A Demirag

Evaluation of Erectile Function in Renal Transplant Recipients

RECTILE dysfunction describes the inability to achieve and maintain penile erection sufficient for coitus. Renal insufficiency is a chronic disease during which erectile function deteriorates, however, the etiology of this condition in such patients is multifactorial, involving organic and nonorganic (psychogenic) factors. 1 The condition may result from neuroendocrine disturbance, uremia, hypoxia, and atherosclerosis. 2 Neuroendocrine disturbance is often reversed by renal transplantation, but not by dialysis. 3 Psychological factors may also cause erectile dysfunction in dialysis patients, since approximately one fourth of these individuals are depressed at any given time. 4 Patients often regain potency after transplantation but in some cases, especially second transplantations, erectile function is adversely affected by interference with arterial blood flow. In this study, we evaluated the effect of renal transplantation on erectile function. PATIENTS AND METHODS Information on erectile function was collected by means of a questionnaire given to 65 men who were renal transplant recipients. The patients ranged in age from 20 to 57 years (mean 42.5 years). A second transplantation had been performed in four cases (6%). Posttransplantation follow-up ranged from 2 to 168 months (mean 72 months). A detailed medical history was taken and complete blood count, urinalysis, and a biochemical and endocrinologic blood analysis were routinely performed for all patients. A papaverine test, penile Doppler ultrasonography, cavernosometry, cavernosography, and pudendal angiography were done where indicated. For patients who had no erectile dysfunction before or after renal transplantation, the questionnaire and routine tests completed the evaluation. This group was considered to have experienced no change in erectile function due to renal transplantation. Similarly, no further tests were performed on patients who were afflicted with erectile dysfunction prior to renal transplantation but regained sexual function following transplantation. These patients were defined as the group with improved sexual function. On the other hand, patients with deteriorated erectile function after renal transplantation were evaluated in detail. All underwent a papaverine test involving intracavernous injection of 50 mg of papaverine and observation of response after 30 minutes. The group which experienced full erection after papaverine treatment (papaverine responders) was considered to have nonorganic (psychogenic) erectile dysfunction. Patients who did not respond to papaverine were further evaluated by penile Doppler ultrasonography for vasculogenic impotence. Papaverine-stimulated penile Doppler ultrasound was performed using a 7.5-MHz linear probe. Peak systolic velocities in the cavernous arteries were measured bilaterally. A peak systolic velocity of ,25 cm/s was considered as arterial insufficiency. Patients with arterial insufficiency underwent pudendal angiography, while those with normal penile Doppler ultrasound findings underwent dynamic infusion cavernosometry and cavernosography to assess for suspected veno-occlusive dysfunction. RESULTS Thirty-two patients (49.2%) experienced no alteration in erectile function before or after renal transplantation. Twelve patients (18.4%) said they regained erectile function after renal transplantation. Twenty-one patients (32.3%) with normal erectile function prior to transplantation during the hemodialysis period reported erectile dysfunction after the transplantation, constituting the group which was evaluated further. Seven of these patients were papaverine responders (nonorganic impotence) and benefited from antiserotoninergic treatment. All seven men received 150 mg/d trazodone initially, however, two patients who reported severe side effects with this drug were switched to sertraline at a dose of 50 mg/d. All patients in this group achieved erections sufficient for coitus within 3 months. In three patients, deterioration of erectile function was associated with hyperprolactinemia accompanied by a low testosterone level. A papaverine test was not performed in these cases. Oral testosterone replacement resulted in improved sexual function. Eleven of 21 patients who reported a deterioration in erectile function after transplantation did not respond to papaverine. These individuals were considered to have vasculogenic impotence. According to penile Doppler ultrasound, nine of these men had arterial insufficiency, while two had normal peak systolic velocities in their cavernous arteries, indicating no arterial insufficiency. These two patients underwent cavernosometry and cavernosography, which confirmed veno-occlusive dysfunction. They were treated with deep dorsal vein embolization using n-butyl cyanoacrylate, and regained satisfactory erections within 3 months, at which time control cavernosometry was normal.

