The Outcome of Patients Presenting with Crush Syndrome after the Marmara Earthquake

In this study, we evaluated the clinical and laboratory data of the patients presenting after the Marmara earthquake. Crush syndrome was diagnosed in 60 patients (30 M, 30 F, mean age: 31.3±13.8 years). They were buried under the rubble for a mean period of 12.3±15.1 hours. On admission, 27 patients were oligoanuric and the mean serum creatinine, creatinine phosphokinase and potassium levels were 4.4±3.2 mg/dl, 18453.1±24527.2 IU/L, and 4.9±1.7 mEq/L, respectively. The most frequent site of trauma was the lower extremity. Dialysis treatment was initiated in 40 patients (19 M, 21 F, mean age: 32.7±13.0 years). Mean number of hemodialysis sessions/patient was 8.9±6.8. Nine (23%) patients among the dialyzed and 4 (20%) among the non-dialyzed died leading to an overall mortality of 21.6%. This low mortality rate suggests that the death rate from acute renal failure due to crush syndrome could be decreased by extensive follow-up.

Effects of Zinc Supplementation on the Immune System and on Antibody Response to Multivalent Influenza Vaccine in Hemodialysis Patients

The depression of the immune system in chronic uremia is a well-known phenomenon but the role of serum zinc (Zn) levels on both cell-mediated and humoral immunity is still controversial. The aim of this study was to investigate the effect of Zn supplementation on the immune system and on antibody response to multivalent influenza vaccine (MIV) in hemodialysis patients (HP).

Twenty-six HP and 11 healthy subjects (HS) were vaccinated with MIV. Hemodialysis patients were randomly divided into two groups. Group 1 (13 HP) was supplemented with 120 mg ZnS04 after each dialysis session. Group II (13 HP) and Grouip III (11 HS) were given placebo. In all cases, the serum Zn levels, CD3, CD4, CD8, CD19, HLA-DR+ cell percentages, CD4/CD8 ratio and CD3+HLA-DR+ cell percentages were determined before and 30 days after vaccination. Antibody levels to subgroups of MIV were also measured.

All the baseline parameters studied were not statistically different between Group I and II. However, there was a significant difference between the basal parameters of Group III and the other two groups, except for CD3 and CD4 cell percentages.

Serum Zn, CD19 cell percentage and antibody levels to MIV subgroups were significantly increased in Group I at the end of the first month of the study (p<0.01, p<0.05, p<0.001, p<0.001, and p<0.01, respectively), but the other parameters showed no significant changes. The only significant change observed in Groups II and III was an increase in antibody levels to MIV subgroups one month after vaccination. Antibody levels to MIV subgroups, were not statistically different between Groups I and II, but in Group III they were strikingly higher than those of HP (p<0.001).

These results led us to conclude that Zn supplementation could not restore the immune parameters and enhance antibody response to MIV in HP.

Relevance of Flow Cytometric Auto-Crossmatch to the Post-transplant Course of Kidney Transplant Recipients

INTRODUCTION

The crossmatch test is essential prior to kidney transplantation (tx) to confirm compatibility between the donor and the recipient. However, its results can be misleading due to "undetectable antibodies" in the recipient's serum. To establish if undetectable autoantibodies are responsible for a positive result, an auto-crossmatch test can be performed. In this study, we aim to determine the long-term prognostic value of auto-flow cytometric auto-crossmatch (FCXM) test on kidney survival in kidney tx recipients.

MATERIALS AND METHODS

The primary outcome variable was reduced renal function. Secondary endpoints were incidence of biopsy-confirmed chronic antibody-mediated rejection (CAMR) and recurrent glomerulonephritis (GN).

RESULTS

There were no differences regarding initial serum creatinine levels between the study and control groups (P = .441). Patients who had positive auto-B FCXM had a significantly reduced renal function compared with the control group (P = .016). Four patients developed biopsy-confirmed CAMR in the study group and 1 patient in the control group (P = .047). Five patients had biopsy-confirmed recurrent GN in the GN study group, and only 1 patient had recurrent GN in the GN control group (P = .026).

