Economic Evaluation of Kidney Transplantation versus Hemodialysis in Patients with End-Stage Renal Disease in Hungary

Background—

Kidney transplantation is generally acknowledged as the more clinically effective and more cost-effective option in managing patients with end-stage renal disease, compared with dialysis. This study looked for confirmatory evidence in a Hungarian population.

Methods—

Patients (n = 242) with end-stage renal disease who received cadaveric kidney transplantation during 1994 were followed up for 3 years. They were compared with patients (n = 840) receiving hemodialysis who were on a waiting list for transplantation. Data were collected retrospectively. Treatments were compared for clinical efficacy and for cost-effectiveness.

Results—

At month 36, the standard mortality hazard function was 3.5 times higher in the group receiving hemodialysis ( P<.0001) than in the transplant recipients. Average treatment costs per patient over the 3 years were also significantly higher ( P<.0001) in the hemodialysis group than in the group that received transplants. The cost of 1 year gained by transplantation was significantly less ( P<.0001) than the cost associated with hemodialysis.

Conclusions—

Compared with hemodialysis, kidney transplantation provides greater survival benefits to patients with end-stage renal disease, at less cost.

Hepatitis C infected hemodialysis and renal transplant patients with elevated α-glutathione S-transferase have increased risk for liver damage

Patients on hemodialysis (HD) and renal transplant recipients (RT) have a high prevalence of HCV infection. Theaimof our study was to determine the prevalence of HCV-RNA in the anti-HCV positive patients and to compare the biochemical parameters of PCR(+) and PCR(−) subgroups.Methods:The 525 sera were screened for anti-HCV. HCV-RNA was detected by polymerase chain reaction (PCR) and liver enzymes [SGOT, SGPT, GGT,α-glutathione S-transferase (GST)] were measured.Results:Active viraemia was found only in 187 of 289 (65%) seropositive HD patients in contrast to 53 of 53 (100%) of seropositive RT patients. Significantly increased (p<0.05) GST values (9.9 μg/l) were found in the PCR(+) subgroups compared to GST levels (2.7 μg/l) of the PCR(−) subgroups. Elevated GST concentration was found in 80% (208/251) of PCR(+) patients. The measured enzymes were not elevated in HCV infected patients. Six percent of HD and 11% of RT patients were screened before seroconversion. Diagnostic sensitivity (80%) and specificity (79%) of GST were calculated as good for early liver damage caused by HCV. In contrast, the sensitivity of the measurement of other liver enzymes were very weak (SGOT: 8%; SGPT: 10%; GGT: 42%).Conclusion:The significantly higher viraemia of the RT subgroup could be related to the immunosuppressive therapy. Increased GST level may be a useful indicator of tissue damage during HCV infection. If HCV infection is suspected, PCR and GST measurement should be performed, even if anti-HCV result is negative.

[Subcapsular hematoma and rupture of the liver graft]

Subcapsular hematoma and/or rupture of the graft is uncommon but serious complication of liver transplantation. It may develop spontaneously or following parenchymal injuries or percutaneous transhepatic invasive procedures. This report describes three cases of subcapsular hematoma and/or rupture of the graft with different courses among 350 liver transplantations. In the first case, the patient died due to graft rupture caused by a pseudoaneurysm after biopsy. In the second case, a small injury of the donor liver resulted in a deep rupture, which required partial resection of the graft. The patient died in sepsis later. The third patient presented with a large subcapsular haematoma during transplantation, which was successfully treated. The authors' strategies developed intraoperatively for the management of hematomas. These involve opening and removing of the haematoma, haemostasis with Argon coagulation, which resulted in an adherent Glisson's capsule to the parenchyma and covering with collagen fleece coated with fibrinogen and thrombin.

[The first successful combined heart-kidney transplantation in Hungary]

Combined heart-kidney transplantation has become a new therapeutic solution for patients with coexisting, irreversible heart and kidney failure. Though this combined approach has several theoretical advantages over sequential transplantation, it remains to be established whether it has a jeopardizing impact on patient and graft outcome. The authors report their experience of the first successful combined heart-kidney transplantation in Hungary from a single donor and review the literature in order to clarify this issue. Young male patient candidate for heart transplantation was suffering from concurrent end stage kidney disease. Donor was selected on the basis of weight and size matching, AB0 compatibility and negative T-cell cross-match. The heart was grafted first, and after the hemodynamic stabilization kidney from the same donor was transplanted. The surgical procedure was uneventful. Heart and kidney function recovered quickly, and the patient is doing very well with good cardiac and renal function even a year following the double organ transplantation. The first Hungarian experience showed that combined heart-kidney transplantation is a therapeutic solution for patients with end stage heart and kidney failure. The lower rate of rejection compared to single heart or kidney transplantation, known from the literature as well, supports their current approach to immunosuppression.

[Investigation of redox homeostasis in liver and renal transplant recipients]

The time course of free radical reactions is evaluated by the authors. Within pretransplant patients as of their poorly functioning metabolism free radical overproduction may be observed, hence their antioxidant capacity decreases. When the graft is functioning well, the free radical-antioxidant balance of homeostasis is reestablished. During the early postoperative period, when symptoms (acute rejection, infection, acute tubular necrosis, cholestasis) appear, free radical reactions increase. The authors demonstrate, this is strengthened by the fact that the mediator [interleukin-6 (IL-6), C-reactive protein, serum amyloid-A], and enzyme levels that take part in the free radical processes rise. The monitoring of these parameters during the early postoperative period is a good early indicator for acute rejection and for the effect of therapy. During acute rejection just as during infection most of these parameters increased significantly compared to the healthy control. They show the activation of the immune system but they are not useful for differential diagnosis, with the exception of IL-6 which we measured in larger quantities during bacterial infection but not so in acute rejection. For the prediction of early renal graft function we used urinary enzyme levels (dipeptidyl-aminopeptidase, glutathione-S-transferase). Tissue damage is followed by enzyme increasing and antioxidant capacity depletion. With choosing of adequate tests, the perioperative redox homeostasis of the transplanted patients can be monitored and with dosing the antioxidants the uncontrolled forming of reactive oxygen metabolites can also be decreased and checked.

[Imaging techniques for the pre- and postoperative evaluation of recipients with living-donor liver transplantation]

Whole-liver transplantation is a worldwide-accepted method for treatment of end-stage liver disease. As a result of the shortage of cadaveric livers, split-liver transplantation and living-donor liver transplantation are becoming more common. Preoperative imaging of the donors and recipients are indispensable for surgery planning, while postoperative imaging highly contributes to the success of transplantation by follow-up the transplanted organ and early diagnosis of possible sequelae. The authors delineate both pre- and postoperative imaging of recipients of living-donor transplantation, including the role of conventional x-ray, ultrasound, CT and MRI techniques, and also the different possibilities in the field of interventional radiology.

