Bernadett Borda

Treatment of Subclinical Injuries Detected by Protocol Biopsy Improves the Long-Term Kidney Allograft Function: A Single Center Prospective Randomized Clinical Trial

BACKGROUND The long-term benefit of early treatment of subclinical disorders detected in kidney allografts by protocol biopsy is controversial. We collected 145 protocol biopsies from 113 recipients for comparison with 51 control patients in a single-center, prospective, randomized trial. METHODS Ultrasound-guided biopsies were performed in recipients with stable renal function. Samples were taken at 3 (n=66) and/or 12 months (n=79) after transplantation. The biopsies were evaluated according to the Banff scheme, and patients were treated based on the diagnosis. Changes in glomerular filtration rate (GFR) were compared with 51 patients who were randomized as a control group. RESULTS The findings on 38 samples (29%) were considered to be normal. Based on the pathology findings, such as subclinical acute rejection (n=23), calcineurin inhibitor toxicity (n=28), chronic rejection (n=6), and other specific pathologies (n=23), including polyoma virus nephropathy (n=2), induced treatment among 82 recipients (57%). Significantly better graft function was observed at 3-year follow-up among the biopsy group, compared with controls: GFR = 46.0 ± 13.8 vs 35 ± 15 mL/min (P=.002). The 5-year graft survival was significantly higher in the biopsy (81%) than in the control (55.6%) group (P=.0012). CONCLUSION Early detection and treatment of subclinical pathologies improved graft function and long-term survival. Protocol biopsies were a valuable tool for posttransplantation management.

Functional and histopathologic changes in renal transplant patients with new-onset diabetes and dyslipidemia

BACKGROUND The principal risk factors for cardiovascular mortality posttransplantation are hyperglycemia, hypertriglyceridemia, obesity, and smoking. METHODS Among 115 patients, we assessed the risk factors for new-onset diabetes (NODM) and dyslipidemia (NODL), and their effects on the function and histopathologic changes in the allografts at 1 year posttransplantation. RESULTS When evaluating the risk factors and the initial recipient data, we observed a significant difference in age when comparing normal vs NODM patients (P=.004), normal versus NODL patients (P=.002), and normal versus NODL + NODM patients (P=.0001). The difference in body mass index (BMI) was significant when comparing normal with NODM + NODL patients (P=.003). In regard to immunosuppressive therapy, NODM was significantly more frequent among/prescribed tacrolimus (tac; P=.005), whereas subjects who received cyclosporine (CsA) showed a significantly higher incidence of NODL (P=.001). The triglyceride levels were 3.02 ± 1.51 mmol/L among those on CsA versus 2.15 ± 1.57 mmol/L for (P=.004). The difference also proved to be significant for total cholesterol level: 5.43 ± 1.23 mmol/L versus 4.42 ± 1.31 mmol/L respectively (P=.001). In regard to allograft function a significant difference was noted at 1 year after transplantation between the NODM + NODL and the normal group in serum creatinine level (P=.02) as well as the estimated glomerular filtration rate (P=.004). Among diabetic patients, the serum creatinine level measured at posttransplant year 5 was significantly higher than that in 1 year (212.43 vs 147.00 μmol/L; P=.0003). When assessing morphologic changes in the kidney, we observed significantly more frequent interstitial fibrosis/tubular atrophy in all 3 groups compared with normal function patients. CONCLUSION Our clinical study suggested that at 1 year after transplantation allograft function is already impaired in the presence of both medical conditions (NODM and NODL). However, in regard to morphology, a single condition (NODM or NODL) was sufficient to produce histologic changes in the kidney.

Side effects of the calcineurin inhibitor, such as new-onset diabetes after kidney transplantation

New-onset diabetes after transplantation (NODAT) is one of the frequent complications following kidney transplantation. Patients were randomized to receive cyclosporine A- or tacrolimus-based immunosuppression. Fasting and oral glucose tolerance tests were performed, and the patients were assigned to one of the following three groups based on the results: normal, impaired fasting glucose/impaired glucose tolerance (IFG/IGT), or NODAT. NODAT developed in 14% of patients receiving cyclosporine A-based immunosuppression and in 26% of patients taking tacrolimus (p = 0.0002). Albumin levels were similar, but uric acid level (p = 0.002) and the age of the recipient (p = 0.003) were significantly different comparing the diabetic and the normal groups. Evaluation of tissue samples revealed that acute cellular rejection (ACR) and interstitial fibrosis/tubular atrophy (IF/TA) were significantly different in the NODAT group. The pathological effect of new-onset diabetes after kidney transplantation can be detected in the morphology of the renal allograft earlier, before the development of any sign of functional impairment.