DISCUSSION

Kidney transplant recipients with positive auto-FCXM test had significantly reduced renal function and a higher incidence of recurrent GN and CAMR compared with the control group. The findings of this study suggest a potential role of auto-antibody causing positive auto-FCXM test result, meanwhile increasing the risk of CAMR, recurrent GN, and new-onset diabetes after tx.

A case of isolated Nocardia asteroides brain abscess in a kidney transplant recipient

Because of the immunosuppressive drugs used after organ transplantation, there is an increased rate of certain infections and malignancies. Nocardia brain abscess is a rare condition, seen most commonly among immunocompromised patients. It may be confused with intracranial tumors and requires long-term combined antibiotic therapy after drainage.

CASE REPORT

A patient who underwent renal transplantation because of end-stage renal disease of unknown origin was shown to have a nocardial brain abscess while she was taking immunosuppressive drugs. The patient was given combined antibiotics and the abscess drained surgically. After 2 months, antibiotic therapy was continued with one drug. Neither a complication nor clinical or radiological sequelae occurred in this patient.

CONCLUSIONS

When central nervous system findings are observed in renal transplant recipients, nocardial brain abscess must be considered in the differential diagnosis. Recommended treatment duration is 6 to 12 months with frequent imaging.

Effects of magnesium sulphate and clonidine on propofol consumption, haemodynamics and postoperative recovery

BACKGROUND

This placebo-controlled, double-blind study was designed to assess the effects of magnesium sulphate and clonidine on peroperative haemodynamics, propofol consumption and postoperative recovery.

METHODS

Sixty ASA I-II patients undergoing spinal surgery were randomized into three groups. Group M received magnesium sulphate 30 mg kg(-1) as a bolus before induction and 10 mg kg(-1) h(-1) by infusion. Group CL received clonidine 3 microg kg(-1) as a bolus before induction and 2 microg kg(-1) h(-1) by infusion during the operation period. The same volume of isotonic solution was administered to the control group (group CT). Anaesthesia was induced with propofol and was maintained with propofol infusion [dose according to the bispectral index (BIS)], fentanyl and cisatracurium. Analysis of variance and the Bonferroni test were used for statistical analysis.

RESULTS

Induction of anaesthesia with propofol was rapid in the presence of magnesium sulphate and clonidine. The time for BIS to reach 60 was significantly shorter in group M and group CL (P<0.0001) but postoperative recovery was slower with magnesium sulphate compared with the clonidine and control groups (P<0.0001). There was no statistical difference in heart rate and arterial blood pressure between the groups. Propofol requirements for induction and maintenance of anaesthesia were significantly lower with magnesium and clonidine (P<0.0001).

CONCLUSION

Clonidine caused bradycardia and hypotension and magnesium sulphate caused delayed recovery, but can be used as adjuvant agents with careful management.

The effect of fluvastatin of hyperlipidemia in renal transplant recipients: a prospective, placebo-controlled study

Posttransplant hyperlipidemia is a common complication which may affect long term cardiovascular mortality. In this prospective, placebo-controlled study, 19 renal transplant recipients (11 male 8 female, mean age 31.2 +/- 8.4 years) with good allograft function (serum creatinine <2 mg/dl) more than 6 months after transplantation were included. All the patients had hyperlipidemia (serum cholesterol >230 mg/dl and/or LDL-cholesterol >130 mg/dl) despite dietary interventions. The patients were treated with a triple immunosuppressive regimen. After a 8-week period of placebo plus diet regimen, the patients were put on fluvastatin plus diet for another 8 weeks. The patients were followed for its effect on lipid parameters and side effects. After convertion to fluvastatin, serum cholesterol (263.0 +/- 31.6 vs 223.2 +/- 31.6 mg/dl, p = 0.001), LDL-cholesterol (174.4 +/- 28.3 vs 136.4 +/- 28.5 mg/dl, p = 0.002), Apolipoprotein (Apo) A1 (131.1 +/- 16.9 vs 114.7 +/- 18.4 mg/dl, p = 0.001) and Apo B (109.0 +/- 29.8 vs 97.3 +/- 31.5 mg/dl, p = 0.02) levels decreased significantly. Serum levels of triglycerides, VLDL-cholesterol and HDL-cholesterol levels did not vary under fluvastatin. Serum lipoprotein (a) levels were also unchanged during the whole study period (24.9 +/- 19.4 vs 23.1 +/- 19.8 mg/dl, p > 0.05). We concluded that fluvastatin effectively decreased atherogenic lipoproteins such as serum cholesterol, LDL-cholesterol, Apo B in posttransplant hyperlipidemia, however fluvastatin had no effect on another independent risk factor of atherogenesis, serum lipoprotein (a) levels.

