Early versus late outset of lymphoproliferative disorders post-heart and lung transplantation: the PTLD.Int Survey.

BACKGROUND AND OBJECTIVES: the presentation time of post-transplantation lymphoproliferative disorders (PTLD) are not well described because of the limited number of cases occurring at each center and lack of a reliable and unequivocal classification together with the absence of multi-institutional prospective studies. We gathered information on the histopathological and clinical features and prognosis of the disease in a very large number of heart and lung transplant recipients, with data from 27 previous reports, with an emphasis of time of presentation. DESIGN AND SETTING: Retrospective analysis of data for individual patients from published studies, entered into a database and reanalyzed. METHODS: a comprehensive review of the literature by PubMed and Google Scholar was performed to find all data available reports on PTLD after heart and lung transplantation. RESULTS: Data from 288 PTLD patients after heart or lung transplantation from 27 reports were entered into analysis. Heart and lung recipients with early-onset PTLD compared with late-onset PTLD were significantly more likely to be of the b cell type (100% vs. 89.8%, respectively; p=.05). PTLD in patients with early onset was less likely to involve the skin (p=.05) and spleen (p=.015), but more frequently complications of the respiratory tract (p=.002). morphology of PTLD lesions was significantly different between the two groups with a priority for late-onset PTLD to represent non-hodgkin lesions (p=.009). no difference was found between the two groups in survival (p=.237). One and five-year survival rates for early-onset PTLD patients were 65% and 46%, respectively; compared to 53% and 41%, respectively, for the late-onset PTLD. CONCLUSION: Due to a higher incidence of respiratory tract involvement in the early-onset PTLD patients and skin and spleen involvement in late-onset PTLD, we suggest that all heart/lung graft recipients should be evaluated for potential multiorgan disease based early or late presentation. further multi-institutional prospective studies are needed to confirm our results.

Repair of iatrogenic large colon perforation using laparoscopic methods. Case report and review of the literature.

Iatrogenic perforation of the colon during elective colonoscopy is a serious complication. Surgical treatment remains the standard of care. We report a patient with a large colonic perforation that occurred during a screening colonoscopy, successfully repaired with laparoscopic methods. Although the safety and efficacy of this approach is not entirely established, laparoscopy can be used to treat iatrogenic colonic perforation when the defect is readily recognized, easily accessible for closure and the bowel preparation is excellent. A laparoscopic approach to treat iatrogenic colon perforation results in decreased morbidity and hospital stay, in addition to a shorter incision length compared to an open method. In those cases where it is feasible and the surgical skill exists, a laparoscopic attempt at colon repair should probably be the initial clinical approach..

Genotyping Pattern among Iranian HCV Positive Patients.

BACKGROUND: Successful treatment to eliminate HCV RNA depends on the identified genotype. In the present study, we compared the frequency of different HCV genotypes, during four years study (2004 till 2008). METHODS: Sera specimens were received from 16 provinces of Iran. We used High Pure Viral Nucleic Acid Purification kit for extraction and samples were tested with improved form of RT-PCR technique. HCV genotypes were determined using Amplisense PCR kit and Amplicor HCV Monitoring Version 2 test utilized a reverse transcription (RT)-PCR approach to quantitative HCV RNA. Two hundreds six HCV positive specimens were entered to the study out of 389 tested samples. RESULTS: Type 3a was the most frequent type (46.6%), followed by type 1 (including 1a and 1b with 25.73% and 17.47% for each respectively) with 43.2%. Looking through collected results of the four years study confirmed the rate of HCV infection in those single genotypes 1b, 3a were slightly increased from 12.22% and 38.88% in the first year to 18.66 and 46.51% in the fourth year of the study period. CONCLUSION: The analyzed data proved that some patients were infected with two different types. High viral load was also more correlated to genotype 1 than other types.

Transplantation research in Iran: a bibliometric study.

