Lajos Zsom

Horseshoe kidney transplantation

Horseshoe kidney is a fusion anomaly found in approximately one in 400-600 people. Due to vascular and ureteral variations, transplantation with a horseshoe kidney presents a technical challenge. In our case, the isthmus connected the upper poles and contained parenchyma. It consisted of three renal arteries, five veins collected to the inferior vena cava, and two ureters and pyelons. It was implanted en bloc to the left side retroperitoneally. During the early period, cellular and humoral rejection was confirmed and treated. For a urine leak, double J catheters were implanted into both ureters. Later, the first catheter was removed. Subsequently, urinary sepsis developed, necessitating graftectomy. The uncommon anatomy of ureters and antibody-mediated rejection (AMR) may both be factors for a ureter tip necrosis led to an infected urinoma. After other Hungarian authors, we also report a horseshoe kidney transplantation that was technically successful. However, after an adequately treated but severe acute humoral rejection, the patient developed sepsis, and the kidney had to be removed. We conclude that transplantation with horseshoe kidney is technically feasible but may increase the risk for urinary complications and resultant infections. Careful consideration of risk and benefit is advised when a transplant professional is faced with this option.

Eredményeink a teljes jogú Eurotransplant-tagság óta. A Debreceni Vesetranszplantációs Központ tapasztalatai

Absztrakt Bevezetes: A Debreceni Egyetemen 1991-ben vegeztek el az első veseatultetest. Hazank 2013-ban csatlakozott az Eurotransplanthoz. Celkitűzes: A szerzők elemeztek a tapasztalatokat. Modszer: 2008. januar 1. es 2013. augusztus 31. kozott (A csoport = 163) es 2013. szeptember 1. es 2015. oktober 22. kozott vegzett cadavervese-atultetesek (B csoport = 90) adatait elemeztek. Eredmenyek: Az elődonorok aranya 3,5%-rol 9,1%-ra nőtt. 2013 ota a recipiensek 25%-a 60 evesnel idősebb, a >30 kg/m2 testtomegindex aranya 31%-ra, a diabetesesek aranya ketszeresere emelkedett. Az ureteroneocystostomia mellett bevezetesre kerult a veg az oldalhoz ureteroureteralis anastomosis. Indukcios kezeles mellett az akut rejectios epizod jelentősen csokkent (34%-rol 8%-ra). A technikai szovődmenyek aranya nem valtozott. A bakterialis fertőzesek aranya csokkent (41%-rol 33%-ra). Az 1, 3 es 5 eves veseallograft-tulelesek 86,6%, 85% es 82,7%, valamint 88%, 84% es 84% voltak a ket csoportban. Kovetkeztetesek: Az extended criteri...

Three-Year Longitudinal Clinical Trial of Arterial Function Assessed by a Oscillometric Non-Invasive Method in Comparison With Carotid Sclerosis and Transferrin Kidney-Transplanted Patients

Chronic kidney disease remains one of the main risk factors of cardiovascular disease. However, patients with kidney transplantation have better life expectancy and better quality of life compared with patients on dialysis. In patients with a well-functioning graft, the main cause of death is cardiovascular in origin. Metabolic pathways have complex effects on arterial function that can be monitored by conventional ultrasonography and with the assessment of arterial stiffness by oscillometric non-invasive technique. Forty-one primer cadaver kidney-transplanted patient were involved in a 3-year longitudinal clinical trial (21 female, 20 male; average age, 40.16 ± 12.56 years). Arterial stiffness parameters referring to rigidity of the arterial wall (pulse wave velocity [PWV], augmentation index, and pulse pressure) were investigated. Correlation between stiffness, and laboratory parameters (serum creatinine, urea, hemoglobin, albumin, cholesterine, triglycerides, transferrin, uric acid, glomerular filtration rate, and C-reactive protein) were analyzed. A non-invasive oscillometric method--Tensiomed Arteriograph--was applied to assess the arterial stiffness parameters. Statistical analysis was performed with the use of Statistica for Windows, version 8.0. A value of P < .05 was considered statistically significant for all statistical tests. We found a positive correlation between PWV and left ventricular wall thickness and a negative correlation between PWV and ejection fraction. We also found a positive significant correlation between serum level of transferrin and PWV. There was simultaneous significant progression concerning PWV and carotid artery sclerosis in a 3-year follow-up. There was no fatal cardiovascular event during the study period among our patients. All of our patients involved in this study are still alive. Our findings suggest that arterial stiffness monitoring is a reliable method to assess global cardiovascular risk among kidney-transplanted patients. The oscillometric method is convenient, fast, painless technique to monitor arterial function, which, in the case of pathological findings, proposes more frequent cardiovascular control.

Cardiovascular Screening and Management Among Kidney Transplant Candidates in Hungary.

