Alihan Gurkan

Early and late urological complications corrected surgically following renal transplantation

The purpose of this study was to assess outcomes of urological complications after kidney transplantation operation. Nine‐hundred and sixty‐five patients received a kidney transplant between 2000 and 2006. In total, 58 (6.01%) developed urological complications, including urinary leakage (n = 15, 1.55%), stenosis (n = 29, 3%), vesicoureteral reflux (VUR) (n = 12, 1.2%), calculi (n = 1, 0.1%) and parenchymal fistulae (n = 1, 0.1%). Urinary leakage cases were treated by ureteroneocystostomy (UNS) via a double‐J stent and stenosis cases by UNS. Fenestration was performed in patients developing lymphoceles and unresponsive to percutaneous drainage. VUR treatment was performed by ureteroneocystostomy revision or UNS. Stent usage during ureteric reimplantation was observed to reduce urinary leakage. Surgical complication rates in renal transplantation recipients according to donor type (living versus cadaveric) and the status of stent use (with stent versus without stent) were 5.53% vs. 7.27% (P = 0.064) and 5.24% vs. 20% (P < 0.01) respectively. No recurrence, graft loss or death was seen after these interventions. Comparison of recipients with and without urological complication showed that there was no difference between groups (P > 0.05) with respect to last creatinine level. No graft or patient loss was associated with urological complications. Urological complications that can be surgically corrected should be aggressively treated by experienced surgeons and graft loss avoided.

Comparing two ureter reimplantation techniques in kidney transplant recipients

We compared the incidence of urological and anastomotic complications for the ureteroureterostomy and Lich–Gregoir techniques in kidney transplant recipients. Between May 2003 and February 2004, 75 kidney transplant recipients from living donors were divided into two similar groups to receive ureteroureterostomy (n = 41, 28 male, 13 female) and Lich–Gregoir techniques (n = 34, 24 male, 10 female) for ureteral reimplantation. Patients with vesicoureteral reflux (VUR) to the native kidneys were excluded from the study. The urological complications included complicated hematuria, ureteral stenosis, symptomatic VUR, recurrent urinary tract infection (UTI). There was no statistical significance between two groups in terms of gender, age, end‐stage renal disease etiology, human leucocyte antigen (HLA) mismatch numbers, type and duration of dialysis, and cold ischemia time. The incidence of urologic and anastomotic complications was 12%. Complications in the Lich–Gregoir group included symptomatic VUR in 8.8% and stent migration in 2.9% of cases. Complications observed in the ureteroureterostomy group were ureteral stricture 7.3% and complicated hematuria in 4.9% of cases. However, symptomatic reflux was not observed in the ureteroureterostomy group. UTI frequency was similar in both groups. Ureteroureterostomy can be safely performed as a primary choice in kidney transplant recipients.

Hemophagocytic Syndrome in Kidney Transplant Recipients: Report of Four Cases from a Single Center

Background: The prognosis of hemophagocytic syndrome (HPS) in kidney transplant recipients is reported to be poor, however the optimal therapeutic approach is still unclear. Patients and Methods: The clinical and follow-up data of the 4 patients with HPS (3 male, 1 female; age 39.7 ± 11.3 years) among 368 kidney transplant recipients during a 5-year period were retrospectively analyzed. Results: HPS developed 35–61 days in the post-transplant period. All 4 patients presented with fever. Hepatosplenomegaly and lymphadenopathy were observed only in the first patient. Laboratory tests revealed pancytopenia and hyperferritinemia in all patients, but elevated liver enzymes were observed in 3. Two patients had cytomegalovirus infection, and 1 had Epstein-Barr virus infection. Three patients died despite aggressive supportive therapy, however the fourth case survived after graft nephrectomy. Conclusion: HPS pathogenesis in kidney transplants appears to be related with the graft itself. Graft nephrectomy may be the preferable therapeutic approach for kidney transplant recipients with HPS resistant to standard supportive therapy.

