Antithymocyte antibody-induced coagulopathy in renal transplant recipients.

BACKGROUND: Antithymocyte antibody (ATA) remains the most commonly used induction immunosuppressive agent in renal transplantation (RT). To date, few case reports of ATA-induced coagulopathy exist. METHODS: We performed a single-center, retrospective analysis of renal transplant recipients (RTRs) who underwent RT followed by ATA therapy between 2007 and 2011. The protocol used for deceased donor and unrelated living donor recipient immunosuppression was Thymoglobulin (TMG), methylprednisolone, Cellcept, Prograf, and Rapamune. In related living donor recipients, Simulect (SIM) was substituted for TMG. The international normalized ratio (INR) was routinely checked on days 0 and 2, and thereafter at the discretion of the surgeon. RTRs were transfused packed red blood cells (PRBCs) or fresh frozen plasma (FFP) at the discretion of the surgeon. RESULTS: During the study period, 257 RTs were performed at our institution. The following 18 RTR were excluded: simultaneous kidney and pancreas transplant recipients (4), RTRs on warfarin at the time of admission (2), RTRs who received OKT3 (2), and RTRs with INR ≥ 1.2 at the time of admission (10). Of the remaining 239 RTR, 208 (87%) underwent TMG induction therapy; 31 RTR (13%) underwent SIM induction therapy. The mean INR peaked in both groups on day 4 but was higher in TMG recipients (TMG 1.35, SIM 1.20). FFP was transfused in 65 TMG (31%) and 3 SIM (10%) recipients (P = .01); PRBCs were transfused in 88 TMG (44%) and 6 SIM (19%) recipients (P = .02). No patients returned to the operating room for bleeding complications within 7 days of RT. Patient age, gender, ethnicity, and diabetes status were not statistically significant factors in the development of coagulopathy. CONCLUSION: TMG administration is associated with coagulopathy. Using an INR screening protocol and an aggressive transfusion protocol, bleeding complications associated with coagulopathy can be avoided in this higher-risk group.

Ureteral stents: a risk factor for polyomavirus BK viremia in kidney transplant recipients undergoing protocol screening.

BACKGROUND: Polyomavirus BK nephropathy (BKN) remains a common cause of early renal transplant dysfunction and graft loss. To date, little has been reported on the role, if any, of transplant ureteral stents in the development of polyomavirus BK viremia (BVK) and BKN. METHODS: We performed a single-center, retrospective analysis of renal transplant recipients who underwent renal transplantation followed by monthly BKV screening at Albany Medical Center between January 1, 2006, and December 31, 2009. A transplant ureteral stent was placed at the discretion of the surgeon. The immunosuppression protocol employed for deceased donor and unrelated living -donor recipients was antithymocyte antibody induction with methylprednisolone, mycophenolate mofetil, tacrolimus, and sirolimus. RESULTS: During the study period, 186 recipients were identified; 124 (67%) underwent intraoperative transplant ureteral stent placement, while 62 patients (33%) did not undergo stent placement. With our monthly screening protocol, we detected BKV in 32 of the 186 recipients (17%) following transplantation; 27 of the 32 (84%) viremic patients were stent recipients. In all patients who developed BKV, an immunosuppression dose reduction protocol was employed. Ureteral stent placement conferred a statistically significant elevated risk of developing BKV (odds ratio = 3.17, 95% confidence interval 1.16-8.70). Patient gender, age, ethnicity, diabetes status, and retransplant status were not statistically significant factors in the development of BKV. CONCLUSION: Our study demonstrated the elevated risk of BKV in recipients who undergo transplant ureteral stenting. Monthly BK polymerase chain reaction screening appears to be a useful tool for the early detection of BKV in this higher-risk group.

Initiation of a screening protocol for polyoma virus results in a decreased rate of opportunistic non-BK viral disease after renal transplantation.

