Preemptive kidney transplantation: analysis of kidney grafts from the same donor

BACKGROUND

From November 2003 to December 2012, in the Gdańsk Center, 64 patients received preemptive transplantation (PET). PET comprised 8% of 794 kidney transplantations performed during this time. The benefits for individual patients and for the health care system are discussed.

METHODS

This study compares the outcomes of these PET patients who had their kidney pairs transplanted after a variable duration of dialysis (PTD), a total of 51 pairs.

RESULTS

The mean Charlson comorbidity index was 2.57 vs 3.04 (P > .05) for the PET and PTD groups, respectively. Both groups did not differ significantly with respect to 1-year patient and graft survivals, and incidences of acute rejection. Five (9.8%) PET patients and 20 (39%) PTD patients experienced delayed graft function (P < .05). The graft function (serum creatinine/4p MDRD) 1 year after transplantation was similar in both groups (1.42/53.7 vs 1.43/57.4; mg/dL/mL/min/1.73 m(2)). More PET patients continued normal professional activities or education before and after transplantation (P < .05).

CONCLUSIONS

Our single-center results confirmed that for both medical and socioeconomic reasons, PET is an optimal mode of renal replacement therapy.

The modification of diet in renal disease and chronic kidney disease epidemiology collaboration formulas versus measured or estimated creatinine clearance in kidney transplant recipients

BACKGROUND

Estimation of glomerular filtration rate (eGFR) after renal transplantation is performed with the use of methods that are standardized for a population of nontransplantation patients with chronic kidney disease. The aim of the study was to compare the performance of GFR estimation formulas in renal transplant recipients.

METHODS

The Modification of Diet in Renal Disease (MDRD) and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formulas were compared with measured creatinine clearance or clearance estimated by the Cockroft-Gault (C-G) formula. The influence of age, body mass index, and eGFR on the relative performance of these formulas also was studied by subgroups analysis.

RESULTS

Mean measured or estimated creatinine clearance overestimates the values of GFR calculated using the MDRD or CKD-EPI equation. This was statistically significant (P < .05) in whole-study population and in subgroups of patients at age above 25 years, with body mass index above 25, and in a subgroup with eGFR-MDRD <50 mL/min/m(2). The mean bias from creatinine clearance was 7.46 mL/min for MDRD, 4.4 mL/min for CKD-EPI and -1.65 mL/min for C-G formula. There was a statistically significant (P < .05) negative correlation between eGFR value and bias from creatinine clearance for all 3 methods of estimation. The correlation coefficient was -0.4 for MDRD, -0.36 for CKD-EPI, and -0.46 for C-G clearance.

CONCLUSIONS

Measured and estimated creatinine clearance overestimate values of eGFR calculated by the MDRD or CKD-EPI formula in a population of kidney transplant recipients, especially in subjects with obesity and worse renal function. Accuracy of analyzed GFR estimation formulas decreases with deterioration of renal graft function.

Should we preserve the inferior mesenteric artery during sigmoid colectomy?

Ligation of the inferior mesenteric artery (IMA) during sigmoid colectomy may cause sympathetic denervation of the rectal stump. The purpose of our study was to investigate the functional results after sigmoid resection following ligation or preservation of the IMA. We prospectively analysed 44 patients (21 female and 23 male, mean age 60.6 +/- 11.79 years) with sigmoid tumour. Sigmoid colectomy with preservation of the IMA was performed in 21 patients, and ligation of the IMA with sigmoidectomy was carried out in 23 patients. Bowel function follow-up was performed by use of questionnaires: standardized functional questionnaire, constipation-specific, and incontinence scales before, 6 and 12 months after surgery. The quality of life was measured by means of the Fecal Incontinence Quality of Life (FIQL) scale. After sigmoid colectomy with division of the IMA, patients presented with a higher rate of fecal incontinence and increased stool frequency compared with patients after sigmoid resection with preservation of the IMA. Deterioration of FIQL was also observed in patients with ligated IMA. Preservation of the IMA during sigmoid colectomy in selected patients lowers the frequency of postoperative impaired anorectal function.

