[Living donor kidney transplantation after resection of carcinoma]. / Gyvo donoro inksto persodinimas po jo naviko rezekcijos.

The aim of the article is to present a case of incidental renal cell carcinoma in living donor kidney, which was successfully transplanted following resection of carcinoma. A 38-year-old female recipient with end-stage renal disease was on maintenance hemodialysis for 4 months. The donor was her mother aged 60 years. Preoperative renal scintigraphy, aortography, and ultrasound examination confirmed good function of donor kidneys. The reason for transplanting the right kidney was slightly diminished phase of secretion revealed by scintigraphy. On February 14, 2001, mother's right kidney was removed, and after hypothermic perfusion, yellowish nodule in the upper part of the kidney was found. Microscopic investigation of the resected material revealed renal clear cell carcinoma. Decision on complete tumor resection was based on the findings of microscopic examination. After suturing the resected segment, mother's kidney was transplanted successfully. The postoperative course was normal in the donor and the recipient as well. Cyclosporine A was replaced with Rapamune. No tumor recurrence was seen for more than 6 years after transplantation, and transplant function was normal.

[Clinical effect of induction therapy with monoclonal antibodies after deceased-donor kidney transplantation (an experience from Vilnius Center)]. / Gydymo monokloniniais antikunais klinikinis poveikis persodinus mirusiu donoru inkstus (Vilniaus centro patirtis).

We aimed at evaluating the impact of monoclonal antibodies on immune response against deceased-donor kidney transplant: the frequency and severity of acute rejection episodes during first 3 months after transplantation and graft loss rate at one year. The frequency of infectious complications during the first 6 months after transplantation and patient survival rate during one year were also analyzed. Our study included 187 deceased-donor renal transplants performed in Santariskes Clinics of Vilnius University Hospital from January 2000 to December 2004. Study group (Group 1) consisted of 66 patients who received additional induction therapy with monoclonal antibodies (31 patients treated with basiliximab and 35 patients treated with daclizumab); 121 patients in control group (Group 2) were treated only with conventional immunosuppression. Both groups received maintenance immunosuppressive therapy including cyclosporine, mycophenolate mofetil, and steroids. Patient and graft survival rates were calculated by Kaplan-Meier method. There were no significant differences in the age of patients, HLA mismatches, percentages of highly sensitized patients (panel-reactive antibody level more than 50%), and repeated transplantation between both groups. The incidence of biopsy-proven acute rejection during the first 3 months after transplantation was significantly lower in Group 1 than in Group 2 (15.2% vs. 28.1%, P<0.05). There were no significant differences in patient survival rates (95.5% vs. 90.1%) between two groups at one year, but graft survival rate was significantly higher in Group 1 than in Group 2 (94.0% vs. 77.0%, P<0.05). The proportion of patients with infectious complications during the first 6 months after transplantation was significantly lower in study group than in control group (33.3% vs. 49.6%, P<0.05). Therefore, induction therapy with monoclonal antibodies reduced the incidence and severity of acute rejection in early period after transplantation and led to higher graft survival rate. The lower frequency of infectious complications was observed in patients receiving induction therapy with monoclonal antibodies.

[Fabry's disease: a clinical case and literature review]. / Fabry liga (klinikinis atvejis ir literaturos apzvalga).

Fabry's disease is a congenital disorder of glycosphingolipid metabolism with an X-linked recessive inheritance, presenting with typical symptoms of pain crises, acroparesthesias, cutaneous and mucosal angiokeratomas, hypohidrosis, heart and kidney lesions, and other symptoms, which are described below. From 2001, this disease is one of inborn errors of metabolism in which enzyme replacement therapy is applied very effectively. Two atypical forms of the disease were discovered, and the first surveys were done revealing that the incidence of Fabry's disease can be much more higher than it was considered before. Not only pediatricians can encounter with these patients in their practice, but also family doctors, nephrologists, cardiologists, neurologists, and physicians of other specialties. A clinical case of Fabry's disease is described, and actual issues of diagnostics and treatment of Fabry's disease are discussed. In spite of very typical symptoms, delayed diagnosis was made: after the first investigation of alpha-galactosidase A activity in dry blood sample, diagnosis of Fabry's disease was rejected; only after lysosomal enzyme activity assay in heparinized blood leukocytes, this diagnosis was confirmed.

