Appropriateness of aspirin use among diabetic patients in primary prevention of atherosclerotic cardiovascular diseases: an analysis of the ASSOS study.

OBJECTIVE: Aspirin is an essential drug in the prevention of atherosclerotic cardiovascular disease (ASCVD). It is ultimately indicated in a patient with ASCVD. However, its role is debated in primary prevention. We aimed to investigate the appropriateness of aspirin use in diabetic patients according to recommendations of recent guidelines. PATIENTS AND METHODS: ASSOS was a multicenter observational study investigating aspirin use in cardiology outpatient clinics. We evaluated aspirin use in diabetic patients in primary prevention from the ASSOS study. We also assessed the appropriate use of aspirin according to the European Society of Cardiology (ESC), American College of Cardiology/American Heart Association (ACC/AHA), American Diabetes Association (ADA), Consensus Statement of Endocrinology, Cardiology, and Nephrology (ENCARNE), and the United States Preventive Services Task Force (USPTF). RESULTS: A total of 5,007 patients of whom 1,537 had type 2 diabetes mellitus (DM) were included in the study. 1,132 of the total participants used aspirin for primary prevention; 313 of them had type 2 DM. Only 248 (76.7%), 132 (40.8%), and 128 (39.6%) diabetic patients indicated aspirin use according to the ESC/INCARNE, ACC/AHA, and ADA/USPTF guidelines, respectively. CONCLUSIONS: Inappropriate aspirin use was common among diabetic patients, according to clinical practice guideline recommendations. In addition, the differences between the indications for the use of aspirin in diabetic patients according to the guidelines were remarkable. Guidelines that minimize these differences are needed for clinicians, and compliance with these guidelines in clinical practice could reduce inappropriate aspirin use.

Real-life use of digoxin in patients with non-valvular atrial fibrillation: data from the RAMSES study.

WHAT IS KNOWN AND OBJECTIVE: Although inappropriate use of digoxin has been described in various populations, a real-world evaluation of patterns of digoxin prescription has not been well studied in patients with atrial fibrillation (AF). The aim of this study was to identify prevalence, indications and appropriateness of digoxin use in the general population of patients with non-valvular AF (NVAF) in Turkey. METHODS: We included and classified patients from the RAMSES (ReAl-life Multicentre Survey Evaluating Stroke prevention strategies in Turkey) study, a prospective registry including 6273 patients with NVAF, on the basis of digoxin use. After excluding the data of 73 patients whose medical history about digoxin use or left ventricle function was absent, 6200 patients were included for the final analysis. Digoxin use was considered inappropriate if patients did not have left ventricular systolic dysfunction or symptomatic heart failure (HF). RESULTS AND DISCUSSION: Digoxin was used in 1274 (20·5%) patients. Patients treated with digoxin were older (71·4 ± 9·8 years vs. 69·2 ± 10·9 years, P < 0·001), more likely to be female (58·8% vs. 55·9%, P = 0·019) and had more common comorbidities such as HF (40·2% vs. 17·4%), diabetes (26·4% vs. 21·1%), coronary artery disease (35·3 vs. 27·6%) and persistent/permanent AF (93·4% vs. 78·4%; P < 0·001 for each comparison). Of the 1274 patients, the indication of digoxin use was considered inappropriate in 762 (59·8%). WHAT IS NEW AND CONCLUSION: Our findings show that nearly one-fifth of the patients with NVAF were on digoxin therapy and nearly 60% of these patients were receiving digoxin with inappropriate indications in a real-world setting.

Prognostic value of transthoracic echocardiography and biomarkers of cardiac dysfunction in community-acquired pneumonia.