Endovascular Treatment of an Acute Superior Mesenteric Artery Occlusion following Failed Surgical Embolectomy

Purpose: To present the successful primary stenting of a superior mesenteric artery (SMA) occlusion following failed surgical embolectomy. Case Report: A 65-year-old woman with a history of atrial fibrillation underwent surgical embolectomy of an acute embolic occlusion of the superior mesenteric artery (SMA). The following day, symptom recurrence suggested reocclusion, which was confirmed with emergent arteriography. Two balloon-expandable stents were deployed primarily, which ameliorated the patients symptoms. Follow-up angiography at 3 months showed continued SMA patency, with no evidence of distal embolization or restenosis. The patient remains asymptomatic at 9 months after the stent procedure. Conclusions: Although more experience is required, primary stenting may be a valuable alternative in the treatment of acute SMA occlusions, in particular, for reocclusions after failed surgery.

Choice of immunosuppressants and the risk of warts in renal transplant recipients.

Sir, Graft-preserving immunosuppressive therapy is associated with many dermatological complications, as shown in renal transplant recipients (RTR) (1–7). Human papillomavirus (HPV) infection is one of the most frequently occurring infections (1–4, 6–8). The presence of HPV may augment the risk of skin cancer. A wide diversity of HPV types can be detected in biopsies from premalignant lesions and skin cancer of transplant recipients (9–10). It is well known that therapy with cyclosporine and azathioprine leads to an increased risk of developing viral warts (3, 11, 12). However, the risk with the new immunosuppressive agents, such as mycophenolate mofetil, which are designed to provide immunosuppression with fewer side-effects, is unknown.

Gastric collision tumor: Case report of a rare adenocarcinoma and a typical carcinoid tumor

We report a case with features of gastric adenocarcinoma colliding with a typical carcinoid component. A 51-year-old female was admitted to the Department of Internal Medicine with complaints of epigastric pain. On physical examination of the patient there was significant epigastric tenderness and the CA19-9 level was higher than the normal titer value. An upper gastrointestinal endoscopy showed an ulcerated polypoid mass located on the cardiac region of the stomach. Pathological and immunohistochemical findings diagnosed as a collision tumor comprising both adenocarcinoma and carcinoid tumor. Metastasis of adenocarcinoma was found in 7 perigastric lymph nodes, while metastasis of the carcinoid was not detected. The admixture of neoplastic endocrine and nonendocrine cells, have been found infrequently in gastric tumors. The mixed tumors can be further classified into composite tumors that show an admixture of two histological components with histological transitions and collision tumors where the two components are not intermixed In general it is not easy to morphologically distinguish a collision tumor, from composite tumor. Microscopically, hematoxylin and eosin-stained tissue sections from two different areas of the mass revealed two different types of tumor; an intestinal type adenocarcinoma and a carcinoid tumor. We report a case with features of adenocarcinoma colliding with a typical carcinoid component, along with a review of the literature.

Pancreas survival in simultaneous pancreas-kidney and pancreas-after-kidney transplantations: A five-year follow-up report

BACKGROUND Pancreas transplantation methods, such as simultaneous pancreas-kidney (SPK) transplantation and pancreas-after-kidney (PAK) transplantation, have become the most important treatments for patients with type-1 diabetes mellitus (DM)-related end-stage renal diseases (ESRD). The purpose of the study was to compare the clinical results of the pancreas graft in patients after SPK and PAK transplantations and to present the findings of our 5-year follow-up. MATERIAL/METHOD A total of 55 patients who had kidney and pancreas transplantation between February 2003 and December 2010 were included in the study. The patients were divided into 2 groups based on the timing of the pancreas transplantation: SPK (n=21) and PAK (n=34). RESULT The patients in the SPK group consisted of 13 males and 8 females, with a mean age of 33.6±6.8 years; whereas 25 males and 9 females formed the PAK group, with a mean age of 32.0±6.0 years. In the early postoperative period, the SPK group had 3 patients with vascular thrombosis (2 venous, 1 arterial) and the PAK group had 7 patients with thrombosis (4 venous, 3 arterial) (p=0.319). At the end of the 5-year follow-up, the patient, kidney and pancreas survival rates in the SPK group were 95.2%, 95.2%, and 61.9% respectively, and the corresponding values in the PAK group were 97%, 91.2%, 61.8% (p=0.382, p=0.504, p=0.927). CONCLUSIONS We concluded that PAK is just as effective as SPK to prevent the destructive effects of DM when the waiting time for SPK is long and a potential live donor is present.