[The role of imaging methods in the pre- and intra-operative evaluation, and in post-operative follow-up of living donors in liver transplantation in Hungary]

The evaluation protocol for liver donors can vary from centre to centre, but the main points are the same. Medical history, physical examination, common laboratory tests and psychosocial evaluation are followed by imaging, and specific haemostasis and viral serology tests. The first imaging examinations have the aim of excluding any disease; conventional chest radiography and abdominal ultrasound are performed. Liver volume, fat content, and vascular and biliary anatomy are then evaluated with contrast-enhanced, multiphase, multidetector row CT/CTA and MR cholangiography. Ultrasound guided liver biopsy, and in some cases digital subtraction angiography, should also be performed. During the first phase of the donor operation, intraoperative investigations are done: cholangiography for the final evaluation of the biliary tree and ultrasound of the hepatic and portal venous system to help draw the resection plane. Donors have regular imaging examinations in the early postoperative period for early detection of complications: mainly US or CT to check the remnant hepatic vascularisation and fluid collections in the operated area, or X-ray for thoracic disorders. It is recommended that regular checkups are performed in the late postoperative period. The paper describes the imaging protocol for donor evaluation applied at our institute at the beginning of our living related liver transplantation programme.

[Lymphocele and kidney transplantation]

INTRODUCTION

Lymphocele is a special complication following kidney transplantation. The authors examined the factors associated with an increased occurrence of clinically significant perinephric fluid collections and/or lymphoceles among sirolimus-treated renal transplant recipients.

AIM

From the point of view of the lymphocele a comparison was made for the risks and benefits of the conventional and a newer immunosuppressive combination.

METHODS

At the University of Texas in Houston in a retrospective study the incidence, predisposing factors, and consequences of these fluid collections among patients treated with sirolimus-cyclosporine-prednisone ( n = 354, Group I) versus cyclosporine-prednisone-azathioprine ( n = 136, Group II) were compared.

RESULTS

More Group I patients (135/354; 38.1%) displayed perinephric fluid collections than Group II patients (24/136; 17.6%; p < 0.001). In both subgroups the serum creatinine levels were elevated at the time of diagnosis from a nadir of 179.5 +/- 141.7 to 359.9 +/- 259.6 mmol/l (Group III, sirolimus treated) and from 222.6 +/- 205.9 to 383.7 +/- 255.2 mmol/l (Group IV, sirolimus free). A significantly greater number of patients required treatment for lymphoceles among Group I (15.8%; 56/354) versus Group II recipients (4.4%; 6/136; p < 0.001). Single or repeated percutaneous drainage procedures successfully treated 35 Group I patients versus all 6 Group IV patients ( p = 0.033). No patients in Group II versus 21 patients in Group I underwent surgical procedures ( p < 0.001). A significantly higher rate and higher histologic grade of acute rejection episodes, particularly proximate to the onset of the lymphocele, occurred among Group IV patients, namely 54.2% (13/24) versus 21.4% (29/135) Group III patients ( p < 0.001). Additionally we report the case of a 29-year-old patient who underwent a lymphocele fenestration with omentoplasty 8 years after his transplantation. Despite an Influenza A + Chlamydia pneumonia and acute rejection which was followed by a GI bleeding and stomach resection he fully recovered and is doing well with an excellent kidney function a year after.

CONCLUSIONS

Addition of sirolimus to a cyclosporine-prednisone regimen resulted in both a higher incidence and a requirement for more aggressive treatment of perinephric fluid collections and/or lymphoceles with a much lower acute rejection frequency.

Antiproliferative and apoptotic effects of mycophenolic acid in human B-cell non-Hodgkin lymphomas

Mycophenolic acid (MPA)/mycophenolate mofetil (MMF), a powerful immunosuppressive agent was tested on human B-lymphoma cells (Epstein-Barr virus +/-) in vitro and in SCID mouse xenograft model. Proliferation, apoptotic activity and tumor volume were evaluated. MPA inhibited lymphoma cell proliferation and induced apoptosis (50-60% at 72 h). In vivo, oral administration significantly inhibited subcutaneous tumor growth. Immunohistochemistry showed significantly decreased proliferation rate and higher apoptotic activity in tumors treated with MMF. Xenografted lymphoma cells remained sensitive to MPA. Our results suggest that MPA may be recommended as an additional component of lymphoma chemotherapeutical regimens, with special considerations to post-transplant lymphomas.

Malignancies after renal transplantation during 33 years at a single center

This study provides an analysis of incidence and characteristics of malignant tumors of 2535 patients who underwent renal transplantation between 1973 and 2007 at the Transplantation Center in Budapest. One hundred ninety-three malignant diseases were found in 188 patients (7.6%). The incidence of thyroid-, renal- hepatic-, skin- and gastric cancers as well as of Kaposi sarcoma and lymphomas increased in our transplant patient cohort compared to the figures of the general population based on the data of our Cancer Registry. On the other hand, colorectal-, oralprostate and lung cancers were underrepresented in our patient cohort. The mean time of diagnosis of malignancies following kidney transplantation was 58.5+/-44.8 months. One fifth of the tumors were detected within the first year. Patients with malignancies were distributed into four groups based on the immunosuppressive regimen: group I (8.5%), azathioprine + prednisone; group II (59.0%), cyclosporine + prednisone; group III (26.6%), cyclosporine + mycophenolate mofetil + prednisone; group IV (5.9%), tacrolimus + mycophenolate mofetil + prednisone. The mean age of patients was 47.3, 53.5, 55.5 and 58.1 years in group I, II, III and IV, respectively. Oncologic and immunosuppressive therapy was decided individually. Immunosuppression was switched to rapamycin-containing regimens in 63 cases. We lost 92 patients (48.9%) with a mean survival time of 25.8+/-39.4 months. Cumulative 1- and 5-year survivals were 69.5% and 52%, respectively. The increasing number of cancers seen early after transplantation and the increased risk of developing a cancer due to the older age of recipients draw attention to the importance of regular oncologic screening in patients on the waiting list and after transplantation.

Bourneville-Pringle Disease for Kidney Transplantation: A Single-Center Experience

The Bourneville-Pringle disease is an autosomal-dominant disease affecting the kidneys in about 60%, causing end-stage renal disease in about 10% of the cases. Among more than 2800 renal transplant recipients during the last 33 years, we had two patients with this original disease. A third patient who underwent bilateral nephrectomy is currently awaiting a graft. The first patient was diagnosed at the age of 20 years after a few episodes of retroperitoneal bleeding. At the age of 26 years her left kidney was removed after a rupture; it measured 7500 g, and the histology described angiomyolipomatosis. A year later she underwent a cadaveric kidney transplantation. Subsequently her right kidney was removed due to bleeding. She is currently 5 years posttransplant with stable kidney function and good health. Our second patient was nephrectomized at the age of 35 years and 38 years because of angiomyolipomatosis. She underwent a cadaveric kidney transplantation 7 years later. After 5 years of excellent kidney function and a year after her arteriovenous fistula was ligated her upperarm had to be amputated because of uncontrollable bleeding. After another 6 months, she displayed rapid progression of a jejunal tumor and during operation received 54 U of blood transfusion but died at the age of 49 years with a well-functioning graft. Our third patient consecutively underwent two nephrectomies because of angiomyolipomatosis of her kidneys at the ages of 25 and 28 years. She has two children with the same disease. In addition she carries Leyden mutation, which has caused deep venous thromboses and pulmonary emboli. She is currently on our waiting list for kidney transplantation. The Bourneville-Pringle disease is a rare indication for kidney transplantation; the prognosis of the patient is dependent on the original disease.

