Rescue Allocation Modes in Eurotransplant Kidney Transplantation: Recipient Oriented Extended Allocation Versus Competitive Rescue Allocation-A Retrospective Multicenter Outcome Analysis

BACKGROUND

Whenever the kidney standard allocation (SA) algorithms according to the Eurotransplant (ET) Kidney Allocation System or the Eurotransplant Senior Program fail, rescue allocation (RA) is initiated. There are 2 procedurally different modes of RA: recipient oriented extended allocation (REAL) and competitive rescue allocation (CRA). The objective of this study was to evaluate the association of patient survival and graft failure with RA mode and whether or not it varied across the different ET countries.

METHODS

The ET database was retrospectively analyzed for donor and recipient clinical and demographic characteristics in association with graft outcomes of deceased donor renal transplantation (DDRT) across all ET countries and centers from 2014 to 2021 using Cox proportional hazards methods.

RESULTS

Seventeen thousand six hundred seventy-nine renal transplantations were included (SA 15 658 [89%], REAL 860 [4.9%], and CRA 1161 [6.6%]). In CRA, donors were older, cold ischemia times were longer, and HLA matches were worse in comparison with REAL and especially SA. Multivariable analyses showed comparable graft and recipient survival between SA and REAL; however, CRA was associated with shorter graft survival. Germany performed 76% of all DDRTs after REAL and CRA and the latter mode reduced waiting times by up to 2.9 y.

CONCLUSIONS

REAL and CRA are used differently in the ET countries according to national donor rates. Both RA schemes optimize graft utilization, lead to acceptable outcomes, and help to stabilize national DDRT programs, especially in Germany.

Roadsaver versus Wallstent for carotid artery stenting: a retrospective cohort study

Introduction

Carotid artery stenting (CAS) is an established alternative option to surgical treatment for carotid artery stenosis, 3 main contemporary types of stent design being used for this purpose (open-, closed-cell, mesh-covered stents). So far, no definite conclusions have been reached on the superiority of any of those devices for CAS. With its new double-mesh design, the Roadsaver stent has emerged as an attractive option for use in CAS, aiming to further reduce neurological events. However, its efficacy as compared to other stents, such as Wallstent, has not been thoroughly explored. We thus aimed to compare the clinical outcomes of Roadsaver and Wallstent for use in CAS.

Methods

This retrospective cohort study included patients who underwent CAS and received either Wallstent or Roadsaver stent at a tertiary centre (centre A) in a Central European country during 2009–2021, and another tertiary centre (centre B) in the same country during 2016–2019. Patients with incomplete baseline clinical records were excluded. Patients were followed up for one year at centre A, and for 30 days at centre B. The primary outcomes were 30-day and 1-year major adverse cardiac or cerebrovascular events (MACCE), defined as a composite of myocardial infarction, stroke, and cardiovascular mortality. The secondary outcome was 30-day bradycardia. Baseline covariates were balanced between groups using inverse probability treatment weighting. Thirty-day outcomes were compared using logistic regression with odds ratio (OR) as the summary statistic, and 1-year MACCE was compared using Cox regression with hazard ratio (HR) as the summary statistic.

Results

In total, 982 patients were identified. After applying the exclusion criterion, 770 patients were included in the analysis (482 patients from centre A and 288 patients from centre B; 287 (37.3%) females, mean age 68±8 years old), of which 589 (76.5%) received Wallstent and 181 (23.5%) received Roadsaver. There was no loss to follow-up. Twenty-three (3%) patients had MACCE by 30 days, and 16 (3.3%) of those who completed one-year follow-up had MACCE by one year. No significant differences in MACCE were observed between the two stents at 30 days (OR 0.697 [0.374, 1.300], p=0.256) and one year (HR 0.512 [0.126, 2.073], p=0.348). Roadsaver was associated with significantly higher odds of 30-day bradycardia (OR 5.391 [4.089, 7.108], p<0.0001), which remained significant after adjusting for the number of post-dilatations performed (p<0.0001). Additionally, Roadsaver was associated with significantly lower risk of one-year MACCE among symptomatic patients (N=184; HR 0.131 [0.024, 0.723], p=0.020; Figure 1), but not among asymptomatic patients (N=298; HR 1.774 [0.332, 9.490], p=0.503).

Conclusion

There was no short- and long-term hazard difference between the 2 types of stent designs, however Roadsaver may be superior to Wallstent among symptomatic patients.

Funding Acknowledgement

Type of funding sources: None.

Comparison of different access sites (radial, brachial and femoral) for subclavian artery intervention

Introduction

The primary purpose of this multicenter prospective register was to evaluate the success and complication rate of different access sites for subclavian artery intervention. Secondary purpose was to investigate the safety of the distal radial artery access for subclavian artery intervention.

Methods

The clinical and angiographic data of 223 consecutive patients with symptomatic subclavian and anonym artery stenosis treated via transradial (TR), transbrachial (TB) and transfemoral (TF) access between 2015 and 2019 were evaluated in a multicenter registry. The exclusion criteria of the intervention was the acute proximal subclavian artery thrombosis. Primary endpoint: angiographic outcome of the subclavian and anonym artery intervention, rate of major and minor access site complications. Secondary endpoints: procedural complications, consumption of the angioplasty equipment, cross over rate to another puncture site and hospitalization in days.