Post-transplant diabetes mellitus - risk factors and effects on the function and morphology of the allograft.

The incidence of post-transplant diabetes mellitus and its effects on the kidney allograft function and morphology were assessed. Patients were divided into three groups according to their glucose metabolism. Risk factors for diabetes were first assessed, and then changes in renal function were checked. Morphological changes in the allografts were examined by protocol biopsies. The overall incidence of diabetes was 16%. The development of diabetes was influenced significantly by the body mass index, the body weight and the age of the recipient. The incidence of diabetes was 8.6% in patients on cyclosporine A therapy and 28.8% in those on tacrolimus (p < 0.05). As to the morphology of the kidney, a significantly higher proportion of the biopsies showed severe interstitial fibrosis/tubular atrophy (p = 0.0004) and subclinical acute rejection ( p = 0.001) in the diabetic group compared to the normal one. This clinical study has revealed that the adverse effect of diabetes on the allograft can be detected with protocol biopsy before the manifestation of a functional deterioration.

Treatment decision based on the biological behavior of pulmonary benign metastasizing leiomyoma.

Benign metastasizing leiomyoma (BML) is a rare disease in women undergoing surgery for uterine leiomyoma. About 100 cases have been reported in the literature, none of which describe the biological behavior of lesions. The authors present the case of a 36-year-old, asymptomatic woman who had undergone uterus extirpation seven years earlier for leiomyoma of the uterus. Routine chest radiography revealed multiple nodules in both lungs. Biopsy verified metastases from the original uterine leiomyoma. During a 41-month interval, 87 lesions were removed in seven operations, through mini-thoracotomy [four left-sided (42 lesions); and three right-sided (45 lesions)] by cautery resection and suturing of the parenchyma (n=83), or by wedge resection (n=4). In between the procedures, the patient received continuous oncological treatment (VIP protocol: etoposide, ifosfamide, cisplatin). Mean hospital stay was 5.14 days. Respiratory function tests performed after the last surgery showed near-normal results (FVC: 77%, FEV1: 64%, FEV1/FVC: 0.83). Over time, a decrease in number of newly developed BML nodules was observed. Mean surgical sensitivity [rate of lesions appearing on computerized tomography (CT) and removed during each surgery] of the seven metastasectomies was 95% (range: 40-150%). Pathological examination of the nodules proved that, despite continuous oncological treatment, there were no signs of necrosis, thrombosis, or fibrosis. The number of mitoses within the nodules did not change. According to our surgical results and the fact that oncological treatment did not have a significant effect on the course of the disease, we conclude that in the management of multiple BML lesions, surgically removing as many lesions as possible is advised.

Laparoscopic Splenectomy Is a Safe Method in Cases of Extremely Large Spleens

INTRODUCTION The aim of this study was to assess if there is a relationship between the outcome of laparoscopic splenectomy (LS) procedures and the size of the spleen, the learning curve, or the method of specimen retrieval. PATIENTS AND METHODS Between January 1, 2002 and December 31, 2013, 70 LS procedures were performed at our department. Based on the weight of the removed spleen, patients were divided into three groups: Group 1, <350 g (n=32); Group 2, 350-1000 g (n=15); and Group 3, >1000 g (n=7). The role of the learning curve was also analyzed with the first 20 surgeries considered as the learning period. The specimen was retrieved with morcellation through the lateral port site in 54 cases, whereas in 11 cases, the large spleen was retrieved through a Pfannenstiel incision. RESULTS The mean duration of surgery was 122 minutes. When considered by spleen weight, durations for Groups 1-3 were 117, 128, and 134 minutes, respectively. When considered by the learning curve, durations for learning and later periods were 149 and 111 minutes, respectively (P=.002). After the learning period, larger spleens were removed (208 versus 519 g; P=.02), and there were fewer conversions. The mean postoperative hospital stay was 5.1 days. In the 11 cases where the specimen was retrieved through a Pfannenstiel incision, the mean duration of surgery was 108 minutes, and the mean spleen weight was 1032 g. CONCLUSIONS Our study supports that the proposal that LS is safe and has numerous advantages, even in the case of massive splenomegaly. Our results were mainly affected by the spleen size and the learning curve.