Evaluation of liver function for hepatic resection

New limits have been established to decrease mortality and morbidity rates after liver resection in cirrhotic and non-cirrhotic patients. Various laboratory data and imaging techniques have been used to complement the Child-Pugh score to predict liver failure after hepatectomy and to assess functional hepatic reserve. The greatest experiences are with the aminopyrine breath test and the galactosyl elimination capacity, which are decreased among hepatic failure patients after liver resection. However, absence of these changes do not totally exclude it. The indocyanine green retention test is the most widely used clearance test. Nevertheless, it remains imperfect because it depends both on hepatic blood flow and on the functional capacity of the liver. Nuclear imaging of the asialoglicoprotein receptors with radiolabelled synthetic asialoglicoproteins provides volumetric information as well a functional assessment of the liver. In summary, while liver function is complex, a successful liver test to assess quantitative functional hepatic reserve still needs to be established. The combination of the Child-Pugh score, the presence of ascites, the serum bilirubin levels, the indocyanine green retention (ICG R15) value, and the remnant liver CT volumetry seems to avoid an index of liver failure after hepatic resection. Cases when ICG R15 is above 15% should be combined with portal vein embolization. If there is no possibility to perform an ICG clearance test, it may be replaced with other available, well known dynamic liver function tests.

Improving results of renal transplantation with the use of elderly donors: the Budapest experience

The use of elderly donors has become a necessity with the increasing demand for deceased donor organs resulting in transplant centers worldwide expanding their donor criteria. We, therefore, thought it appropriate to review our experience using elderly (>60 years) brain-dead donors for kidney transplantation. We investigated the influence of donor parameters on early graft function and survival. A retrospective comparative analysis of three periods was performed: 1994 to 1998 (P1) n = 40; 1999 to 2000 (P2) n = 28; and 2001 to 2002 (P3) with n = 31 donors. Mean donor age in each period was 63.4 +/- 3.3, 64.5 +/- 3.4, and 63.8 +/- 2.7 years; mean diuresis was 473 +/- 450, 307 +/- 316, and 276 +/- 185 mL/hour; and the need for vasopressors during donor management was 81%, 85%, and 70% respectively. The number of kidney recipients was 59, 30, and 37, mean age was 49 +/- 13, 53 +/- 11 and 54 +/- 8 years, the recipient ratio of patients >60 years was 17%, 33%, and 27% respectively, and no differences among the groups in the HLA mismatch. Primary nonfunction occurred in 8.5%, 0%, and 2.8%; acute rejection ratio at 1 year was 35%, 36%, and 32%, the mean serum creatinine at 12 months was 183.7 +/- 66.0, 157.8 +/- 41.2 and 160.7 +/- 46.5 mumol/L. The 1-year graft survival was 71.2%, 91.0% and 92.0% and the 1-year patient survival 88.2%, 96.6%, and 97.2%, respectively, for periods 1, 2, and 3. There has been a considerable improvement in the 1-year graft and patient survivals. With careful donor and recipient evaluation, individualized immunosuppression, and age matching the results of renal transplantation from elderly deceased donors can be comparable to the results of the "optimal" deceased donor kidney transplantation.

[Diagnosis and treatment outcome in primary aldosteronism based on a retrospective analysis of 187 cases]

INTRODUCTION

Primary aldosteronism is the most common form of mineralocorticoid hypertension. The disease has been described by Jerome W. Conn in 1955; since that time there has been a great progress in the knowledge concerning the prevalence, diagnostics and treatment of the disease.

AIMS

The authors retrospectively analyzed the efficacy of diagnostic procedures and the outcome of treatment by the analysis of data of 187 patients with primary aldosteronism examined between 1958 and 2004 at the 2nd Department of Medicine of Semmelweis University.

METHODS

The efficacy of different methods used for the diagnosis, the frequency of the different subtypes of primary aldosteronism, as well as the surgical outcomes in patients with surgically treated subtypes of primary aldosteronism were studied.

RESULTS

Aldosterone-producing adenoma was detected in more than two thirds of patients (n = 135), whereas idiopathic hyperaldosteronism was found in 46 patients. Other subtypes of primary hyperaldosteronism occurred less frequently (unilateral primary adrenocortical hyperplasia in 5 patients and adrenocortical carcinoma in one patient). For the diagnosis of familial hyperaldosteronism type I, molecular biological studies of the aldosterone-synthase/11beta-hydroxylase gene chimera were carried out in 30 patients but none of them showed the presence of the chimeric gene. When comparing the clinical parameters of patients with aldosterone-producing adenoma and idiopathic hyperaldosteronism, no significant differences were found in the time period between the diagnosis of hypertension and the diagnosis of primary aldosteronism, or in the systolic and diastolic blood pressure values. The mean of the lowest documented serum potassium concentration was slightly lower in patients with aldosterone-producing adenoma (2.8 +/- 0.1 mmol/l) compared to those with idiopathic hyperaldosteronism (3.1 +/- 0.2 mmol/l), but the difference was not significant. Normokalemic primary hyperaldosteronism was found in 7 cases. The ratio of plasma aldosterone concentration (ng/dl) to plasma renin activity (ng/ml/h) was above 20 in all patients with aldosterone-producing adenoma and in all but 5 cases with idiopathic hyperaldosteronism. To confirm the diagnosis and to differentiate the subtypes of primary aldosteronism, the postural test combined with furosemide administration was performed in the majority of patients. When cases showing an elevation of plasma cortisol level during the test were excluded, this test differentiated patients with aldosterone-producing adenoma from those with idiopathic hyperaldosteronism with a sensitivity of 69% and a specificity of 92%. In cases of adrenocortical adenomas not or not clearly detectable by radiological imaging techniques, as well as in cases with bilateral adrenocortical adenomas, selective adrenal vein sampling was performed (n = 55). All but 4 patients with aldosterone-producing adenoma underwent adrenalectomy. Histology and postoperative hormone results confirmed the preoperative diagnosis in all operated patients. After surgery serum potassium concentration returned to normal in all patients showing low serum potassium levels before surgery. Also, the moderate to severe preoperative hypertension disappeared or improved after surgery.

CONCLUSIONS

These observations are in contrast with the results of international studies which showed a high frequency of normokalemic primary aldosteronism and a more frequent occurrence of idiopathic hyperaldosteronism well treatable with aldosterone-antagonists. Therefore, it can be presumed that a significant number of primary aldosteronism cases that are not accompanied with severe hypokalemia remain undetected in Hungary.

Laurence-Moon–Bardet-Biedl Syndrome for Kidney Transplantation at the Age of 57 Years

Laurence-Moon-Bardet-Biedl syndrome represents a very rare indication for kidney transplantation. Previous reports mention only pediatric organ recipients with this diagnosis. We present the case of a Caucasian male patient who underwent a cadaveric renal transplantation at the age of 57 years. Our patient had an uneventful immediate postoperative course; however, 4 months after the operation he suffered pneumonia and cytomegalovirus infection. He recovered fully and had an episode of acute cholecystitis. At the time of the laparoscopic cholecystectomy we also laparoscopically removed his Tenckhoff catheter, a procedure he could not undergo for more than a year because of a chronic scabies infection. Now, 18 months after his transplantation he is fully rehabilitated with a serum creatinine of 90 micromol/L. In selected cases even in older age kidney transplantation could offer a higher quality of life for this mentally retarded, blind population.

