Sule Akcay

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.

Pleural effusion following ventriculo-pleural shunt: Case reports and review of the literature

Ventriculo-pleural shunt (VPLS) is an acceptable alternative in the management of hydrocephalus. Imbalance between the production and absorption of cerebrospinal fluid an lead to formation of pleural effusion in patient with VPLS and on occasion produce symptoms. Pleural effusion could be a transudate or a non-specific exudate. We report our experience with this modality in relation to formation of pleural effusion and review the literature to make recommendation for its management. Information related to patients’ demographics, smoking history, prior pulmonary and occupational history, indication, duration and complications of the VPLS and their management was gathered to substantiate current recommendation with our experience.

Pulmonary complications in renal recipients after transplantation.

BACKGROUND Renal transplantation is the most common type of solid organ transplantation. Recipients are susceptible to a variety of pulmonary complications, in particular during intense immunosuppression therapy. OBJECTIVE To evaluate pulmonary complications during the first year after renal transplantation. MATERIALS AND METHODS Medical records were reviewed retrospectively for all patients who underwent renal transplantation between 2007 and 2010. Data pertinent to pulmonary complications were obtained including patient demographics, findings at chest radiography and pulmonary function testing, concentrations of C-reactive protein and albumin, and white blood cell count. RESULTS The study included 136 patients (71.3% men), with mean (SD) age of 36.3 (12.2) years. The most frequently prescribed immunosuppression therapy included prednisolone plus cyclosporine, tacrolimus, or rapamycin. Fifteen patients developed complications during the first year after surgery including respiratory infections in 12 (80%), namely, bacterial pneumonia in 10 (66.6%), and tuberculosis (caused by Mycobacterium tuberculosis) in 2 (33.3%). Pneumonia developed within the first 5 months after transplantation in 6 patients, and tuberculosis after the third month. Microbiologic agents were detected in 3 of the 6 patients (20%), and empyema, postoperative atelectasis, and pulmonary embolism, respectively, in the other 3 patients. No association was observed between complications and baseline pulmonary function test results. C-reactive protein concentration was significantly increased in patients with pulmonary complications. No invasive procedures were performed to diagnose complications, all of which resolved with appropriate treatment. CONCLUSION Pulmonary infections are a primary complication in renal transplant recipients, and are observed most frequently in the first 6 months after surgery. Immunosuppression therapy is the most likely cause of these complications, and rigorous monitoring of drug concentrations is essential. An invasive diagnostic approach may not always be necessary to determine the early specific therapy.

BRONCHIECTASIS-RELATED AMYLOIDOSIS AS A CAUSE OF CHRONIC RENAL FAILURE

Bronchiectasis is defined as acquired and permanent abnormal dilation and destruction of the bronchial walls. Secondary amyloidosis is a disorder characterized by the deposition of amyloid A (AA) in multiple organs and tissues in the body. End-stage renal disease (ESRD) secondary to bronchiectasis-related amyloidosis has only been mentioned in case reports. Little is known about the complications of bronchiectasis-related amyloidosis and the outcomes in patients who develop ESRD due to amyloid deposition in the kidneys. The aim of this study was to identify the clinical characteristics of this patient group, and to report the outcomes of these cases relative to bronchiechtasis type. We assessed the records of 40 patients with AA-type amyloid nephropathy and ESRD who were on hemodialysis (HD) at Baskent University Hospital between 1997 and 2000. The diagnosis of amyloidosis was based on histopathological findings in kidney, rectum, bone marrow, lymph node, thyroid, bladder, liver, and stomach biopsies. Bronchiectasis was diagnosed on the basis of history and findings on physical examination, chest X-ray, and thoracic high-resolution computerized tomography (HRCT). The patients’ records were retrospectively evaluated for cause of secondary amyloidosis, and cases with causes other than bronchiectasis were excluded. Secondary amyloidosis due to bronchiectasis and recurrent pulmonary infection was identified in 40% (16 patients) of the 40 patients. For each of these 16 cases, we recorded patient age, duration of bronchiectasis, duration of HD, amount of lung involvement, and biopsy site(s). The means for age, duration of bronchiectasis, and duration of HD in the 16 patients were 50.6 ± 13.5 years, 22.18 ± 12.02 years (range, 6–42 years), and 30.81 ± 36.94 months (range, 4–144 months), respectively. The most common biopsy site was the rectum (n = 8). Thoracic HRCT revealed cystic bronchiectasis in 8 cases (50%). Four of these 8 patients (25% of the group of 16) died from sepsis within 3-year follow-up period. Two of the four patients who died had bilateral cystic bronchiectasis, and the other two had unilateral cystic bronchiectasis. In the other eight patients in the group, thoracic HRCT showed chronic fibrotic changes in the pulmonary parenchyma and minimal traction bronchiectasis. Four of these patients exhibited apical fibrosis and bronchiectasis (25% of the group of 16), and these radiological findings were considered sequelae of previous tuberculosis infections. In conclusion, chronic respiratory infections and associated bronchiectasis remain a serious problem in Turkey due to insufficient prevention, diagnosis, and treatment. It is important that patients with progressive cystic and diffuse bronchiectasis be followed carefully, as they may develop amyloidosis and ESRD in time. Also, the clinical course in patients with cystic bronchiectasis may be worse than that in other types of bronchiectasis due to complicating pulmonary infections.

