Severe Phlebitis Accompanying Vascular Rejection Type Acute T Cell-Mediated Rejection in Renal Transplantation

Purpose

Renal transplant patients with vascular rejection type acute T cell-mediated rejection (ATCMR) grade II have a poor prognosis. Vascular lesions in those cases are thought to randomly occur, thus we searched for a novel pathological marker related to vascular rejection in kidney transplantation.

Factors Related to Osteosarcopenia in Kidney Transplant Recipients

Introduction

Sarcopenia and osteopenia are highly prevalent in older patients, and are associated with a high risk for falls, fractures, and further functional decline. However, related factors in kidney transplant recipients suffering from osteosarcopenia, the combination of sarcopenia and osteopenia, remain unknown.

Oncological Screening of Kidney Transplant Patients: The Role of Ultrasound Examination

IntroductionImmunosuppressive therapy used after organ transplantation represents a considerable oncological risk. Abdominal ultrasound examinations play an essential role in the oncological screening of organ transplant patients. Our aim was to study the effectiveness of the ultrasound screening protocol currently used in our clinic.MethodsReports of screening abdominal ultrasound examinations of kidney transplant recipients were processed at the Department of Transplantation and Surgery of Semmelweis University from January 2012 to December 2015.ResultsIn 1478 studies, 14 patients were diagnosed with a malignant tumor, 11 of which were formed in the native shrunken kidney. The mean age for tumor diagnosis was 55.6 ± 12.6 years, and 80% of the patients diagnosed with tumor were male. On average, 7.5 ± 4.6 years passed between the transplantation and recognition of the tumor. All of the kidney tumors were diagnosed at an early stage: histologic examination of removed kidneys showed 73% pT1a- and 17% pT1b-stage tumors.ConclusionIn our study, early stage shrunken kidney cancers were outstandingly the most common post-transplant malignancies found by ultrasound screening. Annual ultrasound examinations as part of our current screening protocol allowed the detection of tumors at an early stage in kidney transplant recipients.     

Safety and Effectiveness of Conversion From Cyclosporine to Once-Daily Prolonged-Release Tacrolimus in Stable Kidney Transplant Patients: A Multicenter Observational Study in Japan

This study investigated the safety and effectiveness of conversion from cyclosporine- to prolonged-release tacrolimus (PR-T)-based immunosuppression in kidney transplant recipients (KTRs) in Japanese routine clinical practice.

Pulmonary Arterial Pressure Management Based on Oral Medicine for Pediatric Living Donor Liver Transplant With Portopulmonary Hypertension

Pediatric living donor liver transplantation (LDLT) in patients with advanced portopulmonary hypertension (PoPH) is associated with poor prognoses. Recently, novel oral medications, including endothelin receptor antagonists (ERAs), phosphodiesterase 5 (PDE5) inhibitors, and oral prostacyclin (PGI2) have been used to treat PoPH. Pediatric patients with PoPH who underwent LDLT from 2006 to 2016 were enrolled. Oral pulmonary hypertension (PH) medication was administered to control pulmonary arterial pressure (PAP). Four patients had PoPH. Their ages ranged from 6 to 16 years, and their original diseases were biliary atresia (n = 2), portal vein obstruction (n = 1), and intrahepatic portal systemic shunt (n = 1). For preoperative management, 2 patients received continuous intravenous PGI2 and 2 oral medications (an ERA alone or an ERA and a PDE5 inhibitor), and 2 received only oral drugs (an ERA and a PDE5 inhibitor). One patient managed only with intravenous PGI2 died. In the remaining 3 cases, intravenous PGI2 or NO was discontinued before the end of the first postoperative week. Postoperative medications were oral PGI2 alone (n = 1), an ERA alone (n = 1), or the combination of an ERA and a PDE5 inhibitor (n = 1). An ERA was the first-line therapy, and a PDE5 inhibitor was added if there was no effect. New oral PH medications were effective and safe for use in pediatric patients following LDLT. In particular, these new oral drugs prevent the need for central catheter access to infuse PGI2.     

