Appendiceal carcinoid and mucinous cystadenoma in renal transplant recipients: case reports.

There is an increased incidence of tumors among renal transplant patients, which are associated with immunosuppression. Carcinoids are rare neuroendocrine tumors that arise from the enterochromaffin cells. Although appendiceal carcinoid tumors are the commonest malignant neoplasms affecting the appendix, and mucinous cystadenoma is the commonest benign appendiceal neoplasm, they have not been reported in immunosuppressed patients. We present two renal transplant recipients who developed combined appendiceal carcinoid and mucinous cystadenoma.

Posttransplant lymphoproliferative disorder in the wall of a lymphocele: a case report.

Posttransplant lymphoproliferative disorder (PTLD) is a well-known complication of renal transplantation with increased incidence after introduction of more powerful immunosuppressive drugs. Presenting symptoms are nonspecific; some patients may be entirely asymptomatic. Herein we have reported a case of PTLD arising in the lymphocele wall presenting with B-symptoms and deterioration of graft function. A 62-year-old-female with end-stage renal disease secondary to Balkan endemic nephropathy and positive Epstein-Barr virus (EBV) serology before transplantation received a renal transplant from a deceased donor. Six months after transplantation she was admitted to the hospital with a 1-week history of malaise, weight loss, anorexia, night sweats, and febrile episodes. Multisliced computed tomography demonstrated a cystic structure at the renal hilus. Graft function deteriorated, so the patient underwent puncture of the lymphocele. Urgent graftectomy was necessary to stop the bleeding. Pathohistology demonstrated EBV-positive, CD20-positive PTLD. The patient received 6 cycles of chemotherapy and continued on hemodialysis. We concluded that a high index of suspicion for PTLD should be maintained when evaluating lymphoceles arising in the later posttransplantation period. Irrespective of their imaging features, biopsy should be performed to exclude PTLD.

Outcome after renal transplantation in a "senior" program: the Croatian experience.

BACKGROUND: The Eurotransplant "senior" program allocates kidneys from elderly donors to patients >65 years old. It aims to increase the number of renal transplantations. Kidneys are allocated locally without human leukocyte antigen (HLA) matching to decrease the cold ischemia time. Croatia has introduced its own "senior" program based on HLA matching. We compared results with those from Eurotransplant. METHODS: We identified and prospectively followed all patients aged of >or=65 years who underwent a first renal transplantation. We recorded their HLA matching, cold ischemia time, renal function, surgical and medical complications, and duration of hospitalization. RESULTS: Through October 2007, 22 elderly patients received an allograft from donors who were >65 years old. There were 8 female and 14 male patients of mean age at transplantation of 67.4 years. Mean donor age was 66 years. The number of HLA mismatches ranged from 1 to 5, and cold ischemia time from 7 to 15 hours. One-year patient survival was 95.4%, and graft survival was 81.8%. Delayed graft function, defined as the need for dialysis for >7 days after transplantation, occurred in 63.6% of patients. Older recipients required prolonged hospitalization after transplantation (45 days; range, 16-131). Frequent posttransplant complications included posttransplant diabetes mellitus in 1 patient, delayed wound healing in 5 patients, and lymphocoel in 2 patients. Maligancies occurred in 3 patients, neoplasm of the native kidney, posttransplant lymphoproliferative disease, and skin cancer. One patient experienced acute rejection that was successfully treated with steroids. Seventeen patients experienced 20 viral infections. There was only 1 serious infection (pulmonary tuberculosis). The major problems were cardiovascular complications which occurred in 40.9% of patients.

Anderson-Fabry disease in kidneys from deceased donor.

Anderson-Fabry disease (AFD) is a rare, X-linked lysosomal storage disease that leads to progressive intracellular accumulation of globotriaosylceramide in visceral organs and the vascular endothelium. We report two patients with end-stage renal disease who received renal allograft from deceased female donor who died from heart failure. A 62-year-old women received a renal allograft in July 2006. Except for low-range proteinuria, renal function was normal until 6 months after transplantation when serum creatinine increased from 120 to 150 micromol/L. A renal biopsy was performed. Based on the specific pathological finding, AFD in donor was suspected. In order to prove the diagnosis, the other recipient also underwent renal biopsy 3 months later. This was 45-year-old female with stable graft function and nonnephrotic proteinuria. Light microscopic findings included a 'foamy' appearance of affected cells with swelling and vacuolization of podocytes. Electron microscopic finding show mesangial cells and podocytes filled with dense lysosomal granules appearing as myelin figures and 'zebra bodies'. Changes were less intensive than in the biopsy of the first recipient. The donor was 54-year-old Italian women who died on the Adriatic coast after heart attack. This is the first case of AFD found in a kidney allograft from deceased donor.

Renal transplantation in patients with Balkan endemic nephropathy.

