Iclal Isiklar

OSTEOPOROSIS AFTER RENAL TRANSPLANTATION: SINGLE CENTER EXPERIENCE

Background. Osteoporosis is a major source of morbidity after renal transplantation. The aim of this retrospective study was to determine the independent influences of different parameters on bone mineral density (BMD) in various parts of the body after renal transplantation. Methods. BMD was measured in 130 of 954 renal allograft recipients who underwent surgery between 1985 and 1999. Results. Time since transplantation and cumulative prednisolone doses were significantly higher in patients who had osteoporosis of the lumbar vertebrae (P =0.06 and 0.034, respectively). Logistic regression analysis revealed that cumulative prednisolone dose was the only significant predictor of low vertebral BMD (P =0.02, r=0.33). For the neck of the femur, high blood urea nitrogen and low Mg levels were found to be the predictors of low bone density (P =0.002 and 0.04, respectively). Although parathyroid hormone levels were higher in femoral osteoporosis patients than in those not affected at this site, the difference was not statistically significant (P =0.294). Time since transplantation, cumulative prednisolone dose, and cyclosporine A dose were all found to have a major negative impact on BMD in the radius region (P =0.001, 0.000, 0.001, respectively). Regression analysis showed that cumulative prednisolone dose (P =0.0008, r=0.34), time since transplantation (P =0.005, r=0.27), body mass index (P =0.01, r=−0.21), male gender (P =0.02, r=−0.21), and age (P =0.04, r=0.16) all had major effects on radius BMD. In conclusion, the radius seems to be one of the major parts of the skeleton affected by factors introduced after renal transplantation.

Diffuse Late Gadolinium Enhancement by Cardiovascular Magnetic Resonance Predicts Significant Intraventricular Systolic Dyssynchrony in Patients With Non-Ischemic Dilated Cardiomyopathy

BACKGROUND Left ventricular dyssynchrony and myocardial fibrosis are common findings in patients with nonischemic dilated cardiomyopathy (NDCM). The aim of this study was to investigate the association between myocardial fibrosis and intraventricular systolic dyssynchrony (DYS-sys) in patients with NDCM. METHODS Thirty-nine patients with NDCM and sinus rhythm were enrolled. Intraventricular DYS-sys was evaluated using Doppler tissue imaging, and cardiac fibrosis was assessed with cardiovascular magnetic resonance imaging with a 17-segment cardiac model. Each segment was graded on a 2-point scale (segmental fibrosis score): 0 = absence of late gadolinium enhancement, and 1 = presence of late gadolinium enhancement. A cardiac fibrosis index was calculated as 17/(17 - sum of fibrotic segments). Receiver operating characteristic analysis was performed to determine the utility of the cardiac fibrosis index to predict intraventricular systolic dyssynchrony. RESULTS Patients with DYS-sys had larger left atrial size (P = .004) and left ventricular end-systolic (P = .028) and end-diastolic (P = .034) volumes and lower tricuspid annular Doppler tissue imaging peak systolic velocities (P = .037) compared with patients without DYS-sys. A cardiac fibrosis index > or = 1.4 predicted significant DYS-sys with 92% sensitivity and 60% specificity (area under the receiver operating characteristic curve, 0.703; 95% confidence interval, 0.512-0.893; P = .035). Patients with cardiac fibrosis indexes > or = 1.4 (group 1) had larger left ventricular end-systolic (P = .044) and end-diastolic (P = .034) volumes than those with cardiac fibrosis indexes < 1.4 (group 2). Nine of 11 patients (82%) in group 1 and 6 of 28 patients (21%) in group 2 had significant DYS-sys (Pearsons chi(2) = 12.169, P < .0001). Logistic regression analysis revealed that cardiac fibrosis index > or = 1.4 (odds ratio, 11.2; 95% confidence interval, 1.72-71.4; P = .012) was an independent predictor of DYS-sys. CONCLUSION Patients with NDCM and prominent cardiac fibrosis have significant DYS-sys. The cardiac fibrosis index is a useful tool to predict DYS-sys.

