Evaluation of renal transplantation recipients those who do not use steroid with panel reactive antibody and donor specific antibody / Evaluación de receptores de trasplante renal que no usan esteroides con panel de anticuerpos reactivos y anticuerpos específicos del donante

ABSTRACT Background: Steroids are the mainstream drugs of immu- nosuppressive regimen in renal transplantation. They are successfully used on induction, maintenance and rejection treatment. Due to complications caused by steroids, treatments are switched to immunosuppressive agents. Graft dysfunction risk caused by reduced total immunosuppression disturbs clinicians very often. We documented the differences among patients by means of clinical presentation and PRA/DSA levels between patients who are using steroids and patients that were prescribed for steroid-free regimen. Methods: 82 individuals who did not use steroid and 52 patients on steroid treatment were included with similar rates of age, sex, primary renal disease, dialysis type, posttransplant follow-up duration and donor type. Pre and posttransplant PRA, DSA levels, posttransplant and current graft function and comorbidities were evaluated. Results: Individuals who do not use steroids were found to have a lower posttransplant creatinine level and glomerular filtration rate (GFR) compared to steroid users. Posttransplant and current spot urinary protein/creatinine rates were also lower in the steroid-free group. However DM, BKVN and induction therapy rates were higher in the steroid-free group. PRA and DSA levels were similar in both groups. On the other hand, posttransplant PRA-I levels were significantly higher in those with less steroid use time. Conclusions: Although steroid free regimens usually worry the clinicians, they can be preferred in patients with low immunological risk for rejection to avoid its side effects such as uncontrolled diabetes, obesity, musculoskeletal problems and cataracts.

RESUMEN Antecedentes: Los esteroides son los principales fármacos del régimen inmunosupresor en el trasplante renal. Se utilizan con éxito en tratamientos de inducción, mantenimiento y rechazo. Debido a las complicaciones causadas por los esteroides, los tratamientos se cambian a agentes inmunosupresores. El riesgo de disfunción del injerto causado por la reducción de la inmunosupresión total perturba a los médicos con mucha frecuencia. Documentamos la diferencia entre los pacientes por medio de la presentación clínica y los niveles de PRA/DSA en aquellos que utilizan esteroides y a los que se les prescribió un regimen sin esteroides. Material y métodos: Se incluyeron 82 individuos que no usaban esteroides y 52 pacientes en tratamiento con esteroides con tasas similares de edad, sexo, enfermedad renal primaria, tipo de diálisis, duración del seguimiento postrasplante y tipo de donante. Se evaluaron la ARP pre y postrasplante, los niveles de DSA, la función y comorbilidades postrasplante y actual del injerto. Resultados: Se encontró que las personas que no usan esteroides tienen un nivel de creatinina postrasplante y una tasa de filtración glomerular (TFG) más bajas en comparación con los usuarios de esteroides. Las tasas de proteína/creatinina urinarias postrasplante y puntuales actuales también fueron más bajas en el grupo sin esteroides. Sin embargo, las tasas de DM, BKVN y terapia de inducción fueron más altas en el grupo sin esteroides. Los niveles de PRA y DSA fueron similares en ambos grupos. Por otro lado, los niveles de PRA-I postrasplante fueron significativamente más altos en aquellos con menos tiempo de uso de esteroides. Conclusiones: Aunque los regimenes libres de esteroides suelen preocupar a los clínicos, pueden ser preferidos en pacientes con bajo riesgo inmunológico de rechazo para evitar sus efectos secundarios, como diabetes no controlada, obesidad, problemas musculoesqueléticos y cataratas.

