Cardiovascular risk assessment prior to kidney transplantation.

OBJECTIVES: The objective was to find out risk factors indicating the patients directly to selective coronarography (SCG) to avoid unnecessary non-invasive testing and in their absence to asses low cardiovascular risk and faster inclusion on the waiting list. BACKGROUND: Cardiovascular diseases (CVD) are the most frequent cause of death in dialysed patients. The aim of our retrospective analysis was to identify risk factors for coronary artery disease (CAD) before kidney transplantation (KTx). METHODS: Our retrospective analysis consisted of 55 dialysed patients (46 males, 9 females, p < 0.0001), undergoing SCG before KTx. We divided the patients according to SCG results (negative, n = 40, positive finding, n = 15). RESULTS: We confirmed a significantly lower incidence of diabetic nephropathy (p = 0.0484), ischaemic heart disease (p = 0.0174) and CAD (p = 0.0001) in patients without percutaneous coronary intervention (PCI; negative finding). Haemodynamically significant coronary stenosis correlated with the occurrence of stroke in a patient's history (p = 0.0104). We identified predictors for performing PCI (positive result): type 2 diabetes mellitus (DM) (p = 0.0472), high-density lipoprotein cholesterol ≤ 1.03 mmol/l (p = 0.0359), total calcium level ≤ 2 mmol/l (p = 0.0309), phosphate level ≥ 1.45 mmol/l (OR 0.2034; p = 0.0351). CONCLUSION: In our analysis, patients with DM and poorly managed chronic kidney disease/mineral bone disease were the riskiest subset of the patients with a positive SCG finding (Tab. 4, Fig. 2, Ref. 30). Text in PDF www.elis.sk Keywords: kidney transplantation, coronary artery disease, selective coronarography, cardiovascular risk.

Impact of the venting via vena cava inferior on the outcome of liver transplantation.

BACKGROUND: The liver transplantation is a standard treatment method for the indicated group of patients with a final hepatic failure. The aim of this paper was to compare two reperfusion methods of implanted liver, non-venting and venting vena cava, and to evaluate the impact of both techniques on the post reperfusion syndrome. METHODS: We compared two groups of patients: non-venting (n = 42) and venting (n = 41). We monitored bilirubin, liver enzymes and hemodynamic changes after reperfusion. We recorded monitored parameters immediately prior to the transplantation, during and after the reperfusion and on the 1st postoperative day. All liver grafts were used from the donors after a brain death. RESULTS: We did not find a statistically significant difference in input monitored parameters. We detected significant changes of pH after reperfusion in both monitored groups. We determined a significantly better saturation in the non-venting group, bigger consumption of fresh frozen plasma and thrombo-concentrate in the non-venting group, a significantly higher value of total bilirubin and a lower value of Quick's time in the non-venting group. CONCLUSION: Venting via vena cava inferior did not impact the perioperative and early postoperative course of liver transplantation in our group of patients. However, further analyses are required (Tab. 2, Fig. 3, Ref. 20).

Liver abscess as a rare complication of PEG.

INTRODUCTION: Percutaneous endoscopic gastrostomy (PEG) is one of the most effective methods of providing long-term enteral nutrition in patients with the impossibility of oral intake. Complications are relatively common. The most common is peristomal wound infection at the site of the insertion and leakage along the cannula. Lesscommon complications are colo-cutaneous fistulas and peritonitis. A very rare complication is liver abscess. CASE REPORT: The authors describe a case of a 51-year-old man with a hepatic abscess with inoperable pharyngeal carcinoma with PEG. The patient was admitted to hospital with a developing septic condition due to a liver abscess. The liverabscess resulted from the buried bumper syndrome of the PEG and subsequent complete dislocation of the bumper into the left liver lobe area.. This condition was treated by a surgical review with abscess drainage and the construction of classical gastrostomy. CONCLUSION: Buried bumper syndrome with its complications, such as a liver abscess is a relatively rare complication, but challenges both the diagnosis and therapy of the syndrome itself. Its management requires a close cooperation between a gastroenterologist and a surgeon. Early recognition and treatment can prevent the progression of the condition to sepsis or a septic shock, which can lead to death.