The aim of this study was to determine the prognostic role of echocardiography and compare with admission N-terminal proB-type natriuretic peptide (NT-proBNP) levels in adult patients with community-acquired pneumonia (CAP). Consecutive adult patients hospitalized with CAP were prospectively enrolled and followed-up until hospital discharge or death. Echocardiography was performed within the first 48 hours. Complicated hospitalization (CH) was defined as intensive care unit admission, need for mechanical ventilation or in-hospital mortality. This study was registered with ClinicalTrials.gov, number NCT02441855. A total of 15 CH (13.5%) occurred among 111 patients with CAP. CAP patients with a CH compared with those without CH had significantly higher NT-proBNP values (1267.4±1146.1 vs. 305.6±545.7 pg/mL, p <0.001) and troponin I (23.8±24.3 vs. 10.3±6.3 ng/mL, p 0.02) but had lower left ventricle ejection fraction (52.7±8.7 vs. 60.5±6.7%, p <0.001) and tricuspid annular plane systolic excursion (TAPSE), which is a measure of right ventricular systolic function (17.1±4.4 vs. 21.8±4 mm; p 0.001). Patients with elevation of NT-proBNP and decreased TAPSE at presentation had a significantly higher probability of CH (60%) than patients with either elevated NT-proBNP or decreased TAPSE (40%). Patients with neither elevated NT-proBNP nor decreased TAPSE had a 0% probability of CH. This is the first study to demonstrate that decreased right ventricular systolic function is associated with increased rates of adverse events in patients with CAP.

Impact of QRS morphology on heart rate turbulence and heart rate variability after cardiac resynchronization therapy in patients with heart failure.

OBJECTIVE: Impairment of heart rate turbulence (HRT) and heart rate variability (HRV) are associated with poor prognosis in chronic heart failure (CHF). Although previous studies have demonstrated that patients with a left bundle branch block (LBBB) have a better outcome with cardiac resynchronization therapy (CRT), the effect of QRS morphology on HRV and HRT is not known. We aimed to evaluate the effect of QRS morphology on HRV and HRT after CRT implantation in patients with CHF. PATIENTS AND METHODS: Patients who had been implanted a CRT device with cardioversion-defibrillation feature were included to the study. Forty-three patients with LBBB (group 1) were compared with 21 patients without LBBB (group 2). HRV and HRT parameters were compared before and one month after CRT implantation. RESULTS: We compared the echocardiographic and electrocardiographic changes in both groups after CRT. Cardiac output (CO) was found to be significantly much more increased in group 1 (1.1 ± 0.4 vs. 0.6 ± 0.4, p = 0.001). Similarly, except SDNN and LF, all HRT and HRV parameters were significantly changed in the patients with LBBB (TO 1.4 ± 0.3 vs. 1.2 ± 0.2, p = 0.001; TS -1.8 ± 0.7 vs. -0.9 ± 0.7, p = 0.001; RMSSD -15.7 ± 9.9 vs. -6.3 ± 6.2, p = 0.001; PNN50 -7.0 ± 4.6 vs. -1.7 ± 1.1, p = 0.001; HF -13.3 ± 6.7 vs. -4.3 ± 3.5, p = 0.001; LF/HF 1.9 ± 0.4 vs. 1.5 ± 0.2, p = 0.001) compared to those without LBBB. Lineer regression analysis showed that the CO (ß = 0.2, t = 2.8, p = 0.007) and QRS configuration (ß = 0.6, t = 0.5, p = 0.001) were independent parameters affecting TO. CONCLUSIONS: HRV and HRT are improved after CRT but these improvements are more remarkable in patients with LBBB. CO, QRS configuration (but not duration) were two independent parameters affecting TO, LF and LF/HF ratio after CRT.

Plasma exchange therapy for severe gastrointestinal involvement of Henoch Schönlein purpura in children.

OBJECTIVES: The aim of this report is to evaluate the plasma exchange as a choice for the management of life-threating gastrointestinal system (GIS) involvement in Henoch-Schönlein purpura (HSP) when refractory to conventional therapies. METHODS: We retrospectively reviewed the medical records of HSP patients who had plasma exchange therapy due to massive GIS involvement. We reported age, gender, initial HSP presentation, etiological or triggering factors and disease course. Treatment modalities, side effects and their outcomes were noted. RESULTS: We reported 7 cases of childhood HSP with severe gastrointestinal involvement refractory to common immunosuppression with systemic steroid and cytotoxic therapy. All patients gave inadequate response to pulse methyl prednisolone or oral prednisolone therapy with ongoing GIS bleeding and severe abdominal pain. Therefore, pulse cyclophosphamide was added to the treatment. Two patients received additional intravenous immunoglobulin (IVIG) therapy. Gastrointestinal manifestations continued and plasma exchange was performed. All patients improved after plasma exchange treatment. CONCLUSIONS: Treatment of GI involvement in HSP with plasma exchange has been mainly based on case reports. According to our data, we propose that, plasma exchange may be a safe and efficient management choice in paediatric HSP patients with massive GIS involvement that are refractory to other therapies.

