Kidney transplantation in Romania: two transplant centers experience.

PURPOSE: Kidney graft survival rates improved from decade to decade, but data about factors that affect patient and graft survival remain challenging and even controversial. METHODS: We analyzed retrospectively data from kidney transplanted patients followed in two Romanian transplant centers (Iasi and Bucharest)-new programmes specifically developed after 1989 to cover transplantation requirements for two-thirds of Romania. We used a composite survival outcome defined as 50% reduction in estimated glomerular filtration rate (eGFR), return to dialysis or death. Survival analysis was performed using uni- and multivariable Cox regression with baseline and time-updated covariates. RESULTS: From the entire cohort of 365 patients, 243 had the outcome of interest. In the univariable Cox survival analysis, age, hemoglobin, eGFR, cholesterol, AST and transplant center were associated with the outcome. The multivariable Cox analysis reveals that only cholesterol (HR 0.97, 95% CI 0.94-0.99 per 10 mg/dL increase) and transplant center (HR 3.64, 95% CI 2.67-4.97) remain associated. For the time-updated Cox survival analysis we found that eGFR (HR 0.91, 95% CI 0.87-0.96 per 10 ml/min/1.73 m2 increase) and cholesterol are associated with the outcome in the univariable analysis and only eGFR and transplant center in the multivariable Cox survival analysis. CONCLUSIONS: Our study reports data from two distinct transplant centers from a developing country. Our results are similar to the current literature data, but also reveal that the approach of a center to the transplantation management is an independent factor associated with graft survival.

Measurement of muon antineutrino quasielastic scattering on a hydrocarbon target at Eν ~ 3.5 GeV.

We have isolated ν(µ) charged-current quasielastic (QE) interactions occurring in the segmented scintillator tracking region of the MINERvA detector running in the NuMI neutrino beam at Fermilab. We measure the flux-averaged differential cross section, dσ/dQ², and compare to several theoretical models of QE scattering. Good agreement is obtained with a model where the nucleon axial mass, M(A), is set to 0.99 GeV/c² but the nucleon vector form factors are modified to account for the observed enhancement, relative to the free nucleon case, of the cross section for the exchange of transversely polarized photons in electron-nucleus scattering. Our data at higher Q² favor this interpretation over an alternative in which the axial mass is increased.

Measurement of muon neutrino quasielastic scattering on a hydrocarbon target at Eν ~ 3.5 GeV.

We report a study of ν(µ) charged-current quasielastic events in the segmented scintillator inner tracker of the MINERvA experiment running in the NuMI neutrino beam at Fermilab. The events were selected by requiring a µ- and low calorimetric recoil energy separated from the interaction vertex. We measure the flux-averaged differential cross section, dσ/dQ², and study the low energy particle content of the final state. Deviations are found between the measured dσ/dQ² and the expectations of a model of independent nucleons in a relativistic Fermi gas. We also observe an excess of energy near the vertex consistent with multiple protons in the final state.

Cytotoxic antibodies monitoring in kidney transplantation--their clinical relevance and challenges.

INTRODUCTION: The key of the successful renal transplantation is the ability to identify the best immunological match between donor and recipient considering the possibility of rejection phenomenon. The aim was to identify class I and/or class II cytotoxic antibodies in renal-transplanted patients in order to assess the immunological potential for prevention of subclinical or acute rejection episodes. PATIENTS AND METHODS: We have evaluated ninety-two patients who had kidney transplantation in 2010 in Fundeni Clinical Institute, Bucharest, Romania, concerning HLA matching and anti-HLA immunization status. For HLA genotyping were used molecular biology methods--PCR-SSP (Invitrogen, USA). For cytotoxic antibodies, the methods used were ELISA (GTI Diagnostics, USA) and Luminex (One Lambda, USA). Crossmatch tests between donor cells and recipient serum were performed by ELISA (GTI Diagnostics, USA). Rejection diagnosis was supported by renal biopsy. RESULTS: In the 20 presensitized cases, the rate of acute rejection was 30% while in the 72 unsensitized cases the rejection was 19.4%. The incidence of acute rejection was higher in anti-HLA class I presensitized patients compared with anti-HLA class II (20% and 14.3%, respectively) but there was no significant difference compared to pre-transplant unsensitized patients (19.4%). Sequential post-transplantation monitoring of anti-HLA antibodies has shown in pre-transplant sensitized patients group a constantly increasing of PRA value, while in the pre-transplant unsensitized patients group, 32% developed de novo cytotoxic antibodies. CONCLUSIONS: More sensitive and specific methods to detect anti-HLA antibodies before transplantation and sequential post-transplantation monitoring of these antibodies would be useful to identify patients who are at higher risk for allograft failure.

Atypical primary tuberculosis mimicking an advanced penile cancer. Can we rely on preoperative assessment?

