Evaluation of Cases of Graft Nephrectomy After Graft Loss in Patients With Renal Transplantation

INTRODUCTION

Renal transplantation is undoubtedly considered the best renal replacement therapy. Graft nephrectomy can be performed in patients with renal transplantation because of complications associated with the failed graft. We aimed to retrospectively investigate the characteristics of patients who underwent graft nephrectomy.

MATERIALS AND METHODS

Between January 2000 and November 2013, the records of 757 patients who had renal transplantation in Ege University Faculty of Medicine Hospital Nephrology-Transplantation outpatient clinic were examined. Sixty-four patients who underwent graft nephrectomy were included in the study. Patients were divided into 2 groups according to the timing of graft nephrectomy. The group of 30 patients who underwent graft nephrectomy in the first 56 days after the renal transplantation was referred to as the "early group" and the group of 34 patients who underwent graft nephrectomy after 56 days was referred to as "late group."

RESULTS

In our study, we found the body mass index to be significantly higher in those with early graft loss (P = .02). We found that there was a difference between the groups in terms of sex (P = .012). When the mortality and morbidity rates after graft nephrectomy were examined, mortality was observed in 3 of the 64 patients in the study and morbidity in 1 patient.

CONCLUSION

According to our study, the body mass indices and ages of the subjects who need early graft nephrectomy are higher. However, male sex was significantly more prevalent in patients who underwent graft nephrectomy in the late period compared with the early period.

Kidney Transplant in a Human Immunodeficiency Virus-Positive Patient: Case Report of Drug Interactions

End-stage renal disease in the human immunodeficiency virus-positive population is increasing. Kidney transplant is the optimal therapy for this population rather than dialysis modalities if some criteria are met. These include undetectable plasma human immunodeficiency virus RNA, CD4 cell count over 200 cells/μL, and the absence of any AIDS-defining illness. Here, we describe the first living-donor kidney transplant in a human immunodeficiency virus-positive recipient in Turkey. The patient, a 52-year-old male diagnosed as human immunodeficiency virus positive, was on antiretroviral therapy, which consisted of 400 mg twice daily darunavir, 100 mg/day ritonavir, and 50 mg/day dolutegravir. He had been negative for human immunodeficiency virus RNA for the past 3 years. The patient developed renal insufficiency without any known cause and started hemodialysis. A living donor transplant from his son was performed, and the patient received ATG Fresenius-S (Neovii Biotech, Rapperswil, Switzerland) induction and a maintenance immunosuppression therapy consisting of methyl-prednisolone, mycophenolate mofetil, and tacrolimus. There were no incidences of delayed graft function or acute rejection. Because of tacrolimus and ritonavir interaction, tacrolimus trough levels were too high. With tacrolimus withdrawn, tacrolimus trough level decreased to detectable levels 2 weeks later. Antiretroviral therapy was continued on the same dosage. At month 4 posttransplant, the patient's creatinine level was 1.01 mg/dL. At present, the patient has had no complications and no episodes of rejection. Kidney transplant is the most favorable replacement therapy for HIV-positive patients who are under controlled AIDS care with highly active antiretroviral therapy. However, drug interactions should be carefully evaluated.

Screening of immunocompromised patients at risk of strongyloidiasis in western Turkey using ELISA and real-time PCR

BACKGROUND/AIM

Strongyloides stercoralis causes life-threatening hyperinfection or disseminated strongyloidiasis in immunocompromised patients such as HIV-positive, organ transplantation, and cancer patients. This study investigated the presence of strongyloidiasis in immunocompromised patients for the first time in Turkey.

MATERIALS AND METHODS

Serum and stool samples were collected from 108 patients (25.9% of them were chronic renal failure and 74.1% were renal transplantation patients) who were admitted to Ege University Medical School in İzmir, located in western Turkey. Serum samples were analyzed by ELISA (DRG, Germany) and the presence of 18S rRNA gene of S. stercoralis was detected in stool samples by real-time PCR.

RESULTS

The analysis of serum samples showed that only one patient was anti-S. stercoralis IgG antibody and real-time PCR positive (0.92%). The patient was treated twice with albendazole (400 mg/day for 3 days) at 2-week intervals. Follow up real-time PCR was negative and the patient became seronegative 6 months after the initial diagnosis.

CONCLUSION

This screening showed that the prevalence of strongyloidiasis in this small group of patients who were at risk of strongyloidiasis was 0.92%. Overall, the results showed that more systematic studies are required in Turkey to show the prevalence of strongyloidiasis.

Impact of Prophylaxis vs Pre-emptive Approach for Cytomegalovirus Infection in Kidney Transplant Recipients

Cytomegalovirus (CMV) is the most common viral infection during the post-transplant period, and it is one of the major causes of morbidity and mortality in kidney transplantation. In this study, the incidence and impact of pre-emptive and prophylactic approaches and long-term effects on graft and patient survival of CMV infection were investigated. Among 493 adult kidney transplant recipients, pretransplant CMV IgG-negative patients and patients with a follow-up shorter than a month were excluded. The patients were divided into 2 groups: pre-emptive group (n = 187, regular screening and acyclovir 400 mg twice daily for 6 months), and prophylaxis group (n = 275, valganciclovir 450 mg/d for 3 months). The pre-emptive group was screened for CMV with either pp65 antigenemia or CMV DNA. There were 462 patients, and mean follow-up was 37.7 months. There were more CMV infections in the pre-emptive group than in the prophylaxis group (n = 56, 30.1% vs n = 12, 4.4%, respectively; P < .001). Late CMV infections were significantly more frequent in the prophylaxis group (10 of 12, 83.3%) than in the pre-emptive group (8 of 56, 14.3%, P < .001). In multivariate analysis, valganciclovir prophylaxis was associated with a lower CMV infection (relative risk [RR]: 0.18, 95% confidence interval [CI] 0.08 to 0.39, P < .001). Delayed graft function was the only independent risk factor for graft loss during the follow-up on multivariate Cox regression analysis (RR: 2.66, 95% GA 1.17 to 6.04, P = .02). Valganciclovir prophylaxis was more protective against CMV infection than the pre-emptive approach. Neither prophylaxis/pre-emptive approaches nor CMV infection had negative effect on graft and patient survival.