BACKGROUND: Polyoma BK virus nephropathy (PVN) is a leading cause of renal allograft injury and loss. The mainstay of treatment, as there are no target therapies approved by the US Food & Drug Administration, is reduction in immunosuppression. However, current approaches are shifting to screening for viremia as an indicator of oncoming nephropathy, with subsequent reduction in immunotherapy. We attempted not only to replicate these data but also to evaluate the utility of polyoma viremia as a surrogate marker for overimmunosuppression in general, thus allowing prevention not only of PVN but also of other viral opportunistic infections such as cytomegalovirus (CMV) and Epstein-Barr virus (EBV) disease. PATIENTS AND METHODS: We conducted a retrospective cohort analysis of renal transplant recipients at our center. The historical controls (2003-2005, n = 134) had received their allograft before the institution of a monthly serum polymerase chain reaction (PCR) polyoma screening protocol. The screened cohort received their allograft afterwards (2006-2008, n=134). Screening was performed using PCR techniques with prompt reduction in immunosuppression for viremic patients. The patients were followed for the development of PVN, acute rejection, renal allograft function, and survival. RESULTS: Polyoma viremia was noted in 16% of the screened population, with none developing PVN after prompt reduction of immunosuppression. Clearance of the viremia occurred by 6 months in 95% of the patients after reduction of immunotherapy. No patient in the screened group developed CMV or EBV disease. Of the controls, 7 (5%) developed PVN and 12 (9%) developed CMV or EBV disease, compared with none of the screened patients (P<0.05). The incidence of acute rejection was comparable between the groups (4% controls, 5% screened). No deleterious effects were noted on patient or allograft survival, allograft function (measured by serum creatinine), rates of fungal infection, or the rate of post-transplant lymphoproliferative disorder in the screened patients. CONCLUSIONS: Monthly PCR monitoring for BK viremia, together with a modest decrease in immunotherapy, is not only safe but also effectively prevents PVN and is associated with a significantly decreased rate of CMV and EBV disease in renal transplant patients. BK viremia may also serve as a surrogate marker for overimmunosuppression.

A case of Campylobacter jejuni bacteremia in a renal transplant patient.

Only 2 cases of Campylobacter bacteremia have been reported in renal transplant recipients, to our knowledge, with both resulting in significant morbidity and mortality. We present a case of a 56-year-old renal transplant recipient who presented with brief diarrheal illness followed by Campylobacter jejuni bacteremia. She remained asymptomatic for 5 days after initial presentation despite positive blood cultures. She was treated with levofloxacin for a total of 4 weeks and, fortunately, did not develop any complications. C. jejuni should be considered in the differential diagnosis as a potential cause of bacteremia in immunosuppressed renal transplant patients presenting with diarrheal illness.

Is BMI greater than 60 kg/m(2) a predictor of higher morbidity after laparoscopic Roux-en-Y gastric bypass?

BACKGROUND: It has been hypothesized that patients who are super-super morbidly obese, defined as having a body mass index (BMI) of 60 kg/m(2) or higher, have an increased rate of postoperative complications. As surgical techniques and operator experience with Roux-en-Y gastric bypass improved with time, the selection criteria have expanded to include the super-super morbidly obese. We hypothesize that a higher BMI does not predict a higher postoperative complication rate. METHODS: The prospectively collected database for our Accredited Bariatric Program was queried for all laparoscopic Roux-en-Y gastric bypass procedures performed between January 2004 and July 2006. All cases were performed by a single surgeon at a tertiary-care center. Average postoperative follow-up time was 1 year. Patients were stratified into two groups: BMI < 60 kg/m(2) and BMI >or= 60 kg/m(2). The number of postoperative complications was compared between the two groups using a chi-square method with Yates correction. RESULTS: One hundred and sixty-nine patients with adequate follow-up data were identified during the study period. Of these, 148 patients had BMI < 60 kg/m(2) (group 1) and 21 had BMI >or= 60 kg/m(2) (group 2). There were 28 (19%) total complications in group 1, and 4 (19%) total complications in group 2. There was no statistical difference between the two groups (p = 0.98). Stricture rate was 10% in group 1 and 5% in group 2. CONCLUSION: Patients with BMI >or= 60 kg/m(2) do not have a higher postoperative morbidity compared with other patients undergoing laparoscopic Roux-en-Y gastric bypass. The stricture rate is less in patients with BMI >or= 60 kg/m(2) compared with other patients. Longer follow-up is required to detect complications that occur after 1 year. Our study shows that laparoscopic Roux-en-Y gastric bypass can be safely performed on the super-supermorbidly obese.