Results

The procedure was successful in 182/184 in TR, in 5/5 in TB and in 32/32 patients in TF group. The cross over rate in the TR, TB and TF group was 0%. Chronic total occlusion recanalization was successful in 75/77 cases in TR, and 15/15 cases in the TF group. Contrast consumption was 152±106 ml in TR, 99±22.5 ml in TB and 152±95 in TF group, respectively (p=ns). Cummulativ dose was 602±1205 mGray in RA, 455±210 mGray in BA and 1089±1674 mGray in FA group (p<0.05). Procedural complications occurred in 1/184 (0.5%) case in RA group, in 0 case (0%) in BA group and in 4/32 cases (12.5%) in the FA group (p<0.05). Major access site complication were detected in 3 patients (1.6%) in RA, in 1 patient in BA (20%) and in 1 patient in FA group (3.1%) (p<0.05). Minor access site complication were encountered in 9 patients in the RA (4.8%), in 1 patient in the BA (20%) and in 8 patients in the FA group (25%) (p<0.05). Distal radial access was used in 29 cases and proximal radial access in 155 patients. The rate of radial artery occlusion in proximal and distal radial group was 5.1% and 0% (p<0.05).

Conclusions

Subclavian artery intervention can be safely and effectively performed using radial access with acceptable morbidity and high technical success. Femoral and brachial access is associated with more access site complications than radial artery access. Distal radial access is associated with less radial artery occlusion than proximal radial artery access.

Funding Acknowledgement

Type of funding source: None

TRIACCESS study: randomized comparison between radial, femoral and transpedal access for for percutanous supertfitial femoral artery angioplasty

Background

Traditional access for the treatment of femoral artery lesions is the femoral artery (FA) approach, but radial (RA) and pedal access (PA) is an alternative access site. The aim of the study was to compare the success rate, complication rate of different access sites for the treatment of superfitial artery stenosis in a randomized study

Methods

180 consecutive patients were randomized in a prospective study to treat symptomatic superficial femoral stenosis, via RA, FA and PA. Primary endpoint: technical success, rate of major and minor access site complications. Secondary endpoints: major adverse events (MAE), procedural factors, cross-over rate, and duration of hospitalization.

Results

Technical success was achieved in 96.6%, 100% and 100% patients in RA, FA and PA group (p=ns). Secondary access site was used in 30%, 3.3% and 30% in the RA, FA and PA access group (p<0.01). Stent implantation was done in the femoral artery in 26.6%, 58.3% and 71.6% cases in RA, FA and PA group (p<0.01). CTO recanalization was performed in 34/36 (100%), 30/30 (100%) and 45/45 (100%) cases successfully in RA, FA and PA group (p=ns). Contrast consumption, fluoroscopy and procedure time was not statistically different, but the X Ray dose was significantly lower in PA than in the RA and FA access group (63.1 vs 162 vs 153 Dyn). The cumulative rate of access site complications in the RA, FA and PA group was 3.3% (0% major and 3.3% minor), 15% (3.3% major and 11.6% minor) and 3.3% (0% major and 3.3% minor) (p<0.01), respectively. The cumulative incidence of MAE's at 6 months in the RA, FA and PA group was 8.3% vs 13.3% and 18.3%. (p<0.05)

Conclusion

Femoral artery intervention can be safely and effectively performed using radial, femoral and pedal access, but radial and pedal access is associated with less access site complication rate. Pedal access is associated with less X Ray dose than radial and femoral access.

Funding Acknowledgement

Type of funding source: None

Long-Term Outcomes and Weight Loss After Bariatric Embolization of the Left Gastric Artery

OBJECTIVES

Bariatric embolization of the left gastric artery is a promising technique to induce weight loss in obese patients. We aimed to assess long-term effects.

METHODS

Patients with severe obesity were recruited to undergo left gastric artery embolization via transradial access. We report clinical outcomes and weight loss up to 2 years.

RESULTS

We completed 7 procedures successfully in 7 men with severe obesity after diagnostic coronary angiography. Median weight was 160 kg (interquartile range, 140.0-180.0 kg) and body mass index was 49.4 kg/m² (interquartile range, 43.2-61.7 kg/m²). Acutely, no adverse events were reported other than mild epigastric pain, which subsided within 24 hours with proton pump inhibitors. No delayed gastrointestinal complications were reported up to 2 years after index procedure. One patient died of pulmonary embolism 18 months after the procedure. One patient underwent a second embolization procedure after it was shown that the left gastric artery was patent 18 months after the initial procedure. Compared with baseline in the 6 surviving patients, overall weight loss was 7.7% (range, 3.2%-14.1%).

CONCLUSIONS

Bariatric embolization of the left gastric artery may induce weight loss, which appears sustained up to 2 years. Spontaneous recanalization of the left gastric artery may pave the way for repeat procedures and other interventions. Further research is necessary to define the benefits, safety, and indications for this technique.

Active screening of suicide risk in an adolescent population

Introduction

Suicide has emerged as one of the most important causes of death in the age group 15–34 and ranks as the second cause of death after traffic accidents and other injuries in the age group 15–19. In Europe, more than 13,000 young men and women aged 15–24 die by suicide each year. Therefore, identifying risk factors for suicidal behavior has become a priority, and suicide prevention in the young population is a major area of interest for public health professionals, stakeholders and researchers.

Aim

To actively screen for a range of unhealthy behaviors used as cut-offs in the Romanian SEYLE (Saving and Empowering Young Lives in Europe) sample, and to assess their significance as risk factors for suicidal behavior.