Efficacy and Safety of ATG-Fresenius as an Induction Agent in Living-Donor Kidney Transplantation

BACKGROUND

Induction therapy is mostly recommended for deceased-donor transplantation, whereas it has some controversies in live-donor transplantation. In this study, we described the outcomes of live-donor renal transplant recipients who received ATG-Fresenius (ATG-F) induction.

METHODS

Live-donor transplantations in patients over 18 years old with ATG-F induction between 2009 and 2015 were included. All patients received quadruple immunosuppression, one of which was ATG-F induction. Biopsies after the artery anastomosis (zero hour) and protocol biopsies at the 6th month and at the 1st first year were obtained. Acute graft dysfunction was defined as a 20% to 25% increase in creatinine level from baseline. All acute rejection episodes were biopsy-confirmed. All episodes were initially treated with intravenous methyl prednisolone (MP) or ATG-F if resistant to MP. Four hundred twenty-two patients with live-donor transplantation were evaluated. The mean age was 40 ± 13 (18-73) years. The mean panel-reactive antibody levels were 42% ± 30% and 45% ± 30% for class I and II, respectively.

RESULTS

The mean mismatch number for living unrelated donors (n = 112) was 4.6 ± 1.0. Acute rejection rate was 29.1% (123 patients) within the first year. The mean cumulative ATG-F doses for per patient and per kilogram were 344 ± 217 mg and 5.1 ± 2.7 mg, respectively. Patient survival rates were 98.3% and 96.7% for 12 months and 60 months, respectively. Death-censored graft survival rates were 97.6% and 92.1% for 12 months and 60 months, respectively.

CONCLUSIONS

ATG-F induction provided excellent graft and patient survival rates without any significantly increased side effects. Increasing sensitized patient numbers, more unrelated donors, increasing re-transplantation numbers, and more desensitization protocols make ATG-F more favorable in an induction regimen.

Impedance ratio: a novel marker and a powerful predictor of mortality in hemodialysis patients

PURPOSE

Impedance ratio (Imp-R) obtained by multifrequency bioimpedance analysis (BIA) has been shown to be associated with volume and nutrition status. In this prospective study, the predictive role of Imp-R for mortality in hemodialysis (HD) patients was investigated.

METHODS

Multifrequency (5-50-100-200 kHz) BIA was applied to 493 prevalent HD patients in March-April 2006. Imp-R was defined as the ratio of 200-5 kHz impedance values. Demographical, clinical and laboratory data at the time of the analysis were recorded. All-cause and cardiovascular (CV) mortality were assessed during 3 years of follow-up.

RESULTS

Mean age was 57.7 ± 13.9 years, HD duration 52.1 ± 42.6 months and prevalence of diabetes 21.7 %. Imp-R was negatively correlated with nutritional markers including albumin, creatinine and hemoglobin levels. In addition, there was a positive correlation between Imp-R and age, ratio of extracellular water to total body water and high-sensitive C-reactive protein. Over a mean follow-up period of 27.9 ± 11.1 months, 93 deaths (52 from CV reasons) were observed. In the multivariate analysis, Imp-R was significantly associated with all-cause and CV mortality after adjustments [HR 1.13, 95 % CI (1.04-1.23); p = 0.004 and HR 1.15, 95 % CI (1.03-1.27); p = 0.01, respectively]. The risk of all-cause mortality was 3.4 times higher in the fourth quartile of Imp-R (>83.5 %) compared to the first Imp-R quartile (<78.8 %) as reference. Cutoff value of Imp-R for all-cause mortality was 82.0 % with a sensitivity of 65.5 % and specificity of 64 %.

CONCLUSION

Impedance ratio measured by multifrequency in standardized conditions BIA is an independent and powerful predictor of both all-cause and CV mortality in hemodialysis patients.

Correlation of the Volume Control Parameters With Health Related Quality of Life in Renal Transplant Patients

INTRODUCTION

Transplantation is the most effective treatment strategy for end-stage renal failure. We aimed to investigate the correlation of volume control parameters with health-related quality of life (HRQoL) in renal transplantation patients during the pre- and post-transplantation periods.

MATERIAL AND METHODS

Seventy-seven patients who underwent renal transplantation from deceased donors between January 2011 and January 2013 were included in the study. The biochemical markers, complete blood count, and creatinine levels were measured during pretransplantation and at post-transplantation month 6. The Turkish version of the Short Form 36 (SF-36) health survey questionnaire was used for the assessment of HRQoL. Blood pressure (BP) and echocardiographic measurements were used to evaluate the volume status.

RESULTS

Significant improvements were achieved in all echocardiographic measurements, biochemical parameters except Ca(++), and SF-36 questionnaire domain scores (DSs) except vitality in the post-transplantation period. Systolic BP (SBP), the left atrium index, vena cava inferior collapsibility index (VCCI), and diastolic BP were associated with vitality (P = .02, .03, .05, and .04, respectively); SBP was associated with social functioning (P < .01) and role emotional (P < .01); and left ventricular mass index was associated with mental health (P = .05) DSs during the pretransplantation period. In the post-transplantation period, VCCI, left ventricular mass index, and SBP were associated with general health (P = .02, .05, and .05, respectively); VCCI and SBP were also associated with mental health (P = .05 and .01, respectively); and left atrium index was associated with role emotional (P = .05) DSs.

