Introduction. Renal transplantation is regarded as the optimal treatment for patients with end-stage renal disease. Despite significant improvements in surgical techniques and immunosuppressive therapy, long-term graft survival has not markedly increased over the years, due in part to the occurrence of cytomegalovirus (CMV) infection.Patients and Methods. Between January 2001 and September 2011, we performed 592 kidney transplantations (214 living and 378 cadaveric donors). All patients received induction therapy with interleukin (IL)-2 monoclonal antibodies or antithymoglobulin (ATG) combined with calcineurin inhibitors, mycophenolate mofetil, or mTOR antagonists and steroids. All CMV-seronegative patients and all subjects receiving ATG induction were prescribed prophylactic therapy with ganciclovir-intravenous (IV) for 15 days 2.5 mg/kg BW bid and thereafter oral valgancyclovir once a day. CMV infection was diagnosed using a CMV-PVR of >= 600 copies. We analyzed the time to manifestations of CMV infection, or positive CMV-PCR, patient and graft survival, serum creatinine (Cr), and blood urea nitrogen (BUN) values before and after CMV infection, as well as type of immunosuppression therapy.Results. The overall incidences of CMV infection and CMV disease were 76/592 (12.8%) and 23/592 (3.9%), respectively. The mean +/- standard deviation (SD) times to positive CMV-PCR and CMV disease were 16.66 +/- 23.38 months and 106 +/- 61.2 (range, 28-215) days, respectively. Mortality was 1% (6/592) among our whole population, 7.9% (6/76) for CMV-infected, and 26% (6/23) in the CMV disease cohort. Cr and BUN showed no significant differences among the groups.Conclusions. CMV infection and CMV disease comprise significant clinical problems, increasing morbidity and mortality. The use of prophylactic anti-CMV treatment is of paramount importance.

Introduction. The aim of this study was to evaluate infection complications as the reason for intensive care unit (ICU) admission among transplant recipients.Methods. We studied all renal transplant recipients with infectious complications admitted to our ICU from 1992 to 2012:44.3% of all renal transplant recipients admitted to ICU. The epidemiology and prognosis of infectious complications requiring ICU admission were evaluated with analysis of mortality factors.Results. The 22 men and 5 women included in this study showed a mean age of 42.7 +/- 12.3 years. The Acute Physiologic and Chronic Health Evaluation II and Seguential Organ Failure Assessment scores on ICU admission were 20 +/- 4.6 and 8.6 +/- 3.9, respectively. The main infections complications requiring ICU admission were cytomegalovirus pneumonia (n = 15) and aspergillus pneumonia (n = 4). Sixteen patients required hemodialysis and 14, catecholamine support upon ICU admission owing to septic shock. The mortality rate among study patients was 62.9%, versus 26.5% for noninfectious renal transplant recipients requiring ICU admissions. Catecholamine support at ICU admission was independently related to mortality.Conclusion. The mortality rate of renal transplant recipients admitted to ICU owing infection complications was higher than that of noninfected renal transplant patients. These data suggest that infections and septic shock in renal transplant recipients requiring ICU admission worsen their outcome significantly.

Hepatic artery thrombosis (HAT), a serious complication after orthotopic liver transplantation (OLT), can lead to patient death in the absence of revascularization or retransplantation. Herein we have presented clinical characteristics, imaging findings, and long-term outcomes of 3 OLT patients with HAT who were treated conservatively and developed hepatic arterial collaterals. These patients underwent transplantation due to hepatitis B cirrhosis, cryptogenic cirrhosis, or hepatitis C infection and alcoholic disease. They presented with bile duct stenosis and/or a bile leak at 1, 3, and 36 months after transplantation, respectively, and were treated with percutaneous drainage and stent placement, endoscopic retrograde cholangio-pancreatography (ERCP), or reanastomosis of the bile duct over a T tube. HAT was confirmed using multidetector computed tomography (MDCT) 3-dimensional (3D) angiography and Doppler sonography. They survive in good condition with normal liver function at 30, 50, and 42 months after OLT, respectively. Development of collateral arterial circulation to the liver graft was detected with MDCT 3D angiography and Doppler sonography. From our experience with 3 patients and a literature review, we believe that there are a number of patients who experience long-term survival after the diagnosis of irreversible HAT and the development of collaterals. Although this group is at high risk for sepsis and biliary complications, these are usually self-limiting complications due to improved treatment regimens. The development of collateral arterial flow may also be beneficial.

