Serife Savas Bozbas

Pulmonary Hypertension in Patients With End-Stage Renal Disease Undergoing Renal Transplantation

INTRODUCTION Pulmonary hypertension (PHT) has been reported to occur in a considerable proportion of patients with end-stage renal disease (ESRD). It is a progressive condition of the pulmonary circulation that poses prognostic importance. In this study, we sought to investigate the prevalence and the predictors of PHT among ESRD patients undergoing renal transplantation. PATIENTS AND METHODS We retrospectively evaluated the records, clinical and demographic data as well as laboratory results of 500 adult patients who underwent renal transplantation at our institution. A comprehensive Doppler echocardiographic examination was performed in all patients as part of the preoperative assessment. Systolic pulmonary artery pressure (SPAP) was calculated using Bernoulli equation; a value of >30 mm Hg was accepted as PHT. RESULTS The mean age of the study population was 31.6 +/- 10.2 years. The mean duration of dialysis was 40 months; 432 patients (86.4%) were on hemodialysis (HD) and 68 (13.6%) on peritoneal dialysis (PD). PHT was detected in 85 (17%) patients with a mean SPAP of 46.7 +/- 8.7 mm Hg (range = 35-75 mm Hg). The mean age, sex, and laboratory variables were similar between patients with versus without PHT (P > .05 for all). The mean duration of dialysis therapy was longer in the PHT group than those subjects with normal SPAP (50.8 vs 38.5 months; P = .008). Concerning the type of dialysis, the ratio of patients having PHT was higher in the HD compared with the PD group (18.8% vs 5.9%; P = .008). The prevalence of chronic obstructive pulmonary artery disease, asthma, smoking, hypertension, and diabetes mellitus did not differ between patients with versus without PHT (P > .05 for all). CONCLUSION The findings of this study revealed that PHT was a common clinical condition among patients with ESRD evaluated for renal transplantation. The time on renal replacement therapy particularly HD as the treatment was associated with greater prevalences. Since it may be of prognostic importance in patients undergoing renal transplantation, a careful preoperative assessment including a comprehensive Doppler echocardiographic examination is needed to identify PHT.

The Prevalence and the Impact of Portopulmonary Hypertension on Postoperative Course in Patients Undergoing Liver Transplantation

INTRODUCTION Portopulmonary hypertension (PPH) is an uncommon but serious complication of chronic liver disease. It is accepted to be a poor prognostic factor in the follow-up of patients who have undergone orthotopic liver transplantation (OLT). The presence of severe PPH is accepted as a contraindication to OLT. In this study we sought to identify the prevalence and impact of PPH on the outcome of OLT patients. PATIENTS AND METHODS We retrospectively analyzed the records of 114 adult OLT patients operated on at our institution. A complete transthoracic Doppler echocardiographic examination was performed preoperatively and postoperatively. To identify PPH, patients with Doppler echocardiographically measured systolic pulmonary artery pressure (SPAP) values of >or=30 mm Hg were defined as PPH. We noted the etiology of the liver disease, the postoperative mortality rates, and the pulmonary complications among OLT patients with PPH. RESULTS In 24 patients we detected PPH, a prevalence of 21.1% among patients referred for OLT. Their mean age was 44.0 +/- 13.5 years; 18 patients (75.0%) were males. With regard to the Child classification, 16 (66.7%) were in class C. The mean SPAP was 46.6 +/- 7.6 mm Hg. Compared with preoperative values, a significant decrease in mean SPAP was noted postoperatively; 46.6 +/- 7.6 mm Hg vs 37.8 +/- 15.5 mm Hg (P < .05). Concerning postoperative pulmonary complications, pneumonia developed in 7 (29.2%), pleural effusion in 6 (25%), and respiratory failure and right ventricular failure in 1 (4.2%) subject. Compared with patients with a normal SPAP, the postoperative pulmonary complication rate was higher and the length of hospitalization longer among patients with PPH (P < .05). However, no difference was observed in terms of mortality rates (P > .05). CONCLUSION This study indicated that SPAP decreased among patients with PPH following OLT. Although there was an increase in pulmonary complications, we observed no alteration in mortality rates. Therefore, we suggest that PPH may not be regarded as a contraindication for OLT.