BACKGROUND: Scientific articles are indicators of research interest and efforts in every country. The aim of the current study is to describe the characteristics of the transplantation-related research efforts with respect to the domestic published works in Iran between 1993 and 2003. MATERIALS AND METHODS: In a descriptive design, we searched IranMedex (Iranian database for indexing medical articles; available at: http//www.iranmedex.com) for all the biomedical articles published between 1993 and 2003 in 91 Iranian journals. The search was conducted using "transplantation" and "transplant" as key words. A printed copy of the references was reviewed individually so as to identify the transplanted organ, study design, number of authors, and type of article. RESULTS: Among 11371 articles, 545 (4.8%) were related to transplantation. An increasing trend was observed in the number of publications from 1993 to 2003. Most articles were published in Farsi (90%). The most frequently published articles were original articles (84.4%). The main subjects of were kidney (61.7%), followed by liver (12%) and bone marrow transplantation (10.8%). Cornea was the topic of research in only 3% of the papers. Of all manuscripts, 9.5% consisted of clinical trials. The mean number of authors was 3.6 +/- 2.2 (1 to 14). CONCLUSIONS: Iranian researchers seem to be interested in the topic of transplantation; however, some fields of transplantation are neglected. This pooling of valuable information can be used by other countries, especially by researchers from the Middle East Society for Organ Transplantation region. Such databases could form an invaluable network for an exchange of experience in the region to solve common problems.

Which primary diagnosis has the highest in-hospital mortality rate for kidney recipients?

OBJECTIVES: Although "in-hospital mortality" for several post-renal transplantation complications has been reported in various studies, there is no single published single-center study that compares their hospital mortality rates. We sought to rank the primary diagnoses post-renal transplantation by means of in-hospital mortality. METHODS: We selected 404 consecutive rehospitalizations following kidney transplantation from 2003 to 2005. The causes of rehospitalization were categorized into infection, allograft rejection, surgical complication, cerebrovascular accidents (CVA), malignancy, medication complications, and miscellaneous. Fatality was defined as the relative frequency of death due to the same cause among all admissions. RESULTS: The mortality rate (MR) was 5.7%. From the 23 cases of death, 17 (74%) had a functioning kidney at the time of death. The MR was 40% for CVA, 14.3% for surgical complications, 11.1% for miscellaneous, 5.3% for drug complications, 7% for infections, and 4.8% for graft rejection (P=.002). No death was observed among cases with a diagnosis of malignancy or nephrolithiasis. Inpatient mortality was higher among those with more than one diagnosis at admission: 42.9% for more than two diagnosis, 7.1% for those with two diagnosis, and 4.2% for those with one diagnosis (P=.001). CONCLUSIONS: The in-patient mortality ranking is totally different from the ranking of causes of death in renal recipients. In other words, infection is the leading cause of death due to high incidence, and not high fatality. More rare complications, including CVA and surgical complications, are more often fatal.

A logistic regression model for predicting health-related quality of life in kidney transplant recipients.

BACKGROUND: To develop a logistic regression model capable of predicting health-related quality of life (HRQOL) among kidney transplant recipients and determine its accuracy. METHODS: Three groups of patients were selected: 70 healthy controls, 136 kidney transplant patients as a derivation set, and another 110 kidney transplant patients as a validation set. SF-36 score was used for HRQOL measurement. A cutoff point to define poor versus good HRQOL was calculated using the SF-36 scores of healthy controls. A logistic regression model was used to derive predictive parameters from the derivation set. The derived model was then tested among the validation set. HRQOL predictions made by the model for the patients in the validation set and the SF-36 scores were compared. We calculated sensitivity, specificity, positive and negative predictive values, and model accuracy. RESULTS: SF-36 scores below 58.8 were defined as an indication of poor HRQOL. The regression model suggested that poor HRQOL was positively associated with lower education (below high school diploma), being single or widowed, and diabetes/hypertension as etiology. It was negatively associated with younger age (<45 years) at the time of transplantation. Optimal sensitivity and specificity were achieved at a cutoff value of 0.74 for the estimated probability of poor HRQOL. Sensitivity, specificity, positive and negative predictive values, and accuracy of the model were 73%, 70%, 80%, 60%, and 72%, respectively. CONCLUSION: The suggested model can be used to predict poor posttransplant HRQOL among renal graft recipients using simple variables with acceptable accuracy. This modal can be of use in decision making in the recipients for whom achieving good HRQOL is the main aim of transplantation, to select high-risk patients and to start interventional programs to prevent a poor HRQOL.