BACKGROUND: Balkan endemic nephropathy (BEN) is a chronic tubulointerstitial disease prevalent in Croatia, Romania, Bulgaria, Bosnia and Herzegovina, and Serbia. In addition to renal disease, an increased incidence of upper urothelial carcinomas (UUCs) has been observed in the foci of BEN. Carcinoma may occur alone or in combination with BEN. Immunosuppression is associated with an increased risk for development of different malignancies. There are no data in the literature about the outcome of patients with BEN after transplantation. METHODS: We performed a retrospective evaluation of the database and review of the charts and pathology reports of 601 renal transplant recipients treated at our institution. RESULTS: From January 1995 to December 2004, kidney transplantations were performed in nine patients with BEN. One-year graft survival was 100%. A man, who was transplanted in 1997 died 2 years after transplantation with a functioning graft due to disseminated cancer from the pelvis of his own kidney. A female patient developed UCC 2 years after transplantation. They were both treated with a bolus of methylprednisolone before transplantation, because of four HLA-mismatches. A male patient developed UCC in the native and transplanted kidneys. He underwent a native nephroureterectomy with partial nephroureterectomy of transplanted kidney. His graft function was preserved with decreased immunosuppression. Three years later a urinary bladder carcinoma was discovered on a regularly performed multislice computed tomography. One patient developed a skin malignancy. Other patients have had uneventful posttransplantation courses with excellent graft function. Thus, 33.3% of patients with BEN developed UUC, compared with a 0.67% prevalence of urinary tract tumors among transplanted patients with other causes of end-stage renal disease. CONCLUSION: Patients with BEN are at increased risk for the development of UCC after transplantation. Regular screening for early detection of malignancy is mandatory. Longer follow-up and results from other transplant centers are needed to further investigate the relationship between BEN and UCC after renal transplantation.

Does mycophenolate mofetil increase the incidence of cytomegalovirus disease compared with azathioprine after cadaveric kidney transplantation?

Although most of the published papers had not found increase in the incidence of CMV disease in kidney transplant recipients treated with mycophenolate mofetil (MMF), we had feeling from everyday practice that after its introduction number of patients with CMV disease has increased. To test this hypothesis, we performed retrospective analysis of our database, comparing the incidence of CMV disease in patients treated with azathioprine (AZA) and patients treated with MMF. CMV disease was defined as CMV antigenemia (positive CMV pp65 determined by ELISA test) plus any of the following: decrease leucocytes or platelets, increased transaminases, increase in serum creatinine. The azathioprine treated group (AZA group) included 280 patients (132 female) treated for 17,672 months with AZA + Cyclosporine A (CyA) + steroid, or AZA + steroid, while the MMF group included 219 patients (112 female) treated for 5079 months with MMF + CyA + steroid, or MMF + steroid. There was no difference in acute rejection episodes between the AZA and the MMF group. The AZA group had 51 CMV disease episodes (1 episode per 346.5 treatment months), and the MMF group experienced 43 episodes (1 per 118.1 months) (P < .01). Mean onset of CMV disease was 32.65 +/- 47.69 (SD) months after transplantation in the AZA group, and 3.72 +/- 4.43 in the MMF group. There was no difference between two treatment groups regarding the donor-recipient CMV status mismatch. Despite having the increased incidence of CMV disease, MMF group had less severe disease compared to AZA group with decrease in leukocyte count in 11.6% vs 15.7% of episodes, decrease in platelet count in 20.9% vs 21.6%, elevation of transaminases in 18.6% vs 29.4% respectively, and finally increase in serum creatinine greater than 20% in 51.2% in MMF vs 74.5% in AZA group. Five patients from the AZA group experienced CMV pneumonitis with the mortality rate of 80%. Only one patient from the MMF group had CMV pneumonitis, and he survived. According to our results, patients treated with MMF have increased risk for development of CMV disease. However, the disease course is less severe, and less frequently accompanied with deterioration of renal function in comparison to the AZA group.

Pregnancy outcome in renal transplant recipients.

OBJECTIVE: To correlate pregnancy outcome with complications in pregnancy and transplantation-to-pregnancy interval in renal transplant recipients in Croatia. METHOD: Data on 23 pregnancies after prepregnancy stabilization of blood pressure and normalization of graft function were retrospectively analyzed. RESULT: The mean interval between transplantation and conception was 3.1 years. Primary renal disease was chronic glomerulonephritis in 7, chronic pyelonephritis in 7 and agenesis of right kidney and stenosis of left renal artery in 1 patient. There were 10 term and 5 preterm deliveries, 6 induced and 2 spontaneous abortions. The mean gestational age was 38.1 weeks and the mean newborn birthweight was 3015 g. The prematurity rate was 21.7%. Patients with arterial hypertension in pregnancy, elevated serum creatinine level and bacteriuria, as well as those with conception occurring less than 2 years after transplantation, had a higher rate of therapeutic and spontaneous abortions, preterm deliveries and low birth weight infants. CONCLUSION: The interval between transplantation and conception, as well as allograft function during pregnancy, seem to be of great importance for successful obstetric outcome in renal transplant patients.

Kaposi's sarcoma after renal transplantation. Case reports.

