Prazosin Protects the Liver Against Renal Ischemia/Reperfusion Injury in Rats

Acute kidney injury (AKI) is a common subsequent problem after many medical conditions. AKI is associated with distant organ dysfunction where systemic inflammation and oxidative stress play major roles. In this study, the effect of Prazosin, an α1-Adrenergic receptor antagonist, was investigated on the liver injury induced by kidney ischemia-reperfusion (I/R) in rats. Male adult Wistar rats (n=21) were divided into three groups: sham, kidney I/R, and kidney I/R pre-treated with Prazosin (1 mg/kg). Kidney I/R was induced by vascular clamping of the left kidney for 45 min to reduce the blood flow. Oxidative and antioxidant factors along with apoptotic (Bax, Bcl-2, caspase3), and inflammatory (NF-κβ, IL-1β, and IL-6) factors were measured in the liver at protein levels. Prazosin could reserve liver function (p<0.01) and increase glutathione level (p<0.05) after kidney I/R significantly. Malonil dialdehyde (MDA), a lipid peroxidation marker, was diminished more significantly in Prazosin-treated rats compared to the kidney I/R group (p<0.001). Inflammatory and apoptotic factors were diminished by Prazosin pre-treatment in the liver tissue (p<0.05). Pre-administration of Prazosin could preserve liver function and decrease its inflammatory and apoptotic factors under kidney I/R conditions.

Management of COVID-19 in Liver Transplant Recipients With Immunosuppressant Therapy: Experiences of an Iranian Transplant Registry

OBJECTIVES

With the declaration of the COVID-19 pandemic and the increased COVID-19 risk shown in transplant recipients, the prevalence, clinical course, and outcomes of COVID-19 infections among liver transplant recipients were assessed.

MATERIALS AND METHODS

A questionnaire was designed and used to survey medical services for liver transplant recipients seen at our center in terms of COVID-19 infection.

RESULTS

Twenty-five patients infected with COVID-19 were identified from 265 liver transplant recipients. Most patients were male and had COVID-19 despite quarantine at home. All patients received modified immunosuppressive drugs during infection with COVID-19 with minor changes in routine immunosuppressive therapy. Among the identified patients, 21 recovered and 4 patients died. One of the dead patients, in addition to having a liver transplant, had brain cancer with metastasis to the lungs.

CONCLUSIONS

In liver transplant recipients infected with COVID-19, immunosuppressive drugs seemed to cause only mild to moderate illnesses or even helped them recover from the disease. However, more evidence is needed to prove this hypothesis. It is also recommended that transplant recipients should be warned about personal hygiene and be monitored closely by organ transplant centers.

FIS1 Overexpression Is Correlated with Tumor Metastasis in Gastric Adenocarcinoma

BACKGROUND

Due to poor prognosis and treatment failure, gastric cancer (GC) is still regarded as one of the deadliest malignancies worldwide, demanding new molecular targets for therapeutic and diagnostic approaches. Therefore, the current study was aimed to investigate the expression levels of FIS1 gene involving in mitochondrial fission as a promising target in gastric tumor progression.

MATERIAL AND METHODS

A total of eighty clinical tissue samples including 40 gastric primary tumor samples and 40 paired marginal samples were prepared. Total RNA was extracted and reverse transcribed to complementary DNA. Then, FIS1 expression levels were quantified in GC samples compared to normal ones using q-PCR. Furthermore, the correlation between FIS1 expression and clinicopathological features of patients was evaluated.

RESULTS

The obtained results illustrated that FIS1 is significantly (p = 0.0013) overexpressed in gastric tumors compared to noncancerous marginal tissues; indicating the possible role of FIS1 through gastric tumorigenesis. Further analysis showed that FIS1 upregulation was significantly (p = 0.0419) correlated with metastasis in patients. Also, ROC curve analysis estimated an area under the curve (AUC) value of 0.7209 for FIS1 to discriminate cancer patients from healthy cases.

CONCLUSION

Taken together, our findings suggested FIS1 as a promising tumor marker where its overexpression predicts tumor metastasis of gastric cancer.

Hereditary thrombophilia and thrombosis of tunneled hemodialysis catheters: A single center study

Introduction: Vascular access thrombosis increases the risk of mortality and morbidity in end-stage renal disease (ESRD) patients on hemodialysis (HD). This study aimed to evaluate hereditary thrombophilia factors in HD patients and its association with tunneled cuffed catheters’ thrombosis.

Methods: In this cross-sectional study, 60 consecutive patients with ESRD on HD with tunneled cuffed catheters were selected. Inherited thrombophilia factors (Anti-thrombin III, Protein C, Protein S, and Factor V Leiden) were measured and the patients were followed for 3 months to evaluate the incidence of catheter-related thrombosis. The association between these factors and catheter thrombosis was assessed.

Results: The mean age of patients was 60.30 ± 8.69 years. Forty-seven patients (78.30%) were female and thirteen patients (21.70%) were male. The most common cause of ESRD was diabetes mellitus (41.67%). The most catheter site was the right internal jugular vein (55%). There were 22 (36.67%) and 8 (13.33%) cases of thrombosis and mortality, respectively. The association between hereditary thrombophilia factors and catheter thrombosis was not statistically significant (P > 0.05).

Conclusion: In this small group of our patients, the frequency of hereditary thrombophilia was not significantly different between those with and without thrombosis of tunneled HD catheter.

Successful Kidney Transplant From a Brain Stem-Dead Donor Due To Lethal Methanol Poisoning

Kidney replacement is the best treatment modality for chronic renal failure; however,the greatest obstacle for transplant is the scarce number of donor organs. In the United States and Europe, less than 1% of organs for transplant are provided from patients with lethal poisoning. In this paper, we present a successful kidney transplant from a donor with methanol poisoning. A 38-year-old-man who had methanol poisoning developed brain stem death after unsuccessful treatment and was a candidate to be a kidney donor for transplant to a 27-year-old male patient with chronic renal failure. Three weeks after kidney transplant, the recipient was discharged with good kidney function. We suggest that it may be possible to consider lethal methanol poisoning for kidney donation.

Allocation of liver grafts worldwide - Is there a best system?