Transbronchial needle aspiration "by the books"

BACKGROUND: Training for advanced bronchoscopic procedures is acquired during the interventional pulmonology (IP) Fellowship. Unfortunately a number of such programs are small, limiting dissemination of formal training. OBJECTIVE: We studied success of conventional transbronchial needle aspiration (C-TBNA) in the hands of physicians without formal IP training. METHODS: A technique of C-TBNA was learned solely from the literature, videos and practicing on inanimate models at “Hands-On” courses. Conventional TBNA with 21 and/or 19 gauge Smooth Shot Needles (Olympus®, Japan) was performed on consecutive patients with undiagnosed mediastinal lymphadenopathy. RESULTS: Thirty-four patients (male 23), mean age 54.9 ± 11.8 years underwent C-TBNA. Twenty-two patients had nodes larger than 20 mms. Suspected diagnoses were malignancy in 20 and nonmalignant conditions in 14. Final diagnoses were malignancy 17, sarcoidosis 4, reactive lymph nodes 12, and tuberculosis 1. Final diagnosis was established by C-TBNA in 14 (11 malignancy, 3 sarcoidosis; yield 41.1%), mediastinoscopy in 14, transthoracic needle aspiration in 3, peripheral lymph node biopsies in 2 and by endobronchial biopsy in 1. Nodal size had an impact on outcome (P = 0.000) while location did not (P = 0.33). C-TBNA was positive in 11/20 when malignancy was suspected (yield 55%), while 3/14 when benign diagnosis was suspected (yield 21.4%) (P = 0.05). Sensitivity, specificity, PPV, NPV, and diagnostic accuracy were 66.6%, 100%, 100%, 65%, and 79.4%, respectively. There were no complications or scope damage. CONCLUSION: Conventional-TBNA can be learned by the books and by practicing on inanimate models without formal training and results similar to those published in the literature could be achieved.

Diagnostic utility of flexible bronchoscopy in recipients of solid organ transplants.

