Ebru H. Ayvazoglu Soy

Spontaneous spleen rupture and rectus sheath hematoma in a patient with Klippel-Trenaunay syndrome: Report of a case

We report a case of Klippel-Trenaunay syndrome (KTS) with serious morbidity caused by the rupture of hemangiomas of the spleen and inferior epigastric artery (IEA). A 40-year-old woman, who had suffered from edema and varicose veins in her left leg and toes since birth, underwent emergency laparotomy and splenectomy for a spontaneous splenic rupture. Pathological examination revealed hemangiomatosis of the spleen. She presented again 40 days later with a rectus muscle hematoma, which computed tomography revealed to be actively bleeding. Arteriography confirmed a bleeding IEA, which was then embolized. Hematological investigation revealed a heterozygous form of factor VIII and fibrinogen deficiency. The patient recovered well and was asymptomatic at her 1-year follow-up. We report this case to reinforce that investigations for KTS should involve all organ systems, and include detailed hematologic tests. By defining coagulation and vascular abnormalities, life-threatening bleeding episodes may be prevented.

Mucoepidermoid Carcinoma of the Breast

3 large-cell neuroendocrine tumor. Four of 11 nodes were involved; vascular invasion was present and the posterior resection margin was close to the edge of the tumor although it was completely excised. Immunohistochemistry showed the tumor to be estrogen and progestogen receptor positive, but HER2 negative with a Nottingham Prognostic Index of 6.24. At postoperative clinical review, the patient was offered chemotherapy (carboplatin and etoposide), these being the first line treatment for neuroendocrine tumors whether of the breast or elsewhere.

Significance of Antibody-Mediated Vascular Rejection (AMVR) on Graft Survival: Correlation with Pure Antibody-Mediated Rejection (AMR)

Introduction Traditionally, endarteritis accepted to associate with cellular rejection. Nevertheless, some of the patients with AMR also had endarteritis at the same time. The risk of graft loss was nine times higher in AMVR than T cell-mediated rejection without endarteritis. However, the importance of the endarteritis on the graft survival in recipients with AMR is controversial. Thus we aimed to understand the prognostic value of the presence of endarteritis in recipients with AMR. Materials and Methods Among 155 recipients 72 (46,5%)had pure AMR (Group 1) while 83 (53,5%) had both AMR and endarteritis (Group 2). Endarteritis graded according to Banff. First indication biopsies of all cases reevaluated and the intensity of interstitial, glomerular and peritubular capillary (PTC) inflammation, neutrophil, macrophage and lymphocyte infiltration graded. HLA-DR expression in the arteries, PTCs, and tubules examined. The loss of DR expression on PTCs accepted as the destruction of PTCs. Follow-up biopsies analyzed for the development of interstitial fibrosis (IF), transplant glomerulopathy (TG) and transplant arteriopathy (TA). Results The extensity of the PTC and arterial C4d expression and the degree of PTC destruction found higher in Group 2 compared to Group 1 (P<.001).The degree of the interstitial eosinophil, plasma, and macrophage infiltration found higher in Group 2 patients than Group 1 (p<.001). Also, the intensity of inflammatory cells and neutrophils in both glomeruli and PTCs found higher in Group 2 compared to Group 1 (p<.001). Compared to Group 1 patients, Group 2 patients showed a higher incidence of IF, TG and TA in follow-up biopsies (p<.01).The development of IF and TG increases with the increasing degree of glomerulitis, PTC-itis, C4d expression and PTC destruction (p<.01). Also, the time of the development of IF and TG decreased with increasing intensity of PTC and interstitial infiltration, glomerulitis, PTC destruction and C4d expression (p<.01). The presence of the eosinophil and macrophage infiltration on the wall of arteries of recipients with AMVR rises the risk of the development of TG and TA (p<.01). Also, patients who had arterial C4d staining had a higher risk of TG, TA and graft loss (p<.001). The response to rejection therapy was lower in Group 2 recipients compared to Group 1 patients (p<.001). Overall the 3- and 5-year graft survival was 98%, and 85% respectively for Group 1 patients while it was 57%, and 27% respectively for Group 2 (p<.001). Conclusion Our results have underlined the importance of the presence of endarteritis in AMR. We showed that the course of AMVR are noticeably different from pure AMR, with AMVR having the worst outcome through leading the early development of IF, TG, and TA via augmenting inflammatory and fibrotic pathways. Thus the development of new treatment strategies for AMVR could salvage many kidney allografts.

