Başkent Üniversitesi Yayınları
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Item Mini-Incision Donor Nephrectomy Techniques: A Systematic Review(Başkent Üniversitesi, 2010-06) Aboutaleb, Esam; Hakim, Nadey; Crane, Jeremy; Herbert, PaulObjectives: The aim of this article is to compare different mini-incision donor nephrectomy techniques in the literature. Materials and Methods: We did a literature search using PUBMED using the search term “donor nephrectomy.” We compared different surgical techniques using different parameters like length of incision, length of operation, pain medications required after the operation, site of the operation, and intraoperative and postoperative complications. Results: We found 7 different surgical techniques of mini-invasive donor nephrectomy. Hakim and associates described the smallest initial incision size of 4 cm. There also are limited data on the analgesia requirements in 4 of the series, and 3 series that describe the requirements vary. Conclusions: These techniques offer advantages and disadvantages to the donor and the kidney. We hope to encourage further work. Ideally, there must be a working discussion, long-term outcomes of donor kidney and recipient, as well as accurate pain records, both quantitative and qualitative, and a discussion of time to mobilization.Item Leflunomide Derivative FK778 Inhibits Production of Antibodies in an Experimental Model of Alloreactive T-B Cell Interaction(Başkent Üniversitesi, 2009-12) Ramos-Barrón, M. Angeles; Arias, Manuel; Merino, Ramón; Merino, Jesus; Gimenez, Teresa; Benito, Adalberto; Cosme, Lorena San; Agüeros, Consuelo; Santiuste, Ines; Gómez-Alamillo, CarlosObjectives: The contribution of humoral immune response in allograft and xenograft rejection has been clearly demonstrated in recent years. For this reason, inhibition of alloantibody production has become essential in managing transplanted patients. Here, we assessed the effects of the leflunomide derivative FK778 (FK778) in the control of antibody production resulting from semiallogeneic cognate T-B–cell interactions. Materials and Methods: BALB/c mice were tolerized at birth with semiallogeneic spleen cells from (BALB/c × C57BL/6) F1 mice, with or without overexpression of human bcl-2 transgene in B cells. These tolerized mice were treated with different dosages of FK778, either from birth, or from the third week of age, when autoantibody production was detected. The production of autoantibodies, used as markers of semiallogeneic cognate T-B–cell interactions, was evaluated at different time points during drug administration or after the interruption of treatment. Results: FK778 treatment started at birth inhibited the production of semiallogeneic-driven antibodies in a dose-dependent manner. In addition, FK778 also reduced the levels of preformed circulating autoantibodies in adult mice, although the dosage required was 4 times higher than that used in neonates. However, the levels of IgG antibodies in these tolerized mice increased after FK778 withdrawal, indicating that FK778 failed to induce tolerance to semiallogeneic host CD4+ Th2 and/or donor B cells. Conclusions: Our results demonstrate the efficacy of FK778 in the control of antibody production resulting from semiallogeneic cognate T-B–cell interactions.Item Postlung Transplant Rehospitalization: A Study of Causes, Health Care Burden, and Outcomes(Başkent Üniversitesi, 2009-09) Faeghi, Jamileh; Masjedi, Mohammad Reza; Dezfouli, Azizollah Abbasi; Najafizadeh, Katayoun; Parsa, Tahereh; Shadmehr, Mohammad Behgam; Dabir, Shideh; Mohammadi, Foruzan; Tabarsi, Payam; Lankarani, Maryam Moghani; Assari, Shervin; Marjani, Majid; Fahimi, Fanak; Shafaghi, ShadiObjectives: Rehospitalization is a significant burden for transplant systems, which use data on hospitalization to monitor practice outcomes. In this study, all rehospitalizations after successful lung transplant performed in our medical center during an 8-year period were assessed for cause, health care resource use, cost, and outcome. Materials and Methods: We performed a retrospective chart review of all rehospitalizations of lung transplant recipients in Masih Daneshvari Hospital in Darabad, Tehran, between 2000 and 2008. Baseline data (each patient’s age at transplant and rehospitalization, sex, primary lung disease, medications used), cause of rehospitalization (infection, graft rejection, surgical complications, type of infection), health care resources use (length of hospital stay, intensive care unit stay, physician visits, imaging), rehospitalization costs (accommodations, personnel, drugs, paraclinical [ie, laboratory] tests, supplies, procedures) and outcome (death, survival) were noted. Results: In 69% of patients who were rehospitalized after having received a lung transplant, the cause was infection. Other causes were acute rejection in 31% and surgical complications in 6.9%. In 10.3% of those patients, the primary cause for rehospitalization could not be specified. The mean (SD) duration of rehospitalization was 12.8 ± 10.4 days. Treatment in the intensive care unit was necessary for 93.1% of the study subjects. The mean (SD) number of physician visits was 27.8 ± 27.7, and the fatality rate in the patients studied was 13.8%. Conclusions: These data may guide the monitoring of the causes, burden, and outcomes of lung transplants performed in our medical center in Iran and in other medical centers.Item Inflammatory Mediators of Liver Ischemia-Reperfusion Injury(Başkent Üniversitesi, 2009-06) Walsh, Kyle B.; Toledo-Pereyra, Luis H.; Lopez-Neblina, Fernando; Rivera-Chavez, Fernando A.; Toledo, Alexander H.Liver ischemia and reperfusion — which cause liver damage that is significant in a variety of diseases, injuries, and procedures (including but not limited to