First International Paired Exchange Kidney Transplantations of Turkey.

OBJECTIVE: We estimated that many patients on the waiting list for kidney transplantation in Turkey have immunologicaly incompatible suitable living donors. Paired exchange kidney transplantation (PETx) is superior to desensitization for patients with incompatible donors. Recently we decided to begin an international PETx program. METHODS: We report three international living related paired kidney transplantations which occurred between May 14,2013, and March 7, 2014. The international donor and recipient operations were performed at Medical Park Hospital, Antalya, Turkey. All pairs were living related and written proofs were obtained according to Turkish laws. As with the donor procedures, the transplantation procedures were performed at the same time. RESULTS: The uniqueness of these transplantations was that they are the first international exchange kidney transplantations between Turkey and Kirghizia. Currently all recipients are alive with wel-functioning grafts. CONCLUSION: In our institute, a 5% increase was obtained in living-related kidney transplantations by the help of PETx on a national basis. We believe that international PETx may also have the potential to expand the donor pool.

Renal Transplantation in Recipients Older Than 65 Years: Retrospective Analysis of the Results of a 4-year (2008-2012) Experience.

BACKGROUND: We analyze the results of renal transplantation among recipients older than 65 years old over a 4-year period (2008-2012) from a single renal transplantation unit and compare results with younger recipients. METHODS: We retrospectively analyzed the outcomes of 2018 renal transplantations performed between November 2008 and December 2012. The χ(2) test was used for the comparison of categorical data, and the Student t test was used for the analysis of continuous variables. Patient and graft cumulative actuarial survivals were calculated using the Kaplan-Meier analysis and we tested for differences with the Mantel-Cox log-rank test. RESULTS: Seventy-five (3.7%) recipients were aged ≥ 65 years with a median age of 68 (range, 65 to 82) years. Actuarial graft survivals at 1, 2, and 3 years were 93.8%, 92.5%, and 90.3%, respectively, for the <65 group and 89.7%, 88.1%, and 83.1%, respectively, for the ≥ 65 group (P < .03). Actuarial patient survivals at 1, 2, and 3 years were 96.3%, 95.5%, and 94.7%, respectively, for the younger and 91.8%, 90.2%, and 88%, respectively, for the older samples (P < .03). When graft survival was censored for patient death with a functioning kidney at 1, 2, and 3 years, the results were similar between groups with 95.5%, 94%, and 92.8%, respectively, for recipients aged <65 years and 94.7%, 89.2%, and 89.2%, respectively, for recipients aged ≥ 65 years (P = .213). CONCLUSIONS: Our results showed that renal transplantation in selected patients older than 65 years was associated with good outcomes; this indicates that it seems safe and effective to treat end-stage renal disease in the elderly knowing there are acceptable rates of graft and patient survival.

Post-transplantation Malignancy After Kidney Transplantation in Turkey.

OBJECTIVE: Kidney transplantation is the best treatment option for end-stage renal disease patients. Increased incidence of post-transplantation malignancy can be caused by immunosuppressive drugs and some oncogenic infections. The aim of this study is to show the incidence of post-transplantation malignancy in patients who had surgery and were followed up in the Organ Transplant Center, Medical Park Antalya, Antalya, Turkey. METHOD: The study was based on 2100 kidney transplantation patients who had surgery between May 2008 and December 2012 and also on 1900 patients who had surgery by members of our team in other centers and who were followed up routinely. In all of our patients, the type of malignancy, the time that malignancy developed, immunosuppressive regimens, and viral status (Epstein-Barr virus and cytomegalovirus) were investigated. RESULTS: Malignancy was developed in 30 patients (60% of them were male, median age was 52.1 years). Post-transplantation malignancy development time was a median of 5.1 years. The types of malignancies were as follows: non-melanoma skin cancer in 12 patients (40%), urogenital cancer in 7 patients (24%), breast cancer in 4 patients (14%), lymphoproliferative disease in 3 patients (10%), thyroid cancer in 2 patients (6%), and lung cancer in 2 patients (6%). DISCUSSION: In this study, we did not find any increased post-transplantation malignancy risk in our patients. This finding could be due to the low-dosage immunosuppressive protocols that we used.

