Predisposing risk factors for isolated bile leakage after pancreaticoduodenectomy.

AIM: Isolated bile leakage (IBL) from hepaticojejunostomy, following pancreaticoduodenectomy, is a serious complication that increases morbidity and mortality. We aimed to assess the frequency of IBL development after pancreaticoduodenectomy and its underlying factors. MATERIALS AND METHODS: Patients who underwent pancreaticoduodenectomy for pancreatic diseases between January 2005 and January 2016 were retrospectively evaluated. Patients were dichotomized according to those with and without postoperative IBL. RESULTS: In the 111 patients who underwent pancreaticoduodenectomy during our study period, 8 patients (7.2%; 5 men/3 women) developed IBL. Risk of IBL development was significantly elevated among male patients, those with preoperative serum albumin < 3.5 g/dL, and those with previous cholangitis (P < 0.05). DISCUSSION: Male sex, preoperatively low levels of serum albumin, and preoperative history of cholangitis can be listed as risk factors for IBL development. Physicians should pay attention to the risk of postoperative IBL development in such patients. KEY WORDS: Isolated bile leakage, Pancreaticoduodenectomy, Morbidity.

Is laparoscopic surgery safe and feasible in acute adhesive ileus?

Although the classical surgical treatment of adhesive ileus is performed using the open method, laparoscopic surgery has recently been performed in some centers. This study aimed to discuss the feasibility and role of laparoscopic surgery in the treatment of adhesive small bowel obstruction. In this retrospective study, the data of 830 patients who were operated for ileus in Baskent University Faculty of Medicine, Ankara Hospital, Department of General Surgery between January 2011 and September 2022 were analyzed. Missing data and intraabdominal cancer-related ileus were accepted as exclusion criteria and 648 patients were excluded from the study. The development of adhesion-related ileus and completeness of the data were accepted as inclusion criteria. Data were compared between the 2 groups [open group (OG; 152 cases) and laparoscopic group (LG; 30 cases]). When the patient characteristics were evaluated, it was found that the history of previous abdominal surgery (P < .001) and the number of previous abdominal surgery (P < .001) were statistically significantly higher in OG. Operation time was significantly longer in the LG (P = .022). There were no statistically significant differences between the groups in terms of intraoperative bowel injury (P = .216), bowel resection (P = .284), and stoma creation (P = .331). OG had a significantly higher rate of Clavien-Dindo grade ≥ 3 serious complications (P < .001) and mortality rate (P = .045). The first gas out occurred significantly earlier in the LG (P = .014). Oral intake was initiated earlier in the LG (P = .004). The length of hospital stay was significantly shorter in the LG (P < .001). There was no significant difference between the groups in terms of postoperative ileus, readmission, and reoperation. Laparoscopic surgery can be safely performed for the treatment of selected patients with adhesive small bowel obstruction. In addition, it is advantageous in terms of postoperative recovery.

Long-term effect of eplerenone treatment in children with chronic allograft nephropathy.

BACKGROUND: Literature supports the protective role of mineralocorticoid antagonist (MRA) against the renal injury induced by aldosterone in kidney transplant recipients. However, there is limited data available regarding the safety and efficacy of MRAs in pediatric renal transplant patients. Therefore, we aimed to investigate the effect of long-term eplerenone administration in children with chronic allograft nephropathy (CAN). METHODS: Twenty-six renal transplant children with biopsy-proven CAN, an estimated glomerular filtration rate (eGFR ) > 40 mL/min per 1.73 m2 and with a significant proteinuria were included. Selected patients were randomly divided into two groups as follows; Group 1 (n = 10) patients received 25 mg/day eplerenone and Group 2 (n = 16) patients did not receive eplerenone for 36 months. Patients were examined in the renal transplant outpatient clinic biweekly for the first month and once a month thereafter. The primary outcome of the patients was compared. RESULTS: Mean eGFR stayed stable in group 1 patients, but significantly decreased in group 2 at 36 months (57.53 ± 7.53 vs. 44.94 ± 8.04 mL/min per 1.73 m2 , p = .001). Similarly, spot protein-creatinine ratio was significantly lower in group 1 compared to group 2 patients at 36 months (1.02 ± 7.53 vs. 3.61 ± 0.53, p < .001). Eplerenone associated hyperkalemia was not observed in group 1 patients (4.6 ± 0.2 vs. 4.56 ± 0.3, p = .713). CONCLUSION: The long-term eplerenone administration blunted the chronic allograft nephropathy by maintaining a stable eGFR levels and decreasing urine protein-creatinine ratio. Eplerenone associated hyperkalemia was not observed in our study.

