Başkent Üniversitesi Yayınları
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Item De Novo Postallogeneic Hematopoietic Stem Cell Transplant Membranous Nephropathy(Başkent Üniversitesi, 2013-02) Numata, Akihiko; Muto, Shigeaki; Ando, Yasuhiro; Kusano, Eiji; Yumura, Wako; Takemoto, Fumi; Saito, Osamu; Mori, Masaki; Morishita, YoshiyukiWe report membranous nephropathy in a 61-year-old man after allogeneic hematopoietic stem cell transplant without chronic graft-versus-host disease. A diagnosis of acute myeloid leukemia was made, and the patient received hematopoietic stem cell transplants, twice, from different donors. The first donor was his brother and the second donor was an unrelated man. Human leukocyte antigens between donors and recipient were fully matched. His clinical course was stable without acute or chronic graft-versus-host disease or relapse of acute myeloid leukemia with tacrolimus after the second hematopoietic stem cell transplant. Six months after the second hematopoietic stem cell transplant, tacrolimus was decreased gradually and discontinued because of tacrolimus-induced liver dysfunction. Three months after discontinuing the tacrolimus, the patient developed edema in his leg. The results of a blood analysis showed that plasma albumin level was 21 g/L and plasma total cholesterol level was 11.5 mmol/L, while results from a urinalysis showed proteinuria of 5.6 g/d without hematuria. No abnormalities in the skin, mucosal tissues, and other organs suggestive of chronic graft-versus-host disease were seen. A renal biopsy was done to investigate the cause, which revealed renal disease. Electron microscopic analysis showed dense deposits in the subepithelial region in all glomeruli. Immunofluorescence analysis showed the deposition of IgG4 and C3c in the subepithelial space of all glomeruli. Membranous nephropathy was diagnosed. He then was administered prednisolone at a dosage of 45 mg/d (0.7 mg/kg/d). After prednisolone treatment, urine protein and hypoalbuminemia were markedly improved, and his leg edema disappeared. These results suggest that this membranous nephropathy may have been de novo membranous nephropathy after hematopoietic stem cell transplant because it developed after hematopoietic stem cell transplants without chronic graft-versus-host disease.Item Diabetic Ketoacidosis Associated With Acute Pancreatitis in a Heart Transplant Recipient Treated With Tacrolimus(Başkent Üniversitesi, 2013-02) Im, Moon-Sun; Lee, Hae-Young; Kim, Ki-Bong; Cho, Hyun-Jai; Ahn, Hyo-SukNew-onset diabetes mellitus after transplant is a well-recognized complication of tacrolimus immunosuppression and commonly occurs as a form of type 2 diabetes mellitus. However, tacrolimus-associated acute pancreatitis causing diabetic ketoacidosis has not been reported in heart transplant patients. We report a 22-year-old women hospitalized owing to diabetic ketoacidosis associated with acute pancreatitis 7 months after a heart transplant. Her immunosuppression included tacrolimus. She was admitted with complaints of polydipsia, anorexia, and abdominal pain of 3 days’ duration. Her initial laboratory test revealed a toxic level of tacrolimus (> 30 ng/mL), severe hyperglycemia (39 mmol/L), severe metabolic acidosis (pH 6.9), and ketonuria, although diabetes mellitus had never been diagnosed. Serum amylase and lipase levels and abdominal computed tomography suggested the presence of acute pancreatitis. After correcting the diabetic ketoacidosis and getting the tacrolimus level to the normal range, she was discharged home. Three months later, insulin was replaced with oral hypoglycemic agents. Pancreatitis can present with diabetic ketoacidosis in the recipient of a heart transplant treated with tacrolimus. Clinicians should pay more attention to tacrolimus levels and the risk of pancreatitis.Item Treatment of Liver Transplant Graft-Versus-Host Disease With Antibodies Against Tumor Necrosis Factor-α(Başkent Üniversitesi, 2013-02) Blank, Gregor; Königsrainer, Alfred; Nadalin, Silvio; Handgretinger, Rupert; Kratt, Thomas; Li, JunAcute graft-versus-host disease is uncommon after liver transplant. We recently treated a 60-year-old man with liver transplant for hepatocellular carcinoma. After the primary liver transplant graft did not function, revision liver transplant resulted in excellent function. Subsequently, the patient developed watery diarrhea, systemic inflammatory response syndrome, a skin rash on his limbs and trunk, and palmar erythema. Skin biopsy suggested viral exanthems consistent with cytomegalovirus. Despite treatment for cytomegalovirus, intestinal symptoms worsened. Analysis of peripheral blood with fluorescence-activated cell sorting showed a high proportion of T lymphocytes, with 5% to 10% T cells specific to the second donor, suggestive of graft-versus-host disease. Within 48 hours after beginning therapy with antibodies against tumor necrosis factor-α (infliximab), the skin rash disappeared and endoscopy showed slight improvement of the mucosal regeneration. However, despite