CONCLUSION

Concomitant improvement in the volemic status may contribute to improvements in HRQoL after renal transplantation.

To what extent estimated or measured GFR could predict subclinical graft fibrosis: a comparative prospective study with protocol biopsies

Monitoring of allograft function entails methods more accurate than serum creatinine and creatinine-based GFR equations (eGFR). This prospective trial aimed at investigating the diagnostic accuracy of creatinine- and cystatin C-based eGFR with measured GFR (mGFR) and compared them with graft fibrosis detected by protocol biopsies (PBx). Forty-four kidney transplant recipients were enrolled. PBx were obtained postengraftment and at 6th and 12th months. GFR was measured by Tc-99m DTPA at 3th, 6th, and 12th months after transplantation. Significant correlation existed between eGFR and mGFR at 3, 6, and 12 months (P < 0.0001). Cystatin C-based Hoek and Larsson equations had the lowest bias and highest accuracy. The sum of interstitial fibrosis and tubular atrophy score increased from implantation to 6th and 12th months (0.52 ± 0.79, 0.84 ± 0.88, 1.50 ± 1.35). This was accompanied by reduction of mGFR from 54.1 ± 15.2 to 49.9 ± 15.2 and 46.8 ± 16.5 ml/min/1.73 m(2) , while serum creatinine, cystatin C, and eGFR remained stable. Neither creatinine- nor cystatin C-based GFR equations are reliable for detecting insidious graft fibrosis. In the first year after transplantation, mGFR, with its best proximity to histopathology, can be used to monitor allograft function and insidious graft fibrosis.

Use of suicidal deaths as kidney donors: a single-center experience

OBJECTIVE

Although the number of end-stage renal disease patients on the waiting list has increased, the number of deceased kidney donors has not increased proportionately. Therefore, the use of kidney donors defined as "marginal" has become an issue. Since the acceptance of deaths due to poisoning or suicide as donors has been proposed, we evaluated the clinical courses of kidney transplantations from suicidal death donors.

PATIENTS AND METHODS

We analyzed retrospectively the outcomes of nine deceased donor kidneys (8 males) from suicide victims between 2001 and 2012. Demographic and clinical characteristics of donors and recipients were collected from medical files.

RESULTS

The mean donor age was 27.8 ± 11.9 years. Causes of death were: gunshot wounds to the head (n:4), pesticide intoxication (n:2), methanol intoxication (n:1), hanging (n:1), or carotid artery laceration (n:1). Mean donor creatinine level, urine output per hour, and 24-hour urine volume were 0.94 ± 0.53 mg/dL, 270 ± 113 mL, and 5496 ± 832 mL, respectively. Mean cold ischemia time was 12.3 ± 5.7 hours. Primary allograft nonfunction occurred in one recipient requiring nephrectomy. The average posttransplantation creatinine level at 1 year was 1.19 ± 0.62 mg/dL. The mean follow-up was 55 ± 49 months. Allograft loss occurred due to chronic rejection in three patients at 10, 37, and 40 months. Five patients are still undergoing follow-up with functioning grafts.

CONCLUSION

Brain death cases caused by the suicide should be considered for organ donation.

Rare cause of weight loss in a kidney transplant recipient: iron overload

Various reasons such as malignancies and chronic infections may cause weight loss in kidney transplant patients. In this report, iron overload as a rare cause of weight loss in a kidney transplant patient is presented. Forty-seven-year-old male patient who transplanted from a deceased donor 5 years ago was hospitalized because of 20 kg of weight loss. In medical history, he had history of hemodialysis for 89 months and received 100-300 mg of intravenous iron therapy per week before transplantation and transfused eight units of blood. In physical examination, weight and height were 45 kg and 185 cm, respectively. Respiratory and cardiac auscultation was normal. Laboratory results revealed as follow: glucose 76 mg/dL, urea 60 mg/dL, creatinine 1.35 mg/dL, aspartate aminotransferase 74 U/L, alanine aminotransferase 77 U/L, C-reactive protein 2.59 mg/dL, albumin 3.3 g/dL, globulin 3.4 g/dL, white blood cells 3200/mm(3), hemoglobin 13.1 g/dL and platelets 190,000/mm(3). Chest and abdominal tomography didn't reveal any pathology. Portal Doppler ultrasound showed signs of early cirrhosis. Viral and autoimmune hepatitis markers were negative. Ferritin was 5300 ng/mL and transferrin saturation was 82%. In liver biopsy, hemosiderosis was diagnosed and heterozygous H63D gene mutation was detected. Totally, 19 units of phlebotomy were performed. Liver function tests and serum ferritin decreased gradually. At outpatient follow-up in 6 months, he returned to former weight. In conclusion, there can be several causes of weight loss in kidney transplant patients. Iron overload can come across as a rare cause of weight loss. In these patients, ferritin levels should be checked and diagnosis should be clarified by liver biopsy and gene mutation analysis.

GCF and serum myeloperoxidase and matrix metalloproteinase-13 levels in renal transplant patients

AIM

The rationale of this study was to address whether local or systemic changes reflect proteolytic (matrix metalloproteinase-13) or oxidative (myeloperoxidase) stress in renal transplant patients receiving cyclosporine-A (CsA) and having gingival overgrowth (GO), in patients receiving CsA therapy and having no GO and patients receiving tacrolimus therapy.

MATERIAL AND METHODS

Gingival crevicular fluid (GCF) samples were collected from sites with (GO+) and without GO (GO-) in CsA patients having GO; GO- sites in CsA patients having no GO; sites from tacrolimus, gingivitis and healthy subjects. GCF and serum myeloperoxidase (MPO) and matrix metalloproteinase-13 (MMP-13) levels were determined by ELISA.