BACKGROUND & AIMS

An optimal allocation system for scarce resources should simultaneously ensure maximal utility, but also equity. The most frequent principles for allocation policies in liver transplantation are therefore criteria that rely on pre-transplant survival (sickest first policy), post-transplant survival (utility), or on their combination (benefit). However, large differences exist between centers and countries for ethical and legislative reasons. The aim of this study was to report the current worldwide practice of liver graft allocation and discuss respective advantages and disadvantages.

METHODS

Countries around the world that perform 95 or more deceased donor liver transplantations per year were analyzed for donation and allocation policies, as well as recipient characteristics.

RESULTS

Most countries use the model for end-stage liver disease (MELD) score, or variations of it, for organ allocation, while some countries opt for center-based allocation systems based on their specific requirements, and some countries combine both a MELD and center-based approach. Both the MELD and center-specific allocation systems have inherent limitations. For example, most countries or allocation systems address the limitations of the MELD system by adding extra points to recipient's laboratory scores based on clinical information. It is also clear from this study that cancer, as an indication for liver transplantation, requires special attention.

CONCLUSION

The sickest first policy is the most reasonable basis for the allocation of liver grafts. While MELD is currently the standard for this model, many adjustments were implemented in most countries. A future globally applicable strategy should combine donor and recipient factors, predicting probability of death on the waiting list, post-transplant survival and morbidity, and perhaps costs.

LAY SUMMARY

An optimal allocation system for scarce resources should simultaneously ensure maximal utility, but also equity. While the model for end-stage liver disease is currently the standard for this model, many adjustments were implemented in most countries. A future globally applicable strategy should combine donor and recipient factors predicting probability of death on the waiting list, post-transplant survival and morbidity, and perhaps costs.

Value of CA-125 Glycoprotein in Predicting Acute Appendicitis; a Diagnostic Accuracy Study

INTRODUCTION

Carcinogen antigen 125 (CA-125) is a glycoprotein antigen, which has shown potentials in predicting peritoneal inflammation. The aim of this study is to determine the value of CA-125 in predicting acute appendicitis (AA).

METHODS

This prospective diagnostic accuracy study was conducted on 15 - 70 year-old patients with acute abdominal pain, suspected to AA, referred to emergency department. The serum level of CA-125 was measured for all patients before appendectomy and its screening characteristics in detection of AA case (confirmed by histology findings) were calculated and reported with 95% confidence interval (CI).

RESULTS

95 patients with the mean age of 31.65 ± 12.9 (15-75) years were studied (54.3% male). Based on the histologic findings, 72 (75.8%) cases were categorized as AA (23 cases as severe). AA and non-AA (NAA) groups were similar regarding the mean age (p = 0.59), mean duration of symptoms (p = 0.08), mean white blood cell (WBC) count (p = 0.37), and mean PMN percentage (p = 0.55). Mean CA-125 level was 16.5 ± 20.0 U/mL in the AA group and 30.5 ± 6.1 U/mL in the NAA group (p = 0.001). Adjustment of analysis based on gender revealed a significant correlation between CA-125 level and diagnosis of AA only in females (34.23 ± 39 U/mL in NAA versus 20.7 ± 26.7 U/mL in AA, p = 0.012). The area under the ROC curve of CA-125 was 0.62 (95%CI: 0.51 to 0.72). Sensitivity, specificity, NPV, PPV, NLR, and PLR of CA-125 in 16.4 U/mL cut off (best point) were 77.8% (95%CI: 66.4 - 86.7), 50.0% (95%CI: 28.2 - 71.8), 83.6% (95%CI: 76.7 - 88.7), and 40.7% (95%CI: 27.4 - 55.6), 0.44 (95%CI 0.2 - 0.8), and 1.56 (95%CI: 1.0 - 2.4), respectively.

CONCLUSION

Considering the lower levels of CA-125 in patients with AA compared with NAA cases and also weak screening performance characteristics, it seems that it could not be considered as an accurate screening tool in this regard.

Assessment of probiotic effects on colorectal surgery complications: A double blinded, randomized clinical trial

Background: Probiotics are living bacteria, which can be used as a food supplement to produce inhibitory agents and compete with pathogens in the guts. Nowadays, because of the easy accessibility and misuse of antibiotics, probiotic usage is increasing. The goal of our study is to assess the effects of probiotics on colorectal surgery complications. Methods: The enrolled cases were selected from colorectal surgery candidate patients, who referred to Sina and Imam Reza Hospitals of Tabriz University from April of 2016 to April of 2017. They were divided into two groups of study and control. For the study group, 7 days before surgery, one capsule of probiotics (Familact) was administrated every night, while the control group was given capsules of placebo. Results: Although the infective complications, mortality ratio and duration of hospitalization in the study group were lower than the control group, these differences were not statistically significant. Discussion: Our study confirmed that preoperative probiotic consumption in colorectal surgery had not affected complications or mortality of surgery and this finding is in disagreement with some previous studies. Perhaps, other strains of bacteria or different dosage, duration and rout of administration can have positive effects on these complications. Conclusion: This study showed that there was no correlation between probiotic consumption preoperatively and decreased complications or mortality after colorectal surgery.  

Effects of antecolic versus retrocolic duodenojejunostomy on delayed gastric emptying after pyloric preserving pancreaticoduodenectomy in patients with periampullary tumors

BACKGROUND/OBJECTIVE

Delayed gastric emptying (DGE) is one of the most frequent complications after pyloric preserving pancreaticoduodenectomy (PPPD). The aim of this study is to evaluate the effect of antecolic versus retrocolic reconstruction of gastroentric anastomosis on DGE after PPPD.

METHODS

30 patients with diagnosis of operable periampullary malignancies who candidate for PPPD, randomized in two equal groups. Gastroentric reconstruction were done in two methods: antecolic and retrocolic. All data were collected by the same person who was completely blinded to the type of the procedure. Duration of the surgery, volume of bleeding and total volume of intraoperative blood product transfusion, time to nasogastric tube (NGT) removal, time to solid fluid toleration, volume of NGT secretions, need for NGT reinsertion, daily nausea after NGT extraction, fistula or leakage, gastric leakage, biliary leakage, postoperative abdominal or gastrointestinal bleeding requiring another operation, wound infection, intra-abdominal abscess, and any other systemic complications were measured and then analysed with SPSS software.

RESULTS

According to the results, there was no significant differences between antecolic and retrocolic groups in terms of DGE (p = 0.75). Also, there were no significant differences between two groups in terms of duration of operation, volume of bleeding, blood product requirement, volume of NGT secretions, time to NGT removal, number of NGT re-insertion, time to tolerate solid foods, number of days of vomiting after NGT removal, total hospital stay.

