A Single-Center Experience With Kidney Transplantation in Patients Who Had Low Left Ventricular Ejection Fraction.

OBJECTIVES: Left ventricular hypertrophy is one of the most typical cardiac abnormalities detected in patients with end-stage renal disease. In patients with congestive heart failure, the most crucial factor determining patient survival is left ventricular ejection fraction. Herein, we present our experience with living donor kidney transplant recipients with a left ventricular ejection fraction of <50%. MATERIALS AND METHODS: Patients who underwent living donor kidney transplant in our center between November 2008 and November 2021 and had pretransplant left ventricular ejection fraction <50% were included. All patients had dialysis the day before surgery. All patients underwent 2-dimensional echocardiograms after dialysis and were categorized according to New York Heart Association classification, pretransplant and on posttransplant day 5. Demographic parameters and additional data, including pretransplant and posttransplant day 5 New York Heart Association classification, left ventricular ejection fraction at 6 months, and graft survival at 6 months, as well as patient survival data, were analyzed. RESULTS: Our study included 31 patients (mean age of 46.6 ± 18.3; range, 11-77 years). We found significant differences in New York Heart Association classifications before and after transplant, indicating that kidney transplant had a positive effect on pretransplant congestive heart failure in patients with low left ventricular ejection fraction (P = .001). The mean pretransplant left ventricular ejection fraction was 32 ± 9.9% (range, 1%-45%), whereas the mean 6-month posttransplant left ventricular ejection fraction was 52 ± 8.7% (range, 28%-63%) (P < .001). Both graft loss and all-cause mortality rates were 12.9%. CONCLUSIONS: Low left ventricular ejection fraction is not a contraindication for kidney transplant. We suggest that myocardial scintigraphy should be performed in patients with end-stage renal disease and low left ventricular ejection fraction, and kidney transplant should be considered in those without ischemic findings.

Transcatheter Mitral Valve Repair Using MitraClip in Patients With Renal Transplantation.

OBJECTIVES: To evaluate the renal function in patients with renal transplantation 1 month after treatment of their severe symptomatic mitral regurgitation using transcatheter mitral valve repair (TMVRep) using MitraClip (Abbott Cardiovascular). METHODS: We enrolled 22 patients with previous history of end-stage renal disease and kidney transplant with severe symptomatic mitral regurgitation (MR) in this study. Each patient was evaluated by the structural heart team and underwent transesophageal echocardiographic evaluation for MR etiology, severity, and location of the MR jet, as well as to rule out left atrial appendage clot formation. Serum creatinine and estimated glomerular filtration rate using the Modification of Diet in Renal Disease formula were measured at baseline and at 1-month follow-up. RESULTS: Fourteen patients (64%) were male and mean age of the study group was 50.4 ± 11.0 years. Mean ejection fraction was 29.0 ± 5.6%. The majority (86%) of the MRs treated were classified as functional MR. Follow-up creatinine values were significantly lower after treatment of their symptomatic MR with TMVRep compared with baseline creatinine values (baseline, 3.2 ± 0.49 mg/dL; follow-up, 1.99 ± 0.31 mg/dL; P<.05). CONCLUSIONS: TMVRep in patients with renal transplantation was associated with lower serum creatinine values at 1-month follow-up and represents an alternative to surgery in this high-risk group of patients. Further studies are needed to confirm our findings and to find the best treatment option for these patients.

Laparoscopic Live Donor Nephrectomy: Experience of High-Volume Center with 2,477 Cases.

OBJECTIVE: Donors' health and safety are mandatory in the living-donor kidney transplantation procedure. Laparoscopic live donor nephrectomy (LLDN) provides an increase in donor numbers with its benefits and becomes a standard of care. We aimed to explain the results, complication rates, tips, and tricks of the largest number of LLDN case series ever performed in the literature. MATERIALS AND METHODS: Between August 2012 and December 2019, 2,477 live donor case files were analyzed retrospectively. Age, gender, hospitalization times, body mass index, warm ischemia times, operation times, numbers of arteries, side of the kidneys, and complications were noted. RESULTS: 1,421 (57.4%) of 2,477 donors were female (p = 0.007). Operation times and warm ischemia times were found longer in right-sided LLDN and donors with multiple renal arteries (p = 0.046, <0.001, and <0.001, respectively). Obesity (BMI >30 kg/m2) did not affect warm ischemia times while prolonging the operation times (p = 0.013). Hospitalization times and numbers of complications were higher in obese donors. CONCLUSIONS: LLDN seems to be a reliable solution with fewer complications and higher satisfaction rates. We hope to illuminate the way with tips and trick points for beginner transplant surgeons based on the experience obtained from 2,477 LLDN cases.