Platelet-to-Lymphocyte Ratio as a Potential Indicator of Infection-Associated Emergency Visits of Renal Transplant Recipients.

OBJECTIVES: Infection-associated emergency department use in renal transplant recipients has been increasing as solid-organ transplant has become a more common treatment method for chronic kidney failure. Platelet-to-lymphocyte ratio has been demonstrated to be significantly elevated in nosocomial infections in patients treated at intensive care units and is positively correlated with duration of hospital stay. In this study, we aimed to determine whether the platelet-to-lymphocyte ratio could be used as an indicator of infection in renal transplant patients presenting to emergency departments. MATERIALS AND METHODS: This case-control retrospective study included data from between May 2015 and February 2018. We used the patient information management system to review patient medical records and laboratory test results of study participants. RESULTS: Our study included 156 adults in the patient group (recipients with infection) and 170 adults in the control group (recipients without infection). We observed significant differences between patient and control groups in terms of the number of days of hospital stay; leukocyte, neutrophil, and lymphocyte counts; the platelet-to-lymphocyte ratio; and C-reactive protein levels. We plotted receiver operating characteristic curves to determine the sensitivity and specificity of the platelet-to-lymphocyte ratio along with C-reactive protein. The areas under the curve were 0.892 for C-reactive protein and 0.707 for the platelet-to-lymphocyte ratio. CONCLUSIONS: For systemic inflammation, platelet-to-lymphocyte ratio can be used in conjunction with other biomarkers as an indicator of inflammation in renal transplant recipients who present with infection-associated causes to emergency departments.

Living and Deceased Liver Donation Criteria of Baskent University.

OBJECTIVES: Both living and deceased donor transplants require appropriate donor selection to increase the success of liver transplants. Proper deceased donor criteria will also increase the use of discarded and marginal donor livers. Here, we evaluated the Baskent University deceased and living donor criteria. MATERIALS AND METHODS: Since 1988, our team has performed 704 liver transplants (490 from living [69.6&] and 214 from deceased [30.4&] donors) at our 3 transplant centers (Ankara, Adana, Istanbul). RESULTS: Living donor evaluations follow from simple and noninvasive tests to more complex and invasive, including liver biopsy, with social and medical evaluations being the most important. Living donor candidates must be relatives of the recipient (up to 4th degree) or the spouse of the recipient, and candidates must be ≥18 years old, with no health problems. Candidates undergo computed tomography to assess arterial and venous anatomy, to estimate total and remnant liver volume, and to detect any abnormalities. If graft-to-recipient weight ratio is >1 and remnant liver volume is ≥40% of total liver volume, then the candidate is accepted for further evaluation. All living donor candidates undergo liver biopsy. Age is not important for deceased donor candidates, but biopsy is the most important criterion in deceased donor selection. After histopathological examination, both living and deceased donor candidates are rejected if they have chronic hepatitis, cirrhosis, severe hepatocellular injury, diffuse hepatocellular ballooning, or moderate-to-severe macrovesicular fatty changes >20%. Additional refusal criteria for deceased donors are hypernatremia, sepsis, extracranial malignancy, and high-dose vasopressor support. CONCLUSIONS: A deceased donor is the first choice in organ transplant. Proper evaluations can decrease discard rates of deceased organs. Living donor liver transplants should be performed only at well-established centers with surgical teams who have appropriate medical expertise and adequate institutional resources. To reduce complications and provide adequately functional grafts, careful donor evaluation is imperative.

Association Between Vitamin D Deficiency and Anemia in Pediatric Kidney Transplant Recipients.

