Renal Autotransplantation in a Patient with Bilateral Renal Artery Stenosis Secondary to Takayasu Arteritis.

Involvement of the renal artery is common in Takayasu arteritis. We, herein, present on a patient with Takayasu arteritis causing severe renal failure and a successful auto-transplantation. This case shows that early diagnosis and immediate appropriate interventions are life-saving in patients with Takayasu arteritis. Renal auto-transplantation performed in selected cases increases dialysis-free survival.

Is There a Long-Term Risk for Donors With Heterozygous MEFV Mutation After Kidney Donation?

BACKGROUND: Familial Mediterranean fever (FMF) is an autosomal-recessive autoinflammatory disorder manifested severely by systemic amyloidosis. It has been hypothesized that heterozygous carriers may also have susceptibility to certain symptoms or even diseases. Because the living kidney donors of patients with FMF are generally relatives of the kidney recipients, there is a high possibility that the donors will have a heterozygous mutation of the FMF gene. The goal of this study was to investigate the long-term kidney function of donors who are carriers of the Mediterranean fever (MEFV) gene. METHODS: The medium- to long-term outcomes of 12 asymptomatic donors were compared with MEFV gene carriers and 24 non-FMF recipients' donors. RESULTS: Heterozygous carriers and the control group were similar with respect to age, sex, and follow-up period. The preoperative estimated glomerular filtration rate and 24-hour urine proteinuria levels were similar in the MEFV carrier and control groups. Four years after the donation, both groups had similar estimated glomerular filtration rates, but the change in 24-hour urine protein was statistically higher in the MEFV carrier group, and no significant change was observed in the control group (P = .004). At the end of the follow-up period, neither overt proteinuria nor kidney failure was seen in either group. CONCLUSIONS: This study showed that the medium- to long-term results of the kidney donors who are carriers of the MEFV gene seem to be safe. However, there was more of a tendency for an increase in proteinuria in the MEFV gene carriers compared with control subjects, which necessitated further long-term care for these donors.

Average Tacrolimus Trough Level in the First Month After Transplantation May Predict Acute Rejection.

BACKGROUND: Although tacrolimus is one of the essential drugs used for the prevention of rejection in kidney recipients, target trough levels are not well established. In this study, we aimed to investigate the association between average tacrolimus trough levels (TTLs) of the first month after transplantation and biopsy-proven acute rejection (BPAR) during the first 12 months after transplant. METHODS: A total of 274 patients who underwent kidney-alone transplantation between 2002 and 2014 were enrolled in the study. Average TTLs of the first month were assessed by means of receiver operating characteristic (ROC) curve analysis to discriminate patients with and those without BPAR. Univariate and multivariate Cox proportional hazards models were used to determine the effect of average TTLs of the first month on BPAR. RESULTS: According to ROC curve analysis, the highest area under the curve (AUC) was obtained from 8 ng/mL (AUC = 0.73 ± 0.11; 95% confidence interval [CI], 0.62-0.84). Forty-two (31.8%) of the 132 patients with average TTLs <8 ng/mL and 13 (9.1%) of 142 patients with ≥8 ng/mL had BPAR during the first 12 months after transplant (P < .001). In univariable analysis, average TTLs of the first month <8 ng/mL were associated with higher risk of BPAR (P < .001), and the significance remained in Cox multivariable analysis (hazard ratio, 2.79; 95% CI, 1.76-3.82; P = .001). No significant differences were observed in the glomerular filtration rate, cytomegalovirus, BK viremia, or BK nephropathy between groups at post-transplant month 12. CONCLUSIONS: Keeping the average TTLs of the first month after transplantation at ≥8 ng/mL not only prevents BPAR occurrence but also minimizes the toxic effects of the use of a single-trough level.

Risk Factors of Hyperuricemia After Renal Transplantation and Its Long-term Effects on Graft Functions.