Use of Tacrolimus During Pregnancy After Kidney Transplantaion.

PURPOSE: Motherhood is the greatest privilege that nature gives to women. Although pregnancy is a physiological event for women, every pregnancy is a risky pregnancy. During a normal pregnancy, the health of mother and baby are monitored. In post-transplantation pregnancies, the function of the transplanted organ, along with the mother and the infant, must be monitored, since the continuation of pregnancy depends on both the maternal and infant health and an organ functioning within normal limits. The desire is for every baby to be born in due time and at normal weight, but this is not always possible in pregnancies after transplants. Publications about the pharmocokinetics of tacrolimus are very limited. In this study, we wanted to share our experiences with pregnancy in our clinic. MATERIAL AND METHOD: Patients who used tacrolimus during their pregnancies after renal transplantation (RT) at Antalya Medicapark Organ Transplantation Unit, during November 2008 to July 2018 were included in the study. Patient's gestational age, pregnancy, drug levels, is charge, and labor creatinine clearances were examined. FINDINGS: Four thousand six hundred thirty-five RT occurred between November 2008 to July 2018; 786 of the patients were female between the ages 18 and 45. Thirty-one pregnancies went full term. Twenty-six pregnant women, who used tacrolimus after RT, were included in the study. Five patients had pre-eclampsia, 1 patient had abortus immines, 2 patients had hypertansion due to pregnancy, and 1 patient had aplated placenta. There was a breech presentation in 1 patient with preeclampsia. Acute rejection developed in 3 postpartum patients, but renal values normalized with medical treatment. All the babies were born alive and healthy; postpartum graft loss was not observed. CONCLUSION: If planning to become pregnant after RT,our center recommends waiting at least 2 years after the RT, when graft function should be normal and without any signs of HT and proteinuria. Our recommendation regarding the level of tacrolimus after RT is 4.5 to 7 µg.

Ex vivo stone surgery in donor kidneys at renal transplantation.

OBJECTIVE: To report our experience on the outcomes of ex vivo ureteroscopy and ex vivo pyelolithotomy carried out on the donor kidney before living donor renal transplantation. METHODS: Between 2009 and 2016, 13 stone-bearing donor kidneys underwent ex vivo bench surgery after donor nephrectomy. Of these, six patients underwent ex vivo ureteroscopy and seven patients underwent ex vivo pyelolithotomy. Data were analyzed for technical feasibility, intraoperative and postoperative complications, stone clearance, and stone recurrence. RESULTS: The mean stone burden was 9.1 mm (range 5-15 mm). Renal collecting system access and stone extraction were successfully achieved, and a stone-free status was accomplished with both techniques. The mean duration of ex vivo ureteroscopy was 12.5 min (range 9-20 min), and the mean duration of ex vivo pyelolithotomy was 3.1 min (range 1-8 min). One patient in the pyelolithotomy group developed urinary leakage and underwent surgical repair on the third postoperative day. The mean long-term follow-up duration was 49.6 months (range 14-101 months). None of the 13 patients included in the study suffered from stone recurrence. CONCLUSIONS: Our experience suggests that both ex vivo ureteroscopy and ex vivo pyelolithotomy procedures can safely and effectively be carried out in stone-bearing living donor kidneys, without compromising renal allograft function.

Outcomes of Conservative Management of Asymptomatic Live Donor Kidney Stones.