Banff-score-változások a marginális donorokból származó veséknél

Absztrakt Bevezetes: A transzplantacios varolistan szereplő betegek szamanak folyamatos novekedese miatt az idealis donor kriteriumainak kibővitesere van szukseg. Celkitűzes: A szerzők azt a kerdest vizsgaltak, hogy vesetranszplantacio utan egy es ot evvel van-e szignifikans kulonbseg a vesefunkcioban es/vagy -morfologiaban a marginalis es idealis donorbol szarmazo vesevel rendelkező betegek kozott. Modszer: A vizsgalatba 275 beteget vontak be, kozuluk 97 marginalis es 178 „idealis” veserecipiens volt. A marginalis es az „idealis” veserecipiensek koreben vizsgaltak a donoralapadatokat es elemeztek a transzplantacio utan egy es ot evvel a funkcionalis es hisztopatologiai valtozasokat. Eredmenyek: A graft funkciojat vizsgalva a transzplantacio utan egy evvel nem volt kulonbseg a ket betegcsoport kozott, mig az otodik evben a szerumkreatinin szignifikansan magasabb (p = 0,0001) es a glomerularis filtracios rata szignifikansan alacsonyabb volt (p = 0,003) a marginalis veserecipiensek csoportjaban az idealis v...

Diabetes mellitus talaján kialakult osteomyelitis kezelése

The authors summarize the medical history of a patient with impaired healing of a wound in the sole of foot. The 63-year-old male patient had a second-degree burn in the sole of the left foot as he stepped on the hot concrete after taking off his slipper. On admission to our department, local wound management had already been started, his wound showed no healing tendency. Bilateral X-ray was performed of his left leg, osteomyelitis was not confirmed, soft tissue drainage was applied, and bacterial culture from the wound confirmed methicillin-resistant Staphylococcus aureus infection. After soaking the leg in water, phlegmon developed on the dorsal part of the foot and the patient had septic fever. X-ray was repeated, and osteomyelitis was confirmed. Enucleation of the hallux of the left foot and metatarsal resection were performed. Wound dressing was exchanged and wound toilette was applied daily, insulin therapy was modified after consultation with a diabetologist. 7 months after the surgery, the wound was completely healed, carbohydrate metabolism of the patient was controlled. Our case draws attention to the importance of informing the patients of potential complications - in this case of the diabetic foot and its proper care. Treatment of ulcer of the lower leg requires multidisciplinary care, which means that the diabetologist and the surgeon has to cooperate in the care of these patients, carbohydrate metabolism should be balanced and regular wound care is necessary. Orv Hetil. 2018; 159(42): 1727-1730.

Tüdőlebeny-eltávolítást követő kemoterápia tolerabilitását befolyásoló perioperatív tényezők