Data-entropy analysis of renal transplantation data.

INTRODUCTION: The terms entropy and robustness are currently used by biomedical investigators to predict the risk of change in a system. The former is the mathematical identification of uncertainty about a system, while the latter is the likelihood of system stability. We conducted an entropy-based analysis of our renal transplantation data set. MATERIALS AND METHODS: The input variables in our model included donors and recipients, past medical history, and other clinical data. The output variables were 6- month, 1-year, and 2- year patient and graft survivals. Data-entropy analysis was performed with Ontonix s.r.l. software (www.ontonix.com). RESULTS: The total input and output entropy was 13.14 and 1.54, respectively. The mean input and output robustness was 39.14% and 29.54%. The robustness amplification index was 0.75. The minimum entropy of the input variables was reported for a history of myocardial infarction (0.07), vascular disease (0.1), bladder residual (0.13), or urologic surgery (0.15). The minimum entropy of the output variables was 0.20 for 6-month patient survival; 0.22 for 1-year patient survival; 0.25 for 6-month graft survival; 0.27 for 1-year graft survival; 0.28 for 2-year patient survival; and 0.32 for 2-year graft survival. CONCLUSION: Data-entropy analysis demonstrated a high stability of our transplantation data set. Nevertheless, long-term outcomes, especially those of graft survival, were slightly more unpredictable.

Diabetes as the cause of end-stage renal disease affects the pattern of post kidney transplant rehospitalizations.

INTRODUCTION: Although there are reports that link diabetes-induced end-stage renal disease (ESRD) with several post renal transplantation complications and conditions, few studies have directly focused on this issue. This study compared the pattern of rehospitalizations after renal transplantation among diabetic versus nondiabetic ESRD patients, measuring causes, length of stay, outcomes and costs. METHODS: We retrospectively reviewed 366 randomly selected rehospitalization records of kidney transplant recipients between 1994 and 2006, including 69 who underwent renal transplantation due to diabetic nephropathy and 297, due to nondiabetic ESRD. We compared the two groups with respect to demographic and clinical variables: donor source, readmission pattern, rehospitalization cause, time interval between transplantation and hospitalization (T-H time), length of hospital stay (LOS), and intensive care unit (ICU) admission, hospital charges, and inpatient outcomes of graft loss and mortality. RESULTS: The diabetes group, compared with nondiabetic group, had a greater mean age (53 +/- SD vs. 39 +/- SD years), proportion of admissions due to infections (44.9% vs. 32%) or renal dysfunction (14.5% vs. 29.6%), mean hospital charges ($5056 vs. $3046), and hospital mortality (18% vs. 4.3%; P<.05). Diabetic patients were readmitted sooner after transplantation than nondiabetic patients (11 vs. 18 months; P<.05). There was no difference between the groups with regard to gender, donor source, LOS, ICU admission, and graft loss. CONCLUSION: The etiology of ESRD should be considered for scheduling post renal transplantation follow-up. Renal transplant recipients with diabetes-induced ESRD need further attention in follow-up programs.

Primary kidney disease and post-renal transplantation hospitalization costs.

