Başkent Üniversitesi Yayınları
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Item One-Suture, 1-Knot Technique in Renal Vascular Transplant(Başkent Üniversitesi, 2010-09) Simforoosh, Nasser; Feizzadeh, Behzad; Moslemi, Mohammad Kazem; Gharaati, Mohammad RezaObjectives: We describe the results of our 1-suture, 1-knot technique for vascular anastomosis in renal transplant. This technique can be used for both of the arterial and venous anastomoses. Materials and Methods: Between May 2006 and June 2008, a total of 386 renal transplants were done in our center, using a 1-suture, 1-knot technique. Intraoperative data including the warm and cold ischemic time, arterial and venous anastomotic time, and any early and late postoperative complications in the follow-up were recorded. Results: Mean age of recipients was 37 years. Mean kidney warm and cold ischemia time was 4.8 and 26.2 minutes. Mean arterial and venous anastomotic time was 5.1 and 7.2 minutes. No vascular complications were seen in the early postoperative period. Delayed graft function was diagnosed in 36 patients, but a renal scan showed good perfusion of the allografts of these cases. In the mean follow-up of 18.5 months, we did not encounter any case of renal artery thrombosis or any suspected arterial stenosis. Conclusions: The 1-suture, 1-knot technique is a safe, rapid, and easy method for arterial and venous anastomosis of the renal allograft with low complication rates. It is especially valuable in obese patients and recipients with deep iliac fossa.Item Neutropenia Related to Valacyclovir and Valganciclovir in 2 Renal Transplant Patients and Treatment With Granulocyte Colony Stimulating Factor: A Case Report(Başkent Üniversitesi, 2010-06) Cetinkaya, Ramazan; Polat, Kamil Yalcin; Keles, Mustafa; Yildirim, Rahsan; Uyanik, Abdullah; Turkmen, Meral; Bilen, Yusuf; Aydinli, BulentObjectives: Posttransplant leukopenia is frequently observed in renal transplant. Granulocyte colony-stimulating factor controls the production of functional neutrophils and their release into peripheral blood. Granulocyte colony-stimulating factor has been widely and frequently used for many conditions and disorders in the field of hematology and oncology. Materials and Methods: We present the cases of valacyclovir-related and valganciclovir-related neutropenia in 2 renal transplant recipients. Results: Both cases had renal transplants from live donors. The first one was an 18-year-old man. Laboratory investigations revealed his leukocyte count as 1.7 x 109/L. The patient was using mycophenolate mofetil, cyclosporine, and valganciclovir. Mycophenolate mofetil was stopped because he had neutropenia, and later, valganciclovir was also stopped because the neutropenia persisted. Because the neutropenia did not recover after we discontinued valganciclovir, the patient was administered granulocyte colony-stimulating factor. The neutrophil count increased to 2.2 x 109/L (leucocyte count to 6.5 x 109/L) after 24 hours. The second case was a 37-year-old man and was using mycophenolic acid, tacrolimus, and valacyclovir. Laboratory investigations revealed his leukocyte count to be 1.3 x 109/L. Mycophenolic acid and valganciclovir were stopped owing to neutropenia. The patient was administered granulocyte colony-stimulating factor, and the neutrophil count increased to 3.8 x 109/L (leucocyte count to 5.8 x 109/L). The kidney functions did not deteriorate in either patient, and the patients’ kidney functions were similar to baseline levels 12 months after surgery. Conclusions: We conclude that granulocyte colony-stimulating factor can be used safely and effectively in renal transplant patients.Item Hematologic Adverse Effects of 2 Different Polyclonal Antilymphocyte Preparations in De Novo Kidney Transplant Patients(Başkent Üniversitesi, 2010-06) Rostaing, Lionel; Kamar, Nassim; Lavayssière, LaurenceObjectives: To evaluate the hematologic adverse effects of polyclonal antilymphocyte globulins within the first month after surgery in kidney transplant recipients. Materials and Methods: In this prospective, randomized trial, we included 16 adult-sensitized (panel-reactive antibodies > 30%) recipients of a kidney from a deceased donor. Eight patients received therapy with Genzyme (Thymoglobulin: ATG-G; 6.2 ± 2.9 mg/kg for 7 days), and 