AIM:The outcome of simultaneous pancreas-kidney transplantation (SPK) in type 1 diabetes has dramatically improved in recent years. We report the initial results of our SPK program. PATIENTS AND METHODS:From 2008 to 2010, we performed and prospectively obtained data on 4 SPKs in 4 type 1 diabetic patients with chronic renal failure. The recipients were 3 men and 1 woman, of overall mean age of 40.75 ± 4.78 years, mean time from diabetes diagnosis of 27 ± 15 years, and time on dialysis of 3.5 ± 0.57 years. All grafts were procured from multiorgan brain-dead donors of mean age 26 ± 8.16 years and mean body weight of 74 ± 4.34 kg. The pancreatic grafts were transplanted first into the right iliac fossa with mean cold ischemia times of 10.62 ± 3.09 hours for the pancreatic and 14.00 ± 2.97 hours for the renal grafts. Pancreas arterial inflow was re-established by an end-to-side anastomosis of an extension Y-graft to the recipient right iliac artery. The portal vein was sutured to the iliac vein directly. The exocrine secretions of the pancreas were managed by duodenojejunostomy extraperitoneally (n = 3) or intraperitoneally (n = 1). The ureteral anastomosis was performed using the Taguchi technique. RESULTS:After SPK, endocrine pancreatic function was immediately restored in all patients. Insulin administration was stopped within the first 24 hours after surgery. Two patients displayed delayed renal graft function necessitating dialysis for 9 and 23 days, respectively. The postoperative course was prolonged with a mean hospital stay of 82 ± 1 day. At a 31.75 ± 9.03 months follow up all patients are alive with functioning grafts. CONCLUSION:Our experience with SPK, although limited, has shown encouraging results over a short follow-up period.

Background. Our objective is to provide Provision of primary and secondary patency rates data and incidence of complications. Despite the publication of some review articles and small prospective trials about vascular accesses, controversy still exists regarding the choice of the outflow conduit and especially the choice of the fistula, to be formed in secondary and tertiary access procedures.Methods. This is a retrospective study of 2,422 consecutive patients who underwent 3,685 vascular access procedures in a tertiary care hospital, including radial-cephalic (RCAVF), brachial-cephalic (BCAVF), brachial-basilic (BBAVF), and prosthetic graft (PTFE) fistulas. Maximum follow-up period was 20 years. Actuarial patency rates were obtained by Kaplan-Meier analysis.Results. The median primary patency (days) of the most common 1st choices for vascular access were 712 (95 % CI: 606, 818), 1,009 (95 % CL 823, 1,195), and 384 (95 % CI: 273, 945) days for RCAVF, BCAVF, and PTFE, respectively. The median secondary patency was 1809 days (95% CL 1,692, 1,925) for the RCAVF The median primary patency of BBAVF, (2nd or 3rd choice for vascular access) was 1, 582 days (95 % CL 415, 2, 749). The cumulative incidence of clinically important complications for the patients who received a RCAVF, BCAVF, BBAVF, and u-PTFE was 0.25, 0.57, 0.33, and 0.61 Per Patient-year, respectively.Conclusion. We advocate maximal use of autogenous conduits, except probably the case of the older diabetic patient, in whom access at, the antecubital fossa should be the first choice. BBAVF is an excellent fistula and should probably be constructed before prosthetic graft placement. (Surgery 2009;145:272-9.)

Purpose. Technetium(99M) sestamibi (MIBI) has poor sensitivity and specificity when applied to patients with secondary hyperparathyroidism. We investigated whether the combination of MIBI with preoperative parameters increased its accuracy.Patients and Methods. This prospective study of 453 consecutive patients with secondary hyperparathyroidism who underwent parathyroidectomy (bilateral neck exploration) included preoperative MIBI scintigraphy compared with intraoperative and histopathology findings. Four patient groups were comprised according to the results: true positivity (TP), true negativity (TN), false positivity (FP), and false negativity (FN).Results. MIBI scintigraphy sensitivity, specificity, positive predictive value, and negative predictive value were 66.4%, 50%, 76.3%, and 37.9%, respectively. For the TP group, mean age and mean parathormone (PTH) value were 56 years and 754, respectively. The binary logistic regression for the prediction (1) or not (2) of TP was as follows: 0.138 + (-.011) * age + 0.001 * PTH (P = .012). For the TN group, the mean age and mean phosphate value were 49 years and 5.24, respectively. The binary logistic regression for the prediction (1) versus not (2) of the TN was as follows: -1.463 + age * (-.029) + phosphate * 0.233 (P = .012).Conclusion. MIBI accuracy in patients with secondary hyperparathyroidism was increased when combined with other preoperative parameters. The sensitivity was increased as patients were older and the PTH levels were lower. The specificity was increased as patients were younger and the phosphate levels were lower.