CONCLUSION

The route of gastroentric (antecolic and retrocolic) reconstruction has no impact on DGE after PPPD.

A case report: Primary hydatid cyst of uterus

INTRODUCTION

Echinococcus granulosus is a parasitic tape worm. The definitive host is the dog and humans are one of its intermediate hosts. It involves organs such as liver and lungs. Uterus involvement is very rare.

PRESENTATION OF CASE

We here report a case of primary uterus hydatid cyst that we had to remove her uterine on left ovary and fallopian tube. Generalized toxic shock and infection due to cyst rupture or organ dysfunction due to invasion (like our patient) or pressure of cyst are complications of this cyst.

DISCUSSION

Because of low incidence of hydatid cysts in uterus it can be misdiagnosed by mimicking other conditions such as multi-cystic ovarian tumor, hemorrhagic ovarian cyst, endometrioma, cystadenoma, leiomyoma and etc.

CONCLUSION

Especially in endemic area for this parasite, one of differential diagnoses of pelvic cyst must be echinococcosis.

Is it possible to preserve the blood supply of erectile organs by anastomosis using the hypogastric artery in kidney transplantation?

Introduction

Three modalities for treating chronic kidney failure are peritoneal dialysis, hemodialysis, and kidney transplantation. Among them kidney transplantation is cost-efficient and leads to a somewhat normal quality of life. In this approach, most often the external iliac artery is selected for anastomosis, but this could be disastrous if anastomosis leads to a complication. The traditional end-to-end approach for anastomosis of the kidney artery to the internal iliac artery leads to pelvic organ ischemia. However, if the end-to-end anastomosis is replaced by an end-to-side approach, it is safer. This report discusses some cases of end-to-side anastomosis using the internal iliac artery.

Method

In ten cases of chronic kidney failure, we anastomosed the kidney artery to the internal iliac artery with an end-to-side approach.

Results

After vessels were unclamped, all patients had diuresis. Their creatinine was in normal range and was blood flow in the internal iliac artery, based on color Doppler ultrasound.

Conclusion

End-to-side anastomosis can be done in some chronic kidney failure patients if their internal iliac arteries are large enough. This approach is safer than anastomosis using the external iliac artery.

Outcomes of relocation of basilic vein in brachiobasilic fistulas in chronic renal failure

BACKGROUND

In patients without or with injured cephalic vein, using the basilic vein for creating arteriovenous fistula (AVF) is the best way for hemodialysis. In order to create AVF, the basilic vein should be superficialized and lateralized. This study sought to examine outcome of relocation of basilic vein in brachiobasilic fistulas in patients with chronic renal failure (CRF).

METHODS

We evaluated the outcome of creation of brachiobasilic fistula with transposition of basilic vein in 27 patients (14 males and 13 females with mean age of 60.03 ± 8.04 years) with CRF. The success rate and complications were recorded during the follow-up period. The fistula was regarded efficient if cannulation was feasible conveniently and a minimum flow rate of 250 ml/min for 4 h at least for 3 consecutive hemodialysis sessions through both lines was documented 30 days postoperatively.

RESULTS

The mean time gap between previous AVF creation or try and the relocation of basilic vein was 3.55 months. Thirty days postoperatively, 85.2% of the created AVFs were efficiently working. There were postoperative complications in 40.7% of patients including venous hypertension (14.8%), bleeding (7.4%), hematoma (7.4%) and distal paresthesia (11.1%).

CONCLUSIONS

Brachiobasilic AVF fistula provides a suitable option for vascular access in cases with failed previous AVF. Relocation of basilic vein for brachiobasilic AVF is technically feasible, safe and with excellent patency in short-term and complication rates are acceptable.

Bolus Injection Versus Infusion of Furosemide in Kidney Transplantation: A Randomized Clinical Trial

PURPOSE

Furosemide is commonly administered to increase the urinary output in patients with transplanted kidneys. This study compared the two administration routes of furosemide (bolus versus infusion) in kidney transplanted patients.

MATERIALS AND METHODS

Fifty patients who had undergone kidney transplantation in 2015 in a hospital in Tabriz, Iran, were included in this clinical trial. They were divided into two groups: bolus (120 mg stat) and infusion (4 mg/minute) groups. The primary outcome was urine onset time. Secondary outcomes were urine output volume, vital signs (blood pressure, heart rate), and electrolyte level (creatinine, blood urea nitrogen, sodium and potassium). After arterial and venous anastomoses, arterial clamp removal time and diuresis onset were recorded. Finally, theurinary output volumes of both groups were measured with regular urine bags for an hour after anastomosis. Then it was repeated each three hours for 24 hours, and eventually two and three days thereafter. Finally, all data were statistically analyzed.

RESULTS

Around 72% of the patients were men (mean age of 37.15 &plusmn; 14.67 years). Urine output was higher in bolus group but it was not statistically significant. Diuresis duration was measured after arterial declamping and its averages were 5.41 &plusmn; 3.7 minutes and 9.36 &plusmn; 7.65 minutes in bolus and infusion groups, respectively (P = .040). Furosemide bolus injection and infusion had no significant effect on creatinine, blood urea nitrogen, sodium and potassium.

CONCLUSION

Furosemide bolus injection can reduce diuresis onset time compared to furosemide infusion.

Conjugated linoleic acid improves glycemic response, lipid profile, and oxidative stress in obese patients with non-alcoholic fatty liver disease: a randomized controlled clinical trial

Aim

To investigate if conjugated linoleic acid supplementation (CLA) affects metabolic factors and oxidative stress in non-alcoholic fatty liver disease (NAFLD).

Methods

The study was a randomized, controlled clinical trial conducted in specialized and subspecialized clinics of Tabriz University of Medical Sciences from January 2014 to March 2015. 38 obese NAFLD patients were randomly allocated into either the intervention group, receiving three 1000 mg softgel of CLA with a weight loss diet and 400 IU vitamin E, or into the control group, receiving only weight loss diet and 400 IU vitamin E for eight weeks. Dietary data and physical activity, as well as anthropometric, body composition, metabolic factors, and oxidative stress were assessed at baseline and at the end of the study.