[Features of expression and functional activity of P2X7 receptors in bone marrow cells under the action of doxorubicin].

Mechanisms of the myelotoxic action of doxorubicin associated with changes in the expression and functional activity of P2X7 receptors have been assessed. The acute and subacute exposure of bone marrow cells to doxorubicin in vivo changed the expression of P2X7, altered the intracellular and extracellular ATP concentrations, and modulated the process of programmed cell death. These changes were associated with transformed susceptibility of hemopoietic cells to the apoptogenic action of ATP. Various possible mechanisms of realization of the apoptogenic action of ATP during acute and subacute exposure to doxorubicin are discussed.

[Alteration of CD38 expression and NAD+ metabolism induced by Doxorubicin in bone marrow cells].

Mechanisms of myelotoxic action of Doxorubicin associated with changes in NAD(+)-glycohydrolase/CD38 expression and activity have been assessed. During the acute and subacute exposure of bone marrow cells to Doxorubicin in vivo, expression of CD38 is decreased corresponding to elevation of intracellular and extracellular NAD+ concentrations. These changes are associated with increased susceptibility of hemopoietic cells to the apoptogenic action of Doxorubicin. Possible role of NAD(+)-glycohydrolase/CD38 in the regulation of sensitivity of the cells to the cytotoxic effects of the xenobiotic is discussed.

[Cardiac hemodynamics in patients with ischemic heart disease combined with chronic cholecystitis]. / Kardiogemodinamika u bol'nykh ishemicheskoi bolezn'iu serdtsa v sochetanii s khronicheskim kholetsistitom.

Cardiac haemodynamics have been studied radiocardiographically in 56 men at the age of 40-60 including 15 healthy persons, 24 patients with chronic coronary disease and 17 patients associating coronary disease with chronic cholecystitis. This association was shown to reduce minute heart volume thus playing the role of a factor compromising cardiac blood circulation in such patients. Neuroreflex influence on the coronary arteries and autoimmune damage of myocardium due to similarity of myocardial and gallbladder antigenic determinants may be probable mechanisms of such an effect.

[The treatment of patients with chronic bronchitis and bronchial asthma]. / O lechenii bol'nykh khronicheskim bronkhitom i bronkhial'noi astmoi.

The authors analyzed treatment results in 82 patients with chronic bronchitis and 68 patients with bronchial asthma including association of inhalation of humid and dry sodium chloride aerosols with preliminary administration of a broncholytic drug. Improvement of the patients' condition was confirmed by results of functional examinations and data of immunological tests.

[Prospects of improving step-by-step rehabilitation of patients with peptic ulcer]. / Perspektivy sovershenstvovaniia reabilitatsionno-étapnogo lecheniia bol'nykh iazvennoi bolezn'iu.

The authors provide the data of many years of study into the morphofunctional status of the gastroduodenal system in 396 patients with peptic ulcer exposed to staged rehabilitation treatment. High medical and economic efficacy of the method is demonstrated. Approaches to the improvement of the results of staged rehabilitation treatment have been developed. They are based on systematic training of the medical personnel, improvement of the work of the rehabilitation rooms and departments, adequate dispensarization of the population aimed at early diagnosis of peptic ulcer; follow up and differential treatment of concomitant diseases; rigid differential approach to the choice of the rehabilitation treatment; polypragmasia control; differential approach to the choice of the treatment times; adequate specialized employment of patients; continuity in the work of the internists and surgeons at all the stages of the treatment.