LaMO3 (Me: Mn, Co, Fe) powders were synthesized through a Pechini-type polymerizable complex route, based on the ability of citric acid (CA) to form stable metal chelates and the polyesterification between CA and ethylene glycol (EG). The effect of the molar ratios of reactants (CA:total cations=1–4 and EG:CA=1–3) on the precursors and the final powders was studied. The gelation procedure was monitored through continuous conductivity measurements. The calcination reactions were recorded using TG/DTA measurements, while XRD and FTIR were used for the characterization of the precursors and the final products. The results indicated that the polymerizable complex method can be successfully applied for the preparation of LaMO3. The formation requires a 3-h calcination at 600°C. The molar ratios citric acid:total cations=2 and ethylene glycol:citric acid=3 are the most favorable ratios for the synthesis of LaMO3.

BACKGROUND:The aim of this experimental study was to investigate the effect of mycophenolate mofetil (MMF) during the three phases of colonic anastomosis healing and specifically to check the effect of MMF on the expression of transforming growth factor-beta1 (TGF-beta1), one of the most important growth factors contributing to mechanical stability of colonic anastomosis. MATERIALS AND METHODS:Sixty male Wistar rats underwent colonic resection and end-to-end anastomosis. The animals were divided into two groups, a study group given MMF 40 mg/kg, intraduodenally and a control group given vehicle. The rats were sacrificed at 3, 7, and 14 days (10 animals in each group). The anastomoses were tested by measuring bursting pressure and hydroxyproline content. Histological examination and immunohistochemical expression of TGF-beta1 also were assessed. RESULTS:The mean bursting pressure in the study group was significantly lower on day 3 and 7, but there was no statistical significance on day 14. The mean hydroxyproline content was lower in the study group on days 3, 7, and 14. Histology showed decreased number of macrophages and fibroblasts on days 3 and 7 but no difference on day 14. The expression of TGF-beta1 was significantly reduced in the study group, with the difference being more pronounced on days 3 and 7. CONCLUSION:MMF weakens the integrity of colonic anastomosis, and this effect is more significant during the inflammatory phase of healing. MMF has a negative effect on macrophages and TGF-beta1 expression, resulting in decreased collagen accumulation at the anastomosis.

Midgut volvulus as a result of malrotation classically presents in early life and is associated with intestinal obstruction and compromised vascular supply of the gut. On rare occasions this condition may manifest itself in teenagers and adults, often with disastrous outcome. We report a 28-year-old patient who presented with maelena and endoscopy showing varices in the duodenum and large bowel. During the neonatal period of his life he had been operated on for intestinal obstruction, but the details of the operation were unknown to us. Angiography demonstrated superior mesenteric vein thrombosis and ectopic varices. On laparotomy he was found to have midgut volvulus. Recommendations for diagnosis and treatment are discussed.

P344 Aims: Donor age was identified recently as a major factor that determines long term outcome after kidney transplantation. However, the mechanism that is responsible for increased graft loss from the elderly kidney donors is unknown. The aim of our study was to evaluate the outcome of kidney grafts originated from elderly donors. Methods: In this study we compare 97 kidney grafts from living related donors (LRD) (group 1) with 34 cadaveric kidney grafts (group 2). In both groups donors were older than 60 years. Recipients transplanted from LRD were younger than those transplanted from cadaveric donors (group 1: recipients mean age 37,78 ± 9,30, group 2: recipients mean age 45,88 ± 11,21). Results: Patient survival rates at 1,3 and 5 years, respectively, were 95%, 95% and 93% (group 1) and 85%, 85%, 85% (group 2) (p=0.10, NS). Graft survival rates from LRD were 92%, 87% and 81% in group 1 versus 79%, 73% and 73% in group 2 (p=0.15, NS) and death censoring kidney graft survival was 96%, 91% and 86% in group 1 vs 93%, 86% and 86% in group 2 (p=0.10, NS). Acute rejection was a significant determinant for worse renal graft outcome (graft survival in recipients with at least one rejection episode (n1=35) at 1, 3 and 5 years : 94%, 78% and 67% vs graft survival in recipients without rejection episodes (n2=96) : 96%, 94% and 94% respectively (p= 0.0002). However, delayed graft function (DGF) itself, as well as donor – recipient HLA matching were not associated neither with the occurrence of early acute rejection episodes nor with worse renal graft outcome (graft survival in recipients with DGF (n3=22) at 1, 3 and 5 years: 85%, 85% and 85% vs graft survival in recipients without DGF (n4=109): 96%, 90% and 85% respectively, p=0.51, NS). Conclusions: We conclude that kidneys from older donors, irrespectively of their origin (LRD or cadaveric), can be successfully transplanted to younger patients. Acute rejection episodes in kidney grafts from elderly donors have a significant negative impact on long term renal graft outcome.