The role of proteinuria, paricalcitol and vitamin D in the development of post-transplant diabetes mellitus.

INTRODUCTION: Post-transplant diabetes mellitus (PTDM) occurs most frequently during the first year after transplantation. We focused on parameters of calcium-phosphate metabolism and proteinuria as possible new risk factors for PTDM after kidney transplantation. MATERIALS AND METHODS: We have prospectively identified risk factors for post-transplant diabetes mellitus with follow-up of 12 months in a set of 167 patients after kidney transplantation. Patients with diabetes mellitus type 1 and type 2 as well as patients using ciclosporin A or mTOR inhibitor have been excluded from the monitoring. From the perspective of immunosuppression it was a homogeneous set of patients. RESULTS: We identified the following independent risk factors for PTDM in our set: average proteinuria > 0.300 g/24 h (HR 3.0785, (95 % CI 1.6946-5.5927), p=0.0002), level of vitamin D<20 ng/ml (HR 5.4517, (95 % CI 2.3167-11.8209), p1.45 mmol/l (HR0.0821, (95 % CI0.0042-1.5920), p=0.0439). The lowest occurrence of PTDM and proteinuria was recorded in patients whose treatment included paricalcitol (p<0.0001) and these patients had at the same time the highest level of vitamin D (p<0.0001). CONCLUSION: Deficit of vitamin D, proteinuria and hyperphosphatemia have been independent risk factors for the development of PTDM in our set. We identified the usage of paricalcitol as protective factor with regard to the PTDM development (Tab. 6, Fig. 4, Ref. 29).

Occurrence of malignancies after kidney transplantation in adults: Slovak multicenter experience.

Malignancies are one of the three major causes of renal recipient´s death with a functioning graft after cardiovascular diseases and infections. Among the variety of risk factors, including conventional and specific to transplant recipients, the duration of immunosuppressive therapy, the intensity of therapy, and the type of immunosuppressive agent all have an impact on development of post-transplant malignancy. The aim of our retrospective study was to document the incidence, the type of malignancies, the patient/graft survival in the group of kidney transplant recipients in Slovak Republic, and to identify the factors which influenced the outcome. We analyzed the data of 1421 patients who underwent renal transplantation from deceased or living donors in the period from 2007 to 2015 in the Slovak transplant centers. The incidence of malignant tumors was 6%, the malignancy was diagnosed in 85 patients at the age of 54.1 ± 9.8 years, more frequently in men (68.2 %; P < 0.0001). The mean time of malignancy occurrence was 45 months after transplantation. The most frequent malignancies were skin cancers- basal cell carcinoma (BCC) in 17.6%, squamous cell carcinoma (SCC) in 8.2%, and malignant melanoma (MM) in 2.4% of patients, followed by non-skin tumors such as renal cell carcinoma (RCC) in 16.5%, cancer of colon in 12.9%, prostatic cancer in 9.4%, breast cancer in 9.4%, cancer of lung in 7.1%, post-transplant lymphoproliferative disease (PTLD) in 2.4%, cancer of urine bladder in 2.4%, and cancer of sublingual gland in 1.17% of patients. Surgical treatment was used in 40% of patients, chemotherapy in 7.1%, radiotherapy in 2.4%, treatment with biological agents in 15.3%, combined therapy in 29.4% and palliative treatment in 5.9% of patients. 55.3% of patients underwent conversion from other immunosuppressive agents into mTORi at the time of malignancy occurrence. The remission was achieved in 48.2% of patients, 28.2% of patients were in the oncology treatment in the end of the year 2015, and 23.5% of patients died. There was no difference in the kidney function at the time of malignancy occurrence (s-creat 133.7 ± 59.8 µmol/l) and one year later (s-creat 131.1 ± 47.9 µmol/l) (P = 0.7768). The patients after successful treatment more frequently suffered from BCC (P = 0.0140), did not undergo palliative treatment (P = 0.0033), but were more frequently treated surgically (P < 0.0001).