trauma and transplant) — have been the focus of many investigations in recent years. Although the mechanisms of ischemia-reperfusion injury are numerous and complex, many advances in treatment have been made. The following review considers recent advances in the understanding of hepatic ischemia-reperfusion injury and focuses on inflammatory mediators of significance. To provide a unique analysis and evaluation, we emphasized the most recent pertinent investigations of the last decade. Specific topics addressed include reactive oxygen species, nitric oxide, toll-like receptors, ischemic preconditioning, T cells, heme oxygenase-1, heat shock proteins, erythropoietin, selectins, protein kinases, matrix metalloproteinases, and cytokines.Item Impact of Donor and Recipient Age on Allograft Tolerance(Başkent Üniversitesi, 2009-06) Martins, Paulo N.The elderly represent the fastest growing segment of the population with end-stage organ disease and the use of aged grafts increased exponentially. Since aging of the immune system, or "immunosenscence" is generally associated with weaker immune responses, one might expect the elderly to be less reactive against transplanted organs than younger patients and therefore to show better results in terms of transplant outcome. Paradoxically, however, experimental studies and clinical data of organ transplantation show that old age of either the recipient or the donor is associated with poorer outcomes. On the other hand transplant tolerance is easier to be induced in the neonatal period. One potential reason for this discrepancy may lie in the effects of immunosenescence on the induction of tolerance. While the impact of aging on acute and chronic allograft rejection has been extensively studied, its role on establishing transplant tolerance is not well known. Since tolerance is an active process, and not just the absence of an immune response, the immunologic changes associated with the aging process may interfere with graft survival. In experimental and clinical transplantation, most successful tolerance induction protocols have been tested on young individuals, using grafts from young donors. However, some experiments that have utilized aged animals have demonstrated resistance to tolerance induction. Extrapolation of these results to humans suggests that protocols for clinical tolerance induction may not be effective in the elderly and may need to be revised for this population. The resistance to achieving immunological tolerance with aging is complex and multifactorial. Here, we review the age associated changes that may interfere with immunologic tolerance. Understanding this phenomenon may help in developing novel therapeutic approaches to reverse the crucial dysfunctions of the aging immune system and achieve effective tolerance regimens for the elderly.Item Do We Need To Maximize the Knowledge and Attitude Level of Physicians and Nurses Toward Organ Donation and Transplant?(Başkent Üniversitesi, 2008-12) Bener, Abdulbari; Al-Maslamani, Yousuf; El-Shoubaki, HatemObjectives: We sought to assess the knowledge level, attitudes, and personal views of physicians and nurses toward organ donation and transplant. Materials and Methods: This is a cross-sectional survey, carried out from November 2007 to June 2008 in the intensive care units and accident and emergency departments of the hospitals of the Hamad Medical Corporation. A representative sample of 685 health care professionals working in the hospitals was approached; 521 agreed to participate in the study (76.1%). Face-to-face interviews were based on a questionnaire that included sociodemographic information, knowledge level, and personal views toward organ donation and transplant. Results: Of the 521 participants, there were 268 physicians (51.4%) and 253 nurses (48.6%). The knowledge level of nurses was significantly lower for most of the questions related to organ donation, compared with physicians. Mean ± standard deviation for the score reflecting knowledge level was higher for physicians (4.9 ± 1.9) than it was for nurses (4.4 ± 2.0). The majority of the nurses believed, more than physicians, that brain-dead persons are eligible for organ donation (71.5% vs 63.1%), and that certain organs can be donated while the person is living, including kidneys, lobes of livers, and lungs (71.5% vs 62.3%). Many physicians (72.4%) and nurses (74.7%) did not know that brain death can be described as death. Most physicians and nurses supported organ donation (91.8% vs 79.8%), although a lower proportion of physicians and nurses were willing to donate a kidney to a family member in need (64.6% vs 68.0%). More than physicians (23.9%), nurses (61.3%) agreed that they lacked sufficient information about organ donation. Conclusions: Although the physicians and nurses had an acceptable level of knowledge about organ donation, the mean knowledge score for physicians showed significantly better understanding of the criteria for organ donation and procurement.Item Long-Term Donor Outcomes After Living Kidney Donation(Başkent Üniversitesi, 2008-09) Soneji, N. D.; Papalois, V. E.; Vyas, J.Kidney transplant is the first choice of treatment for end-stage renal failure. The issue of long-term donor safety again has been raised by recent increases in living-donor kidney transplants worldwide, relaxation of donor selection criteria, and the introduction of new surgical techniques. In this review, we collated the results of various studies to discuss the effects of donation on the quality of life of donors, encompassing their physical, mental, and social well-being. We found that the health risks donors face are minimal in the long term with respect to renal function, hypertension, and life span. Furthermore, donors scored higher in quality of life studies than