Are mesh anchoring sutures necessary in ventral hernioplasty? Multicenter study

BACKGROUND

Avoiding mesh fixation to the surrounding tissue in ventral hernioplasty would simplify the operation, decrease the time of the procedure, and decrease the risk of suture-related complications.

METHODS

Four hospitals included 111 patients according to the common protocol for prospective clinical evaluation of sutureless ventral hernioplasty. Surgical technique involves placement of the polypropylene mesh with flat-shape memory in either the retromuscular or preperitoneal space without suture anchoring.

RESULTS

Local complication rate was low (12.6%, 14 patients), postoperative pain measured according to the visual analogue scale was minimal (mean 4, range 1-8). Three recurrences (3%) were recorded. Mild scar discomfort, which did not require treatment nor limit physical activity, was recorded in 28 (25%), 18 (17%), and 11 (14%) patients at 6-month, 1- and 2-year follow-up, respectively.

CONCLUSIONS

Results of the study suggest that the sutureless sublay technique is safe and effective in the treatment of ventral abdominal hernia, especially in small and medium defects.

Renal transplantation in dialysis patients with the history of coronary artery bypass grafting and cardiac valve replacement

Death with a functioning kidney is the most frequent cause of graft failure. Cardiovascular disease is the most frequent cause of death after renal transplantation. Therefore, prior to grafting, it is mandatory to diagnose and treat coronary artery disease and heart valve impairment. Transplantation is the best option for renal replacement therapy as far as the quality of life and life expectancy are concerned, although patients with such comorbidities may experience a higher short-term mortality risk. The objective for this study was to analyze both short- and long-term results of patients after coronary artery bypass grafting (CABG) or cardiac valve replacement (CVR). The cardiac surgery recipient group (CSR) included 16 patients (15 men, 1 woman) aged from 44 to 73 (mean 54.9 +/- 7.8) years. CABG was performed in 13/16 patients, and CVR in 3/16. The rest of our patients were treated as a comparative noncardiac surgery recipient (non-CSR) group. It consisted of 422 patients (264 men, 158 women) aged from 14 to 68 years (mean 43.2 +/- 12.9). The comparison revealed that graft function estimated at 1 year after transplantation was not different: serum creatinine concentrations of 1.7 +/- 0.2 and 1.6 +/- 0.5 mg/dL in CSR and non-CSR, respectively. One-year patient survival in the CVR group of 93.8% was slightly worse than that in the non-CSR group (97.9%), but death-censored 1-year graft survivals were comparable in both groups (93.8% vs 92%). Urinary tract and cytomegalovirus infections were the most common complications in the CSR group. One patient lost his graft in month 3(rd) due to many serious infectious complications. One patient died at the end of 12 months as a result of a cardiovascular event (1/16). Our single-center results confirm that transplantation in patients after CABG or CVR is a safe procedure; therefore, such patients should be referred into the waiting list.

Assessment of usefulness exhibited by different tacks in laparoscopic ventral hernia repair

BACKGROUND

Laparoscopic ventral hernia repair is becoming a popular technique with good results and fast postoperative recovery. The mesh is placed directly under the peritoneum and anchored with transabdominal sutures and tacks. However, the ideal size of the mesh covering the hernia orifice is know, nor the ideal type or amount of tacks has to be described.

METHODS

To assess the forces acting on a single tack, a mathematical model of the ventral hernia was created. The force was described in reference to the surface of the hernia orifice and the pressure in the abdominal cavity. The following different types of mesh were examined in vitro: Proceed (knitted mesh), Dual Mesh (expanded polytetrafluoroethylene [ePTFE] flat mesh), and Shelhigh (biologic flat mesh). The following different tacks also were examined: Protac, Anchor, and EMS. A pig model was used to measure the forces needed to destroy the connection between mesh and tissue and to describe the place of destruction (mesh, tissue, or tack) and the force needed.