The use of autologous rectus facia sheath for replacement of inferior caval vein defect in orthotopic liver transplantation

Occasionally, during liver transplantation, vascular reconstructions have to be performed. Donor vessels can be harvested for this purpose. However, when these are lacking, alternatives should be available. A possible alternative can be the use of autologous rectus fascia sheath, folded as a tube with the mesothelium on the inside. Earlier experimental studies from our centre showed the successful use of the rectus fascia sheath graft in vascular defects in animal experiments. This report describes the first use of this autologous tubular graft for replacement of the inferior caval vein interponate during liver transplantation in men.

Factors in association with sepsis after liver transplantation: the Hungarian experience

Sepsis is the major cause of patient death after orthotopic liver transplantation (OLT). To identify risk factors for sepsis, we analyzed all 199 primary OLTs performed between 1995 and 2004. Patients were divided into 2 groups according to whether they experienced sepsis after liver transplantation. Recipient, perioperative factors, and complications were subjected to univariate analyses. Statistically significant factors were exposed to multivariate analyses: Cox regression and Hosmer-Lemeshow test. Sepsis occurred in 45 (23%) patients. Recipient Child-Pugh score, preoperative broad spectrum antibiotic (meropenem) prophylaxis, intraoperative red blood cell transfusion, starch infusion, postoperative bleeding, hepatic artery thrombosis, and biliary leakage/necrosis were independent risk factors for sepsis. Our results agree with the international experience. A high amount of starch infusion and an extended use of broad spectrum antibiotics for prophylaxis adverse experiences in our center and have been removed from the protocol.

Significant differences in the efficacy of kidney transplantation between Hungarian Caucasians and Gypsies

In a retrospective study we examined the differences between Caucasian (Group A) and Gypsy (Group B) renal allograft recipients transplanted in Hungary. From 1983 to 2001, 1918 transplants were performed in Budapest (1825 Caucasian and 93 Gypsy recipients). Group B patients were younger (34 +/- 12 vs 42 +/- 14 years of age; P < .01) and Group A had more polycystic kidney disease (12% vs 3%; P < .025). Blood group B was more common in Group B (27% vs 19%; P = NS) than in Group A patients, and Group A had seemingly more diabetes (5% vs 1%; P = NS) than did Group B. There were no differences in HLA mismatches or panel reactive antibodies (PRA). No differences were seen in Group A vs Group B patient survivals at 1, 3, 5, or 10 years' posttransplant (98% vs 95%; 90% vs 93%; 85% vs 88%; and 74% vs 82%, respectively). However, Group A graft survivals were significantly better than Group B at 1, 3, 5, and 10 years' posttransplant (89% vs 77%; 82% vs 66%; 76% vs 54%; and 57% vs 34%; each comparison P < .01). Group B recipients experienced a greater number of acute rejection episodes (66% vs 49%; P < .01), irreversible acute rejections (15% vs 6%; P < .001), chronic rejections (34% vs 18%; P < .001), and graft loss due to immunosuppression noncompliance (5% vs 1%; P < .05) than did Group A recipients. As has been previously described for other non-Caucasian ethnic groups (eg, African-Americans), Hungarian Gypsies appear to be at a greater immunological risk for rejection and poorer long-term graft survival.

Mutation scanning of the p53 tumor suppressor gene in renal and liver transplant patients in Hungary

INTRODUCTION

The increased incidence of malignancies among transplanted patients is well known. Abnormal function of the p53 tumor suppressor gene has been reported in more than half of all tumors. The aim of our study was to detect point mutations of p53 gene in transplanted patients because the presence of mutations may be a predictive factor for tumor development. An earlier diagnosis can help to develop new strategies for immunosuppressive therapies.

METHODS

Three point mutations were chosen based on the literature: exon5-codon175, exon7-codon248, exon8-codon273. Genomic DNA from the plasma of 60 liver, 362 renal transplants, and 45 nontransplanted patients with different tumors and 20 suspected healthy patients were analyzed with a real-time PCR method using the Roche LightCycler. The mutations were evaluated by melting curve analysis.

RESULTS

We elaborated a special protocol for scanning the above mentioned p53 point mutations, which were proved by sequencing as well. Among 487 patients, 486 showed a wild-type genotype. The only patient carrying a mutation at codon 273 (heterozygous) was a liver transplant patient, who developed pancreas carcinoma and had already died.

CONCLUSION

Our data suggest that mutations of the targeted codons in leukocyte DNA seem to be rare, but a mutation could be lethal. The evaluated three point mutations of p53 gene were not predictive for tumor development.

[Clinical factors influencing the complications and survival of liver transplantation in Hungary]

Clinical factors in association with the complications and the outcome of liver transplantation. The Hungarian experience. Demography, morbidity, perioperative characteristics and mortality.

INTRODUCTION

The authors summarize the demographic, morbidity and mortality characteristics of the Hungarian Liver Transplant Program. They evaluate the changes and development, that has taken place with regard to indications, recipient population and characteristics, operation technique, and peroperative patient management.

METHOD

In order to present the development, data are compared between two time periods (before and after 1999). Categorical variables are evaluated by chi-square test, continuous ones are with Levene Test (for homogeneity of means), Student T test and Mann-Whitney U-test. Cumulative survivals are computed with Kaplan-Meyer log rank analysis. Variables showed statistical significance on survival bz univariate analysis were then put into multivariate Cox-regression analysis. ROC analysis was performed to set the cut off point of certain continuous parameters in relation to survival.

RESULTS

The results are summarized on Tables and statistical Figures. Regarding patients mortality in the beginning the main factors with impact were respectively technical ones like arterial thrombosis, while in the last 4 years perioperative fluid management and transfusion policy became important. Both sepsis and postoperative renal insufficiency remained key factors for mortality, however their incidence diminished dramatically.

DISCUSSION

The overall outcome of the retrospective analysis is, that the program has been developed to European standards with respect to its volume, technical capabilities and results.

[The demographic, perioperative and mortality characteristics of the Hungarian Liver Transplant Program]

INTRODUCTIONS

The authors summarize the demographic, morbidity and mortality characteristics of the Hungarian Liver Transplant Program.

AIMS

They evaluate the changes and development, that has taken place with regard to indications, recipient population and characteristics, operation technique, and peroperative patient management.

METHOD

In order to present the development, data are compared between two time periods (before and after 1999). The results are summarized on Tables and statistical Figures. Categorical variables are evaluated by chi2-test, continuous ones are with Levene Test (for homogeneity of means), Student T test and Mann-Whitney U-test. Cumulative survivals are computed with Kaplan-Meier log rank analysis.

RESULTS

194 primary liver transplantation have been performed. The hepatitis C was the leading indication from the beginning. Ten (10) liver transplantation have been performed in 1995, while 44 in 2004. The mortality within the first 2 months decreased from 24% to 5%. The 1, 3 and 5 year cumulative patient survival increased from 55%, 45% es 39% (1995-1997), to 72%, 64% es 61% (1998-2000). Recently this is 78%, 77% es 77%.