Renal Scintigraphy Findings in Allograft Recipients With Increased Resistance Index on Doppler Sonography

AIM The measurement of intrarenal resistance indices (RIs) by doppler ultrasound plays an important role in the evaluation of renal transplant recipients. Although an elevated RI was initially considered to be specific for rejection, later studies revealed this parameter as a nonspecific marker of transplant dysfunction. In this study, we analysed Tc-99m DTPA renal scintigraphy findings in patients with increased RI during the early posttransplantation period. METHODS This study included 22 patients with increased RI on doppler sonography during the first week after transplantation. Twenty-two recipients with uncomplicated early postoperative courses were used as a control group. An RI value >0.7 was considered pathologic. All patients underwent Tc-99m DTPA renal scintigraphy just after doppler sonography. In addition to visual interpretation of images, renogram curves were evaluated for patterns suggestive of acute tubular necrosis and acute rejection. Glomerular filtration rate (GFR) was calculated using computer software. Perfusion time-activity curves were assessed for the presence of peak and plateau patterns to calculate this ratio (P:PL). RESULTS The mean value for P:PL in patients with increased RI and in the control group were 1.37 +/- 0.33 and 1.53 +/- 0.47, respectively (P < .05). The mean value for GFR was significantly lower in the patient group compared with control subjects. Six patients had normal perfusion and function (27%). Perfusion pattern and renogram changes were suggestive of acute tubular necrosis in 5 patients and acute rejection in 6 patients. These diagnoses were confirmed later with serial scintigraphic changes or biopsy results. Three patients had an accumulation pattern on the renogram suggesting partial obstruction. CONCLUSION During the early posttransplantation period an increased RI on doppler sonography was seen in both normal functioning grafts and those with allograft dysfunction. Renal scintigraphy with perfusion and renogram patterns highly suggestive of specific allograft pathologies seemed to provide useful information to distinguish early postoperative renal allograft pathologies.

Management strategies for patients with nipple discharge

Background and aimsThe aim of this study was to assess management strategies for patients with nipple discharge (ND).Patients and methodsThe records of 13,443 women with breast-related complaints who were examined by the same surgeon between 1 January 1960 and 31 December 2000 were retrospectively assessed. Patients with ND were grouped according to whether they had had a spontaneous or provoked discharge. The parameters investigated in each group were age, physical findings, number of pregnancies, duration of lactation, duration of discharge, colour of discharge, and histopathological features. Chi-square and Mann–Whitney U-tests were used for statistical analysis.ResultsND was the presenting symptom in 603 (4.5%) of the cases. Two hundred and eighty-seven (48%) of the 603 patients showed spontaneous nipple discharge (SND group) and the other 316 (52%) showed provoked nipple discharge (PND group). In the SND group, 124 (43%) tissue specimens were obtained by either biopsy or sub-areolar exploration. Histopathological examination revealed that the most frequent causes of ND in these cases were intraductal papilloma (49 patients; 40%), intraductal carcinoma (35 patients; 28%), and cystic disease (15 patients; 12%). Twenty tissue specimens were obtained from the group with PND. In these cases, the most frequently identified causes of ND were cystic disease (seven patients; 35%), intraductal papilloma (six patients; 30%), ductal ectasia (two patients; 10%), and carcinoma (one patient; 5%). The SND and PND groups differed significantly with respect to age (P=0.001) and duration of ND (P=0.008). The incidence of cancer was higher in the SND specimens than in the PND specimens (28% vs 5%, respectively; P=0.01). The number of pregnancies was significantly higher and the duration of lactation was significantly longer in the SND group (P=0.03 and P=0.02, respectively).ConclusionThe study confirms previous reports that patients with SND have a higher incidence of carcinoma than those with PND. The results suggest that older age, higher number of pregnancies, and longer duration of lactation may predispose to cancer development in patients with SND. The possibility of breast cancer should also be kept in mind when one is assessing patients with PND. Careful physical examination and close follow-up is the optimal management strategy for patients with any type of ND.