Results

Weight, body composition, and serum oxidative stress, insulin, and lipid profile significantly improved in both groups, while hemoglobin A1c (HbA1c) levels (P = 0.004), total cholesterol to high density lipoprotein ratio (P = 0.008), low density lipoprotein to high density lipoprotein ratio (LDL/HDL) (P = 0.002), and alanine aminotransferase to aspartate aminotransferase (ALT/AST) ratio (P = 0.025) significantly decreased in the intervention group. At the end of the study, fat mass (P = 0.001), muscle mass (P = 0.023), total body water (P = 0.004), HbA1c (P < 0.001), triglycerides (P = 0.006), LDL/HDL ratio (P = 0.027), and ALT/AST ratio (P = 0.046) were significantly better in the CLA group than in the control group.

Conclusion

CLA improved insulin resistance, lipid disturbances, oxidative stress, and liver function in NAFLD. Therefore, it could be considered as an effective complementary treatment in NAFLD.

Registration number: IRCT2014020516491N1.

Effects of adding Braun jejunojejunostomy to standard Whipple procedure on reduction of afferent loop syndrome - a randomized clinical trial

BACKGROUND

Whipple surgery (pancreaticodeudenectomy) has a high complication rate. We aimed to evaluate whether adding Braun jejunojejunostomy (side-to-side anastomosis of afferent and efferent loops distal to the gastrojejunostomy site) to a standard Whipple procedure would reduce postoperative complications.

METHODS

We conducted a randomized clinical trial comparing patients who underwent standard Whipple surgery (standard group) and patients who underwent standard Whipple surgery with Braun jejunojejunostomy (Braun group). Patients were followed for 1 month after the procedure and postoperative complications were recorded.

RESULTS

Our study included 30 patients: 15 in the Braun and 15 in the standard group. In the Braun group, 4 (26.7%) patients experienced 6 complications, whereas in the standard group, 7 (46.7%) patients experienced 11 complications (p = 0.14). Complications in the Braun group were gastrointestinal bleeding and wound infection (n = 1 each) and delayed gastric emptying and pulmonary infection (n = 2 each). Complications in the standard group were death, pancreatic anastomosis leak and biliary anastomosis leak (n = 1 each); gastrointestinal bleeding (n = 2); and afferent loop syndrome and delayed gastric emptying (n = 3 each). There was no significant difference between groups in the subtypes of complications.

CONCLUSION

Our results showed that adding Braun jejunojejunostomy to standard Whipple procedure was associated with lower rates of afferent loop syndrome and delayed gastric emptying. However, more studies are needed to define the role of Braun jejunojejunostomy in this regard.

TRIAL REGISTRATION

IRCT2014020316473N1 (www.irct.ir).

Surgical treatment of gallbladder carcinoma: a critical review

Gallbladder carcinoma is a relatively uncommon cancer of gastrointestinal (GI) tract. Medical literature is full of nihilistic reports about the treatment of gallbladder carcinoma, especially due to its resistance to current radiotherapeutic or chemotherapeutic treatment modalities and difficult surgical approach for complete resection of these tumors. Herein, we review current diagnostic and therapeutic approaches to this rare GI cancer.

Carotid-esophageal fistula due to a retained foreign body

We describe a case of carotid-esophageal fistula due to retention of an ingested foreign body in a 65-year-old woman. Late diagnosis resulted in severe hemorrhage and postoperative cerebrovascular accident because of the impossibility of repairing the carotid artery due to severe local inflammation.

Diagnostic accuracy of 64-MDCT angiography in the preoperative evaluation of renal vessels and compared with laparotomy findings in living donor kidney

INTRODUCTION

Multidetector-row computed tomography (MDCT) angiography is a reliable technique in preoperative renal anatomy evaluation in live renal donors.

OBJECTIVES

To investigate the accuracy of early arterial phase findings and compares them with intraoperative findings.

METHODS

In this prospective study, 100 potential live donors undergoing preoperative MDCT and nephrectomy during 2010-2013 were included. The examination was performed with a 64-detector scanner including early arterial and venous phase. MDCT angiography started by bolus tracking and venous phase was acquired 9 s after arterial phase. Anatomical findings and vein and artery attenuation values were recorded and arterial phase findings were compared with intraoperative findings.

RESULTS

All anatomical findings reported by MDCT in early arterial phase were confirmed by intraoperative findings with sensitivity of 100%. Right renal vein was supernumerary in 17 cases and left renal vein was circumaortic in 3 and retroaortic in 5 cases. Renal arteries had early branching in 13, two arteries in 12 and accessory in 8 cases. Vein and artery attenuation values had significant difference between early arterial and venous phase (p < 0.001).

CONCLUSION

Early arterial phase has similar results to venous phase in preoperative evaluation and intraoperative findings and could be used alone to reduce radiation dose.

Video assisted rigid thoracoscopy in the diagnosis of unexplained exudative pleural effusion

INTRODUCTION

An undiagnosed exudative pleural effusion is often a difficult diagnostic dilemma that needs further histological study for a definitive etiological diagnosis. Video assisted rigid thoracoscopy is a minimally invasive procedure with a minor morbidity and mortality risk that could resolve this problem.

METHODS

Between January 2010 and December 2011, we performed thoracoscopy in 26 patients for diagnosis of undiagnosed exudative pleural effusion. Clinical and paraclinical data of patients were collected prospectively and analyzed.

RESULTS

Sole pleural effusion was the most common CT scan finding seen in 17 (65.4%) patients. Thoracoscopy was diagnostic in 24 patients (92.3%). The pathologic findings were carcinoma (46.2%), tuberculosis (30.8%) and chronic inflammation without a definitive microbiologic culture (15.4%). Surprisingly mean ADA level in the tuberculosis group was in normal range. No mortality or complication related to our operation was observed.

CONCLUSION

Video assisted thoracoscopy is a minimally invasive procedure with a high definitive diagnostic accuracy in the evaluation of tuberculosis and malignant pleural effusions. Pulmonologist should refer these patients sooner to decrease the waiting period of diagnosis and treatment of such conditions.

Serum Neutrophil Gelatinase-Associated Lipocalin versus Serum Creatinine for the Prediction of Acute Kidney Injury after Liver Transplantation

BACKGROUND

Acute kidney injury (AKI) is a common complication after liver transplantation (LT), and considerably increases the morbidity and mortality of the procedure. The gold standard of measuring the kidney function, the serum creatinine level (sCr), has poor specificity and sensitivity for the early diagnosis of AKI. Novel biomarkers for the prediction or early diagnosis of AKI, would potentially increase the opportunities for therapeutic interventions.