OBJECTIVES: The association between vitamin D deficiency and anemia is known. Vitamin D deficiency and anemia are common in kidney transplant recipients. We examined the relationship between vitamin D levels and anemia in pediatric kidney transplant recipients. MATERIALS AND METHODS: We reviewed retrospectively the data of 75 pediatric kidney transplant recipients (0-18 years of age). Patients were evaluated in 3 groups according to serum 25-hydroxyvitamin D levels (<20, 20-30, and >30 ng/mL) in the first year posttransplant: group 1 was the vitamin D deficiency group, group 2 was the vitamin D insufficiency group, and group 3 was normal vitamin D level group, respectively. Groups were compared in terms of anemia parameters, calcium, phosphorus, alkaline phosphatase, and parathyroid hormone levels, as well as infection, rejection, and graft loss status. All patients included in the study were grouped as those with anemia and without anemia, and the 2 groups were compared in terms of vitamin D levels, serum parathyroid hormone values, estimated glomerular filtration rate, and infection, rejection, and graft loss status. RESULTS: There were 41 patients (54.7%) in group 1, 24 patients (32%) in group 2, and 10 patients (13%) in group 3. There were 65 patients (86.7%) with vitamin D deficiency/insufficiency. When groups were compared, the hematocrit level was found to be lower in groups 1 and 2 (P < .05) and ferritin level was found to be lower in group 1 (P < .05). Anemia was present in 20 patients (26.6%): 61% of patients with anemia had vitamin D deficiency and 33% had vitamin D insufficiency (P > .05). In total, 94% of patients with anemia had vitamin D deficiency/insufficiency. CONCLUSIONS: Vitamin D deficiency/insufficiency is common in pediatric kidney transplant recipients. Vitamin D levels should be measured, especially in all kidney transplant recipients with persistent anemia. Thus, risk factors associated anemia can be reduced by treating the deficiency/insufficiency.

An Alternative Abdominal Closure Technique After Pediatric Liver Transplant: Bogota Bag Technique.

OBJECTIVES: In conditions such as large-for-size syndrome, postreperfusion hepatic edema, and intestinal edema, primary closure of the abdominal wall can cause respiratory complications and thrombosis of vascular structures. Here, we compared results of primary abdominal closure versus a temporary patch closure technique (the Bogota bag technique) in pediatric liver transplant recipients. MATERIALS AND METHODS: We performed primary abdominal closure in 295 recipients. In 39 pediatric liver transplant recipients, the Bogota bag technique was used as the abdominal closure technique because of suspected intraoperative tense abdominal closure. In patients who had the Bogota bag technique, we sutured the sterilized saline bag to the skin at the edge of the defect by shaping the defect so as not to cause abdominal hypertension. Primary abdominal closure was achieved in patients after control laparotomies at 48-hour intervals. RESULTS: The mean age of the primary abdominal closure group was 8.38 years, whereas the mean age of the Bogota bag group was 2 years. The average weight of patients in the primary abdominal closure group was 26.38 kg, and the average weight of patients in the Bogota bag group was 7.93 kg. Biliary atresia was the most common indication in both groups. Mean length of hospital stay was 21 days in the primary abdominal closure group and 24 days in Bogota bag group. Six patients in the Bogota bag group died from sepsis or bleeding in the early postoperative period. In the Bogota bag group, wound closure was achieved within 2 weeks in 25 patients and within 3 weeks in 8 patients. CONCLUSIONS: Temporary patch closure techniques can be used safely in low-weight and young children, children with large-for-size grafts, and those who display increased intra-abdominal pressure.

Use of Eculizumab in Pediatric Patients with Late Antibody-Mediated Rejection After Kidney Transplantation.

Late antibody-mediated rejection triggered by donor-specific antibodies is a leading cause of kidney allograft failure. Effective treatment options for late antibody-mediated rejection are limited in renal transplant recipients. Here, we report 2 pediatric cases of severe late antibody-mediated rejection resistant to conventional immunosuppressive therapy who were successfully treated with eculizumab. Two patients who fulfilled the late antibody-mediated rejection diagnostic criteria (positive donor-specific antibodies, elevated mean fluorescence index, acute and/or chronic morphological lesions in the microvasculature, and abnormal kidney function test) were included in this study. Both patients were previously unsensitized with negative panel-reactive antibody. Case 1 was a 12-year-old male patient with kidney failure secondary to vesicoureteral reflux who underwent related-living donor kidney transplantation 2 years ago. Eleven months later, he was diagnosed with late antibody-mediated rejection. Despite an aggressive conventional immunosuppressive regimen, signs of rejection persisted. After the patient was treated with 2 doses of eculizumab, his mean fluorescence index dropped and serum creatinine decreased from 3.8 to 1.5 mg/dL. Case 2 was an unsensitized 16-year-old male patient with kidney failure secondary posterior urethral valve who underwent related-living donor kidney transplantation 4 years ago. Two years later, he was diagnosed with late antibody-mediated rejection. Despite an aggressive conventional immunosuppressive regimen, signs of rejection persisted. After treatment with 2 doses of eculizumab, his mean fluorescence index dropped and serum creatinine decreased from 2.1 to 1.01 mg/dL. In both patients, eculizumab therapy effectively reduced the markers of late antibody-mediated rejection and improved the kidney function.

