Başkent Üniversitesi Yayınları
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Item Unusual Presentation of Cytomegalovirus Infection in Patients After Organ Transplant(Başkent Üniversitesi, 2009-03) Guilbeau-Frugier, Céline; Rostaing, Lionel; Tiple, Aurélien; Kamar, Nassim; Esposito, Laure; Mengelle, Catherine; Combelles, Sophie; Otal, PhilippeObjectives: Cytomegalovirus (CMV) infection has an enormous impact in solid-organ transplant patients. In immunocompromised patients, CMV is associated with well-known direct effects. We herein describe 3 unusual patterns occurring in the setting of tissue-invasive CMV associated with high viral load. Materials and Methods: Of our 3 cases, the first patient after kidney transplant presented with cholestasis related to radiological cholangitis; the second patient after heart transplant presented with erythema nodosum with CMV infection as the sole cause; and the third patient after kidney transplant presented with acute renal failure related to mild interstitial nephritis with acute tubular necrosis and tubulitis. Results: The first patient’s cholestasis resolved with antiviral therapy, as did the erythema nodosum and CMV infection of the heart transplant patient. The third patient’s acute renal failure resolved by increased steroid dosage, plasma exchanges, and ganciclovir therapy. Conclusions: These 3 unusual presentations of tissue-invasive CMV had favorable outcomes with antiviral therapy.Item Portal Hyperfusion or Hepatic Venous Congestion: Which One Affects Kupffer Cell Function More?(Başkent Üniversitesi, 2009-03) Firat, Ozgur; Yuzer, Yildiray; Kitapcioglu, Gul; Omur, Ozgur; Yilmaz, Funda; Makay, Ozer; Mutlukoca, NadideObjectives: Because of their effects on the liver parenchyma after surgery, portal hyperperfusion and hepatic venous congestion are challenging problems for hepatobiliary surgeons. However, the effects of those conditions on Kupffer cells have not been established. The aim of this study was to investigate the effects of vascular streams modified by portal hyperperfusion and hepatic venous congestion on Kupffer cell function. Materials and Methods: Thirty rats were allocated into 3 groups of 10 rats each and were subjected to right portal vein ligation to induce hyperperfusion in the left lobe of the liver (group 1), occlusion of the right hepatic vein to produce venous congestion (group 2), or sham operation (controls; group 3). After 72 hours, the right and left liver lobes of the subjects were submitted separately for scintigraphic and histopathologic evaluation, and the radiocolloid uptake per gram of liver tissue and the number of Kupffer cells per square millimeter were calculated. Results: The mean technetium-99m labeled sulfur colloid uptake values of the liver tissue per gram were 0.126 ± 0.038 for group 1, 0.106 ± 0.032 for group 2, and 0.110 ± 0.031 for group 3. Portal hyperperfusion significantly increased the technetium-99m labeled sulfur colloid uptake of the liver tissue per gram (P = .043). The mean number of Kupffer cells per square millimeter was calculated for each group as follows: 321 ± 094 × 10-6 for group 1, 369 ± 083 × 10-6 for group 2, and 355 ± 096 × 10-6 for group 3. Both vascular streams produced no significant effects on the number of Kupffer cells (P > .05). Conclusions: In this experimental model, portal hyperperfusion affected Kupffer cell function more than did hepatic venous congestion.Item Role of Folic Acid in Atherosclerosis After Kidney Transplant: A Double-blind, Randomized, Placebo-controlled Clinical Trial(Başkent Üniversitesi, 2009-03) Farjad, Reza; Einollahi, Behzad; Nafar, Mohsen; Khatami, Fatemeh; Kardavani, Babak; Farhangi, Soudabeh; Kalantar, Akbar; Firouzan, Ahmad; Pour-Reza-Gholi, FatemehObjectives: We investigated the effects of folic acid supplementation on plasma total homocysteine levels and carotid intima-media thickness after kidney transplant. Materials and Methods: Sixty patients who had undergone a kidney transplant were studied in this double-blind, randomized, placebo-controlled clinical trial. Those subjects were randomized to receive either 5 mg/d of oral folic acid or an equivalent dosage of placebo. The main outcome variables were the plasma total homocysteine level and carotid intima-media thickness (determined via B-mode sonography) at baseline and 2, 4, and 6 months after