OBJECTIVE

To compare the diagnostic value of the standard renal marker, sCr and neutrophil gelatinase-associated lipocalin (NGAL) to predict AKI within 48 hours of LT.

METHODS

During a 9-month period from 2010 to 2011, NGAL was measured two times in 90 patients who underwent LT from deceased donors-after induction of anesthesia (NGAL1) and 2 hours after reperfusion of the liver graft (NGAL2). Patients were grouped according to the presence of risk factors for developing AKI according to the Acute Kidney Injury Network criteria (increase of ≥0.3 mg/dL in plasma creatinine above the baseline value within 48 hours).

RESULTS

60 men and 30 women with mean±SD age of 40.2±14.2 years were included in this study. The incidence of AKI was 34% (95% CI: 24%-44%). The difference between the NGAL1 and NGAL2 (ΔNGAL) and the baseline NGAL concentration was predictive of AKI in all patients. Receiver operating characteristic (ROC) curve and area under curves (AUCs) of ΔNGAL and sCr levels during the first 48 hours of LT were similar in predicting AKI. The AUCs of the ΔNGAL to predict AKI was 0.64 (95% CI: 0.52-0.76). The development of AKI was significantly correlated with the number of units of fresh frozen plasma transfused intra-operatively (p=0.017) and cold ischemic time (p=0.042).

CONCLUSION

Serum NGAL concentrations obtained during surgery is a predictor of AKI in patients undergoing LT.

Mixed germ-cell testicular tumor in a liver transplant recipient

The development of malignancies after solid organ transplants is a well-known complication. Cancer is associated with significant consequences for the organ transplant patient. It is expected that cancer will surpass cardiovascular complications as the leading cause of death in transplant patients within the next few years. We report on a 36-year-old male patient who developed mixed germ-cell testicular tumor seven years after liver transplantation for alcoholic cirrhosis. He was treated with orchiectomy, retroperitoneal lymph node dissection and post-operative chemotherapy.

Bronchial leiomyoma in a chemical warfare victim-a causative agent or an incidental finding: A case report

INTRODUCTION

Bronchial leiomyoma is one of the rarest benign tumors of the lower respiratory system, compromising less than 2% of reported benign pulmonary tumors. Chemical warfare is a known cause of chronic pulmonary diseases in soldiers who survives of the chemical wars. Most of these patients are chronically under treatment by respiratory drugs and acute exacerbations of their symptoms prompt for investigations for diagnosis of a new complication in these patients.

PRESENTATION OF CASE

In this case report we present a 43 y/o male chemical warfare victim who was under treatment for his respiratory disease for near 20 years but at last bronchial leiomyoma was diagnosed as the cause of exacerbation of his symptoms. He was undergone right thoracotomy and sleeve resection of left main bronchus. Severe adhesions plus lymphadenitis in the mediastinum might be due to the effects of prior inflammatory process.

DISCUSSION

Because of rarity of this tumor, bronchial leiomyoma in this patient may be the result of previous exposure to nitrogen mustard but the exact relationship remained to be confirmed.

CONCLUSION

Although the association between chemical warfare and lung neoplasias has not been well understood, it is the first time that a bronchial leiomyoma is reported in a nitrogen mustard survivor.

Surgical treatment of postintubation tracheal stenosis: Iranian experience of effect of previous tracheostomy

BACKGROUND

Postintubation tracheal stenosis remains the most common indication for tracheal surgery. In the event of a rapid and progressive course of the disease after extubation, surgical approaches such as primary resection and anastomosis or various methods of tracheoplasty should be selected. We report our experience with surgical management of moderate to severe postintubation tracheal stenosis. We also compared intraoperative variables in postintubation tracheal stenosis between those with and without previous tracheostomy.

METHODS

Over a 5-year period from June 2005 to July 2010, 50 patients aged 14-64 years with moderate (50%-70% of the lumen) to severe (>70%) postintubation tracheal stenosis underwent resection and primary anastomosis. Patients were followed up to assess the surgical outcome. To study the effect of previous tracheostomy on treatment, surgical variables were compared between patients with previous tracheostomy (group A, n = 27) and those without previous tracheostomy (group B, n = 23).

RESULTS

Resection and primary anastomosis was performed via either cervical incision (45 patients) or right thoracotomy (five patients). In two patients with subglottic stenosis, complete resection of the tracheal lesion and anterior portion of cricoid cartilage was performed, and the remaining trachea was anastomosed to the thyroid cartilage using a Montgomery T-tube. There was only one perioperative death in a patient with a tracheo-innominate fistula. The length of the resected segment, number of resected rings, and subsequent duration of surgery were significantly greater in group A compared with group B (P < 0.05). Six months after surgery, the outcome was satisfactory to excellent in 47 (95.9%) patients.

CONCLUSION

This surgical approach leads to highly successful results in the treatment of moderate to severe postintubation tracheal stenosis. In addition, previous tracheostomy might prolong the duration of surgery and increase the need for postoperative interventions due to an increase in the length and number of resected tracheal segments. Therefore, in the event of emergency tracheostomy in postintubation tracheal stenosis, insertion of the tracheostomy tube close to the stenotic segment is recommended.

Accuracy of pulse oximetry in the detection of hypoxia in liver transplant candidates

BACKGROUND/AIMS

Hypoxia is common in patients with chronic liver disease. Screening guidelines for detecting the presence of arterial hypoxemia do not exist. The aim of this study was to investigate the accuracy and utility of pulse oxymetry in the detection of hypoxemia (PaO2<65) in a group of patients with liver cirrhosis who were candidate for liver transplantation.

METHODOLOGY

Two hundred and ninety-five transplant candidates enrolled in this study. Arterial oxyhemoglobin saturation was obtained by pulse oxymetry (SpO2) and compared with simultaneous arterial blood gas (ABG) oxyhemoglobin values (SaO2). Bias, the overestimation or underestimation of one method compared with another, is defined as the difference between SpO2 and SaO2.

RESULTS

SpO2 overestimated SaO2 in 78.3% (n=231) and underestimated in 18.6% (n=54) cases. The bias was over 4% or less than -4% (Bias4) in 11.6% (n=34) of the cases and significantly different between the patients with SaO2 =94%. PaO2 =65 mmHg (p=0.000) and SpO2 =94% (p=0.003). Also, when we used the cut-off level of A-a O2 gradient =20 and =15, the bias was significantly different between the patients (p=0.000).