Endovascular Treatment of a Recipient Celiac Trunk Stenosis after Orthotopic Liver Transplantation

Purpose: To present the successful endovascular treatment of a severe recipient celiac trunk stenosis that led to allograft ischemia following liver transplantation. Case Report: A 56-year-old woman underwent orthotopic liver transplantation because of hepatitis C—induced cirrhosis. After the operation, routine hepatic Doppler ultrasonography showed a tardus parvus flow pattern in the hepatic artery, suggesting an impending hepatic artery thrombosis. Digital subtraction angiography (DSA), however, showed severe stenosis of the recipient celiac trunk and moderate splenic artery steal. The stenosis was dilated and stented in the same session. The postprocedural DSA showed good dilation of the lesion with immediate improvement of hepatic opacification. Follow-up Doppler ultrasound scans showed normal flow patterns in the hepatic artery at 3 and 6 months. Conclusions: In the presence of a tardus parvus flow pattern on Doppler ultrasound after liver transplantation, the possibility of an undetected recipient celiac stenosis should be considered in the differential diagnosis. Such lesions can successfully be treated with angioplasty and stenting.

The Impact of Method on Kidney Graft and Patient Survival in Kidney-Pancreas Transplantations for Type I Diabetes Mellitus

Patients who develop end-stage renal disease (ESRD) associated with Type I Diabetes Mellitus may receive kidney alone (KA) transplantation, simultaneous pancreas-kidney (SPK) transplantation, or a pancreas after kidney (PAK) transplantation. The goal of this study is to examine the long-term impact of pancreas transplantation on kidney graft and patient survival rates. A total of 85 transplantation cases, consisting of 30 that received living donor KA, 21 that received SPK, and 34 that received PAK, from 2003-2010 at Akdeniz University Organ Transplantation Institute were retrospectively screened. There was a graft loss in 4 cases from the KA group, and in 1 case from each of the SPK and PAK groups. The five-year kidney graft survival rates were 86.7% in KA, 95.2% in SPK, and 97.1% in PAK. There was a single patient loss in both KA and SPK. The kidney survival percentages were higher in SPK and PAK groups compared to the KA group. Therefore, SPK should be the primary preference in these patients; however, for the cases that have a living donor, pancreas transplantation should be considered after kidney transplantation, or the patients can be followed-up on with close blood sugar control.

Concurrent unilateral or bilateral native nephrectomy in kidney transplant recipients

BACKGROUND The aim of this study is to present results of patients who have undergone renal transplantation concurrent with bilateral or unilateral native nephrectomy, with a special focus on polycystic kidney disease (PKD). MATERIAL AND METHODS We presented the outcome of renal transplantation patients who have undergone native nephrectomy unilaterally (n=38) and bilaterally (n=125) and compared the results of patients with PKD and other nephrectomy indications. RESULTS Overall graft survival in the 1st, 3rd, and 5th years were 93%, 90%, and 89%, respectively, in transplantation with concomitant nephrectomy patients. Overall patient survival in the 1st, 3rd, and 5th years were 97%, 94%, and 94%, respectively. Overall surgical complications rate was 17.7% and medical complication rate was 19%. Patients with PKD had more frequent complications. CONCLUSIONS Despite additional surgery, the long-term results of patients with complications were not affected negatively by early diagnosis and treatment. We believe that native nephrectomy concurrent with transplantation can be successfully performed when indicated in selected patients at experienced centers.