Outcome of living unrelated (commercial) renal 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.

Model based analysis of the variation in Korotkoff sound onset time during exercise

In this study, a minimal mathematical model of the cardiovascular system is used to study the effects of changes in arterial compliance and cardiac contractility on the onset time of Korotkoff sounds during an auscultatory procedure. The model provides blood pressure waveforms in the ventricle, the aorta and the brachial artery. From these waveforms, pre-ejection time, pulse propagation time and rise time of the blood pressure at the brachial artery can be computed. The time delay between onset time of ECG Q wave and onset time of Korotkoff sound is the sum of these three times. Rise time is zero and the time delay is minimal when the cuff pressure is slightly above the diastolic pressure. This minimum time delay is represented by QKD. Simulation results suggest that during the Bruce exercise protocol QKD decreases to one-third of its pre-exercise value if the cardiac contractility increases threefold. The effect of arterial compliance is not as significant as that of the cardiac contractility. From data recorded during an exercise test, it is observed that QKD decreases considerably as the test load is increased. We show in this study that the amount of decrease in QKD can be used as an index of the amount of increase in cardiac contractility during an exercise ECG test. Use of signal averaging for reducing the effect of motion artifacts during an exercise test is also shown to be very instrumental for making accurate QKD measurements.

Successful therapy combined with surgery for severe post-transplant nocardiosis

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.

Cardiac and intestinal amyloidosis in a renal transplant recipient with familial Mediterranean fever

In Turkey, familial Mediterranean fever (FMF) is an important cause of nephrotic syndrome and endstage renal disease due to renal deposition of AA type amyloid. We report a case of living-related donor renal transplant recipient with FMF and renal AA type amyloidosis, who died of progressive heart failure due to cardiac involvement. The patient also had intractable diarrhea caused by biopsy-proven intestinal amyloidosis. The patient was on 1 mg/day colchicine. Although he was attack-free throughout the post-transplant period, intestinal and clinically significant cardiac amyloidosis, which implied the presence of sustained inflammation and continuing amyloid deposition, appeared three years after renal transplantation. Cardiac deposition of AA amyloid may cause clinically significant heart disease, leading to cardiovascular mortality after renal transplantation for end-stage renal disease in FMF patients.

The outcome of patients presenting with crush syndrome after the Marmara earthquake

In this study, we evaluated the clinical and laboratory data of the patients presenting after the Marmara earthquake. Crush syndrome was diagnosed in 60 patients (30 M, 30 F, mean age: 31.3+/-13.8 years). They were buried under the rubble for a mean period of 12.3+/-15.1 hours. On admission, 27 patients were oligoanuric and the mean serum creatinine, creatinine phosphokinase and potassium levels were 4.4+/-3.2 mg/dl, 18453.1+/-24527.2 IU/L, and 4.9+/-1.7 mEq/L, respectively. The most frequent site of trauma was the lower extremity. Dialysis treatment was initiated in 40 patients (19 M, 21 F; mean age: 32.7+/-13.0 years). Mean number of hemodialysis sessions/patient was 8.9+/-6.8. Nine (23%) patients among the dialyzed and 4 (20%) among the non-dialyzed died leading to an overall mortality of 21.6%. This low mortality rate suggests that the death rate from acute renal failure due to crush syndrome could be decreased by extensive follow-up.