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.

FROM DONOR TO RECIPIENT: Doppler US, power US and scintigraphy of kidney perfusion before and after transplantation

Purpose: To follow kidneys from the donor to the recipient by assessing whether perfusion changes occur by using duplex Doppler US, power Doppler US and scintigraphy. Material and Methods: The prospective study included 12 donors and their corresponding 12 recipients. For each donor, both donor kidneys were evaluated by duplex Doppler US, power Doppler US and scintigraphy 1 day before surgery. The same procedure was carried out on the renal allografts at days 1, 3, 5 and months 1 and 3 post-transplantation. Power Doppler findings were classified according to a grading system of 1 to 4. Resistive indices (RIs) were determined based on interlobar and segmental arterial flow. Peak systolic velocity and RIs of the main renal artery were also measured. A perfusion parameter named the peak-to-plateau ratio was calculated. Statistical analysis was performed using the paired-samples t-test. Results: Intrarenal RI elevation and decreased renal artery peak systolic velocity was observed in normally functioning recipient kidneys. Conclusion: Duplex Doppler sonography demonstrated that transplanted kidneys had an increase in intrarenal vascular resistance at 1 month and a decrease in renal artery peak systolic velocity at 3 months post-transplantation. Scintigraphy and power Doppler US did not reveal any statistically significant perfusion change in normally functioning kidneys from donor to recipient.

Sensitivity of Radionuclide Imaging, Doppler, and Gray-Scale Ultrasound to Detect Acute Rejection Episodes, Based on the Pathologic Grade of Acute Rejection

Radionuclide imaging, doppler ultrasound (DUS), and gray-scale ultrasound (US) are well established methods for evaluating both the perfusion and function of newly transplanted kidneys. Acute rejection is generally accepted to be characterized by poor perfusion with decreased uptake and minimal excretion or a deterioration of perfusion and function, as indicated by serial imaging performed at intervals of 2 to 3 days. The aim of this study was to determine the sensitivity of these three imaging modalities to detect acute rejection episodes based on the pathologic grade of Banff classification.

Evaluation of Transplanted Kidneys and Comparison with Healthy Volunteers and Kidney Donors with Diffusion-Weighted Magnetic Resonance Imaging: Initial Experience.

OBJECTIVES The aim of this study was to evaluate the feasibility of diffusion-weighted magnetic resonance, by comparing imaging in renal allograft recipients for functional assessment of kidney transplants versus imaging of these features in healthy volunteers and kidney donors with native kidneys. MATERIALS AND METHODS Seventy renal transplant recipients (group A) with stable graft function at postoperative month 1, 40 healthy volunteers (group B), and 40 kidney donors (group C) underwent diffusion-weighted magnetic resonance imaging. An echo-planar diffusion-weighted imaging sequence was performed in coronal orientation by using 6 b values (0, 200, 400, 600, 800, 1000 s/mm²). The apparent diffusion coefficients were determined for the upper and lower poles of the kidney cortex and medulla. Relations between apparent diffusion coefficients and allograft function, determined by the estimated glomerular filtration rate (comparing rates > 60 mL/min/1.73 m² [group A1] versus < 60 mL/min/1.73 m² [group A2]), were investigated in renal transplant recipients, and apparent diffusion coefficients in groups A, B, and C were compared. RESULTS Apparent diffusion coefficients were statistically higher in group A1 than in group A2 (P < .05) and statistically higher in group A than in groups B and C (P < .001). There were no significant differences between groups B and C (P > .05). CONCLUSIONS We observed that apparent diffusion coefficients of transplanted kidneys at postoperative month 1 were higher than values in native kidneys of healthy volunteers and kidney donors. In addition, apparent diffusion coefficients of transplanted kidneys with estimated glomerular filtration rates > 60 mL/min/1.73 m² were higher than transplanted kidneys with rates < 60 mL/min/1.73 m².

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.