Introduction. Venous thromboemboli and bleeding are the complications that threaten the graft and patient's life in the early postoperative period after cadaveric renal transplantation. For this reason, heparin administration after renal transplantation should be administered carefully. The aim of this study was to evaluate the necessity for heparinization after cadaveric renal transplantation.Methods. Between March 2009 and October 2010, we formed 2 study groups among 50 recipients who underwent either cadaveric (n = 25) or living donor transplantations (n = 25). We did not observe any risk factors for thromboembolism while group 1 did not undergo heparinization, group 2 received a prophylactic dose of low-molecular weight heparin for 1 week. Doppler ultrasonography (USG) was performed between postoperative 24-48 hours to examine the transplanted kidney vessels, and in one group 1 case for a bilateral lower extremity venous system examination. We were also compared postoperative. thromboembolic and hemorrhagic complications, lymphorrhagia, and serum creatinine levels.Results. The female/male ratios in group 1 and 2 were 14/11 and 8/17 with mean ages of 36.7 (range, 17-51.) and 35.9 (range, 17-59) years, respectively. The mean preoperative serum creatinine levels were 7.9 +/- 2.9 mg/dL and 6.8 +/- 2.4 mg/dL, and at postoperative week 1, they were 5.1 +/- 4.3 ing/dL and 1.2 +/- 0.5 mg/dL, respectively. We did not encounter any partial or total thrombus upon doppler USG studies for renal and lower extremity venous systems. No clinical symptoms of pulmonary emboli Were detected in any patients. Only 1 subject group 2 experienced massive postoperative bleeding.Conclusion. Herein, we have reported that, except for the patients with risk factors for venous thromboemboli, heparinization was not necessary in the early postoperative period and did not add benefits to outcomes of cadaveric renal transplant recipients.

Background. This study was designed to determine whether human leukocyte antigen (HLA) and major histocompatibility complex class I chain-related A (MICA) antibody (Ab) production during the first 6 months posttransplantation correlated with long-term graft survival and rejection rate. The study group included 147 first transplantations from either living related (LRDs) or deceased donors (DDs) who were divided into two subgroups: rejection (RG, n = 28) and nonrejection (NRG, n = 119). Serum samples (n = 441) collected from each patient on posttransplant days 30, 90, and 180 were tested for HLA and MICA Ab using the Luminex technique.Results. Among 82 Ab-positive patients (55.8%), 40 had both HLA and MICA, 33 only HLA, and 9 only MICA Ab in the posttransplant period. The rates of HLA class I, class II, or both Ab positivities were greater in the RG than the NRG (P = .011, .037, and .0275, respectively). At 180 days posttransplant, 64.3% of patients in the RG had Ab and 41.2% in the NRG (P = .0349). The data for the LRD (n = 116) group were similar to those for the entire group; whereas there was no significant difference in Ab positivity between RG and NRG patients who received organs from DDs. There was no significant difference with respect to HLA class II and/or MICA Ab positivity between RG and NRG among patients who lacked HLA class I Ab.Discussion. We confirmed that HLA and MICA Ab may be harmful posttransplant, promoting rejection processes and representing an important cause of graft failure. HLA class II and MICA Ab positivities were only important predictors of graft failure when present together with HLA class I positivity. Patients who developed HLA alone or both HLA and MICA Ab rejected their grafts more frequently than Ab-negative recipients.