kidney transplant. We used independent and paired sample t tests for data analysis. Results: The mean age of the patients was 40.9 ± 10 years, and 32 of those subjects (58.2%) were men. In the control group, the plasma total homocysteine levels were 19 µmol/L at baseline, 18.7 µmol/L after 2 months, 19.3 µmol/L after 4 months, and 20 µmol/L after 6 months; and the carotid intima-media thickness measurements were 0.81 mm at baseline, 0.82 mm after 2 months, 0.84 mm after 4 months, and 0.85 mm after 6 months. In the folic acid group, the plasma total homocysteine levels were 18.5 µmol/L at baseline, 4.7 µmol/L after 2 months, 12.9 µmol/L after 4 months, and 10.9 µmol/L after 6 months; and the carotid intima-media thickness measurements were 0.73 mm at baseline, 0.73 mm after 2 months, 0.72 mm after 4 months, and 0.71 mm after 6 months. Conclusions: Folic acid supplementation reduces both the plasma total homocysteine level and carotid intima-media thickness shortly after kidney transplant.Item Renal Transplant in Patients with Spinal Cord Injuries(Başkent Üniversitesi, 2009-03) Basiri, Abbas; Azadvari, Mohaddeseh; Parvaneh, Masoud Javadi; Hosseini-Moghddam, Seyed Mohammadmehdi; Shakhssalim, NasserObjectives: There is no knowledge on the outcome of renal transplant for end-stage renal disease secondary to neurogenic bladder caused by spinal cord injury. In this study, we evaluated the outcome of kidney allograft recipients with spinal cord injury. Materials and Methods: We evaluated graft survival, clinical course, laboratory findings, and imaging studies in 21 men (veterans) with spinal cord injury and renal failure secondary to neurogenic bladder. They underwent renal transplant between 1990 and 2006. Bladder dysfunction was appropriately managed before or with receiving the kidney allograft. Results: Mean (± SD) age of patients was 43.8 ± 5.9 years. Mean glomerular filtration rate at the closing date of the study was 89.5 ± 33.6 mL/min. During follow-up (median: 6 years, range: 1-17 years), mean duration of graft survival was 15.4 ± 1.0 years (95% confidence interval, 13.2-17.5 years). Following renal transplant, mean nadir level of serum creatinine was 74.25 ± 16.79 µmol/L (0.84 ± 0.19 mg/dL). Six patients (28.6%) had kidney stones before renal transplant, and 2 patients (9.5%) after (1 patient with new kidney stones and 1 patient with kidney stones before and after transplant). Pyelonephritis occurred in 18 patients (85.7%) before transplant, and in 9 patients (42.9%) patients after (P = .07). Graft loss occurred in 2 patients (9.5%) 4 and 18 months after the transplant. Conclusions: Spinal cord injury patients who receive allograft kidney transplants have acceptable outcomes, and transplant may reduce urolithiasis and upper urinary tract infection.Item Effects of Surgical Technique on Postoperative Renal Function After Orthotopic Liver Transplant(Başkent Üniversitesi, 2009-03) Gholami, Siavosh; Malek-Hosseini, Seyed Ali; Nikeghbalian, Saman; Salahi, Heshmatollah; Bahador, Ali; Kazemi, Kourosh; Kakaei, Farzad; Rajaei, ElnazObjectives: The classic technique for orthotopic liver transplant consists of the total excision of the retrohepatic inferior vena cava during native hepatectomy. Controversy about the effects of the classic technique on postoperative renal function continues. The aim of this study was to evaluate the effects of the chosen hepatectomy technique on postoperative renal function. Materials and Methods: Of 253 patients who received an orthotopic liver transplant between June 2006 and July 2008 in the Shiraz transplant unit, only 15 underwent operation with the classic technique. Patient demographics and factors including cold ischemic time, warm ischemic time, operative time, transfusions, blood loss, and early postoperative renal function were assessed retrospectively. The criteria for acute renal failure were a serum creatinine level of > 133 µmol/L (1.5 mg/dL), an increase in the baseline serum creatinine level by 50%, or oliguria requiring renal replacement therapy. Results: All patients received a liver from a deceased donor, and none required venovenous bypass during the operation. The minimum mean arterial blood pressure value of the patients during clamping was 65 ± 19 mm Hg. The mean preoperative plasma creatinine level was 87.51 ± 39.78 µmol/L (0.99 ± 0.45 mg/dL). During the