[The first experience with sirolimus (Rapamune) after kidney transplantation in Lithuania]. / Pirmoji sirolimo (Rapamune) vartojimo po inkstu persodinimo patirtis Lietuvoje.

Sirolimus is a new immunosuppressive agent. This study aimed to evaluate the efficiency of sirolimus in patients after renal transplantation and to compare graft function, the frequency of rejection episodes and complications with patients under cyclosporin A treatment. From May 2002 to January 2005 26 renal transplant patients were treated with sirolimus. 13 patients (group A) were treated with sirolimus before renal transplantation and 13 patients (group B) were converted to sirolimus in late period after transplantation because of chronic cyclosporin A nephrotoxicity, chronic graft nephropathy and due to intolerance of cyclosporin A (mean time after transplantation: 18 months). Sirolimus was started as a loading dose 5-6 mg per day and reduced to 2-3 mg per day. Mean sirolimus blood concentration was 8.19+/-6.7 ng/ml. Results were compared according to age, gender, the number of HLA matches, plasma renin activity levels, etc., with 52 patients (control (C) group) under cyclosporin A, mycophenolate mofetil and steroids treatment. During 3 months, the acute rejections were in 30.8% of patients (4/13) and 65.4% of patients (17/26) for group A and group B, respectively (chi2=6.568, p<0.05). Renal function at 12 months: mean serum creatinine was 165.5+/-29 micromol/l vs. 214.2+/-67.9 micromol/l, urea 9.6+/-2.6 mmol/l vs. 13.9+/-9.3 mmol/l. There were no differences in platelet counts between groups, but serum cholesterol value was higher in the patients of group A (8.11+/-0.9 mmol/l vs. 6.54+/-1.4 mmol/l), blood pressure (140+/-13/87+/-14 mmHg vs. 150+/-15/85+/-12 mmHg). Patients were treated for different infections, cytomegalovirus infection and sepsis (28.6% (6/21) vs. 45.2% (19/52) for group A and group B, respectively). Our results have shown that sirolimus in combination with mycophenolate mofetil and steroids is an effective alternative to continuous therapy without cyclosporine.

[Delayed graft function and its impact on the antigraft response after cadaver kidney transplantation]. / Uminis persodinto inksto nepakankamumas ir jo rysys su imuniniu atsaku i transplantata

The purpose of this study was to evaluate the incidence of delayed graft function and its impact on the antigraft response after cadaver kidney transplantation. The analysis is based on 183 consecutive cadaver kidney transplantations performed in Vilnius University Hospital Santariskiu klinikos from January 2000 to December 2004. Delayed graft function occurred in 21.3% (39/183) of kidney transplantations. The frequency and severity of acute rejection episodes in recipients during first three months after transplantation and graft survival rate at one and two years were evaluated. Group 1 consisted of 39 patients with delayed graft function and group 2 (control group) of 144 patients with graft function immediately after transplantation. The maintenance immunosuppressive therapy consisted of cyclosporine, mycophenolate mofetil/azathioprine and prednisolone. The proportion of patients treated with monoclonal antibodies was similar in both groups (35.9% vs. 33.3%). Actuarial graft survival was estimated by the modified Kaplan-Meier method, graft loss was censored for death of recipient with functioning transplant and other causes of loss not related to rejection. There were no significant differences in the age of recipients (42.3+/-11.3 vs. 39.4+/-14.1), as well as in HLA matching (2.2/6 M vs. 2.2/6 M), in the number retransplanted patients (10.3% vs. 10.4%) and in highly sensitized patients (plasma renin activity >50.0%) (5.1% vs. 4.8%) between those groups. Significant differences were observed in donors over 50 year (33.3% vs. 18.7%; p<0.05), in cold ischemic time over 20 h (53.8 vs. 32.6%, respectively). The occurrence of acute rejection episodes was higher in group 1 than in group 2 (69.2% (27/39) vs. 34.7% (50/144); chi2=14.9945, p<0.05). Graft survival was 88.5%, 84.3% at one year and two years in group 1 and 94.7%, 93.8% at one year and two years in group 2 (ns). Donor age >50, cerebral vascular disease as cause of donor death, and cold ischemic time >20 h are the main risk factors for delayed graft function. Delayed graft function is a risk factor for acute rejection episodes, but it has no impact on graft loss due to immunological reason at one and two years. These data may serve for tailoring immunosuppressive protocols.