RESULTS

GO+ sites in CsA patients having GO had elevated GCF MPO levels than those of CsA patients having no GO, tacrolimus and healthy subjects (p<0.005), but comparable to those of gingivitis. GCF MPO levels were higher in GO+ compared to GO- sites in CsA patients having GO (p<0.05). Patient groups had similar, but higher GCF MMP-13 levels than healthy group.

CONCLUSIONS

These results show that CsA and tacrolimus therapy have not a significant effect on GCF MPO and MMP-13 levels, and gingival inflammation seems to be the main reason for their elevations.

The acquisition time of infection: a determinant of the severity of hepatitis C virus-related liver disease in renal transplant patients

BACKGROUND

The aim of this study was to compare the clinical and histopathological course of HCV infection acquired before and during or after renal transplantation.

METHODS

According to HCV status, 197 RT patients were divided into three groups. At the time of RT, anti-HCV antibody was positive in 47 patients (pre-RT HCV group). In 27 patients, in whom anti-HCV negative at the time of RT, anti-HCV and/or HCV RNA was found to be positive following an ALT elevation episode after RT (post-RT HCV group). Both anti-HCV and HCV RNA were negative at all times in remaining 123 patients (control group).

RESULTS

Liver biopsy was performed in 31 of 47 patients in pre-RT and 24 of 27 in post-RT HCV group after RT. Duration of follow-up was similar in all groups with a mean of 7.1 +/- 4.0 yr. Ascites and encephalopathy were seen in only post-RT HCV group (22%). Histological grade (6.5 +/- 2.7 vs. 4.1 +/- 1.4) and stage (2.0 +/- 1.5 vs. 0.8 +/- 0.8) was significantly severe in post-RT HCV group (p < 0.01). Three patients died due to liver failure in post-RT HCV group.

CONCLUSIONS

HCV infection acquired during or after RT shows a severe and rapidly progressive clinicopathological course, which is significantly different from pre-transplant anti-HCV positive patients.

Long-term outcomes of CMV disease treatment with valganciclovir versus IV ganciclovir in solid organ transplant recipients

Though an important cause of morbidity and mortality in solid organ transplantation (SOT), the long-term outcomes of cytomegalovirus (CMV) disease treatment have not been well studied. In a randomized trial, 321 SOT recipients with CMV disease were followed 1 year after treatment with either twice daily intravenous ganciclovir or oral valganciclovir (for 21 days) followed by once daily valganciclovir until day 49 in all patients. Clinical and viral eradication of CMV disease was similar between groups. Clinical recurrence beyond day 49 was found in 15.1% and virological recurrence in 30.0%, no difference between groups (p > 0.77). In a multivariable logistic regression analysis, the only independent predictor for recurrence was failure to eradicate DNAemia by day 21 (clinical: OR 3.9 [1.3-11.3], p = 0.012; virological: OR 5.6 [2.5-12.6], p < 0.0001). Eight patients developed ganciclovir resistance, with no difference between groups (p = 0.62). Twenty patients (valganciclovir: 11, ganciclovir: 9, p = 0.82) died, 12 due to infections, two involving CMV disease. There were no differences in long-term outcomes between treatment arms, further supporting the use of oral valganciclovir for treatment of CMV disease. Persistent DNAemia at day 21, CMV IgG serostatus and development of resistance may be relevant factors for further individualization of treatment.

[Tuberculin skin test reactivity in patients with chronic renal failure]

The aim of this study was to evaluate the response of tuberculin skin test (TST) and the parameters that affect the response in patients with chronic renal failure (CRF) on different treatment regimens. The study population consisted of 150 patients (78 females, mean age 48.1 + or - 16.7 years, the mean disease duration 6.6 + or - 6.1 years). Of these patients, 50 were on haemodialysis (HD), 50 were renal transplant patients, 26 were on peritoneal dialysis (PD) and 24 were treated medically. TST was performed to all patients, an induration with a diameter of 10 mm or more was accepted as positive response in HD, PD, medical treatment groups, whereas 5 mm or more was considered as positive in transplant group. TST was positive in 52% of the study population (56% in HD group, 54% in PD group, 44% in transplant group, 58% in medical treatment group, p> 0.05). There was a positive correlation between TST and age in patients older than 60 of transplant and medical treatment groups (p= 0.008). In HD patients with negative TST, the number of female patients was higher (p= 0.02). In transplant patients with positive TST, duration of HD was shorter (p= 0.01), the blood urea level was lower (p= 0.04), hemoglobin level was higher (p= 0.04). The ratio of negative TST was higher (p< 0.05), TST reactivity was smaller (p= 0.01) in only transplant patients with no BCG scar. The number of BCG scar was correlated positively with TST (p= 0.04). In the medical treatment group, patients with positive TST response were older (p= 0.02) and in PD group the tuberculin reactivity was not affected by any of the patient-related parameters. It must be considered that the response to TST is low in young patients with uncontrolled CRF and under immunosuppressive therapy.