BACKGROUND: Hyperuricemia is a common complication in renal transplant recipients. Recent studies have suggested that hyperuricemia may contribute to the deterioration of graft function. METHODS: In this study, we aimed to investigate the risk factors related to hyperuricemia and the effects of hyperuricemia on graft dysfunction, graft survival, cardiovascular events, and mortality rates. Between the years 2005 and 2016, 141 renal transplantation patients with at least 5 years of follow-up were included in this retrospective cohort study. Multi-linear regression analysis was used to determine the relationship between mean serum uric acid level and estimated glomerular filtration rate (eGFR). RESULTS: The average transplant age was 37.1 ± 12.1 years and the average follow-up time was 83.09 ± 20.30 months; the prevalence of patients with hyperuricemia was 39 (27.6%). The mean uric acid levels were higher in women (P < .001) in the condition of dyslipidemia (P = .026), ß-blocker usage (P = .002), and thiazide diuretics (P = .020). Patients with hyperuricemia (P < .001), new-onset hypertension (P = .027), ß-blocker usage (P = .005), and thiazide diuretics (P = .040) had statistically different eGFR levels than other recipients. Multivariant regression analyses showed that eGFR levels after transplantation were correlated with mean uric acid levels (ß = -0.46, P = .001), donor age (ß = -0.18, P = .048), recipient age (ß = -0.28, P = .0003), and mean hemoglobin levels (ß = 0.31, P = .003). CONCLUSIONS: There was no difference in graft loss, general mortality, and cardiovascular events between normo-uricemic and hyperuricemic groups. Increased uric acid levels contribute to eGFR decline in patients with renal transplantation. On the other hand, effects of uric acid levels on graft survival, cardiovascular events, and general mortality are still controversial.

Prevalence and Risk Factors of BK Viremia in Patients With Kidney Transplantation: A Single-Center Experience From Turkey.

BACKGROUND: BK virus is the cause of nephropathy, which can progress to graft loss after kidney transplantation. In this study, we aimed to investigate the prevalence and risk factors of BK viremia in patients with kidney transplantation at our center. METHODS: This was a retrospective single-center study. We included recipients transplanted between 2010 and 2015. Patients were stratified according to BK virus DNA follow-up values into three groups (0-999 copies/mL, 1000-9999 copies/mL and ≥10,000 copies/mL). The parametric t test and the non-parametric χ2 test were used to detect differences between groups. Multivariate analysis was used to identify risk factors for BK viremia. RESULTS: One hundred eighty-three patients were included in the study, with mean follow-up time of 33.6 ± 14.9 months. BK viremia prevalence was found 15.8% (n = 29), and time to detection of viremia was 7.6 months. Cadaveric transplantation and matching human leukocyte antigen (HLA) A24 and HLA B55 subgroups were found to be independent risk factors for BK viremia [odds ratio (OR), 3.65; 95% confidence interval (CI), 1.42-9.39; P < .001; OR, 4.94; 95% CI, 1.84-13.2; P < .001 and OR, 14.03; 95% CI, 1.07-183.5; P = .04, respectively]. Risk factors for BKV level ≥10,000 copies/mL cadaveric transplantation, male sex, and HLA A24 matching (OR, 4.53; 95% CI, 1.49-13.7; P < .001; OR, 3.47; 95% CI, 1.11-10.86; P = .03 and OR, 3.63; 95% CI, 1.08-12.1; P = .03, respectively). CONCLUSIONS: Patients should be followed more carefully for BK viremia who have cadaveric transplantation, are male, and have matching in certain HLA groups, which were independent risk factors in the present study. Our results are important to individualize screening methods and provide early diagnosis in our country.

Klebsiella pneumoniae peritonitis shortly after kidney transplantation.