OBJECTIVE: To evaluate the long-term outcomes of asymptomatic stones ≤4 mm that are left in situ during renal transplantation (RT). MATERIALS AND METHODS: Between 2009 and 2017, 31 patients who received stone-bearing (≤4 mm) kidneys were analyzed. At their last follow-up, the patients were evaluated with computerized tomography (CT) imaging and the results were compared to the initial CT findings obtained during donor evaluation. RESULTS: The mean stone size was 2.9 mm (range 1-4.3). The mean follow-up period after RT was 43.1 months (range 12-97). According to the CT findings of the last follow-up, the stone had passed spontaneously in 26 patients (83.9%). Three patients (9.6%) with a stone size of 4 mm required surgical intervention because the stone became symptomatic within the first year after transplantation. In the remaining 2 patients (6.4%), the stone remained in situ, without a change in its size. In terms of spontaneous passage rate, there was no significant difference between lower and midupper pole stones (P = .948). De novo stone formation was observed in 2 patients (6.4%). CONCLUSION: Asymptomatic stones <4 mm that are detected on donor evaluation may safely be left in situ during RT. Regardless of their localization in the kidney, these stones have high spontaneous passage rates after RT, and the long-term recurrence rates are also considerably low.

HPV type 45-positive condyloma acuminata of the bladder in a renal transplant recipient.

Condyloma acuminata (CA) are warty lesions caused by human papilloma virus (HPV) that generally affect the external genitalia and mucocutaneous junctions. Involvement of the urinary tract is rare, and involvement of the urinary bladder is thought to be due to immunosuppression. A 30-year-old woman was diagnosed with urethral CA 12 months after renal transplantation. She underwent transurethral resection (TUR) of the urethral lesions. During the operation, multiple sessile warty lesions were found incidentally inside the bladder and were also removed by TUR. The patient's postoperative course was uneventful. Pathological examination confirmed that the lesions were CA. Multiplex real-time polymerase chain reaction was performed to confirm the HPV genotype and revealed type 45 HPV DNA. CA of the urethra are uncommon, and bladder involvement is extremely rare. This case is the first reported, to our knowledge, to involve HPV type 45 in bladder condyloma. TUR may be the preferred option for the management of CA in the urinary bladder.

Outcomes of combined cardiac surgery and kidney transplant compared with kidney transplant after cardiac surgery.

CONTEXT: Patients with chronic renal failure have a high prevalence of coronary artery disease and cardiovascular death. The mortality and the morbidity rates of cardiac surgery are particularly high in these patients with end-stage renal disease. Performing cardiac surgery and kidney transplant in the same session can reduce these complications in the early postoperative period by normalizing renal function. OBJECTIVE: To compare the mortality and morbidity rates between patients who had undergone cardiac surgery and kidney transplant separately and patients who had combined surgeries. METHODS: This retrospective study consisted of 75 patients. One group of 60 patients underwent cardiac surgery and kidney transplant in separate sessions, and the other group of 15 patients had combined surgeries in the same session, between March 2008 and September 2012. RESULTS: Patients who had combined surgeries achieved fluid electrolytic balance more easily, had shorter extubation times, used less blood and blood products, and had fewer major complications. The patients recovered faster and thus had shorter stays in the intensive care unit and hospital. This combined surgical approach allows normalized kidney function in patients with end-stage renal disease, so mortality and morbidity in the early postoperative period could be significantly reduced.

Transplantation tourism: high risk for the recipients.

BACKGROUND: The shortage of donor organ supply is forcing patients with end-stage renal disease to alternative searches. The aim of this study is to present the clinical and laboratory data of five patients who were transplanted in Egypt from paid living-unrelated donors and followed at our institution. METHODS: Five patients (four male, one female, mean age 51 yr) were included in this retrospective study. RESULTS: All allografts still have good function with a mean serum creatinine level of 0.9 mg/dL. Surgical and medical problems were common such as wound infection (n = 3), evisceration (n = 2), deep vein thrombosis (n = 2), unexplained abdominal incision requiring removal of an abdominal surgical compress left in situ during previous surgery, placement of allograft on the side of an unrepaired indirect inguinal hernia and transplant pyelonephritis. CONCLUSION: Although recent developments increased success in renal transplantation, receiving a kidney from a paid living donor at a commercial transplant center still carries great risks for the recipient.

Low toxicity regimens in renal transplantation: a country subset analysis of the Symphony study.