Vascular Complications in Pediatric Liver Transplants and Their Management.

OBJECTIVES: The blood supply of the liver occurs through the hepatic artery and portal vein. Outflow of blood circulation in the liver is via the hepatic veins. Any disruption in this blood circulation results in deterioration of liver functions. In this study, we evaluated early vascular complications in pediatric liver transplant recipients seen at our center. MATERIALS AND METHODS: From November 1988 to December 2021, our team has performed 701 liver transplant procedures, which have included 334 pediatric liver transplants. Among these pediatric liver transplant recipients (mean age of 7.34 y), 176 were male patients. Nineteen patients (5.7%) were recipients of deceased donors. Reason for liver failure was mainly biliary atresia (n = 169). Mean weight of recipients was 23.3 kg. Most graft types were left lateral grafts (n = 204). RESULTS: Three patients had hepatic vein complications. All 3 patients were successfully treated with interventional radiological methods by placing a stent in the anastomosis region. Portal vein complications occurred in 3 patients. One patient had hemostasis performed surgically. The second patient had surgically revision of the anastomosis because of thrombus formation. Because of stenosis of more than 50% in the portal vein anastomosis, the third patient required stent placement in the anastomosis region. Hepatic artery complications occurred in 54 patients: 31 patients had hepatic artery thrombosis, 13 patients had hepatic artery stenosis, 7 patients had bleeding from hepatic artery anastomosis, 2 patients had hepatic artery dissection, and 1 patient had pseudoaneurysm in the hepatic artery. Forty-three of these patients were successfully treated with interventional radiological methods and 11 required surgical treatment. CONCLUSIONS: Vascular complications after liver transplant can cause deterioration in hepatic functions and acute liver failure. Vascular complications can be successfully treated in experienced organ transplant centers.

Our Pediatric Liver and Kidney Transplant Activities in 2021.

OBJECTIVES: In children with end-stage renal disease, chronic liver failure, or acute liver failure, liver transplant and kidney transplant are the most effective modalities for better clinical outcomes compared with other therapies. However, children are particularly susceptible to surgical complications, so pediatric solid-organ transplants should be reserved for centers with substantial experience and multidisciplinary expertise. Here, we assessed liver and kidney transplants performed at our center in 2021. MATERIALS AND METHODS: From November 3, 1975, to December 31, 2021, we performed 701 liver transplants and 3290 kidney transplants. From January 1, 2021, to December 31, 2021, we performed 21 liver transplants (19 in children) and 114 kidney transplants (12 in children). We recorded age, sex, body mass index, comorbidities, etiologies, laboratory values, and clinical outcomes. RESULTS: For the year 2021, we performed 19 pediatric liver transplants and 12 pediatric kidney transplants. Mean age of liver recipients was 3.4 years, and 8 were male patients. The most common etiology was biliary atresia (n = 7). All liver grafts were from living related donors who were first-degree (n = 16) or second- degree (n = 3) relatives of the recipients. Mean hospital stay was 17.6 days. All but 2 liver transplant recipients were discharged successfully (2 died from sepsis in the early postoperative period). Mean age of kidney transplant recipients was 14.1 years, and 4 were male patients. The most common etiology was vesicoureteral reflux (n = 3). One kidney graft was from a deceased donor, with the rest from living related donors who were first-degree relatives of the recipients (n = 11; mother for 8 recipients and father for 3 recipients). Mean hospital stay was 4.3 days. All kidney transplant recipients were discharged successfully. CONCLUSIONS: Solid-organ transplants for young children are often complex but can be performed successfully at experienced transplant centers.

BK Polyomavirus Infection and Risk Factors in Pediatric Patients Undergoing Kidney Transplant.