RESULTS

The force acting on a single tack proportionally depends on the surface of the hernia orifice and the pressure in the abdominal cavity. The force needed to disconnect the tissue and mesh reached 8.97 +/- 0.11 N for ProTac, 2.67 +/- 0.22 N for Anchor, and 6.67 +/- 1.32 N for EMS. These values do not allow the mesh to be held in the right position when the orifice exceeds 10 cm for Protac and EMS. The disconnection of the EMS and Protac junction damages the tissue. Anchor tacks are insufficient to hold the mesh and stay in the tissue

CONCLUSIONS

In the case of small hernias (diameter<10 cm) EMS or ProTac used alone are not enough to hold the mesh. Anchor is not recommended alone in any hernia.

Management of inguinal hernia on peritoneal dialysis: an audit of current Polish practice and call for a standard

Peritoneal dialysis is becoming more and more common as a method of treating patients at the final stage of renal failure. In the year 2002 the number of patients treated with this method in Poland amounted to 1324. Studies have demonstrated that inguinal and abdominal hernias develop more frequently in chronic renal failure patients. The percentage of patients with hernia diagnosed within the first five years of dialysis is about 10%. Continuation of dialysis with the hernia condition left untreated may result in severe complications which are the third most frequent cause of converting treatment method into hemodialysis in PD patients. Currently in Poland there is no national standard in existence as to the management of hernias, and the only British standard from 1998 does not reflect the present expertise of either surgical treatment or dialysis methods. The aim of the current questionnaire based study investigating Polish peritoneal dialysis centers was to assess the treatment when hernia had been diagnosed in the PD patient. Of 49 dialysis centers in Poland, 39 do have protocols on managing the patient before and after the operation. A considerable diversity has been found as to surgical techniques used and the ways the patients are managed in hospital. Following the need expressed by 33 dialysis centers in Poland for some standard for relevant procedures, the authors formulated principles of modern hernia treatment in PD patients. Accordingly, the main principles include: 1) consulting a surgeon collaborating with the center before qualifying for peritoneal dialysis and when hernia symptoms have manifested; 2) Tension-free methods used in a treatment of choice (recommended by PHS); 3) Application of antibiotic prophylaxis (preferably first generation cephalosporin); 4) Induction of local or epidural anesthesia; 5) Peritoneal dialysis programme does not need to be discontinued but low volume dwells or preferably intermittent APD is recommended immediately after surgery.

Is there a need for a mesh plug in inguinal hernia repair? Randomized, prospective study of the use of Hertra 1 mesh compared to PerFix Plug

Although the mesh plug procedure is an effective operation, sutureless implantation of a single onlay mesh, if successful, would avoid the risks of plug-related complications. One hundred patients with primary inguinal hernias were randomized to undergo PerFix Plug or Hertra 1 implantation. Mean duration of the operation was similar, 38 versus 35 min for plug and onlay mesh implantation, respectively (nonsignificant, NS). The level of postoperative pain and early complication rate was similarly low in both groups (NS). Recurrence rate was the same-2 patients in each group (4%)-all following large hernia repair. The level of long-term discomfort was low after each type of operation (NS). Implantation of the onlay mesh-Hertra 1 as compared to the use of PerFix Plug is simple, safe, and equally effective in small and medium inguinal hernia repair, suggesting that a plug device is not necessary for successful hernia surgery.

Nonalcoholic fatty liver disease treated by gastroplasty

Nonalcoholic steatohepatitis (NASH), which is the most severe histologic form of nonalcoholic fatty liver disease (NAFLD), is emerging as the most common clinically important form of liver disease in obese patients. The prevalence of NASH may increase with the rise in the rate of obesity and metabolic syndrome in affluent communities. The aim of this work is to describe clinical and histopathologic findings and correlate liver tissue damage to the length of duration of the obesity in the group of patients who underwent surgery as obesity treatment. Eighty-seven severely or morbidly obese patients underwent gastroplasty. Each patient was evaluated with complete clinical and laboratory medical assessment together with wedge liver biopsy taken from 59 unselected patients during the surgery. Patients were followed up for 41 months. Repeat liver biopsy was taken from 10 patients. Pathologic analysis recorded the presence and degree of steatosis, portal and lobular inflammation and fibrosis. Age, body mass index (BMI), and laboratory assessment correlated with pathologic data. Male patients showed more pronounced metabolic syndrome and fatty liver damage. Patients who become obese in childhood or as teenagers showed no differences in metabolic syndrome and NAFLD in mature age. There was statistically significant association between BMA, elevated transaminases, NAFLD, and fibrosis. Significant weight reduction was observed within first year after surgery, was slower in the second year, and stabilized within third year. Remarkable improvement followed in biological markers of metabolic syndrome. Ninety-six percent of initial liver biopsies had steatosis; 16% developed steatohepatitis and mild perivenular fibrosis. Significant improvement of the degenerative and inflammatory hepatic lesions in repeated biopsies and liver function readings was noted within 8 months after surgery. Obesity is a major and independent risk factor for the metabolic syndrome, NAFLD, NASH, and fibrosis. Surgical treatment improves metabolic abnormalities and hepatic lesions in long-term observations.