Tuberculosis of penis is a very rare clinical entity. There are isolated reports of its presentation as a subcutaneous nodule with or without superficial ulcers and can be interpreted as advanced penile cancer. We present a case of penile tuberculosis that presented in our Center with a bulky penoscrotal formation treated in other center for the suspicion of Fournier gangrene.

Morphological aspects of the kidney: can normality be predicted?

PURPOSE: Our study aimed to assess the normal parameters of renal parenchyma and upper urinary tract from a contrast enhanced computed tomography assessment in order to create a mathematical model of normal kidney. PATIENTS AND METHODS: We conducted a retrospective observation study on 520 patients with a normal abdominal contrast enhanced CT scan in our Institute during November 2008-November 2010. All CT examinations were performed using 16 slices Siemens Emotion 2007 (Siemens Medical Solutions, Malvern, PA, USA). Two experienced radiologists evaluated all the evaluations and reformatted axial sections and after excluding patients with urinary tract pathology, the images were transferred to a separate workstation (eFilm Workstation(TM) 2.2.1, Merge Healthcare, Milwaukee, USA). Parameters measured were: the number of kidneys, craniocaudal diameter (CCD) in a coronar reconstruction, transverse diameter (TD) and anteroposterior diameter (APD) as the maximum diameter of the kidneys in the axial sections, parenchymal (PW) and cortical width (CW) in axial sections, kidney pyelon width (KPW), parenchymal index (PI), kidney rotation, measured in relation to the sagittal axial plane of reference (AR) and rotation of the kidney measured in the sagittal plane in relation to the coronary reference (SR). To identify factors that can influence the variables CCD, CW and PW, multivariate regression models were performed using SPSS software (SPSS 15, SPSS Inc., Chicago, Illinois, USA). We considered p<0.05 statistically significant. RESULTS: CCD remains high until the fifth decade of life (p=0.0053 on the right side, p=0.0012 on the left, ANOVA), PW values were found to be somewhat increased (p=0.0293 on the right side, p=0.2924 on the left, ANOVA). There are linear correlations between height and CCD, CW and PW, with statistical significance (p<0.05 each, Spearman ρ between 0.13 and 0.4). In multivariate analysis, only BMI, male gender and height had statistical significance. CONCLUSIONS: There is a wide range in size kidney. Among factors that strongly influence the values of CCD, CW, and PW in adults, BMI, male gender and height are most important. Also, cranial and caudal position of the kidney influences renal size. As for the size of the renal cortex, the factor most influencing these values is the absence of a contralateral kidney.

Management of small renal masses--update 2011.

RATIONALE: The management of renal parenchymal tumors has known many changes over time, a trend that continues today, as a result of technological advances, clinical research and improved diagnostic and therapeutic tools. Unfortunately, conventional cancer treatments--chemotherapy and radiotherapy have proven ineffective and modern approaches such as immunotherapy, angiogenesis inhibitors, though they enjoyed an initial enthusiasm, subsequent studies have shown limited and controversial effects. Thus, surgery remains the gold standard therapy for this type of cancer. The options for the treatment of RCC are numerous, with options that have advantages and disadvantages, with oncological results, in most cases, positive at five years and with different impact on cancer specific survival. It is difficult to compare the results, as these are different techniques with various instruments and intraoperative steps, with more questionable inclusion criteria, selection biases and prosecution, with a tendency for preferential enrollment, different reasons to why randomized prospective studies have not been performed until today. OBJECTIVE: This article is a review of the diagnosis and methods of treatment of small renal masses 2011. CONCLUSION: At the beginning of the new millennium, kidney cancer, with all the arsenal of techniques and methods of ablative surgery, remains a potentially fatal disease for a high percentage of patients, and the decision to choose a treatment or another should be taken with responsibility, depending on currently existing medical records, the degree of expertise and not based on subjective or other non-standard parameters.

Highlights in the minimally invasive treatment of SUI in women.

OBJECTIVE: Treatment of stress urinary incontinence consists of a wide range of options, from conservative therapies like lifestyle changes, medication, pelvic floor muscles exercises, electro-stimulation, to minimally invasive procedures--injection of collagen, suburethral slings TVT/TOT and last but not least, invasive surgical treatment reserved for recurrent and complex cases. Among the latest minimally invasive procedures reported in literature, the injection of intra-and perisphincterian of autologous stem cell (mioblasts and/or mature fibroblasts grown and multiplied in the laboratory from biopsy samples taken from the pectoralis muscles). MATERIAL AND METHOD: On October 18, 2010, in 'Fundeni' Clinical Institute of Uronephrology and Renal Transplantation was performed the first stem cell implantation procedure in the urethral sphincter, in Romania. RESULTS: Assessment at 6 weeks, the quality of life questionnaires, micturition diary and clinical examination revealed a stunning decrease of urine loss from 6 pads/day at one per day, which significantly improved the patient's quality of life. CONCLUSIONS: Stem-cell-mioblasts therapy may represent in the future an every-day intervention in the urologist's armamentarium. The effectiveness of this treatment can change the course of therapy and last but not least, the accessibility to urological evaluation of patients with stress urinary incontinence. Clinical and urodynamic evaluations will continue and will be future scientific topics.