antifungal prophylaxis with caspofungin, the patient developed angioinvasive pulmonary aspergillosis and multiple organ failure, and he died. In conclusion, typical clinical symptoms of graft-versus-host disease after liver transplant may include skin rash and gastrointestinal symptoms, and diagnosis may be confirmed by histologic examination and testing for blood chimerism. A consensus for the treatment of graft-versus-host disease still is lacking, but tumor necrosis factor-α is an encouraging target for therapy to decrease the symptoms of graft-versus-host disease and enable mucosal regeneration.Item Treatment of Pure Red-Cell Aplasia With Cyclosporine in a Renal Transplant Patient(Başkent Üniversitesi, 2013-02) Yildirim, Rahsan; Aydinli, Bulent; Gokbulut, Puren; Uyanik, Abdullah; Keles, Mustafa; Bilen, YusufAcquired pure red-cell aplasia is a rare disorder that can be either idiopathic or associated with certain autoimmune diseases, pregnancy, lymphoproliferative disorders, nutritional deficiencies, or medicines. We present a deceased-donor renal transplant patient who developed pure red-cell aplasia associated with mycophenolate mofetil or tacrolimus and was treated with cyclosporine. A 20-year-old woman was transplanted from a deceased donor 1 month earlier and presented to us with symptoms of fatigue, prostration, and palpitation. The results of a laboratory examination revealed anemia. A diagnostic work-up resulted in a diagnosis of pure red-cell aplasia. Mycophenolate mofetil was discontinued. Tacrolimus also was replaced with cyclosporine 2 months after mycophenolate mofetil was halted because of a lack of improvement in anemia. Three months later, her anemia improved with cyclosporine. Starting cyclosporine instead of tacrolimus or mycophenolate mofetil showed good improvement in our patient within 6 months of therapy.Item Relapsing Mycobacterium Genavense Infection as a Cause of Late Death in a Lung Transplant Recipient: Case Report and Review of the Literature(Başkent Üniversitesi, 2012-12) Lhuillier, Elodie; Dauriat, Gaëlle; Ruimy, Raymond; Mal, Hervé; Mourvilliers, Bruno; Danel, Claire; Veziris, Nicolas; Brugière, OlivierMycobacterium genavense is recognized as a life-threatening pathogen in severely immunocompromised patients, mostly in those with advanced human immunodeficiency virus infection. We report a case of M. genavense infection in a lung-transplant recipient with late-onset death occurring from disseminated infection. In human immunodeficiency virus-negative patients, there exist only about 10 reports of disseminated M. genavense infection in immunocompromised hosts; and to our knowledge, this is a first reported case of M. genavense infection after a lung transplant. Diagnosis of M. genavense was obtained only with nucleic acid-based identification technique, as frequently observed in a few cases of human immunodeficiency virus-negative patients. A striking feature was the recurrence of this infection in our patient after a seemingly infection-free period of 3 years. Because M. genavense infection can be life-threatening, clinicians must be aware of the frequent requirement for nucleic-acid–based identification for its diagnosis.Item Long-term Survival After Liver Transplant for Recurrent Hepatocellular Carcinoma With Bile Duct Tumor Thrombus: Case Report(Başkent Üniversitesi, 2012-12) Liu, Chao; Wang, JieObjectives: Hepatocellular carcinoma with bile duct tumor thrombus is considered an aggressive malignancy, and the prognosis of liver transplant for it remains obscure. Materials and Methods: A 42-year-old man with recurrent hepatocellular carcinoma and a history of surgical resection was admitted to our hospital with a 10-day history of yellowish urine and itchy skin. There were 3 lesions in the right lobe with the diameter of 2 cm each. A mass was found in the upper part of common bile duct, and the intrahepatic bile duct was dilated. His serum alpha-fetoprotein level was 2476 µg/L, total bilirubin level was 327 µmol/L, direct bilirubin level was 261 µmol/L, and alanine aminotransferase was 714 U/L. There was no main portal vein thrombus or extrahepatic metastases. Because of his poor liver function, he was listed for a liver transplant. During the wait (30 d), he underwent 9 episodes of plasmapheresis to decrease the serum level of bilirubin. He had an orthotopic liver transplant with the graft from a deceased donor. After the liver transplant, he received 5 cycles of chemotherapy with the regimen of oxaliplatin and 5-fluorouracil. Results: This patient has survived without recurrence of hepatocellular carcinoma for more than 82 months and remains in good condition. Conclusions: Liver transplant may have a favorable result for hepatocellular carcinoma patient with a bile duct tumor thrombus, within the Milan criteria.Item Treatment of Antibody-Mediated Rejection in Kidney Transplant Recipients: A Single-Center Experience With a Bortezomib-Based Regimen(Başkent Üniversitesi, 2012-12) Nigos, Janice G.; Sureshkumar, Kalathil K.; Ko, Tina