data on the etiopathogenesis, pathology, clinical presentation, diagnosis and therapy of P. carinii pneumonia.

[Treatment with antitubercular agents after kidney transplantation]. / Lécba antituberkulotiky po transplantaci ledviny.

After kidney transplantation 1-3.6% of patients develop tuberculosis. At early diagnosis and addressly applied treatment the disease is not life threatening. On the basis of the author's own experience and literary data, suitable combinations of antituberculotics are recommended. At normal or reduced function of the kidney transplant a combination of isoniazid, rifampicin, and pyrazinamide is advocated. In deranged liver function the combination of choice consists of isoniazid, streptomycin, and ethambutol. (Ref. 9).

[Lung infections after kidney transplantation. II. Diagnosis and therapy]. / Plicní infekce po transplantaci ledviny. II. Diagnóza a lécení.

In the diagnosis of pulmonary infections in patients after transplantations of the kidneys the main requirement is rapid assessment of the causal agent. This demand can be met only by collaboration of many specialists. Only when the diagnosis is established in time, the infectious process can be treated and the patient saved. An analysis of diagnostic and therapeutic procedures used in the examination of patients with pulmonary infections after transplantations of the kidneys is the subject of part II of the authors' paper.

[Lung infection after kidney transplantation. I. Etiology, pathogenesis and clinical picture]. / Plicní infekce po transplantaci ledviny. I. Etiologie, patogeneze a klinický obraz.

Pulmonary infection is a frequent and serious complication following kidney transplantation. Increased susceptibility to infection is due to a decrease in the patient's immunological response caused by immunosuppression through drug administration, and by other influences. The majority of bacterial sources are gram-negative, often hospital strains. The most important gram-positive bacterium is Staphylococcus aureus. Lung tb occurs with a 10-25 times higher frequency than in the rest of the population. Nocardial and Legionella pneumonias are no exception. Candida and Aspergillus are the most common fungus infections. They affect patients weakened by previous bacterial or virus infections. Cytomegalovirus is the most serious among the latter. The disease is usually accompanied by fever, leukopenia, thrombocytopenia and hepatitis. Pneumocystic pneumonia is characterized by a rapid progression of hypoxemia without any marked skiagraphical changes. Disseminated toxoplasmosis affects also the central nervous system simultaneously with the lungs, and the clinical picture shows a combination of interstitial pneumonia and a focal neurological finding with consciousness impairment.

[Tuberculosis after kidney transplantation]. / Onemocnení tuberkulózou po transplantaci ledviny.

The authors deal with the problem of tuberculosis in patients after transplantation of the kidney. They give an account of eight cases of the disease in 647 patients where during the last 22 years transplantations where performed in the Institute for Clinical and Experimental Medicine. The lungs were affected in six patients, incl. three with miliary dissemination affecting also other organs incl. the graft. In one instance the patient's own kidney was affected and once the talar joint. The authors emphasize this atypical course of the disease and the necessity to search for BK in patients where the febrile condition does not recede after corresponding antibiotic treatment. In case of early antituberculotic treatment the prognosis is on the whole favourable.

[Miliary tuberculosis after kidney transplantation]. / Miliární tuberkulóza po transplantaci ledviny.

The authors describe a case of tuberculosis after kidney transplantation. They discuss diagnostic and therapeutical problems arising from the specific course of this disease which appears in patients with chronic renal insufficiency treated with immunosuppressives after kidney transplantation.