Efficacy and Safety of Ultra-Low-Dose Valganciclovir Chemoprophylaxis for Cytomegalovirus Infection in High-Risk Kidney Transplantation Patients

IntroductionValganciclovir (VGCV) prophylaxis of 900 mg twice daily for 6 months is recommended to prevent cytomegalovirus (CMV) infection, which is a major cause of decreased graft and patient survival in kidney transplant recipients. However, recent studies have shown the efficacy of 900 mg once daily for 3 to 6 months. Maintaining VGCV compliance is difficult because of high drug costs and side effects, such as thrombocytopenia and leukopenia. Therefore, we studied the efficacy of ultra-low dose, short-duration VGCV (450 mg every other day for 3 months) in preventing CMV infection in ABO-incompatible (ABOiKT) and deceased donor kidney transplant (DDKT) recipients.MethodsWe retrospectively reviewed the medical records of all kidney transplant patients > 18 years old treated at Bong Seng Memorial Hospital from June 2009 to July 2016 who received ultra-low-dose VGCV prophylaxis (450 mg every other day for 3 months). The review included 74 CMV seropositive donor/seropositive recipient (D+/R+) ABOiKT and 78 CMV D+/R+DDKT recipients. The primary outcome was occurrence of CMV infection. Secondary outcomes were graft and patient survival and hematologic side effects.ResultsMean prophylaxis and follow-up were 3 and 98 months, respectively. CMV disease occurrence was significantly higher in DDKT than in ABOiKT (12 cases, 8.1%, vs 1 case, .7%, P < .01). There were no significant differences in patient survival rate, graft survival rate, or hematologic side effects between the groups.ConclusionUltra-low-dose VGCV prophylaxis to prevent CMV infection is effective in ABOiKT, but other treatment protocols are needed for DDKT patients.     

Hounsfield unit of screw trajectory as a predictor of pedicle screw loosening after single level lumbar interbody fusion

Object

This study aims to clarify the clinical potential of Hounsfield unit (HU), measured on computed tomography (CT) images, as a predictor of pedicle screw (PS) loosening, compared to bone mineral density (BMD).

Femoral tunnel enlargement after anatomic anterior cruciate ligament reconstruction: Bone-patellar tendon-bone /single rectangular tunnel versus hamstring tendon / double tunnels

Purpose

This study aimed to prospectively compare the femoral tunnel enlargement at the aperture as well as inside the tunnel after anatomic anterior cruciate ligament (ACL) reconstruction with bone-patellar tendon-bone (BTB) graft to that with hamstring tendon (HST) graft.

Tibial tunnel enlargement after anatomic anterior cruciate ligament reconstruction with a bone–patellar tendon–bone graft. Part 1: Morphological change in the tibial tunnel

BackgroundThree-dimensional (3D) computed tomography (CT) is reliable and accurate imaging modality for evaluating tunnel enlargement after anterior cruciate ligament (ACL) reconstruction. The purpose of this study was to evaluate the tibial tunnel enlargement including the morphological change after anatomic ACL reconstruction with a bone–patellar tendon–bone (BTB) graft using 3D CT models.MethodsEighteen patients with unilateral ACL rupture were included. The anatomic rectangular-tunnel (ART) ACL reconstruction with a BTB autograft was performed. 3D CT models of the tibia, the tibial tunnel, and the bone plug at 3 weeks and 1 year after surgery were reconstructed and superimposed using a surface registration technique. The cross-sectional area (CSA) of the tibial tunnel perpendicular to the tunnel axis was evaluated at the aperture and 5, 10, and 15-mm distal from the aperture. The CSA was measured at 3 weeks and 1 year after surgery and compared between the two time points. The locations of the center and the anterior, posterior, medial, and lateral edges of the tunnel footprint were also evaluated based on the coordinate system for the tibial plateau and compared between the two time points.ResultsAt the aperture, the CSA of the tibial tunnel at 1 year after surgery was significantly larger by 21.9% than that at 3 weeks (P < 0.001). In contrast, the CSA at 1 year was significantly smaller than that at 3 weeks at 10 and 15-mm distal from the aperture (P = 0.041 and < 0.001, respectively). The center of the tunnel footprint significantly shifted postero-laterally with significant posterior shift of the anterior/posterior edges and lateral shift of the lateral edge (P < 0.001).ConclusionThe tibial tunnel enlarged at the aperture by 22% 1-year after anatomic ACL reconstruction with a BTB graft, and the tunnel morphology changed in a postero-lateral direction at the aperture and into conical shape inside the tunnel.     