INTRODUCTION Cardiovascular disease is a major cause of morbidity and mortality in end-stage renal disease patients on dialysis and the most common cause of death in the immediate post-transplantation period. The aim of our study was to describe a novel approach of cardiovascular screening and management of dialysis patients evaluated for the transplant waiting list. METHODS Twenty-eight patients with end-stage renal disease put on the waiting list between July 2013 and July 2014 were subjected to a prespecified cardiovascular screening protocol utilizing noninvasive and/or invasive tests. Patients were subsequently divided into 3 strata in terms of their estimated cardiovascular risk. Each of these groups were then prescribed interventions aiming to improve their cardiovascular condition. RESULTS According to our prespecified protocol of cardiovascular screening studies, 15 (54%) patients were identified as low, 5 (18%) as intermediate, and 8 (28%) as high risk. Four (14%) patients were current smokers. In the low-risk group, we initiated a patient education program involving counseling on regular exercise such as swimming or cycling to improve their functional capacity. In the high-risk group revascularization was done in 5 cases (63%), including 3 percutaneous transluminal coronary angioplasties (PTCA) with stents for single-vessel disease, and coronary artery bypass graft surgeries (CABG) for triple-vessel disease in 2 cases. In the medium-risk group medical management was opted for, including introduction of beta-blockers, inhibitors, statins, and ezetimibe, as well as efforts to optimize anemia management, indices of bone-mineral disease, and fluid status. CONCLUSION In our regional transplant program, we introduced a comprehensive multidisciplinary approach to treat potential transplant candidates according to cardiovascular risk stratification based on a prespecified screening protocol. Further studies are needed to correlate this novel strategy with post-transplantation outcomes.

Placental gene expression of transforming growth factor beta 1 (TGF-β1) in small for gestational age newborns.

Abstract Objective: The gene expression of transforming growth factor beta-1 (TGF-β1) in human placental samples obtained from pregnancies with small for gestational age fetuses (SGA) was compared to those of normal pregnancies. Methods: In 2011 placental samples from 101 pregnancies with SGA and from 140 normal pregnancies were obtained for analysis of TGF-β1 gene expression. Several clinical parameters were also assessed for correlation between genetic and clinical parameters. Results: There were no significant differences in gene activity of the TGF-β1 gene between the SGA versus normal pregnancy groups (Ln2α: 0.16; p = 0.07). Within the SGA group, no fetal gender-dependent differences were seen in TGF-β1 gene expression (Ln2α: −0.11; p = 0.05). Similarly, no significant differences in gene activity were observed by the degree of severity of SGA as assessed by percentile fetal birth-weight (Ln2α: 0.32; p = 0.06). Conclusion: We found no change in gene expression of TGF-β1 in placental samples obtained from SGA pregnancies versus normal pregnancy suggesting an absence of a direct role of the TGF-β1 gene in the development of SGA. However, the absence of increased gene expression of TGF-β1 in SGA can be conceptualized as a failure to mount a compensatory response in the SGA environment.

Pregnancy management of women with kidney transplantation.

Women with renal disease, besides many dysfunctions, face increasing infertility and high-risk pregnancy due to uremia and changes of the hormonal functions. After renal transplantation, sexual dysfunction improves, providing the possibility of successful pregnancy for women of childbearing age. However, kidney transplanted patients are high-risk pregnant patients with increased maternal and fetal risks, and the graft also may be compromised during pregnancy; most studies report on several successive deliveries due to multidisciplinary team management. In clinical practice, the graft is rarely affected during the period of gestation. Fetal development disorders are also rare although preterm delivery and intrauterine growth retardation are common. For now, several studies and clinical investigations proved that, under multidisciplinary control, kidney transplanted female patients are also possible to have safe pregnancy and successful delivery. There are conflicting data in the literature about the prevention of complications and the timing of pregnancy. Herein, we would like to present some experience of our centre. A total of 847 kidney transplantations have been performed between June 1993 and December 2013 with 163 childbearing aged females (18-45 years) in our center. We report on three kidney transplanted patients who have given birth to healthy newborns. In our practice, severe complications have not been observed.

Donorszelekciós kritériumok vizsgálata a debreceni veseátültetési programban

Absztrakt Bevezetes: A donorszervhiany, a donorok eletkoranak novekedese es a tarsbetegsegek gyakoribba valasa arra osztonzi a transzplantalokozpontokat, hogy olyan donorvesek elfogadasat is merlegeljek, amelyeket korabban elutasitottak volna. A donorszelekcios kriteriumok segithetnek ennek eldonteseben. Celkitűzes: A kulonboző kriteriumok hasznossagat illetően nincs egyseges allaspont, ezert a szerzők megvizsgaltak az expanded criteria donor, a deceased donor score es a kidney donor risk index donorszelekcios kriteriumok hatasat a posztoperativ vesefunkciora es grafttulelesre. Modszer: Oteves intervallumban 205 donor parametereinek es 138 veseatultetes kimenetelenek retrospektiv elemzeset vegeztek el. Eredmenyek: Az expanded criteria donor rendszer szerint optimalisnak velemenyezett donorok negyede a magas kockazatu csoportba kerult a deceased donor score alapjan. A magas kockazatu csoportokban rosszabb volt a műtet utani graftfunkcio. A deceased donor score segitsegevel tovabb lehetett bontani a magas k...