CONCLUSIONS

Between 1995-1997 conventional liver transplantation became standard, while piggy back turned to be popular from 1998. From 1999 the HCV-PCR monitoring, the combined antiviral treatment, the UW perfusion of the donors took place. From 2003 we introduced the tailored immunosuppression, the steroid-free protocol for viral diseases. Total infused volume was decreased together with the amount of transfusion. The retrograde graft reperfusion (from the caval side) was introduced in 2004 together with the split technique in the liver transplantation and the rebirth of the pediatric program. The overall outcome of the retrospective analysis is, that the program has been developed to European standards with respect to its volume, technical capabilities and results.

[Comparison of the results of conventional, crossclamp and piggyback technique in liver transplantation]

The authors evaluate the results of the technical variants of liver transplantion in the first 10 years. They present the technique of conventional and piggyback liver transplantation. Their aim is to compare the outcome of the two surgical implantation techniques. Using the piggyback technique, the need for intraoperative blood transfusion was less (10U) compared to conventional transplantion (15U). Vascular complication rate was lower with conventional, compared to piggy back technique. Hepatic artery thrombosis rate was higher (14% vs. 5%) while venous outflow occlusion rate was lower (0% vs. 8%) in conventional technique compared to piggyback. Postoperative kidney failure was more frequent after conventional and crossclamp technique (45%). The 1, 3, and 5 year cumulative patient survival rates were 62%, 55% and 52% in the conventional group, and 79%, 71% is 63% after piggyback. The 1, 3 and 5 years graft survival were 60%, 53% and 50% after conventional and 74%, 66% and 60% after piggyback implantation. The piggyback technique became routine standard procedure in Hungary, with lower transfusion need, less kidney failure and very good results.

Comparing cytomegalovirus prophylaxis in renal transplantation: single center experience

BACKGROUND

Cytomegalovirus (CMV) presents a serious threat to CMV-seronegative recipients (R-), who have received an organ from a seropositive donor (D+).

OBJECTIVES

We compared the effectiveness of three different prophylactic protocols in CMV D+/R- patients and reviewed data on patients who received no prophylaxis.

PATIENTS AND METHODS

We reviewed 1137 kidney transplantations from 1995 to 2004. Of these, 147 recipients were CMV negative (D+/R-); 125 patients received CMV prophylaxis. Group I received CMV hyperimmune gammaglobulin only, group II received CMV hyperimmune gammaglobulin plus oral ganciclovir, and group III received prophylaxis with oral ganciclovir only.

RESULTS

In group I, CMV infection was observed in 31 of 53 patients (59%), and CMV disease was diagnosed in 9 (17%) during the prophylaxis. In the first year post transplant, a total of 41 of 53 patients (77.5%) had primary CMV infection. In group II, CMV infection occurred in 7 of 30 patients (23%), and CMV disease was diagnosed in only 2 (7%) during prophylaxis. In the first year post transplant, a total of 9 of 30 patients (30%) had primary CMV infection. In group III, 9 of 42 patients (21%) developed CMV infection during prophylaxis, and CMV disease was not observed. In the first year post transplant, a total of 13 of 42 patients (30%) had primary CMV infection. In contrast, all 22 CMV D+/R- patients without prophylaxis developed CMV infection (100%); CMV disease was diagnosed in 10 (45%), and 1 patient died.

CONCLUSIONS

Prophylaxis with hyperimmune gammaglobulin and/or oral ganciclovir significantly reduces CMV infection and disease. Prophylaxis with ganciclovir was significantly more effective than hyperimmune gammaglobulin monoprophylaxis, and more cost effective than combined prophylaxis.

Successful islet after kidney transplantations in a distance over 1000 kilometres: Preliminary results of the Budapest-Geneva collaboration

To overcome critical islet processing and to ensure patient safety and quality care, we have established an international collaboration between two geographically distant transplant centers for islet transplantation. Four pancreata were harvested and immediately preserved by the two-layer method (oxygenated perfluorocarbon+University of Wisconsin) and subsequently transported for the automated method isolation to Geneva. After purification, the islets were cultured overnight and transported the next day back to Budapest. Three consecutive kidney transplant patients with type 1 diabetes mellitus underwent islet transplantation via percutaneous transhepatic portal embolization using the bag-method. The immunosuppression consisted of daclizumab, sirolimus, and low-dose tacrolimus. Mean donor age was 43.7 years, mean body mass index: 26.5. The islet isolation process began within 8 hours from the donor aorta cross-clamp in all cases. The isolation success rate was 80% (4 of 5). In Budapest, the islets were assessed for viability. No complications occurred during the transplantation, and the portal pressure remained within the normal range. The first patient received 12,000 IU/BW from two donors and the insulin requirement decreased from 40 U/d to 10 U/d. The second patient received 7200 IU/BW from a single donor and became immediately insulin free. The third patient was given 7100 IU/BW; the insulin requirement decreased from 39 U/d to 14 U/d. Posttransplant follow-up for the three patients are 7 months, 4 months, and 2 weeks, respectively. All patients achieved metabolic stability. These preliminary results demonstrate the feasibility of an international collaborative islet transplantation program at a distance over 1000 km.

[Our experiences with surgical treatment of gastrointestinal stromal tumors]

INTRODUCTION

Stromal tumors of the gastrointestinal tract are rare neoplasms, but they are the most common ones of mesenchymal origin. In a large proportion of patients clinical onset is represented by surgical emergencies. Incidence of GIST is calculated to be 10-20 cases per million per year. GISTs account for 0.1-3% of all gastrointestinal tumors, up to 20% of small bowel malignancies. At least 30-70% of the cases are malignant.

PATIENTS

We summary our experiences of surgical treatment of GIST, apropos of five patients handled at our department in 2003. There were 3 male, 2 female, 55.8 years. The 5 patients had altogether 21 operations. Diagnosis was recognized before op. in three cases.

RESULTS

In one case the tumor was inoperable, in one other technical operable, but oncologically not complete. In another case recurrence is known, and in one dissemination was observed during operation. There is only one case of fives, where we can hope, that a tumor-free situation had been left. Diagnosis was confirmed in every case with CD117 strain.

SUMMARY

Surgery remains the standard treatment for GISTs. Disease recurrence is quite common, the rate is 65-75%, even when surgery is performed with intent to cure. In a surgical emergency or in the absence of a perioperative diagnosis, the surgeon is responsible for recognizing and treating these tumors. The benefit of surgical exercises for recurrent disease is unclear. In our opinion it is worth operating these cases, because in some cases amazing survival can be available.

Detection of Tinuvin 770, A Light Stabilizer of Plastic Materials from Dialysis Membranes, by High-Performance Liquid Chromatographic Analysis

Tinuvin 770 [bis(2,2,6,6-tetramethyl-4-piperidinyl)sebacate] is a pharmacologically active agent used worldwide as a light stabilizer for plastic materials. In vitro studies show that it is an L-type Ca(2+) channel and neuronal nicotic acethylcholine receptor blocker. Hypotension, vegetative dysfunction, and neurological symptoms are frequently observed during a haemodialysis treatment. The release of Tinuvin 770 from plastic materials applied in haemodialysis may play a part in the development of clinical signs. In our study, four different commonly used haemodialysis membranes (polysulphon, cuprophan, and two types of hemophan) are examined. The polymers are soaked for 72 h in physiological saline solution. Isolation is carried out using a Waters Oasis SPE column for solid-phase extraction and by high-performance liquid chromatography (HPLC) with electrospray ionization-mass spectrometric detection. Tinuvin 770 release is detected from all examined membranes. Validation studies show a satisfactory selectivity, linearity, accuracy, and recovery of this method. Our results suggest that Tinuvin 770 could have specific toxicological and therapeutic importance related to haemodialysis treatment. The developed HPLC method is suitable for the detection of Tinuvin 770.