CONCLUSIONS

Pulse oximetry is a useful screening test to detect hypoxemia in patients with liver disease.

Long-term survival of living donor renal transplants: A single center study

Kidney transplantation is the treatment of choice for end-stage renal disease. The aim of this study was to determine the ten-year graft survival rate of renal transplantation in patients who have been transplanted from live donors. This is a historical cohort study designed to determine the organ survival rate after kidney transplantation from live donor during a 10-year period (from March 1999 to March 2009) on 843 patients receiving kidney transplant in the transplantation center of Namazi hospital in Shiraz, Iran. Kaplan-Meier method was used to determine the survival rate, log-rank test was used to compare survival curves, and Cox proportional hazard model was used to multivariate analysis. Mean follow-up was 53.07 ± 34.61 months. Allograft survival rates at 1, 3, 5, 7, and 10 years were 98.3, 96.4, 92.5, 90.8, and 89.2%, respectively. Using Cox proportional hazard model, the age and gender of the donors along with the creatinine level of the patients at discharge were shown to have a significant influence on survival. The 10-year graft survival rate of renal transplantation from living donor in this center is 89.2%, and graft survival rate in our cohort is satisfactory and comparable with reports from large centers in the world.

Autologous transplantation of bone marrow-derived mononuclear and CD133(+) cells in patients with decompensated cirrhosis

BACKGROUND

Cirrhosis, the end stage of progressive hepatic fibrosis, is characterized by distortion of the hepatic architecture and the formation of regenerative nodules. Liver transplantation is one of the few available therapies for such patients. However, due to a severe shortage of organ donors, surgical complications, transplant rejection and the high cost of this procedure much interest has focused on research to find new treatment modalities for this disease. There is accumulating evidence for the contribution of bone marrow stem cells to participate in liver regeneration.

METHODS

Here we report on six patients with end stage liver disease who were subjected to intraportal administration of autologous bone marrow-derived CD133(+) in comparison to mononuclear cells in short-term (6 months) and long-term (24 months) follow up.

RESULTS

There were no adverse effects in any of the patients during the short- and long-term follow up period. Moreover, there were no significant alterations of liver function parameters, liver enzymes, serum albumin, creatinine, serum bilirubin and/or liver volume after transplantation of both types of autologous cells in these patients.

CONCLUSION

Our study has shown both the safety and feasibility of this type of liver cell therapy and may be a bridge to liver transplantation. The trial was registered with NIH clinical trials (www.clinicaltrials.gov) as identifier: NCT00713934.

Ten-year graft survival of deceased-donor kidney transplantation: a single-center experience

BACKGROUND

Kidney transplantation is the treatment of choice for end-stage renal disease that restores the patients' quality of life and reduces the morbidity and mortality rates induced by renal failure and its complications. However, after transplantation the organ and patient survival rates are important issues of interest in many centers worldwide.

SUBJECTS AND METHODS

This is a historical cohort study planned to determine the organ survival rate after kidney transplantation from deceased donor during a period of 10 years (March 1999-March 2009) in Shiraz Transplant Center, Namazi Hospital, Shiraz, Iran. We tried to clarify the probable contributory risk factors implicating in graft loss. Kaplan-Meier method was used to determine the survival rate. Log-rank test was used to compare survival curves, and Cox regression model to define the hazard ratio and for modeling of factors implicating in survival rate.

RESULTS

Mean follow-up period was 37.54 +/- 28.6 months. Allograft survival rates at 1, 3, 5, and 9 years after kidney transplantation from deceased donor (calculated by Kaplan-Meier method) was found to be 93.7, 89.1, 82.1, and 80.1%, respectively. Duration of dialysis before operation and creatinine level at discharge were showed to be the most important factors influencing survival rate of renal allograft.

CONCLUSION

Overall long-term graft survival in our cohort is satisfactory and comparable with reports from large centers in the world. Duration of dialysis before operation and creatinine level at discharge are the only independent factors that could correlate with long-term graft survival in our cohort.

Liver transplantation for homozygous familial hypercholesterolemia: two case reports

Homozygous familial hypercholesterolemia (HFHC) is a rare inherited condition with an incidence of one in one million. It is associated with severe premature atherosclerosis and early death from cardiovascular complications. Mutation in the gene that encodes the synthesis of the cellular receptor for low-density lipoprotein (LDL) is responsible for this metabolic disorder. Currently, the only effective treatment for this disease is liver transplantation, which alone or in association with medications, normalizes plasma cholesterol level. The authors report the results of liver transplantation for two cases of HFHC. The first case, a 15-year-old boy received a whole liver from a deceased donor, and the second, an 11-year-old boy, received a left liver lobe transplant from his mother's sister. Their preoperative fasting lipid concentrations were grossly raised. The older boy had severe atherosclerotic heart disease and had undergone coronary artery bypass grafting 5 months before transplantation. Both had preoperative plasma cholesterol levels higher than 750 mg/dL with normal thyroid and liver function tests. After the operation, the patients received methylprednisolone as pulse therapy followed by oral prednisolone, mycophenolate mofetil, and tacrolimus for immunosuppression. Their hospital stays were 24 and 13 days, respectively. The first case needed reexploration because of bleeding on the second day after the operation. The lipid concentrations rapidly returned to the normal range in the first week after the operation, remaining in this range over the first 6 months of follow-up. Liver transplantation offers an highly effective treatment for HFHC. It is better to operate on patients before severe atherosclerotic changes in the coronary arteries. All patients must undergo a complete cardiac evaluation before surgery.

The effect of ischemic preconditioning of the pancreas on severity of ischemia/reperfusion-induced pancreatitis after a long period of ischemia in the rat

BACKGROUND

The role of ischemia/reperfusion injury in the pathogenesis of acute pancreatitis is still ill-defined. It is accepted, however, that ischemia/reperfusion induces the development of postimplantation pancreatitis that is responsible for considerable morbidity. Preconditioning by brief exposure to ischemia protects the organ against damage evoked by subsequent severe ischemia. This study was undertaken to examine whether two brief ischemic periods protect the pancreas against severe ischemia/reperfusion-induced pancreatitis.