Exposure to human leukocyte antigens (HLA) via blood transfusions, pregnancies, and previous transplantations can result in anti-HLA antibody production. The presence of anti-HLA antibodies in recipient sera before transplantation is an important risk factor. To demonstrate the anti-HLA antibody status of Turkish end-stage renal disease (ESRD) patients, 674 patients (mean age, 40.35 +/- 13.15 years; female/male, 328/346) were enrolled into the study. Anti-HLA antibody screening and identification tests were performed using an enzyme-linked immunosorbent assay (ELISA) method. The panel-reactive antibody (PRA)-negative group consisted of 564 (83.6%) and the PRA-positive group consisted of 110 (17.3%) patients. Of the 110 (17.3%) PRA-positive patients, 43 (6.4%) were class I (+) and class II (-); 19 (2.8%) were class I (-) and class II (+); 48 (7.1%) were both class I and II (+). The most frequent antibodies were directed against the A2 crossreactive group (CREG) and the A10 CREG with less frequent reactions against the B7 CREG, indicating antibodies to both frequent (members of A2 CREG) and relatively rare (members of A10 CREG and B7 CREG antigens). These data also suggested that some antibodies occur at greater than expected frequency because of shared epitopes. Our findings confirmed the significant correlation between female gender, pregnancy, failed graft history, long dialysis duration, and blood transfusions with PRA positivity (P < .05).

AIM:This retrospective report analyzed the demographic features of kidney transplant outpatients grafted in Turkey and in different regions of the world. METHODS:The patients were divided into 4 groups: Every cohort was subgrouped as either receiving a cadaveric (CT) or a live donor transplant (LT) performed in our institute (ICT, n = 147, ILT, n = 304), other institutions in Turkey (TCT, n = 16, TLT, n = 86), or in a foreign country (FCT, n = 66, FLT, n = 154). RESULTS:Among the patients with functional grafts, FLT transplantations, of which the vast majority were paid transplantations, constituted the second largest group (n = 105) following ILT (n = 214). In the ILT group, 5- and 10-year graft survival rates were 76% and 50%, respectively, and patient survival rates were 88% and 78%, respectively. Considering the FLT group, 5- and 10-year graft survival figures were 70% and 42%, respectively, while patient survival rates in these periods were 81% and 69%, respectively. Patients with paid donor transplantations were characterized by a high risk of unconventional infectious complications in the early period, while midterm patient and graft survival was somewhat better than expected considering the high rate of complications in the early period. CONCLUSIONS:Paid organ transplantation should be discouraged. Organ donation should be stimulated by every means to avoid potentially fatal unconventional infections after transplantation from paid donors. If patients receive a paid transplant, however, they should be closely followed for these complications, since, if they survive the early period the midterm and long-term outcomes are quite reasonable.

We report a case of a 35-year-old man with nocardiosis infection involving soft tissue and the central nervous system who had received a cadaveric donor kidney. The patient was admitted with fever, malaise and right shoulder pain. Soft tissue abscess was seen on ultrasound examination. It was presumed due to gram (+) microorganisms, so 4 g day (IV) ampicillin/sulbactam was started empirically once the abscess was drained. Nocardia asteroides was found in the pus specimen. On the second day in hospital, severe headache, ataxia and signs of meningeal irritation appeared. The cranial CT showed two intracranial abscesses in the frontal lobe and cerebellum. We assumed Nocardia asteroides was the infective agent for the cerebral abscesses, so antibiotic therapy was switched to trimethoprim-sulphamethox-asole (3x160/800 mg/d). Nausea and vomiting occurred on the fifth day of therapy, improving after drainage from the frontal abscess. However, these complaints recurred five days later. CT showed cerebellar abscess had become bigger. The patient's complaints improved after the second surgical drainage. N. asteroides was again grown in the aspiration fluids of both cerebral abscesses. Complete regression of the abscesses was seen in the CT after two months. Co-trimoxazole was continued for six months then withdrawn. Graft dysfunction was not observed. Early medical and surgical interventions may be life-saving in this potentially lethal disease.