We report a case of spontaneous bacterial peritonitis caused by Klebsiella pneumoniae in a 34-year-old male recipient shortly after kidney transplantation. On posttransplant day 10, the patient started complaining of severe abdominal pain and nausea. Body temperature was 38.4 degrees C. The abdomen was diffusely tender with rigidity and rebound. Laboratory data showed a normal erythrocyte sedimentation rate and serum creatinine level but a slightly elevated C-reactive protein concentration and leukocytosis of 36,200 cells/mm(3) with 88% neutrophils. Explorative laparotomy revealed diffuse purulent peritonitis without an intraabdominal source of infection, such as intestinal perforation. The peritoneal fluid revealed greater than 1000/mm(3) white blood cells and many gram-negative bacilli. Fluid cultures yielded growth of Klebsiella pneumoniae. The patient responded to antibiotic therapy; he was discharged in good condition. This case report draws attention to the impaired host defense that may predispose to spontaneous bacterial peritonitis in renal transplant recipients and alerts the clinician to the possibility of this rare disease.

Brain Death and Organ Donation: Knowledge, Awareness, and Attitudes of Medical, Law, Divinity, Nursing, and Communication Students.

BACKGROUND: Throughout the world, there is a shortage of suitable organs for organ transplantation. The aim of this study was to assess the level of knowledge, awareness, and attitudes of medical, law, divinity, nursing, and communication students, who will be involved in this issue in the future, regarding brain death and organ donation. METHODS: Data were collected with the use of a 30-item questionnaire. RESULTS: Of the 341 participants, 228 (66.8%) were female and overall average age was 21.6 ± 2.8 years. Nearly one-half of them (51.3%), especially nursing and medical students, wanted to be a donor, but only 2% had an organ donation card; 78.3% emphasized that family must have the right to make the decision for organ donation, and the vast majority of the participants considered that the organs could not be taken without any permission. Kidney and heart were the most commonly identified transplantable organs; the less frequently known organ was intestine. Only 71 participants, most of them medical, divinity, and law students, correctly answered all questions about brain death; 68.6% stated that organ donation is allowed by religion, and 5% expressed that it is religiously forbidden; 37.3% did not have confidence in health care policy. Law students were more confident, nursing students less confident. CONCLUSIONS: Better understanding of organ donation and concepts by the doctors, nurses, legislators, religious officials, and mass communications professionals who will give direction to society's behaviors and beliefs would help to spread positive attitudes toward organ donation and transplantation in the public.

Evaluation of Infectious Complications in the First Year After Kidney Transplantation.

Kidney transplantation (KT) is the best available therapy for patients with end-stage renal disease. Infectious complications are a common cause of morbidity and mortality. In this study, we evaluated the risk factors and outcomes of infectious complications in the first year after transplantation. This is a retrospective and observational study of kidney transplant recipients at Ankara University's Ibni Sina Hospital between January 2009 and August 2013. A total of 206 kidney transplant recipients were evaluated. In 129 patients, 298 infectious episodes occurred: 55 (26.7%) had 1; 33 (16%) 2; 19 (9.2%) 3; 7 (3.4%) 4; and 15 (7.3%) had 5 or more infectious episodes. The most common bacterial infection was urinary tract infection (128, 42.9%). Only 4 urinary tract infection episodes (3.1%) were associated with bacteriemia. Seventeen patients (5.7%) had bacteremia. Viral infections after transplantation were CMV infection (10.1%), BK virus infection (5.7%), and zona zoster (1.1%). Deceased donor kidney transplantation was the independent risk factor. Mean follow-up period was 66 months and was the same for the patients with and without infections. There was no significant difference in 5-year survival and creatinine levels at the last follow-up (logrank P = .409). Infections are the second most common cause of mortality in KT patients. The successful treatment of these complications and effective prophylaxis may decrease these complications.

Predictive Role of Neutrophil Gelatinase-Associated Lipocaline in Donor-Specific Antibody-Positive and Donor-Specific Antibody-Negative Renal Transplant Patients.