Hand transplant--a challenge in immunological management of patients.

The concept of composite tissue allotransplantation (CTA) for restoration of congenital or acquired deformities is not new and the recent success of clinical composite tissue allotransplantation (CTA) attests to the fact that composite tissue allografts have tremendous potential in these life-enhancing reconstructions. A hand transplant, unlike a solid organ transplant, involves multiple tissues (skin, muscle, tendon, bone, cartilage, fat, nerves and blood vessels) and can be considered the 'gold standard' in CTA. In this regard, no other organ or tissue transplant matches the hand transplant in its immunogenicity as well as complexity. Development of assays that allow us to monitor the current state of an immune response (rejection/tolerance) is of great interest and requires an in-depth understanding of the complex and rare phenomenon of tolerance.

Minimally invasive treatment for female stress urinary incontinence - Romanian highlights.

RATIONALE: Stress urinary incontinence is still a "battlefield" for many minimally invasive therapies, but, unfortunately, few can restore the anatomical and functional background of this disorder. OBJECTIVE: Assessing the latest minimally invasive procedures of intra and perisphincterian injection of autologous stem cells. METHOD AND RESULT: The first stem cell implantation (myoblasts and /or mature fibroblasts grown and multiplied in the laboratory from biopsy samples taken from the pectoralis muscle) in the urethral sphincter was performed on October 18, 2010, in "Fundeni" Clinic of Urology and Renal Transplantation, in Romania. DISCUSSION: The follow-up at six weeks with the quality of life questionnaires, micturition diary and clinical examination revealed a decrease of urine loss from six pads/ day at one per day, which significantly improved the patient's quality of life according to visual analogue scale. Clinical and urodynamic evaluations will continue and will be future scientific topics.

Prognostic factors in retroperitoneal fibrosis.

UNLABELLED: The aim of this study is to evaluate effective prognostic factors in the evolution of patients with retroperitoneal fibrosis and to establish the validity of fractal analysis in determining the disease severity in these patients. MATERIAL AND METHODS: This study included 19 patients (M/F: 5/14) treated for idiopathic retroperitoneal fibrosis and bilateral obstructive renal failure between Jan 2004-Dec 2008. Patients were identified retrospectively, searching for patients diagnosed with IRF, after retroperitoneal biopsy or, in most cases the diagnosis rested on radiological findings, especially CT, with identification of a retroperitoneal mass, the absence of other demonstrable renal or ureteric disease or any other pathology that could explain the findings. CT was very useful in describing the retroperitoneal mass around the aorta and inferior vena cava, the extent of the lesion and for monitoring the response to surgical treatment during the follow-up. The data were evaluated about medical history, physical examination findings, laboratory tests (serum urea and creatinine, blood sugar, sodium, potassium, bicarbonate levels, serum pH, uric acid, haematocrit, white blood cell count), imaging methods (renal ultrasound, abdominal CT-scan, MRI). At admission all patients had active disease with obstructive renal failure and underwent bilateral ureteric stenting in order to normalize the BUN levels. After normalizing of BUN levels, ureterolysis and omental wrapping was performed. Postoperatively, ureteric stents were removed after 1 month and remission of renal disfunction was obtained in approximately 5 months (range 2-10 months). All patients were followed for at least 1 year. Patients were regularly checked every 3 months. RESULTS: Of the 19 patients, there were 5 men and 14 women. The median age at diagnosis of RF was 50 years (range 42-64 years). The most frequent presenting symptoms were back or abdominal pain, weakness, weight loss, oligoanuria, arterial hypertension and mild fever. The duration of symptoms before diagnosis ranged from 6 to 18 months. At presentation all patients had active disease, presenting renal dysfunction with a median serum creatinine of 5.18 mg/dl (range 1-15.4 mg/dl). Most of the patients had moderate bilateral hydronephrosis (2nd degree hydronephrosis). In our study, all patients had excellent prognosis, with full recovery of renal function in 78% of cases (15 patients). The fractal dimension of the fibrosis mass contour correlates with level of renal function impairment. Even more, the fractal dimension seems to slightly variate between CT evaluations (1.30 +/- 0.1), suggesting a non aggressive pattern of extension of the fibrotic mass characteristic for benign lesions. CONCLUSIONS: The imaging parameters did not predict the disease severity, except the increase in fractal dimension of fibrosis surface area. Efficacy of bilateral ureteric stenting in improving renal function is limited in most of the cases. Dispite the level of renal function impairment at admission, full recovery can be achieved after bilateral ureteric stenting/nephrostomy and ureterolisis.