FAMILIAL Mediterranean fever (FMF) is an autosomal recessive disorder, common in some ethnic groups such as Sephardic Jews, Armenians, Turks, and Arabs. The disease is characterized by recurrent attacks of fever associated with serositis affecting the pleura, peritoneum, and/or large joints as well as systemic amyloidosis of the AA type causing nephropathy and end-stage renal failure (ESRF). There is a wide variation in the reporting of this disease as a cause of ESRF. Among the member countries of European Dialysis and Transplantation Association (EDTA), amyloidosis was responsible 1.6% of all ESRF patients. In 76% of these patients, chronic inflammatory diseases were the underlying etiology for amyloidosis, and FMF was the second cause. Most of the FMF patients were localized to Egypt, Israel, and Turkey. Even a lower incidence (0.3%) of amyloidosis as a cause of ESRF has been reported from the United States; however the underlying etiology of these cases was not defined in this report. In contradistinction, amyloidosis represents a more common cause of chronic renal failure among patients from the Middle East and the Mediterranean countries; and FMF has been identified as the most frequent underlying cause for the disease in these groups. Indeed, FMF amyloidotic patients represent 6% of the candidates for renal transplantation in Israel. In Turkey 4.2% of ESRF patients suffer from amyloidosis, although the underlying etiology was not identified in this report. Thus, at least in some countries, amyloidosis is an important etiologic factor for ESRF. As most of the patients with renal amyloidosis progress to ESRF, the selection of the renal replacement therapy modality (ie, hemodialysis, peritoneal dialysis, or renal transplantation) is a major concern. It has been reported that amyloidotic patients maintained on chronic hemodialysis experience higher rates of morbidity and mortality when compared to dialysis patients whose causes of ESRF were due to other diseases. There is not enough information regarding the patients on chronic peritoneal dialysis; because the effects of repeated peritoneal inflammation on peritoneal permeability has not been well defined. Considering kidney transplantation, many authors have concerns, because amyloidosis is a generalized disorder and most patients show systemic manifestations of the disease. There are four concerns when considering these patients for transplantation.

Background. Due to inadequate cadaveric and living related organ supply, many end-stage renal disease patients go to Third World countries for commercial transplantation, although the high risk of complications is well established and ethical arguments debate this practice.Methods. The midterm outcome of 115 patients who had been commercially transplanted in various countries and admitted to our center for post-transplant care and follow-up between 1992 and 1999 was retrospectively analyzed. Data considering the transplantation practice and post-transplant course were collected from the patient files. Outcome of these patients was compared with those with a living related transplant performed at our center.Results, The patients (91 male and 24 female; mean age of 42 +/- 12 years) were transplanted in India (N = 106), Iraq (N = 7), and Iran (N = 2). The mean follow-up period was 64.5 +/- 23.9 months. Post-transplant course was complicated by numerous surgical and/or medical complications, and many of the latter were unconventional infections caused by malaria, invasive fungal infections, and pneumonia due to various opportunistic pathogens. Overall, 52 patients still have functioning allografts, while 22 lost their grafts, 20 died, and 21 were lost to follow-up. Graft survival rates at two, five, and seven years were 84, 66, and 53%, respectively, for the study group, while it was 86. 78, and 73% for living related transplantations performed at our center (P = 0.036). Patient survival rates for the same periods were 90, 80, and 74% for the study group and 90.85, and 80% for the living related transplantations (P = 0.53).Conclusions. Besides the ongoing ethical debate, commercial transplantation carries a high risk of unconventional complications, and despite that the patient survival rate is comparable. graft survival is worse than conventional living related transplantations at the midterm.

In this report, the results of renal transplantation in patients with renal amyloidosis were retrospectively analysed and compared with the control group. Fifteen (3.04%) of the 493 renal transplant recipients whom were followed up in Istanbul School of Medicine transplant outpatient clinic, between 1983 and 1997, were included in the study. The etiology of amyloidosis was familial Mediterranean fever in all patients. The mean follow‐up period was 38.3 ±31.8 (range 7‐65) months. Twelve of the patients were male and 3 female with the mean age 34.13 ±10.87 (range 21‐60) years. Seven patients had living related, 4 living‐unrelated and 4 cadaveric donors. Five patients were lost because of different complications: Three patients died from cardiac amyloidosis all with well functioning grafts, 2, 3 and 36 months after the operation. sepsis and cardiovascular failure was the probable cause of death in 1 patient who also had chronic rejection. Another one patient with chronic rejection died from hepatic failure. acute rejection developed in 2 patients. Renal functions of these patients improved by anti‐rejection therapies. Chronic rejection developed in 3 patients. In the control group, acute rejection and chronic rejection were diagnosed in 5 and 1 patients, retrospectively. While 1 patients returned to hemodialysis in control group, the others are alive with satisfactory graft function. There was no death in control group. The 5‐yr graft and patient survival rates in amyloidosis and the control groups were 75, 77, 95 and 100%, respectively. It was concluded that although transplantation is not a contraindication for the treatment of end stage renal failure in patients with renal amyloidosis, it carries high risk of cardiac complications in the postoperative period. Detailed preoperative cardiovascular evaluations are mandatory in these patients and this intervention should improve the prognosis by excluding the patients who have already been complicated with this problem.

