Unusual variability of the superficial venous system of the upper limb and its consequences for deep venous system.

In our report we would like to present a variation of the two main superficial veins of the upper limb. In 21 (88%) explored upper limbs, the venous system showed a pattern similar to that presented in the anatomical textbook. However, in 4 (12%) others venous patterns differed from those already described. Especially in one of them the variant of the veins of the upper limb distinctly contrasted with the others. In that case, the basilic and cephalic vein, instead of the normal course to the arm where they should bypass the elbow pit, unexpectedly merged into one and formed one of the two brachial veins. Towards the axillary cavity it ran laterally over the entire arm regardless of the second brachial vein. In the armpit cavity, instead of connecting with the second one, it gave rise to an independent second vein - the accessory axillary vein. This uniqueness was based on that, independently from deep venous system, the superficial one formed their own net. The accessory axillary vein and the second brachial vein were completely formed by two main superficial veins: the basilic and cephalic vein. By describing this case we wanted to emphasize that in any surgical procedure on the upper limbs, especially on the venous system, there is a certain probability of encountering this anatomical variation. Another conclusion is that the catalogue of patterns of the venous system of the upper limb seems to be endless.

Anatomical traps for arteriovenous fistula creation.

BACKGROUND: The risk of complications in undisclosed vascular variability appears relatively likely. Therefore, it is important to assess the probability of encountering anatomical-topographic variability in the venous system of the upper limb. The catalogue of patterns of the upper limb venous system seems to be unlimited and should therefore be constantly updated. The aim of the study was to explore the venous system of upper extremity and discuss some problems that would be encountered with the formation of an arteriovenous fistula. RESULTS: In 17 (85%) explored upper limbs, the venous system showed a pattern similar to the reports already described. But in (15%) 3 of them, the venous system showed certain differences in relation to the accepted anatomical textbooks. Especially in one of them the anatomical variant of basilic and cephalic vein contrasted distinctly with the other veins. Based on the revealed anomalies, a statistical analysis of the probability of occurrence of any anatomical variant and the risk of complications associated with fistula creation was conducted. Even on such small group an assessed probability of anatomical variability of the upper limb venous system was statistically significant at p < 0.0244 (odds ratio 0.0828; 95% confidence interval 0.0095-0.7252). CONCLUSIONS: The probability of any anatomical-topographic variability in the venous system of the upper limb should be considered as statistically significant. Only intense anatomical dissections would undoubtedly help to avoid some anatomical traps and then minimise some complications in the creation of arteriovenous fistulas.

The impact of interleukin 12B (1188A>C), interleukin 16 (-295T>C), and interleukin 18 (607C>A, 137G>C) gene polymorphisms on long-term renal transplant function and recipient outcomes.

BACKGROUND: Inflammatory mediators play an important role in kidney graft outcome. The cytokine and chemokine gene polymorphisms are associated with variable production, activity, expression, or ligand-receptor affinity. Genetic variation in the DNA sequence of the interleukin 12B (IL12B), interleukin 16 (IL16), and interleukin 18 (IL18) genes may lead to altered cytokine production and activity. These variations can lead to changes in individual patient outcomes after kidney transplantation. It is known that polymorphisms of interleukins have an influence on inflammatory diseases, eg, Crohn's disease, diabetes, and asthma. AIM: The aim of this study was to evaluate the correlation between IL12B, IL16, and IL18 gene polymorphisms with delayed graft function (DGF), acute rejection episodes (AR), and chronic rejection episodes (CR). MATERIALS AND METHODS: A total of 267 (38.6% women, 61.4% men) recipients were included in the study. Cadaveric kidney transplantations were performed at the Department of General Surgery and Transplantation. Polymerase chain reaction was used to determine gene polymorphisms of IL12B (rs3212227), IL16 (4778889), and IL18 (rs1946518, rs187238) in 2 mL of serum. Statistical significance (P < .05) was analyzed by logit regression, ANOVA and odds ratio (OR) of χ(2) with Yates correction (95% confidence interval). RESULTS: Regression analysis revealed no significance between AR/DGF/CR and IL-2B, IL16, IL18rs1946518, and IL18-rs187238 (P > .05). The CR group, AA vs CC genotype of IL18 (rs1946518), had an OR = 2.35 (P = .04). AR and DGF groups had no significance in OR. CONCLUSIONS: There was no statistical significance between IL12B, IL16, and IL18 (rs187238) gene polymorphisms and kidney graft outcome after transplantation. Presence of AA genotype (IL18-rs1946518) is connected with a 2.35 times higher risk of CR occurrence.