Evaluation of failing hemodialysis fistulas with multidetector CT angiography: comparison of different 3D planes.

PURPOSE: To evaluate failing hemodialysis fistula complications using 16-detector MDCTA, and to assess the accuracies of different 3D planes. MATERIALS AND METHODS: Thirty patients (16 men, 14 women, aged 27-79 years) were referred for hemodialysis access dysfunction. Thirty-one MDCTA exams were done prior to fistulography. For MDCTA, contrast was administered (2mL/kg at 5mL/s) via a peripheral vein in the contralateral arm. Axial MIP, coronal MIP, and VRT images were constructed. Venous complications were evaluated on axial source images, on each 3D plane, and on all-planes together. Results were analyzed using McNemar test. RESULTS: Axial MIP, VRT and all-planes evaluations were most sensitive for fistula site detection (93%). Coronal MIP had the highest sensitivity, specificity and accuracy (35%, 96%, and 85%, respectively) for detecting venous stenosis. VRT and all-planes had the highest sensitivity and accuracy for detecting aneurysms (100%). All-planes and axial MIP were most sensitive for detecting venous occlusion (61% and 54%). Comparisons of detection frequencies for each venous pathology between the five categories of MDCTA revealed no significant differences (P>0.05). MDCTA additionally showed 3 partially thrombosed aneurysms, 4 anastomosis site stenosis and 12 arterial complications. CONCLUSION: MDCTA overall gives low sensitivity for detection of central vein stenosis and moderate sensitivity for occlusion. For most pathology, all-planes evaluation of MDCTA gives highest sensitivity and accuracy rates when compared to other planes. For venous stenosis and occlusion, MDCTA should be considered when ultrasonography and fistulography are inconclusive. MDCTA is helpful in identifying aneurysms, collaterals, partial venous thromboses and additional arterial, anastomosis site pathologies.

In vitro activity of tigecycline against resistant micro-organisms isolated from burn patients.

Infections in burn patients are usually caused by multidrug-resistant micro-organisms. Tigecycline, a derivative of glycylcyclines, is an effective antibiotic against the resistant strains. The aim of this study is to determine the in vitro activity of tigecycline against the multidrug-resistant bacteria isolated from burn patients. Fourty-seven bacteria isolated from 118 patients hospitalized in the burn unit during 2003-2006 were included in the study. Gram-negative bacteria that were resistant to at least six broad-spectrum antibiotics, methicillin-resistant staphylococci and ampicillin-resistant enterococci were studied. Minimal inhibitory concentration values of tigecycline against these bacteria were tested by E-test strips. Susceptibility breakpoints were determined according to the previous studies;

Burns in Turkish children and adolescents: nine years of experience.

AIM: The aim of this study was to describe information about burns that occur in children and adolescents in Turkey. PATIENTS AND METHODS: The subjects were 362 patients whom were younger than 18 years who were treated at 3 burn centers in 2 different regions of Turkey between 1997 and 2005. The data collected for each case were age, gender, place of residence, cause and extent of burn, body sites affected, environment in which the injury occurred, interval from injury to arrival at a burn center, hospitalization status (inpatient versus outpatient), surgical treatment, and mortality. RESULTS: The 362 patients comprised 35.5% of all 1021 burn victims admitted during the study period. There were 183 boys and 179 girls (ratio 1:0.98) and the mean total body surface area burned was 17.7+/-16.5%. The highest proportion of patients were in the 1-6 years age group. Non-bath (not immersed) hot water scalding (216 cases, 59.7%) was the leading burn cause. The most common environment in which burn injury occurred was the home. The trunk was the body site most frequently affected (62.7%). 241 (66.6%) subjects lived in urban environments and 121 (33.4%) lived in rural areas. 171 patients (47.2%) were taken directly to the burn units, whereas the others (52.8%) were referred from other medical centers. 124 (34.3%) subjects were treated as outpatients and 238 (65.7%) were hospitalized. The overall mortality rate was 8.6% (31 deaths). Of the 238 inpatients, 92 (38.7%) were treated with daily dressings only, 128 (53.8%) required debridement, and 75 (31.5%) needed both debridement and grafting. CONCLUSION: Every country needs a nationwide public education system that is aimed at preventing burns and ensuring that burn victims receive proper first aid and age-appropriate, specialized burn care.