Comparative study on cardiotoxic effect of Tinuvin 770: a light stabilizer of medical plastics in rat model

Tinuvin 770 [bis(2,2,6,6-tetramethyl-4-piperidinyl) sebacate], is a UV light stabilizer plastic additive used worldwide. It is a component of many plastic materials used in medical and food industries. Earlier studies demonstrated its in vitro L-type Ca2+ channel and nicotinic acetylcholine receptor blocking properties. Our previous experiments have proved the toxic effects of Tinuvin 770 on isolated rat cardiomyocytes. The present study investigates the cardiotoxic effects of Tinuvin 770 in vivo. Wistar rats were intraperitoneally injected with increasing doses of Tinuvin 770 (1, 10, 100 microg, and 1 mg) 15 times during a 5-week period. Myocardial samples were analyzed by light, electron, and fluorescent microscopy. The lead-acetate method was used to detect intracellular Ca2+, and glyoxylic acid technique to assess alteration in adrenergic innervation. Focal myocytolysis and hypercontraction necrosis could be observed in rats treated with higher doses of Tinuvin 770. In these groups, intracellular Ca2+ accumulation and increased catecholamine release were detected. Tinuvin 770 not only displays L-type Ca2+ channel blocking properties, but can also lead to catecholamine release, similar to effects of the first generation of L-type Ca2+ channel blockers. Morphological results correspond to catecholamine-induced myocardial damage. Current literature, as well as our study, indicates that more detailed toxicological analysis of Tinuvin 770 should be required, and current regulations in medical and food industries should adopt the new results.

Experimental vascular graft for liver transplantation

Hepatic artery thrombosis is a major cause of graft failure in liver transplantation. Use of donor interponates are common, but results are controversial because of necrosis or thrombosis after rejection. Reperfusion injury, hypoxia and free radical production determinate the survival. The aim of the study was to create an 'ideal' arterial interponate. Autologous, tubular graft lined with mesothelial cells, prepared from the posterior rectus fascia sheath, was used for iliac artery replacement in eight mongrel dogs for six months under immunosuppression. Patency rate was followed by Doppler ultrasound. Eight grafts remained patent and another two are patent after one year. The patency rate was good (median Doppler flow: 370 cm/sec) and there was no necrosis, thrombosis or aneurysmatic formation. The grafts showed viable morphology with neoangiogenesis, appearance of elastin, smooth muscle and endothelial cells. Electron microscopy showed intact mitochondrial structures without signs of hypoxia. Tissue oxygenation was good in all cases with normal (< 30 ng/ml) myeloperoxidase production. In conclusion, this autologous graft presents good long-term patency rate. Viability, arterialisation and low thrombogenicity are prognostic factors indicating usability of the graft in the clinical practice without the risk of rejection. Further investigations such as cell cultures and standardisation are necessary.

De novo tumors after kidney transplantation: the Budapest experience

In a retrospective study we analyzed the incidence and characteristics of de novo tumors developing in renal transplant recipients treated in our center. The 5% incidence de novo tumors developing among patients treated with azathioprine and prednisolone (n = 241) was similar to the 5.4% incidence of de novo tumors developing among patients treated with calcineurin-based immunosuppression (n = 1918). The most common malignancies among our patients were basal cell (21.7%) and squamous cell (13.9%) carcinomas of the skin, followed by urogenital (10.4%) and lung malformations (9.6%). A high incidence of Kaposi's sarcoma (9.6%; half cutaneous and half visceral) and a lower than expected incidence of posttransplant lymphoproliferative disorder (PTLD; 3.5%) was found. Among patients developing de novo tumors, the incidence of death with a functioning graft was higher than among recipients without tumors. Moreover, the incidence of tumor-related death was high among the de novo tumor recipients. Among our recipients, the most aggressive tumors were Kaposi's sarcoma, lung tumors, lymphomas, and gastrointestinal tumors, which occurred relatively early after transplantation and were the cause of death in most cases. Compared to tumor registry data, we found an inverse basal-to-squamous cell carcinoma ratio, a lower incidence of PTLD, and a higher incidence of Kaposi's sarcoma.

Economic evaluation of kidney transplantation versus hemodialysis in patients with end-stage renal disease in Hungary

BACKGROUND

Kidney transplantation is generally acknowledged as the more clinically effective and more cost-effective option in managing patients with end-stage renal disease, compared with dialysis. This study looked for confirmatory evidence in a Hungarian population.

METHODS

Patients (n = 242) with end-stage renal disease who received cadaveric kidney transplantation during 1994 were followed up for 3 years. They were compared with patients (n = 840) receiving hemodialysis who were on a waiting list for transplantation. Data were collected retrospectively. Treatments were compared for clinical efficacy and for cost-effectiveness.

RESULTS

At month 36, the standard mortality hazard function was 3.5 times higher in the group receiving hemodialysis (P < .0001) than in the transplant recipients. Average treatment costs per patient over the 3 years were also significantly higher (P < .0001) in the hemodialysis group than in the group than received transplants. The cost of 1 year gained by transplantation was significantly less (P < .0001) than the cost associated with hemodialysis.

CONCLUSIONS

Compared with hemodialysis, kidney transplantation provides greater survival benefits to patients with end-stage renal disease, at less cost.

A light stabilizer Tinuvin 770-induced toxic injury of adult rat cardiac myocytes

Tinuvin 770/bis(2,2,6,6-tetramethyl-4-piperidinyl)sebacate is a worldwide used light stabilizer for plastic materials like polyolefins. Tinuvin 770 is a biologically active component of polypropylene tubes. Glossmann and his study group managed to extract this compound by aqueous or organic solvents from laboratory plastic tubes, and propose that Tinuvin 770 is a potent blocker of L-type Ca(2+)-channel through the phenylalkylamine and benzothiazepine-selective drug binding domains of the alpha(1) subunit of the receptor [Proc. Natl. Acad. Sci. U.S.A. 90 (1993) 9523]. We examined the direct morphological effect of Tinuvin 770 in give 25nmol, 0, 30, 60, 120 minute exposure time in isolated cardiomyocytes from adult rats. Incubation of myocytes with Tinuvin resulted in a progressive decline of rod-shaped and viable cells. It was accompanied by an increase in number of hypercontracted myocytes with microbleb formation compared to control and depletion of ATP level. In summary, our results demonstrate that plasma membrane damage and hypercontraction are manifestations of Tinuvin-induced injury of isolated cardiomyocytes.

[Qualitative and quantitative detection of hepatitis C virus RNA by PCR technique. Monitoring of viral copies after liver transplantation]

The authors demonstrate the HCV nucleic acid amplification method is not wide-spread in Hungary yet. The HCV-RNA is usually detectable 2-4 weeks after infection independently the immunostate of the patients. The authors help to select the adequate measurement(s) in logical order when HCV infection is suspected. The benefit of the PCR method is emphasized. Monitoring of the HCV-RNA titer of the liver transplanted patients promotes to establish the fluctuation of HCV-RNA copies and the effectivity of therapy following transplantation. The detection of HCV-RNA by PCR method is a proof of an acute or chronic infection and rules out past infection. The quantitative PCR measurement is useful for determination of indication and control of efficacy of antiviral therapy.