OBJECTIVES: BK polyomavirus infection is a critical complication affecting graft survival after kidney transplant. We aimed to determine the frequency, the effect on graft function, and the risk factors of BK polyomavirus infection in pediatric kidney transplant patients. MATERIALS AND METHODS: We retrospectively reviewed data of 144 pediatric patients (female/male: 67/77; 0-18 years of age) who received kidney transplants in the past 10 years at our center. Demographic/ laboratory data, kidney failure etiologies, donor types, and immunosuppressive treatments were recorded. Patients were grouped as those with and without BKV infection, with groups compared in terms of transplant age, sex, kidney failure etiology, donor type, immunosuppressive treatments, presence of ureteral stents, acute rejection episodes, accompanying viral infections, glomerular filtration rate, and graft loss rate. RESULTS: Twelve patients (8.3%) had BK polyomavirus infection. All 12 patients had viruria (8.3%), 8 (5.5%) had viremia, and 4 (2.8%) had BK polyomavirus nephropathy. Two patients (1.4%) had graft loss because of BK polyomavirus nephropathy. When patients with and without infection were compared, no significant differences were found in terms of sex, transplant age, donor type, presence of a ureteral stent, acute rejection, graft loss, or immunosuppressive treatment (P > .05). Rates of congenital anomalies of the kidney and urinary tract were 30.3% and 66.6% in those without and with BK polyomavirus infection, respectively (P < .05). The group positive for BK polyomavirus had a significantly higher incidence of cytomegalovirus infection versus the group without infection (P < .05). Glomerular filtration rate values at years 1 and 3 were similar between groups (P > .05). CONCLUSIONS: Frequency of BK polyomavirus nephropathy in pediatric patients undergoing kidney transplant in our center was consistent with data from other centers. Graft loss can be prevented by early detection and treatment through close periodic control and adequate evaluation of risk factors.

The Role of Platelet-Lymphocyte Ratio and Neutrophil-Lymphocyte Ratio in Predicting the Delayed Graft Function in Pediatric Renal Transplant Patients.

OBJECTIVES: Delayed graft function is a common adverse outcome after renal transplant. Attempts for early prediction and prevention of delayed graft function are often challenging and misleading. Herein, we investigated for the first time the correlation between delayed graft function and preoperative noninvasive hematologic parameters to predict the possible adverse outcomes for renal transplant in pediatric patients. MATERIALS AND METHODS: In this study, preoperative hematologic parameters of 51 pediatric renal transplant recipients followed between 2015 and 2021 were analyzed retrospectively. The selected 16 renal transplant patients with delayed graft function and 35 patients without delayed graft function had no concomitant comorbidities. The cutoff values for platelet-to-lymphocyte ratio of <5 and neutrophilto- lymphocyte ratio of <175 were considered low. RESULTS: We retrospectively evaluated a total of 51 (male/female, 33/18) pediatric kidney transplant recipients with a median age of 12 (interquartile range, 8-18) years. Median level of circulating lymphocytes was significantly higher in patients with delayed graft function compared with patients without delayed graft function (2 vs 1, P = .040). The preoperative low values for platelet-to-lymphocyte ratio and neutrophil-to-lymphocyte ratio were more prevalent in recipients who developed delayed graft function versus those who did not develop delayed graft function (68.8% vs 31.4% [P = .014] and 68.8% vs 34.3% [P = .023], respectively). CONCLUSIONS: Pretransplant low platelet-to-lymphocyte ratio and neutrophil-to-lymphocyte were associated with increased number of delayed graft dysfunction. These novels and noninvasive inflammatory biomarkers may contribute to an early prediction of delayed graft function in pediatric kidney transplant recipients.

Long-Term Outcomes of Kidney Transplant Recipients With Juvenile Nephronophthisis.

OBJECTIVES: Nephronophthisis is the most common genetic cause of kidney failure in childhood. Treatment for nephronophthisis is symptomatic, and kidney transplant is a good treatment option when kidney failure has developed. We reported the outcomes of kidney transplant recipients with primary diagnosis of juvenile nephronophthisis who were followed-up in our center. MATERIALS AND METHODS: We retrospectively examined medical records of 17 kidney transplant patients with a primary diagnosis of juvenile nephronophthisis. We compared this group of 17 patients with kidney transplant recipients who had other etiologies of kidney failure in terms of transplant age, donor type, immunosuppressive treatment, acute rejection, graft loss rates, and glomerular filtration rates at 1 and 5 years posttransplant (N = 180 total analyzed). RESULTS: Among 180 kidney transplant recipients, the 17 patients (9.4%) with nephronophthisis had a mean age of 12.6 ± 4.3 years and mean follow-up time posttransplant of 79.5 ± 41.9 months. Five of 17 patients received a kidney transplant from a deceased donor (29.4%), and the remaining 12 patients (70.6%) received transplants from living related donors. Preemptive kidney transplant was performed in 4 patients (23.5%). There was a statistically significant difference (P < .05) in terms of acute rejection between patients with nephronophthisis (17.6%) versus patients with other primary diagnoses (34%). However, the patients with nephronophthisis versus those with other primary diagnoses were similar (P > .05) in terms of transplant age (12.6 ± 4.3 vs 13.8 ± 6.7 years, respectively) and follow-up time (79.5 ± 41.9 vs 59.1 ± 38.8 months, respectively). Donor type, immunosuppressive treatment, and 1-year (96.7 ± 23.2 vs 97.6 ± 28.4 mL/min/1.73 m2) and 5-year (84.7 ± 31.1 vs 86.7 ± 21.7 mL/min/1.73 m2) glomerular filtration rates were also similar (P > .05) between groups. CONCLUSIONS: Posttransplant prognosis was good among kidney transplant recipients with juvenile nephronophthisis.