INTRODUCTION Lung cancer is the leading cause of malignancy-related deaths in Hungary, involving complex surgical and oncological treatment. AIM Factors influencing the tolerability of complete/planned and incomplete postoperative chemotherapy after surgery were analyzed. METHOD During a 6-year period (January 1, 2011-December 31, 2016), data of 72 patients operated with lung cancer (adenocarcinoma and squamous cell carcinoma), receiving complete (4 cycles) and incomplete (<4 cycles) postoperative chemotherapy were analyzed. The following factors among the two groups [complete: n = 53; incomplete: n = 19] were analyzed: gender, mean age, body mass index, Malnutrition Universal Screening Tool, Charlson Comorbidity Index, second malignant tumor, atrial fibrillation, Forced Expiratory Volume 1 sec, Performance Status, open/Video-Assisted Thoracic Surgery (VATS) lobectomy, duration of surgery, postoperative fever, need for transfusion, prolonged air leak, redo surgery, histology, tumor stage. RESULTS The rate of complete postoperative cycles obtained from logistic regression analysis, were substantially higher after VATS lobectomies [n = 26 (83.87%)] compared to open procedures [n = 27 (65.85%)]; (p = 0.092; OR = 0.356), without significance. Multivariate analysis (open/VATS lobectomy, upper/middle-lower lobe resection, diabetes, prolonged air leak, postoperative fever) showed significantly increased successful uptake of complete cycles after VATS (p = 0.0495), while upper/middle lobe resections (p = 0.0678) and the lack of diabetes (p = 0.0971) notably increased the number of complete cycles, without significance. CONCLUSION Twenty-six percent of patients were unable to receive complete planned postoperative chemotherapy. VATS lobectomy patients received significantly higher number of complete cycles of postoperative chemotherapy. Diabetes and lower lobe lobectomies had a negative effect on the tolerability of postoperative chemotherapy. Orv Hetil. 2018; 159(19): 748-755.INTRODUCTION Lung cancer is the leading cause of malignancy-related deaths in Hungary, involving complex surgical and oncological treatment. AIM Factors influencing the tolerability of complete/planned and incomplete postoperative chemotherapy after surgery were analyzed. METHOD During a 6-year period (January 1, 2011-December 31, 2016), data of 72 patients operated with lung cancer (adenocarcinoma and squamous cell carcinoma), receiving complete (4 cycles) and incomplete (<4 cycles) postoperative chemotherapy were analyzed. The following factors among the two groups [complete: n = 53; incomplete: n = 19] were analyzed: gender, mean age, body mass index, Malnutrition Universal Screening Tool, Charlson Comorbidity Index, second malignant tumor, atrial fibrillation, Forced Expiratory Volume 1 sec, Performance Status, open/Video-Assisted Thoracic Surgery (VATS) lobectomy, duration of surgery, postoperative fever, need for transfusion, prolonged air leak, redo surgery, histology, tumor stage. RESULTS The rate of complete postoperative cycles obtained from logistic regression analysis, were substantially higher after VATS lobectomies [n = 26 (83.87%)] compared to open procedures [n = 27 (65.85%)]; (p = 0.092; OR = 0.356), without significance. Multivariate analysis (open/VATS lobectomy, upper/middle-lower lobe resection, diabetes, prolonged air leak, postoperative fever) showed significantly increased successful uptake of complete cycles after VATS (p = 0.0495), while upper/middle lobe resections (p = 0.0678) and the lack of diabetes (p = 0.0971) notably increased the number of complete cycles, without significance. CONCLUSION Twenty-six percent of patients were unable to receive complete planned postoperative chemotherapy. VATS lobectomy patients received significantly higher number of complete cycles of postoperative chemotherapy. Diabetes and lower lobe lobectomies had a negative effect on the tolerability of postoperative chemotherapy. Orv Hetil. 2018; 159(19): 748-755.

Vesetranszplantáció utáni szénhidrátanyagcsere-változások és annak hatásai a cardiovascularis rizikóra

INTRODUCTION Cardiovascular disease is the major cause of deaths after transplantation, with diabetes mellitus being the main risk factor in development. AIM The aim of our study was to assess the prevalence of new onset diabetes mellitus in connection with the cardiovascular risk predicted by the HEART Score. METHOD 44 patients were involved in our study; after overview of baseline data, OGTT was performed, followed by patient classification into the following groups: normal, impaired fasting glucose/impaired glucose tolerance, and new onset diabetes mellitus. Insulin resistance and kidney function were also assessed. RESULTS Concerning baseline data, cold ischemic time (p = 0.016), body weight (p = 0.035), BMI (p = 0.025), and HbA1C (p = 0.0024) proved to be significantly different between normal and diabetic patients. Significant difference was found based on HOMA IR between the two groups 1.69±0.51 vs 6.46±1.42; p = 0.0017). Based on the HEART Score, patients with new onset diabetes mellitus were put into Group 3, which also reflects the risk which diabetes carries for the development of cardiovascular diseases. CONCLUSION Cardiovascular risk can be decreased with increased allograft survival by early diagnosis and management of diabetes. Orv Hetil. 2017; 158(38): 1512-1516.INTRODUCTION Cardiovascular disease is the major cause of deaths after transplantation, with diabetes mellitus being the main risk factor in development. AIM The aim of our study was to assess the prevalence of new onset diabetes mellitus in connection with the cardiovascular risk predicted by the HEART Score. METHOD 44 patients were involved in our study; after overview of baseline data, OGTT was performed, followed by patient classification into the following groups: normal, impaired fasting glucose/impaired glucose tolerance, and new onset diabetes mellitus. Insulin resistance and kidney function were also assessed. RESULTS Concerning baseline data, cold ischemic time (p = 0.016), body weight (p = 0.035), BMI (p = 0.025), and HbA1C (p = 0.0024) proved to be significantly different between normal and diabetic patients. Significant difference was found based on HOMA IR between the two groups 1.69±0.51 vs 6.46±1.42; p = 0.0017). Based on the HEART Score, patients with new onset diabetes mellitus were put into Group 3, which also reflects the risk which diabetes carries for the development of cardiovascular diseases. CONCLUSION Cardiovascular risk can be decreased with increased allograft survival by early diagnosis and management of diabetes. Orv Hetil. 2017; 158(38): 1512-1516.