[Nephrotoxicity of cyclosporin A after kidney transplantation]. / Nefrotoksinis ciklosporino A poveikis po inkstu persodinimo.

Cyclosporin A (CsA) is an effective immunosuppressive drug for the prophylaxis of rejection after organ transplantation. However, CsA is potentially toxic to various tissues: kidney, liver, pancreas, nervous system, etc. The aim of this study was to ascertain the frequency of CsA nephrotoxicity incidence according to the changes in graft biopsy material and its association with whole blood CsA levels. Data were obtained from 30 recipients after cadaver or living related kidney transplantation. All patients (pts) were divided into two groups: Gr1 included 17 pts with biopsy evidence of CsA damage and Gr2 -13 pts without these changes. The mean age of recipients (38.6+/-11.3 vs 34.6+/-13.3), donor and recipient human leucocyte antigen (HLA) match (2.5/6 vs 2.3/6), cold ischemic time (12.0+/- 9.3 h vs 13.8+/-10.3 h), percentage of kidney from cadaver donors (64.7% vs 69.2%) were similar in both groups. Comparison of CsA blood levels (>200 ng/ml) between Gr1 and Gr2 revealed statistically significant differences (70.6% vs 15.4%, p<0.05), correspondingly. The mean CsA blood level was higher in Gr1 (328.7+/-153.8 ng/ml vs 202.4+/-145.6 ng/ml, p<0.03). Thus, we suggest that CsA nephrotoxicity is associated with elevated CsA levels of more than 200 ng/ml. Biopsy is a very important criteria that helps to distinguish CsA nephrotoxicity and acute rejection.

[Anti interleukin-2 receptor alpha antibodies (daclizumab) application for the treatment of kidney recipients]. / Antikunu pries IL-2alpha receptorius (daclizumab) skyrimas inksto recipientams.

UNLABELLED: Acute rejection is a known risk factor for developing chronic allograft nephropathy, which remains as a major cause of long-term graft loss. Daclizumab (Zenapax), a humanized anti interleukin-2 receptor (IL-2R) alpha monoclonal antibody, is a novel selective immunosuppressive agent for the prophylaxis of acute rejection. Six patients (aged from 32 to 48) after cadaver and living donor kidney transplantation (Tx) have been treated with Daclizumab since 2000 in Lithuania. Daclizumab was prescribed (1.0 mg/kg intravenously before Tx and once every other week afterwards (five dozes in total) for all patients, except one, who received two dozes. The induction therapy was administered due to various immunological risk factors: retransplantated, sensitized and poorly HLA-matched patients, as well as non-immunological risk factors such as patients with diabetes, with kidney from sub-optimal donors, obesity of patients, etc. The maintenance immunosuppression consisted of cyclosporine, mycophenolate mofetil and prednisolon in all patients except one, who was treated without steroids. All the patients have been folloved-up for 5-36 months. Within the observation period in early time after Tx all the patients are alive and have no clinical signs of rejection. The graft function is normal (serum creatinine ranges between 100-120 micromol/l). CONCLUSION: Induction therapy with Daclizumab is safe and efficacious in preventing acute rejection in high risk kidney recipients.

Malignancy after renal transplantation: a single-center experience.