The effect of various chemical fire retardants: (NH4)(2)SO4, (NH4)(2)HPO4, a commercial retardant contained 10% w/w phosphate salt, on the pyrolysis mass residue of Pinus halepensis needles was studied on preparative-scale. Samples of 2.00 g were treated under isothermal (400 degreesC and 500 degreesC) and non-isothermal conditions (50 - 500 degreesC), with pyrolysis time between 0.00 - 3.00 h. The results of this study were found similar with those obtained with much lower sample sizes (i.e., 6 mg) used in analytical methods such as Thermogravimetry (TG). The phosphate based retardants had the most significant action, under the experimental conditions used. However, the retarding effect was reduced, when the phosphate retardants were diluted in sea water. This might be attributed to the formation of insoluble salts (i.e., MgNH4PO4). Such reactions might bind the active phosphates, thus reducing the fire retarding effect.

P531 Aims: Acute rejection (AR) is a common complication of liver transplantation (LT). Although, mild episodes resolve without anti-rejection treatment, severe episodes may cause graft dysfunction. AR episodes may also be a factor in the development of chronic rejection. The aim of the study was to evaluate the impact of BSX (Simulect) on prevention of AR in LT patients (1st transplantation) by comparing a triple immunosuppression regimen with, or without BSX (Simulect®). Methods: The study includes two groups of patients who were sequentially recruited into this study: Group 1: Regimen of methylprednisolone, azathioprine (or MMF) and Neoral®. 93 patients were enrolled: (M/F:66/27, age 6months-72yrs) who received 95 grafts for HBV= 27(29%), HBV+HDV=13(14%), HCV=8(8,6%), PBC=9(9,7%), PSC=6(6,4%), other 30(32,3%), Child Pugh stage: A=2(2,2%), B=19(20,4%), C=72(77,4%) and recruited between May1990 and December 2001 and Group 2: Regimen of methylprednisolone, azathioprine (or MMF) and Neoral and BSX (20 mg bolus IV on days 0 and 4 post-tx. 40 patients were enrolled: (M/F:23/17, age:27-62yrs) who received 40 grafts for HBV =14(35%), HBV+HDV=3(7,5%), HCV=4(10,0%), PBC=3(7,5%), PSC=3(7,5%), other 13(32,5%), Child Pugh stage: B=6(15%), C=34(85%) and recruited between December 2001 and October 2003. Groups 1 and 2, including the subgroups, were statistically evaluated and proved to be homogeneous. Results: Patients were followed for 6 months after LT and monitored for incidence of biopsy proven AR and for the development of infections, (Microbial ones during the first month and viral ones up to the 6th month post LT). 29% of the patients in Group 1 developed AR (only 2 of the episodes were steroid resistant) compared with 6% incidence in Group 2 (p =0.006). All AR episodes in Group 2 responded to steroid treatment. Neoplasia recurred in 2 of the 6 patients in Group 1 who were transplanted due to liver neoplasia (HCC=5, CCa=1) and survived beyond the 6 month, while 1metastasis was detected in the 4 patients with HCC in Group 2 (p= NSS). HBV infection recurred in 12 patients in Group 1, while no recurrence was observed in the Group 2 (p=0,003). HCV infection recurred in 2 and in 1 patients respectively (p=NSS). Both groups developed similar microbial infection rates during the 1st month post LT (81% v.s 87%, p=NSS). CMV infections were more prevalent in the BSX group (10% vs 18%; p =NSS) Conclusions: BSX in combination with a Neoral-based triple regimen significantly reduces incidence of AR at 6 months post-tx. The BSX-combination treatment is well tolerated and does not increase the recurrence of the viral infection or neoplasia in the graft while the HBV infection proved to be significantly lower than the non BSX-combination treatment.

A115 Aims: Rocuronium is a new neuromuscular blocking drug with a duration of action similar to that of vecuronium but with a more rapid onset of effect. The aim of the present study was to determine the time for maximum block for intubation and duration of relaxation in patients undergoing renal transplantation and in patients with normal renal function. Methods: We studied twenty patients with end-stage renal disease undergoing renal transplantation (group 1) and twenty patients with normal renal function (group 2), with the approval of Ethics Committee. Any patient receiving medication known to interfere with neuromuscular transmission was excluded from the study. Anesthesia was indused with fentanyl 2γ/kg, midazolam 0,02mg/kg, etomidate 0,2mg/kg IV and intubation was performed with rocuronium 0,9mg/kg in both groups. Anesthesia was maintained with 67%N2O in oxygen and 0,5-1% isoflurane and further increments of fentanyl as required. Neuromuscular function was monitored by stimulating ulnar nerve in train of four (T.O.F) mode of stimulation.Intubation was performed when none of the four answers of T.O.F were received (T1) and next dose of rocuronium was administered when we received the second answer of T.O.F.(T2). The Mann-Whitney test was used for statistical analysis and p<0,05 was considered significant.FigureComparing the two groups there were no statistical difference: T1 p:0,14, T2 p:0,69. Conclusions: The onset of action and the duration of relaxation of rocuronium were not altered in patients with renal failure undergoing renal transplantation.