8 patients received Fresenius (Lymphoglobulin: ATG-F; 22.6 ± 7.9 mg/kg for 6 days). Other immunosuppressants included mycophenolate mofetil, tacrolimus, and steroids. Results: Platelet counts were normal before transplant and significantly reduced after transplant; however, this was more pronounced in ATG-F patients, and had normalized by day 7 in the ATG-G and by day 10 in the ATG-F groups. Mean leukocyte/polymorphonuclear cell counts remained within the normal range in both groups through follow-up. Hemoglobin levels were similar at ~10 g/dL for both groups, up to day 10. However, erythropoietin-stimulating–agent therapy had been given to more patients in the ATG-F group than patients in the ATG-G group. Reticulocyte counts were significantly lower in ATG-F patients by days 3, 5, 7, and 10. From day 14 onwards, reticulocyte counts were similar in both groups. With regard to lymphocyte counts, these were normal in both groups before transplant and then significantly decreased afterward. No patient presented with acute rejection or serum-sickness disease. Conclusions: Reduced platelet and reticulocyte counts occur more frequently immediately after transplant when using ATG-F compared with ATG-G therapy. Consequently, erythropoietin-stimulating agent therapy was needed more often for ATG-F patients.Item Kidney Transplant in Highly Sensitized Patients After Desensitization With Plasmapheresis and Low-dose Intravenous Immunoglobulin(Başkent Üniversitesi, 2010-06) Yuan, Xiao-peng; He, Xiao-shun; Fu, Qian; Gao, Wei; Wang, Chang-xiObjectives: This study sought to evaluate the efficacy of plasmapheresis plus low-dose intravenous immunoglobulin in highly sensitized patients waiting for a deceased-donor renal transplant. Materials and Methods: Thirty-five highly sensitized patients (HLA class I panel reactive antibody > 50%) received plasmapheresis, plus low-dose intravenous immunoglobulin treatment. In 25 patients (group 1), a positive T- and/or B-cell cytotoxicity crossmatch was rendered negative by plasmapheresis, plus low-dose intravenous immunoglobulin treatment. Two patients did not receive renal transplants owing to persistent positive crossmatch. Eight patients already had a negative crossmatch before desensitization. During the same time, 32 highly sensitized patients (group 2), without desensitization, had a negative crossmatch and received deceased-donor renal transplants. Results: Group 1 showed a numerically higher rate of acute rejection (32.0% vs 21.9%; P = .6) and antibody-mediated rejection (20.0% vs 9.4%; P = .3), but the difference was not statistically significant. Four of 5 cases of antibody-mediated rejection in group 1 had a peak donor specific antibody titer ≥ 1:8. Comparable mean serum creatinine levels at 24 months were observed (group 1: 130 ± 38 µmol/L vs group 2: 123 ± 41 µmol/L; P = .5). No difference in Kaplan-Meier graft survival was found between group 1 and group 2 after follow-up of 52 ± 26 months (P = .7). Conclusions: Desensitization with plasmapheresis, plus low-dose intravenous immunoglobulin enables successful deceased-donor renal transplant in highly sensitized patients with a positive crossmatch. Antibody-mediated rejection occurred predominantly in recipients with donor-specific antibodies of high titers.Item Calcium and Phosphorus Metabolism in Stable Renal Transplant Recipients(Başkent Üniversitesi, 2007-12) Khosroshahi, Hamid T.; Ardalan, Mohammad R.; Etemadi, Jalal; Safa, Javid; Tubbs, R. Shane; Azar, Sima Abedi; Shoja, Mohammadali M.Objectives: This study sought to elucidate the status of calcium, phosphorus, and parathyroid hormone in patients following kidney transplant. Materials and Methods: In this cross-sectional study, 20 renal transplant recipients were evaluated. For each patient, age, sex, time since transplant, and body weight were recorded. Inclusion criteria were age > 14 years and good allograft function defined as a serum creatinine level < 132.6 µmol/L for at least 6 months after transplant. Exclusion criteria were immunosuppressive therapy other than the standard triple regimen (cyclosporine, prednisolone, and mycophenolate mofetil or azathioprine) and use of any drug known to alter calcium hemostasis. Levels of 24-hour urine calcium, phosphorus, creatinine, and uric acid, as well as concentrations of