Incidence and importance of c4d deposition in renal allograft dysfunction

Recent studies showed that peritubular capillary deposition of C4d is a marker of humoral immune responses directed against a renal allograft. The aim of this retrospective study was to investigate the incidence, clinical features, and prognostic implications of C4d deposition in renal allograft biopsy specimens. The biopsies had been performed due to acute graft dysfunction. This study of 104 renal allograft biopsies performed in 2004 classified histopathological findings according to Banff criteria. All paraffin-embedded biopsy samples were stained with an immunohistochemical method for C4d deposition. Demographic data, clinical findings, and biochemical findings were obtained from patients' charts. C4d staining was positive in 15/104 (14%) samples. The staining pattern was diffuse in 8 and focal in 7 patients. Nine patients were males. The overall mean age was 33 +/- 6 years. Ten received live-donor grafts. The biopsy occurred at a mean of 1007 +/- 1415 (range, 15-4712) days after the operation with a mean serum creatinine (SCr) level of 2.8 +/- 1.5 (1.25-6.0) mg/dL. Patients were divided into 2 groups according to the occurrence time: early (before 100 days) and late (after 100 days). Among the early group (n = 5), the mean SCr level was 2.8 +/- 1.5 mg/dL; a diffuse staining pattern was seen in 4 (80%) patients. Histological findings were acute rejection in 3, borderline changes in 1, or thrombotic microangiopathy in 1 patient. Two patients were treated with pulse steroids and 3 with ATG, intravenous immunoglobulin, and plasmapheresis. Three patients lost their grafts at the mean of 118 +/- 100 days after the biopsy. In the late group (n = 10), the mean SCr level was 2.8 +/- 1.7 mg/dL with a diffuse staining pattern in 4 (40%) patients. The histological findings included acute rejection in 6, chronic vascular rejection in 2, thrombotic microangiopathy in 1, and chronic allograft nephropathy in 1 patient. Six patients were treated with pulse steroids, and 3 with ATG and intravenous immunoglobulin. Five patients lost their grafts at a mean of 200 +/- 270 days. The overall incidence of C4d deposition was 14%; it was seen both in the early and late posttransplantation period. Although a diffuse staining pattern was more frequently seen in the early period, C4d deposition indicated a poor allograft prognosis in both periods. Introduction of C4d staining into the routine may guide more specific treatments directed toward the humoral alloresponse.

Gingival crevicular fluid and serum matrix metalloproteinase-8 and tissue inhibitor of matrix metalloproteinase-1 levels in renal transplant patients undergoing different immunosuppressive therapy

AIM

We investigated gingival crevicular fluid (GCF) and serum matrix metalloproteinase-8 (MMP-8) and tissue inhibitor of matrix metalloproteinase-1 (TIMP-1) levels from renal transplant patients receiving cyclosporine-A (CsA) and having gingival overgrowth (GO), from patients receiving CsA therapy and having no GO and patients receiving tacrolimus therapy.

MATERIAL AND METHODS

GCF samples were collected from sites with GO (GO+) and without GO (GO-) in CsA patients having GO; and GO- sites in CsA patients having no GO; sites from tacrolimus, gingivitis and healthy subjects. GCF and serum MMP-8 and TIMP-1 levels were determined by a time-resolved immunofluorometric assay (IFMA) and enzyme-linked immunosorbent assay.

RESULTS

GO+ sites in CsA patients having GO had elevated GCF MMP-8 levels compared with those of CsA patients having no GO, tacrolimus and healthy subjects (p<0.005), but these levels were similar to those of gingivitis. The GCF MMP-8 level was higher in GO+ compared with GO- sites in CsA patients having GO (p<0.05). GCF TIMP-1 levels were similar between groups. Tacrolimus patients had lower GCF MMP-8 levels than gingivitis (p<0.005), but levels similar to the healthy group.

CONCLUSION

These results show that CsA and tacrolimus therapy has no significant effect on GCF MMP-8 levels, and gingival inflammation seems to be the main reason for their elevations.

Gingival crevicular fluid transforming growth factor-beta1 in cyclosporine and tacrolimus treated renal transplant patients without gingival overgrowth

BACKGROUND

Gingival crevicular fluid (GCF) levels of transforming growth factor-beta(1) (TGF-beta(1)) have been previously investigated in relation to the pathogenesis of cyclosporine-A (CsA)-induced gingival overgrowth (GO) but no clinical data are available regarding the GCF levels of TGF-beta(1) in patients treated with tacrolimus (Tac). However, as gingival inflammation is pronounced at sites of GO and this consequently may lead to an elevation in TGF-beta(1) levels the present study aimed to evaluate gingival crevicular fluid (GCF) TGF-beta(1) levels in renal transplant patients using CsA or Tac without GO.

METHODS

GCF TGF-beta(1) levels were investigated in 30 renal transplant patients without GO medicated with either CsA (n=15) or Tac (n=15). Sixteen gingivitis patients and 15 periodontally healthy subjects were selected as controls. Periodontal status was evaluated by measuring probing depth, plaque index and papilla bleeding index. The TGF-beta(1) levels were analysed by enzyme-linked immunosorbent assay.

RESULTS

Both CsA and Tac groups had significantly elevated GCF TGF-beta(1) total amount compared to gingivitis and healthy groups (p<0.008). GCF TGF-beta(1) total amount of CsA and Tac groups was similar (p>0.008). Gingivitis and healthy groups had also similar GCF TGF-beta(1) total amount (p>0.008).

CONCLUSIONS

Within the limits of the present data it is unlikely that TGF-beta(1) is an exclusive mediator of CsA- or Tac-induced GO. However, pathogenesis of GO is multifactorial and contribution of TGF-beta(1) to the interrelations between cytokines and growth factors with fibrogenic potential cannot be disregarded.

Differential expression of receptor activator of nuclear factor-?B ligand and osteoprotegerin mRNA in periodontal diseases

BACKGROUND AND OBJECTIVE

Receptor activator of nuclear factor-kappaB ligand (RANKL) is responsible for the induction of osteoclastogenesis and bone resorption, whereas its decoy receptor, osteoprotegerin, can directly block this action. Because this dyad of cytokines is crucial for regulating the bone remodelling process, imbalances in their expression may cause a switch from the physiological state to enhanced bone resorption or formation. This study investigated the mRNA expression of RANKL and osteoprotegerin, as well as their relative ratio, in the gingival tissues of patients with various forms of periodontal diseases.

MATERIAL AND METHODS

Gingival tissue was obtained from nine healthy subjects and 41 patients, who had gingivitis, chronic periodontitis, generalized aggressive periodontitis, and chronic periodontitis and were receiving immunosuppressant therapy. Quantitative real-time polymerase chain reaction was employed to evaluate the mRNA expression of RANKL and osteoprotegerin in these tissues.