Preventable thermal burns associated with the ignition of paint thinner: experience of a burn care network in Turkey.

AIM: This retrospective study evaluated the epidemiology of burn injuries, due to paint thinner ignition, in patients treated at the burn units of a university hospital network. METHODS: From 1997 to 2005, 28 patients with thermal burns caused by ignition of paint thinner were admitted to our burn units. Age, sex, etiologic factors, extent and localization of burns, length of hospitalization, outcomes compared with other causes of thermal burns, and mortality rates were recorded for each patient. RESULTS: There were 25 males and 3 females. Mean age of the patients was 27.88+/-14.74 years. Two patients (7.4%) came from rural regions; the majority (92.9%; n=26) lived within city boundaries. The most common etiologic factor was attempting to start a fire in the stove with paint thinner. Mean extent of burns was 48.82+/-27.39% of the total body surface area. When compared with other flame burn causes, the extent of burns was significantly greater in paint-thinner burn patients. Affected body sites, in order of most affected to least affected, were the hands, feet, head and face, neck, and trunk and genital regions. Mean length of hospitalization for survivors was 39.65+/-37.83 days. The overall mortality rate was 39.3%. Sepsis (63.6%), excessive burns with inhalation injury (18.2%), pulmonary embolism (9.1%), and respiratory failure (9.1%) were the causes of the deaths. CONCLUSION: Paint thinner ignition may cause excessive burns with high mortality rates. Its common misuse in starting stove fires by persons living in urban areas should be prevented immediately.

Effect of secondary interventions on patency of vascular access sites for hemodialysis.

PURPOSE: To determine the impact of secondary procedures performed to maintain arteriovenous fistula (AVF) and arteriovenous graft (AVG) patency. METHODS: There hundred and eighty six vascular access procedures were retrospectively evaluated. 156 (40.4%) patients required radiological interventions to treat acute thrombosis, swelling of the extremity with the access site, insufficient hemodialysis, or stenosis at an anastomotic site. RESULTS: The 386 cases comprised 106 AVGs and 280 AVFs. In 138 of the 156 cases, which required a radiological intervention, the treatment was successful and saved the vascular access site. The unassisted post-intervention patency time for these 138 successful cases was 13.1 +/- 12 months (range, 1-65 months). Twenty-nine (63%) of the 46 access sites treated with surgical thrombectomy were saved. CONCLUSIONS: Frequent, regular follow-up of hemodialysis patients with vascular access sites is the best way to diagnose problems early and allow the best chance of long-term function.

Angiotensin-converting enzyme and endothelial constitutive nitric oxide synthase polymorphisms in Turkish renal transplant population and possible influence on renal artery atherosclerosis and graft survival.

BACKGROUND: Renal transplant recipients are prone to accelerated atherosclerosis secondary to immunosuppressants, which may decrease graft survival. We sought to analyze the effects on renal graft survival of atherosclerotic degeneration in the renal artery and the influence of angiotensin-converting enzyme (ACE) endothelial constitutive nitric oxide synthase (ecNOS) gene polymorphisms. METHODS AND PATIENTS: Thirty three renal transplant recipients (25 men) of mean age 28.4 +/- 9.6 years, received organs from 11 living related donors and were followed for at least 36 months. Genotyping was performed for the insertion/deletion ACE (I/D), angiotensin (AGT) (M-->T, 235), angiotensine 1 receptor (A-->C, 1166), angiotensin 2-receptor (A-->G, 1223), and ecNOS (b-->a, intron4) gene polymorphisms. Renal artery biopsies were performed during transplantation surgery to analyze the presence of atherosclerosis. RESULTS: Pathological examination indicated that 18 donor specimens and nine recipient specimens had atherosclerotic degeneration. Survival analysis (36 months) indicated that graft survival rates of recipients who had atherosclerosis in the renal artery and who received an organ from donors with an atherosclerotic renal artery were shorter than in their counterparts (P = .02, P = .04, respectively). Comparison of genetic variations of recipients revealed that CC/TC variation of AGT was higher in patients with atherosclerosis (81% vs 53%, P = .03). There was no significant difference between groups in means of other gene polymorphisms. CONCLUSION: Renin-angiotensin system gene polymorphism analysis of patients in renal transplantation waiting list may provide information about allograft survival and posttransplant atherosclerotic degeneration at graft vasculature of young transplant recipients.