Neurological complications after liver transplantation.

This was a single-centre, prospective study to assess the frequency of neurological complications and their impact on prolonged hospitalization in 137 liver transplant patients presenting between September 1997 and June 2010. Neurological complications were seen in 22 (16%) patients during their postoperative stay in the intensive care unit. Complications included new-onset, recurrent headache (five patients), generalized seizures (four patients), dysarthria (two patients), delirium with agitation (three patients), persistent flapping tremor (two patients), alteration in level of consciousness (three patients), central pontine myelinolysis (one patient), myopathy (one patient) and visual hallucinations (one patient). Seizures were associated with immunosuppressive drug toxicity (tacrolimus). Myopathy presenting as quadriplegia was diagnosed by muscle biopsy. The patient with central pontine myelinolysis lived in a persistent vegetative state for 2 years and died of pneumonia. In conclusion, neurological complications are frequently encountered after liver transplantation, and are an important cause of severe morbidity and prolonged intensive care unit and hospital stay.

Comparison of two different techniques for brachial plexus block: infraclavicular versus axillary technique.

BACKGROUND: Brachial plexus block via the axillary approach is problematic in patients with limited arm mobility. In such cases, the infraclavicular approach may be a valuable alternative. The purpose of our study was to compare axillary and infraclavicular techniques for brachial plexus block in patients undergoing arm or forearm surgery. METHODS: After institutional approval and informed consent were obtained, 30 patients (ASA physical status I or II) scheduled for forearm and hand surgery under brachial plexus anesthesia were included in the study. Patients were randomly allocated into two groups. Brachial plexus block was performed via the axillary approach in the Group A patients and via the infraclavicular approach in the Group I patients using a peripheral nerve stimulator. All blocks were performed with a total dose of 40 ml 0.375% bupivacaine. RESULTS: In each nerve territory (radial, ulnar, median, and musculocutaneous), the mean values of the degree and the duration of the sensory block and motor block were not significantly different between the two groups (P > 0.05). Inadvertent vessel puncture was significantly more frequent in the axillary approach (P < 0.05). CONCLUSION: Brachial plexus block performed via the infraclavicular approach is as safe and effective as the axillary approach. Infraclavicular approach may be preferred to the axillary approach when the upper arm mobility is impaired or not desired.

The analgesic and sedative effects of intrathecal midazolam in perianal surgery.

BACKGROUND AND OBJECTIVE: Our purpose was to evaluate the analgesic and sedative effects of intrathecal midazolam when added to spinal bupivacaine in patients undergoing perianal surgery under spinal anaesthesia. METHODS: Forty-four patients were randomly allocated into two equal groups: Group I (B) received hyperbaric bupivacaine 0.5% 2 mL + saline 0.9% 1 mL in a total volume of 3 mL intrathecally; Group II (BM) received hyperbaric bupivacaine 0.5% 2 mL + 1 mL of 2mg preservative-free midazolam in a total volume of 3 mL intrathecally. In both groups, the onset and recovery times of sensory block, the degree and recovery times of motor block as well as the sedation and visual analogue pain scores were recorded, and statistically compared. RESULTS: In Group BM, the postoperative visual analogue pain scores were significantly lower at the first 4 h (P < 0.05), the average time until the first dose of additional analgesic requirement was significantly longer (P < 0.05), and sedation scales were significantly higher (P < 0.05), compared to Group B. There were no statistically significant differences in the onset and the full recovery times of sensory and motor blocks in the two groups. CONCLUSION: The use of intrathecal midazolam combined with intrathecal bupivacaine produces a more effective and longer analgesia with a mild sedative effect in perianal surgery.

Frequency of spinal reflex movements in brain-dead patients.

