The incidence and significance of late acute cellular rejection (>1000 days) after liver transplantation

Acute cellular rejection (ACR) after liver transplantation occurs in as much as 70% of patients within the first year. There is very little known about ACR that occurs more than 1 yr after transplant, and it is generally believed that late occurring ACR may be more resistant to medical treatment and is associated with a higher rate of chronic ductopenic rejection and graft loss. A total of 532 recipients with more than 1000 d follow-up and who did not have hepatitis C were identified. Forty-three (8.1%) had biopsy proven late ACR at a mean of 1545 +/- 441 d post-transplant. Additionally, 38 of the 43 (88.4%) patients with late ACR had earlier episodes of ACR before 1000 d post-transplant vs. only 295 of the 488 patients (60.5%) that did not have late ACR (p < 0.01). The incidence of primary sclerosing cholangitis (PSC) was 32.6% among patients with late ACR and 11.1% among patients without late ACR (p < 0.01). The overall patient survival for patients who had late ACR (n = 43) is 81.4% while for patients without late ACR (n = 488) it is 82.0% (p = ns). Patients remain at risk for ACR even after 1000 d post-transplant, particularly those with PSC.     

Post-liver transplant acute renal failure: factors predicting development of end-stage renal disease

BACKGROUND: Acute renal failure (ARF) occurs in 5-50% of patients undergoing orthotopic liver transplantation (OLT). The aim of this study was to determine factors that might predict the development of end stage renal disease (ESRD) in patients who had ARF after OLT. METHODS: We studied all OLT recipients between 9/1/1988 through 12/31/2000. RESULTS: A total of 1602 patients underwent OLT during the study period. About 350 patients (22%) developed ARF requiring dialysis post-operatively. One hundred and twenty-three (39.8%) died within a year after OLT. Median follow up was 5.8 yr (range 1-12 yr). Forty-three patients (23%) developed ESRD over median of 3.79 yr (range 1-8 yr). Multivariate logistic regression analysis revealed creatinine levels > 1.7 mg/dL at 1 yr (p < 0.001), cyclosporine as immunosuppression (p = 0.026), and the presence of diabetes pre-OLT (p < 0.001) to be associated with the development of ESRD. The development of ESRD did not decrease patient survival (p = 0.111). ESRD patients who received subsequent kidney transplantation had significantly improved survival rates (p = 0.005). CONCLUSIONS: Serum creatinine levels at 1 yr, cyclosporine as immunosuppression, and the presence of diabetes pre-OLT are independent predictive factors for the development of ESRD. ESRD patients who received kidney transplantation had higher 10-yr survival rates when compared with patients maintained on dialysis.     

Major retroperitoneal vascular injuries during laparoscopic cholecystectomy and appendectomy

BACKGROUND: Serious complications may occur during laparoscopic surgery, as in any surgical procedure. Injuries of major retroperitoneal vascular structures are uncommon but important complications of laparoscopy. METHODS: We report on 9 major vascular injuries in 8 patients in the course of 8 laparoscopic procedures between 1994 and 2002. RESULTS: The primary operations were cholecystectomy in 7 patients and appendectomy in one patient. Six vascular injuries occurred during placement of the first umbilical trocar, two in the course of the insertion of a Veress needle, and one during the insertion of the second trocar. A laparotomy was performed immediately in all cases. Left common iliac arteries were injured in two patients, aorta in three patients, right common iliac vein in one patient, both right common iliac artery and vein in one patient, and inferior vena cava in one patient. Polytetrafluoroethylene (PTFE) graft interposition was employed in two common iliac arteries and a tubular PTFE graft in one aortic injury, and Dacron patchplasty in one common iliac artery injury. Two aortic, two common iliac vein, and an inferior vena cava injury were repaired primarily. There were also four visceral organ injuries, which were repaired primarily. The major retroperitoneal vascular complication rate was 0.07%. An average of 3.5 units of whole blood were transfused in each case and the average stay in hospital was 6.8 days. There was no mortality. CONCLUSIONS: The surgeon's experience and knowledge are the essential factors for prevention of major vascular injuries during laparoscopic procedures. In case of an injury, immediate laparotomy must be performed to achieve hemostasis and a surgeon who is familiar with vascular surgery should employ the definitive treatment.     