RESULTS

Compared with healthy individuals, patients in all periodontitis groups, but not those with gingivitis, exhibited stronger RANKL expression and a higher relative RANKL/osteoprotegerin ratio. In addition, osteoprotegerin expression was weaker in patients with chronic periodontitis. When patients with generalized aggressive periodontitis and chronic periodontitis were compared, the former exhibited stronger RANKL expression, whereas the latter exhibited weaker osteoprotegerin expression, and there was no difference in their relative ratio. When chronic periodontitis patients were compared with chronic periodontitis patients receiving immunosuppressant therapy, osteoprotegerin, but not RANKL, expression was stronger in the latter.

CONCLUSION

This study demonstrates that RANKL and osteoprotegerin expression are differentially regulated in various forms of periodontitis, and the relative RANKL/osteoprotegerin ratio appears to be indicative of disease occurrence. This information may confer diagnostic and therapeutic value in periodontitis.

Improvement in "uremic" cardiomyopathy by persistent ultrafiltration

Some patients with end-stage renal disease suffer severe cardiac dilatation with functional disturbances, notably low ejection fraction (EF) and valvular regurgitation. They often have normal or low blood pressure, and tolerate ultrafiltration (UF) poorly. The aim of our study was to investigate to what extent this condition can still be improved by persistent slow UF. Twelve patients with cardiothoracic index >0.54 and EF <0.45 but otherwise uncomplicated were treated by slow, prolonged UF during hemodialysis (3 times a week) sessions, if necessary supplemented by isolated UF sessions on a separate day. Repeated chest X-rays and Doppler echocardiography were applied. During treatment periods varying from 20 to 120 days, all of the patients lost weight (12+/-10 kg) and became edema free. Cardiothoracic index decreased in all patients from a mean of 0.59+/-0.04 to 0.47+/-0.03. Blood pressure decreased when it had been elevated and increased when it was below normal. Ejection fraction increased in all of them from a mean of 0.31+/-0.9 to 0.50+/-0.9. Mitral and tricuspid regurgitation were found in every patient and disappeared or improved in all of them. Striking improvement of cardiac dilatation and dysfunction can be achieved by carefully monitored persistent UF in the majority of patients with seemingly intractable dilated cardiomyopathy.

Gingival crevicular fluid levels of RANKL and OPG in periodontal diseases: implications of their relative ratio

AIM

Receptor activator of NF-kappaB ligand (RANKL) and osteoprotegerin (OPG) are a system of molecules that regulate bone resorption. This study aims to compare the levels of RANKL, OPG and their relative ratio in gingival crevicular fluid (GCF) of healthy and periodontal disease subjects.

MATERIAL AND METHODS

GCF was obtained from healthy (n=21), gingivitis (n=22), chronic periodontitis (n=28), generalized aggressive periodontitis (n=25) and chronic periodontitis subjects under immunosuppressant therapy (n=11). RANKL and OPG concentrations in GCF were measured by enzyme-linked immunosorbent assays.

RESULTS

RANKL levels were low in health and gingivitis groups, but increased in all three forms of periodontitis. OPG levels were higher in health than all three periodontitis, or gingivitis groups. There were no differences in RANKL and OPG levels between chronic and generalized aggressive periodontitis groups, whereas these were lower in the immunosuppressed chronic periodontitis group. The RANKL/OPG ratio was significantly elevated in all three periodontitis forms, compared with health or gingivitis, and positively correlated to probing pocket depth and clinical attachment level.

CONCLUSION

GCF RANKL and OPG levels were oppositely regulated in periodontitis, but not gingivitis, resulting in an enhanced RANKL/OPG ratio. This ratio was similar in all three periodontitis groups and may therefore predict disease occurrence.

Patients with failed renal transplant may be suitable for peritoneal dialysis

BACKGROUND

It has been claimed that patients with late transplant failure returning to peritoneal dialysis have lower patient and technique survival.

PURPOSE

In this retrospective study, we aimed to clarify this issue in a large PD population.

METHODS

Thirty-four PD patients with a failed renal transplant (FTx) and 82 PD patients who had never received a kidney transplant (Non-Tx) or HD treatment were investigated. All fTx patients were using only steroids (5-10 mg/day) for first 3 months of peritoneal dialysis. The groups were similar regarding to age, sex, residual renal function and KT/V; none of them was diabetic.

RESULTS

Ftx group had a higher number of peritonitis attack than Non-Tx group (2.42 +/- 0.41 v 1.61 +/- 0.15, attack per patient, p = 0.013). PET status was not different. One, 3 and 5 year patient survival calculated with the Kaplan Meier method were 93%; 93%; 93% respectively in Ftx and 97%; 89%; 82% respectively in Non-Tx patients. Technique survival was 83%; 77%; 60% in Ftx and 91%; 64%; 48% in Non-Tx patients respectively.

CONCLUSIONS

We conclude that PD appears to be a good option for fTx patients. A previous renal transplantation does not adversely affect patient and technique survival. Although the somewhat higher infection risk is of some concern, we did not observe earlier loss of peritoneal functions (high transporter) in the post transplant patients.

Intima media thickness as a predictor of atherosclerosis in renal transplantation

It has been reported that an increase in carotid artery intima-media thickness (IMT), a sign of early atherosclerosis, has a predictive value for future cardiovascular (CV) events. There are limited data about IMT measurements in renal transplant patients who display a high rate of CV mortality. In this study carotid artery IMT was measured by high resolution B-mode ultrasonography in 102 randomly selected RT patients to assess the relationship between IMT and CV disease and risk factors. A positive correlation was found between IMT and age, triglyceride level, and hematocrit. IMT was significantly higher among patients who were diabetic (0.68 +/- 0.27 vs 0.50 +/- 0.2) or had CV disease (0.88 +/- 0.28 vs 0.53 +/- 0.21). An increased IMT was associated with a longer duration of ESRD, higher lipid level, lower serum albumin, and presence of previous CMV disease. CV disease was more frequent among patients with increased IMT. Considering its relation to CV risk factors, it is concluded that the measurement of carotid artery IMT is an easy, reliable and non-invasive method to be used to assess atherosclerotic disease in renal transplant patients.