A Single Center Experience in Preemptive Kidney Transplantation

Transplantation is recognized as preemptive if it takes place before the initiation of chronic dialysis. This maneuver has the potential to avoid the morbidity and burden of chronic dialysis. From November 2003 to April 2005, 15 (7 male, 8 female) end-stage renal failure patients of mean age 40 +/- 14.8 years received preemptive grafts from 2 living-related and 13 cadaveric donors, constituting 11.5% of all kidney transplantations performed in our center at that time. The period on the waiting list for preemptive recipients, namely, 2 weeks to 6 months (mean, 2.4 months), was significantly shorter than that of other patients (mean, 13.8 months). The mean creatinine clearance calculated from the Cockroft Gault formula and the mean plasma creatinine level in preemptive recipients before transplantation were 12.7 +/- 3.1 mL/min and 6.6 +/- 0.8 mg/dL, respectively. The donors for preemptive and non-preemptive groups of recipients did not differ significantly in respect to age, gender, and renal function. The mean number of mismatches of 3.73 and 3.25 and the mean total ischemic times of 9.53 +/- 5 and 11.2 +/- 5 hours, in preemptive and non-preemptive groups of recipients, respectively. The incidence of delayed graft function (dialysis in the first week after transplantation) was significantly lower among preemptive recipients (20% versus 42%, respectively). The groups did not differ either in respect to the occurrence of acute rejection episodes or graft and patient survivals. In preemptive patients the mean plasma creatinine levels at 3 and 12 months were 1.37 +/- 0.3 and 1.09 +/- 0.3 mg/dL, and in non-preemptive patients 1.7 +/- 0.5 and 1.4 +/- 0.4 mg/dL. In conclusion, these results are promising, confirming the notion that preemptive kidney transplantation is the optimal treatment for end-stage renal disease patients.

Hemolytic anemia after renal transplantation: analysis of case reports

Hemolysis after renal transplantation in some cases is clearly related to hemolytic-uremic syndrome (HUS) and usually attributed to cyclosporine (CsA) treatment. Acute hemolysis in other recipients is related to anti-erythrocyte autoantibodies. In most cases these patients have received ABO-compatible, although ABO-nonidentical, organs, mostly from O blood group donors. We report three cases of autoimmune hemolytic anemia after renal transplantation. Two patients (patients: 1 and 2; ABO-compatible, but nonidentical kidneys) suffered acute hemolysis in the third week after transplantation. One patient (patient 3: ABO-identical kidney) suffered a chronic, subclinical course of disease beginning 5 months after transplantation. The clinical picture of this disease was completely different from HUS. The existence of severe anemia (patients 1 and 2), hyperbilirubinemia (particularly high in patient 3), increased serum lactic dehydrogenase levels, and decreased serum haptoglobin in the presence of good graft function suggested an hemolytic anemia. In all patients the direct antiglobulin test was positive. The acute or chronic symptoms of hemolysis disappeared, at 2 and 5 weeks, respectively, after conversion from CsA to tacrolimus. Hemolysis in these patients probably relates to alloantibodies derived from passenger B lymphocytes transplanted with the organs. Because hemolysis has been most frequently related to CsA therapy, it is suggested that B lymphocytes proliferated and produced antibodies because CsA effects to inhibit T-cell function generally spares B-cell activity. It is proposed that a subtype of B cells, which are resistant to CsA, produces anti-A and/or anti-B antibodies. Treatment with tacrolimus appears to be successful, probably due to its alternate, and likely more effective, manner of B-cell suppression.