Regional transplant practices may affect clinical outcomes within multinational studies. This study evaluated whether the overall results from the Symphony study can be generalized to the participating countries. De novo adult renal transplant recipients (n = 1645) were randomized to receive standard-dose cyclosporine, or daclizumab induction plus low-dose cyclosporine, low-dose tacrolimus,or low-dose sirolimus, all in addition to mycophenolate mofetil and steroids. Data for the highest patient-recruiting countries, Spain (n = 275),Germany (n = 316) and Turkey (n = 258), were compared. Patient transplant characteristics were different among the country subsets; only deceased donors in Spain, more expanded criteria donors in Germany, and mainly living donors in Turkey. Efficacy results for the three countries were consistent with that of the overall study - renal function and biopsy-proven acute rejection (BPAR)rates were superior with low-dose tacrolimus. Turkey had higher mean calculated glomerular filtration rate across all treatment groups (60.6-72.2 ml/min)compared with that of Spain (51.1-57.5 ml/min) and Germany (51.3-62.9 ml/min). Spain and Turkey had lower BPAR rates across the four treatment groups compared with the overall study; Germany had much higher rates(21.0-54.2%). These findings confirm the general applicability of the Symphony study results and highlight the importance of inclusion of patients from different geographic origins in randomized clinical trials.

Skin infections in 401 renal transplant recipients in southern Turkey.

OBJECTIVES: Renal transplant recipients are predisposed to the development of a variety of skin infections that can result from graft-preserving immunosuppressive therapy. In this study,we aimed to determine the prevalence of skin infections in a group of renal transplant recipients in the Mediterranean region of Turkey. MATERIALS AND METHODS: The medical records of 401 patients followed up by the Transplantation Center at Akdeniz University in Antalya, Turkey, were used in a retrospective analysis. The prevalence of skin infections was calculated, and the effects of age, sex, and time after transplant on skin infections were evaluated. RESULTS: Of the patients studied, 220 (54.9%) had a skin infection. Of 280 infections identified in those individuals, 180 (64.3%) were fungal, 77 (27.5%) were viral, and 23 (8.2%) were bacterial. Pityriasis versicolor was present in 95 patients (23.7%), human papillomavirus infection in 44 (11%), onychomycosis in 23 (5.7%), and fungal toe-web infection in 20 (5%). The duration of immunosuppression significantly affected the prevalence of skin infections, and the mean interval for the development of fungal infections after transplant was earlier than that for viral or bacterial infections (25.8 -/+ 29.3, 50.7 -/+ 36.7, and 52.1 -/+ 47.9 months, respectively). CONCLUSIONS: In this study, pityriasis versicolor was the most common skin infection in renal transplant recipients in our region. Except for the higher prevalence of superficial fungal infections, the overall results in our population agree with those of other similar series.

Evaluation of the first 100 liver transplantations.

BACKGROUND/AIMS: We aimed to present the experience of the first 100 liver transplantations carried out at Akdeniz University. METHODS: The data of 100 patients in pediatric and adult age groups who underwent liver transplantation at Akdeniz University Organ Transplantation Center between January 2000 and January 2007 were examined retrospectively. The cases between January 2000 and December 2003 were evaluated as the first term and those between January 2004 and January 2007 as the second term. RESULTS: The mean age of the 100 patients (52M, 48F) was 38.6+/-17.3 (1-68) years. One-year and three-year survival rates of the patients were determined as 67.3% and 54.3% in the first term and 88.7% and 79.3% in the second term, respectively. CONCLUSIONS: With better comprehension of recipient and donor surgery technique, in addition to accumulation of knowledge and experience, the results in liver transplantation might be improved.

Reduced exposure to calcineurin inhibitors in renal transplantation.