Correlation of quantitative dynamic magnetic resonance imaging findings with pathology results in renal transplants: a preliminary report

ENAL transplantation is being used worldwide to spare chronic renal insufficiency patients from hemodialysis and to improve their quality of life. Medical and surgical complications have increased along with the number of transplantations performed. There are many causes of renal allograft dysfunction, the most significant being acute rejection, cyclosporine (CyA) toxicity, acute tubular necrosis, and chronic rejection. 1 It is particularly important to differentiate between acute rejection and CyA toxicity, because the dosage of immunosuppressive therapy should be increased in the former, but decreased in the latter condition. Biopsy remains the technique of choice for reaching a definitive diagnosis, but this procedure carries the risk of complications, such as major hemorrhage and infection that can occasionally result in graft loss. 2,3 Various noninvasive methods have been used to evaluate renal allograft dysfunction. The most common are serum creatinine levels, Doppler ultrasonography, and renal scintigraphy. However, none of these are specific enough to differentiate acute rejection from CyA toxicity. 4,5 The aim of this study was to assess dynamic magnetic resonance imaging (MRI) as a possible effective noninvasive technique to differentiate between rejection and CyA toxicity.

Renal magnetic resonance angiography with Gd-DTPA in living renal transplant donors

DEMONSTRATION of the renal vascular anatomy is a major part of the preoperative evaluation of potential living-related kidney donors, for the safe, uncomplicated removal of the donor allograft. Accurate determination of number, length, location of renal arteries, the length of the main renal artery proximal to the first parenchymal branch, and identification of accessory renal arteries is essential for proper presurgical planning. Radiologic evaluation of these patients has traditionally included conventional angiography (CA) and intraarterial digital subtraction angiography (DSA). These techniques are costly and associated with multiple problems. Threedimensional (3D) gadolinium (Gd)-enhanced magnetic resonance angiography (MRA) has been suggested as a potential screening technique owing to its noninvasive nature. In addition to this benefit, it is the most useful technique visualizing renal arteries and smaller vessels in detail due to the use of carefully selected acquisition parameters, suspension of respiration, and correct gadolinium bolus timing. The purpose of this study was to evaluate the accuracy of Gd-enhanced renal MRA in showing the variations and numbers of renal arteries of potential living-related renal donors before transplantation.

Power Doppler ultrasonography compared with scintigraphy in the diagnosis of renal allograft dysfunction.

POWER Doppler imaging is based on the integrated power of the Doppler signal as opposed to mean frequency shift, the feature used in color Doppler imaging. The power Doppler modality has several advantages over color Doppler, including angle independence, the absence of aliasing, and extended dynamic range. As a result of these benefits, power Doppler ultrasonography is sensitive to low-velocity blood flow in small vessels. Marked blood flow alterations in renal transplants can occur before a recipient shows any change in urine output. Intimal thickening in arteries leads to progressive ischemia of the cortex in acute and chronic renal graft rejection. Decreased outer cortical flow on the power image and decreases in mean value on the power histogram have been documented in patients with chronic transplant rejection. Impaired perfusion is manifested as decreased amplitude of the power Doppler signal. Calculation of a perfusion index using Tc-99m-labeled compounds can be used as an indicator of renal blood flow. Our aim was to investigate renal transplant dysfunction using power Doppler sonography and scintigraphy, and to compare these modalities by relating the respective findings to core biopsy results.

Results of living-unrelated donor kidney transplantation at our center

THE extreme shortage of cadaver kidneys is an evergrowing problem in Turkey, despite the intensive efforts that have been made toward a solution. Livingrelated donors have become the primary source of kidneys in developing countries. When a first-degree relative of the patient is not available, second-degree relatives or genetically unrelated but emotionally related donors, such as spouses, and close friends, become alternatives. The use of unrelated-living donors has not been widely accepted due to some ethical issues. Most transplant centers seek at least an emotional relation for genetically matching unrelated donors as a solution to this ethical issue.

Media effect on organ donation and transplantation.