BACKGROUND: The aim of this study was to evaluate the incidence and characteristics of malignant tumors in kidney transplant recipients (KTR) in Lithuania and to access the changes in KTR survival after developing cancer. We also analyzed and compared results with data from other centers worldwide. MATERIAL AND METHODS: We performed a retrospective cohort study of all 395 patients transplanted at Renal Transplantation Center of Vilnius University Hospital Santariskiu Klinikos (RTC of VUHSK) between 1 January 2000 and 31 December 2010. RESULTS: Mean age at transplantation was 40.33 ± 11.46 years; 54.9% of recipients were male, 45.1% female; 23 (5.8%) recipients developed 25 malignancies, of which 1.5% had urinary system cancer, 0.8% had non-melanoma skin cancer, hematolymphopoetic cancer, or cancer of gastrointestinal tract, and 0.5% developed cancers of female reproductive system, breast, central nervous system cancer, or had more than 1 malignancy. Average time to first malignancy was 46.7 months. Cumulative incidence of malignancy was 1.8%, after 1 year, 4% after 5 years, and 14.2% after 10 years. There were 32 patients (8.1%) with pre-malignant lesions. Recipients older than 45 years had higher frequency of malignancies (p = 0.005). KTR who developed gastrointestinal cancer had significantly shorter survival time than patients without malignancy (p = 0.01). Recipients who had been on dialysis for more than 35 months also had a significantly shorter survival (p=0.001). CONCLUSIONS: Older patients had higher risk for developing malignancies, and recipients with gastrointestinal cancer had the worst survival. That suggests we need better screening programs for this type of cancer and for older patients at RTC of VUSHK.

Orthotopic liver transplantation: the first experience and results of the Vilnius University Hospital Santariskiu Klinikos.

BACKGROUND: Liver transplantation has become the treatment of choice for chronic and acute end-stage liver failure as well as for selected cases of malignancies and metabolic disorders. We report our first experience of the orthotopic liver transplantation. MATERIAL/METHODS: Between 2005 and 2008 16 cadaveric orthotopic liver transplantations in 16 adults (12 males, 4 females, mean age 44 years) were performed. Main indications for orthotopic liver transplantation were cholestatic liver disease (31%), viral-induced cirrhosis (25%), alcoholic liver disease (19%), hepatocellular carcinoma associated with hepatitis virus infection (13%), autoimmune cirrhosis (6%), cryptogenic acute liver failure (6%). Mean follow-up was 15 month (range: 4 days - 43 month). RESULTS: Intraabdominal haemorrhage was observed in 6 patients (37.5%). Vascular complications were observed in 3 patients (18.75%). Biliary complication were observed in 3 patients (18.75%). Overall 1 year patient survival was 87,5%. Four (25%) patients died during follow-up. All patients died because of sepsis and multiorgan system failure. CONCLUSIONS: Our first results showed that secret of successful liver transplantation is perfect interdisciplinary team approach, including selection of the recipient and timing of transplantation, the operative procedure itself, prevention and treatment of complications, the perioperative anaesthesiological and intensive-care management, and careful follow up after transplantation.

[Antigraft response in advanced age cadaveric renal recipients]. / Vyresnio amziaus recipientu imuninis atsakas i lavono inksto transplantata.

We aimed to compare graft loss due to acute rejection (AR) and chronic allograft failure (CAF) in first cadaveric kidney recipients, subsequently grafted during 1992-2000. All recipients (n=225) were divided into 3 age groups: Gr 1 (n=39) - 13-25 yrs, Gr 2 (n=169) - 26-55 yrs and Gr 3 (n=47) 56-71 yrs. There were no differences between the groups in terms of sex (m/f ratio 1.2-1.4), ischemia time and HLA matching. Incidence of high presensitization (PRA> or =50%) were observed in 15%, 5% and 9%, correspondingly (statistically significant difference was found only between Gr 1 and Gr 2). Immunosuppression consisted of CyA, AZA or MMF and steroids. Antigraft response was evaluated by graft loss due to acute rejection or chronic allograft failure. Actuarial graft survival was estimated with the Kaplan-Meier method with p values given for log-rank test. Graft loss was censored for death of recipient with functioning transplant and other causes of loss not related to rejection. Graft survival was 77%, 86% and 100% at 1yr in groups 1, 2, 3; 74%, 78% and 88% at 3 yrs; 67%, 73% and 88% at 5 yrs; 54%, 65% and 88% at 7 yrs, correspondingly (for Gr 1-3 - p<0.005, for Gr 2-3 p<0.025). In conclusion, antigraft response in elderly cadaveric kidney recipients is weaker - the incidence of transplant rejection is smaller than in young and grown-up recipients.