The effect of HA330 hemoperfusion adsorbent method on inflammatory markers and end-organ damage levels in sepsis: a retrospective single center study.

OBJECTIVE: In this study, we aimed at evaluating the impact of HA330 hemoperfusion adsorbent application on inflammatory markers and end-organ damage markers in patients with sepsis/septic shock. PATIENTS AND METHODS: Patients who were diagnosed with sepsis/septic shock and treated with HA330 hemoperfusion adsorbent in addition to the standard treatment were included in this retrospective study conducted at Inonu University Turgut Ozal Medical Center between January 1, 2019 and January 1, 2021. RESULTS: A total of 150 patients were included in the study. The mean±SD age of the patients was 51.9±17.7 years. 102 patients (68%) were in septic shock. Mean±SD APACHE II scores were 15.3±4.8. The need for mechanical ventilation was noted in 64 patients (42.7%). WBC, neutrophil count, hemoglobin, platelet count, BUN, creatinine, AST, ALT, CRP and procalcitonin levels were measured before and after the procedure. Overall, 104 patients (69.3%) died median (min-max) 2.5 (1-114) days after the cytokine adsorption, while 46 patients (30.7%) recovered from sepsis and were discharged. The increase in BUN levels and decrease in platelet count after the procedure were statistically significant (p≤0.001, 0.041, respectively) in the overall study population. The laboratory findings in 46 survivors indicated significantly decreased AST and ALT levels after cytokine adsorption compared to baseline pre-treatment levels. WBC, neutrophil count, CRP, procalcitonin, BUN and creatinine values were also decreased after cytokine adsorption in survivors, whereas the change was not statistically significant. There was also a non-significant tendency for an increase in platelet count and hemoglobin levels after cytokine adsorption compared to pre-treatment values in these patients. CONCLUSIONS: Although no effect of HA330 hemoperfusion application on inflammatory markers and end-organ damage markers was demonstrated in our study, we used the HA330 hemoperfusion adsorbent method as a last resort in terminal patients with a mortality rate of approximately 90% and for whom antibiotic treatment did not benefit. Therefore, multicenter, prospective studies are needed to clarify the effect of early HA330 hemoperfusion use in the treatment of sepsis.

Geographic Distribution of Multiple Arteries and Veins of 878 Kidney Donors From a Transplant Center in Turkey.

AIM: The diagnosis and management of multiple renal arteries and veins have gained importance with the increasing number of kidney transplantations and improved techniques in interventional radiology and vascular reconstructions. The aim of this study is to define and to detect the rate of multiple renal arteries and veins in our living kidney transplant donors coming from all parts of our country. METHODS: Abdominal computed tomography angiogram findings of 878 kidney transplant donors were analyzed. The presence and the distribution of multiple renal arteries and veins in donors coming from 7 geographic regions in Turkey were noted. RESULTS: The presence of multiple renal arteries was observed in 34% (48/141) of patients in the Marmara Region, 36.7% (79/215) of patients in the Black Sea Region, 37.2% (64/172) of patients in the Central Anatolia Region and 36.1% (30/83) of patients in the Southeastern Anatolia Region. The highest incidences of multiple renal arteries were observed in the Mediterranean and Aegean regions, affecting 40% (32/80) and 41.9% (26/62) of patients, respectively, while East Anatolia was found to have the lowest incidence, affecting 28% (35/125) of patients. The incidence of multiple renal veins also varied across regions. The highest incidence was observed in the Central Anatolia Region, where 23.3% (40/172) of patients were affected; the lowest was seen in the Aegean Region, where 11.3% (7/62) of patients were affected. In Turkey as a whole, 35.8% (314/878) of patients presented with multiple renal arteries, while the rate of multiple renal veins was found to be 19% (167/878) among our donors. CONCLUSIONS: As 80% of the kidney transplantations performed in Turkey involve living donors, we think it will be useful to have knowledge of not only the presence of multiple renal arteries and veins, but also the distribution of this feature throughout the different regions of the country.

