Başkent Üniversitesi Yayınları
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Item Proteinuria Among Renal Transplant Patients and Its Relation to Hepatitis C Virus and Graft Outcome: A Single Center Experience(Başkent Üniversitesi, 2010-06) Sabry, AlaaObjectives: Chronic hepatitis C virus has been associated with glomerular disease in native and transplanted kidneys. Reports suggest that hepatitis C virus-infected renal recipients may develop de novo glomerulonephritis. We evaluated the presence of hepatitis C virus at transplant, the occurrence of proteinuria in Egyptian renal transplant patients, and its possible link with graft survival. Materials and Methods: Three hundred seventeen patients with end-stage renal disease receiving transplants in Mansoura Urology and Nephrology Center were retrospectively evaluated between 2000 and 2003. Their sera were assayed for anti-hepatitis C virus-antibodies at transplant. The relation between hepatitis C virus and development of posttransplant proteinuria was evaluated, along with possible effects of proteinuria on long-term graft survival. Results: Two hundred seventy-three recipients fulfilled the inclusion criteria, 169 were positive and 104 were negative for hepatitis C virus-antibodies by ELISA. Mean duration of posttransplant follow-up was 87.73 ± 26.79 and 84.29 ± 28.55 months for both groups. Groups were comparable regarding the incidence and quantity of hepatitis C virus-positive patients and 0.4 grams/day (P = .09 of proteinuria). In both hepatitis C virus-positive and negative groups, those with nephrotic range proteinuria showed worse graft survival (P = .001) and higher frequency of chronic allograft nephropathy (P = .05) compared with nonproteinuric patients. Conclusions: There is a high prevalence of hepatitis C virus in our end-stage renal disease patients awaiting renal transplant. The incidence and quantity of proteinuria is similar in both hepatitis C virus-positive and hepatitis C virus-negative transplant recipients. Nephrotic range proteinuria is associated significantly with a higher incidence of chronic allograft nephropathy. Independent from serology, it is associated with poorer graft outcome.Item Conversion of Cyclosporine to Sirolimus Before 12 Months is Associated With Marked Improvement in Renal Function and Low Proteinuria in a South African Renal Transplant Population(Başkent Üniversitesi, 2010-03) Maharaj, Suman; Assounga, Alain GuyObjectives: Avoidance of calcineurin inhibitor-associated nephrotoxicity has recently gained focus. To assess the impact of the conversion to sirolimus, we performed a retrospective audit on renal transplant patients switched to sirolimus at the Inkosi Albert Luthuli Central Hospital (South Africa) from 2003 until June 2007. Materials and Methods: Medical records of transplant recipients were analyzed. Twenty-four–hour urine protein excretion and estimated glomerular filtration rates before initiation of sirolimus (baseline), and at their last clinic visit, were compared. Patients were then subcategorized according to their specific indications for switching to sirolimus. Results: Thirty patients were included. Average follow-up was 25 months. Indications for use of sirolimus were group 1 (cyclosporine-induced biochemical toxicity, n=6); group 2 (chronic allograft nephropathy, n=6); group 3 (severe gum hypertrophy, n=9); group 4 (posttransplant diabetes, n=4); group 5 (calcineurin-inhibitor–induced histologic nephrotoxicity, n=2); and group 6 (calcineurin inhibitor associated malignancy, n=3). Average urine protein excretion rate and estimated glomerular filtration rate before starting sirolimus were 0.44 ± 0.08 g/24 h and 50.1 ± 3.1 mL/min respectively, compared to 0.94 ± 0.2 g/24 h and 52.1 ± 4.8 mL/min, at an average follow-up of 25 months. On subgroup analysis, estimated glomerular filtration rate was increased/unchanged in groups 1 (47.3 vs 51.16 mL/min) and 4 (60.0 vs 60.0 mL/min) when compared to baseline, but decreased in groups 2 (47 vs 27.6 mL/min), 3 (51.3 vs 42.2 mL/min), 5 (54.0 vs 29.5 mL/min), and 6 (60.0 vs 56.5 mL/min). Combining the latter 2 groups, most patients (80%) received sirolimus within 1 year of transplant, whereas only 2 patients in the former groups (10%) received the drug within 1 year of transplant. Conclusions: Overall, sirolimus therapy was associated with improved estimated glomerular filtration rate, and also an increase in urine protein excretion rates. Maximum benefit was achieved when patients were switched to sirolimus within the first transplant year.Item Impact of the