[Surgical procedure and urologic complications after 922 kidney transplantations: our experience]. / Kirurski postupak i uroloske komplikacije nakon 922 transplantacije bubrega: nase iskustvo.

Between January 30 1971 and January 30 2011 922 kidney transplants were performed at our center, 360 (39%) from living related donor and 562 (61%) from cadaver. During first eight years an ureteroureterostomy was routinely used. The notable incidence of urological complications (fistula 11%, complications of stenting 10.7%, stenosis and lithiasis 4%) was observed after 140 transplantations. Majority of these complications (60%) were treated conservatively. A significant reduction in this incidence (P<0.001) was achieved (fistula 1,28%, complications of stenting 0,26%, lithiasis 0.12%) by introducing an extravesical ureteroneocystostomy by Lich-Gregoire. Stenosis had the highest incidence (4,23%). Majority of complications (76%) were treated surgically. A native ureter was commonly used in replacing the transplant ureter. In majority of patients an end-to-end pyelo(uretero)stomy was performed. Two patients were reoperated because of fistula, and the third had a prolonged healing. In last nine patients with urological complications an end-to-side pyelo(uretero)stomy was done. There was no urinary leakage. The safety of method results probably from an intact native ureter which has normal blood irrigation.

[Pseudoaneurysm after renal transplantation]. / Pseudoaneurizma nakon transplantacije bubrega.

AIMS: Renal arterial pseudoaneurysm is a rare complication of renal transplantation that often causes a graft loss. A recent successful outcome of the operative treatment and a reappearance of a pseudoaneurysm and a possibility of watchful followup of pseudoaneurysm encouraged us to present our modest experience with pseudoaneurysm after renal transplant. MATERIAL AND METHODS: In our series of 843 renal transplants performed during 37 years vascular complications were observed in 57 (6.76%) patients. Pseudoaneurysm occurred in three patients (0.35%). The first pseudoaneurysm was found in 1973. A 23-year-old male patient received a double renal artery kidney from HLA identical brother. The upper renal artery was anastomosed by an end-to-end way with the internal iliac artery, and and the lower renal artery by end-to-side way to the external iliac artery. Five weeks after transplant an arteriography was performed because of the bruits heard over the transplant. A 15 x 10-mm pseudoaneurysm was revealed on the end-to-end anastomosis between internal iliac and upper renal artery. Six weeks after transplant a renal arterial resection and an end-to-side anastomosis between renal artery and common iliac artery was performed. The 38-year-old male patient received his second transplant from a 17-year-old female donor dead after craniocerebral trauma in December 2004. Two renal arteries were anastomosed separately with external iliac artery using aortic patches. Two and half moths after transplant he was admitted for an increase of creatinine level and hypertension. Color Doppler, dynamic scintigraphy and an angiography revealed a 20 x 1,3 mm aneurysmatic formation at the anastomosis of upper renal artery. The flow in the belonging part of the transplant was reduced. At surgical intervention a saphenous vein graft between internal iliac artery and renal artery was performed. Ischemia time was 15 min. The pseudoaneurysm was removed. A hole on external iliac artery was closed with a saphenal patch. The 38-year-old female patient received her second transplant in January 2005 from cadaver. There were 3 arteries. The upper polar arterywas first anastomosed to principal renal artery Then both arteries were anastomosed to external iliac artery termino-laterally. RESULTS: In the first patient a lesion of the ureteral anastomosis caused an infection, thrombosis of lower artery and a graft loss 4 months and half after transplant. The second patient was admitted urgently 3.5 months after the repair of his pseudoaneurysm because of the pain in the pelvic region. He was working that day during several hours in sitting position on his terrace. Immediate examination with color Doppler revealed a large 6 x 7-cm pseudoaneurysm medially of the transplant. An arteriography demonstrated a pseudoaneurysm with a blood leakage most likely at the site of the closure of external iliac artery with a saphenal vein patch. The arteriography showed a slower and diminished blood flow in the lower part of the transplant. At intervention the pseudoaneurysm was removed. The external iliac artery was considerably damaged and replaced with Goretex prostesis 6 mm. Unfortunately the transplant lower artery could not be saved. A microbiological examination of pseudoaneurysm in both patients was negative. In the third case we chose a watchful follow-up. Last Doppler controls show reduction of psudoaneurysm. DISCUSSION AND CONCLUSIONS: The development of a pseudoaneurysm of a transplant artery is very rare complication. Since actually ultrasonography is routinely used, a pseudoaneurysm can be easily detected. Color Doppler allows a differential diagnosis from hematoma, urinoma and lymphocele. Unfortunately a pseudoaneurysm after renal transplant often causes a loss of the transplant. The first patient had successful resection of a pseudoaneurysm, but the transplant was lost because of infection. The other patient had a subsequent pseudoaneurysm after the repair of the first. Unfortunately its repair caused an exclusion of the lower part of the kidney, but the residual renal function is satisfactory. In the third patient we chose a follow-up aware that each intervention could cause a graft loss.

[pp65 antigenemia in evaluation of cytomegalovirus infection after kidney transplantation]. / pp65 antigenemija u pracenju citomegalovirusne infekcije nakon transplantacije bubrega.