Candidaemia among Adult Solid Organ Transplant Recipients

Introduction To evaluate the local epidemiology, Candida species distribution and compare the distribution, demographic, clinical characteristics and outcome of candidaemia episodes in between Candida albicans and non-albicans Candida (NAC) candidaemia episodes among adult solid organ transplantation (SOT) recipients. Materials and Methods The medical records for each adult SOT recipient from January 2007 to August 2014 were evaluated. Candidaemia was defined as at least one blood culture positive for a Candida species in patients with clinically apparent signs and symptoms of infection. The interval betweeen two seperate candidaemia episodes was accepted as thirty days. Results There were 183 candidaemia episodes among 179 adult patients with female predominance (67%) throughout all adult inpatients within the study period. Of these, 10 SOT recipients with female predominance (n=7) developed 11 candidaemia episodes: 6 episodes in 5 liver recipients, 4 episodes in 4 kidney recipients and 1 episode in 1 heart transplant recipient. The median age of SOT recipients at the time of candidaemia was 58 years (IQR: 26 y). Preinfection hospital stay and length of hospital stay did not differ statistically among C. albicans and non-albicans candidaemia groups. The source of candidaemia among SOT recipients was intraabdominal (6/11, 56%) predominantly occurring among liver recipients (67%). Although both the presence of central venous catheter (CVC) (91%) and total parenteral nutrition (82%) in the previous month before candidaemia were more commonly seen, CVC was the least source of candidaemia among SOT recipients. All transplant recipients with candidaemia had a history of antimicrobial therapy within the last month. Antifungal usage history was not statistically significantly associated with any of the Candida species (one of each: C. albicans, C. glabrata, C. lusitaniae, C. krusei). Concomitant bacterial bloodstream infections was detected in 46% of the candidaemia episodes. Crude mortality within first month after candidaemia was 46%. Discussion The well known risk factors for infection due to Candida species are rejection episode, renal insufficiency, hepatic insufficiency, malnutrition, wide-spectrum antimicrobial use, abdominal surgery, total parenteral nutrition. The epidemiology of candidaemia changes geographically even among various centers in the same country. National TRANSNET surveillance study revealed that bloodstream was the most common infection site in invasive candidiasis among SOT recipients from 2001-2006. Conclusion Candidaemia is a fatal medical emergency among all inpatients including SOT recipients. Continuous local and national surveillance will preserve its pivotal importance in therapeutic guidance of candidameia for all patient groups.

Posttransplant Malignancies in Adult Renal and Hepatic Transplant Patients

Introduction The risk of some types of cancer increases after organ transplantation compared to general population and it is well documented in clinical studies. As a result of prolongation of survival and higher number of procedures cancer is a rising health concern in high volume transplantation centers. The occurrence of malignancy has an important impact on short- and long-term graft and patient survival. In this study we evaluate the cancer frequencies in transplant patient’s follow up. Materials and Methods Single center data of patients those were underwent solid organ transplatation in Baskent University Medical Faculty Hospital from 1997 to 2017 were retrospectively evaluated. Renal and hepatic transplant patients older than 16 years at the time of transplantation and diagnosed with cancer after transplantation were included the study. In total, 1176 of 2018 renal and 274 of 548 hepatic transplant patients were eligible for the analysis due to age. Results Fifty-three (4.5%) of 1176 renal and 9 (3.3%) of 274 hepatic transplant patients developed post transplant cancer during follow-up. Of the total 62 cancer patients, there were 46 males (74.1%) and 16 females (25.9%), with a median age at transplantation of 42.5 years. Overall, the incidence of cancer in transplant recipients was 4.2%. The most frequent cancers was basal and squamous skin cancers seen in 18 patients (29%) and Kaposi’s sarcoma seen in 11 patients (18%). 47 of 62 (%75.8) patients were still alive at the time of the study. Conclusion Although there are recent developments in the use of immunosuppressive drugs, posttransplant malignancy is still a health problem. Fortunately most seen cancers have good prognosis and can be cured by surgical resections. Transplant physicians must pay attention to early detection of these diseases. Table. No title available.

The Role of Smoking on Early Postoperative Pulmonary Complications in Renal Transplantation Patients

Introduction Smoking cessation prior to surgery is associated with lower rates of postoperative pulmonary complications (POPCs). Our study was performed to research the role of smoking on POPCs in renal transplantation patients. Materials and Methods Data from 1840 patients who performed renal transplantation between 1987 and 2015 at Baskent University were analyzed retrospectively. The patients with smoking data were included in the study. Patient’s demographic, smoking status, comorbid diseases, postoperative early pulmonary complications recorded. The relation between postoperative pulmonary complications and risk factors were investigated. Results A total of 141 (39 women and 102 men; mean age 39.22 ± 12.91 years) adult renal transplant recipients included in the study. The incidence of early POPCs was 17% (n = 24). The most POPCs were atelectasis (n=12), pleural effusion (n=6), pneumonia (n=3), respiratory failure (n=3), respectively. Pulmonary embolism was occurred in 1 patient as a major complication. Smoking history was found in 60 of the patients (60/141 and 42.5%). Thirty-two of the patients were ex-smokers and 28 were current smoker at the time of transplantation surgery. There was a statistically significant relationship between the presence of atelectasis and smoking history (p=.004). A positive and statistically significant correlation was detected between atelectasis and pack years smoking (r=0.434 and p=0). Conclusion Smoker renal transplantation patients have an increased risk for early postoperative pulmonary complications. Smoking cessation prior to surgery can reduce the risk of early postoperative complications.