Liver Transplant Recipients Who Survive for More Than 10 Years: A Long-Term Survey.

OBJECTIVES: Liver transplant is the gold standard treatment for end-stage liver failure. Short-term and midterm surveys have been published, but there are few long-term surveys. Here, we report the outcomes of our long-term liver transplant survivors. MATERIALS AND METHODS: Since 1988, we have performed 694 liver transplants (366 adult, 328 pediatric), including the first deceased donor transplant in Turkey (December 8, 1988); the first pediatric segmental living related transplant in Turkey, the Middle and Near East, and Europe; the world's first adult segmental living related transplant (April 24, 1990); and the world's first living related donor combined liver-kidney transplant (May 16, 1992). We retrospectively evaluated data from recipients who survived >10 years with normal graft function. RESULTS: Of 215 recipients, survival ranges were ≥20 years (n = 13), 15 to 19 years (n = 86), and 10 to 14 years (n = 116); 211 remain alive today with normal liver function. There were 5 retransplants to treat chronic graft rejection, of which 4 recipients are alive with normal graft function after a second liver transplant (15, 20, 22, and 31 years after first transplant). One patient died soon after the second liver transplant (15 years after first transplant). Acute rejection episodes were seen in 72 (34%), and 7 were steroid resistant. There were 48 (22.7%) drug-induced complications. Ten patients had de novo malignancy: 5 lymphoma, 2 squamous cell carcinoma, 1 gastrointestinal stromal tumor, 1 thyroid papillary carcinoma, and 1 multiple myeloma. There were also 31 patients with hepatocellular carcinoma before liver transplant: 13 were beyond Milan criteria, 6 had incidental HCC, and 12 were within Milan. CONCLUSIONS: Long-term survival after liver transplant is possible with expert care. Few reports have mentioned long-term surveys; our long-term liver transplant survey is among the largest series in the literature.

Clinical Outcomes of Liver Transplantation for Patients Over 60 Years Old: A Single-Center Experience.

OBJECTIVES: Although advanced age is no longer considered an absolute contraindication for liver transplant, transplant in elderly patients with comorbid diseases remains debatable because of high risks with surgery. Here, we report patient outcomes in this population. MATERIALS AND METHODS: We retrospectively reviewed medical records of 276 liver transplant recipients, grouped by age. Group 1 (≤59 years old) consisted of 247 recipients, and group 2 (≥60 years old) consisted of 29 recipients. Reviewed data included age, sex, cause of liver disease, presence of hepatocellular carcinoma, Child-Pugh and Model for End-Stage Liver Disease scores, survival, and posttransplant complications. RESULTS: In both groups, most patients (n = 108) required liver transplant for hepatitis B virus. Mean age was 40 ± 12.3 and 63 ± 2.3 years in groups 1 and 2, respectively, with more men than women in both group 1 (71.7% vs 28.3%) and group 2 (75.9% vs 24.1%). No significant differences were shown between groups for patient characteristics, except group 1 had significantly higher Model for End-Stage Liver Disease score. Group 1 mean survival time was 10.2 ± 0.6 years, with patient survival rates at 1, 5, 10, and 15 years of 65.5%, 53%, 46.3%, and 40%, respectively. In group 2, respective results were 10.6 ± 1.3 years and 75.9%, 68.6%, 61%, and 48.8% (no significant difference vs group 1). CONCLUSIONS: Liver transplant recipients >60 years of age had survival rates, acute rejection rates, and complications similar to younger recipients. Liver transplant should not be withheld from older recipients on the basis of age alone. However, comprehensive screening for comorbidities should be performed.