Preventive OKT3 treatment with cyclosporine (Sandimmun) for second kidney transplantation

A total of 793 kidney transplantations (KTx) were performed from November 1073 to March 1993. Two hundred and forty-two patients were treated with conventional immunosuppression (azathioprine + prednisolone) and all the others with cyclosporine (Sandimmun) and prednisolone (SIM + PRED). The survival of the second graft was less good in both therapeutic groups than that of the first ones, so we have started to use preventive immunotherapy with OKT3 (CILAG) in combination with SIM (both before operation) and PRED. We compared 32 SIM-PRED patients with 20 OKT3 + SIM + PRED patients. All underwent a second KTx. The two groups were found to be comparable and homogeneous with regard to 14 of 18 parameters analysed statistically. Statistically significant differences were found between the two groups as regards the frequency of acute rejection within 30 days (46.69% vs 20%), the delta creatinine value on the 1st and 2nd postoperative days (-4.3: -8 vs -8.6: -19.7%), patient survival after 4 years (78.2 vs 100%), and graft survival after 1 and 4 years (-58.9: -42.8 vs -83.5: -83.5%), with better results in the OKT3 group. We conclude that the preventive use of OKT3 simultaneously with SIM + PRED for the second KTx is the method of choice to prevent rejection and improve survival. This treatment results in patient and graft survival following the second KTx being as good as after the first KTx with SIM + PRED.

Primary hepatic carcinoid in a renal transplant patient

There seems to be a world-wide increase in the incidence of tumors among immunosuppressed patients. Of 1350 renal allografts transplanted in the past 23 years at the Department of Transplantation and Surgery, 56 cases were malignant tumors. The case of a 58-year-old female patient is reported, with disseminated primary carcinoid in the liver detected 86 days after renal transplantation. According to the literature only 39 patients with primary liver carcinoids have been reported until 1997, but this is the first where the carcinoid developed in an immunosuppressed patient. The rapid progression of the carcinoid could be associated with the immunosuppression.

[Haemodialysed, hemiparetic patient operated on for aortic aneurysm followed by successful renal transplantation]

The authors present the case of a 58 years old male patient. According to his preceding record in 1991 he suffered speech disturbance and left-side hemiparesis due to multiplex vascular lesions. A fresh cerebral ictus caused a right side hemiparesis mainly in the upper limb in 1993 and sensomotororic aphasia has also been developed. In 1995 the patient was begun acute haemodialysis treatment due to his gravis uremic state, then his dialysis was continued 3 times 4 hours weekly. In 1997 the then 56 years old inveterate right-sided hemiparetic patient, treated with chronic haemodialysis requested to be put on the transplantation waiting list. The first thing that had to be done in case of this high-risk patient was the resection of the abdominal aortic aneurysm (38 mm x 67 mm x 115 mm in size) noticed at the ultrasound examination which was carried out in January 1997. The continuity of the vessel was secured by graft-interposition where the arteria mesenterica was also implanted. Following the successful operation, the patient was qualified for the transplantation list and in the February of 1998 a successful kidney-transplantation was carried out. Following the temporary, post-transplantation difficulties (post-operative 5th day acute rejection well-reacting to 3 steroid-shots; the two re-operations due to partial necrosis in the uretero-ureteralis anastomosis and successfully overcoming the Pseudomonas aeruginosa uroinfection) the patient is currently doing well and has no complaint.

[Health prospects in the alternative strategies of renal replacement therapies]

The authors are publishing the health outcome results of a cost-effectiveness analysis on renal replacement therapies. They analysed the mortality data of the main renal replacement therapies between the 3-year time period of 1994-1997 in a retrospective way. They found that although there is a high initial postoperative mortality risk of the surgical procedure, the kidney transplantation reduces the relative risk of 3-year mortality by 27.7% (p = 0.0601) in comparison with the waiting listed hemodialysis. This means 5.6% absolute risk reduction. As it is proved that transplantation improves quality of life of patients on renal replacement therapy, the loss of a potential donor decreases the expected quality adjusted life years (QALY) benefit of those dialysed patients who are on the waiting list.

[Forecasting the number of patients with end-stage renal disease (Model of the system)]

The authors are dealing with the renal replacement therapies in Hungary. They are on the opinion that in view fo patient flow renal replacement therapies (such as various methods of dialysis and kidney transplantation) can be considered as one system. With analysing the number of patients in the past years they can establish that end-stage renal disease puts significant burden on the health insurance fund. According to their calculations the number of patients with end-stage renal disease will increase by 14-16% in the next few years if current trends continue. If we want to operate the system efficiently, we can reduce--up to a certain extent--the economic burden of dialysis by increasing the number of kidney transplantations.

Prediction of early renal graft function by the measurement of donor urinary glutathione S-transferases

BACKGROUND

We have investigated the possibility of urinary alpha- and pi class glutathione S-transferases (GST-a; GST-pi) serving as a valuable parameter to predict early graft function after transplantation.

METHOD

Urinary GST concentrations of 61 donors (DON) and recipients (REC) were analyzed at preoperative, intraoperative, and postoperative periods. We grouped recipients according to the early postoperative graft recovery days.

RESULTS

The donor graft function, represented by the donor urinary GST concentration (GST-pi:17,1+/-12 microg/l mmol creatinine (crea); GST-a:14,3+/-10 microg/mmol crea), sustained a loss in comparison to the healthy controls (GST-a; pi< or =1 microg/mmol crea). According to statistical analysis, the donor GST-pi level showed a strong correlation with graft recovery days-pi (r = 0.84; P<0.001). The early graft function cannot be predicted by means of cold ischemia time (22.8+/-3.4 hr), nor handling time (42.4+/-11.1 min), nor even the intraoperative enzyme concentrations. The GST-pi cut off level (12.55 microg/mmol crea) might predict the possible posttransplant graft dysfunction. The discriminative analysis showed that using only DON GST-pi alone could discriminate well between the groups among all grafts in 68%.

CONCLUSION

Prognosis is poorer if the donor GST-pi concentration is above 12.55 microg/mmol crea. On the basis of the determination of GST-pi concentration in the donor urine, we can predict graft viability before the surgical procedure with a reliability of 68%.

Papillary microcarcinoma of the thyroid gland in renal transplant patients

Among organ transplant recipients there is a world wide increase in the number of de novo tumors as well as a decrease in the time of the first appearance after the transplantation. Between 1973 and the 31st of August 1999 1709 cadaver renal allograft transplantations were performed in our Department. Four thyroid cancers were detected among the renal transplanted patients. Two of them proved to be papillary microcarcinomas. Although the elevated risk of thyroid cancers is well established in the literature papillary microcarcinomas have never been reported before in an immunosuppressed patient. Authors highlight that the thyroid gland should always be carefully checked in organ transplant recipients, since better survival might be achieved even in the immunosuppressed population. Metastatic tumor is relatively benign which is in correlation with the literature, but there has been little experience in organ transplanted patients so far.