Y.; Marcus, Richard J.; Hussain, Sabiha M.; Nath, Parineesha; Arora, SwatiObjectives: Antibody-mediated rejection after kidney transplant is less responsive to conventional antirejection therapies. The proteasome inhibitor bortezomib has activity against mature plasma cells that produce damaging donor-specific antibodies. We present our experience of using a bortezomib-based regimen in patients with severe antibody-mediated rejection. Materials and Methods: A retrospective chart review was performed on patients with biopsy-proven antibody-mediated rejection after kidney transplant at our institution over 12 months. Diagnosis of antibody-mediated rejection was made on the basis of positive peritubular capillary C4d staining along with either histologic evidence of acute rejection or positive donor-specific antibody titers. Treatment for antibody-mediated rejection included plasmapheresis, intravenous immunoglobulin, steroids, single-dose rituximab (375 mg/m2) along with bortezomib (1.3 mg/m2) on days 1, 4, 8, and 11. Antibody-mediated rejection was diagnosed in 6 patients. Patients received induction with either alemtuzumab (n=4) or rabbit-antithymocyte globulin (n=2) and were maintained on a tacrolimus/mycophenolate mofetil/early steroid withdrawal protocol. Results: Four of 6 patients responded to treatment. Patients had stable kidney function during follow-up (median 14 months) after bortezomib therapy. Conclusions: In this series, we demonstrated the effectiveness of a bortezomib-based treatment regimen in achieving reduction of donor-specific antibody titers and stable renal function in patients experiencing severe antibody-mediated rejection.Item Rhinomaxillary Mucormycosis in a Renal Transplant Recipient: Case Report(Başkent Üniversitesi, 2012-12) Azarpira, Negar; Khademi, Bighan; Kazemi, Kourosh; Ashraf, Mohamd JavadObjectives: Rhinomaxillary mucormycosis is a clinical manifestation of zygomycosis in solid-organ transplant recipients. Without proper diagnosis and treatment, rhino-orbital-cerebral zygomycosis, particularly a central nervous system disease, will develop with substantial complications. Case report: A 42-year-old man who had undergone renal transplant was admitted to our otolaryngology department with unilateral bloody nasal discharge. Mucormycosis was detected in the necrotic tissue of the maxillary sinus. Surgical ablation of the infected parts, along with antifungal treatment, restricted extension of the infection. Conclusions: Early detection of opportunistic infections in transplant recipients plays an important role in preventing dissemination. Fungal infections, including zygomycosis, should be considered in all solid-organ recipients, especially in persons with local unusual manifestations. Early diagnosis and successful treatment reduce mortality.Item Emergency Endovascular Repair in a Patient With Abdominal Aortic Aneurysm With Pelvic Transplant Kidneys: Case Report(Başkent Üniversitesi, 2012-12) Smedile, Gianluca; Tisone, Giuseppe; Leporelli, Paolo; Orlando, Giuseppe; Booth, Christopher; Luca, Linda De; Castrucci, Tommaso; Laria, Giuseppe; Bellini, Maria IreneAbdominal aortic aneurysms after a kidney transplant are becoming treated more frequently owing to the extension of renal transplant in severely arteriosclerotic older patients. Renal transplant recipients with autosomal dominant polycystic kidney disease are prone to develop abdominal aortic aneurysms. We present the case of a ruptured abdominal aortic aneurysm that occurred in a renal transplant patient with autosomal dominant polycystic kidney disease. The patient was treated with emergency endovascular repair because open surgery could not be performed successfully owing to the presence of massive polycystic native kidneys and a liver that was occupying the entire peritoneal cavity. His postoperative course was uneventful without complications. The important lessons to be learned from our case are 2-fold: (1) Autosomal dominant polycystic kidney disease renal transplant recipients should be screened annually for abdominal aortic aneurysms to prevent ruptures and (2), emergency endovascular repair may be a preferred treatment in renal transplant recipients owing to its low surgical risk and success.Item Bilateral Lung Transplant for Bronchioloalveolar Carcinoma: First Case in China(Başkent Üniversitesi, 2012-10) Wang, Yeming; Chen, Jingyu; Zheng, Mingfeng; Wang, Zhenxing; Wei, DongBecause of the potential risk of recurrence and dissemination, lung carcinoma is rarely considered an indication for lung transplant, but as the technique has improved, novel end-stage pulmonary diseases can be treated successfully. Experience in lung transplant for patients with lung carcinoma has shown that select patients may benefit from this therapy. In this report, we examine the case of a bilateral lung transplant in a young man with bilateral bronchioloalveolar carcinoma. This report suggests that bilateral lung transplant might be an efficient therapeutic option for select patients with lung carcinoma.