Primary Focal Segmental Glomerulosclerosis Recurrence After Pediatric Renal Transplantation.

OBJECTIVES: Focal segmental glomerulosclerosis recurrence after renal transplant occurs frequently in pediatric patients and is associated with poor graft survival when patients reach adulthood. We investigated recurrence rates, recurrence risk factors, management strategies, and long-term graft function among pediatric renal transplant recipients with focal segmental glomerulosclerosis as primary disease. MATERIALS AND METHODS: We retrospectively evaluated medical records of 34 pediatric patients with primary focal segmental glomerulosclerosis who had undergone renal transplant between 2004 and 2019 at our center. Focal segmental glomerulosclerosis recurrence was diagnosed by the presence of nephrotic range proteinuria after transplant and confirmed by graft biopsy. Preoperative prophylactic plasma exchange was administered to pediatric renal transplant recipients with primary focal segmental glomerulosclerosis. Plasma exchange was also used to treat focal segmental glomerulosclerosis recurrence, with rituximab added if the patient did not respond to plasma exchange. RESULTS: All patients (male-to-female ratio of 19:15) in our group underwent renal transplant. Mean patient age at the time of transplant was 12.72 ± 5.46 years. Twenty-nine patients received living- related donor allografts (85.3%) and 5 received organs from deceased donors (14.7%). We identified focal segmental glomerulosclerosis recurrence in 5 recipients (14.7%). Time from focal segmental glomerulosclerosis diagnosis to end-stage renal disease and duration of dialysis were shorter in the recurrence group than in the nonrecurrence group (48.4 months [range, 2-90 mo] vs 65.1 months [range, 8-123 mo] and 1.41 ± 0.82 vs 3.18 ± 1.88 years, respectively; P < .05). Donor type and transplant age were similar in both groups. Of those with recurrence who had received plasma exchange and rituximab, 3 patients (75%) had complete remission and 1 patient (25%) had partial remission. CONCLUSIONS: Prophylactic plasma exchange and the combined plasma exchange-rituximab regimen for treatment of focal segmental glomerulosclerosis recurrence resulted in low recurrence and good remission rates in our pediatric cohort.

Relation of Anxiety, Depression, and Behavioral Problems With Time Allocated to Television, Computer, and Smartphone in Children Receiving Renal Replacement Therapy.

OBJECTIVES: Children and adolescents with chronic diseases have more screen exposure time compared with their healthy peers. In this study, we investigated screen exposure time of children who received renal replacement therapy, which included kidney transplant and dialysis treatment, versus a healthy control group. MATERIALS AND METHODS: Our study included 55 children and adolescents between the ages of 8 and 18 years. Although 28 participants did not have any chronic disease, 27 had chronic diseases and received renal replacement therapy. Among these patients, 17 had kidney transplant and 10 were receiving dialysis. A sociodemographic information form and the Conners Short-Form Parent Rating Scale were given to parents. Pediatric and adolescent patients completed the Children's Depression Inventory and Spielberger State-Trait Anxiety Scale-2. We analyzed differences between the groups with and without renal replacement therapy and examined relations between continuous variables. RESULTS: Duration of television screen time was significantly higher in children and adolescents receiving renal replacement therapy. Patients in the renal replacement therapy group showed a positive correlation between the Conners Short-Form Parent Rating Scale anxiety subscores and duration of smartphone use. In the kidney transplant recipient group, smartphone and computer durations were positively correlated and television duration was negatively correlated with the Conners Short-Form Parent Rating Scale behavioral problems subscores. CONCLUSIONS: Children on renal replacement therapy may be at risk in terms of excessive television exposure. Children who are on dialysis and have had a kidney transplant may be more prone to the negative effects of screen exposure than healthy peers who do not have chronic illnesses. These children and adolescents should be closely monitored to avoid the negative effects of excessive screen exposure.

COVID-19 Infections in Pediatric Renal Transplant Recipients.