[Experience with hepatoblastoma treatment in small children - the use of preoperative 3D virtual analysis MeVis for liver resections]. / Skúsenosti s liecbou hepatoblastómu u najmensích detí - vyuzitie predoperacnej 3D virtuálnej analýzy MeVis pri resekciách pecene.

INTRODUCTION: Hepatoblastoma is an uncommon but most frequent liver cancer in infants and children. The therapy is complex, including neoadjuvant, surgical, and adjuvant therapy. For surgery, the presence of a specialized surgeon and an anaesthesiologist is required. For planning the surgery, the 3D analysis MeVis is currently available. The objective of the work is the assessment of a group of children operated for a liver hepatoblastoma and the assessment of contribution of a pre-surgery virtual 3D analysis MeVis for a surgeon. METHODS: It represents a retrospective assessment of the operated children for the given diagnosis. Upon confirming the disease, the patients underwent neoadjuvant therapy, and then the MeVis analysis of a liver, a surgery, and an adjuvant therapy. The oncologic treatment was performed according to the SIOPEL recommendations. RESULTS: In the period of 2012 to 2016, we treated 5 infant patients with the diagnosed hepatoblastoma. The children were at the age between 4 and 37 months, 4 girls, 1 boy. The size of tumours according to the SIOPEL classification was PRETEXT II to IV. All children underwent a surgery without any complications and without any signs of post-operative failure of the post-resection remnant of the liver. The functional volume of the post-resection remnant of the liver was between 28%70% according to the MeVis analysis. During the long-term monitoring, one patient underwent lung metastasectomy, all children are currently without any signs of relapse of the disease. CONCLUSION: In case of quick catching and correct management of a hepatoblastoma, the results of therapy are very good. For successful treatment, a surgeon experienced in liver resection, presence of a specialized paediatric anaesthesiologist, and a paediatric oncologist are is required. The exact volumetric analysis MeVis is a contribution for a pre-operational review of the finding, and for the preparation of the surgery. The disease is uncommon, and therefore, the groups of patients are small. Due to that reason, the treatment should be centralized to a specialized department.Key words: hepatoblastoma MeVis volumetry liver resection.

[Splenosis as a rare cause of abdominal pain]. / Splenóza ako zriedkavá prícina bolestí brucha.

INTRODUCTION: Splenosis is the autotransplantation of splenic tissue in atypical locations in the abdomen, chest or other parts of the body. CASE REPORT: Authors present a case of splenosis in a 35 years old woman hospitalized with abdominal pain, who underwent splenectomy for traumatic rupture with splenic tissue implantation in the omentum 19 years ago. Surgical revision was indicated for intensive pain. Histopathology confirmed the diagnosis of splenosis in the excised tissue. CONCLUSION: Despite the abandonment of splenic tissue autotransplantation after splenectomy, surgeons may still encounter the diagnosis of splenosis in patients after traumatic splenic rupture. Any incidental finding of splenosis during an operation for another indication should be sent for histopathology examination. KEY WORDS: splenosis, splenectomy abdominal pain scintigraphy.

Surgical treatment of hepatocellular carcinoma.

The incidence of hepatocellular carcinoma (HCC) in Europe and throughout the world is currently increasing. This is caused by an increase in the number of patients with alcoholic liver damage, metabolic syndrome, and by increasing incidence of hepatitis B and C.From January 1, 2004 to December 31, 2013, resection or radiofrequency ablation of the liver was done in 360 patients with benign lesions or malignant tumors of the liver. In 28 patients HCC was diagnosed and histologically confirmed (7.8 %). Seven patients had HCC associated with liver cirrhosis (25 %), and 21 patients were without histologically confirmed cirrhosis (75 %). R0 resection was done in 18 (64 %) patients.Surgical complications occurred in 6 (21 %) patients and reoperation due to tumor relapse or progression was done eight times in 6 (21 %) patients. One-year and five-year patients' survivals were 64 % and 10 %, repectively, and did not statistically differ from the survival of the whole set of patients with tumor diseases in the given time period. In the future it will be possible to improve the long-term survival of patients with HCC by using screening methods for presymptomatic diagnosis of HCC, precise preoperative diagnosis and efforts for R0 resection (Tab. 1, Fig. 4, Ref. 11).