Effect of Obesity on Clinical Outcomes of Kidney Transplant Patients.

PURPOSE: Correlating with the obesity epidemic, the number of obese transplant candidates is increasing. This study was designed to evaluate the effect of obesity on the survival of our kidney transplant recipients. METHODS: Among 1033 kidney transplants performed during the last 7.5 years in our center, 750 adult recipients were transplanted from living donors and were evaluated, and 561 of them were included in the study. Demographic and clinical data were collected. Body mass index (BMI) values at the time of transplant and post-transplant during the first year, the presence of delayed graft function, hospitalization duration, number of readmissions within the first year post-transplant, presence of post-transplant diabetes mellitus (PTDM) and cardiovascular disease, and graft and patient survival rates at 1, 3, and 5 years were investigated. RESULTS: Obesity (BMI >30) was observed in 148 (19.7%) at the time of the transplant (initial obesity) and in 174 (23.2%) recipients at post-transplant first year. Initial obesity was not only found to be correlated with delayed wound healing (P = .03), increased hospitalization duration (P = .03), number of readmissions within the first year (P = .04), presence of PTDM (P = .02), and cardiovascular disease (P = .03) but also with lower graft survival rate (P = .04) at the first year. On the other hand, obesity at post-transplant the first year was associated with lower 3- and 5-year grafts (P = .04 and P = .03, respectively) and 5-year patient (P = .03) survival rates. CONCLUSION: Obesity should not be considered as a contraindication for kidney transplantation; however, to achieve better results, certain precautions should be taken pre- and postoperatively.

Transplantation of a Blue Kidney: A Case Report.

A blue kidney, although very rare, can be encountered upon a live kidney donor. Literature has shown hemosiderin deposits, lipofuscin pigment, and melanosis as possible reasons. We report on a 37-year-old woman who wished to donate a kidney to her husband. The donor's preoperative biochemistry and imaging tests showed normal renal function. During the laparoscopic left kidney nephrectomy, the kidney was observed to be blue in color. Perioperatively, Doppler ultrasonography was used to rule out vascular reasons, and a wedge biopsy was performed. The other kidney was also explored, and it turned out to be blue as well. Histopathological analysis showed melanosis in the tubules without malignity or pathologic changes in the glomeruli, the interstitium, or the vessels. Even though some causes of blue kidney may result in impairment of the renal function, after the necessary tests show no signs of malignity and functional impairment, a blue-colored kidney may be suitable for transplantation.

Comparison of Two Different Laparoscopic Donor Nephrectomy With Vaginal Extraction Techniques-A Single-Center Experience.

OBJECTIVE: The aim of this study was to compare the results of standard laparoscopic donor nephrectomy with vaginal extraction (SLDN-VE) and laparoendoscopic single-site donor nephrectomy with vaginal extraction (LESSDN-VE). METHODS: We analyzed the data of 95 female donors who underwent SLDN-VE (group I; n = 87) and LESSDN-VE (group II; n = 8) in our center. Parameters regarding donor age, body mass index (BMI), length of hospitalization, duration of surgical procedure, amount of blood loss, warm and cold ischemia times, side of graft nephrectomy, number of renal arteries and veins, postoperative visual analog pain scores at 6th and 12th hours (VAS6, VAS12), peri-and postoperative complications of donors and recipients, and graft function at discharge and follow-up were compared between the 2 groups. RESULTS: No significant difference regarding donor age, mean operative time, amount of blood loss, or warm ischemia time was observed between the 2 groups. However, BMI (P = .018) and pain scores (VAS6: P = .047; VAS12: P = .009) were lower and length of hospitalization (P = .005) shorter in group II. On the other hand, cold ischemia time (P = .047) was lower in group I. No peri- or postoperative complications occurred for donors and recipients in both groups. Graft function at discharge and during follow-up were similar in both groups. CONCLUSIONS: Because our first priority is to minimize the morbidity of donors, LESSDN-VE can be chosen in selected female donors for not only decreased pain and hospital stay, but also for better cosmetic outcomes.