BACKGROUND: Renal transplantation is the best choice for the treatment of dialysis patients with end-stage renal failure because it provides better quality of life and more life time. However, despite successful surgical techniques, immunological issues in kidney transplantation are not completely resolved. Thus, after transplantation, patients must be followed up closely. Although patient follow-up with the use of creatinine and renal biopsy are common, it is thought that biopsy is too invasive and that creatinine is unreliable. Hence, new parameters that correlate with the patient's immunological condition are needed in clinical monitoring. METHODS: One of the biomarkers that has been studied recently is neutrophil gelatinase-associated lipocalin (NGAL). Its diagnostic value in cases of acute renal failure, delayed graft function, and IgA nephropathy is widely investigated. However, data are insufficient as to whether NGAL can be used for follow-up in the chronic process after renal transplantation. We aimed to investigate the predictive value of NGAL in terms of rejection in donor-specific antibody (DSA)-positive and DSA-negative renal transplant patients. Ninety patients were included. RESULTS: We found that rejection rates were higher in patients whose NGAL values were ≥ 50 and DSA-positive. Delayed graft function was seen more frequently in patients whose NGAL values were ≥ 50. CONCLUSIONS: An increase in NGAL level does not always indicate renal injury because NGAL is also an acute-phase reactant. NGAL cannot be used alone to diagnose rejection, but, if NGAL level is high, it is necessary to study DSA, and sub-clinical rejection must be researched.

Exotic arteriovenous fistulas for hemodialysis.

The rate of patients with exhausted upper extremity arteriovenous fistula (AVF) sites who have lost all chances for a conventional upper extremity AVF has been increasing in line with the general increase in the hemodialysis patient population. In this prospective study, we report the early and late follow-up results of "exotic" AVFs in which central veins are used for the outflow. Patients having no chance for an upper extremity AVF based on previous catheterization, surgical AVF history, detailed physical examination, and radiological assessment, were included in the study. Between June 1999 and January 2003, 27 central AVFs were created with a 6 mm synthetic vascular graft in 26 patients. The inflow artery was the proximal axillary artery in all except one. All but one operation was done by the same surgeon. The outflow vein was the internal jugular vein in 16 and infraclavicular axillary vein in 11 cases. One-year primary and secondary graft patency rates were 33.33 +/- 10.49 and 57.06 +/- 11.29, respectively. The early complications were facial edema and hemiparesis, both of which resolved spontaneously. The only late complication, pseudoaneursym, was treated by a graft interposition. In selected patients who have no suitable upper extremity vessels for an AVF, the central veins may be used with an acceptable success rate. Another advantage of this procedure is the avoidance of undesired femoral interventions; sometimes it may be the only opportunity and lifesaving for the patient.

Femoral vein transposition versus femoral loop grafts for hemodialysis: a prospective evaluation.

In this first clinical trial femoral vein transposition (FVT) was prospectively compared with its "graft" counterpart. Patients requiring vascular access due to occluded central veins were divided into two groups: group I (n = 17) underwent femoral loop grafts and group II (n = 15), FVT. Complications were recorded prospectively and patency rates were compared by the Kaplan Meier method with statistical comparisons by Mann Whitney U and chi-square tests as appropriate. Between 1999 and 2003 30 patients underwent 32 operations. Mean follow-up was 8.9 months in group I and 6.8 months in group II (P >.05). Three group I patients developed a steal, requiring closure of the fistula in one. Five group II patients developed a steal, requiring closure of the fistula in one. The incidence of steal was similar in both groups (P >.05). The infection rates were similar: 35.3% and 26.7% in group I versus group II (P >.05), respectively. Among the six infections in group I, four patients required excision of the graft due to infection, whereas only one arteriovenous fistula (AVF) was closed in group II for infection. The 1-year primary patency rate in group I was 37.5% versus 86.7% in group II (P <.05). In conclusion, Femoral AVF grafts have been condemned because of the unacceptable high rate of septic complications. FVT obviates the need for a graft and has fewer infectious problems and better patency rates.

Technical implications of living donor liver transplantation: a single-center experience.