Method

1143 9th grade pupils aged between 14 and 16 from 16 high schools in two counties in North-Western Romania were randomized in the SEYLE protocol. They were screened for suicidal ideation and behavior, depression, anxiety and a number of risk-taking behaviors: non-suicidal self injury, unhealthy eating behavior, sensation seeking & delinquent behavior, substance abuse, increased exposure to media, limited social relationships, bullying, and truancy.

Results and conclusions

Suicidal behavior in adolescents is commonly associated with anxiety and a number of risk-taking behaviors, which may be used as warning signs while actively screening for suicide risk in adolescent populations. Although a high number of at-risk pupils were identified at baseline, no completed or attempted suicides were recorded in the assessed sample at 3-months follow-up.

P5611Feasibility of distal radial access for carotid interventions: the RADCAR-DISTAL pilot study

Aims

The aim of our study was to demonstrate the feasibility and safety of the distal transradial approach (DTRA) for carotid artery stenting (CAS).

Methods and results

We included 209 consecutive patients (151 Trans-Radial Access (TRA) and 58 DTRA) treated in a single center by CAS with cerebral protection between 2016 and 2018. DTRA punctures were performed by ultrasound guidance, and the carotid artery cannulations were done using a 6.5 F coronary sheathless guiding catheter. The groups showed similar demographic profile regarding age, gender and comorbidities, however the proportion of symptomatic patients was significantly higher in the DTRA cohort (DTRA: 75,86% vs. TRA: 46.36% p<0.001). Procedural success rate was similarly high in both groups, while the overall complication rate was very low, with no major adverse events and only a few vascular complications. The cannulation times were similar, while the overall procedure length was slightly higher in the DTRA group. The cumulative X-ray dose was similarly low regardless the access used.

Conclusion

DTRA is a safe and effective alternative of conventional trans-radial approach for CAS, with a potential to further improve the patient comfort.

P4705Transpedal access for below-the-knee lesions in critical limb ischemia

Background

Traditional access for the treatment of below-the-knee (BTK) lesions is the femoral approach, but in failed anterograde cases transpedal access can be utilized. The aim of the study was to evaluate the safety and technical and clinical success of endovascular BTK artery revascularization by a primarly retrograde transpedal access.

Methods

The clinical and angiographic data of 115 consecutive patients treated via transpedal access with symptomatic BTK stenosis were evaluated two cardiovascular centers (Europe and USA). We have selected patients with good distal run-off and non-infected distal puncture zone. The distal pedal artery was punctured by ultrasound guidance, and the procedural guidance was done by transpedal (TPA) or transradial angiography (TRA). Distal pressure at the end of the pedal sheath was also measured before and after the intervention. The primary endpoint was a composite of procedural success, major adverse events, and rate of access site complications. Secondary endpoints were: angiographic result of BTK intervention, fluoroscopy time, X-ray dose, procedure length, cross over rate to another puncture site and duration of hospitalization.

Results

The indication of the intervention was critical limb ischemia in all patients. Overall technical success was achieved in 99.1% of the patients at least in one BTK artery. The distal puncture was successful in 114/115 patients 99.1% of the patients and the access site was anterior tibial artery in 96 patients (83.55), posterior tibial artery in 15 patients (13%) and peroneal artery in 4 patients (3.5%). Pedal to femoral access site cross over was 0.5%. Control angiography was done in 73 patients (63.5%) from radial and in 42 patients (36.5%) from transpedal access. The average contrast, procedure and fluoroscopy time was 109.9 [97–123]vs 31.4 [27–35]ml (p<0.001), 43.2±22.3 vs 47.8±25.5 min and 581±448.7 vs 788±605 sec in the TR and TP group.The average systolic transpedal pressure has been increased from 100.1 mmHg ±44 to 131±36.4 mmHg after the procedure. Major adverse event at one month was detected in six patients (5.2%).Radial and pedal artery access site complications were encountered by ultrasound in 3/73 (4.1%) and 3/115 patients (2.6%) during follow up.

Conclusion

Below-the-knee artery angioplasty can be safely and effectively performed using radial and transpedal access in selective patient population.

P4703Distal radial artery access using slender technique for superfitial femoral artery intervention

Purpose

The purpose of this pilot study was to evaluate the acute success and complication rate of the distal radial artery access for femoral artery intervention.

Methods and results

The clinical and angiographic data of 195 consecutive cases with symptomatic superficial femoral stenosis, treated via distal radial (DR) or proximal radial (PR) access using 6F sheathless guiding between 2014 and 2018, were evaluated in a pilot study. Secondary access was achieved through the pedal artery. Primary endpoint: major adverse events (MAE), rate of major and minor access site complications. Secondary endpoints: angiographic outcome, procedural factors, cross-over rate to femoral access site, and duration of hospitalization. Overall technical success was achieved in 186 patients (95.4%) with 25/26 (96.1%) success in DR and 161/169 (95.2%) success in PR group (ns). The cross over rate to femoral access site was 3.8% in DR and 4.7% in PR group (ns), while dual (transradial and transpedal) access was used in 9/26 (34.6%) patients in DR and 39/169 (23%) patients in PR group (p<0.05). Stent implantation was necessary in 8/26 (30.7%) cases in DR and in 42/169 (24.8%) cases in PR group (ns). CTO recanalization was performed in the DR and PR group with 94.1% (16/17) and 92.6% (79/81) technical success rate. The mean contrast consumption, fluoroscopy time and procedure time was in the DR and PR group was: 93.4 [78–108]ml vs 120 [108–131]ml, 662 [501–822]vs 769 [671–866]min, and 33.4 [27–39]vs 36.5 [32–40]min (ns), respectively. The rate of access site complications in the DR and PR group was 0% and 4.7% (0% major, 4.7% minor) (p p<0.001), respectively. The cumulative incidence of MAE at 3 months in the DR and PR group was 3.8% vs 10.6% (p<0.05).