Corticosteroid associated lupus pancreatitis

SUMMARY The relationship between acute pancreatitis and the administration of glucocorticoids is unclear because most reported cases have been diagnosed with systemic vascular diseases, such as systemic lupus erythematosus, which may be responsible for pancreatitis. A 22-year-old woman with eye involvement of a newly diagnosed systemic lupus erythematosus was admitted to our hospital. Pulse intravenous methylprednisolone therapy was given at 1mg/kg day for 3 days, and oral prednisolone at 40 mg/day thereafter. During pulse steroid therapy, she had abdominal pain, back pain, distention, nausea, and vomiting. Her physical examination was compatible with acute abdomen and peritonitis. Abdomen Computerized Tomography scan revealed diffuse liquid perihepatic and perisplenic area with heterogeneity around the mesentery. Due to the symptoms of acute abdomen, explorative laparotomy was performed. There was diffuse free fluid in the abdomen and edematous changes were observed around the pancreas. Amylase and lipase from intraabdominal fluid were studied and found to be high. The postoperative prednol dose was reduced carefully. On the sixth postoperative day, the drain was removed, and the patient was discharged without any problem. Physicians should keep in mind that acute pancreatitis may also be a cause of differential diagnosis of newly developed abdominal pain in patients receiving pulse steroid therapy with a normal level of serum amylase and lipase.

RESUMO A relação entre pancreatite aguda e a administração de glicocorticoides é incerta pois a maioria dos casos relatados foram diagnosticados com doenças vasculares sistêmicas, como lúpus eritematoso sistêmico, que pode causar pancreatite. Uma paciente de 22 anos com envolvimento ocular e lúpus eritematoso sistêmico recém-diagnosticado foi admitida em nosso hospital. Pulsoterapia intravenosa com metilprednisolona 1mg/kg foi administrada por 3 dias. Depois disso, a paciente foi tratada com prednisolona oral 40 mg/dia. Durante a pulsoterapia com corticoides, a paciente apresentava dor abdominal, dor nas costas, distensão, náusea e vômitos. O exame físico era compatível com quadro de abdome agudo e peritonite. Tomografia computadorizada do abdome revelou líquido difuso na região perihepática e periesplênica, com heterogeneidade ao redor do mesentério. Devido aos sintomas de abdome agudo, foi realizada laparotomia exploradora. Havia líquido livre difuso no abdome e alterações edematosas foram observadas em torno do pâncreas. A amilase e lipase do líquido intra-abdominal foram analisadas e consideradas elevadas. A dose pós-operatória de prednol foi reduzida com cuidado. No sexto dia de pós-operatório, o dreno foi retirado, e a paciente recebeu alta sem qualquer problema. Médicos devem lembrar que a pancreatite aguda também pode ser uma causa de diagnóstico diferencial para dor abdominal recém-desenvolvida em pacientes recebendo pulsoterapia com corticoides e com níveis normais de amilase e lipase séricas.

Symptomatic cholelithiasis may be the first sign of sarcoidosis

SUMMARY Sarcoidosis is a multisystemic noncaseating granulomatous disease that rarely affects the gastrointestinal system. The initial diagnosis of sarcoidosis with gallbladder/gallbladder-associated lymph node involvement is a very rare condition in the literature. Herein, we aimed to report a case of newly diagnosed sarcoidosis with lymph node involvement associated with the gallbladder.

RESUMO A sarcoidose é uma doença granulomatosa multissistêmica não-caseosa que raramente afeta o sistema gastrointestinal. O diagnóstico inicial de sarcoidose com envolvimento de linfonodo da vesícula biliar ou associado à vesícula biliar é muito raro na literatura. Aqui, o nosso objetivo foi relatar um caso de sarcoidose recém-diagnosticado com envolvimento de linfonodos associados à vesícula biliar.