Relationship between gingival hyperplasia and class II histocompatibility antigens in renal transplant recipients

Gingival hyperplasia, a well-known side effect of ciclosporin A (CS-A), is much more prominent when CS-A is used in combination with calcium channel blockers, especially dihydropyridines. On the other hand, it is interesting to note that this complication is not observed in all patients using this drug combination. This study was conducted in order to investigate the relationship (if any) between major histocompatibility complex antigens and gingival hyperplasia. Seventy-six renal transplantation patients were evaluated by an experienced dentist for gingival hyperplasia. The patients were then divided into two groups according to the presence (group 1, n = 18) or absence (group 2, n = 58) of gingival hyperplasia. There was no significant difference between the two groups regarding age, sex, transplant age, donor type, antihypertensive and immunosuppressive therapy protocols, and CS-A levels. HLA-DR2 antigen was present in 63% of the patients with gingival hyperplasia and in 34% of the patients without gingival hyperplasia. However, the HLA-DR1 antigen frequencies were found to be 11 and 22% in group 1 and group 2, respectively. In patients receiving nifedipine as an antihypertensive therapy, gingival hyperplasia developed more often than in patients receiving verapamil or diltiazem. As a result, in renal allograft recipients with HLA-DR1 antigen, gingival hyperplasia was seen less frequently than in HLA-DR2-positive patients. It is believed that the presence of these antigens regulates the response of the patients to either CS-A and/or calcium channel blockers.

The prognostic importance of severity and type of post-transplant proteinuria

Proteinuria, developing after renal transplantation may influence allograft and patient outcomes. This study aimed to investigate the effect of proteinuria on patient and allograft survival. Among 514 patients, 56 (11%) patients with good allograft function and proteinuria were evaluated retrospectively. Patients with proteinuria were classified as group P (20 patients with permanent proteinuria, Male/Female: 16/4) and group T (36 patients with temporary proteinuria, M/F: 29/7) according to the type of proteinuria. Also, considering the amount of proteinuria, patients were classified as group M (32 patients with massive proteinuria, M/F: 29/3) and group NM (24 patients with non-massive proteinuria, M/F: 16/8). The mean time interval between transplantation and appearance of proteinuria was 23.7 months (range 0-121 months) and no difference was found between groups. Two- and 5-yr allograft survival rates were found to be 85 and 80% in group M, and 95 and 82% in group NM. respectively (p = 0.24). In terms of type of proteinuria, 2- and 5-yr allograft survival rates were found to be 70 and 58% in group P and 92 and 87% in group T, respectively. The difference between groups P and T was found to be statistically significant (p = 0.02). Most (85%) of the patients with permanent proteinuria also had massive proteinuria. In conclusion, we found a significant relation between type and severity of proteinuria. The type of post-transplant proteinuria had a stronger effect on allograft outcome than the severity of proteinuria.

Transplantation in renal amyloidosis

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.

Kaposi's sarcoma after renal transplantation in Turkey

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.

Improvement of uremic autonomic dysfunction after renal transplantation: a heart rate variability study

Autonomic dysfunction in hemodialysis patients is one of the components of uremic neuropathy. In this prospective study, we investigated the effect of renal transplantation on uremic autonomic dysfunction with long-term time-domain and frequency-domain heart rate variability. Fourteen hemodialysis patients (10 male, 4 female; mean age 33 +/- 11 (range 16-50) years) were examined before and at the early after transplantation period (mean 4.6 +/- 1.5 (range 3-7. 5) months). The mean time spent on hemodialysis was 16.7 +/- 15.6 (range 6-65) months. In time-domain analysis, significant increases in all parameters except pNN50 (SD, SDANN, SDNN, rMSSD) were observed after renal transplantation (p < 0.01). In frequency-domain analysis, low-frequency (LF) (0.04-0.15 Hz) and high-frequency (HF) (0.15-0.40 Hz) spectral power were found to be significantly increased after renal transplantation (4.54 +/- 1.04 vs. 12.58 +/- 8. 69 for LF (p = 0.005), 2.80 +/- 1.0 vs. 6.50 +/- 3.55 for HF (p = 0. 005)), but the LF/HF ratio was not different from a pretransplant period (1.71 +/- 0.349 vs. 1.85 +/- 0.49, p = 0.26). It was concluded that autonomic dysfunction in hemodialysis patients is reversible and renal transplantation reverses the sympathetic and parasympathetic autonomic dysfunction simultaneously and at a relatively early stage.