Conclusion

Femoral artery intervention can be safely and effectively performed using distal transradial access and distal radial access is associated with lower access site complications.

Surgical Treatment of Hyperparathyroidism After Kidney Transplant

Chronic renal impairment is often associated with complex bone disorders. Improvement of secondary hyperparathyroidism (HPT) is expected after kidney transplant (KT) if the glomerular filtration rate is normalized.

PATIENTS AND METHODS

There were 888 KTs performed between 1996 and 2017 at our department. A total of 558 general patients have been operated on for HPT during the same period. The 2 populations had a common part: out of the 558, a total of 69 (12.4%) were in end-stage renal failure when operated on because of secondary HPT. That also means that 7.8% of all KTs were associated with HPT. Retrospective, single-center analysis was performed using the patients' medical records. The aim of our study was to analyze the results of parathyroidectomies after KT.

RESULTS

Parathyroid surgery was performed on 19 patients (2.14%) because of HPT after KT. The applied surgical technique was total parathyroidectomy with autotransplant in 6 cases, subtotal parathyroidectomy in 3 cases, and selective parathyroidectomy in 10 cases. In all cases, histology revealed benign disease. Complications were observed in 10 cases (52%); there were 6 cases of postoperative hypocalcaemia (31.58%), 1 case of transient laryngeal recurrent nerve paresis (5.26%), and 6 cases of recurrent HPT (31.58%).

SUMMARY

The first step of HPT management is calcimimetic drug treatment. It is essential to prevent possible complications with regular laboratory monitoring. If the proper conservative therapy is refractory or severe in complications, surgery should be chosen. If the patient is already waiting for a KT, it is worth performing the parathyroid surgery before KT. Close collaboration with endocrinologists and nephrologists is needed to achieve successful therapy.

Regulatory T Cells in the Context of New-Onset Diabetes After Renal Transplant: A Single-Center Experience

BACKGROUND

New-onset diabetes mellitus after transplant (NODAT) is a well-known complication of renal transplant that severely affects graft and patient survival. It is necessary to explore further risk factors and reveal the underlying pathomechanism.

METHODS

Renal transplants performed between January 2010 and June 2018 were involved. Exclusion criteria were the recipient age younger than 18 years, follow-up period less than 6 months, and patients with diabetes at the time of transplant. Only primary kidney transplants were involved in our study, which totaled 223 cases. Besides donor and recipient demographic data, the type of immunosuppression, the average fasting glucose level, and T-subset profiles were compared.

RESULTS

Of 223 cases there were 33 patients (14.8%) with NODAT (17 female; mean age, 54.2 [SD, 10.3] years; mean body mass index [calculated as weight in kilograms divided by height in meters squared], 27.8 [SD, 5.1]; mean follow-up, 43.3 [SD, 25.5] months). The control group consisted of 190 patients. The average fasting blood glucose level was higher in the NODAT group vs the control group (P < .001). The average fasting blood glucose level above diabetic threshold (≥7 mmol/L) was in association with a 6-fold higher risk of NODAT (odds ratio, 5.86; 95% CI, 2.46-13.97; P < .001). Absolute value of CD4⁺CD25^brightCD127^dim regulatory T cells was lower in the NODAT group at the first month after transplant (P = .048) Immunosuppressive protocol and survival data did not differ.

CONCLUSIONS

Intensive management of the carbohydrate excursions during the early post-transplant period may decrease the incidence of NODAT. Further investigations will be required to decide whether the reduced CD4⁺CD25^brightCD127dim/regulatory T-cell count contributes the development of NODAT.

Effectiveness of the Gerundium Youth Educating Program in Hungary

The acceptance of brain death and the legitimation of organ transplantation is very much dependent on the general knowledge of the society. In Hungary, the legislation of brain death is based on presumed consent. There is no structural education about the topic so far.

AIM

The role of the Gerundium program is to educate high school students about the importance of transplantation and the meaning of brain death. The goal of this study was to evaluate the effectiveness of the Gerundium contemporary educational program in a pilot study.

METHOD

The education was held by medical students who successfully completed a preparatory elective course consisting of relevant information in the topic. Medical students used simple language during the 45-minute presentations. Two tests with simple but representative questions created by experts were completed by high school students: one directly before contemporary education and another 5 to 6 weeks after the lecture.

RESULTS

A total of 147 tests were completed: 78 before and 69 after the presentation in the city of Debrecen and 294 before the lecture in the city of Győr. In Debrecen, the overall correct answers increased by 6.05% (P < .05; before vs after). The results show that the knowledge transfer is highly effective in this manner and the students know significantly more weeks after the lectures.

CONCLUSION

There is much to do to broadly inform society about transplantation and brain death, but we will continue to increase the number of students and measure the dynamic change of the students' knowledge.