[Widened resection in locally advanced carcinomas of the right half of the colon]

We describe two cases of locally advanced carcinomas of the right half of colon. In spite of big tumour size and infiltration of adjacent organs we decided to perform widened "en block" resection. Microscopically no neoplastic cells were found in lymph nodes. During a year observation we did not ascertain any features of neoplasm relapse what is consistent with data published by other authors. They indicate that radical resection of big-sized tumours infiltrating adjacent organs in the case of absence of metastases into lymph nodes gives the patient a chance for long-term survival.

Iron deficiency anemia as the sole symptom of small intestine carcinoma

BACKGROUND

The isolated longstanding hypochromic hyposideremic anemia can be a unique symptom of the jejunal tumor.

CASE REPORT

The authors present a case of 43-year-old woman with small intestine cancer, which manifested as longstanding anemia, decreased serum iron and remained undiagnosed over a period of several years. Special attention has been paid to the problem of adequate diagnostic procedure for disclosing the latent small intestine tumor.

Experimental pancreatitis induced by synthetic prooxidant tert-butyl hydroperoxide

The purpose of this study was to verify whether injection of tert-butyl hydroperoxide (Bu(t)OOH, a well-known prooxidant agent) into the bile-pancreatic duct can induce acute pancreatitis. A rapid blockade of the secretion was observed in the majority of the animals after 3 hours of observation. After 6 hours, the secretion reached a very low level, significantly different compared with controls. In groups of rats injected with Bu(t)OOH, pancreatic weight gain was observed compared with the rats injected with physiologic saline. Histology of pancreata removed 3 hours after injection of Bu(t)OOH showed acinar cell vacuolization, interstitial edema, focal necrosis of pancreatic acini, fat-tissue necrosis, and leukocyte infiltration of the organ. These changes were considerably greater after the 6-hour observation period. Electron-microscopic inspection revealed profound morphologic changes 3 hours after Bu(t)OOH injection. The control rats receiving physiologic saline alone had well-preserved pancreatic tissue structure. In conclusion, injection of the prooxidant agent, tert-butyl hydroperoxide, into common bile-pancreatic duct induces acute necrotizing pancreatitis, which indicates the crucial role of free radical reactions in pathogenesis of this disease.

[Modification of proteins in the course of oxidative stress in acute experimental pancreatitis]

This study aimed to investigate the protein peroxidation process in cerulein induced acute pancreatitis. Eighteen rats were divided into three equal groups: group 1 acted as control rats had intraperitoneal injection of 0.9% NaCl, in group 2 and 3 rats had injection of cerulein 40 micrograms kg-1 for 3 or 6h of induction period respectively. Protein carbonyls which reflect peroxidative damage were found to be increased after 3h up to 2.53 +/- 0.49 comparing to 1.05 +/- 0.17 in control group and returned to control level 0.95 +/- 0.04 after 6h. These data suggest that during acute pancreatitis free radicals may play an essential role in protein damage. Decrease in protein carbonyls content after 6h suggests an elevated proteolysis of oxidatively damaged proteins.

Protective effect of 4-hydroxy-TEMPO, a low molecular weight superoxide dismutase mimic, on free radical toxicity in experimental pancreatitis