Ectopic ureter associated with Zinners syndrome in a kidney recipient: case report and literature review

SUMMARY INTRODUCTION Zinner's Syndrome is a triad of mesonephric duct anomalies comprising unilateral renal agenesis, seminal vesicle cyst, and ejaculatory duct obstruction. In this study, we present a kidney recipient with ectopic ureter associated with Zinner's syndrome and a literature review. CASE PRESENTATION A 59-year-old male with a history of chronic kidney disease and left renal agenesis underwent deceased donor kidney transplantation. After securing optimal renal functions, the patient underwent abdominal computed tomography (CT) scan for the seroma that occurred under the incision. The final diagnosis was an ectopic distal ureter ending in the seminal vesicle cyst's wall and ipsilateral renal agenesis. The patient was discharged without any complications and the clinical follow up was uneventful. DISCUSSION AND CONCLUSION Congenital seminal vesicle disorders are usually associated with ipsilateral urinary duct anomalies stemming from the same embryonic structure. To our knowledge, this is the first case report that describes kidney transplantation in a patient with ipsilateral renal agenesis and ectopic ureter ending in the seminal vesicle cyst. In patients with renal agenesis, during the ipsilateral urinary tract anastomosis, the possibility of ectopic ureter should be kept in mind otherwise graft loss can occur with a high morbidity rate.

RESUMO INTRODUÇÃO A Síndrome de Zinner é uma tríade de anomalias do ducto mesonéfrico que compreende agenesia renal unilateral, cisto da vesícula seminal e obstrução do ducto ejaculatório. Neste estudo, apresentamos um receptor de rim com ureter ectópico associado à Síndrome de Zinner e revisão da literatura. APRESENTAÇÃO DO CASO Homem de 59 anos com história de doença renal crônica e agenesia renal esquerda foi submetido a transplante de rim de doador falecido. Após função renal ideal, foi realizada tomografia computadorizada do abdome (TC) devido ao seroma sob incisão. O diagnóstico final foi um ureter distal ectópico que termina na parede do cisto da vesícula seminal e agenesia renal ipsilateral. O paciente recebeu alta sem complicações e o acompanhamento clínico ocorreu sem intercorrências. DISCUSSÃO E CONCLUSÃO Os distúrbios congênitos da vesícula seminal geralmente estão associados às anomalias do ducto urinário ipsilateral devido a uma mesma estrutura embrionária. Até onde sabemos, é o primeiro relato de caso que descreve o transplante renal em um paciente com agenesia renal ipsilateral e ureter ectópico terminado no cisto da vesícula seminal. Em pacientes com agenesia renal, durante a anastomose do trato urinário ipsilateral, deve-se ter em mente a possibilidade do ureter ectópico, caso contrário, poderá ocorrer perda do enxerto com alta taxa de morbidade.

Outcomes of Laparoscopic Cholecystectomy in Patients 65 Years and Older.

Aim: Laparoscopic surgery is considered to be the gold standard in gall bladder surgery and to take advantage of its benefits, the number of laparoscopic procedures carried out on elderly patients is increasing daily. The aim of this study was to determine the mortality and morbidity rates of laparoscopic cholecystectomy (LC) in a patient group over 65 years of age and to analyze the predictive factors for conversion to open surgery. Study Design: A retrospective analysis of patients, 65 years of age and over, who had undergone laparoscopic cholecystectomy operation. Place and Duration of Study: Tepecik Training and Research Hospital, Department of General Surgery, Izmir, Turkey between January 2012 and June 2014 in our clinic was conducted. Methodology: A retrospective analysis of 385 patients, 65 years of age and over, who had undergone cholecystectomy operation When excluding the patients who had open cholecystectomy or additional surgical procedures, 240 patients were included in the study. The patients were also divided into two age groups (65-74 years; 75+ years) for further analysis. Results: The median age of the patients was 70. The rate of conversion from laparoscopy to open surgery was 12.5% (n=30). Multivariate analysis showed the leukocytosis and pathological acute cholecystitis to be independent risk factors for conversion. A longer total hospital stay was seen in patients with inflammatory bile duct diseases (5±4 days - 3±2 days). The surgical morbidity rate was 19.6% (n= 47); the rate of systemic complication was 2.5% (n=6). Conclusion: Inflammation related to gallstones in the biliary system is a definite risk factor for conversion to open surgery. Laparoscopic cholecystectomy, with its acceptable rates of morbidity, mortality and conversion, is a reliable surgical procedure in the 65 and over age group.