Visceral Kaposi's sarcoma with intracranial metastasis: a rare complication of renal transplantation

The incidence of Kaposi's sarcoma (KS) has increased in solid organ transplantation recipients. This type of KS tends to be aggressive, involving lymph nodes, mucosa and visceral organs in about half of patients, sometimes in the absence of skin lesions. Brain involvement of KS has rarely been reported. A 16-yr-old Turkish boy underwent renal transplantation from his mother. The immunosuppressive regimen included prednisolone, cyclosporin A and azathioprine. Fourteen months later the azathioprine was changed to cyclophosphamide (3 mg/kg/day) because of the development of a nephrotic syndrome. After 12 weeks, the cyclophosphamide was changed to mycophenolate mofetil (MMF) to control the nephrotic syndrome. At this time his serum creatinine level rose to 2.1 mg/dL. Polyclonal or monoclonal antibodies were never given. Multiple intra-abdominal lymphadenopathy was detected on abdominal tomography at the 32nd month after renal transplantation. Kaposi's sarcoma was diagnosed via laparotomy and biopsy. He had a generalized tonic and clonic seizure and contrast enhanced cranial tomography showed two intracranial masses which had an abundant vascular component which caused a mild shift. One of the masses was removed via a burr-hole with the aim of diagnosis and treatment of the shift. A pathologic examination of the intracranial lesion was also reported as Kaposi's sarcoma. Herpes virus-8 DNA was detected by PCR in the intracranial lesion.     

The effects of losartan and enalapril therapies on the levels of nitric oxide,malondialdehyde, and glutathione in patients with essential hypertension

Several recent studies have shown that essential hypertension is associated with increased oxidative stress, which may cause hypertension via enhanced oxidation and inactivation of nitric oxide. In this study, we investigated the malondialdehyde, nitric oxide, and glutathione levels in newly diagnosed essential hypertensive patients and whether or not there was any effect of antihypertensive treatment with angiotensin II type 1 receptor antagonist, losartan or angiotensin converting enzyme inhibitor, enalapril on plasma malondialdehyde, nitric oxide, and glutathione values. We selected 17 patients (F/M: 10/7, mean age: 46.12 +/- 9.2 years) for enalapril therapy (10-20 mg/d) and 14 patients (F/M: 8/6, mean age: 47.7 +/- 7.5 years) for losartan therapy (50-100 mg/d), and compared them with 12 normotensive controls. At the beginning of the study, both treated groups showed significantly higher plasma malondialdehyde and lower glutathione and nitric oxide in exhaled air compared to the control group. After 9 weeks of enalapril and losartan treatment, both systolic and diastolic pressure were significantly reduced. Both enalapril and losartan produced a significant decrease in plasma malondialdehyde and a significant increase in plasma glutathione levels and nitric oxide in exhaled air after 9 weeks. Initial values of plasma nitrate levels in patient groups were similar to the control group and increased significantly after the treatment period. In conclusion, both losartan and enalapril may be regulators between oxidant stress and the antioxidant system.     

Bone density loss after spinal cord injury: elite paraplegic basketball players vs. paraplegic sedentary persons

OBJECTIVE: To compare the bone mineral density of elite paraplegic basketball players with the values obtained from their paraplegic sedentary counterparts. DESIGN: A total of 17 male paraplegic basketball players and 17 male paraplegic sedentary persons were included in the study. Bone mineral densities of the distal third of radius of the dominant arm, L2-L4 spine, and trochanters, Ward's triangles, and the femoral necks of both hips were measured. RESULTS: The densities of trochanters, Ward's triangles, and the femoral necks were found to be decreased in both groups, with no significant difference between them. The densities of lumbar and radial regions were found to be increased in both groups. Radial density was significantly higher in paraplegic basketball players than in paraplegic sedentary patients, whereas the groups were not significantly different for lumbar density. CONCLUSIONS: Wheelchair basketball in spinal cord-injured patients was associated with greater bone density in distal radius compared with sedentary paraplegics. However, it was not associated with greater density below the injury level.     