Bacterial Infections After Kidney Transplantation: A Single-Center Experience

BACKGROUND

Bacterial infections significantly affect graft loss and mortality after kidney transplantation (KT). We reviewed the frequencies, risk factors, and sources of bacterial infections after KT and their impact on graft and patient survivals.

METHODS

The data of 154 kidney recipients who underwent transplantation from 2010 to 2015 were explored. Donor, recipient, and surgical parameters were collected, and source, type, and frequency of infectious complications, number of infective episodes, multidrug-resistant (MDR) bacteria, and the bacterial spectrum were established.

RESULTS

The most common infection was urinary tract infection, which is in line with the literature. Out of the 154 recipients, 72.1% (n = 111) had at least 1 occasion of a bacterial infection episode with clinical symptoms. It occurred 0-43 months (mean, 19.5 mo) after transplantation. Ninety-three KT recipients (67.9%) developed 274 episodes of infection in the postoperative 1st year (1.8 episodes/patient/y), and 42 patients had admission to the hospital ward (5.2 d/patient/y). MDR was detected in 19.8% of the infections.

CONCLUSIONS

A bacterial infection had no significant impact on survival by itself. However, in case of sepsis graft and patient survivals were lower compared with normal control subjects.

Surgical Complications Following Kidney Transplantations: A Single-Center Study in Hungary

Surgical complications (SCs) are still high potential causes of graft loss. The incidence has a huge amount of variations depending on many factors. Our aim was to study the postoperative technical complications following kidney transplantations (KTs) during a 5-year period between 2011 and 2015. In the observed time frame there were 47 SCs occurring in 32 (19.4%) patients of 165 KTs. Every complication was classified into 3 groups: vascular (11; 6.6%), urologic (16; 9.7%), and any others (20; 12.1%). The most common postoperative SCs in our center were hemorrhage (14; 8.5%), urinary leakage (12; 7.2%), and renal artery stenosis (6; 3.6%). Twenty-seven patients, 84% of those having had a SC, needed an intervention, mainly a surgical correction (28; 62%). Half of these interventions (21; 51%) were performed due to urologic reasons. As possible predicting factors, we studied the type of arterial and ureter anastomosis in relation to onset of vascular and urologic complications. There was no significant correlation. The same was true for any donor and/or recipient demographic parameters. However, the presence of SCs impaired both patient and graft survival. The cumulative 6-month, 1-, 3-, and 5-year patient survival rates were 97% versus 99%, 93% versus 99%, 84% versus 97%, and 84% versus 97% for patients with/without (w/wo) a SC, respectively (P = .028). The cumulative 6-month, 1-, 3-, and 5-year graft survival rates were 81% versus 96%, 77% versus 94%, 68% versus 86%, and 54% versus 86% for the same 2 groups, respectively (P = .003).

Genetic Counselling in Psychiatric Disorder with High Suicide Risk

Introduction

A better understanding of the genomics of mental illnesses allowed genetic counselling to be provided to individuals with severe mental illness and their families.

Aim

The present study was aimed at assessing the efficacy of genetic counselling for severe mental illnesses with high suicide risk.

Method

Assessment was performed before and after genetic counselling session. Measures used were evaluation of traumatic events in childhood, multidimensional scale for perception of social support (SMSSP), positive and negative affect schedule (PANAS-X), Brief Psychiatric Rating Scale (BPRS), Paykel questionnaire and Genetic Counselling Outcome Scale (GCOS). Paykel's questionnaire consists of five questions about suicidal thoughts and attempts, including: life-weariness, death wishes, suicidal ideation, suicidal plans and suicide attempts. Intervention and assessment lasted approximately one and a half hour. Data from 48 patients was analysed.

Results

Mean age of participants was M = 38.4, SD = 9.7, and the group was batter represented by females (57%). The participants had various diagnoses, 22% had schizophrenia, 36% bipolar disorder and 42% recurrent depressive disorder. Forty percent of participants reported suicidal ideation and 22,5% had a past history of suicide attempt. Genetic counselling had a direct positive influence upon GCOS specific items and reduced the Paykel scores among participants presenting with suicidal ideation.

Conclusion

Genetic counselling offers information about the disorder, the role of genetics and the impact of environmental factors. Preliminary data suggest that providing genetic counselling decreases the suicidal ideation frequency.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

CORTISOL LEVELS AND SUICIDE IN BIPOLAR I DISORDER

CONTEXT

Hypothalamic-pituitary-adrenal (HPA) axis irregularities have been described both in bipolar disorder and suicidal behaviour, but few studies have examined the relationship between suicidal behaviours and cortisol levels in bipolar disorder.

OBJECTIVE

We compared HPA axis activity in bipolar I (BPD I) individuals with and without suicidal ideation and behaviour through multiple measurement of serum and salivary cortisol.

DESIGN

Cross-sectional, observational study.

SUBJECTS AND METHODS

75 BPD I patients were assigned into 3 groups (no history of suicidal behaviour, history of suicidal ideation, history of suicide attempt), according to the C-SSRS. Socio-demographical and clinical data was obtained by using MINI 6.0 and a semi-structured questionnaire. Salivary samples were collected using Sarstedt Cortisol Salivette synthetic swab system for two consecutive days at 08:00, 16:00, 23:00 and salivary cortisol concentrations were determined by ELISA technique. A unique 1mg dose of dexamethasone was administered on the first day, at 23:00, after the collection of the saliva sample. Blood was collected on the first day at 8:00 AM and basal morning serum cortisol levels were determined by immunoassay with fluorescence detection.