Orthotopic Renal Transplantation With Spleno-Renal Shunt

Introduction Renal transplantation usually is performed via transperitoneal approach and the graft is placed in iliac fossa. When iliac vessels are not appropriate for anastomosis, graft position can be changed. Here we report a Buerger disease patient who had successful orthotopic renal transplantation through native renal artery and splenic vein. Case Report The case is a 68 years old male patient with chronic renal failure due to Buerger disease. He suffered from Buerger disease for 30 years and he had aorta-bifemoral bypass. Preoperative evaluation revealed that both iliac arteries (external and internal iliac) were obliterated in both sites. Besides, right native renal artery was also thrombosed. So, we decided to perform orthotopic renal transplantation from a related living donor. In the same session we performed native nephrectomy and orthotopic renal transplantation. The artery of the graft was anastomosed to native renal artery through PTFE graft. In the first attempt the vein of the graft was anastomosed to renal vein but venous outflow was inadequate. So venous anastomosis is displaced to splenic vein and spleno-renal anastomosis was done through PTFE graft. At the 10th day of operation he was discharged from hospital with normal creatine value (0.6 mg/dL). Conclusion In cases with lack of vascular access for renal transplantation splenic vein can be safely used for venous outflow of the graft.

The Effects of Graft Weight on Allograft Outcomes in Pediatric Patients

Introduction Renal mass plays an important role for a balanced graft function after transplantation. Our aim is to evaluate the relation between transplanted renal mass and long term graft outcomes in pediatric renal transplant recipients. Materials and Methods Forty six children (M/F: 26/20) with kidney transplant from living related donor were enrolled to the study. Demographic data and laboratory findings were noted. The estimated glomerular filtration rate (eGFR) was calculated by Schwartz Formula. Grafts (Gw) and recipients (Rw) were weighed before transplantation. Patients were divided into three groups according to the Gw/Rw ratios (Gw/Rw<3.9 (P25), Gw/Rw=3.9-9.3 (P25-P75), Gw/Rw>9.3 (P75)). Relation between Gw/Rw ration and allograft outcomes was evaluated. Results Mean age at the time of the transplantation was 14.09±4.71 years. Mean age of donors (M/F:20/26) was 37.97±0.94 years. Mean follow-up time after transplantation was 3.87±1.08 years. Mean weight of recipients was 35.04±2.57 kg, mean weight of donors was 77.06±1.72 kg. Mean Gw/Rw ratio was 6.63±3.69. Delayed graft function was not observed. At 3rd years of follow-up, mean creatinine level was 0.89±0.26 mg/dl and mean GFR value was 97.07±16.86 ml/min. A statistically significant negative correlation was demonstrated between Gw/Rw ratio and creatinine levels at 3rd and 6th months and 1st and 3rd years of follow-up (r=-7.00, p<0.01, r=-7.28 p<0.01, r=-4.70 p<0.01, r=-5.86 p<0.05). Patients with Gw/Rw>9.3 had lowest mean creatinine levels during the first 6 months of transplantation when compared with patients with Gw/Rw ratio<3.9; but this difference between creatinine levels could not be demonstrated after 6th month of transplantation. Gw/Rw ratio was not associated with acute rejection episode and HLA mismatch. Gw/Rw ratio was not an independent risk factor for graft survival at 3rd year of follow-up in a multivariate logistic regression analysis. Conclusion We demonstrated a significant relation between renal mass and creatinine levels after transplantation. Pediatric renal transplantation from an adult donor is mostly results with higher Gw/Rw ratio. Higher Gw/Rw ratio can cause hyperfiltration during the first 6 months of transplantation, but it has no effect on long term outcomes.