OUR GROUP at Hacettepe University carried out extensive experimental studies using canine and porcine transplantation models in the early 1970s. We performed the first successful living-related (mother-to-son) kidney transplantation in Turkey nearly 2 decades later on November 3, 1975, marking the first successful kidney transplantation. While our living-related kidney transplantation program continued, we performed the first cadaverdonor kidney transplantation with an organ supplied by Eurotransplant on October 10, 1978. Until the early 1980s, alternatives to cadaveric transplantation did not exist for recipients who lacked living-related donors. Our team established more integral links with international organ networks such as the South Eastern Organ Procurement Foundation (SEOPF, Richmond, Virginia) and Eurotransplant, which were initially the only sources for cadaveric kidneys. In the face of limited cadaveric donors and the need to expand the cadaver donor pool, we intensified our efforts to educate the Turkish public about the benefits and need for organ transplantation and donation. The efforts of the Turkish Parliament, the media, and the Board of Religious Affairs boosted our progress and contributed to the enactment of laws 2238 and 2594, which legalized the harvesting, storage, grafting, and transplantation of cadaver-source organ and tissues in our country. Our workload skyrocketed to meet the needs of the donor-seeking Turkish public, and these efforts resulted in the first cadaver-donor kidney transplantation from a local source in July 1979, an operation performed by our team. A national organ sharing program was initiated by our team in 1989. This facilitated the distribution of organs nationwide and improved the communication among the transplantation centers, thereby increasing the number of cadaveric organ transplantations. More than 3750 kidney transplantations involving 18 centers have been reported to the Ministry of Health since the first transplantation in Turkey. Our team performed 1167 kidney transplantations from November 3, 1975 to January 1, 1998, the most recent 846 procedures having been carried out at our new center at Baskent University. The past year in Turkey has seen wider publicity and television news coverage of organ donation and transplantation issues, largely as a result of chronic liver disease in a patient who was a press member. At the present time in our country, only 25% of kidney transplants come from cadavers, and of these only 25% are local. In 1997 we performed 72 kidney transplantations, 18 using cadaver organs and 16 of these transplants being from local sources. To date, this is the best yearly record we have achieved for local cadaveric kidney transplantation. In 1993, we performed 20 cadaveric transplantations but only three organs were local; in 1991 only 1 of the 18 cadaveric transplants used was from a local source. In 1986 our average cold ischemia time was 63 hours; that year 12 of 13 cadaveric kidney transplants were shipped to Turkey from abroad. In what could be viewed as a measure of the progress made since then, the average cold ischemia time for cadaveric kidney transplantations in 1997 was 17 hours. In addition, the total number of renal transplantations performed last year outnumbered those done in each of the past 8 years (Table 1). In developing countries, educating the public and broadening awareness about organ donation and transplantation is critical to the progress of harvesting and transplantation programs. Our workload, especially in organ harvesting, has

Is common femoral artery flow affected by the ipsilateral transplanted kidney

RENAL transplantation is the preferred treatment for the majority of patients with end-stage renal disease. Many potential complications of renal transplantation are well-documented in the literature. A transplanted kidney placed in the iliac fossa is presumed to decrease blood flow to the lower extremity on the same side by the “steal phenomenon” and/or by compression of the iliac arteries due to the mass effect. To our knowledge, there are no reports in the literature concerning posttransplantation flow changes in the femoral arteries in the absence of atherosclerotic disease or perirenal fluid collection. We used Doppler ultrasound imaging to assess blood flow velocity and volume in the common femoral artery ipsilateral to the graft, and compared these findings to those on the contralateral side.

Analysis of 1167 consecutive kidney transplants at our center.

KIDNEY transplantation has a definite role in the treatment of end-stage renal disease and prolongs the life of these patients. This method is currently a safe procedure and is less expensive than long-term dialysis therapy. The first living-related kidney transplantation in Turkey was performed by our team on November 3, 1975, and this step was followed by the first cadaveric kidney transplantation, using an organ supplied by the Eurotransplant Foundation, on October 10, 1978. Since 1975, 1167 kidney transplantations have been carried out by our transplantation team. Following the enactment of a law pertaining to transplantation, we performed the first local cadaverdonor kidney transplantation in 1979. However the supply of cadaveric kidneys in Turkey does not meet the demand. The number of potential transplant recipients has dramatically increased in the face of the rising incidence of end-stage renal disease and the insufficient quantity of cadaveric grafts. These factors have spurred the expansion of living-related kidney transplantation in Turkey. Consequently, since 1975 our kidney transplantation program has remained largely dependent on living-related donors. This study analyzes the 846 most recent kidney transplantations carried out at our center.

Cytomegalovirus infection in kidney transplant recipients at our center.

CYTOMEGALOVIRUS (CMV), one of the human herpes group viruses, is the most important microbial pathogen affecting organ transplant recipients, contributing directly and indirectly to both morbidity and mortality in these patients. Three main patterns of CMV infection have been described: primary CMV infection, reactivation of CMV infection, and superinfection with a new strain of CMV virus. The clinical effects of CMV in transplant recipients can be grouped into four categories: (1) clinical infectious disease syndromes by the virus itself; (2) the production of an immunosuppressed state, which exceeds that caused by the immunosuppressive drugs being administered; (3) production of acute and chronic allograft injury, which is different from classic allograft rejection; and (4) a possible role in the development of malignancies. In this study we evaluated the incidence of CMV seropositivity and infection in our renal allograft recipients retrospectively. We also assessed whether steroid pulse treatment was a predisposing factor for CMV seroconversion or reactivation, and evaluated the effect of CMV infection on allograft function.