[Hyponatremia - carbamazepine medication complications]. / Hyponatrémia - komplikácia liecby karbamazepínom.

Hyponatremia can be defined like the low sodium concentration, lower that 135 mmol/l. It becomes really serious when the concentration is lower than 120 mmol/l. The most frequent causes of hyponatremia are: the extrarenal loss (GIT, skin, bleeding, sequestration), the renal loss (diuretics, nephritis with the salt loss, osmotical diuresis, the Addison disease), hypothyroidism, the lack of glucocorticoids, emotional stress, pain, pseudohyponatremia (incorrect taking, dyslipoproteinemia). There is fatigue, exhaustion, headache and vertigoes dominating in the clinical record file. By the deficit increasing a patient becomes delirious, comatose even with the shock development. It is necessary to separate sufficient supply of sodium from much more often reason, which is loss of sodium which can be caused by: excessive sweating, vomitting with the metabolical alkalosis development, diarrhoea with the metabolical acidosis development, renal losses (a phase of renal failure). Treatment of hyponatremia: intensive treatment starts at the level of plasmatic concentration of sodium under 120 mmol/l or when neurological symptoms of brain oedema are present. In the therapy it is necessary to avoid fast infusions of hypertonic saline solutions (3-5% NaCl solutions) because of the danger of the development of serious CNS complications (intracranial bleeding, etc.). It is recommended to adjust the plasmatic concentration of sodium up to 120 mmol/l during the first four hours and a subsequent correction should not be higher than 2 mmol per an hour. Treatment of the basic illness is very important. We present 2 case histories: a 74-year old female patient and a 69-year old female patient both with the hyponatremia caused by taking of carbamazepine. We want to inform and warn about not only a well known side effect during long-term treatment but about hyponatremia that arose within 48 hours after the start of taking medicine as well.

Kidney transplantation as a treatment of choice for AA amyloidosis due to periodic fever syndrome.

Renal AA amyloidosis is the most serious complication of periodic fever syndrome, which, inadequate suppression, due to persistent inflammation, leads to nephrotic syndrome and renal failure over several years. In most cases, periodic fever syndromes begin to manifest clinically in early childhood. Occurrence in adulthood is considered rare and is associated with a poorer clinical course. Kidney transplantation (KT) is an effective and safe treatment for end-stage chronic kidney disease (CKD) based on AA amyloidosis. In this paper, we present cases of two patients after deceased donor KT, who have been diagnosed with adult periodic fever syndrome. In the first one, diagnosis and treatment began in advanced stage of CKD and therefore underwent KT with compensated disease, while in the second patient, the disease manifested and diagnosed in the post-KT period. Timely initiation of treatment ensured protection of the graft from amyloid deposition.

Metabolic syndrome and new onset diabetes after kidney transplantation.