Endovascular Management of Arterial Complications Following Renal Transplant Biopsy

Introduction Percutaneous biopsy remains the gold standard for evaluating the pathologic conditions of the renal transplant. Although reports indicate significantly decreased complication rates with the use of real time ultrasound guidance and the 18-Gauge automated needle, bleeding, arteriovenous fistula, and pseudoaneurysm formation are still clinically important complications requiring adequate treatment. The purpose of this study was to evaluate the effectiveness of endovascular therapy in the management of arterial complications following renal transplant biopsy. Materials and Methods Renal transplant biopsies performed in the interventional radiology unit between January 2000 and September 2017 were retrospectively reviewed. Patients who underwent endovascular intervention following biopsy were evaluated for indications, techniques used and outcomes of the intervention. Results Twelve endovascular interventions were performed in 6 male and 5 female patients, aged between 8 and 62 years (mean=40.5 y). Indications for endovascular intervention were arterial perirenal bleeding secondary to percutaneous biopsy in 5 patients, arteriovenous fistula in 5 patients and persistent hematuria in 1 patient. Technical success was achieved in all procedures (100%). Clinical success was achieved in 9 patients with a single intervention (81.8%) and in 1 patient with 2 interventions (9.1%). Four of the 5 patients with active bleeding and 1 patient with persistent hematuria were treated with a single intervention combining coil and N-butyl 2-Cyanoacrylate (NBCA) embolization techniques. Bleeding persisted after gelfoam embolization and a second intervention using coils and NBCA was necessary to control the perirenal bleeding in one patient. After embolization procedures, one patient underwent graft nephrectomy 1 day after endovascular embolization (Clinical failure rate, 9.1%). All patients with an arteriovenous fistula were successfully treated with a single intervention using the coil embolization technique. No complications related to angiography or embolization procedure occurred. Conclusions Hemorrhage is the predominant complication related to renal transplant biopsy. Arterial injury may also result in arteriovenous fistulae or a pseudoaneurysm formation which are rarely symptomatic. Endovascular management of these complications is effective and safe.

Comparison of Recipients with Early and Later Presentation Polyomavirus Nephropathy (PVN) with Regard to Histological Findings and Graft Survival: What is the Influence of CD4/CD8 Ration on the Presenting Time of PVN

Introduction PVN is a common complication occurring around 12 months after transplant (Tx). Although unusual, the number of patients with late-presenting PVN is too much to underestimate. Thus, we aimed to understand if there are any differences between early and late-presenting PVN with regard to histological findings and graft survival. Materials and Methods All indication and follow-up biopsies of 71 patients with PVN re-evaluated and examined for the development of interstitial fibrosis (IF). Interstitial plasma cells, neutrophils, and CD3, CD4, CD8, HLA-DR positive cells, and macrophages graded. Patients separated into four groups in regards to the time of the development of PVN after Tx [Group A: <12 months (n:35), Group B: 12-24 months (n:13), Group C: 24-48 months (n:15), Group D: >48 months (n:8)]. Also, recipients correlated in two groups as Group 1 (n:48) early PVN (⩽12 months) and Group 2 (n: 23) late PVN (>12 months). Results The mean interval between the diagnosis of PVN and Tx was 17±22 months. Group 1 had higher mean hemodialysis (HD) time before Tx than Group 2 (p<.05). At the same time with PVN, CMV viremia was found in 27 patients. The mean viral load in urine and plasma at diagnosis was found higher in Group 1 than those Group 2 (p<0,01). Group 1 showed lower stages and higher degrees of polyoma viral load (Pvl) in biopsy compared to Group 2 (p<.05). Viral load in urine, plasma, and biopsy found to increase from Group A to Group D. Compared to Group 2; Group 1 showed higher degrees of interstitial neutrophil, plasma, macrophage, lymphocyte, DR-positive cell infiltration and lower degrees of the CD4/CD8 ratio (p<.01). All inflammatory cell types in interstitium found to increase from Group A to Group D. Interstitial CD4/CD8 ratio showed a significant negative correlation with Pvl (r=-0.320, p=.01), viremia (r=-0.602, p<.001) and viruria (r=-0.748, p<.001). Total 43 patients (60.6%) developed IF during follow-up, and 31 (43.7%) cases lost their graft at a mean time of 18±14 months after PVN. The risk of the development of IF increases from Group A to Group D (p<.01). Compared to Group 2 (28.7±16 months), the mean time of the graft loss after PVN was significantly early in Group 1 (13.3±9 months). The mean time of graft loss also decreases from group A to D (p<.05). Positive correlation found between the graft loss and CD4/CD8 ratio (r=0.391, p<.05). Conclusion This study pointed out that late-onset PVN is not uncommon. Recipients with late-onset PVN had a better prognosis than early-onset cases. Although the cause of late-onset PVN remains unclear, it is possible that host cells could influence the time of the onset of PVN. We showed that lower CD4 and higher CD8 proportions were risk factors for early-onset of PVN and poor graft survival. Contrarily patients who had high CD4/CD8 ratio developed late-onset PVN and better graft survival.