Effects of peripheral neuropathy on exercise capacity and quality of life in patients with chronic obstructive pulmonary diseases

Introduction Chronic obstructive pulmonary diseases (COPD) have some systemic effects including systemic inflammation, nutritional abnormalities, skeletal muscle dysfunction, and cardiovascular, skeletal and neurological disorders. Some studies have reported the presence of peripheral neuropathy (PNP) at an incidence of 28-94% in patients with COPD. Our study aimed to identify whether PNP affects exercise performance and quality of life in COPD patients. Material and methods Thirty mild-very severe patients with COPD (male/female = 29/1, mean age = 64 ±10 years) and 14 normal subjects (male/female = 11/5, mean age = 61 ±8 years) were included in the present study. All subjects underwent pulmonary function testing (PFT), cardiopulmonary exercise testing, electroneuromyography and short form 36 (SF-36). Results Peak oxygen uptake (PeakVO2) was lower in COPD patients (1.15 ±0.53 l/min) than healthy subjects (2.02 ±0.46 l/min) (p = 0.0001). There was no PNP in healthy subjects while 16 (53%) of the COPD patients had PNP. Forced expiratory volume in 1 s (FEV1) and PeakVO2 were significantly different between patients with PNP and those without (p = 0.009, p = 0.03 respectively). Quality of life of patients with PNP was lower than that of patients without PNP (p < 0.05). Conclusions The present study demonstrates the exercise limitation in COPD patients with PNP. Thus, presence of PNP has a poor effect on exercise capacity and quality of life in patients with COPD. Furthermore, treatment modalities for PNP can be recommended to these patients in order to improve exercise capacity and quality of life.

Evaluation of liver transplant candidates: A pulmonary perspective.

Chronic liver disease is one of the leading causes of mortality and morbidity in the worldwide adult population. Liver transplant is the gold standard therapy for end-stage liver disease and many patients are on the waiting list for a transplant. A variety of pulmonary disorders are encountered in cirrhotic patients. Pleura, lung parenchyma, and pulmonary vasculature may be affected in these patients. Hypoxemia is relatively common and can be asymptomatic. Hepatopulmonary syndrome should be investigated in hypoxic cirrhotic patients. Gas exchange abnormalities are common and are generally correlated with the severity of liver disease. Both obstructive and restrictive types of airway disease can be present. Abnormal diffusion capacity is the most frequently observed pulmonary function disorder in patients with cirrhosis. Hepatic hydrothorax is another finding which is usually seen in conjunction with, but occasionally without ascites. Portopulmonary hypertension is a complication of long standing liver dysfunction and when severe, is accepted as a containdication to liver transplant. Since respiratory disorders are common and have significant impact on postoperative outcome in patients undergoing liver transplant, a careful preoperative pulmonary assessment is important.

Portopulmonary hypertension in liver transplant candidates.

Pulmonary vascular disorders including portopulmonary hypertension (PoPHT) are among the common complications of liver disease and are prognostically significant. Survival is very low without medical treatment and liver transplantation. With advances in medical therapy for elevated pulmonary artery pressure (PAP) and liver transplant surgery, survival of patients with PoPHT and advanced liver disease is significantly improved. Because of the prognostic significance of PoPHT and the limited donor pool, a comprehensive preoperative cardio-pulmonary assessment is of great importance in cirrhotic patients prior to transplant surgery. Therefore, a detailed transthoracic Doppler echocardiographic examination must be an essential component of this evaluation. Patients with mild PoPHT can safely undergo liver transplant surgery. In cases of moderate to severe PoPHT, right heart catheterization (RHC) should be performed. In patients with moderate to severe PoPHT on RHC (mean PAP 35-45 mmHg), vasodilator therapy should be attempted. Liver transplantation should be encouraged in cases that demonstrate a positive response. Bridging therapy with specific pulmonary arterial hypertension treatment agents should be considered until the transplant surgery and should be continued during the peri- and post-operative periods as needed.

Effect of thyroid function on COPD exacerbation frequency: a preliminary study.

BackgroundFrequent exacerbations of chronic obstructive pulmonary disease (COPD) have negative effects on quality of life and survival. Thus, factors related to exacerbations should be determined. We aimed to evaluate the effects of thyroid function on quality of life and exacerbation frequency in COPD patients.MethodsThe study population (n = 128) was divided into 3 groups (Group 1: COPD patients with hypothyroidism (n = 44); Group 2: COPD patients with normal thyroid function tests (n = 44); Group 3: Healthy subjects (n = 40)). Pulmonary function tests, maximum inspiratory pressure (MIP) and maximum expiratory pressure (MEP) measurements were performed. Quality of life questionnaire (Short Form 36, SF-36) was carried out. Patients were followed up for one year and number of exacerbations was recorded.ResultsFVC, FEV1/FVC, and FEF 25–75% measurements were statistically different between group 1 and 2 (p = 0.041, p = 0.001, p = 0.009 respectively). Although MEP values were significantly different between group 1 and 2 (p = 0.006), there was no significant difference in MIP values between groups (p = 0.77). Quality of life scores in group 1 and 2 were significantly lower than control group. Exacerbation frequency was significantly higher in group 1 than in group 2 (p = 0.017). TSH values and exacerbation frequency had positive correlation (p < 0.0001; r = 0.82).ConclusionsThe results of the present study suggest that thyroid function has an effect in exacerbation frequency of COPD. Decrease in exacerbation numbers with early detection of impairment in thyroid function will have positive contribution on quality of life in COPD patients.