BACKGROUND AND AIM: This study sought to assess posttransplantation hospitalizations costs in diabetic and nondiabetic subjects to see whether diabetes mellitus (DM) as a primary cause of end-stage renal disease (ESRD) increased posttransplantation hospitalization costs. METHODS: From 2000 to 2005, the hospitalization costs of 387 consecutive rehospitalizations of kidney recipients were retrospectively compared for two groups: patients with ESRD due to DM (n=71) and those with ESRD of non-DM etiologies (n=316). The hospitalization costs included the costs of hotel, medications, surgical procedures, paraclinical tests, imaging tests, health personnel time, special services (ie, patient transportation by ambulance), and miscellaneous costs. Societal perspective was used with costs expressed in PPP$ purchase power parity dollars (PPP$) estimated to be equal to 272 Iranian rials. RESULTS: Compared with the non-DM group, DM patients experienced significantly higher median costs both in total (1262 vs 870 PPP$, P=.001) and in cost components related to hotel (384 vs 215 PPP$, P=.001), health personnel time (235 vs 115 PPP$, P<.001), paraclinical tests (177 vs 149 PPP$, P=.012), and special services (100 vs 74 PPP$, P=.041). The mean of age was higher (P<.001), and the transplantation hospitalization time interval was also shorter in the DM group (median: 2.7 vs 12, P=.025). CONCLUSIONS: Considering DM as a leading cause of ESRD and its increasing prevalence in some countries, the association between hospitalization costs of posttransplant patients and DM may be of great economic importance to many transplantation centers.

Prediction of inpatient survival and graft loss in rehospitalized kidney recipients.

INTRODUCTION: Despite a sizeable amount of research conducted hitherto into predictors of renal transplantation outcomes, there are scarce, data on predictors of in-hospital outcomes of post-kidney transplant rehospitalization. This study sought to provide a user-friendly prediction model for inpatient mortality and graft loss among rehospitalized kidney recipients. METHOD: This retrospective review of 424 consecutive kidney recipients rehospitalized after kidney transplantation between the years 2000 and 2005 used multiple logistic regression analysis to evaluate predictors of hospitalization outcomes. RESULTS: Multivariate analysis showed that age at admission, diabetes mellitus as the cause of end-stage renal disease (ESRD), admission due to cerebrovascular accident (CVA), surgical complications were predictors of in-hospital death; age at transplantation, surgical complications, and rejection were predictors of graft loss. Equation for prediction of in-hospital death was Logit(death) -0.304 * age at transplantation (year) + 0.284 age at admission (year) + 1.621 admission for surgical complication + 4.001 admission for CVA-ischemic heart disease + 2.312 diabetes as cause of ESRD. Equation for prediction of in-hospital death was Logit(graft loss) = 0.041 age at transplantation (year) + 1.184 admission for graft rejection + 1.798 admission for surgical complication. CONCLUSIONS: Our prediction equations, using simple demographic and clinical variables, estimated the probability of inpatient mortality and graft loss among re-hospitalized kidney recipients.

Cytomegalovirus disease after kidney transplantation: clues to accurate diagnosis.

BACKGROUND: The clinical diagnosis of cytomegalovirus (CMV) disease after kidney transplantation is often not accurate. We evaluated the factors associated with a correct diagnosis of CMV disease in these patients. MATERIALS AND METHODS: This retrospective study of all renal transplant patients between 2004 and 2005 with a clinical diagnosis of CMV disease included both donors and recipients who were seropositive for CMV at transplantation. We assessed the rate and correlated factors with a correct diagnosis. RESULTS: Among 127 cases, the 30 (23.6%) patients who had a correct diagnosis of CMV disease. Showed higher ages at transplantation (48.8 +/- 15.3 vs. 39.8 +/- 14.4 years; P=.004) and a shorter interval between transplantation and symptom presentation (9.7 +/- 20.7 vs. 25.6 +/- 33.6 days; P=.048). Diabetes mellitus (DM) was the cause of end-stage renal disease (ESRD) in 41% of patients with a correct diagnosis, whereas it was the cause in 11% of CMV disease-negative patients (P<.001). A multiple logistic regression model showed that DM as the cause of ESRD (P=.001; odds ratio [OR] 16.331), >5 months duration between transplantation and the presence of symptoms (P=.001; OR, 0.060), and age at transplantation >55 years (P=.022; OR, 3.833) were predictors of a correct diagnosis of CMV disease (chi(2)=46.45; P<.001). CONCLUSION: The results herein showed that considering some variables significantly improved the accuracy of a correct diagnosis of CMV disease after kidney transplantation.