did persons in the general population. Despite these findings, there is a clear need to monitor the minimal risks with long-term follow-up of donors to promptly recognize and treat any negative health effects. Such data from thorough follow-up studies also would provide accurate information on long-term donor health and improve the safe expansion of donor selection criteria.Item Parvovirus B19 Microepidemic in Renal Transplant Recipients With Thrombotic Microangiopathy and Allograft Vasculitis(Başkent Üniversitesi, 2008-06) Ardalan, Mohammad R.; Jayne, David; Tubbs, R. Shane; Shoja, Mohammadali M.Parvovirus B-19 (B-19) can lead to various clinical scenarios in renal transplant recipients. Here, we report a B-19 microepidemic that occurred between January and March 2007, involving renal transplant recipients from a single center in Tabriz, Iran. We observed 6 patients in whom there was a temporal association between active B-19 infection and thrombotic microangiopathy and intrarenal small- and medium-sized vessel vasculitis. Patients typically presented with deteriorating renal allograft function and anemia, and laboratory findings revealed thrombotic microangiopathy. Ultimately, extensive endothelial injury and renal allograft vasculitis that mimicked a vascular rejection ensued. In conclusion, B-19–related thrombotic microangiopathy may precede allograft vasculitis in renal transplant recipients. A high index of suspicion is required for early diagnosis and treatment of B-19 infection. To the best of our knowledge, this series represents the first report of B-19–related renal allograft vasculitis in the English literature.Item Ethical Aspects of Organ Donation Activities(Başkent Üniversitesi, 2007-12)Renal transplant remains the treatment of choice for patients with end-stage renal disease. Human organs can be harvested from 2 main sources: living and deceased donors. Preference should be given to deceased-donor transplants since they represent the only source of organs for several nonrenal solid-organ transplants and the only modality where there is no risk to the donor. Unfortunately, even the most well-developed deceased-donor program (eg, the Spanish program) can barely cover 50% of its waiting list because the demand for deceased-donor organs far exceeds supply. The success of transplant surgery has created a waiting list dilemma. Despite all efforts, deceased-donor donation cannot meet current needs and therefore, living donation demands serious consideration. This is supported by the fact that the risk to live donors is minimal, graft survival is significantly better than that of deceased-donor kidneys regardless of HLA matching, and professional ethical philosophers have fewer difficulties with voluntary living donations than with the removal of an organ from a cadaver. This is especially true in our region. Living-related donation has always been acceptable ethically. It is, however, limited by the number of willing and qualified donors, the high incidence of familial renal diseases, and donor coercion (especially in our area). Living-unrelated donation increases the availability of donors, decreases the chances of coercion, and eliminates the problem of consanguinity. It raises, however, the ethical issues of commercialism, transplant tourism, and organ trafficking. The arguments for and against living-unrelated donation are innumerable. They have been the subject of several international forums and have raised endless discussions. We have set long ago a series of rules and regulations that are in close agreement with the recent Amsterdam and Kuwait resolutions. We have been continually modifying them over the last 15 years to try to implement our ideal, which is to protect the interest of the living donor and avoid commercialism.Item Recurrent Glomerulonephritis in the Renal Allograft: An Update of Selected Areas(Başkent Üniversitesi, 2005-06) Couser, WilliamGlomerular diseases, including diabetes and various forms of glomerulonephritis, account for more than 70% of patients undergoing renal transplantation. Among these patients, more than 40% develop significant proteinuria, and around 15% develop persistent nephrotic syndrome. The most common cause of posttransplantation proteinuria is chronic allograft nephropathy (60%), followed by recurrent (15%) and de novo (10%) glomerulonephritis. Persistent proteinuria is associated with a significantly reduced rate of graft survival but often can be controlled with non–disease-specific therapy including angiotensin-converting enzyme inhibitors and angiotensin receptor blockers with favorable effects on long-term prognosis. Recurrent or de novo glomerulonephritis occurs in 6%-20% of patients overall and is more common in patients transplanted with glomerulonephritic organs. Glomerulonephritis in the allograft is also associated with a reduction in long-term (5-year) graft survival (40% vs 70%). The most common diseases associated with allograft glomerulonephritis and their recurrence rates in transplantation patients are idiopathic focal glomerular sclerosis (20%-30%), IgA nephropathy (25%), membranoproliferative glomerulonephritis (type 1, 25%; type 2, 80%), membranous nephropathy (30%), and hemolytic-uremic syndrome (classic, 10%; atypical, 40%; familial, 60%). This article reviews new developments in the understanding of 3 of these diseases—focal glomerular sclerosis, membranous nephropathy, and hemolytic-uremic syndrome—as they relate to the incidence of recurrence, the effects of recurrence on graft survival, risk factors for recurrence, and management issues for nephrologists caring for patients with renal allografts. Proper donor selection, early diagnosis in high-risk patients, and appropriate management can prolong graft survival and improve long-term outcomes.