Liver transplantation for end-stage liver disease is the treatment of choice in current surgical practice. However, the shortage of cadaveric organs has limited this treatment option for many years. Living donor liver transplantation (LDLT) may be an option to overcome the organ shortage. In the present series we report a single-center experience with 39 LDLT performed from March 2000 to June 2003. The main indications for LDLT was hepatitis B cirrhosis (11 patients). The recipient hepatectomy was performed with caval preservation. The hepatic vein anastomosis was performed either to recipient hepatic vein or inferior vena cava. The portal vein anastomosis was performed either to the recipient's main or right portal branch. Biliary diversion was performed to the recipient biliary ducts if possible, otherwise to a jejunal loop in Roux-en-Y fashion. The survival rate at the end of one year was 71%. The leading cause of mortality was sepsis in five patients. Biliary complications developed in 20% of the recipients. All bile leaks were from the Roux-en-Y hepaticojejunostomy. Hepatic artery thrombosis was diagnosed in four patients by loss of hepatic blood flow on Doppler ultrasound. LDLT is a major surgical option for end-stage liver disease, particularly for countries with low rates of organ donation. However, there are technical challenges to be overcome such as small vessels from segmental grafts and multiple small bile ducts.

Could the use of interposition grafts for arterial reconstruction be avoided by more caudate graft placement in living donor liver transplantation?

One of the major challenges in living donor liver transplantation (LDLT) is short and small vessels (particularly the hepatic artery), particularly in segmental liver grafts from living donors. In the present study we report an alternative surgical technique that avoids interpositional vessel grafts or tension on the connection by anastomizing the allograft hepatic vein to the recipient inferior vena cava in a more caudate location. From March 2000 to January 2003, 28 patients (11 women/17 men) underwent 28 LDLT. Until June 2001, the preferred technique for hepatic vein anastomosis was end-to-end anastomosis between the allograft hepatic vein and the recipient hepatic vein (HV-HV) (n = 10). Thereafter an end-to-side anastomosis was performed between allograft hepatic vein and recipient inferior vena cava (HV-IVC) (n = 18). The level of venotomy on the recipient vena cava was decided according to the pre-anastomotic placement of the allograft in the recipient hepatectomy site with sufficient width to have an hepatic artery anastomosis without tension or need for an interposition graft during hepatic artery and portal vein anastomoses. Except the right lobe allograft with anterior and posterior portal branches, all portal and hepatic artery anastomoses were constructed without an interposition graft or tension in the HV-IVC group. Only one hepatic artery thrombosis developed in the HV-IVC group. As a result, this technique may avoid both hepatic artery thrombosis and the use of interposition grafts in living donor liver transplantation.

Identification of sentinel lymph node in breast cancer by lymphoscintigraphy and surgical gamma probe with peritumoral injection of scintimammographic agent "99mTc MIbI".

UNLABELLED: The purpose of this study was to evaluate the efficacy of lymphoscintigraphy and the surgical gamma probe (SGP) with peritumoral injection of 99mTc MIBI in sentinel lymph node (SLN) detection in breast cancer regardless of whether metastatic or not. METHOD: Thirty patients with T1/ T2 breast cancer had peritumoral injections of 99mTc MIBI (74 MBq/0.2 ml at 4 different locations) at 2, 6 and 24 hours before surgery. Anterior, anterolateral, and lateral spot images were taken at 10, 30, 45, 60 and 120 minutes. Counts were collected from the injection site, affected breast tissue, internal mammaries, axillary and supraclavicular regions, and the contralateral side. Peritumoral blue dye was also injected at surgery. The first lymph nodes with counts twice the background tissue and/or with blue dye uptake were surgically isolated, and histopathological evaluations were made. Modified radical mastectomy was performed on all patients. RESULTS: 23/30 patients had lymph nodes in scintigrams and the sentinel lymph nodes were identified with SGP in 25/30 patients. CONCLUSION: Lymphoscintigraphy and subsequent SGP detection with peritumoral injection of 99mTc MIBI can be used for identifying SLN in breast cancer.

A case of Behçet's disease with an abdominal aortic aneurysm and two aneurysms in the common carotid artery. A case report.