Gastro-duodenal lesions and Helicobacter pylori infection in uremic patients and renal transplant recipients.

BACKGROUND: Upper gastrointestinal (UGI) symptoms are common in uremic patients, and higher serum levels of urea have been suggested to be related to Helicobacter pylori (HP) colonization and UGI mucosal inflammation. AIM: The aim of this study was to compare HP infection and UGI endoscopic findings between uremic patients, renal transplant (RT) recipients, and controls. METHODS: A total of 474 subjects (71 chronic renal failure [CRF], 73 hemodialysis [HD], 25 Tx, and 305 controls) from Baqyiatallah Hospital, Tehran, Iran were recruited between April 2002 and March 2004 for evaluation of dyspepsia, excluding those receiving any HP-eradication therapy. All subjects were examined for esophagus, stomach and duodenum mucosa, and infection with HP on 2 distinct tissue samples of the anthral region. RESULTS: Four groups of subjects (mean +/- 2 se; age, 45 +/- 1.6 years; 62.9% male) were studied. Duodenal ulcer in the uremic patients (CRF, 16.1%; HD, 13.7%) was more common than that in the RT-recipients (8%) and controls (6.5%); P=.038. Erosive gastritis and duodenal bulb deformity were also more common in the uremic subjects (CRF, 23.9%, 36.9%; HD, 30.1%, 20.5%, respectively) than those in the other subjects (RT recipients, 16%, 8%; controls, 8.2%; 0%, respectively); P<.001. HP infection was found to be higher in the uremic patients (CRF, 66.2%; HD, 63%) than in the RT recipients (40%) and controls (34.8%); P<.001. CONCLUSION: Higher rates of gastric and duodenal mucosal lesions and HP infection in the uremic patients in comparison with the subjects with normal renal function may have resulted from higher serum levels of urea, anemia, and fluctuations in the gastric blood supply in the CRF and HD patients. However, more tenable evidence from controlled trials is required for the eradication of HP in all uremic patients and transplantation candidates.

Does etiology of end-stage renal disease affect sleep quality in kidney transplant recipients?

BACKGROUND: That hypertension (HTN) as a leading cause of end-stage renal disease (ESRD) is linked to sleep disorders in the general population can be the basis of a hypothesis that HTN may be a contributing factor to the poor quality of sleep in some kidney transplant recipients. This study was designed to investigate the correlation between ESRD secondary to HTN and sleep quality among kidney transplant recipients. METHODS: In this case control study, 201 kidney transplant recipients were divided into group I (ESRD) secondary to HTN, (n=82) and group II (ESRD secondary to other causes, n=119). The groups were matched for medical comorbidities, demographic and clinical data, and symptoms of anxiety and depression. Sleep quality assessed by means of the Pittsburgh Sleep Quality Index (PSQI) was compared between the study groups. RESULTS: The mean (SD) of the total PSQI score was significantly high in group I compared with group II (7.42 +/- 2.36 vs 6.60 +/- 3.07, P=.042). Similar results were observed for the sleep duration scores in the groups (1.22 +/- 1.12 vs 0.86 +/- 1.12, P=.026). In group I, all the other PSQI components were higher than those in group II, difference that were statistically significant. CONCLUSION: Sleep quality and duration was poorer among our kidney transplant recipients with ESRD secondary to HTN compared with the controls. Further studies, however, are required to investigate whether HTN is responsible for the reported poor quality of sleep in some kidney transplant recipients.

Sleep quality and its correlates in renal transplant patients.