Clinical course of soft tissue sarcomas presenting as malignant wounds

BackgroundSoft tissue sarcomas can invade the skin and occasionally present as malignant wounds characterized by bleeding, exudate, odor, and infection. This study aimed to highlight the clinical problems associated with sarcomas with malignant wounds.MethodsThe patient group comprised 12 males and 1 female, with a median age at diagnosis of 75 (range 23–95) years old. The average follow-up was 28.3 months. Clinical information concerning the patients with soft tissue sarcomas presenting as malignant wounds was retrospectively investigated.ResultsEleven out of 13 malignant wounds cases were male and over 65 years old. Tumors were located in the chest wall in 4 patients and the thigh in 4, respectively. The histology was high-grade in 12 patients. Persistent bleeding from malignant wounds was observed in 6 patients. The patients' pre-operative hemoglobin level was 7.5 ± 1.9 g/dl. For the purpose of temporary hemostasis, Mohs' paste was applied in 1 case and zinc oxide starch was applied in 3. Surgical removal was done in 10 patients, and amputation in 2. Six patients needed skin reconstruction. Post-operative surgical site infection was found in 5 patients, but the infection did not occur in the patients who underwent skin reconstruction of musculocutaneous flaps. The 5-year survival rate was 25.4%.ConclusionsMassive bleeding from the tumor impairs patients' quality of life and can be life-threatening. To avoid exacerbating the systemic condition of elderly cancer patients, urgent surgical removal is recommended, especially in cases of exposed tumors with persistent bleeding. Orthopedic oncologists should be aware of surgical site infection as a potential post-operative complication.     

Difference in the fusion rate and bone formation between artificial bone and iliac autograft inside an inter-body fusion cage – A comparison between porous hydroxyapatite/type 1 collagen composite and autologous iliac bone

Background

Lateral inter-body fusion (LIF) using cages with a large bone grafting space can lead to a shortage of autologous grafting materials. The use of artificial bone is an option to increase the volume of grafting materials. However, the rate of bony fusion for these materials compared to that of autologous bone is unclear.

Changes in Bone Mineral Density After Kidney Transplantation

Background

Numerous studies have shown that osteoporosis is common in kidney transplant recipients. However, the change in bone mineral density after kidney transplantation (KT) is not fully understood.

A Half-Century 3000 Cases of Kidney Transplant Experiences in a Single Hospital: the Longest Registry in Korea

BackgroundThis study aims to analyze the entire registry of kidney transplant over the past 50 years and understand the clinical significance.MethodsFrom the data on 3012 kidney transplants performed at our center between March 1969 and September 2018, we analyzed retrospectively clinical variables.ResultsUntil September 2018, there have been 3012 kidney transplants performed. The number of primary transplant cases was 2755 (91.8%), which included 16 cases of simultaneous liver-kidney transplant, and the number of repeated transplants was 245 (225 second transplants [7.5%] and 20 third transplants [0.7%]). There were 3 simultaneous pancreas kidney transplants, and 3 small bowel–kidney transplants, one of them being transplanted at the same time. There was a single simultaneous heart-kidney transplant. The viability rates of a transplanted kidney for 1, 5, 10, 20, and 30 years were 97%, 92%, 90%, 51%, and 36%, respectively, and the patient survival rates were 96%, 89%, 82%, 64%, and 52%, respectively. Five-year graft survival rate of the first 1000 cases was 64.6%; those of the 1001st to 2000th cases and 2001^st to 3012th cases were 87.6% and 88.8%, respectively. There are statistically significant differences among the groups.ConclusionThis study has identified the appropriate selection or control of immunotherapy, based on the risk level of kidney transplant recipient, is needed to minimize chronic rejection, which is the key cause of transplanted kidney failure.     