first week after transplant, 7 patients (46.6%) experienced acute renal failure, and 3 of those 7 required renal replacement therapy. By the sixth postsurgical month, 4 of those 7 patients had died (1 from adult respiratory distress syndrome, 2 from sepsis, and 1 from recurrent cholangiocarcinoma). In all other patients, the plasma creatinine level had returned to the normal range by the third postsurgical week 3 or during short-term follow-up. Conclusions: Use of the classic technique for orthotopic liver transplant may increase the rate of postoperative renal failure, but that complication usually resolves during short-term follow-up.Item Moral and Ethical Issues in Living-Donor Liver Transplant in Egypt(Başkent Üniversitesi, 2009-03) Adawy, Nermine M.; Helmy, Amr; Abdeldayem, Hesham M.; Allam, Naglaa A.; Salah, Essam; Aziz, Amr Mostafa; Kashkoush, Samy; Gad, HishamObjectives: Since brain-death criteria are not accepted in Egypt, only organs acquired from living donors can be used for transplant. Our objective was to highlight the ethical issues raised by living-donor liver transplant. Materials and Methods: The study was conducted by reviewing publications from centers performing living-donor liver transplant in Egypt and by consulting with a group of experts in the fields of liver transplantation, clinical ethics, and religious scholarship. Results: The first successful living-donor liver transplant in Egypt was performed at the National Liver Institute in 1991; however, this program did not continue because of poor early results. In August 2002, transplants began at Dar-Al-Foaud Hospital; since then, almost 500 cases of living-donor liver transplant have been performed at 9 centers. Although the donor risk is estimated to be low, 2 donors died (0.4%). The ethical principle that best applies to living-donor liver transplant is primum non nocere (first, not to harm), as the donor derives emotional benefit from donation and the opportunity to save a life. It is important to stress that the alternative to living-donor liver transplant in Egypt is not deceased-donor liver transplant. There are no doubts that this is a beneficial procedure for the recipient with acceptable risks to the donor. Conclusions: It is ethically appropriate to perform liver transplant using living donors.Item A Report of Outcomes After Orthotopic Liver Transplant With Allografts From Heparin Antibody-Positive Donors(Başkent Üniversitesi, 2009-12) Aloia, Thomas A.; Goss, John A.Heparin-induced thrombocytopenia (HIT) is an immune-mediated condition associated with thrombocytopenia and thrombotic complications. The condition is increasingly recognized in hospitalized patients including severely injured trauma patients. Because these patients may eventually be considered for organ donation, management of the HIT screen-positive donor has become an important issue in transplant surgery. We describe the recent management of 2 liver allograft donors with relative thrombocytopenia and positive HIT antibody screens. In both cases, systemic anticoagulation at the organ recovery operation was accomplished with argatroban, a synthetic thrombin inhibitor. This management strategy resulted in successful transplants for 7 recipients (1 heart, 2 liver, 4 kidney). Neither of the liver recipients demonstrated signs or symptoms of HIT, and neither had any postoperative thrombotic complications. Based on this experience, a treatment algorithm for managing HIT-positive donors is proposed. In addition, the pathophysiology of HIT and various testing modalities for the disorder are discussed.Item Forkhead Box P3 (FOXP3) mRNA Expression Immediately After Living-Donor Liver Transplant(Başkent Üniversitesi, 2009-03) Sakamoto, Rieko; Inomata, Yukihiro; Nishimori, Aya; Yoshimoto, Kazuhiko; Ramirez, Manuel E. Zeledon; Asonuma, KatsuhiroObjectives: The forkhead box P3 (FOXP3) gene is considered to be the master gene of regulatory T cells. The significance of regulatory T cells in liver transplant has been investigated in previous reports, but quantitative FOXP3 messenger RNA (mRNA) expression after living-donor liver transplant has not been assessed. The objective of this study was to determine whether the human FOXP3 gene is a good marker for regulatory activity in T cells in living-donor liver transplant recipients during the immediate posttransplant period. Materials