Effect of amyloidosis on long-term survival in kidney transplantation.

Amyloidosis is characterized by the accumulation of an amorphous material in various organs and tissues secondary to a variety of inflammatory, immune, infectious, and hereditary diseases. Since 1975, our transplantation team has performed 1470 renal transplantations. Between 1985 and July 2004, among 1159 kidney transplantations, 953 (82.3%) were from living donors and 206 (17.7%) from cadaveric donors. There were 32 recipients (28 men, 4 women; mean age, 31.4 +/- 1.7 years; range, 21 to 48 years) with amyloidosis, including, 28 (87.5%) who received grafts from living donors and 4 (12.5%) from cadaveric donors. Amyloidosis was secondary to familial Mediterranean fever in 22 (68.7%) patients and rheumatoid arthritis in 1 (3.1%). The remaining 9 (28.1%) patients had primary amyloidosis. The mean follow-up time was 51.2 +/- 5.7 months (range, 2-124 months). Mean HLA mismatch rate was 2.2 +/- 1. Twenty-six (81.2%) patients are alive at this time with functioning grafts, and a mean serum creatinine value of 2.1 +/- 1.5 ng/dL. The 1- and 5-year patient and graft survival rates were 90.6% and 84.3%, and 81.2% and 68.7%, respectively. We conclude that patients with amyloidosis may undergo kidney transplantation safely expecting outcomes similar to those patients who receive transplantations for other reasons.

Influence of HLA compatibility on success with living-related pediatric liver transplantation.

It is not clear how HLA compatibility influences acute rejection and postoperative complications in cadaveric liver transplantation. Even less is known about this factor in pediatric living-related liver transplantation (LRLT). This research assessed HLA compatibility relative to rejection rates and complications in pediatric LRLT. The study retrospectively investigated data from 14 pediatric LRLTs in which the donor and recipient HLA genotypes were determined preoperatively. Three recipients (21.4%) developed biliary complications (two biliary leakage, one bile duct stenosis). Three others (21.4%) developed vascular complications (two hepatic artery thrombosis, one hepatic artery stenosis). Eight recipients (57.1%) were diagnosed with acute rejection. The incidence of acute rejection was not correlated with the number of HLA mismatches (P > .05), or with the number of HLA class I mismatches (P > .05); however, it was negatively correlated with number of HLA class II mismatches (P = .02). Arterial and biliary complications were not correlated with any of these categories of HLA compatibility. In conclusion, the data from this small group of patients provided no evidence that closeness of donor-recipient HLA matching influences outcome in pediatric LRLT.

Comparison of hemodynamic changes associated with two different polytetraflouroethylene arteriovenous fistulae in hemodialysis patients.

The aim of this prospective study was to identify hemodynamic factors associated with two different types of polytetrafluroethylene (PTFE) AV grafts. The study was conducted on 46 hemodialysis patients over a 3-year period. The subjects were randomly assigned to one of two study groups: Group 1 patients (n = 24) underwent a brachiocephalic loop PTFE fistula; Group 2 patients (n = 22), a brachioaxillary PTFE fistula. Preoperatively, we recorded each individual's subclavian catheter history, hemodialysis frequency, and serum levels of parathormone (PTH), calcium (Ca)-phosphorus (P) product, homocysteine, protein C, and protein S. Doppler ultrasonography was used to evaluate vascular hemodynamic changes in the proximal and distal portions of the AV fistula at 48 hours and 1 week postoperatively. Group 1 showed a significantly greater number of ipsilateral subclavian catheter interventions prior to AV graft surgery than Group 2 (14 versus 7, respectively; P = .05; chi-square). The mean peak systolic velocity in the brachial artery in Group 1 was significantly higher than that in Group 2 at 1-week postoperatively (P = .04, paired t-test). The mean radial artery diameter in Group 1 was greater than that of Group 2 at 1 week postoperatively (P = .05, Student t-test). At 48 hours postoperatively the observed change in cephalic vein diameter in Group 1 was significantly greater than the change in axillary vein diameter in Group 2 (P = .08, paired t-test). Preoperatively, the mean serum protein C and protein S levels in Group 1 were higher than those in Group 2 (P = .03 and P = .04, respectively; Mann-Whitney U test). The total numbers of dialysis sessions per week in each group were significantly different (P = .001, chi-square). Six Group 1 patients exhibited graft thrombosis at 48 hours after AV graft surgery. None of the patients in Group 2 exhibited thrombosis at 48 hours or 1 week postoperatively. The results indicate that patients with brachiocephalic PTFE AV grafts show more significant changes in the cephalic vein and brachial artery than patients with brachioaxillary PTFE AV grafts. The findings also suggest that more ipsilateral subclavian catheter interventions and a higher weekly frequency of hemodialysis prior to AV graft surgery are risk factors for early thrombosis of PTFE AV grafts.