AIMS: The metabolic syndrome developed after kidney transplantation is the result of several factors which are identical with the risk factors in normal population, however, also some factors typical for the transplanted patients-especially the effects of immunosuppressive therapy. MATERIAL AND METHODS: In the groupof 268 patients after kidney transplantation, which had no type 1 or type 2 diabetes mellitus before transplantation, we identified patients with metabolic syndrome(based on IDF criteria), 12 months from the kidney transplantation. In all patients, we recorded the following parameters: age at the time of transplantation, type of immunosuppression, waist measure, the value of triacylglycerols, the value of HDL cholesterol, presence of arterial hypertension, andthe value of glycaemia in fasting state (or presence of diabetes mellitus). The groupof patients was divided into the control group and the group of patients with metabolic syndrome. RESULTS: The average age of patients was 46.1±11.6years. The control group included 149 patients (55.6%),and we identified the metabolicsyndromein 119patients (44.4%). The patients with metabolicsyndrome were significantly older (P<0.0001), had significantly larger waist (both the entiregroup and the males andfemales) P<0.0001.The femaleswith metabolic syndrome had significantly lower value of HDL-cholesterol (P=0.0013), and significantly higher number of patients with metabolic syndrome had hyperglycaemia in fasting state or diabetes mellitus (P=0.0006). CONCLUSION: By controlling the weight and waist, we may identify the risk patients for development of metabolic syndrome after kidney transplantation.

Flow Cytometry Panel-Reactive Antibody Screening of Anti-HLA Antibodies in the Waiting List Significantly Reduces the Occurrence of Acute Rejection After Kidney Transplantation.

INTRODUCTION: The presence of preformed HLA-reactive antibodies in recipient serum before transplantation has long been recognized as a prominent risk factor for a generally worse graft outcome. Screening and identification of HLA antibodies can be used to stratify patients into high- and low-risk categories. MATERIALS AND METHODS: We determined patients' anti-HLA antibodies using flow cytometry panel-reactive antibody (flowPRA) screening, specifying more than 5% after positive screening. According to the results of the screening test, patients were allocated to the induction immunosuppressive protocol according to the actual immunologic risk. RESULTS: In the group of 78 patients, screening with flowPRA of anti-HLA antibodies was done twice a year. Patients were divided into 2 groups of immunologic risk (low or medium), and we chose the induction immunosuppressive protocol according to the risk. Stratification of the risk was correct, because the only predictor for development of acute rejection in the monitored period of 12 months was delayed graft function (odds ratio 33.2501; 95% confidence interval 10.0095-110.4508; P < .0001). The occurrence of acute rejection upon implementing the screening was reduced in our transplant center from 44% to 19% (P < .0001). No difference was recorded in the 12-month survival of grafts and patients according to the applied induction immunosuppressive protocol. CONCLUSION: We confirmed significantly reduced occurrence of acute rejection in the follow-up period of 12 months by using individualized induction according to flowPRA screening of anti-HLA antibodies. FlowPRA screening represents a suitable alternative for screening and specification of anti-HLA antibodies in case the Luminex methodology is unavailable.

Impact of Trough Levels of Tacrolimus on Kidney Function and Graft Survival in Short and Longer Periods After Renal Transplantation.

BACKGROUND: Optimizing immunosuppressive treatment in the early posttransplant period is important for achieving long-term graft function and survival. MATERIAL AND METHODS: There were 205 renal transplant recipients involved in this study. Patients were divided into groups according to the induction therapy (no induction vs basiliximab/daclizumab vs rabbit antithymocyte globulin), maintenance therapy at the time of transplantation (tacrolimus [TAC] vs cyclosporine), the average trough TAC levels in months 4 to 6 after TO and serum creatinine 5 years after renal transplantation. RESULTS: The incidence of acute rejection was significantly higher in cyclosporine than in TAC group of patients (P = .0364). The average TAC levels on elapsed time after transplantation significantly decreased (P < .0001). Five years after renal transplantation, there were higher TAC levels (5.6 ± 0.7 ng/mL) in the group with "zero" low levels than in the group with "zero" high levels (4.6 ± 1.1 ng/mL), which was statistically significant (P < .0001). We did not find any difference in graft and patient survival in posttransplant years 2 to 5 according to TAC levels or the induction treatment. CONCLUSIONS: In our study, we have confirmed that better graft function 5 years after transplantation was connected with higher trough tacrolimus levels on elapsed time after renal transplantation.

Correlation between CMV Infection and Post-transplantation New-onset Diabetes Mellitus.