Evaluation of the state of health of living related kidney transplantation donors

Renal transplantation is the optimal mode of therapy for patients with end-stage renal disease; the results are even better with living related donors. This procedure, therefore, favours the recipients, but what are the consequences for the donor? At our Department, between 1973 and 1996, 1325 kidney transplantations were performed, 78 from living, related donors (5.89%). We decided to follow up these patients and investigate the function of the remaining kidney and also their current general health status. Thirty donors (38.4%) were investigated. Of these, 25 of had normal blood pressure and 5 were hypertensive, needing antihypertensive treatment. The average age was higher in the hypertensive group (60.2/53.25 years). The time interval since transplantation was longer in the hypertensive group than in the normal one. We carried out a scintigraphy of the kidney with Tc-99mMAG-3. The mean value of the glomerular filtration rate calculated from the MAG clearance was 98.1 ml/min and this value is higher than half of the normal isotope clearance value, i.e. higher then the expected value for a single kidney. We conclude that no impairment of renal function is observed in the living, related kidney donors. In 16.66% a mild hypertension developed. With isotope investigation we found hypertrophy of the remaining kidney. Thus, after a correct preoperative assessment, unilateral nephrectomy has no long-term consequences in healthy donors.

Attitudes of donors towards organ transplantation in living related kidney transplantations

The demand for transplantation exceeds the availability of cadaveric organs, which is why the importance of living, related kidney transplantation is increasing. In our study we wanted to evaluate the experiences of living related donors (LRD). Between 1973 and 1996, 1325 kidney transplantations were performed at our Department. Of these 1247 were from cadaver donors while 78 were from LRD. We contacted each living donor by post. We carried out a physical examination, laboratory tests, ultrasound and isotope investigations and they were interviewed and completed a questionnaire. Thirty previous kidney donors came to our Department who were all blood relatives of the recipients. In the recipient group, 16 still have a functioning kidney, the average time since transplantation being 8.92 years. The longest kidney survival time is 18 years. All the donors willingly donated their kidney, none was worried about their own health and their only concern was whether the kidney would function or not. Regarding general attitudes towards living related organ transplantation, all were in favour of blood relative donor transplantation and also husband/wife transplantation. Opinions regarding non-related transplantation were more mixed; 63.3% would have given their kidneys to a friend, only 46.6% to a stranger. Almost two-thirds (63.3%) of donors were not in favour of selling and buying organs but, controversially, they would have bought an organ had one been available. All agreed that the donation did not change their general health. In conclusion, the donors of living, related kidney transplantation all agreed that it was a good thing to donate; All confirmed they would go through the same procedure again in order to help. Apart from one person, who emphasised that he is agnostic, all belonged to a Christian religion.

Effect of diet and fluvastatin treatment on the serum lipid profile of kidney transplant, diabetic recipients: a 1-year follow up

The effect of a cholesterol-lowering diet and subsequent fluvastatin treatment (Lescol, Novartis; 20 mg/day) on serum lipids and lipoproteins was investigated in 21 diabetic patients (eight women, 13 men, age range 31-63 years, BMI 25.9 +/- 4.5 kg/m2) who had undergone successful kidney transplantation. A cholesterol-lowering diet followed for 8 weeks had apparently no effect on serum lipid concentrations. Fluvastatin applied afterwards for 12 months significantly decreased the total cholesterol, triglyceride and LDL cholesterol levels from 7.7 +/- 0.94, 2.84 +/- 0.85 and 4.87 +/- 1.05 mmol/l to 6.40 +/- 0.74, 2.64 +/- 0.86 and 3.52 +/- 0.69 mmol/l, P < 0.001, < 0.05 and < 0.001, respectively, while the level of HDL cholesterol increased from 1.12 +/- 0.28 to 1.52 +/- 0.39 mmol/l, P < 0.001. Serum concentration of lipoprotein(a) remained unchanged. The serum level of apolipoprotein-A1 increased from 1.52 +/- 0.28 to 1.83 +/- 0.29 mmol/l (P < 0.01) and that of lipoprotein-B decreased from 1.37 +/- 0.20 to 1.20 +/- 0.36 mmol/l (P < 0.05). These maximum changes were achieved by the 12th week of fluvastatin treatment, and no further significant change was observed in the remaining part of the year. The other parameters that could have influenced lipid metabolism (doses of diuretics and steroid, daily dose and serum level of cyclosporin, kidney function, degree of proteinuria, HbA1c, etc.) remained unchanged throughout the study. Thus, the improvement in lipid concentrations can be ascribed exclusively to fluvastatin. No side effects were observed during the 1-year follow up. Liver enzymes and CPK remained within the normal reference limits. Fluvastatin proved to be an effective and safe drug for treating the dyslipidaemia of transplanted patients receiving steroid cyclosporin immunosuppression.

Comparative analysis of kidneys retrieved from the same donor and transplanted into different recipients

We have reviewed the outcome of kidney transplantations where both kidneys retrieved from the same donor were transplanted at our Department and the factors which might be decisive in the outcome. Between 1973 and 1996, 1325 kidney transplantations were performed at our Department. In 360 cases, both kidneys retrieved from the same donor were transplanted at our Department. We evaluated only first transplant cases who were treated with a combination of cyclosporin and prednisolon. After this selection, 248 pairs of kidneys were left for analysis. We divided them into three groups. The first comprised immediately functioning kidneys (135 pairs), the second, no immediate graft function in any of the recipients (29 pairs). The third group was mixed: the kidneys retrieved from the same donor were functioning in one recipient and not in the other, so this group was omitted from the analysis. We therefore analysed the donor factors of age, sex and cause of death. We found no significant difference between the groups relating to the cause of donor death. There was, however a significant difference in the age of donors: those kidneys functioning well in both recipients derived from a younger donor group (16-40 years), 18/58 versus 136/270, P < 0.01, chi 2 = 7.17. There were significantly fewer older donors (41-65 years) in the immediately functioning group than in the other, 38/58 versus 110/ 270, P < 0.001, chi 2 = 11.84. We investigated the number of HLA mismatches, ischaemic time, cytotoxicity index and the type and duration of pretransplantation dialysis. It appears from this analysis that the age of the donor is a significant factor in the short-term outcome of transplanted kidneys. Recipient factors as HLA match, ischaemic time and cytotoxicity index seems to be less important.

[Diagnostic value of glutathione-S-transferase]

The authors evaluated the diagnostic value of the glutathione-S-transferase (GST) enzyme in the medical practice. The GST is widely distributed in human tissues, the majority of the enzyme protein is present in the cytoplasm. GST plays a pivotal protective role against the environmental damages. It can be made a conclusion from the quantity, the localization of the enzyme expression and enzyme forms to the degree of chemical insult suffered by the organism. The increase of alpha GST izoenzyme can reflect the degree of the hepatocellular and renal proximal tubular epithelium damage. The overexpression of pi-class GST represents the injury of bile epithelium and renal distal tubules. Overexpression of GST is associated with tumor appearances and with resistance to cytostatic agents. It was possible to took the enzyme izoenzymes apart, to identify them--hereby to explore their origin--and to detect their quantity with the development of the separation techniques, the immunological and genetical methods. Since the enzyme expression is in direct proportion to the magnitude organs and tissues damage or/and the presence of specific izoenzymes suspects tumor formation, for this reason the monitoring of the GST expression could give a help for the physicians in creating the diagnosis.