Role of Everolimus on Cardiac Functions in Kidney Transplant Recipients.

BACKGROUND: Kidney transplantation is known to increase the survival of dialysis patients by ameloriating cardiac status, including both systolic and diastolic functions. We aimed to evaluate the role of immunosuppressive drug regimens on cardiac functions of kidney transplant recipients (KTRs). METHODS: We prospectively evaluated 120 KTRs immediately before and 1 year after the kidney transplantation, using tissue Doppler echocardiography. A triple immunosuppressive therapy including tacrolimus, mycophenoloic acid (MPA), and prednisolone was started for all patients. After 3 to 6 months, the tacrolimus dose was lowered to achieve target serum levels of 5 to 8 ng/mL in both groups. MPA was switched to everolimus, with target levels of 4 to 6 ng/mL, in group 1 (n = 58), whereas group 2 (n = 62) continued with MPA. RESULTS: No differences in age, sex, or dialysis duration existed between the groups. The prevalence of diabetic or hypertensive nephropathy as the etiology of chronic kidney disease was similar. Blood pressure was strictly controlled. The number of acute rejection episodes was not different in both groups, and no graft loss was observed in either group. Improvement in cardiac parameters including ejection fraction, left ventricular diastolic diameter, posterior wall thickness, and left ventricular hypertrophy was significantly better before and 1 year after transplantation. Interestingly, when compared with group 2, ameloriation of all of the parameters mentioned above was even better in group 1 patients (P = .02, P = .03, P = .04, and P = .04, respectively). Multivariate analysis of the significant variables determined by univariate analysis identified albumin (relative risk [RR] = 1.05, P = .02) and everolimus (RR = 1.07, P = .01) as two independent factors of improving cardiovascular function. CONCLUSIONS: Better ameloriation of cardiovascular functions with everolimus may favor the choice of this drug in KTRs.

Evaluation of Bone Disease in Kidney Transplant Recipients.

BACKGROUND: Kidney transplant recipients are known to have bone disease, specifically osteoporosis. In this descriptive clinical study we aimed to evaluate the incidence of osteoporosis and to determine the risk factors among our transplant recipients. METHODS: A total of 109 patients (82 males and 27 females) aged from 19 to 70 years, who had undergone kidney transplantation 12 to 69 months previously, were included in the study. Bone mineral densitometry was performed using dual-energy X-ray absorptiometry. The correlation between femur and lumbar spine T-scores with age, gender, post-transplantation duration, serum 25 hydroxy vitamin D, parathyroid hormone, calcium, phosphorus, creatinine, and hemoglobin values were investigated. RESULTS: The incidence of osteoporosis was 22% (24 of 109 patients). The most common sites of osteoporosis were the femur (osteoporotic in 17 patients [15.5%] and osteopenic in 57 [52.2%]) and the lumbar spine (osteoporotic in 24 patients [22%] and osteopenic in 50 [45.8%]). Osteoporosis was found to have no relationship with age and gender. There was a significant negative correlation between serum parathyroid hormone levels with both femur and lumbar spine T-scores (P = .013 and .033, respectively). However, serum phosphorus levels were negatively correlated with only femur T-scores (P = .037). A positive correlation of hemoglobin with lumbar T-scores and a negative correlation with post-transplantation duration (P = .038 and .012, respectively) were also observed. CONCLUSION: Bone disease after transplantation is a frequent complication, which may decrease the quality of life, so we believe it is important to reduce the morbidity; it is required to detect and correct the risk factors of this complex pathophysiological situation.

Laparascopic Donor Nephrectomy Is Safe for Extremely Old Donors and Provides a Good Outcome for Their Recipients.