Usefulness of Dietary Salt Restriction in Kidney Transplant Recipients: Analysis of Blood Pressure Levels Depending on the Differences in the Levels of Salt Intake

BackgroundSodium retention causes post-transplant hypertension, and sodium restriction is recommended in kidney transplantation recipients. We investigated the changes in salt intake and age-specific differences in salt intake over the post-transplant periods and considered what guidance is important for salt reduction tailored to individual recipients.MethodsWe calculated salt intake for 38 recipients who underwent kidney transplantation from August 2013 to August 2018 using Tanaka's equation and extracted their blood pressure (BP) levels.ResultsThe rate of achieving the desired level of salt intake (<6 g/d) was 7.9%. The average salt intake was 7.8 ± 1.4 g. Average BP by salt intake was as follows: <6 g/d, 109/71 mm Hg; 6 to <7 g/d, 127/84 mm Hg; 7 to <8 g/d, 124/79 mm Hg, 8 to <9 g/d, 130/73 mm Hg; 9 to <10 g/d, 133/83 mm Hg; and >10g/d, 137/81 mm Hg.DiscussionAwareness of the need for salt restriction diminishes as time passes after transplantations, leading to increased salt uptake; therefore, regular guidance for keeping salt intake low is necessary for patients to maintain the awareness of salt restriction. The recipients with higher salt intake had higher blood pressure, suggesting the need for managing salt reduction.ConclusionsDietary counseling showed a short-term efficacy for reducing sodium intake and clinically relevant BP improvement in renal allograft recipients.     

Increase in 24-Hour Protein Excretion Immediately After Donation Is Associated With Decreased Functional Recovery in Living Kidney Donors

ObjectivesIn this study, we evaluated the occurrence of proteinuria in living kidney donors during the immediate postdonation period, aiming to determine its clinical significance in renal function recovery.Patients and methodsWe enrolled living kidney donors with predonation protein excretion rate (PER) < 150 mg/24 h. Participants were divided into 2 groups according to immediate postdonation PER (4 days after nephrectomy): non-microproteinuria (non-mPr; PER < 150 mg/24 h), n = 244; and immediate postdonation microproteinuria (ImPr; PER ≥ 150 mg/24 h), n = 605.ResultsEstimated glomerular filtration rate (eGFR) did not differ significantly between groups immediately after nephrectomy but was consistently lower in the ImPr group 1 week to 1 year postdonation (1-year postdonation eGFR: ImPr group, 63.6 ± 12.1 mL/min/1.73 m²; non-mPr group, 68.6 ± 12.3 mL/min/1.73 m²; P = .001). Immediate postdonation microproteinuria was an independent predictor of eGFR at 1 year postdonation (β [standard error] = -2.68 [1.15], 95% confidence interval -4.94 to -0.42, P = .02), along with predonation eGFR, age, and sex. Immediate postdonation microproteinuria was more common in donors who were older or male and occurred in 71.3% of kidney donors, suggesting renal injury in this period.ConclusionsAlthough proteinuria generally resolves, its impact persists and can impair renal function recovery. Donors who are older and male are more likely to undergo immediate hyperfiltration after donation.     

Surgical Complications in Kidney Transplantation: An Overview of a Portuguese Reference Center