BACKGROUND: New-onset diabetes mellitus after transplantation (NODAT) is a well-known complication of transplantation. OBJECTIVE: To determine the correlation between CMV infection and NODAT. METHODS: Retrospectively, we detected CMV replication (PCR) in every month after renal transplantation in the first 12 months of the procedure in a homogenous group of patients from the immunosuppression point of view. RESULTS: In 167 patients (64 with NODAT and 103 in the control group), the average amount of CMV viremia was not significantly different between the NODAT and the control group (p=0.929). In the 10th month of transplantation, we recorded a significantly higher CMV viremia in the NODAT group (p<0.0001), however, in the multivariant analysis, the observed statistical difference vanished. The survival of patients and grafts was 12 months after kidney transplantation without any statistically significant difference between the studied groups (p=0.611 and p=0.538, respectively). CONCLUSION: CMV is not a risk factor for NODAT.

Incidence of Diabetes Mellitus After Kidney Transplantation in Slovakia: Multicentric, Prospective Analysis.

BACKGROUND: The incidence rate of post-transplant diabetes mellitus (PTDM) after kidney transplantation (KT) is 5% to 40%. The objective of this analysis was to identify the risk factors of PTDM after KT in the Slovak Republic (SR). METHODS: In the group of 133 patients/non-diabetics, we identified the risk factors of PTDM in the monitored period of 12 months from transplantation. RESULTS: The incidence of PTDM in the SR in 2014 was 38.3%. By logistic regression, we discovered that the age at the time of KT [odds ratio, 1.0885; 95% CI, 1.0222-1.1592; P = .0082], the value of body mass index (BMI) at the time of KT [odds ratio, 1.4606; 95% CI, 1.0099-2.1125; P = .0442], and the value of insulin resistance index (homeostatic model assessment for insulin resistance) at the time of KT [odds ratio, 2.5183; 95% CI, 1.7119-3.4692; P < .0001] represented predictive factors of PTDM. The independent risk factors of PTDM in our group were age at the time of KT of more than 60 years [HR 0.3871; 95% CI 0.1659-1.7767; P = .0281], waist circumference at the time of KT in men more than 94 cm and in women more than 80 cm [HR, 3.4833; 95% CI, 1.2789-9.4878 (P = .0146)], BMI at the time of KT [HR 3.0011; 95% CI 1.0725-8.3977 (P = .0363)], and triacylglycerols at the time of KT more than 1.7 mmol/L [HR, 2.9763; 95% CI, 1.0141-8.7352; P = .0471]. CONCLUSIONS: In the group of Slovak patients after kidney transplantation, the dominating risk factor for PTDM development was insulin resistance prior to KT.

Twelve-Month and Five-Year Analyses of Risk Factors for New-Onset Diabetes After Transplantation in a Group of Patients Homogeneous for Immunosuppression.

OBJECTIVE: In the case of new-onset diabetes after transplantation (NODAT) development, it is suitable to reduce calcineurin inhibitors and corticosteroids. But change of immunosuppression can be counterproductive and can cause development of rejection and leads to further NODAT aggravation. METHODS: We retrospectively evaluated risk factors after kidney transplantation. Comparison groups were homogeneous in terms of administered immunosuppression, and individual monitored parameters were not distorted by the immunosuppression administered. RESULTS: In the 12-month analysis we identified these risk factors for NODAT: age at the time of transplantation, 50-59 years (P = .0034); age at the time of transplantation, ≥ 60 years (P < .0001); positive family anamnesis for diabetes mellitus type 2 (P < .0001); body mass index at the time of transplantation, ≥ 30 kg/m(2) (P = .0236); prediabetes before transplantation (P < .0009); and proteinuria, >0.15 g/d (P < .0002). In the 5-year analysis, we identified patients who were diagnosed with NODAT after the 1st year. We identified age ≥ 50 years at the time of transplantation to be an independent risk factors for NODAT. CONCLUSIONS: It is advisable to carry out the oral glucose tolerance test even in patients with physiologic levels of fasting glycemia.