PURPOSE: This study sought to evaluate the outcomes of laparoscopic donor nephrectomy in donors age 70 years and older, who may be considered extremely old. PATIENTS AND METHODS: We compared the outcomes of grafts from donors age 70 years and older (group ≥ 70; n = 28) with donors younger than 55 years (group < 55; n = 28) after matching these 2 groups in terms of sex, date of surgery, body mass index, and immunological features, retrospectively. RESULTS: There was no statistical difference between the 2 groups in terms of operation duration, estimated blood loss, and cold ischemia time. However, warm ischemia time was found to be slightly longer in the younger group. The mean hospital stay length was similar for both groups, and no postoperative complications occurred in any donor. Early and intermediate-term serum creatinine levels of donors and their recipients were not statistically different in both groups. CONCLUSIONS: Laparoscopic donor nephrectomy can be performed safely in selected extremely old donors without concern for early and intermediate-term graft function, with the aim of extending donor pool.

Comparison of the right and left laparoscopic live donor nephrectomies: a clinical case load.

BACKGROUND: The aim of the present study was to retrospectively compare the results of right- and left-laparoscopic donor nephrectomy (LDN) performed in our Center. PATIENTS AND METHODS: Two hundred and eight patients who were operated on between October 2010 and October 2011 were included. Of the patients, 65 underwent right-LDN and 143 underwent left-LDN. The groups were compared in terms of duration of surgery, warm ischemia time, postoperative complications, length of hospital stay, and donor outcomes. RESULTS: The mean duration of surgery was 144±19.7 min and 147.8±20.2 min in the right- and left-LDN groups, respectively. The mean warm ischemia times were 139.1±54.1 s and 141.5±37.9 in the right- and left-LDN groups, respectively. The mean length of hospital stay was 2.4±1.0 days for both groups. No major complications were observed in the groups. There was no significant difference between the groups in terms of donor outcomes. CONCLUSIONS: The right-LDN is approached cautiously because of short length of vein and the risk for thrombosis. The results of the present study demonstrated that the right-LDN is as safe and effective as the left-LDN.

Comparison of serum creatinine and spot urine interleukin-18 levels following radiocontrast administration.

Radiocontrast administration is an important cause of acute renal failure. In this study, compared the plasma creatinine levels with spot urine IL-18 levels following radiocontrast administration. Twenty patients (11 males, 9 females) underwent radiocontrast diagnostic and therapeutic-enhanced examinations. The RIN Mehran risk score was low (≤5). The radiocontrast agents used were 623 mg/mL Iopromid (1.5 mL/kg), and 100 mL of 650 mg/mL meglumine diatrizoate as three-way oral and rectal contrast material for abdominal computed tomography (CT) scans. Serum blood urea nitrogen, creatinine, Na, K, Cl, Ca, P, creatinine clearance, and spot urine IL-18 levels were analyzed before and repeated at 24, 48, and 72 h after radiocontrast administration. Six and 24-h urinary IL-18 levels were measured with a human IL-18 ELISA kit following radiocontrast administration. An increase in plasma creatinine 24 and 48 h following radiocontrast administration was observed compared with precontrast values, but it was not statistically significant (P=0.052 and P=0.285, respectively). A statistically significant increase in IL-18 levels was observed at 6 and 24 h, compared with precontrast values (P=0.048 and P=0.028, respectively). A tendency for postcontrast 24-h urinary IL-18 levels to increase was observed compared with 6 h, but the increase was not statistically significant (P=0.808). Our results show that plasma creatinine starts to increase at 24(th) hour; however, spot urine IL-18 levels go up at 6(th) hour following radiocontrast administration implying urine IL-18 to be an earlier parameter for kidney injury.

Avoiding abdominal flank bulge after lumbotomy incision: cadaveric study and ultrasonographic investigation.