IntroductionKidney transplantation (KT) is a surgery performed worldwide and has some complications. The objective of this study is to evaluate our surgical complications, comparing the outcomes with those KTs without surgical complications.Patients and MethodsAn observational cross-sectional study of all surgical complications among 3102 kidney transplants performed between June 1980 and April 2018.ResultsOf 3102 kidney transplantations, 490 (15.8%) had the following complications: surgical complications (n = 527); urinary (n = 184; 5.9%); vascular (n = 140; 4.5%); wound-related (n = 78; 2.5%); lymphocele (n = 56; 1.8%); and others (n = 69; 2.2%). The most common complications were ureteral obstruction (n = 85; 2.7%) and urinary fistula (n = 72; 2.3%). The immunosuppression regimen did not influence the surgical complications rate. Surgical complications mainly occurred in male (71.4% vs 66.7%) and heavier (67.6 ± 13.9 vs 65.9 ± 13.5 kg) recipients (P < .05). The hospitalization time was also different (26.3 ± 30.6 vs 15.0 ± 38.8 days, P < .05). Serum creatinine values were different until the second year. After that, the renal function was approximately the same. Nearly 26.1% of complicated kidney transplants had delayed graft function (vs 14.8%, P < .001). Only 23.9% of complicated kidney transplants needed transplant nephrectomy (vs 6.2%, P < .001). The survival of kidneys with surgical complications was lower (64.2 ± 4.5 vs 94.09 ± 2.6 months, P < .001).Discussion/ConclusionKidney transplant surgical complications occur over time, especially urinary and vascular complications, remaining a problem that leads to prolonged hospitalization and decreased graft survival.     

Quantitative measurements of hip abduction strength in lumbar surgery patients

BackgroundWe sought to evaluate the hip abduction strength in patients before and after lumbar surgery.Materials and methodsEighty-four patients (51 males and 33 females) undergoing surgery for lumbar disc herniation or lumbar canal stenosis were selected. Mean age was 64.7 ± 13.8 years. Seven patients (8.3%) had surgery at multiple levels, including L2-L3 (group A), 27 (32.1%) patients had surgery at multiple levels including L3-L4 (group B), 32 (38.1%) patients had surgery at the L4-L5 level only (group C), and 18 (21.4%) patients had surgery at the L5-S1 level only (group D). Hip abduction strength was measured in the 84 patients preoperatively and in 49 patients postoperatively.ResultsIn all patients, preoperative mean hip abduction strength on the symptomatic side and the asymptomatic side was 71.4 ± 34.5 N and 90.7 ± 36.5 N, respectively (p = 0.0008). In groups A and B, there were no significant differences between the mean hip abduction strength on the symptomatic and contralateral side. In group C, those on the symptomatic and contralateral side were 68.0 ± 33.5 N and 89.3 ± 34.8 N, respectively (p = 0.0181). In group D, those on the symptomatic and contralateral side were 74.3 ± 42.4 N and 101.7 ± 44.7 N, respectively (p = 0.0314). In the 49 patients of all groups that could be measured postoperatively, there were no significant differences between the mean hip abduction strength on both sides.ConclusionsIt was confirmed that the gluteus medius, which was main hip abductor, was mainly innervated by L5 and its mean strength significantly improved postoperatively. The possibility of improvement of hip abduction strength, especially with unchanged tibialis anterior strength, could be very useful for operative decisions.     

Patient reported outcomes after high tibial osteotomy show comparable results at different ages in the mid-term to long-term follow-up

BackgroundFew studies have evaluated the impact of age on patient-reported outcomes in the long-term follow-up after high tibial valgus osteotomy (HTO). The purpose of this study is to assess the association between age at surgery and patient-reported clinical outcomes in the mid-term to long-term follow-up of HTO.Materials and methodsWe mailed the 2011 Knee Society score (KSS) questionnaires to 234 consecutive patients (295 knees) who had undergone closing-wedge HTO, and 158 patients (202 knees, 68.5%) returned a completed questionnaire. The cohort was divided into two groups depending on the age at the time of surgery, and pairs matched the follow-up period and sex was created. The mean follow-up period was approximately 12 years. KSS scores at the final follow-up were compared between two groups using the Student t test and chi-square test, and the survival rates were calculated using Kaplan–Meier survival curves.ResultsThe symptom, satisfaction, and expectation scores were not significantly different between the ≤64-year-old patients and ≥65-year-old patients. The functional activities score was significantly lower in older patients than in younger patients. The overall survival rates of HTO were 99.1 ± 0.4% at 5 years, 94.4 ± 1.2% at 10 years, and 84.6 ± 2.7% at 15 years. There was no significant difference in the survival rate after HTO between the two groups divided by the age (p = 0.602).ConclusionsPain relief and satisfaction after HTO in older patients were comparable to those in younger patients in the mid-term to long-term follow-up, although the functional activity was affected by age.