Addition of Maintenance Steroids to a Rapid Steroid Discontinuation Immunosuppressive Protocol Following Acute Renal Transplant Rejection(Başkent Üniversitesi, 2009-12) Arora, Swati; Sureshkumar, Kalathil K.; Dikkala, Sudharani; Marcus, Richard J.Objectives: Rapid steroid discontinuation immunosuppressive protocols are increasingly used in renal transplant. The optimal immunosuppressive regimen in patients who develop acute rejection while on a rapid steroid discontinuation protocol is less clear. We examined our experience of adding maintenance steroid therapy in renal transplant recipients who developed 1 or more acute rejection episode while on a rapid steroid discontinuation protocol. Materials and Methods: The outcome of 145 patients who underwent renal transplant from 2002 to 2007 and initiated a rapid steroid discontinuation protocol was analyzed. Patients were divided into the following 5 groups: (i): acute rejection × 1 and no maintenance steroids, (ii): acute rejection × 1 and started on maintenance steroids, (iii): acute rejection × 2 and no maintenance steroids (iv): acute rejection × 2 and started on maintenance steroids, and (v): no acute rejection Results: Compared with patients with no acute rejection, graft survival was significantly inferior in patients who experienced 2 or more acute rejection episodes—whether they were started on maintenance steroids (P = .003) or not (P = .006)—but was similar in patients who experienced only 1 episode of acute rejection, and were started either on maintenance steroids (P = .87) or were continued on the rapid steroid discontinuation protocol (P = .69). In patients who sustained 2 episodes of acute rejection, addition of maintenance steroids had no impact on graft survival (P = .97). Conclusions: More than 1 episode of acute rejection in renal transplant recipients on rapid steroid discontinuation protocol is associated with poor, long-term, graft survival, which remains unchanged despite starting maintenance steroids. The use of maintenance steroids may not have a positive impact on graft survival after acute rejection.Item Value of Donor-specific Antibody Detection in First-Graft Renal Transplant Recipients with a Negative Complement-dependent Cytotoxic Crossmatch(Başkent Üniversitesi, 2009-06) Kamal, Mohamed Mohamed; Ghoneim, Mohamed Ahmed; Mahmoud, Khaled Mohamed; Ismail, Amani Mostafa; Sheashaa, Hussein Attia; Gheith, Osama AshryObjectives: The clinical significance of pretransplant donor specific antihuman leukocyte antigen antibodies that occur despite negative cytotoxicity crossmatches is still unclear. In this study, we assessed the impact of those antibodies on the outcome of renal transplants. Materials and Methods: Our study subjects consisted of 153 living-donor kidney transplant recipients whose pretransplant sera were available. All subjects had a negative complement-dependent cytotoxic crossmatch and were retrospectively evaluated for antihuman leukocyte antigen antibodies and their donor specificities by means of LABScan 100 Flow analyzer (Luminex Corporation, Texas, USA). The follow-up data of all subjects were reviewed. Results: Antihuman leukocyte antigen antibodies were detected in 49 patients, donor nonspecific antihuman leukocyte antigen antibodies were found in 33, and donor specific antihuman leukocyte antigen antibodies were identified in 16. There was a trend toward more acute rejection in the patients with antihuman leukocyte antigen antibodies (22%) than in those without antihuman leukocyte antigen antibodies (17%), but that difference had no statistical significance (P = .378). Patients with donor specific antihuman leukocyte antigen antibodies had a significantly higher incidence of acute cellular rejection (19% vs. 6%, respectively) and vascular rejection (25% vs. 6%, respectively) than did patients with donor nonspecific antihuman leukocyte antigen antibodies (P = .04). Conclusions: Our results suggest that there is a higher incidence of acute rejection in patients with donor specific antihuman leukocyte antigen antibodies and a negative complement-dependent cytotoxic crossmatch; however, those factors had no statistically significant impact on patient or graft survival.Item Pretransplant Detection of Anti-Endothelial Cell Antibodies Could Predict Renal Allograft Outcome(Başkent Üniversitesi, 2009-06) Ismail, Amani M.; Mansour, Merveet A.; El-Agroudy, Amgad E.; Badawi, Rasha M.Objectives: Endothelial cells that line the vasculature are targets for immune-mediated assault through anti-endothelial cell antibodies. The aim of this work was