MATERIALS AND METHODS

This study was performed on 30 rats in three groups. The first group (control) underwent a laparatomy without clamping of any artery. The second group underwent 30-minute clamping of the inferior splenic artery followed by 1-hour reperfusion of the pancreas, and the third group underwent clamping of inferior splenic artery (2 x 5 minutes with 5-minute interval) as ischemic preconditioning and then 30-minute clamping of inferior splenic artery followed by 1-hour reperfusion.

RESULTS

Exposure to 30-minute pancreatic ischemia followed by 1-hour reperfusion led to the development of severe alterations greater than the other group that underwent ischemic preconditioning and then ischemia/reperfusion. Ischemia preconditioning applied prior to induction of pancreatitis reduced plasma lipase and interleukin-1beta concentrations as well as less histological signs of pancreatic damage.

CONCLUSION

We concluded that pancreatic ischemic preconditioning reduced the severity of ischemia/reperfusion-induced pancreatitis. This effect seemed to be related at least in part to the release of the proinflammatory mediator interleukin-1beta.

Liver transplantation in the presence of old portal vein thrombosis

BACKGROUND

Portal vein thrombosis (PVT) has been mentioned as a potential obstacle to liver transplantation (LTx).

OBJECTIVE

To review the impact of PVT on orthotopic liver transplant (OLT) outcome.

METHOD

Between January 2006 and April 2009, 440 OLT were performed in Shiraz Transplant Unit of whom, 35 (7.9%) cases had old PVT with recanalization. Data were retrospectively collected regarding the demographics, indication for OLT, Child-Turgot-Pugh classification, pre-transplant diagnosis of PVT, perioperative course and managements, relapse of PVT, early post-operative mortality and morbidity. All patients received liver from deceased donors, underwent thrombendvenectomy with end-to-end anastomosis without interposition graft and evaluated daily for 5 days and thereafter, biweekly by duplex sonography during the follow-up period for 2 months. They were treated by therapeutic doses of heparin followed by warfarin to maintain an INR of 2-2.5.

RESULTS

The causes of end-stage liver disease were hepatitis B in 11, cryptogenic cirrhosis in 11, primary sclerosing cholangitis in 5 and other causes in 8 recipients. Extension of thrombosis was through confluence of superior mesenteric and splenic vein in 32 and to superior mesenteric vein in 3 patients. The mean±SD operation time was 7.2±1.5 hrs. The mean±SD transfusion requirement was 5.4±2.8 units of packed cells. The mean±SD duration of hospital stay in these patients was 17.7±10.9 days. Eight patients died; 1 developed early in-hospital PVT, 1 had hepatic vein thrombosis, and 1 died of in-hospital ischemic cerebrovascular accident, despite a full anticoagulant therapy. The mean±SD follow-up period for those 28 patients discharged from hospital was 16.6±7.9 months; none of them developed relapse of PVT. The overall mortality and morbidity was 28% and 32%, respectively. There was no relapse of PVT in the other patients.

CONCLUSION

The presence of PVT at the time of OLT is not a contraindication for the operation but those with PVT have a more difficult surgery, develop more postoperative complications, and experience a higher in-hospital mortality.

Experience of living donor liver transplantation in Iran: a single-center report

BACKGROUND

Living donor liver transplantation (LDLT) has been accepted as a valuable treatment for patients with end-stage liver disease seeking to overcome the shortage of organs and the waiting list mortality. The aim of this study was to report our experience with LDLT.

METHODS

We retrospectively analyzed 50 LDLTs performed in our organ transplant center from January 1997 to March 2008. We reviewed the demographic data, family history, operative and hospital stay durations as well as postoperation complications among donors and recipients. We also performed a retrospective analysis of recipient chemical and biochemical data.

RESULTS

Among 50 patients (30 males and 20 females) of overall mean age of 7.21 +/- 5.35 who underwent LDLT (10 right lobe, 38 left lobe, and 2 left lateral segments), 47 received a liver graft from their parent, two from a brother, and one from an uncle. The most common indications for LDLT were end-stage liver disease due to Wilson's disease (16%), cryptogenic cirrhosis (16%), tyrosinemia (14%), biliary atresia (12%), autoimmune hepatitis (12%), and progressive familial intrahepatic cholestasis (12%). The mean follow-up was 16.91 +/- 23.74 months. There were 13 (26%) recipient mortalities including vascular complications; three to sepsis after bowel perforation, two from liver dysfunction, two from chronic rejection due to noncompliance, and one from diffuse aspergillosis. The morbidity rate was 50%, including 19 reexplorations during the hospital course and five biliary complications.

CONCLUSION

This study demonstrated that LDLT can decrease the number of patients awaiting liver transplantation especially in the pediatric group. However, because of relatively high mortality and morbidity, we must improve our treatment outcomes.

De novo inflammatory bowel disease after pediatric orthotopic liver transplant: a case report

OBJECTIVES

The improvement of pre-existing inflammatory bowel disease after orthotopic liver transplant might be anticipated. However, both the exacerbation of inflammatory bowel disease and de novo inflammatory bowel disease after orthotopic liver transplant (despite sufficient allograft immunosuppressive therapy) have been described.

MATERIALS AND METHODS

We present a case of ulcerative colitis in a pediatric liver transplant recipient.

RESULTS

A 13-year-old boy with cryptogenic liver cirrhosis received an orthotopic liver transplant from a deceased donor. Five months later, he presented with watery diarrhea and abdominal distention. He was treated with the immunosuppressive agents tacrolimus (0.15 mg/kg/d) and mycophenolate mofetil (20 mg/kg/d). A general physical examination revealed a boy with stable vital signs and without fever. The only positive finding was enlargement of the abdomen without tenderness. Many pus cells and a few red blood cells were detected in the patient's stool, but the results of a stool culture for bacteria were negative. Because of his chronic diarrhea, this patient underwent colonoscopy, which revealed diffuse erythematous mucosa, multiple ulcers, exudate, and pseudopolyps with a diffuse loss of vascularity. Those findings are indicators of colitis. The results of histopathologic examination of the colonic mucosa suggested ulcerative colitis. The patient was treated with mesalamine and prednisolone, and a repeat colonoscopy revealed an improvement in his bowel disease.

CONCLUSIONS

De novo inflammatory bowel disease should be considered in patients in whom chronic diarrhea develops after an orthotopic liver transplant. We suggest that colonoscopy and biopsy should always be performed if other causes of diarrhea have been excluded.