BACKGROUND Solid organ transplant (SOT) recipients are prone to develop pulmonary complications (PC) due to their immunocompromised state. Flexible bronchoscopy (FB) is frequently performed to diagnose the nature of these complications. The aim of this study was to evaluate the diagnostic utility of FB in SOT recipients with suspected PC. METHOD We examined the medical records of patients who underwent FB between 2000 and 2010; patients who received SOT were included patient demographics, transplantation type, primary diagnoses, thorax computed tomography results, total blood count and chemistries, immunosuppressant therapies, indication, results, specimen cultures, as well as suspected and final diagnoses were recorded. RESULTS Among 1368 either liver or kidney transplant recipients 61 subjects including 49 male patients of overall mean age 42.8±12 years underwent FB. FB was performed for lung infiltrates (n=42), lung nodules (n=2), atelectasis (n=1), bronchopleural fistula (n=1), stridor (n=1), mediastinal lymphadenopathy (n=2), pleural effusion (n=1), fever (n=9), and/or hemoptysis (n=2). FB was unremarkable in 17. Other findings were as follows: increased secretions (n=24), chronic mucosal changes (n=7), endobronchial lesion (n=1), edematous mucosa (n=3), submucosal narrowing (n=1), necrotic plaque (n=2), hemorrhage (n=2), tracheal stenosis (n=1), and/or friable mucosa (n=3). We performed bronchial washings (n=56) and/or bronchoalveolar lavage (n=5). In 24 patients the microorganisms were Mycobacterium tuberculosis, Staphylococcus aureus, Moraxella catharralis, Candida albicans, Klebsiella pneumonia, Escherichia coli, Streptococcus pneumonia, Stenotrofomonas maltofilia, Aspergillus fumigatus, and Pseudomonas aerigunosa. In 34 patients a final diagnosis was established using FB (diagnostic yield, 55.7%). Thirty-one patients had received tacrolimus (10.5±5.3 ng/ng/mL); 22 cyclosporine (187.1±79.3 ng/mL); and 8, sirolimus (6.2±2.2 ng/mL). No significant difference was observed between high versus low drug levels and the culture results (P>.05). CONCLUSION Suspected pulmonary infection is the most common indication for FB in SOT recipients. It may identify the causative organism in more than 30% of patients and should be considered in the presence of a lung infection.

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.

Effect of pulse steroid therapy in a patient with Langerhans' cell histiocytosis.

Langerhans’ cell histiocytosis (LCH) is a condition in which granulomas form in various tissues through the accumulation of abnormal histiocytes (Langerhans’ cells), granulocytes and lymphocytes. An important distinction between LCH and primary pulmonary histiocytosis (PPH) is that smoking cessation is known to often lead to spontaneous improvement in PPH patients, while this has not been demonstrated in patients with multisystem LCH. In this case report, we describe the case of a 20‐year‐old man who presented with cough and palpably enlarged lymph nodes in his neck. An inguinal lymph node biopsy led to the diagnosis of multisystem LCH in the lungs, the cervical, intra‐abdominal, and inguinal lymph nodes and the spleen. The patient was a smoker, and had averaged 30 cigarettes per day for 7 years. To address the multisystem involvement, intravenous pulse steroid therapy was administered (30–40 mg/kg daily) in two 3‐day treatment periods separated by 3–4 weeks. The patient was also advised to stop smoking, and did so. Serial follow‐up examinations confirmed an objective improvement with complete remission. The patient was still healthy at 18 months post‐treatment, reflecting a dramatic and positive response to pulse steroid therapy. This encouraging result makes this case an important one to highlight.

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.

Lung Related Complications in Heart Transplant Recipients: Results of a Single Center Experience.

Introduction Heart transplantation which is an option for end-stage heart diseases can be associated with various complications during follow-up. In this study we report the lung related complications in heart transplant recipients performed in 88 patients. Materials and Methods Medical records related to orthotopic heart transplant recipients from January 2003 to November 2017 were reviewed retrospectively. Results A total of 88 patients were included in the study. 19 of them were female and mean age was 39 ± 14 years at time of transplantation. 37 patients (%42) presented with pulmonary complications. Pneumonia was the most common complication (n=31). 13 of these patients had pulmonary aspergillosis (mainly aspegillus fumigatus, flavus and terreus), 9 of them had community acquired pneumonia and 9 of them nosocomial type. 2 patients had lung tuberculosis, 1 had pulmonary thromboemboli and 1 case developed lung cancer during follow-up. 5 patients had prolonged respiratory failure requiring tracheotomy. As far as concerns the thorax tomography findings pneumonic infiltrations (n=23), pleural effusion (n=18), atelectasis (n=17), nodules (n=12), ground glass appearance (n=7) and pneumothorax in 7 patients were detected. Mortality was calculated as 51%. Conclusion Pulmonary complications are quite common after cardiac transplantation and can occur at any time during follow-up. Close monitoring of these patients is necessary for early detection of especially pulmonary infections which might be even invasive like aspergillosis that can be hardly detected because of obscure findings and symptoms in transplant patients. Thorax tomography and bronchoscopy should be the procedures of choice in diagnosis of lung complications.