The effect of cause of cadaveric kidney donors death on fibrinolysis and blood coagulation processes.

BACKGROUND: Organ donors can be generally divided into two groups according to the cause of their death. The first group is composed of those who died because of physical injuries, especially road traffic injury, and the second group, those who died from central nervous system (CNS) stroke or bleeding. The aim of our work was to examine hemostatic processes among kidney donors. MATERIALS AND METHODS: The 38 deceased kidney donors (KD) included 11 women and 27 men of overall average age of 37±12 years. The donor group of according to the cause of death, included 14 injured donors (ID) (41%) and 24 noninjured donors (ND) donors (59%). The control group consisted of 25 healthy volunteers matched for sex and age. We determined the following concentrations: antithrombin (AT), thrombin/antithrombin complexes (TAT), and prothrombin F1+2 fragments. The fibrinolytic parameter concentrations were: plasminogen (PL), plasmin/antiplasmin complexes (PAP), and D-dimers. RESULTS: Deceased kidney donors showed an increased plasma concentrations of TAT complexes (P<.000001) and prothrombin fragments F1+2 (P<.0000001); however, the protein C concentration was decreased (P<.000001). The antithrombin activity was similar to the control group. The concentrations of PAP complexes and d-dimers were higher (both P<.000001), but the level of PL lower among KD compared with controls (P<.0000001). The higher of TAT, PAP complexes, d-dimers, and F1+2 concentrations as well and as lower plasminogen and PC concentrations were evidence for increased activation of blood coagulation and fibrinolysis in cadaveric KD. However, analysis compairing ID versus ND donors revealed increased concentrations of PAP complexes (P<.05) and decreased amounts of TAT complexes (P<.01) among ID subgroup. The positive predictive value (PPV) and negative (NPV) for PAP complexes were 75% and 68% and for TAT, 71% and 57%, respectively. On the basis of these observations, we concluded that an intensive activation of fibrinolytic process occurs among the ID. In contrast, ND show intensive activation of blood coagulation.

Graft infection in kidney recipients and its relation to transplanted kidney function.

INTRODUCTION: Following kidney transplantation, septic complications are the leading causes of therapeutic failure including recipient death or graft removal. The serum creatinine level is one of the earliest metrics of kidney metabolic function. We examined the influence of graft infection on serum creatinine levels in kidney recipients. STUDY DESIGN: We analyzed the function of 220 kidneys transplanted in nine centers in Poland. The kidneys were recovered from 146 multiorgan donors. Donor urea and creatinine levels were within the normal range. We investigated the influence of perioperative graft infection incidence on recipient creatinine levels at 1, 2, 3, 7, 14, 30, 90, and 180 days after kidney transplantation. The association of the serum creatinine level with categorical variables was assessed using either Student t test analysis of variance and multivariate techniques. In all analyses P<.05 indicated statistical significance. RESULTS: There were 25 graft infections revealing a significant relationship with increased recipient serum creatinine level after kidney transplantation (P=.003). Multivariate analysis confirmed the impact of infection. CONCLUSION: Perioperative kidney graft infection influenced graft funtion in the early and late periods post-transplantation.

The outcomes of treatment and the etiology of lymphoceles with a focus on hemostasis in kidney recipients: a preliminary report.

BACKGROUND: The etiopathogenesis of lymphoceles remains incompletely understood. The aim of our work was to analyze the perturbations of blood coagulation process for their possible impact on the etiology of lymphoceles. Additionally we performed an evaluation of the incidence and effectiveness of treatment methods for lymphoceles. MATERIALS AND METHODS: During 2004 to 2010, we performed 242 kidney transplantations in 92 female and 150 male patients. The hemostatic parameters included concentrations of: antithrombin, plasminogen, thrombin/antithrombin complexes (TAT), prothrombin products F1+2 (F1+2), d-dimers, and plasmin/antiplasmin complexes. RESULTS: At 7 years follow-up 27 (11%) recipients had developed symptomatic lymphoceles, namely abdominal discomfort, a palpable mess in the lower abdomen, arterial hypertension, infection of the operative site with fever, lymphorrhoea with surgical wound dehiscence, decreased diurnal urine output with an elevated plasma creatinine, voiding problems of urgency and vesical tenesmus, and/or symptoms of deep vein thrombosis. We applied the following methods of treatment aspiration alone, percutaneous drainage, laparoscopic fenestration or open surgery. In two only patients did perform open surgery. Since 2008 we have not performed an aspiration alone because of high rate of recurrence (almost 100%) and abandoned open surgery in favor of a laparoscopic approach. Our minimally invasive surgery includes percutaneous drainage guided by ultrasound and a laparoscopic procedure with 100% effectiveness. The examined hemostatic parameters revealed decreased concentrations of TAT complexes and F1+2 in subjects with lymphocele showing positive predictive values of 33% and 41% respectively. The negative predictive values for TAT complexes and F1+2 were 14% and 10%, respectively, suggesting decreased blood coagulation activity among effected recipients. Altered blood coagulation processes may explain some aspects of the disturbances of postoperative obliteration of damaged lymphatic vessels and formation of pathological lymph collection afterward. CONCLUSIONS: Perturbations of blood coagulation may be one cause for a lymphocele.