BACKGROUND: Immunosuppressive regimens with the fewest possible toxic effects are desirable for transplant recipients. This study evaluated the efficacy and relative toxic effects of four immunosuppressive regimens. METHODS: We randomly assigned 1645 renal-transplant recipients to receive standard-dose cyclosporine, mycophenolate mofetil, and corticosteroids, or daclizumab induction, mycophenolate mofetil, and corticosteroids in combination with low-dose cyclosporine, low-dose tacrolimus, or low-dose sirolimus. The primary end point was the estimated glomerular filtration rate (GFR), as calculated by the Cockcroft-Gault formula, 12 months after transplantation. Secondary end points included acute rejection and allograft survival. RESULTS: The mean calculated GFR was higher in patients receiving low-dose tacrolimus (65.4 ml per minute) than in the other three groups (range, 56.7 to 59.4 ml per minute). The rate of biopsy-proven acute rejection was lower in patients receiving low-dose tacrolimus (12.3%) than in those receiving standard-dose cyclosporine (25.8%), low-dose cyclosporine (24.0%), or low-dose sirolimus (37.2%). Allograft survival differed significantly among the four groups (P=0.02) and was highest in the low-dose tacrolimus group (94.2%), followed by the low-dose cyclosporine group (93.1%), the standard-dose cyclosporine group (89.3%), and the low-dose sirolimus group (89.3%). Serious adverse events were more common in the low-dose sirolimus group than in the other groups (53.2% vs. a range of 43.4 to 44.3%), although a similar proportion of patients in each group had at least one adverse event during treatment (86.3 to 90.5%). CONCLUSIONS: A regimen of daclizumab, mycophenolate mofetil, and corticosteroids in combination with low-dose tacrolimus may be advantageous for renal function, allograft survival, and acute rejection rates, as compared with regimens containing daclizumab induction plus either low-dose cyclosporine or low-dose sirolimus or with standard-dose cyclosporine without induction. (ClinicalTrials.gov number, NCT00231764 [ClinicalTrials.gov].).

Simultaneous augmentation ileo-cystoplasty in renal transplantation.

INTRODUCTION: Renal transplantation is not contraindicated in end-stage renal disease developing as a result of complication of overactive bladder with uninhibited detrusor contractions. As an amendatory surgical approach, augmentation ileo-cystoplasty is the preferred option to achieve a low intravesical storage pressure. However, the timing of the augmentation ileo-cystoplasty in combination with renal transplantation is still controversial. TECHNICAL CONSIDERATIONS: We analyzed data from 3 of the 1100 renal transplantation patients treated at the Akdeniz University Transplantation Center in whom concomitant augmentation ileo-cystoplasty and renal transplantation were performed owing to hypocompliant bladder. CONCLUSIONS: The operation times were 360, 270, and 240 minutes. No perioperative major complication or rejection was detected. Bladder augmentation using ileum patch can be concomitantly performed with renal transplantation safely, and this approach avoids the requirement for a second operation in another session.

Early and late urological complications corrected surgically following renal transplantation.

The purpose of this study was to assess outcomes of urological complications after kidney transplantation operation. Nine-hundred and sixty-five patients received a kidney transplant between 2000 and 2006. In total, 58 (6.01%) developed urological complications, including urinary leakage (n = 15, 1.55%), stenosis (n = 29, 3%), vesicoureteral reflux (VUR) (n = 12, 1.2%), calculi (n = 1, 0.1%) and parenchymal fistulae (n = 1, 0.1%). Urinary leakage cases were treated by ureteroneocystostomy (UNS) via a double-J stent and stenosis cases by UNS. Fenestration was performed in patients developing lymphoceles and unresponsive to percutaneous drainage. VUR treatment was performed by ureteroneocystostomy revision or UNS. Stent usage during ureteric reimplantation was observed to reduce urinary leakage. Surgical complication rates in renal transplantation recipients according to donor type (living versus cadaveric) and the status of stent use (with stent versus without stent) were 5.53% vs. 7.27% (P = 0.064) and 5.24% vs. 20% (P < 0.01) respectively. No recurrence, graft loss or death was seen after these interventions. Comparison of recipients with and without urological complication showed that there was no difference between groups (P > 0.05) with respect to last creatinine level. No graft or patient loss was associated with urological complications. Urological complications that can be surgically corrected should be aggressively treated by experienced surgeons and graft loss avoided.

Horseshoe kidney for transplant: report of 3 cases.

Owing to the limited donor pool at transplant centers, grafts may be taken from marginal donors with congenital abnormalities, one of the most common of which is a fusion abnormality. Horseshoe kidneys may be transplanted to a single recipient en bloc or to 2 recipients after division. In our clinic, 3 grafts (1 obtained from a living donor and 2 from a deceased donor) were successfully transplanted to 3 patients. In select patients, horseshoe kidneys may be used for transplant.

Comparing two ureter reimplantation techniques in kidney transplant recipients.