Immunodeficiency in transplant recipients with chronic immunosuppressive treatment may have influence to developing of virus infection diseases. This publication shows a case report kidney transplant recipient which develops Kaposi's Sarcoma correlated with HLA typing.

Aluminium in water for preparation of dialysate and in serum of dialysed patients.

The aim of this study was to develop and verify the electrothermal atomic absorption method for aluminium determination in human serum and correlate the concentration of aluminium in serum of patients on dialysis and in water for preparation of dialysate. Two centres were included: centre A with accidentally enhanced concentration of aluminium in water for preparation of dialysate and centre B with very low water aluminium. Aluminium level in serum of healthy people was also analysed. The results showed that the analytical method was reproducible and sufficiently accurate in determining serum and water aluminium. Normal values obtained for aluminium in the sera of healthy people ranged from 0.9 to 12 micrograms/L and were significantly lower than all values obtained from the dialysis centre A. The aluminium concentration in serum of dialysed patients displayed linear correlation to aluminium concentration in water used for preparation of dialysate.

Bioequivalence of two oral cyclosporine preparations.

A comparison of bioequivalence of two cyclosporine (CAS 59865-13-3) preparations was performed. Ten cyclosporine treated patients with transplanted kidneys were included. Criteria were successful transplantation and minimum period from transplantation of at least 6 months. Two months before the experiment, cyclosporine concentrations had to be in therapeutic range without significant oscillation, and kidney function stabile. There had to be no signs of cyclosporine nephrotoxicity. During the objective biochemical analysis it was not allowed to find malfunction in any of the patient's organ important for cyclosporine pharmacokinetics. Cyclosporine concentrations in whole blood were measured with a specific fluoroimmunoassay. Cyclosporine and metabolites concentrations were measured with radioimmunoassay with non-specific antibody. Mean value and standard deviations and shape of distribution were calculated for all numeric data of patients, measured biochemical and other laboratory parameters. Variance analysis for all measured cyclosporine concentrations according to sampling times (C0 to C12, maximal concentrations C(M), time to maximal concentrations t(M), times of absorption delaying t(Lag) and area under the measured concentration curves (AUC) were statistically checked. According to these data it is concluded that the preparations are bioequivalent; a time to reach maximum concentration was slightly shorter for test preparation (2.5 and 3.2 h, respectively), but not statistically significant. There are no significant differences between the areas under the concentration curves (1667 and 1665 ng.h/ml, respectively). After the calculation of pharmacokinetic parameters of concentration data measured by a non-specific method a significant difference for areas under concentration curves was seen (3709 and 4600 ng.h/ml, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

[Long-term follow-up of related kidney donors after nephrectomy]. / Visegodisnje pracenje srodnih davatelja nakon donorske nefrektomije.

From 1973 to July 1990, 183 kidney transplantations were performed at the Transplantation Unit of the Department of Urology--Faculty of Medicine--University of Zagreb. Out of these, 57 were from the living related donors. The research included 50 (88%) living related donors (28 mothers, 12 fathers, 5 brothers and 5 sisters) followed up from 1 to 15 years after donor nephrectomy. The donors' health conditions were evaluated by clinical-laboratory examinations (biochemical tests, renal function tests, urinoculture, ultrasound, isotopic renal studies, arterial blood pressure). In 48 (96%) neither morphological nor functional changes of the urinary system were found. A certain number of donors requested a transfer to less physically strenuous jobs. Except for the grafts functioning well in the recipients, the results also showed that the quality of donors' lives remained unchanged.

[Immunologic and clinical definition of the rejection reaction in kidney transplantation]. / Imunolosko i klinicko definiranje reakcija odbacivanja transplantiranog bubrega.

In the evaluation of the immunological state of a kidney transplant there is no reliable diagnostic test. Therefore, several various tests should always be applied. The aim of this study was to define the type of immunological reaction (cellular or humoral) that causes the rejection of transplanted kidney. A group of 45 patients with a kidney transplant were tested 175 times, in various phases of the kidney transplant, starting on the day of transplantation up to several months posttransplant. Specific antibodies (SA) and specific cytotoxic lymphocytes (SCL) directed against donor cells in lymphocyte-mediated cytolysis tests in the presence of antibodies (ADLMC) or without them (LMC) were determined. LMC was significantly correlated with acute rejection (85%). In the phase of clinical quiscence of the kidney transplant LMC was positive in 4% of the cases. During the period of chronic rejection it was positive in 75% of the cases. ADLMC test is significantly correlated with chronic rejection (88%). In the period of acute rejection it was positive in 27% while in clinical quiscence in 11% of the cases. Twenty-two patients with non-immunological disorders of the kidney transplant were tested 62 times. LMC test was always negative, while ADLMC test was positive in 6.4% of the cases. These tests prove to be good parameters for defining immunological reaction. Thus, they can be of great importance in determining adequate immunosuppressive therapy. Negative results of tests in non-immunological disorders of graft function are highly significant.