Liver tumors in children

Primary hepatic neoplasms in children are relatively infrequent, accounting for between 0.5 and 2.0% of all pediatric neoplasms. They are a diverse group of epithelial and mesenchymal tumors whose incidence can vary considerably with patient age. They are clinically relevant tumors however as two thirds of them are malignant. The therapy of these tumors has evolved over time and it currently involves a combination of surgery, adjuvant and neoadjuvant chemotherapy and possible transplantation.     

Psychosocial factors and sexual dysfunctions: a descriptive study in Turkish males

The study of human sexuality has dramatically changed in the last decade. The conceptualization of sexual dysfunction developed in the West is now mushrooming in different parts of the world and there is a dearth of research on characteristics of patients seeking treatment for sexual dysfunction in non-Western countries. This paper describes the demographic characteristics, related factors, and clinical symptomatology of 40 male patients with various sexual dysfunctions attending the psychiatric out-patient clinic of Cukurova University, Turkey. Turkey's population is predominantly Muslim and the country unites Europe and Asia, showing the cultural characteristics of both continents. Our results suggest that the patterns of manifestation are similar to those reported elsewhere with the exception of premarital patterns of sexuality.     

A patient with metachronous gastric,colonic, and thyroid cancers: a case report

In this paper, we discuss a 62-year-old woman who, in the course of 7 years (1994-2001), developed three cancers: adenocarcinoma of the stomach, adenocarcinoma of the cecum, and insular thyroid carcinoma, which metastasized to the retroperitoneal lymph nodes and liver. The patient died from complications related to the metastases. The results of basic genetic tests were normal. To the best of our knowledge, no other patient with the combination of these three cancers has been reported in the literature. Although patients with multiple cancers are not common, it is nonetheless important for clinicians to consider the possibility of second and third cancers in patients who were treated for a primary malignant tumor.     

Chest radiography and thoracic computed tomography findings in children who have family members with active pulmonary tuberculosis

OBJECTIVE: The chest radiography and TCT findings in children who had contacted with adult family members with active pulmonary tuberculosis were compared. The contributions of thoracic computed tomography to the diagnosis of tuberculosis were investigated. METHODS AND MATERIAL: The children who were 0-16 years old (n=173) and children of families with an adult member which was diagnosed as pulmonary tuberculosis were evaluated. The children were considered in two groups based on the absence (n=125) or presence (n=48) of complaints and/or ambiguous symptoms such as lack of appetite, mild cough, sweating, history of lung infection, low body weight and those with suspicious chest radiography findings (12 cases) were included in this study. Asymptomatic patients (n=125) did not undergo TCT. Patients who had positive PPD skin tests only received isoniazid. If the TCT demonstrated enlarged lymph nodes or parenchymal lesions, minimally active pulmonary tuberculosis was diagnosed and antituberculous treatment was given. RESULTS AND DISCUSSIONS: TCT revealed lymph node enlargement or parenchymal lesions in 39 children (81.2%). Of the 12 children whose CXRs revealed suspicious lymph node enlargement and/or infiltration, five had normal findings in TCT whereas the initial findings were confirmed in the remaining seven. These data suggest that there is a correlation between the presence of ambiguous symptoms in exposed children and TCT findings; chest radiography and TCT findings do not yield parallel findings. All the patients who received anti-TB treatment were resolved in the control examinations. CONCLUSION: In this study there is a correlation between presence of ambiguous symptoms and TCT findings, but the chest radiography and TCT findings do not yield harmony in exposed children with ambiguous symptoms (suspicious tuberculosis cases). These observations should be considered in children with symptoms similar to those of exposed children, but with no definite history of exposure. If similar TCT findings observed in such patients, treatment for tuberculosis should be considered.