Oxidant and antioxidant levels in preterm newborns with idiopathic hyperbilirubinaemia.

OBJECTIVES: Newborns, particularly preterm infants, have limited antioxidant protective capacity. The organism's defence system against reactive oxygen species including vitamins A, E and C, trace element selenium (Se) and enzymes, such as catalase (CAT), superoxide dismutase (SOD), and glutathione peroxidase (GSH-Px) are essential components of the antioxidant system against the oxidative injury to the cellular membranes of erythrocytes. In this study, our aim was to compare the oxidant nitric oxide (total plasma nitrite level as an indicator of nitric oxide (NO)), antioxidant vitamins and selenium and erythrocyte antioxidant enzymes in premature babies with hyperbilirubinaemia with healthy preterms. METHODS: Twenty preterm infants with newborn jaundice were included in the study group, while 15 preterm infants without jaundice were enrolled in the control group. We evaluated the mean plasma levels of, respectively, the total nitrite as an indicator of NO, bilirubin, vitamins A, E, C and selenium, and the activity of erythrocyte antioxidant enzymes such as CAT, SOD and GSH-Px of preterm infants with idiopathic hyperbilirubinaemia and compared to those of the control group. RESULTS: The mean plasma total nitrite and total serum bilirubin levels and blood reticulocyte counts of the study group were found to be significantly higher than those of the control group (P < 0.001, P < 0.001 and P < 0.05, respectively). Furthermore, the activity of erythrocyte antioxidant enzymes (all P < 0.001) and the mean plasma levels of the antioxidant vitamins A, E, and C (P < 0.05, P < 0.05 and P < 0.001, respectively) and selenium (P < 0.001) of the study group were all found to be significantly lower than those of the control group. CONCLUSION: We hypothesize that low antioxidants in pretem babies may predispose them to increased oxidative stress, and cause hyperbilirubinaemia.

Health care professionals' knowledge of procedural issues in transplantation: the need for continuing education programs.

Organ transplantation is a multidisciplinary field that requires a good knowledge of the processes and excellent cooperation throughout the entire hospital. The aim of this study was to determine the level of knowledge of health care professionals (HCPs) at our transplantation center concerning general definitions and procedural issues related to transplantation. A questionnaire including nine items-five questions on general definitions and four on procedural issues-was distributed to 100 randomly selected HCPs. Four participants were excluded because they completed the questionnaire incorrectly; thus, there were 96 total respondents. The mean number (+/-SD) of correct answers overall was 5.78 +/- 1.36. Concerning general definitions, 11.5% of the respondents answered all of the questions correctly. However, the corresponding rate for the procedural questions was 3.1%. One percent of the respondents answered 1 or zero definition questions correctly, and 19.8% answered 1 or zero procedural questions correctly. The HCPs showed better knowledge of general issues related to transplantation than procedural issues. The results of this study suggest that the knowledge of HCPs in transplantation centers in Turkey is limited to the extent that their specialty is linked to transplantation. It is important that continuing medical education programs be instituted in organ procurement and transplantation centers in Turkey. These in-service training programs would enhance HCPs' understanding of and participation in procedures related to transplantation, and thus improve the total quality of the transplantation process.