OBJECTIVES: The new coronavirus SARS-CoV-2 (COVID-19) first appeared in Turkey in March 2020, spread rapidly, and caused many deaths. Although COVID-19 is mostly a respiratory disease, it can cause kidney and multiorgan failure in some cases. We believe that by sharing information about the course and effects of COVID-19 infection in kidney transplant recipients receiving long-term immunosuppressive therapy our understanding will improve. MATERIALS AND METHODS: Between March 2020 and October 2021, COVID-19 was researched in kidney transplant recipients under the age of 20 years who were followed at the Baskent University Transplantation Center. We documented the clinical characteristics and prognosis of pediatric kidney transplant recipients with COVID-19 disease. RESULTS: Our study group included 23 patients with COVID-19 infection from 215 pediatric kidney transplant recipients. The mean age of the patients was 14.6 ± 4.7 years; there were 9 female patients. The mean follow-up time posttransplant was 62.3 ± 43.2 months. In 13 patients (56.5%), fever was the most frequent symptom. Most patients (n = 18, 78%) had minor symptoms and recovered completely after receiving supportive treatment. Four patients (17%) required hospitalization. One was diagnosed with COVID-19 infection 1 week after being treated with rituximab for acute antibody-mediated rejection. That patient died because of significant lung disease and multiorgan failure. CONCLUSIONS: Despite the fact that most of our pediatric transplant recipients had mild symptoms of COVID-19, we believe that particular caution should be observed in patients who have recently received intensive immunosuppressive medications. As a result of potential new vaccines, national immunization programs, and the emergence of novel virus strains, the clinical picture may change in the future. We believe that, as information sharing increases, we will learn more about COVID-19 in renal transplant recipients.

Treatment of Posttransplant Hepatocellular Carcinoma Recurrence.

OBJECTIVES: In patients who receive liver transplant to treat hepatocellular carcinoma, 10% to 15% posttransplant recurrence is observed. In the present study, we evaluated the long-term outcomes of patients who had received liver transplant for treatment of hepatocellular carcinoma. MATERIALS AND METHODS: Of the 683 livertransplants that we performed, 72 were in response to hepatocellular carcinoma. The physical examination and laboratory and imaging results of the patients were retrospectively analyzed and recorded. The recipients were evaluated according to the Baskent criteria and divided into 2 groups: early diagnosis and late diagnosis. RESULTS: Among 72 total patients in our study, 19 (26.3%) were pediatric recipients. Hepatocellular carcinoma recurred in 7 patients (9.7%; 5 adult, 2 pediatric). Except for one patient, all were in the late diagnosis group.The mean survivaltime of all patients was 137.45 ± 10 months.The mean survival in the early diagnosis group was longer than in the late diagnosis group. During follow-up, 11 patients died from recurrence and distant metastasis. CONCLUSIONS: In patients with hepatocellular carcinoma who received liver transplant, we found that postoperative recurrence of hepatocellular carcinoma and distant metastasis can be treated with surgery and/or with interventional radiology methods, which may improve patient survival after liver transplant.

Efficacy of the Sonoelastography Method for Diagnosis of Fibrosis in Renal Transplant Patients.

OBJECTIVES: Although biopsy is the most important method for diagnosing the cause of renal allograft dysfunction, sonoelastography, a new ultrasonography method, can be used to distinguish between the soft or hard nature of lesions. In this study, our aim was to investigate whether sonoelastography could diagnose fibrosis in renal transplant patients. MATERIALS AND METHODS: In this prospective study, we included patients over 18 years old who were recommended for clinical biopsy. Sonoelastographic evaluation was made by conducting acoustic radiation force impulse measurements for each patient after they were admitted to the clinic for biopsy. Measurements were performed just before the biopsy procedure. All results were examined by 2 experienced radiologists using the Siemens S3000 Ultrasound Machine (Erlangen, Germany). Comparisons of ultrasonographic values with biopsy results were made with SPSS software (SPSS: An IBM Company, version 20, IBM Corporation, Armonk, NY, USA). RESULTS: Of the 65 patients included in this study, pathology showed acute T-cell-mediated rejection in 37 patients. There was a significant correlation between the pathologic Banff scores and the sonographic acoustic radiation force impulse values (P = .002), where the degree of Banff increased as the mean acoustic radiation force impulse values elevated. A rise in mean impulse values correlated with increased degree of interstitial fibrosis in renal allografts. Renal parenchymal echogenicity of patients significantly differed by sex (P = .009), with an average renal echogenicity of grade 1 in women and grade 0 in men. Also, a statistically significant difference was found between age of the renal transplant recipient and resistive index values. CONCLUSIONS: Our study showed a significant correlation between Banff degree and the acoustic radiation force impulse values of renal transplant patients. In addition to biopsy, sonoelastography can be beneficial for the diagnosis of fibrosis in renal transplant patients.