INTRODUCTION: Cytomegalovirus (CMV) infection is the most common infectious complication after organ transplantation. Serology is useful only for detecting previous CMV infection. Dissatisfied with serologic follow-up after kidney transplantation, three years ago we introduced detection of CMV antigenemia by an immunocytochemical method using a monoclonal antibody specific for the pp65 CMV matrix protein. This test allows for quantification of positive leukocytes. The purpose of this paper is to present our three-year experience. PATIENTS AND METHODS: From May 1999 till May 2002 CMV antigenemia was examined in 76 patients: 55 patients submitted to kidney transplantation during the study period, and 21 patients previously. Antigenemia became positive at 25.68 +/- 15.51 days after transplantation. These 76 patients were divided into three groups according to the number of positive cells per 200,000 leukocytes: < 5 (group I), 6-20 (group II) and > 20 (group III). The groups consisted of 23, 20 and 11 patients, respectively. The percentage of patients treated by ganciclovir was 4.34%, 15% and 100%, respectively. In group I only one patient received ganciclovir because of geographic indication, in group II three patients because of septicemia, thrombopenia and leukopenia and previous miliary tuberculosis. RESULTS: One patient from group III with steroid diabetes died from pneumonia with abscess formation three days from admission. In another two patients, interstitial pneumonia and abscess of the arm developed. Five patients had an acute rejection episode each and were treated by high doses of methylprednisolone. Five patients had elevated temperature, transaminases were elevated in five patients, and neutropenia with or without thrombopenia was found in six patients. One patient had recurrent CMV disease and lymphocele. Two patients had preemptive treatment by ganciclovir based on positive CMV antigenemia. DISCUSSION: Various centers differ according to the approach to treatment of CMV infection, ranging from prophylaxis to deferred treatment for CMV disease. Determination of pp65 CMV antigenemia allowed us a safe follow-up of patients after kidney transplantation. Compared with previous serologic follow-up antigenemia is a considerable progress. We did not use CMV prophylaxis because it is more expensive and can cause resistance to ganciclovir. A promising novel drug valganciclovir will allow for good prophylaxis owing to its better absorption from the gut. Based on our three-year experience, optimal cut-off for antigenemia has been set at 20 positive cells per 200,000 leukocytes. The existence of symptoms or changes in the level of leukocytes, platelets or transaminases goes in favor of treatment decision. CONCLUSION: Cytomegalovirus pp65 antigenemia is a reliable tool in the follow-up of patients after kidney transplantation. Patients with primary CMV infection, those with rejection episode and threshold of 20 positive cells require preemptive treatment with ganciclovir. The measurement of pp65 CMV antigenemia has clinical, analytical and cost-effective advantages. Intensive monitoring for CMV infection allows for quick and specific detection of active CMV infection. This approach avoids resistance to ganciclovir. The method is simple and specific without expensive equipment. Avoidance of unnecessary prophylaxis adds to its cost-effectiveness.

[Evaluation and selection of candidates for renal transplantation at the Clinical Hospital Center in Rijeka]. / Ispitivanje i odabir kandidata za transplantaciju bubrega u Klinickom bolnickom centru Rijeka.

On December 31, 2001, 2486 patients with terminal renal failure received dialysis treatment in Croatia. Only one third of the patients are registered on the national waiting list for cadaveric kidney transplant. In most of the others, transplantation is impossible because of comorbidity. This is mainly due to the steadily growing age of the dialytic population and therefore a higher incidence of cardiovascular disease and diabetes. Still, evaluation of the potential recipients of cadaveric kidney transplant, registered on the waiting list, often reveals contraindications for transplantation. The aim of this study was to determine the incidence and type of contraindications in transplant candidates, found during immediate preoperative evaluation. Analysis of these data should help in determining how contraindications can be early detected and prevented. Before registering onto the national waiting list transplant candidates need to be thoroughly investigated including detailed history, physical examination, routine diagnostic procedures and additional examinations, if needed, to exclude or evaluate the possibly existing contraindications for transplantation. During the period from January 1997 until June 2002, 145 potential recipients from the national waiting list were referred to the Rijeka University Hospital Center and evaluated for kidney transplantation. Eighty-eight patients underwent transplantation. Preoperative evaluation revealed contraindications for transplantation in 52 (35.9%) candidates. Twenty-two (15.2%) patients had a positive cross-match with donor lymphocytes, 6 (4.1%) patients refused transplantation, and in 24 (16.6%) patients serious comorbidity was the reason for not being accepted for transplantation and for their withdrawal from the national waiting list. Comorbidity was mainly due to cardiovascular disease (12 patients--8.3%) and infection (8 patients--5.5%). These data show a high incidence of contraindications found during the immediate preoperative evaluation of potential kidney recipients. It was the case in more than one third of patients. During the evaluation of potential candidates for kidney transplantation special attention should be addressed to the presence of cardiovascular morbidity and infection. Peripheral vascular occlusive disease, cardiac status and/or cerebrovascular disease should be evaluated. Measures used to treat or reduce the development of complications include an optimal control of blood pressure, serum phosphate, hyperparathyroidism, dyslipidemia, and renal anemia. The sites of infection must be treated and eradicated, because immunosuppressive treatment is a threat to the transplant recipient's life. The second most common cause of refusal of potential candidates was a positive cross-match with donor lymphocytes. Sensitization to human leukocyte antigens can be prevented by the avoiding of blood transfusions and use of erythopoietin in treating renal anemia. To minimize the morbidity and mortality, the potential kidney recipients should undergo rigorous selection and thorough evaluation before including them into the waiting list for kidney transplantation. Afterwards, regular examinations are obligatory to reveal contraindications, proceed to medical interventions and treat concomitant diseases in time, which can influence the patient's survival. In case that contraindications for transplantation arise, the patient must be temporarily or definitely removed from the waiting list.