hemoglobin, serum creatinine, calcium, and phosphorus were measured. To obtain a mean value of serum intact parathyroid hormone in transplant recipients at our center, serum intact parathyroid hormone levels were additionally quantitated in another group of 30 renal transplant recipients. Results: The mean hemoglobin level was 135.6 ± 17.7 g/L, the mean serum creatinine level was 105.0 ± 15.3 µmol/L, and the mean serum calcium and phosphorus levels were 2.25 ± 0.17 mmol/L (normal range, 2.02-2.60 mmol/L) and 1.28 ± 0.24 mmol/L (normal range, 0.81-1.61 mmol/L), respectively. The mean serum intact parathyroid hormone level was 33.17 ±14.67 ng/L (normal range, 10-60 ng/L). Mean 24-hour urine calcium and phosphorus values were 2.32 ± 1.68 mmol/day (normal, 2.49-6.24 mmol/day) and 19.77 ± 8.31 mmol/day (normal, 12.91-41.98 mmol/day), respectively. A positive correlation was found between serum calcium and alkaline phosphatase levels (r = +0.71, P = .006). Hemoglobin level was negatively correlated with serum phosphorus level (r = –0.65, P = .003) and sex (r = –0.57, P = .003) and positively correlated with urine creatinine levels (r = +0.69, P = .001). Conclusions: Renal transplant recipients with stable allograft function may have normal serum calcium, phosphorus, and intact parathyroid hormone levels. However, presence of hypocalciuria and elevated serum alkaline phosphatase levels might imply impaired calcium metabolism in these patients.Item Serial Changes in the Expression of CXCR3 and CCR5 on Peripheral Blood Lymphocytes Following Human Renal Transplantation(Başkent Üniversitesi, 2007-12) Inston, Nicholas; Drayson, Mark; Ready, Andrew; Cockwell, PaulObjectives: In animal models of transplantation, chemokine receptors have been shown to direct the infiltration of T cells in immune responses and inflammation and to be critical in cellular recruitment. Although the chemokine receptors CXCR3 and CCR5 and their ligands have been found during acute rejection in transplanted human kidneys, the kinetics of expression on peripheral blood lymphocytes is unknown. Materials and Methods: Using a whole-blood red-cell lysis fluorescence-activated cell sorter, serial expressions of CXCR3 and CCR5 on T-cell subsets were analyzed in 19 human renal transplant recipients following transplant. Results: In patients developing allograft rejection (n=6), increased expression of CXCR3 occurred on the surface of CD4+ T cells by the third day after transplant. In patients remaining rejection free (n=13), decreased expression was seen. In patients experiencing allograft rejection and in those remaining rejection free, levels of CXCR3 on CD8+ T cells and CCR5 on CD4+ and CD8+ cells remained stable throughout the study. Conclusions: During allograft rejection, expression of CXCR3, but not CCR5, increases on peripheral CD4+ T cells prior to clinical evidence of allograft rejection and remains elevated for more than 2 weeks following transplantation. This may represent a specific molecular target for identifying and preventing allograft rejection.Item Cytokine Gene Polymorphisms in Renal Transplant Recipients(Başkent Üniversitesi, 2006-12) Azarpira, N.; Aghdaie, MH.; Geramizadeh, B.; Behzadi, S.; Nikeghbalian, S.; Sagheb, F.; Rahsaz, M.; Behzad-Behbahanie, A.; Ayatollahi, M.; Darai, M.; Azarpira, MR.; Banihashemie, M.; Tabei, SZ.Objective: Acute rejection remains an important cause of graft loss after renal transplantation, and cytokines are key mediators in the induction and effector phases of all immune and inflammatory responses. However, the influence of gene polymorphisms on the functional immune response of transplant recipient outcomes remains controversial. Materials and Methods: The amplification refractory mutation system polymerase chain reaction was used to detect the interleukin-10 (IL-10) (-1082 G/A), tumor necrosis factor-alpha (TNF-α) (-308 G/A), and interferon-gamma (IFN-γ) (+874 T/A) single nucleotide polymorphisms in 100 of the first adult kidney recipients at our institution who were receiving cyclosporine-based immunosuppressive therapy. The diagnosis of acute rejection was based on clinical and histologic findings according to the Banff criteria. Results: The results of multivariate analyses showed no significant association between episodes of acute rejection and