Histopathologic evaluation of pretransplantation biopsy as a factor influencing graft function after kidney transplantation in 3-year observation.

BACKGROUND: Many factors affect long-term results in kidney transplantation including histologic damage as a independent predictor, eg, chronic allograft dysfunction (CAD) in protocol biopsies and age-dependent lesions. Histopathologic findings correlate with the incidence of delayed graft function, eventual renal function, and allograft survival, allowing a rather precise prediction of graft outcomes. PATIENTS AND METHODS: We analyzed 92 thick-needle preimplantation renal biopsies and 29 from grafts after explantation. They had been preserved in 4% formalin and immersed in paraffin. Evaluable specimens contained ≥10 glomeruli and ≥2 arterial cross-sections. We analyzed tubulitis, intensity of acute tubular necrosis (ATN), inflammatory infiltration, glomerulonephritis, arterial hyalinization, arteritis, fibrosis, tubular atrophy, arterial intimal fibrosis, increased mesangial matrix, and glomerulosclerosis percentage, although for comparative analysis not only optimal ones were taken into consideration. Over postoperative time, we analyzed patient condition, urine output, serum concentrations of creatinine, urea, uric acid, and ions as well as necessity for postoperative dialysis, ie, delayed graft function (DGF). During the 3-year observation we analyzed living recipients, graft loss, death with a functioning graft, incidence of dysfunction (CAD), and acute rejection episodes (ARE). RESULTS: We observed significant correlations between immediate graft function (IGF) and lack of ATN in the pretransplantation biopsy. The presence of ATN significantly correlated with DGF and primary graft non-function. There was no correlation between renal function and arterial hyalinization or fibrosis, inflammatory infiltration, and tubular atrophy. Over postoperative time we observed significant correlations between IGF and the lack of interstitial fibrosis as well as significantly lower levels of creatinine, urea, and potassium as well as greater urine output early after transplantation. IGF correlated with shorter time to reach a creatinine level of 2 mg/dL, lower concentrations of creatinine, urea, and potassium, as well as greater diuresis during the first 5 days. In addition, lower creatinine and urea concentrations after 1 month and of urea at 6 and 36 months were associated with IGF. Female recipients showed lower concentration of creatinine over 3 months, of urea during the 1st day, and of potassium at 1 month; however, thereafter the differences were not significant. Better function of the right kidney was observed. The presence of severe ATN (ATN III) correlated with lower creatinine concentrations at 6 months and urea after 3 years. The presence of hyalinization in biopsies correlated with higher concentrations of urea at 1 year and of borderline significance after 3 years; surprisingly, potassium concentrations were lower after 2 and 3 years. The presence of inflammatory infiltrates correlated with higher creatinine concentrations after 1 and 3 years; similar correlations, albeit of borderline significance, were observed in tubular atrophy. Interstitial fibrosis correlated with creatinine concentrations during 10 days after the operation and after 12 months, also with potassium concentrations 5 days after the operation. Borderline correlations were observed between donor age and creatinine concentration in the first day after the operation, after 6 months, and time to achieve a creatinine concentration of 2 mg/dL. We observed that biopsies with greater numbers of glomeruli correlated with better graft function, namely, lower creatinine concentrations after 5 days as well as at 1 and 6 months, as well as lower urea concentrations after 5 days and 6 months. We also observed differences in renal function depending on gender. The presence of acute tubular necrosis, arterial fibrosis and a lack of inflammatory infiltration in pretransplantation biopsy correlated with worse late renal function. Explantation biopsies showed signs of CAD in 66.4% and histologic features of ARE in 38.51%.

Risk factors for septic complications in kidney transplant recipients.