RESULTS

Cortisol parameters in our BPD I sample did not vary significantly in respect to suicidal history. However, patients with a history of suicidal ideation have significantly higher total cortisol outputs than patients with no history of suicidal behaviour in the 18 to 40 age category compared with the above 40 age category.

CONCLUSIONS

Total cortisol daily output varies significantly in an age-dependent manner in respect to suicidal thoughts in BPD I individuals.

Transradial and transulnar access for iliac artery interventions using sheathless guiding systems: A feasibility study

PURPOSE

Our aim was to evaluate the acute success and complication rates of the transradial and transulnar access for iliac artery stenting using sheathless guiding systems.

METHODS

Clinical and angiographic data from 156 consecutive patients with symptomatic iliac artery stenosis who were treated with transradial or transulnar access were evaluated. All patients underwent Duplex ultrasound before and after the intervention. The primary endpoints were the procedural success rate, major adverse events, and access site complication rates. The secondary endpoints were the angiographic result of the iliac artery intervention, fluoroscopy time, X-ray dose, procedure length, crossover rate to another puncture site and hospitalization duration. The impact of the learning curve was also investigated, along with right or left radial access.

RESULTS

The indication for the intervention was intermittent claudication in 109 patients (69.9%), critical limb ischemia in 44 (28.2%) subjects and acute limb ischemia in three individuals (1.9%). Technical success was achieved in 155 patients (99.4%), with a crossover rate of 3.8%. Radial and ulnar artery access was used in 151 (96.8%) and 7 (4.5%) patients, respectively. The Ankle-brachial index increased from 0.69 [0.65-0.72] to 0.91 [0.88-0.95] as a result of the procedures (P < 0.001). The cumulative incidence of major adverse events was 3.8% at the 2-month follow-up (0% in patients with intermittent claudication and 13.8% in patients with critical limb ischemia). Radial artery access site complications were encountered in eight patients (5.1%). We documented decreased X-ray doses (1742.0 [783.9-2701] vs. 1435 [991.1-1879] vs. 692.8 [275.3-1110] Gy cm-2 P < 0.05) over time; however, the fluoroscopy time, procedure time, and contrast consumption were not significantly different. Left hand access was not associated with significantly better results than right radial artery access.

CONCLUSIONS

Iliac artery stenting can be safely and effectively performed using radial or ulnar artery access and sheathless guiding catheters, with acceptable complication rates and high levels of technical success. The physician learning curve plays an important role in decreasing the X-ray dose. © 2016 The Authors. Catheterization and Cardiovascular Interventions Published by Wiley Periodicals, Inc.

Cardiovascular Screening and Management Among Kidney Transplant Candidates in Hungary

INTRODUCTION

Cardiovascular disease is a major cause of morbidity and mortality in end-stage renal disease patients on dialysis and the most common cause of death in the immediate post-transplantation period. The aim of our study was to describe a novel approach of cardiovascular screening and management of dialysis patients evaluated for the transplant waiting list.

METHODS

Twenty-eight patients with end-stage renal disease put on the waiting list between July 2013 and July 2014 were subjected to a prespecified cardiovascular screening protocol utilizing noninvasive and/or invasive tests. Patients were subsequently divided into 3 strata in terms of their estimated cardiovascular risk. Each of these groups were then prescribed interventions aiming to improve their cardiovascular condition.

RESULTS

According to our prespecified protocol of cardiovascular screening studies, 15 (54%) patients were identified as low, 5 (18%) as intermediate, and 8 (28%) as high risk. Four (14%) patients were current smokers. In the low-risk group, we initiated a patient education program involving counseling on regular exercise such as swimming or cycling to improve their functional capacity. In the high-risk group revascularization was done in 5 cases (63%), including 3 percutaneous transluminal coronary angioplasties (PTCA) with stents for single-vessel disease, and coronary artery bypass graft surgeries (CABG) for triple-vessel disease in 2 cases. In the medium-risk group medical management was opted for, including introduction of beta-blockers, inhibitors, statins, and ezetimibe, as well as efforts to optimize anemia management, indices of bone-mineral disease, and fluid status.

CONCLUSION

In our regional transplant program, we introduced a comprehensive multidisciplinary approach to treat potential transplant candidates according to cardiovascular risk stratification based on a prespecified screening protocol. Further studies are needed to correlate this novel strategy with post-transplantation outcomes.

Gerundium: A Comprehensive Public Educational Program on Organ Donation and Transplantation and Civil Law in Hungary

BACKGROUND

Organ transplantation has become an organized, routine, widely used method in the treatment of several end-stage diseases. Kidney transplantation means the best life-quality and longest life expectancy for patients with end-stage renal diseases. Transplantation is the only available long-term medical treatment for patients with end-stage liver, heart, and lung diseases. Despite the number of transplantations increasing worldwide, the needs of the waiting lists remain below expectations.

METHODS

One of the few methods to increase the number of transplantations is public education. In cooperation with the University of Debrecen Institute for Surgery Department of Transplantation, the Hungarian National Blood Transfusion Service Organ Coordination Office, and the Local Committee Debrecen of Hungarian Medical Students' International Relations Committee (HuMSIRC), the Gerundium, a new educational program, has been established to serve this target. Gerundium is a special program designed especially for youth education. Peer education means that age-related medical student volunteers educate their peers during interactive unofficial sessions.