In this report, the results of renal transplantation in patients with renal amyloidosis were retrospectively analysed and compared with the control group. Fifteen (3.04%) of the 493 renal transplant recipients whom were followed up in Istanbul School of Medicine transplant outpatient clinic, between 1983 and 1997, were included in the study. The etiology of amyloidosis was familial Mediterranean fever in all patients. The mean follow-up period was 38.3 +/- 31.8 (range 7-65) months. Twelve of the patients were male and 3 female with the mean age 34.13 +/- 10.87 (range 21-60) years. Seven patients had living related, 4 living-unrelated and 4 cadaveric donors. Five patients were lost because of different complications: Three patients died from cardiac amyloidosis all with well functioning grafts, 2, 3 and 36 months after the operation. Sepsis and cardiovascular failure was the probable cause of death in 1 patient who also had chronic rejection. Another one patient with chronic rejection died from hepatic failure. Acute rejection developed in 2 patients. Renal functions of these patients improved by anti-rejection therapies. Chronic rejection developed in 3 patients. In the control group, acute rejection and chronic rejection were diagnosed in 5 and 1 patients, retrospectively. While 1 patients returned to hemodialysis in control group, the others are alive with satisfactory graft function. There was no death in control group. The 5-yr graft and patient survival rates in amyloidosis and the control groups were 75, 77, 95 and 100%, respectively. It was concluded that although transplantation is not a contraindication for the treatment of end stage renal failure in patients with renal amyloidosis, it carries high risk of cardiac complications in the postoperative period. Detailed preoperative cardiovascular evaluations are mandatory in these patients and this intervention should improve the prognosis by excluding the patients who have already been complicated with this problem.

In this report, incidence and clinical characteristics of Kaposi's sarcoma (KS) were retrospectively analyzed among renal transplant recipients who were being followed-up in the outpatient clinic of the Istanbul School of Medicine. Between October 1983 and December 1997, 17 cases of KS were diagnosed among 557 patients (3%). Of the total 25 post-transplant malignancies, KS was the most common tumor, representing a rate of 68%. Diagnosis was suspected with typical skin lesions and was confirmed by biopsy. Gastroduodenal endoscopy was applied to 7 patients in order to assess gastrointestinal tract involvement. Of the total number of patients diagnosed with KS 14 were male and 3 female, with the mean age of 40 +/- 15 (range 13-68) yr. The mean duration between the date of transplantation and diagnosis of KS was 15.9 +/- 20.3 (range 1-65) months. The lesions were limited to the skin in 13 patients, while skin and gastrointestinal tract were involved in 2 patients and generalized disease was noted in 2 patients. The initial therapeutic approach was to withdraw cyclosporine and to reduce azathioprine. In the case of progression of the lesions azathioprine was also stopped. Besides, surgical excision of the lesions, radiotherapy and/or chemotherapy were performed according to the clinical picture. Remission was observed in 14 patients after this therapy protocol. The 2 patients with gastrointestinal involvement and 1 patient with generalized KS died in spite of the above-mentioned therapeutic interventions. One of the patients on remission died of pneumonia. It was concluded that KS carried a high risk of morbidity and mortality in renal transplant recipients, and tapering of immunosuppression, especially withdrawal of cyclosporine, affected the prognosis favorably.