and Methods: In peripheral blood mononuclear cells of 15 living-donor liver transplant recipients during the first month after transplant, we measured the population of CD4+CD25+ T cells using flow-assisted cell sorting and the expression of FOXP3 mRNA using real-time polymerase chain reaction. Results: Fold induction of FOXP3 mRNA significantly increased on postoperative day 7 (3.3-fold) compared with the reference preoperative value (P < .01) but returned to baseline by 28 days after transplant. The population of CD4+CD25+ T cells did not change significantly. Expression of FOXP3 mRNA on days 14, 21, and 28 were lower in recipients with acute cellular rejection within 60 days after living-donor liver transplant. Conclusions: Increased expression of FOXP3 mRNA immediately after living-donor liver transplant might be influenced by activation of T cells including regulatory T cells and other T cells. However, after stabilization of these activation profiles, it seems likely that FOXP3 mRNA expression is associated with graft acceptance. Further studies are necessary with measurement of FOXP3 mRNA expression at appropriate sampling points.Item Ethical Issues in Live Donor Kidney Transplant: Views of Medical and Nursing Staff(Başkent Üniversitesi, 2009-03) Mazaris, Evangelos M.; Papalois, Vassilios E.; Warrens, Anthony N.Objectives: The ongoing development of live donor kidney transplant has generated many ethical dilemmas. It is important to be aware of the attitudes of transplant professionals involved in this practice. Materials and Methods: An anonymous and confidential questionnaire was sent to 236 members of the medical and nursing staff of the West London Renal and Transplant Centre, to assess their views on the ethics of the current practice of live donor kidney transplant. Results: Of the 236 questionnaires, 108 (45.8%) were returned. Respondents considered live donor kidney transplant ethically acceptable between blood relatives (100%), nonblood relatives and friends (92.6%), and strangers (47.2%). Most respondents were willing to donate a kidney to a blood relative (92.6%) or a nonblood relative or friend (81.5%), and 12.0% were willing to donate to a stranger. Considering themselves as potential recipients if they had end-stage renal disease, most would accept a kidney from a blood relative (91.7%) or nonblood relative or friend (85.2%), while 44.5% would accept a kidney from a stranger. The highest number of respondents (43.5%) believed that the recipient should approach the potential donor. About one-third believed there should be no financial reward, not even compensation for expenses, for donors; 8% favored direct financial rewards for donors known to recipients, and 18% favored rewards for donors not known to recipients. Slightly more than half were in favor of accepting donors with mild to moderate medical problems. Conclusions: Live related and unrelated kidney donation are considered ethically acceptable procedures, and non-directed donation is gaining support among transplant professionals. A substantial minority favored direct financial rewards for donors, especially in the case of non-directed donation.Item Acute Tubular Necrosis After Renal Allograft Segmental Infarction: The Nephrotoxicity of Necrotic Material(Başkent Üniversitesi, 2008-12) Ardalan, Mohammad Reza; Shoja, Mohammadali Mohajel; Ghabili, Kamyar; Nasri, HamidObjectives: Renal allograft dysfunction can be caused by renal vessel thrombosis, acute tubular necrosis, hyperacute or acute rejection, nephrotoxicity induced by cyclosporine or tacrolimus, thrombotic microangiopathy, or urinary tract obstruction. Materials and Methods: We describe a renal transplant recipient in whom oliguria developed during the first week after transplant, although his early renal allograft function was good. Results: A Doppler ultrasonographic study revealed a lack of perfusion in the lower pole of the allograft. A perfusion defect was noted in the lower pole that was supplied by a polar artery, which had been damaged during engraftment. Light microscopy disclosed tubular cell necrosis without evidence of vascular or humoral rejection. Conclusions: We suggest that toxic molecules such as tumor necrosis factor-alpha released from a segmental infarcted area can induce tubular cell damage and necrosis leading to renal allograft dysfunction.