Spontaneous and reflex movements may occur in brain-dead patients. These movements originate from spinal cord neurons and do not preclude a brain-death diagnosis. In this study, we sought to determine the frequency and characteristics of motor movements in patients who fulfilled diagnostic criteria for brain death. Patients admitted to our department between January 2000 and March 2003 and diagnosed as brain-dead were prospectively evaluated in terms of spinal reflexes. Clinical brain death was diagnosed according to our national law. We also prefer to document the diagnosis of brain death with an EEG and/or TCD. Spinal reflex movements were observed in 18 out of 134 (13.4%) brain-dead patients during the study period. Lazarus sign, the most dramatic and complex movement seen in brain-dead patients, was observed a few times in two patients during an apnea test, an oculocephalic test, after a painful stimulus, and after removal of a ventilator. The other reflex movements observed in our brain-dead patients were finger and toe jerks, extension at arms and shoulders, and flexion of arms and feet. The occurrence of spinal reflexes in brain-dead patients may certainly delay decision making, such as starting a transplantation procedure, because of difficulties in convincing the family or even a physician taking part in the diagnosis of brain death. An awareness of spinal reflexes may prevent delays in and misinterpretations of the brain-death diagnosis.

Brain death and donor management in the intensive care unit: experiences over the last 3 years.

We sought to examine the frequency of brain death in the ICU, the donation rate, and the problems encountered during donor management between the years of January 2000, the date we began treating patients with neurologic pathologies and traumatic brain injury, and March 2003. Between January 2000 and March 2003, 134 patients diagnosed with brain death in our ICU were studied prospectively for the reason of brain death, the time between admission to ICU, and the diagnosis of brain death, the frequency of diabetes insipidus, the inotrope requirement, hypothermia, electrolyte imbalance, arrhythmia, and cardiac arrest. Among the approximately 2600 patients admitted to the general 24-bed ICU, 940 had cerebral injuries. In this group, the mortality rate was 33.5% (315 out of 940 patients) including brain-dead patients. Donor care was performed in 94 patients with organs suitable for transplantation out of 134 brain-dead patients. Fifty (53.2%) out of 94 patients became organ donors. The donor ratio was 12 per million-population per year as a mean value of the study period, which was approximately 10 times higher than the average ratio in Turkey. Although we observed many life-threatening problems during donor management, none of these patients died or had acute organ dysfunction.

[The factors affecting morbidity and mortality in surgical treatment of severe necrotizing pancreatitis]. / Nekrotizan pankreatit'in cerrahi tedavisinde morbidite ve mortaliteyi etkileyen faktörler.

Necrotizing pancreatitis is the most severe form of acute pancreatitis with high morbidity and mortality rates. In this retrospective study we report our experience with 22 patients (17 men, 5 women with a mean age of 52.714) who were operated on at Akdeniz University School of Medicine Department of General Surgery, from February 1993 to July 2000 and define the factors affecting the morbidity and mortality in surgical treatment of NP. Diagnosis of NP and decision of laparotomy was performed by clinical findings and contrast-enhanced abdominal computed tomography (CT). The patients with pancreatic and peripancreatic necrosis confirmed intraoperatively included to the study. All patients had required intensive care therapy. The relationship between mortality/morbidity and with demographic and clinical data of patients, APACHE II score, presence of multiple organ dysfunction (MOD), and local-regional complications (LRC) was examined. The Fischer Chi-Square test was used to evaluate statistical significance and p < 0.05 was accepted as meaningful. The mean number of reoperations were 4.44.9 (1 to 23). Local-regional complications were observed in 17 (77%) patients and mostly consisted of intra-abdominal abscess (15 patients). The overall hospital mortality rate was 36% (8 of 22 patients died). In the 7 patients with low APACHE-II score on admission (< or = 10) no mortality was encountered. Eight of 15 patients with high APACHE-II score (> 10) on admission were died. Multiple-organ dysfunction developed in 7 (32%) patients and 6 (86%) of them died. Two of the 15 patients (13%) died without MOD. In conclusion, poor outcome was associated with high APACHE-II score (> 10) on admission (p = 0.02), and progression of MOD (p = 0.002) during the treatment. Local-regional complications increase the hospital stay and frequency of surgical interventions but these complications do not effect the mortality in negative manner in the surgical treatment of NP.