Comparison of tacrolimus and cyclosporin in renal transplantation by the protocol biopsies

Acute and chronic lesion scores on renal allograft protocol biopsies may predict long-term graft function. The aim of this study was to compare the effects of tacrolimus (Tac) and cyclosporine microemulsion (CsA) based immunosuppressive protocols using protocol biopsies from well-functioning renal allografts. 35 consecutive renal transplant patients were randomized to Tac (n: 17) versus CsA (n: 18) treatment arms. Patient age and sex, donor type and age, histocompatibility, cold ischemia time and prior delayed graft function were similar between the two groups. Treatment protocol consisted of prednisolone, azathioprine and Tac or CsA. Biopsies performed on the third, sixth and twelfth months were blindly evaluated by the same pathologist. The incidences of acute rejection (AR) episodes among CsA vs Tac groups were 33% vs 29%, respectively (NS). The Creatinine level was lower in Tac than CsA, although it was not significant (Table). Subclinical AR and subclinical chronic allograft nephropathy were detected on protocol biopsies in 3 (2 CsA, 1 Tac) and 12 (7 CsA, 5 Tac) patients, respectively. Acute lesion score at the third month PBx was significantly lower in the Tac group (p < 0.05). Chronic lesion scores in all biopsies were lower in the Tac group, although not significantly. The protocol biopsy findings suggest that graft injury may be less pronounced among the Tac group.

Is “zero-hour” biopsy of the transplanted kidney risky?

"Zero-hour" renal allograft biopsy provides valuable diagnostic information for comparison to subsequent kidney material. However, the invasive nature of the biopsy procedure tends to limit its widespread use in many centers. We undertook this retrospective study to examine the rate and clinical importance of complications in our series of patients routinely undergoing zero-hour biopsies performed between 1994 and 2001. Two hundred thirty-six zero-hour biopsies included only one sample performed with a 14G needle from lower posterior part of kidney by using a manual tru-cut technique. Doppler ultrasonography was performed after first 5 days. An average of 34 +/- 19 glomeruli were obtained in the biopsies. The biopsy specimens were adequate for diagnosis in 77% of the procedures. Ten (4%) patients experienced complications of intraparenchymal arteriovenous fistula (n = 4), which regressed spontaneously; perirenal hematoma (n = 4); intraparenchymal hematoma (n = 2); and a minimal perirenal collection (n = 41). We conclude that zero-hour biopsy is a safe diagnostic method. The rate of complications is low, as well as generally mild and self-limiting.

[Human herpesvirus 6 infections in kidney and bone marrow/stem cell transplant recipients]

In this study, active human herpesvirus (HHV)-6 infection were investigated in 39 renal and 9 bone marrow/stem cell transplant recipients. For this purpose, the presence of HHV-6 DNA in patients sera have been searched by nested polymerase chain reaction (nPCR). In addition, HHV-6 IgM and IgG antibodies were performed by micro-enzyme immunoassay (EIA) to detect seronegative patients before transplantation and IgM response in active or primary HHV-6 infection. Active infection with HHV-6 DNA positivity was detected in 5.3% of renal and 22.2% of bone marrow/stem cell transplant recipients. Active HHV-6 infection was found to be related with asymptomatic reactivation, graft disfunction and cytomegalovirus disease in renal transplant recipients, and, fever and graft versus host disease in bone marrow/stem cell transplant recipients. It has been concluded that, the investigation of HHV-6 DNA by nPCR in the transplant sera, was a practical and useful method for the laboratories, in order to diagnose active HHV-6 infection, while HHV-6 IgG antibody detection was also useful for the differential diagnosis of primary infection or reactivation/reinfection, but HHV-6 IgM antibodies has low value to detect active HHV-6 infection.

Successful treatment of post-transplant Kaposi's sarcoma by reduction of immunosuppression

BACKGROUND

The aim of this study was to investigate retrospectively the clinical presentation, the efficacy of reducing immunosuppression and the consequences of this therapeutic approach in Kaposi's sarcoma (KS) developing after renal transplantation.

METHODS

We reviewed the records of 502 patients who had been followed up at our transplantation unit between October 1, 1987 and December 30, 1998. Twelve patients (2.4%) with KS were included in the study.

RESULTS

The mean age of KS patients was 38+/-11 years (one female, 11 males). All were on prednisone, azathioprine (AZT) and cylcosporin treatment. KS was encountered at a mean of 18+/-10 months post-renal transplantation. Typical Kaposi's lesions were present in the skin of 11 out of l2 patients. In the only patient without skin involvement, who died from haemophagocytic histiocytic syndrome caused by septicaemia, KS was diagnosed post-mortem in a lymph node. In five patients only skin involvement was present, while the others also had visceral involvement (oropharynx in two patients, trachea and lung in three, lymph node in two, stomach and duodenum in two). Cyclosporin was stopped within 1 month after KS diagnosis, and AZT was stopped in three patients. Both cutaneous and visceral KS manifestations disappeared and no patient was lost due to KS. During a follow-up period 46+/-19 months, KS recurred in the lungs in one patient together with lung tuberculosis, while he was on prednisone and AZT. Two patients lost their graft due to chronic rejection. The remaining eight patients currently have a functioning graft with a mean creatinine level of 1.4+/-0.5 mg/dl.