Effect of D-penicillamine on liver fibrosis and inflammation in Wilson disease

BACKGROUND

Wilson disease is a disorder of copper metabolism characterized by copper overload. A mutation in the ATP7B gene causes dysfunction of ATP7B protein and a reduction in copper excretion into the bile in hepatocytes. Excess copper accumulation leads to liver injury. D-penicillamine primarily can inhibit fibrogenesis and prevent the appearance of scar lesions in the liver. We studied this phenomenon in our patients.

MATERIALS AND METHODS

Pathology slides from the explanted livers of 26 patients diagnosed as having Wilson disease with hepatoneurologic manifestations between 2000 and 2008 who had undergone a liver transplant were investigated retrospectively. Patients were divided into 2 groups according to their history of D-penicillamine use before transplant. The degree of fibrosis and inflammation were classified as mild (1), moderate (2), and severe (3), and were reviewed by an impartial hepatopathologist.

RESULTS

Of 26 patients (20 male, 6 female) who had Wilson disease with a mean age of 17.6 -/+ 8.6 years, 69% (18/26) had a history of D-penicillamine use before liver transplant from 6 months to 9 years (mean, 3.4 -/+ 2.7 years). In the D-penicillamine group, 14 patients (77%) had grade 1 fibrosis. Grade 2 and 3 fibrosis was seen in 5.6% and 16% of patients, respectively. In the D-penicillamine group, inflammation was grade 3 in 44% (8/18), grade 2 in 44% (8/18), and grade 1 in 11% of the patients (2/18). In the non- D-penicillamine group (8 patients), grades of fibrosis were grade 3 (62%), grade 2 (25%), and grade 1 (12%); 87% of the patients had grade 2 and 3 inflammation. The degree of fibrosis was significantly lower in the D-penicillamine group than it was in the non-D-penicillamine group (P < .05).

CONCLUSION

D-penicillamine may reduce the rate of liver fibrogenesis in patients with Wilson disease.

Effects of surgical technique on postoperative renal function after orthotopic liver transplant

OBJECTIVES

The classic technique for orthotopic liver transplant consists of the total excision of the retrohepatic inferior vena cava during native hepatectomy. Controversy about the effects of the classic technique on postoperative renal function continues. The aim of this study was to evaluate the effects of the chosen hepatectomy technique on postoperative renal function.

MATERIALS AND METHODS

Of 253 patients who received an orthotopic liver transplant between June 2006 and July 2008 in the Shiraz transplant unit, only 15 underwent operation with the classic technique. Patient demographics and factors including cold ischemic time, warm ischemic time, operative time, transfusions, blood loss, and early postoperative renal function were assessed retrospectively. The criteria for acute renal failure were a serum creatinine level of > 133 micromol/L (1.5 mg/dL), an increase in the baseline serum creatinine level by 50%, or oliguria requiring renal replacement therapy.

RESULTS

All patients received a liver from a deceased donor, and none required venovenous bypass during the operation. The minimum mean arterial blood pressure value of the patients during clamping was 65 -/+ 19 mm Hg. The mean preoperative plasma creatinine level was 87.51 -/+ 39.78 micromol (0.99 -/+ 0.45 mg/dL). During the first week after transplant, 7 patients (46.6%) experienced acute renal failure, and 3 of those 7 required renal replacement therapy. By the sixth postsurgical month, 4 of those 7 patients had died (1 from adult respiratory distress syndrome, 2 from sepsis, and 1 from recurrent cholangiocarcinoma). In all other patients, the plasma creatinine level had returned to the normal range by the third postsurgical week 3 or during short-term follow-up.

CONCLUSIONS

Use of the classic technique for orthotopic liver transplant may increase the rate of postoperative renal failure, but that complication usually resolves during short-term follow-up.

Pancreas transplantation in shiraz organ transplant center; the first Iranian experience

BACKGROUND

Pancreas transplantation is the treatment of choice for selected patients with type 1 diabetes mellitus. We reviewed our first 40 patients who underwent pancreas transplantation in Shiraz Organ Transplant Center.

METHODS

Between April 2006 and April 2008, we performed pancreas transplantation on 40 recipients. The operation included portal venous drainage and exocrine enteric drainage. Immunosuppressive therapy included prednisolone, tacrolimus, and mycophenolate mofetil. Ganciclovir was administered as prophylaxis for cytomegalovirus. Peri-operative and regular follow up data on survival and complication were gathered and analyzed.

RESULTS

The mean follow-up was 10.1+/-6.5 months (range: 1 - 24 months). Mean age of donors and recipients was 23.6+/-8.2 and 32.30+/-8.9 years, respectively. The mean pretransplant insulin consumption was 43.75+/-17.4 IU. Fasting blood glucose before transplantation was 275.5+/-72.3 mg/dL that decreased to 95.6+/-7.01 at six months follow-up (P<0.001). Complications were as follows: re-exploration (n=9), gastrointestinal complications (n=10), acute rejection episodes (n=12), and chronic rejection (n=4). We lost one patient due to diffuse cytomegalovirus and aspergillus infection three months after the operation with a functioning graft. Overall graft survival was 84.9% and patient survival 97.5%.

CONCLUSION

Good patient and graft survival in these series encouraged us to continue the program with all its difficulties.

Repair of Aortic Coarctation in Adults: The Fate of Hypertension

The benefit of coarctation repair on the resolution of systolic hypertension in adults has been questioned. In this retrospective study, hypertension was assessed in 38 adults (22 men, 16 women; mean age, 25.6 ± 6.9 years; range, 16–39 years) who underwent coarctation repair between 1996 and 2006. Thirty patients had preoperative hypertension (mean systolic pressure, 158.3±18.6; range 140–200 mm Hg). At preoperative catheterization, the peak mean systolic gradient across the coarctation was 70.6 ± 21.2 mm Hg (range, 38–120 mm Hg). Operative procedures were resection and end-to-end anastomosis (11 patients), patch aortoplasty (24) and resection with interposition of a Dacron tube graft (3). The patients were followed up for 2–90 months (mean, 37 ± 23 months). Of the 30 patients with preoperative hypertension, 25 (83%) were normotensive at the last follow-up. The mean postoperative systolic blood pressure was significantly lower than the preoperative level. More than half of the patients (58%) were still taking antihypertensive medication. Surgical repair of coarctation of the aorta in adults can lead to regression of systolic hypertension and a decreased requirement for antihypertensive medication.