A sixteen-year-old boy presented with varied symptoms to the hospital. After he had been diagnosed as having Behçet's disease, investigations revealed two carotid aneurysms in the right common carotid artery and one abdominal aortic aneurysm. The aneurysms were resected, medical therapy was started, and the patient recovered well. Although multiple aneurysms have been reported previously, the authors believe this is the first reported case involving both the carotid and the aorta.

Simultaneous manifestation of an aortocaval and aortoduodenal fistula.

An unusual case of traumatic aortocaval and aortoduodenal fistula is presented in which the two conditions occurred simultaneously. A 19-year-old man was admitted with acute upper gastrointestinal bleeding and a pulsatile abdominal mass. An aortography revelead an aortocaval fistula and at the operation an aortocaval and aortoduodenal fistula was found. An aortocaval fistula can be discovered when a patient presents with an abdominal bruit or cardiomegaly with or without heart failure. The diagnosis of an aortoenteric fistula is difficult because of the subtleties in manifestation. The presence of an abdominal pulsatile mass and acute gastrointestinal bleeding should indicate that an aortoenteric fistula is possible.

A late onset carotido-jugular fistula following shotgun injury.

The incidence of arteriovenous fistulae (AVF) is quite rare in the head and neck region comprising less than 4% of all the traumatic AVF encountered elsewhere in the body. A 42-year-old man presented with a palpable thrill in the cervical region and headache. He had a shotgun injury 10 years ago and had no problem until the previous three months. Diagnosis of a high output traumatic AVF between right common carotid artery and internal jugular vein was made arteriographically. Presence of a neighbouring traumatic aneurysm on the common carotid artery and 9 mm diameter of the fistula tractus suggested open surgery. At the operation ligation of the tractus and aneurysmorraphy was performed and the patient was discharged in the third postoperative day. He has still no problem. This case documented that a shotgun injury even 10 years later may result with an AVF.

Epithelioid leiomyosarcoma of the gastrocolic ligament.

We present the case of a 56-year old man who presented with a large, well circumscribed cystic mass in the gastrocolic ligament. The histopathological study revealed an epithelioid leiomyosarcoma. Epithelioid leiomyosarcomas are generally solid tumours of the stomach. It is uncommon in the gastrocolic ligament and in a cystic formation. Preoperative diagnosis with ultrasound, computerized tomography and endoscopy was not made. Complete surgical resection of the mass was performed. Histopathological study confirmed the diagnosis of epithelial leiomyosarcoma. Two years after surgery, clinical and radiological examinations of the patient were normal.

Kidney transplantation from hepatitis B (HB)-positive donors to HB negative recipients: anti-HB Core immunoglobulin G became positive in all recipients after the transplantation.

OBJECTIVE: Hepatitis B surface antigen (HBsAg)-positive donors are not accepted by many transplant centers as a kidney source owing to risk of transmission of hepatitis B; however, some reports show that these donors can be used under a special protocol. Herein, we report our cases of kidney transplantation from HBsAg(+) donors to HbsAg(-) recipients. METHODS: In the years 2010-2012, we transplanted 4 kidneys from 4 HBsAg(+) donors to HBsAg(-) recipients. They were all living related. All antiHBs(-) recipients were vaccinated before transplantation and became HBsAg(-), anti-HB core immunoglobulin G antibody negative [antiHBcIg(-)], and antiHBs(+). Pretransplantation antiHBs titers were targeted to be >100 IU. If lower, hepatitis B Ig was used at the time of transplantation. One patient received hepatitis B Ig at the time of transplantation (owing to titer of 62 IU/L antiHBs). Lamivudine was prescribed for all kidney allograft recipients after transplantation. RESULTS: Two patients had special induction treatment including rituximab, intravenous immunoglobulin, and plasmapheresis owing to the presence of donor-specific antibody. CONCLUSIONS: All patients became antiHBcIgG(+) at 1-6 months after the transplantation, despite the presence of antiHBs positivity, which might be explained by transmission of hepatitis B virus through the graft.