Lack of association of matrix metalloproteinase-9 promoter gene polymorphism in obstructive sleep apnea syndrome

PURPOSE Obstructive sleep apnea syndrome (OSAS) is a public health problem. There is an effort to establish the genetic contributions to the development of OSAS. One is matrix metalloproteinases, extracellular matrix degrading enzymes related to systemic inflammation. However, the impact of matrix metalloproteinase-9 (MMP-9) genotypes on the development of OSAS is unknown. Our aim was to determine whether MMP-9 single nucleotide polymorphism (SNP) (MMP-9 -1562C > T) is related to susceptibility to OSAS. MATERIAL AND METHODS A total of 106 patients with a history of sleep apnea and 88 controls without a history of sleep apnea were enrolled in this study. Genotypes were determined by restriction fragment length polymorphism analyses after polymerase chain reaction. RESULTS Genotypes and allele frequencies of the MMP-9 -1562C > T SNP was not statistically different between the patient and control groups (p > 0.05). There was a statistical association between apnea-hypopnea index (AHI) and body mass index (BMI), and also between AHI and neck circumference (p < 0.001). There was no association among the genotypes and AHI, neck circumference, or BMI (p > 0.05). CONCLUSIONS We found no association between MMP-9 -1562C > T SNP and OSAS. Studies to investigate the role of other polymorphisms and expression of MMP-9 gene will provide more information.

Renal transplant improves pulmonary hypertension in patients with end stage renal disease

BackgroundPulmonary hypertension (PH) is present in a significant proportion of patients with end stage renal disease (ESRD) and is of prognostic importance. Data on the effect of renal transplant on PH is very limited. In this study, the aim was to examine the effect of renal transplant on systolic pulmonary artery pressure (SPAP) determined by Doppler echocardiography.MethodsAnalysis was performed on the records of 500 consecutive patients who underwent renal transplant at our center between the years 1999 to 2008. The prevalence of PH in the preoperative assessment period was established. Patients were diagnosed as having PH when measured SPAP values were > 35 mm Hg.ResultsPulmonary hypertension was detected in 85 of the 500 (17%) patients under pre-transplant evaluation. At post-transplant follow up Doppler echocardiographic examination was performed on 50 of the 85 patients. After exclusion of 8 cases (1 due to massive pulmonary thromboemboli; 7 due to graft failure requiring dialysis therapy) analyses were performed on 42 patients who had undergone both pre- and post-transplant echocardiographic examination. Mean SPAP at pre-transplant evaluation was 45.9 ± 8.8 mm Hg and in 6 (14.3%) cases SPAP was above 50 mm Hg.Compared to pre-transplant values, a significant decrease was observed in mean SPAP values in an average of 53 months of postoperative follow up (41.8 ± 7.4 mm Hg vs. 45.9 ± 8.8 mm Hg, p < 0.0001).ConclusionThese findings indicate that patients with ESRD accompanied by PH may benefit from renal transplant. Further research is required for more concrete conclusions to be drawn on this subject.RiassuntoRazionaleL’ipertensione polmonare (PH) è presente in una quota rilevante di pazienti con grave insufficienza renale ed ha rilevanza prognostica. Dati sugli effetti del trapianto renale sulla PH sono molto limitatı. Scopo di questo studio era valutare gli effetti del trapianto renale sulla pressione arteriosa polmonare sistolica (SPAP) stimata con l’ecocardiografia Doppler.MetodiAnalisi retrospettiva dei dati di 500 pazienti consecutivi sottoposti a trapianto renale presso il nostro centro tra il 1999 ed il 2008. È stata individuata la prevalenza di PH nel periodo di valutazione pre-trapianto, definita come valore di SPAP > 35 mm Hg.RisultatiUna ipertensione polmonare è stata diagnosticata in 85 (17%) dei 500 pazienti sottoposti a valutazione pre-trapianto. Al follow up post-trapianto 50 degli 85 pazienti sono stati sottoposti ad una ecocardiografia Doppler. Dopo avere escluso 8 casi (1 per tromboembolia polmonare massiva, 7 per fallimento del trapianto che ha reso necessario proseguire con la dialisi) l’analisi è stata effettuata sui 42 pazienti di cui erano disponibili i dati pre- e post-trapianto. Il valore medio della SPAP alla valutazione pre-trapianto era 45,9 ± 8,8 mm Hg e in 6 (14,3%) casi la SPAP era oltre 50 mm Hg. Dopo trapianto si è osservata una riduzione significativa dei valori medi di SPAP nei 53 mesi di media del follow up post-trapianto (41,8 ± 7,4 mm Hg vs 45,9 ± 8,8 mm Hg, p < 0,0001).ConclusioniI nostri dati indicano che i pazienti con PH associata a ESRD possono trarre beneficio dal trapianto di rene, ma ulteriori studi saranno necessari per trarre conclusioni più certe su questo tema.