We compared the incidence of urological and anastomotic complications for the ureteroureterostomy and Lich-Gregoir techniques in kidney transplant recipients. Between May 2003 and February 2004, 75 kidney transplant recipients from living donors were divided into two similar groups to receive ureteroureterostomy (n = 41, 28 male, 13 female) and Lich-Gregoir techniques (n = 34, 24 male, 10 female) for ureteral reimplantation. Patients with vesicoureteral reflux (VUR) to the native kidneys were excluded from the study. The urological complications included complicated hematuria, ureteral stenosis, symptomatic VUR, recurrent urinary tract infection (UTI). There was no statistical significance between two groups in terms of gender, age, end-stage renal disease etiology, human leucocyte antigen (HLA) mismatch numbers, type and duration of dialysis, and cold ischemia time. The incidence of urologic and anastomotic complications was 12%. Complications in the Lich-Gregoir group included symptomatic VUR in 8.8% and stent migration in 2.9% of cases. Complications observed in the ureteroureterostomy group were ureteral stricture 7.3% and complicated hematuria in 4.9% of cases. However, symptomatic reflux was not observed in the ureteroureterostomy group. UTI frequency was similar in both groups. Ureteroureterostomy can be safely performed as a primary choice in kidney transplant recipients.

Hemophagocytic syndrome in kidney transplant recipients: report of four cases from a single center.

BACKGROUND: The prognosis of hemophagocytic syndrome (HPS) in kidney transplant recipients is reported to be poor, however the optimal therapeutic approach is still unclear. PATIENTS AND METHODS: The clinical and follow-up data of the 4 patients with HPS (3 male, 1 female; age 39.7 +/- 11.3 years) among 368 kidney transplant recipients during a 5-year period were retrospectively analyzed. RESULTS: HPS developed 35-61 days in the post-transplant period. All 4 patients presented with fever. Hepatosplenomegaly and lymphadenopathy were observed only in the first patient. Laboratory tests revealed pancytopenia and hyperferritinemia in all patients, but elevated liver enzymes were observed in 3. Two patients had cytomegalovirus infection, and 1 had Epstein-Barr virus infection. Three patients died despite aggressive supportive therapy, however the fourth case survived after graft nephrectomy. CONCLUSION: HPS pathogenesis in kidney transplants appears to be related with the graft itself. Graft nephrectomy may be the preferable therapeutic approach for kidney transplant recipients with HPS resistant to standard supportive therapy.

Effect of renal transplantation on endothelial function in haemodialysis patients.

BACKGROUND: Haemodialysis patients (HD) have been characterized by a high incidence and prevalence of atherosclerotic cardiovascular disease. Based on the traditional cardiovascular risk factors in this population, we cannot explain this high incidence and prevalence. One of the mechanisms contributing to cardiovascular risk in HD patients may be to uraemic toxins. Cardiovascular risk factors and uraemic toxins themselves may cause endothelial dysfunction, which may play a pivotal role in the development and progression of atherosclerosis in this population. We hypothesized that elimination of uraemic toxins in response to renal transplantation (RTx) can improve endothelial function as assessed by flow-mediated dilatation of brachial artery in haemodialysis (HD) patients. METHODS: Endothelial function measured by flow-mediated dilatation of the brachial artery (FMD) and glyceryltrinitrate-induced dilatation of the brachial artery (NMD) were assessed twice, during haemodialysis treatment and after RTx in 30 chronic haemodialysis patients. All patients were characterized by absence of known atherosclerotic disease and traditional cardiovascular risk factors. We also studied age- and gender-matched 20 normotensive healthy controls. RESULTS: FMD values significantly improved after RTx (6.69+/-3.1% vs 10.50+/-3.0%, P<0.001) in HD patients. FMD of patients both during haemodialysis and after RTx was lower than in healthy controls (6.69+/-3.1%, 10.50+/-3.0% vs 14.02+/-2.3%, P<0.001 and P<0.01, respectively). There was no change in NMD values after RTx in HD patients (16.27+/-1.9% vs 16.30+/-1.8%, P>0.05). Also, NMD values in all patients were similar to healthy control values. CONCLUSIONS: There is an improvement of endothelial function as assessed by FMD of the brachial artery after RTx in HD patients. This may be attributed to the elimination of uraemic toxins by successful RTx.