Chlamydia pneumoniae okozta infektív endocarditis májtranszplantációt követően

Absztrakt Az infektiv endocarditis a szervtranszplantalt betegek koreben aluldiagnosztizalt korkep. A korokozok spektruma kulonbozik az atlagpopulaciot erintőtől. A szerzők az 58 eves nőbetegben atipusos korokozo altal okozott, atipusos megjelenesű infektiv endocarditis eredmenyes kezeleseről szamolnak be. A betegnel alkoholos majcirrhosis talajan kialakult majelegtelenseg miatt 2000. februarban majatultetest vegeztek. Egy evvel a majatultetest kovetően kronikus hepatitis B-virus-fertőzest allapitottak meg, es a beteg antiviralis kezelesben reszesult. Kalcineurintoxicitas miatt veseelegtelenseg alakult ki, ezt kovetően a beteg 2007 juliusaban vesepotlo kezelesre szorult. 2013 novembereben rovid ideig tarto afazia jelentkezett. A transoesophagealis echokardiografia az aortabillentyűn vegetaciot talalt, a magneses rezonancias vizsgalat agyi embolisatiot mutatott ki. A laboratoriumi vizsgalatok enyhen emelkedett C-reaktiv protein- es normalis prokalcitoninszinteket igazoltak, verkepeben leukopenia volt latha...The incidence of infective endocarditis is underestimated in solid organ transplant recipients. The spectrum of pathogens is different from the general population. The authors report the successful treatment of a 58-year-old woman with infective endocarditis caused by atypical microorganism and presented with atypical manifestations. Past history of the patient included alcoholic liver cirrhosis and cadaver liver transplantation in February 2000. One year after liver transplantation hepatitis B virus infection was diagnosed and treated with antiviral agents. In July 2007 hemodialysis was started due to progressive chronic kidney disease caused by calcineurin toxicity. In November 2013 the patient presented with transient aphasia. Transesophageal echocardiography revealed vegetation in the aortic valve and brain embolization was identified on magnetic resonance images. Initial treatment consisted of a 4-week regimen with ceftriaxone (2 g daily) and gentamycin (60 mg after hemodialysis). Blood cultures were all negative while serology revealed high titre of antibodies against Chlamydia pneumoniae. Moxifloxacin was added as an anti-chlamydial agent, but neurologic symptoms returned. After coronarography, valvular surgery and coronary artery bypass surgery were performed which resulted in full clinical recovery of the patient.

On Poor Agreement Between Dialysis Unit and Ambulatory Blood Pressures

To the Editor: With regard to blood pressure (BP) during dialysis and those obtained during ambulatory BP monitoring (ABPM), we read the paper from Liu and colleagues with interest. BP monitoring is performed, primarily, for safety purposes during dialysis. In doing so, the BP readings obtained during dialysis are more of an incidental by-product of technology and are not intended to guide BP control off dialysis. Wide limits of agreement and heterogeneity between studies limit generalizability of conclusions among these patients. In particular, the escalating disagreement with increasing stages of hypertension is a particular concern in the study by Liu and colleagues. All too often, farreaching conclusions are made about BP control for the rest of the week based on these readings. Indeed, if anything, the casual practice of attempting to control BPs with ultrafiltration is clearly superior to changing medications based on predialysis and postdialysis BP. It is unfortunate that nephrologists in current North American practice are rarely present on site during outpatient renal dialysis, unlike their European or Japanese counterparts. The relative lack of “presence” of a nephrologist, along with limited reimbursement and scarcity of trained nursing staff may have contributed to the slow implementation of ABPM among dialysis patients in North America, despite its proven efficacy and excellent acceptance of the procedure. One interesting but perhaps less well-studied aspect of dialysis-derived BP readings is the relative correlation of predialysis or postdialysis values, independent of each other, with results obtained by ABPM. In a smaller cohort of patients recruited from the University of Mississippi Medical Center, we observed that when both predialysis and postdialysis systolic BP measurements were entered as explanatory variables in a linear regression model, only the postdialysis systolic BP (P<.001) but not predialysis systolic BP (P=.276) retained a significant independent association with ABPM systolic BP. On the other hand, for diastolic BPs, both predialysis (P=.001) and postdialysis (P=.037) values maintained a statistically significant correlation with diastolic BP with ABPM. In this cohort of Chinese patients, we wonder whether the authors similarly observed an independent association between predialysis and postdialysis BP measurements with ABPM values.