CONCLUSION

KS is the most frequent post-transplant neoplasia (80%) in our country. In the present study cohort, half of the patients had visceral involvement. Reduction or discontinuation of immunosuppression caused complete remission in all patients without surgical intervention, chemotherapy or radiotherapy.

Clinicopathological features of hepatitis C virus infection in dialysis and renal transplantation

BACKGROUND

Liver biopsy (LB) gives an accurate picture of the severity of hepatitis C virus (HCV) infection in end-stage renal disease. The aim of this study was to find out whether clinical and histopathological course of HCV infection in renal transplant (RT) patients (pts) is different from dialysis (Dx) pts.

METHODS

Forty Dx and 46 RT pts underwent LB. Clinical and biochemical data were retrospectively collected from medical charts. ALT level above the upper limit was described as elevated. LB was done regardless of the ALT level. LB specimens were examined using a semiquantitative scoring system locally modified from Scheuer. Histological activity (grade) and fibrosis (stage) were scored separately.

RESULTS

ALT was elevated in 65% of Dx pts. At the time of LB 30% of Dx pts had elevated ALT and 95% were viremic. Normal/minimal inflammation was detected in 25% of LBs, chronic hepatitis in 72.5%, cirrhosis in 2.5%. Stage and grade were respectively 1.08 +/- 1.02 and 4.30 +/- 2.98. Normal/minimal inflammation was detected in 9% of the 46 RT pts, chronic hepatitis in 84%, cirrhosis in 7%. Stage and grade were respectively 1.74 +/- 1.1 and 5.39 +/- 2.21. Although there was no significant difference in the histological grade between Dx and RT pts, histological stage was significantly higher in RT pts than Dx. The frequency of cirrhosis, hepatitis and normal inflammation was similar in the two groups.

CONCLUSION

Histopathological liver injury due to HCV infection seems to be more severe in RT than Dx pts but this does not seem to be clear at the clinical and biochemical level. Sequential histopathological assessment and longer follow-up will be required to clarify this issue.

Strict volume control normalizes hypertension in peritoneal dialysis patients

The aim of this study is to investigate whether normal blood pressure (BP) can be achieved in patients with hypertension on continuous ambulatory peritoneal dialysis (CAPD) therapy by strict volume control without the use of antihypertensive drugs. Of the 78 patients in our center, 47 persons had hypertension and/or were on antihypertensive drug therapy. After discontinuing these drugs, a strong dietary salt restriction was imposed by repeatedly explaining the need for it to patients and families. If this approach did not result in sufficient BP decrease, ultrafiltration (UF) was added by increased use of hypertonic (3.86% glucose) peritoneal dialysis solution. Cardiothoracic index (CTI) on the chest radiograph was also used as a measure of volume control. With salt restriction alone or combined with UF, body weight decreased by a mean of 2.8 +/- 0.5 kg, and BP decreased from a mean of 158.2 +/- 17.0/95.7 +/- 10.3 to 119.7 +/- 16.0/77.9 +/- 9.7 mm Hg in 37 patients, accompanied by a decrease in CTI from 48.0% +/- 5.6% to 42.9% +/- 4.5%. In 19 patients who had residual renal function, 24-hour urine volume decreased to 28% of the pretreatment volume, accompanied by a mean decrease in Kt/V urea from 2.06 +/- 0.5 to 1.85 +/- 0.4. In 7 of the remaining patients who did not respond to the applied treatment, BP decreased from 158.8 +/- 23.2/111.6 +/- 9.8 to 113.5 +/- 14.3/76.4 +/- 6.2 mm Hg after administration of an angiotensin-converting enzyme (ACE) inhibitor. Their CTI was 41.2% +/- 1.3%, indicating the absence of hypervolemia. In 3 patients, the desired results could not be reached because of noncompliance. Our findings show that normal BP can be achieved by severe salt restriction combined with increased UF in the majority of CAPD patients. This is accompanied by a decrease in CTI from upper limits into the normal range, but also by a decrease in residual renal function and Kt/V index. In most of the remaining patients, normal BP can be reached by the use of ACE inhibitors.

Treatment of hypertension in dialysis patients by ultrafiltration: role of cardiac dilatation and time factor

We retrospectively analyzed the blood pressure (BP) and cardiothoracic index (CTi) of 67 hemodialysis patients with hypertension who could be followed up for at least 8 months. A new treatment policy was adopted, aimed at strict volume control. Dietary salt restriction was strongly emphasized. Ultrafiltration (UF) was applied during regular dialysis sessions and sometimes in additional sessions, as long as BP and CTi remained at greater than normal values. All antihypertensive drugs were discontinued at the beginning of treatment. Average BP decreased from 173 +/- 17/102 +/- 9 to 139 +/- 18/86 +/- 11 mm Hg after 6 months and to 118 +/- 12/73 +/- 6 mm Hg after 36 months. Corresponding values for CTi were 52% +/- 4%, 47% +/- 3%, and 42% +/- 4%, respectively. Conventional relatively short dialysis (three times weekly for at least 4 hours) can achieve normal BPs with prolonged effort in most patients, whereas improvement in heart condition facilitates this.

Dilated uremic cardiomyopathy in a dialysis patient cured by persistent ultrafiltration

A patient is presented who after 2 years of hemodialysis showed all of the features of congestive cardiomyopathy to a very severe degree: dilation of all cardiac compartments, increased left ventricular mass, low ejection fraction, diastolic disturbances, third- to fourth-degree mitral and tricuspid regurgitation, ascites, and low blood pressure. All of these abnormalities gradually but completely disappeared during 5 months of persistent ultrafiltration during or between dialysis sessions. It was concluded that chronic fluid overload was a major factor in the cardiac disease of this patient. Unrecognized hidden fluid overload has long been known (but also neglected), and its prevention deserves top priority in chronic dialysis patients.