single nucleotide polymorphisms in IL-10, TNF-α genes, or dinucleotide repeat polymorphisms in the IFN-γ gene. Conclusions: Our results demonstrate that cytokine gene polymorphisms did not influence the early outcome of kidney transplantation.Item Plasmapheresis in the Treatment of Early Acute Kidney Allograft Dysfunction(Başkent Üniversitesi, 2006-12) Nafar, Mohsen; Farrokhi, Farhat; Hemati, Keyvan; Pour-Reza-Gholi, Fatemeh; Firoozan, Ahmad; Einollahi, BehzadObjective: To evaluate the efficacy of plasmapheresis (PP) in kidney transplant recipients with acute humoral rejection (AHR). Patients and Methods: A retrospective review was conducted of all kidney allograft recipients who had undergone PP rescue therapy for early acute allograft dysfunction diagnosed as AHR at Shaheed Labbafinejad Medical Center from 1995 to 2002. Results: Twelve patients (4 men and 8 women; median age, 32 years; age range, 15-68 years) with AHR were treated with PP. The median time from transplantation to AHR was 6 days (range, 2-7 days). PP was performed in 2 to 11 sessions (median, 8.5 sessions) in the patients studied. Eight patients responded to that treatment, and their creatinine value normalized. Those responders were monitored for a median of 162.5 weeks (range, 69.3-484.7 weeks), and all had a functioning allograft during the follow-up period except for 1 patient in whom the graft failed 154 weeks after transplantation. In the 4 remaining patients (nonresponders), the allograft failed within the first posttransplant month. The median time from the acute serum creatinine elevation to the initiation of PP was 6 days in responders and 18.6 days in nonresponders (P = .37). Conclusions: We suggest that PP with or without other therapeutic measures may have a role in the salvage of grafts with early acute dysfunction that is resistant to conventional therapy. Our findings indicate that graft survival in patients with AHR who respond to PP can be comparable to that in other kidney recipients.Item Urologic Complication Rates in Kidney Transplantation after a Novel Ureteral Reimplantation Technique(Başkent Üniversitesi, 2006-12) Haberal, Mehmet; Karakayali, Hamdi; Sevmis, Sinasi; Moray, Gokhan; Arslan, GulnazOur transplantation team has performed 1615 renal transplantations since 1975. After September 2003, we began a corner-saving technique for urinary tract continuity. In this study, we analyzed these 174 renal transplantations retrospectively. The mean recipient age was 31.6 years (range, 7 to 66). The mean donor age was 39.8 years (range, 6 to 67). For ureteral reimplantation, a running suture is started 3 mm ahead of the middle of the posterior wall and is finished 3 mm afterward. After the last stitch, both ends of the suture material are pulled, and the posterior wall of the ureter and bladder are approximated tightly. The anterior wall is sewn either with the same suture or another running suture. Since using this technique, we have not employed a double-J or any other stent to prevent ureteral complications at the anastomosis site. We have seen only 4 (2.2%) ureteral complications (2 ureteral stenosis and 2 anastomotic leaks) during a follow-up period of 18.9 months. In conclusion, due to the low complication rate, we believe that our new technique is the safest way to perform a ureteroneocystostomy.Item Ethical Issues in Living Donor Kidney Transplantation(Başkent Üniversitesi, 2006-12) Mazaris, Evangelos; Papalois, Vassilios E.The ethical issues of living donor kidney transplantation, which is the treatment of choice for patients with end-stage renal failure, are the focus of intense debate. Some of those issues are related to the safety of the operation for the donor, and others are related to the motivation of the donor, the approach to and evaluation of the donor, donation by strangers, the commercialization of donation, surrogate consent for donation, and the acceptance of minors as donors. The lack of clear consensus regarding these issues results in differences in practice, not only among countries but also among transplant centers. We believe that after an open debate, agreement on certain generally accepted principles can be achieved. Such an agreement would protect potential donors and recipients and would ensure the future of living donor kidney transplantation.