Graft and patient outcomes among recipients of renal grafts with multiple arteries.

Anastomosis of multiple renal arteries in living donor kidney transplantation is technically demanding. Previously this condition was considered a relative contraindication to use of the donor, due to an increased risk of vascular and urologic complications. We conducted this retrospective study to determine the prevalence of multiple renal arteries in kidney transplants and their relation to graft and patient survival acute tubular necrosis, as well as vascular and urologic complications for comparison with the outcomes of recipients of single-artery grafts. Among the 1425 patients who underwent renal transplantation at our center, between November 1975 and March 2003 the present analysis concerned the most recent 1095 recipients. Seventy-nine (7.2%) cases required multiple-artery anastomoses (group I) and 1016 (92.8%) a single-artery anastomosis (group II). There were no significant differences between groups I and II with respect to creatinine clearance at 1 year, cold ischemia time at 1 year, or serum creatinine values at 1, 2 or 5 years (P <.05 for all). There were also no significant differences between the groups with respect to rate of posttransplantation hypertension (P =.67), acute tubular necrosis (P =.55), or number of acute rejection episodes (P =.34). The respective graft survival rates at 1 and 5 years posttransplantation were 95.1% and 73.2% in group I and 95.0% and 79% in group II. The corresponding patient survival rates were 95% and 88% for group I and 97.1% and 83.1% for group II. These findings indicate that kidney grafts with multiple arteries may be used with excellent results.

Pregnancy and renal transplantation.

Ovarian dysfunction, anovulatory vaginal bleeding, amenorrhea, high prolactin levels, and loss of libido are the causes of infertility in women with chronic renal failure. After renal transplantation, endocrine function generally improves after recovery of renal function. In this study we retrospectively evaluated the prepregnancy and postdelivery renal function, outcome of gestation, as well as maternal and fetal complications for eight pregnancies in eight renal transplant recipients between November 1975 and March 2003 of 1095 among 1425. Eight planned pregnancies occurred at a mean of 3.6 years posttransplant. Spontaneous abortion occured in the first trimester in one case. One intrauterine growth retardation was observed with a full-term pregnancy; one intrauterine growth retardation and preterm delivery; one preeclampsia with preterm delivery and urinary tract infection; and one preeclampsia with preterm delivery and oligohydramnios. The mean gestation period was 35.5 +/- 3.0 weeks (31.2 to 38.0). Pregnancy had no negative impact on renal function during a 2-year follow-up. No significant proteinuria or acute rejection episodes were observed. Among the seven deliveries, no congenital anomaly was documented and no postpartum problems for the child and the mother were observed. Our study suggests that successful pregnancy is possible in renal transplant recipients. In cases with good graft function and absence of severe proteinuria or hypertension, pregnancy does not affect graft function or patient survival; however, fetal problems are encountered such as intrauterine growth retardation, low birth weight, and preeclampsia.

Immunosuppressive therapy and Kaposi's sarcoma after kidney transplantation.

Immunosuppressive therapy for organ transplant recipients is complicated by high rates of malignant diseases, one of which is Kaposi's sarcoma (KS). Between November 1975 and March 2003, 1425 patients underwent renal transplantation at our center, including the 1095 most recent procedures. Fifty-two malignancies were observed in 50 patients (4.7%), including 16 cases of KS. The 16 recipients comprised 6 men and 10 women of mean age 39 +/- 9 years (range 10 to 62 years). At the time of KS diagnosis, 14 recipients were receiving cyclosporine, azathioprine, and prednisolone, and the other 2 azathioprine and prednisolone. The mean time from transplantation to diagnosis was 24 +/- 15.2 months (range 8 to 74 months). One recipient showed a lymphoma concomitant with KS. Seven patients had lesions limited to the skin, 5 had the skin and gastrointestinal tract disease, and 4 had disseminated disease. After KS was confirmed, the first-line treatment was cyclosporine and azathioprine withdrawal with tapering of prednisolone. The tumors were managed by appropriate surgical and/or medical therapy. At the time of this presentation, 9 individuals are alive, 4 with normal renal function. Five patients lost their grafts due to chronic rejection. We found that the combination of immunosuppressive drug withdrawal and chemotherapy is effective in patients with limited disease, but the results are poor in cases of generalized disease.