BACKGROUND: The aim of this study was to evaluate correlated morbidity measures with poor sleep quality among kidney transplanted patients. METHODS: In a cross-sectional study of 125 Iranian kidney transplant patients in 2006, we employed self-administered questionnaires to evaluate the quality of sleep (PSQI), quality of life (SF-36), anxiety and depression, sexual activity, marital relationship, and medical comorbidity. Patients with PSQI score of >5 were considered to be "poor sleepers." Students t-test was used to compare the morbidity measures between the two groups: "poor sleeper" versus "good sleepers." RESULTS: Seventy-eight (62%) patients were poor sleepers. This group showed a higher total medical comorbidity score (P=.009), more bodily pain, poorer general mental health, and less physical function on SF- 36 (P=.02), less sexual function, and more severe anxiety (P=.02). There was no significant difference between poor sleepers and good sleepers in the mean of other subscores of the SF-36, marital status, and depressive symptoms. CONCLUSIONS: A poor quality of sleep is common after kidney transplantation. This problem is associated with higher medical comorbidity and poorer emotional state. Therefore, more attention should be paid to evaluation of sleep quality in this patient population.

Impact of pregnancy on the outcome of kidney transplantation.

BACKGROUND: There is still controversy over whether pregnancy adversely affects renal transplantation outcomes. We, thus, compared two groups of kidney transplant recipients in terms of patient survival and allograft function: those who did versus did not conceive posttransplant. METHODS: This historical cohort study conducted between 1996 and 2002, divided female kidney transplant recipients of reproductive age into group I (n=86, at least one posttransplant pregnancy) and group II (n=125, no posttransplant pregnancy). The two groups were matched for age, cause of end-stage renal disease (ESRD), treatment protocol, and first creatinine (Cr). All patients received a first transplant and all had a Cr less than 1.5 mg/dL on entry into the study. The subjects were followed for 45.4 +/- 22.0 and 46.3 +/- 19.8 months, respectively (P>.05). Five-year patient and graft survivals and Cr were considered to be the main outcome measures. RESULTS: Mean (SD) age in groups I and II was 26.6 +/- 6.6 and 26.9 +/- 8.1 years, respectively (P>.05). Five-year patient and graft survival rates were not significantly different between the study groups. Of the women in group 1, only 9 (10.5%) subjects displayed elevated serum Cr levels (>1.5 mg/dL) at the end of follow-up, while the serum Cr levels in 35 (28%) group II patients were above 1.5 mg/dL (P=.024). CONCLUSION: Our results indicates pregnancy did not seem to adversely affect patient and graft survival among kidney transplant recipients. Renal transplantation in stable women of childbearing age should not be a contraindication to pregnancy.

Distal esophagitis in patients with mustard-gas induced chronic cough.

Although confounded by some factors such as medications or surgical complications, the relationship between esophageal pathology and pulmonary disorders has been the subject of many studies. The present study sought to investigate the said relationship in patients inflicted by respiratory disorders induced by mustard gas (MG). A case group of patients complaining of respiratory complications and chronic coughs following MG exposure, and a control group of patients with chronic coughs but without a history of MG exposure were studied. All the case and control subjects had symptoms of gastro-esophageal reflux disease. Chest high resolution tomography (HRCT) was performed to evaluate the existence of pulmonary disorders. Endoscopy and histological studies were carried out to determine the severity of esophagitis in both groups presenting with gastroesophageal reflux. Ninety male patients, who had met our criteria, along with 40 male control cases underwent the diagnostic procedures. The frequency of endoscopic esophagitis findings in the chemically exposed group was significantly higher than that in the control group (70.0%vs. 42.5%). A pathological evaluation revealed that the frequency of esophagitis in the cases was more than that in the controls (32.3%vs. 14.2%). Chest HRCT evaluation demonstrated that half the case group had more than 25% air trapping in expiratory films, mostly compatible with bronchiolitis obliterans (BO). In addition, they were suffering from asthma, chronic bronchitis and bronchiectasis. Bronchiolitis obliterans, along with other lung disorders, can be considered as contributors in the pathogenesis of esophagitis in MG exposed patients.