Lung Malignancy in Solid Organ Transplant Recipients: A Case Series

Introduction Transplant recipients are at a higher risk for developing malignancies when compared to general population. These malignancies can be transmitted by a donor organ, can be related to the recipients’ past history of a cancer which relapses or develops de novo as a result of extensive immunosuppressive drug regimens. We aim to characterize the transplant recipients who were diagnosed with a lung malignancy over the past 10 years. Materials and Methods Medical records of solid organ transplant (SOT) recipients from January 2007 to November 2017, who presented with lung malignancies to our clinic were reviewed retrospectively. Results For the last 10 years a total of 6 SOT recipients (5 male and 1 female) with an average age of 58.6 ± 7.4 years were identified to have been diagnosed with a lung malignancy. Within these patients 4 had a liver transplant, 1 had kidney and 1 had a heart transplant history. 3 of the liver recipients had a history of hepatocellular carcinoma (HCC) and 1 patient with cholangiocellular carcinoma before transplantation, whereas the kidney and heart transplant patients had no history of cancer. Half of the patients were smokers. The median time from the transplantation to the diagnosis of lung cancer was measured as 12.5 months. 3 of the liver transplant patients who presented with multiple metastatic lesions in lung were diagnosed with metastatic carcinoma upon pathological examination of transbronchial biopsy and lobectomy material. 1 liver transplant patient who was also a heavy smoker had a diagnosis of squamous cell carcinoma 12 years post-transplant. 2 of the liver transplant patients had also acute rejection diagnosed upon liver biopsy at the same time as cancer detection. The renal transplant patient, also a smoker, had a diagnosis of small cell carcinoma, extended type with liver and bone metastasis, whereas the heart transplant patient was diagnosed with a low grade differentiated neuroendocrine type of cancer. 2 of the patients died. Discussion The incidence of lung cancer is shown to be especially increased in heart and lung transplant patients and related to smoking. However the incidence is also increased following other SOTS. When compared to the general population the increased incidence of lung malignancy was found to be similar to those diagnosed with HIV which reflects the critical role that chronic and prolonged immunosuppression has on lung. In our series 3 metastatic carcinomas of the primary tumor were identified pretransplant, 2 primary lung cancers related to heavy smoking and one case without previous cancer or smoking history were presented. Even though the number is low the variety shows that multiple mechanisms are responsible for increased cancer incidence in transplant patients. Conclusion Transplant patients, regardless of previous malignancy history or risk factors, should all be closely monitored life-long with periodic screening examinations for early malignancy detection.

Coronary flow reserve is impaired in patients with obstructive sleep apnea

Study Objectives: Obstructive sleep apnea (OSA) is common in adult populations. Accumulating data indicate that it is independently associated with a variety of cardiovascular diseases and has prognostic importance in affected cases. In this study, we aimed to evaluate coronary flow reserve (CFR) in patients with OSA and controls. Methods: Sixty-one patients undergoing an overnight polysomnography were enrolled in this study. Patients with an apnea–hypopnea index (AHI) >5 were accepted as OSA group (n = 45) and those with an AHI <5 were taken as controls (n = 16). Using Doppler echocardiography at baseline and following dipyridamole infusion, coronary peak flow velocities were obtained. CFR was calculated as the ratio of peak diastolic flow to baseline diastolic flow. A CFR value <2 was accepted as impaired coronary microvascular function. Results: The mean age was 50.8 ± 10.8 years, of which 16 (26.2%) were female. Both groups had similar features with regard to demographic and clinical variables. The mean value of CFR was significantly lower in patients with OSA compared to those controls (2.24 ± 0.46 vs. 2.74 ± 0.62, respectively, P = 0.001). An abnormal CFR value was observed in 12 (26.7%) patients with OSA and in 1 (6.3%) participant in control group. Conclusions: The findings of this study indicate that CFR, an indicator of coronary microvascular function, is significantly impaired in patients with OSA. Coronary microvascular function, an early sign of atherosclerosis, can be evaluated noninvasively in these patients might be used as a predictor of cardiovascular risk.