OBJECTIVE: The object of this study was to better define the relevant anatomy and innervation of the anterolateral abdominal wall musculature seeking to avoid abdominal wall complication after open donor nephrectomy. We dissected four cadavers and retrospectively assessed donor ultrasonographic imaging of anterolateral abdominal muscle atrophy after donor nephrectomy with a lumbotomy incision. METHODS: Anatomic study was performed on four cadavers using bilateral dissections. The 8th, 9th, 10th, 11th, and 12th (subcostal) intercostal nerves were dissected from the intercostal space to the rectus sheath. With the experience gained from anatomic study, we performed 40 living donor incisions 1.5 to 2 cm medial to the tip of 12th rib, toward the lateral border of the rectus muscle and the umbilicus. Donors were invited to the hospital at 1 year postoperative to examine abdominal wall complications. Ultrasonography (USG) was performed to assess the thickness of the abdominal wall muscles bilaterally to ascertain whether there was atrophy. RESULTS: All distal intercostal nerves ran as multiple mixed segmental nerves, communicating with each other widely within the neurovascular plane. The thick 12th nerve was located at 1.5 to 2 cm medial and under the tip of the 12th rib, running to the suprapubic area. Postoperative USG confirmed that the mean percent thickness of the abdominal muscles of the operative side was not significantly different from the other side (P < .05). CONCLUSION: Most significant intercostal nerve contributions to the anterolateral abdominal wall arise from T12. Damage to the intercostal nerves will be minimal if the lombotomy incision is performed above the safe line between the tip of the 12th rib and the umbilicus.

Dermatologic findings in renal transplant recipients: Possible effects of immunosuppression regimen and p53 mutations.

OBJECTIVE: To analyze the dermatologic lesions and possible effects of immunosuppression treatment and p53 gene mutations on dermatologic findings in renal transplant recipients. MATERIALS AND METHODS: The study included 163 renal transplant recipients. After dermatologic examination, cultures, and histopathologic and genetic analyses were performed. A single-strand conformation polymorphism technique was used to analyze p53 gene mutations. Patients were categorized into 3 groups according to time since the transplantation procedure. Results were analyzed using the χ(2) test, using a software program (SPSS version 13.0; SPSS, Inc, Chicago, Illinois). RESULTS: Mean (SD) age of the 163 transplant recipients (65 women and 98 men) was 40 (11) years, and posttransplantation follow-up was 65 (55) months. The most frequently observed drug-related lesion was hypertrichosis, in 46 of 150 patients. Of 115 lesions, the most commonly observed were verruca vulgaris (n = 34) from viruses, and pityriasis versicolor (n = 21) from superficial fungal infections. Of the total group, 20 patients (12.2%) were mutation carriers. Compared with the entire cohort, the group with premalignant lesions demonstrated more p53 mutations (11% vs 50%; P = .004). Patients given cyclosporine therapy exhibited more premalignant or malignant cutaneous lesions compared with patients who received other agents (P = .03). CONCLUSION: Patients carrying p53 mutations developed a malignant lesion in the late posttransplantation period, which suggests the importance of prediction of risk.

The clinical significance of parathyroid tissue calcium sensing receptor gene polymorphisms and expression levels in end-stage renal disease patients.

BACKGROUND: The calcium sending receptor (CaSR) allows parathyroid and kidney tubular cells to regulate PTH secretion and tubular calcium reabsorption. In the present report, we examined the relationship between CaSR gene polymorphisms and parathyroid CaSR expression and serum calcium/parathyroid hormone (PTH) levels and clinical progress in ESRD patients in the Turkish population. METHODS: We genotyped the CaSR R990G and Q1011E variants in 192 end-stage renal disease (ESRD) patients by allele-specific PCR. CaSR expression in parathyroid tissues of operated 33 patients was quantified with quantitative reverse transcription-PCR. RESULTS: Compared with other genotypes, the ratio of both codon 990-AA and 1011-CC polymorphisms was found higher in operated patients (p = 0.001). In the total patient group PTH levels were found higher in patients with CC1011 genotype than those with CG1011 (1015.15 +/- 925.41 pg/ml; 523.84 +/- 544.6 pg/ml, respectively, p = 0.002). There were statistically important higher Ca2+ levels in the AA990 allele carrying cases than AG990 positive ones (9.3 +/- 1.0 mg/dl vs. 8.8 +/- 0.9, p = 0.006). On the other hand, the expression of CaSR in parathyroid tissue was found inversely proportional with serum PTH level (r = -0.71). CONCLUSION: Present data suggest that co-presence of CaSR gene AA990 and CC1011 alleles is a possible risk factor for bad prognosis in secondary hyperparathyroidism. Patients carrying this genotype have tendency to require operation early in their medical therapy period and need postoperative close follow up for possible recurrences.