The frequency and clinical characteristics of plasmodium infection were reported in 420 renal transplant recipients who were followed in the Transplantation Unit and Out-Patient Clinic of the Medical School of Istanbul. Plasmodium infection was diagnosed in eleven (9 male, 2 female) of the 420 patients (2.6%). Ten of the patients were transplanted in India, and one in our institution. The mean duration between the transplantation and the diagnosis of malaria was 21.7 + 44.4 days in patients who were transplanted in India. All of the patients were taking triple immunosuppressive drugs (CsA, AZA PRED). Plasmodium falciparum was diagnosed in 6 patients, P vivax in 1 patient and P malariae in 1 patient. Also mixed infection with P falciparum and P malariae was diagnosed in 3 patients. After definite diagnosis, the patients were hospitalized. Chloroquine phosphate plus primaquine phosphate was administered for P vivax infection, whereas chloroquine phosphate alone was given for P falciparum and P malariae infection as a first line antimalarial therapy. As a result of therapy, infection improved clinically and the plasmodia disappeared rapidly from the thick blood film in 10 of the patients. Severe hemolysis and acute renal failure developed in one patient, who improved after hemodialysis therapy and exchange transfusions.It was concluded that malaria is quite a frequent infection of transplant recipients who get their allografts from donors living in high-risk areas, and all transplant recipients having this kind of transplantations should be suspected and examinedfor malaria. This may help to diagnose and treat the complication in the early period, thus resulting in an improved prognosis for this potentially life-threatening complication of the posttransplant period.

Due to inadequate cadaveric and living related organ supply, many end-stage renal disease patients go to third-world countries for living unrelated (paid) kidney transplantation. Thirty-four patients who have had transplantations in two centres in India before coming to our centre for post-transplant care and follow-up are reported in this study. In the post-transplant phase at our centre, the mean follow-up period of the patients was 209.7±137.3 (range 6—450) days. Fourteen of them, having an uneventful course, were followed on an outpatient clinic basis. The rest of the patients were hospitalized because of the following surgical and/or medical complications during admission: urinary fistula in two patients; lymphocele in three patients; urinary tract obstruction in two patients; decubitus ulcer in one patient; severe wound infection in one patient; subacute myocardial infarction in one patient; acute irreversible vascular rejection in two patients; urinary tract infection in two patients; pneumonia in two patients; congestive heart failure and severe electrolyte disturbance in two patients; post-transplant diabetes mellitus and ketoacidosis in one patient; cyclosporin nephrotoxicity in two patients; cyclosporin nephro-, hepato-, and neurotoxicity in one patient. Plasmodium falciparum malaria in three patients, generalized mucormycosis infection in one patient, and genitourinary aspergillosis in one patient were seen during the first month. Hepatitis B virus infection followed by chronic active hepatitis was diagnosed in two patients, 2 and 4 months after the operation; and Kaposi's sarcoma was noted in another two patients, 1 and 5 months after the operation. One of the patients died as a result of disseminated mucormycosis and another one as a result of pneumonia. Transplant nephrectomy was performed in the case of two other patients because of irreversible symptomatic rejection. A possible cause of the above-cited high incidence of complications was thought to be the inadequate evaluation of the donors and the patients in the preoperative period. Furthermore, many of the patients were sent to their countries without treatment of postoperative-period complications. It was concluded that living unrelated (paid) kidney transplantation in developing countries carried high risks of medical and/or surgical complications, beside the ethical problems.

In those cases where hypertriglyceridaemia was present before renal transplantation, it persisted after transplantation, and hypercholesterolaemia also developed. We studied serum lipid, lipoprotein, and apolipoprotein concentrations and plasma fibronectin concentrations in 57 renal transplantation patients and 29 healthy controls. We concluded that atherosclerosis in renal transplantation patients might be related to alterations in the constitutions of lipoproteins and apolipoproteins, but fibronectin synthesized by vascular endothelial cells seemed not to be associated with the atherosclerotic process.