to detect anti-endothelial cell antibodies and describe the association with kidney allograft rejection and graft survival. Materials and Methods: The study included 60 patients who had undergone live-donor kidney transplant. Inclusion criteria included first kidney transplant, panel reactive antibody titer less than 5%, cause of end-stage renal disease not including vasculitis or systemic lupus erythematosus, and age > 18 years. Patients were classified into 2 groups: 40 patients with anti-endothelial cell antibodies (referred to as the positive group) and 20 patients without anti-endothelial cell antibodies (referred to as the negative group). Results: Serum creatinine level was higher in the positive group at 1 month and 1 year (P = .04). The occurrence of acute rejection was not significantly different in the positive group (18 patients [45.0%]) compared with the negative group (5 patients [25.0%], P = .5). However, the number of acute rejection episodes was higher in the positive group (22 episodes) compared with the negative group (6 episodes, P = .04). In patients who experienced acute rejection, chronic nephropathy was more frequent in the positive group (6 of 18 patients, 33.3%) compared with the negative group (1 of 5 patients, 20.0%) (P = .03). One-year and 5-year graft survival was 91% and 79% in the positive group, and 100% and 91% in the negative group, respectively. The difference at 5 years was significant (P = .04). Conclusions: The presence of anti-endothelial cell antibodies was associated with a higher number of acute rejection episodes and lower long-term graft survival in kidney transplants. It could be an informative test to identify patients at high risk for immunological graft loss.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 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 A Fast and Safe Living-Donor "Finger-Assisted" Nephrectomy Technique: Results of 225 Cases(Başkent Üniversitesi, 2008-12) Hakim, Nadey S.; Canelo, Ruben; Papalois, VassiliosRenal transplant remains the treatment of choice for end-stage renal disease. It improves both the quality of life and the quantity of life in recipients. We present a living-donor nephrectomy technique that is less invasive than the conventional open flank incision. This technique involves only 1 incision and is smaller than the one used in the laparoscopic technique. We have successfully introduced this new technique at our center. The procedure may be done safely and is applicable in all potential donors regardless of the body mass index of the donor or the size of the surgeon’s hands. It provides excellent grafts and has allowed us to expand our living-donor program.Item Immunosuppression Modifications and Graft Outcome in Patients With Chronic Allograft Nephropathy(Başkent Üniversitesi, 2008-09) El-Agroudy, Amgad E.; Ghoneim, Mohamed A.; Shokeir, Ahmed A.; El-Baz, Mahmoud; Ismail, Amani M.; Mahmoud, Khaled; El-Dahshan, KhaledObjectives: This retrospective study was done to assess the efficacy and safety of immunosuppression conversion on progression of chronic allograft nephropathy Materials and Methods: One hundred seventy-four cyclosporine-treated renal transplant recipients were studied. Patients were included if they had biopsy-proven chronic allograft nephropathy (mild to moderate) with a serum creatinine level of 300 µmol/L or less. The treatments groups were (1) mycofenolate mofetil and reduced-dosage cyclosporine (group MMF/CsA; n=132) and (2) azathioprine and reduced-dosage tacrolimus (group Aza/Tac; n=42). Patient records were checked for graft function, survival, and comorbidities after conversion. Results: Mean follow-up before conversion was 52.2 ± 31.1 and 47.9 ± 27.4 month in groups MMF/CsA and Aza/Tac, respectively. There was a significant deterioration of graft function in group Aza/Tac after 5 years (P < .05). Ten-year actuarial graft survival in group MMF/CsA was 38%; in group Aza/Tac it was 19% (P = .04). Nine patients started dialysis within 12 months. Tacrolimus-treated patients had a lower insignificant incidence of hyperlipidemia (P = .05) but a significantly higher incidence of diabetes mellitus (P = .04). There were no significant changes or differences in blood pressure between the groups. Conclusions: Our results suggest that in patients with chronic allograft nephropathy and deteriorating allograft function, cyclosporine minimization and addition of mycofenolate mofetil achieve favorable effects in retarding the decline of graft function. Further prospective studies with larger cohorts are needed for validation.