Quality of life analysis of renal donors.

OBJECTIVE: The aim of this study was to investigate the quality of life of renal donors during long-term follow-up. PATIENTS AND METHODS: The short form health survey (SF-36) questionnaire was compared between renal donors and the general population. We evaluated the relationship to postoperative complications and preoperative information with the quality of life. RESULTS: Fifty renal donors of mean age 55.8 +/- 12 years (range, 29-70 years) had a mean follow-up of 55.1 +/- 47.2 months (range, 12-168 months). Complications after donor nephrectomy were related with physical function loss (r = -.397; P < .05) and vitality (r = -.463; P = .01). Renal donor candidates who did not have satisfactory information before the operation experienced difficulty with decision making (r = -.555; P = .0001). Physical function, limitation of physical role and limitation of emotional role were comparable to the general population. Pain scale was worse among donors compared with the general population (P = .001). Educational status of renal donors was related to the pain scale and vitality (r = .369; P < .05 and r = .523; P < .05, respectively). General health perception, vitality, mental health, and social functioning were worse compared with the general population (P = .0001, P = .002, P = .0001, and P = .001, respectively). Health problems occurring after donation were related to negation of interfamily relations (r = .695; P = .0001). CONCLUSIONS: Reducing complications after nephrectomy will directly increase the quality of the donor's life. Informing renal donor candidates and their families about the postoperative course with consideration of the candidate's and his or her family's educational status is a sociological approach which helps to increase the donor's quality of life. In addition to good patient selection/preparation, meticulous surgery, and follow-up.

Ultrasonography-guided jugular venous catheter insertion for renal transplant recipients before renal transplantation: a prospective study.

AIM: Anatomical landmark technique for central venous catheter insertion preoperatively during renal transplantation may result in serious complications. In this prospective study, we sought to evaluate the results of ultrasonography-guided central venous catheter insertion before renal transplantation. PATIENTS AND METHODS: Since March 2004 routine ultrasonography-guided central venous catheter insertion was performed before the operation for living related renal transplantation. Chest X-ray was used as a control after catheter insertion. Visual pain scale was evaluated after the procedure. We recorded the duration of the procedure, amount of local anesthetic, number of punctures, and complications, namely, hematoma, carotid artery puncture, hemorrhage, and hemo-pneumothorax. RESULTS: Since March 2004, 120 jugular venous catheters were inserted into renal transplant recipients preoperatively. Mean visual pain scale was 2.5 +/- 1.2 cm (range, 0.6-4.1 cm). Mean duration of the procedure was 9 +/- 3 minutes (range, 6-15 minutes); the amount of local anesthetic injected was 1.6 +/- 0.6 mL (range, 0.9-2.3 mL). There was no carotid artery puncture, hemo-pneumothorax, or hematoma. During the study period, 3 of the first 10 catheter insertions required more than 1 puncture, for the rest 1 puncture was sufficient for catheter insertion. There was no bleeding or intravenous fluid leakage from the catheter insertion site. CONCLUSION: Ultrasonography-guided jugular venous catheter insertion is a successful safe method. Routine ultrasonography-guided procedures before renal transplantation avoided the complications related to catheter insertion.

Evaluation of pretransplant serum cytokine levels in renal transplant recipients.