Rats develop acute pancreatitis when infused iv for 3 h with cerulein (10 micrograms/kg/h). Autopsies of the pancreas seen by light microscope show interstitial edema, acinar cells vacuolization, and leukocyte margination in pancreatic capillaries; under electron microscope, severe damage concerning mitochondrial and zymogen granules structures are apparent. Particularly, swelling of the mitochondria and disruption of mitochondrial cristae was observed as well as formation of large vacuoles arising from zymogen granules and liposome fusion. A significant increase of lipid hydroperoxide level in the pancreatic tissue was observed. The purpose of this study was to evaluate the effect of 4-hydroxy-TEMPO--a low-mol-wt superoxide dismutase mimic--in a rat cerulein model of acute pancreatitis, with the expectation that free radical mediated hydroperoxide formation and tissue damage may be reduced significantly. Twenty-one male Wistar rats were divided into three groups: Group 1 (n = 5) served as a control and was infused iv for 3 h with physiologic saline; Group 2 (n = 8) was infused i.v. for 3 h with cerulein 10 micrograms/kg/h; and Group 3 (n = 8) infused i.v. both with cerulein and 4-hydroxy-TEMPO 22.6 mg/kg/h. Pancreatic tissue damage was quantified by measuring lipid hydroperoxide (LOOH) level, the weight of the organ, and by light and electron microscopic examination. 4-hydroxy-TEMPO penetration across cellular membrane barriers was quantified by ESR spectrometric measurements of 4-hydroxy-TEMPO concentration in pancreatic tissue samples and pancreatic juice as well. Administering 4-hydroxy-TEMPO to rats resulted in preventing both lipid hydroperoxide formation and severe morphological damage. 4-hydroxy-TEMPO crossed cellular membrane barriers and was excreted to pancreatic juice. Infusion of 4-hydroxy-TEMPO appears to prevent pancreatic injury caused by free radicals in experimental cerulein pancreatitis.

Diagnostic and surgical procedures in acute necrotizing pancreatitis (ANP)

The main subject of considerations is acute necrotizing pancreatitis, based on the authors opinion and literature. Frequency of the necrosis in acute pancreatitis is established in between 7-15%. Because of very severe and often lethal complications these patients need special surgical attention. Enhanced CT is the most valuable diagnostic procedure to visualize the extend of pancreatic necrosis. There is no common agreement upon the mode of treatment except from that infected necrotizing pancreatitis should be operated. Indications for surgical treatment with particular analysis to necrosectomy and laparostomy is discussed.

Effect on hemodynamics of therapeutic infusion of gabexate mesilate (FOY) in experimental acute pancreatitis

Acute pancreatitis was induced in ten anesthetized dogs by retrograde injection for bile mixed with trypsin into the pancreatic duct. Five animals were treated with i.v. infusion of gabexate mesilate in a dose of 1 mg/kg per hour. Hemodynamic data were regulary monitored during a 10-h observation period. Cardiac output (CO), mean arterial pressure (MAP), and left ventricular stroke volume (LVSV) decreased rapidly in untreated animals. An increase of systemic vascular resistance (SVR) and pulmonary vascular resistance (PVR) was observed in dogs without treatment. Gabexate mesilate given as a therapy significantly improved the hemodynamic parameters. The study demonstrates an advantageous influence of synthetic antiprotease gabexate mesilate on the course of acute experimental pancreatitis.

[Parathormone, calcitonin, 25-hydroxycalciferol and bone histology in patients with chronic renal insufficiency]

In 18 patients with chronic renal failure the parathormone (PTH), calcitonin (CT) and 25-OH-D blood levels were estimated before and after an intravenous calcium load. In ten patients the above mentioned biochemical parametres were confronted with histological findings obtained in bone biopsy material. Significantly elevated levels of PTH and CT were found while those of 25-OH-D were normal. Serum PTH decreased after a calcium load. In contrast to healthy persons no increase of serum CT was stated. Significant positive correlations were found between PTH and CT levels in blood serum as well as between the mineralized bone volume and 25-OH-D levels in serum. In addition a significant negative correlation was stated between the osteoid volume and 25-OH-D levels in blood serum. From the results obtained it is concluded, that from estimations of PTH, CT and 25-OH-D in blood serum histological alterations in bone biopsy material from chronic uremic patients can not be predicted. Beside secondary hyperparathyreoidism, relative deficiency of CT and active vitamin D metabolites other factors are also involved in the pathogenesis of renal osteodystrophy.

The usefulness of Resusci-Anne manikin in teaching modern methods of resuscitation

From experiences gained during the training of personnel the authors evaluate the effectiveness of teaching the principles of modern methods of resuscitation. They concluded that there are no essential differences in the preparation of carrying out resuscitation precedures between laymen and medical personnel. It is necessary to organize refreshing courses periodically. The Recording Resusci-Anne manikin with a device controlling the correctness of resuscitation procedures has been found to be an indispensable training aid in teaching the principles of resuscitation.