RESULTS

Volunteers were trained during specially designed training. Medical students were honored by HuMSIRC, depending on their activity on the basis of their own regulations. Uniform slides and brochures to share were designed. Every Hungarian secondary school was informed. The Local Committee Budapest of HuMSIRC also joined the program, which helps to expand our activity throughout Hungary. The aim of the program is public education to help disperse disapproval, if presented.

CONCLUSIONS

As a multiple effect, our program promotes medical students to have better skills in the field of transplantation, presentation, and communication skills. Our program is a voluntary program with strong professional support and is free of charge for the community.

MicroRNA profile before and after antiviral therapy in liver transplant recipients for hepatitis C virus cirrhosis

BACKGROUND AND AIM

Management of hepatitis C virus (HCV) recurrence is a major challenge after liver transplantation. Significant dysregulated expression of HCV receptors (i.e. claudin-1, occludin, tetraspanin CD81, scavenger receptor type B1) has been shown recently during HCV infection. This might facilitate hepatocytic entry and reinfection of HCV. MicroRNAs (miRs) play role in the regulation of gene expression. We aimed to characterize miR expression profiles related to HCV infection and antiviral therapy in adult liver transplant recipients, with special emphasis on miRs predicted to target HCV receptors.

METHODS

Twenty-eight adult liver transplant recipients were enrolled in the study. Paired biopsies were obtained at the time of HCV recurrence and at the end of antiviral treatment. MiRs for HCV receptors were selected using target prediction software. Expression levels of miR-21, miR-23a miR-34a, miR-96, miR-99a*, miR-122, miR-125b, miR-181a-2*, miR-194, miR-195, miR-217, miR-221, and miR-224 were determined by reverse transcription-quantitative polymerase chain reaction.

RESULTS

miR-99a* and miR-224 expressions were increased in HCV recurrence samples, while miR-21 and miR-194 were decreased in comparison to normal liver tissue. Increased expressions of miR-221, miR-224, and miR-217 were observed in samples taken after antiviral therapy when compared with HCV recurrence samples. High HCV titer at recurrence was associated with higher level of miR-122.

CONCLUSIONS

Samples at recurrence of HCV and after antiviral therapy revealed distinct HCV-related miR expression profiles, with significant dysregulation of those miRNAs potentially targeting mRNAs of HCV receptors. In particular, miR-194 and miR-21 might be involved in the regulation of HCV receptor proteins' expression during HCV infection and antiviral therapy.

A dimensional approach of suicidal personality

Although the last decade research has shown that personality disorders (PD) represent a major risk in suicidal behavior, the role of personality dimensions in determining this type of behavior hasn't been yet studied thoroughly.

AIM

we intend to highlight some personality traits that may induce a suicidal behavior in patients diagnosed with PD.

METHODS

the sample consisted of 131 patients with PD, 46 of them presenting both a personality disorder and suicide behavior (suicidal ideation/suicide attempt). The personality dimensions were studied using the Temperament and Character Inventory (T.C.I.) developed by Robert Cloninger. Suicide risk was assessed using the Mini-International Neuropsychiatric Interview (M.I.N.I.), Module C- Suicide Ideas.

RESULTS

although the sample was analyzed in Clusters DSM type A, B, C and an analyze of co morbidities with the Axe I was also made, the analyze was taken further in our attempt to find a common factor that would differentiate the non-suicidal patients from the suicidal ones. The evident result appeared in two character dimensions that are highly related with suicide attempts.

CONCLUSION

self-conducting and cooperativeness could be considered marker-dimensions in a quick evaluation of suicide risk.

Significance of mycophenolate monitoring in liver transplant recipients: toward the cut-off level

Mycophenolate mofetil blocks the "de novo" -purine synthesis to reduce the incidence and severity of acute rejection episodes. There has been an increased interest in utility of monitoring mycophenolic acid (MPA) levels, however currently the MPA monitoring is not part of the protocol following liver transplantation. We assessed whether trough MPA monitoring could be advisable in liver transplant patients or not. For this reason MPA levels of 56 liver transplants were measured on 3, 5, 10, 14, 21, 30, 60, and 180 posttransplant days. The optimal cut-off of MPA level (≥1.73 mg/L) for all (56) and ≥1.34 mg/L for ciclosporin-treated- and ≥1.98 mg/L for the tacrolimus-treated transplants were calculated by statistical analysis to reduce the incidence of acute rejection. MPA concentrations of 3 days period before the day of clinical diagnosis acute rejection were well below the cut-off value. Only 3 (16%) out 19 patients with acute rejection had higher MPA levels than the cut-off value on the day of diagnosis of acute rejection. In conclusion, our data suggests that MPA predose level monitoring, especially in the early "filling phase" after transplantation, is applicable in liver allograft recipients given adjunctive MMF, protecting them from the ineffective immunosuppression.