AIM: Cytokines are early predictors of graft dysfunction. In this study we evaluated pretransplant cytokine levels and graft outcomes among renal transplant recipients. PATIENTS AND METHODS: Donor selection was based on results of blood group matching and negative crossmatches. A panel of 35 human serum samples from patients (female/male = 0.4) awaiting renal transplantation and 15 healty control sera were analyzed for interleukin (IL) 1alpha, IL-2, IL-6, IL-10, tumor necrosis factor-alpha, interferon-gamma, transforming growth factor-beta concentrations by enzyme-linked immunosorbent assay. The average age of the patients was 34.5 +/- 10.1 years (range 15 to 60). The average duration of renal replacement therapy before renal transplantation was 42.1 +/- 57.9 months (range 0 to 288). The types of renal replacement therapy were; hemodialysis (n = 27) and CAPD (n = 8). RESULTS: Pretransplant IL-6 levels were higher among recipients who displayed acute rejection episodes compared with those fact of this complications (P < .05) or control sera (P < .05). Pretransplant IL-6 levels were higher among recipients with graft failure than those with a functioning graft (P < .05). Pretransplant IL-10 levels were higher among recipients with acute rejection episodes and graft failure than those without acute rejection or control subjects, but the difference did not reach significance. There was no correlation between pretransplant cytokine levels and age, gender, type, or duration of renal replacement therapy (P > .05). CONCLUSION: High pretransplant serum IL-6 levels are associated with an increased risk of acute rejection episodes and graft failure. IL-10 might contribute an anti-inflammatory action to patients with high serum IL-6 levels.

Doppler ultrasonography-guided surgery for high-flow hemodialysis vascular access: preliminary results.

AIM: We sought to investigate the results of flow reduction with prospective Doppler ultrasonography (USG)-guided surgery. PATIENTS AND METHODS: Thirty patients with end-stage renal failure with high-flow arterio-venous (AV) fistulae (n = 25) or AV grafts (n = 5) were included in the study. The indications for operation were as follows: cardiac failure (n = 18) or steal syndrome (n = 12). AV fistula flow >800 mL/min or AV graft >1200 mL/min was the selection criterion for definition of a high-flow vascular access. The desired postoperative flow was 400 mL/min or 800 mL/min for AV fistula or AV graft, respectively. Before the surgical intervention, a vascular clamp was used to simulate the planned intervention with evaluation by Doppler USG after the anastomosis was narrowed. RESULTS: There were 16 men and 14 women with a median age of 48 +/- 9 years (range, 39-57 years). Preoperative measurements of median AV fistula, AV graft flow, and anastomosis diameter were as follows: 2663 mL/min (range, 1856-3440 mL/min); 2751 mL/min (range, 2140-3584 mL/min); and 7.3 mm (range, 6.1- 8.5 mm), respectively. The flow was reduced to 615 mL/min (range, 552-810 mL/min) for AV fistulae and 805 mL/min (range, 745-980 mL/min) for AV grafts. The median diameter of the anastomosis was reduced to 4 mm (range, 3.5-4.3 mm). There were no reinterventions. During the median 1-year follow-up, AV fistula and AV graft patency rates were 100% and 80%, respectively and clinical complaints resolved. Cardiac output rate was reduced from 8.5 +/- 2.9 L/min to 6.1 +/- 1.9 L/min (P < .01). CONCLUSION: Cardiac failure and steal syndrome resulting from high-flow vascular access can be treated successfully with Doppler USG-guided surgery. The desired anastomotic diameter and flow are limited in cases of excessively dilated efferent veins for vascular access.

Medical risk analysis of renal transplant donors.