Fever in dialysis patients with recently rejected renal allografts

INTRODUCTION

Fever of unknown origin is a complex problem in dialysis patients with recently rejected renal allografts, due to the contribution of the newly withheld immunosuppressive agents to the immunosuppression of uremia, resulting in an atypical presentation of infections, a main cause of fever in these cases.

MATERIALS AND METHODS

Two dialysis patients with recently rejected renal allografts who were hospitalized because of fever of unknown origin are reported. Biochemical, bacteriological and imaging studies were performed for specific diagnosis.

RESULTS

Extensive laboratory investigations failed to yield any diagnosis and allograft nephrectomy was performed in one patient, with a probable diagnosis of inflammation of the allograft, which resulted in no improvement. Eventually, both patients were found to have adrenal insufficiency responsible for the fever, which improved after steroid replacement.

CONCLUSIONS

Adrenal insufficiency should be suspected in all dialysis patients presenting with fever and atypical symptoms, but only after other potential causes are eliminated; since steroid administration may normalize fever regardless of the etiology, it may mask the signs and symptoms and delay the treatment of other (if any) underlying disorder(s).

Tuberculosis after renal transplantation: experience of one Turkish centre

BACKGROUND

In this study, renal transplant recipients with tuberculosis of different organs, were retrospectively analysed with respect to prevalence, outcome and drug toxicity.

PATIENTS AND METHODS

In 520 patients, 22 (4.2%) tuberculosis of various organs was diagnosed. The time interval between transplantation and diagnosis of tuberculosis was 44.4 +/- 33.5 (range 3-111) months. In 18 (82%) of the patients, tuberculosis was detected after the first year of transplantation. The most common form was pleuro/pulmonary tuberculosis (54%), and other localizations included jejunum, liver, bone, and urogenital tract.

RESULTS

Sixteen of the 22 patients responded favourably to the treatment and maintain excellent allograft function, whereas six patients (27.2%) died. Toxic hepatitis was seen in four (18%) patients, and one case was complicated with acute hepatocellular failure due to isoniazide (INH). However, of the 23 patients at risk of tuberculosis who had had INH prophylaxis for 1 year, neither tuberculosis, nor hepatotoxicity was observed.

CONCLUSION

Tuberculosis is a common infection of renal transplant recipients in developing countries. The peak incidence is after the first year of transplantation and mortality is considerable. Hepatoxicity is a considerable risk of treatment, possibly as a result of additive toxic effects of immunosuppressive drugs.

Effects of zinc supplementation on the immune system and on antibody response to multivalent influenza vaccine in hemodialysis patients

The depression of the immune system in chronic uremia is a well-known phenomenon but the role of serum zinc (Zn) levels on both cell-mediated and humoral immunity is still controversial. The aim of this study was to investigate the effect of Zn supplementation on the immune system and on antibody response to multivalent influenza vaccine (MIV) in hemodialysis patients (HP). Twenty-six HP and 11 healthy subjects (HS) were vaccinated with MIV. Hemodialysis patients were randomly divided into two groups. Group I (13 HP) was supplemented with 120 mg ZnSO4 after each dialysis session. Group II (13 HP) and Group III (11 HS) were given placebo. In all cases, the serum Zn levels, CD3, CD4, CD8, CD19, HLA-DR+ cell percentages, CD4/CD8 ratio and CD3+ HLA-DR+ cell percentages were determined before and 30 days after vaccination. Antibody levels to subgroups of MIV were also measured. All the baseline parameters studied were not statistically different between Group I and II. However, there was a significant difference between the basal parameters of Group III and the other two groups, except for CD3 and CD4 cell percentages. Serum Zn, CD19 cell percentage and antibody levels to MIV subgroups were significantly increased in Group I at the end of the first month of the study (p<0.01, p<0.05, p<0.001, p<0.001, and p<0.01, respectively), but the other parameters showed no significant changes. The only significant change observed in Groups II and III was an increase in antibody levels to MIV subgroups one month after vaccination. Antibody levels to MIV subgroups, were not statistically different between Groups I and II, but in Group III they were strikingly higher than those of HP (p<0.001). These results led us to conclude that Zn supplementation could not restore the immune parameters and enhance antibody response to MIV in HP.

Posttransplant malaria

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 examined for 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.