Measurement and clinical significance of interleukin 28B in hepatitis C virus-infected liver transplant patients

One-third of the liver transplantations are performed because of hepatitis C cirrhosis all over the world and also in Hungary. The recurrence rate is practically 100%, influencing graft and patient survivals; within 5 years cirrhosis develops again in 20% to 30% of cases. The therapy is pegylated interferon α-2a and α-2b plus ribavirin as for nontransplanted subjects with the goal to eradicate the virus and maintain graft function. In 25% to 45% of treated patients, it is possible to achieve a sustained virological response (SVR). The response is influenced by viral, donor, and recipient factors. We investigated the genotype of 68 liver recipients transplanted because of hepatitis C virus (HCV) infection between September 1998 and February 2011. We focused on the interleukin (IL) 28B gene locus single nucleotide polymorphism found on chromosome 19; the rs12979860 minor allele (homozygous [wild TT and CC], heterozygous [CT]) in relation to the interferon response. Ten percent of the patients belonged to the CC, 62% to the CT, and 28% to the TT group, and 83% of the CC group became negative or therapy is still ongoing. The CT genotype reached 15.4% SVR with ongoing treatment for most patients. In TT carriers showed a 23.5% SVR. Our patients formed a homogenous group regarding the surgical team, the therapy, and the HCV genotype. Ninety percent belonged to the possible "hard to treat" group. The 10% CC group gave the highest number of SVR and HCV polymerase chain reaction negativity upon antiviral therapy. Regarding our results, one has to take in consideration the small patient number and the fact that the cirrhotic patients were listed for transplantation where they could not be treated or became therapy-resistant. IL28B is just one predictive factor among others for successful posttransplant HCV therapy; further examinations are needed to fully understand its role.

The impact of Milan criteria on liver transplantation for hepatocellular carcinoma: first 15 years' experience of the Hungarian Liver Transplant Program

In addition to hepatitis C, hepatocellular carcinoma. is a leading indication for orthotopic liver transplantation (OLT). The indications for OLT in HCC remains a topic of debate. The successful Milan criteria are still accepted as the gold standard to select candidates with a good chance for long-term survival. The Hungarian Liver Transplant Program launched in 1995 reached 45 OLT/year in 2010. Among 412 first OLTs, there were 49 cases of a malignant tumor, including 41 among which the indication was the tumor. Of the 412 patients, 154 (37.4%) were hepatitic C virus (HCV) positive, including 29 with HCC and 23 cases in which HCC was the indication itself. Half of the HCC patients were within the Milan criteria; 50% exceeded the criteria. We observed a solitary HCC in 36% of cases: 2 foci in 18%; 3 in 7%, 4 in 14%, and ≥5 in 25%. Only 12 patients underwent a "down-staging" treatment before OLT: 8 radiofrequency ablation (RFA) and 4 transarterial chemoembolization (TACE). Cumulative 1-, 3-, and 5-year patient survivals were 62%, 54%, and 43%, respectively in HCC/HCV-positive patients and they were 74%, 67%, and 61% among non-HCC HCV-positive subjects. The cumulative HCC patient survival rates of 64%, 64%, and 53% among Milan criteria were superior to those of 57%, 40%, and 27% among subjects exceeding the Milan criteria (P=.01). Pre-OLT "down-staging" treatment increased the 1-year patient survival from 64% to 70%; however, it did not affect the long-term results. Among items of the Milan criteria tumor size had less impact on outcomes then number of foci. The majority of cases who exceeded the Milan criteria had been transplanted before 2003. Our results suggested that the Milan criteria should be applied for the selection of candidates in order to promise good survival after OLT for HCC.

Examination of claudin-1 expression in patients undergoing liver transplantation owing to hepatitis C virus cirrhosis

The cell adhesion molecule claudin-1 (CLDN-1) is a well known co-factor for the cell entry of hepatitis C virus (HCV). We examined 24 hepatic biopsies from liver transplant patients. Reverse transcriptase polymerase chain reaction (RT-PCR) and immunohistochemistry were performed according to standard procedures. RT-PCR results were shown as relative expression (ΔCT) with beta-actin as the reference gene. Immunohistochemistry results are shown by morphometry. The CLDN-1 mRNS expression rate was significantly lower when the patient displayed favorably with an unsatisfactory to antiviral therapy 0.756 ± 0.249 versus 1.304 ± 0.28 (P=.012). There was also a strong positive correlation between CLDN-1 protein expression and liver fibrosis (Pearson correlation coefficients: r=0.476; P=.034).

Relationship between hepatitis C virus recurrence and de novo diabetes after liver transplantation: the Hungarian experience

De novo diabetes mellitus is a common complication after liver transplantation. It is strongly associated with hepatitis C virus (HCV) infection. We analyzed the relationship between HCV recurrence and de novo diabetes among the Hungarian liver transplant population. This retrospective study included cases from 1995 to 2009 on 310 whole liver transplantations. De novo diabetes was defined if the patient had a fasting plasma glucose ≥126 mg/dL permanently after the third month post liver transplantation, and/or required sustained antidiabetic therapy. De novo diabetes occured in 63 patients (20%). The cumulative patient survival rates at 1, 3, 5, and 8 years were 95%, 91%, 88%, and 88% in the control group, and 87%, 79%, 79%, and 64% in the de novo group, respectively (P=.011). The majority of the patients in the de novo group were HCV positive (66% vs 23%). Early virus recurrence within 5 months was associated with the development of diabetes (80% vs 20% non-diabetic controls; P=.017). The fibrosis (2.05 ± 1.5 vs 1 ± 1; P=.039) and Knodell scores (3.25 ± 2 vs 1.69 ± 1.2; P=.019) were higher among the de novo group after antiviral therapy. Rapid recurrence, more severe viremia, and fibrosis showed significant roles in the developement of de novo diabetes after liver transplantation.