AIM: The aim of this study was to evaluate the long-term medical risks of living-related donors in our center. PATIENTS AND METHODS: 185 living-related donors participated in the study. The factors assessed were creatinine clearance rate (CrCl), serum creatinine (SCr), BUN, hematocrit levels, proteinuria, microalbuminuria and hypertension rates, and renal parenchyma thickness and kidney dimensions predonation as well as at the last follow-up. In addition, we examined postoperative complications. A lombotomy incision was the choice for donor nephrectomy procedure routinely. RESULTS: The mean length of hospital stay after donor nephrectomy was 3.2 +/- 0.6 days (range, 2-5 days). Seven donors readmitted during the first month after operation with surgical site infection were treated successfully. Four donors were reoperated for incisional hernia repairs and discharged without complication. The mean follow-up period was 61.6 +/- 50.4 months (range, 2-180 months). Mean ages of the donors at operation and at the last follow-up were 50.9 +/- 12.7 years (range, 20-81 years) and 56.5 +/- 11.9 years (range, 29-77 years), respectively. The male-to-female ratio was 0.69. Mean SCr levels and CrCl rates predonation and at the last follow-up were 0.83 +/- 0.22 mg/dL versus 1.1 +/- 0.2 mg/dL (P < .001), and 103.9 +/- 28.8 mL/min versus 88.3 +/- 25.9 mL/min (P = .03), respectively. SCr levels were within normal limits in all donors at predonation and at the last follow-up. At the last follow-up, CrCl was also within expected normal limits in all donors. Hypertension was detected in 13 donors. Mean predonation and at the last follow-up renal parenchymal thickness, BUN, and hematocrit levels were similar. Kidney dimensions were significantly different at the last follow-up after donation (P = .001). Eleven donors displayed proteinuria and 19 had microalbuminuria at the last follow-up, which had been negative for all donors predonation. There were seven surgical site infections and 4 incisional herniae. CONCLUSION: Donor nephrectomy was performed with low surgical morbidity and comparable results of clinical and laboratory data to the age-matched general population.

Surgical treatment of urologic complications after renal transplantation.

AIM: The incidence of urologic complications after renal transplantation has been reported to be between 2.5% and 27%. The aim of this study was to evaluate urologic complications of and their surgical treatment in our series of renal transplantations. MATERIALS AND METHODS: We retrospectively evaluated urologic complications among 395 renal transplant recipients in our institute. RESULTS: The urologic complications were ureteral leakage (n = 8), stricture of ureteral anastomosis (n = 3), hydronephrosis secondary to stone (n = 2) and bladder outlet obstruction (n = 2), recurrent urinary infection because of vesicoureteral reflux to native kidney (n = 2), renal tumor in native kidney (n = 1), hydroceles (n = 3), technical complications (n = 2), and clot retention (n = 1). CONCLUSION: Major urologic complications following renal transplantation are ureteral leakage and stricture resulting from disrupture of the distal ureteral blood supply during the donor operation. Extravesical ureteroneocystostomy over a JJ stent seems feasible to minimize urologic complication. Early diagnosis and endourologic techniques are the mainstays of treatment.

Pediatric renal transplantation: Clinical analysis of 28 cases.

We performed an outcome analysis of 28 pediatric renal transplant recipients whose mean age at transplantation was 15.2 +/- 2 years (range: 11 to 17 years) and the M/F ratio, 0.75. Four patients received cadaveric grafts. One patient needed retransplantation due to primary nonfunction. Mean HLA match was 3.6 (range: 3 to 5). Immunosuppression was cyclosporine (n = 13) or tacrolimus (n = 11) or sirolimus (n = 4), as well as steroids and azathioprine or mycophenolate mofetil. Delayed graft function occurred in four patients. The main complications were arterial hypertension (n = 11), anemia (n = 4), urinary tract infection (n = 10), hypercholesterolemia (n = 7), and cytomegalovirus infection (n = 1). An acute rejection episode (ARE) occurred in four patients. ARE and hypertension rates were similar between the immunosuppressive drug groups. All the patients with graft failure were on cyclosporine (P = .03). Hemodialysis and peritoneal dialysis (median duration: 6 months) were performed preoperatively in 25 and 3 patients, respectively. The length of pretransplant dialysis was longer among patients with graft failure (P > .05). Noncompliance (10.7%) resulted in an ARE in one patient and graft loss in two patients. One patient died with a functioning graft. Primary disease recurred in one patient. The median follow-up period was 44 months (range: 6 to 157 months). Mean serum creatinine level was 1.35 +/- 0.74 mg/dL at the last follow-up. One- and 3-year graft survival rates were 92% and 86%, respectively, and patient survival was 100%, each. Seventeen patients (60.7%) continued their education after the transplantation; six started working. Successful transplantation in the pediatric age group together with intensive rehabilitation posttransplantation are important to make these children productive individuals to the society.