INTRODUCTION: Septic complications following kidney transplantation are a leading cause of therapeutic failure. An early diagnosis may protect the recipient from the severe consequences of sepsis. We sought to determine the risk factors influencing the occurrence of septic complications among kidney transplant recipients. MATERIALS AND METHODS: The 146 potential donors included in the study were evaluated for brain stem death criteria. Supportive management included mechanical ventilation to normocapnia, rewarming, as well as fluid and electrolyte replacement. Dopamine infusions and desaminovasopressin were titrated to predetermined mean arterial pressure (MAP). Central venous pressure (CVP) was maintained at 8 to 11 mm Hg. Hemodynamic data were acquired by the thermodilution method prior to organ procurement: MAP, CVP, pulmonary capillary wedge pressure (PCWP), and systemic vascular resistance index (SVRI). Recipient data included age, gender, period of prior hemodialysis, panel reactive antibodies, cold ischemia time, and cause of renal insufficiency. The 232 kidney recipients were examined for occurrence of septic complications including septicemia, pneumonia, peritonitis, or graft infection. RESULTS: Kidney transplants from donors with MAP < 70 mm Hg and SVRI < 1200 dyne x s/cm(5) x m(2) showed a significantly higher occurrence of septic complications in recipients (P < .05) where mortality rate was also significantly greater (P < .01). CONCLUSIONS: MAP < 70 mm Hg and SVRI < 1200 dyne x s/cm(5) x m(2) among organ donors predicted greater occurrence of septic complications and increased mortality among kidney transplant recipients.

Minimally invasive methods for the treatment of lymphocele after kidney transplantation.

BACKGROUND: One common complication after kidney transplantation is a lymphocele. The aim of our work was an analysis of incidence of lymphocele and the effectiveness of minimal invasive methods in the management of this complication. MATERIALS AND METHODS: The examined group was consisted of 158 patients (68 female and 90 male) with end-stage renal disease who underwent kidney transplantation. RESULTS: Twenty-one patients (13%) developed symptoms of lymphocele after transplantation procedure within an average time of 34 weeks. The clinical symptoms included a decrease in 24-hour urine collection, an increase in plasma creatinine concentration, abdominal discomfort, lymphorrhea with a surgical wound dehiscence, voiding problems of urgency or vesical tenesmus, febrile states, or symptoms of deep vein thrombosis. The following methods were applied with variable efficacy: aspiration with recurrence 75%; percutaneous drainage with 55%, effectiveness; laparoscopic fenestration with 72% satisfactory outcomes (1 patient presented an excessive bleeding after the procedure), and classic surgery with favorable results. CONCLUSION: Percutaneous drainage guided by ultrasonic imaging should be recommended as the first attempt to cure a lymphocele. Laparoscopy is a feasible, safe technique that should be used after unsuccessful percutaneous drainage. A larger series of patients is required to confirm the superiority of minimal invasive methods to the classical approach.

Experience with autosomal dominant polycystic kidney disease in patients before and after renal transplantation: a 7-year observation.

OBJECTIVE: Autosomal dominant polycystic kidney disease (ADPKD) is characterized by the presence of multiple cysts in both kidneys. Symptoms of the disease may arise either from the presence of cysts or from increasing loss of kidney function. First symptoms usually appear in the third decade of life: lumbar pain, urinary tract infections, arterial hypertension, or renal colic due to cyst rupture or coexistent nephrolithiasis. An early diagnosis, male gender, large kidneys by sonography, arterial hypertension, hematuria, and urinary tract infections are predictive factors of a faster progression of the disease. Our aim was to establish the indications for nephrectomy among symptomatic ADPKD patients before kidney transplantation and to assess the risks of posttransplantation complications among ADPKD patients without nephrectomy. PATIENTS AND METHODS: The observed group consisted of 183 patients with ADPKD among whom 50 (27.3%) underwent kidney transplantation during a 7-year observation period (2000-2007). Among those subjects were 3 groups: (I) nephrectomy preceding transplantation; (II) nephrectomy during kidney transplantation; and (III) without nephrectomy. RESULTS: Among group I before transplantation we observed: arterial hemorrhage, wound infections, and splenectomy 4 weeks after ADPKD nephrectomy; afterward we observed: urinary tract infections and contralateral cyst infection. Among group II we only observed 1 case of wound infection. Among group III we observed: ascending urinary tract infections, cyst infections, and cyst hemorrhage. Cyst hemorrhage and cyst infections led mainly to ADPKD kidney nephrectomy. During the observation time, 80.95% of grafts were functioning. CONCLUSIONS: Unilateral nephrectomy is a well-founded preliminary surgical treatment before kidney transplantation. Bilateral nephrectomy before or during transplantation eliminates ADPKD complications and does not significantly increase general complications. The greatest numbers of complications and of graft losses were observed among the group without pretransplantation nephrectomy.