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Abstract

Arterioportal fistula — either acquired or congenital — is a rare syndrome, which is a real challenge in gastroenterologic diagnostics. We report a case of a 76-year-old female, who was admitted to the hospital with symptoms of permanent abdominal pain and a bruit in the epigastric region. Twelve years prior she underwent Billroth II gastrojejunostomy due to a perforating duodenal ulcer, followed by cholecystectomy 6 months later. CT and MR angiography showed a fistula between the gastroduodenal artery and the portal vein. Successful treatment of the arterioportal fistula was achieved by intravascular coil embolization resulting in the resolution of the symptoms. After six years of follow-up, abdominal ultrasonography did not show any novel findings and our patient is still doing well with no recurrence.

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Authors: Á. Szél, B. Merkely, K. Hüttl, J. Gál, B. Nemes and A. Komócsi
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Abstract

Hepatitis C (HCV) is one of the main causes of liver transplantation (OLT). Previously we have reported that high serum C RNA level correlates with the severity of histopathological signs and poor clinical outcome. The core antigen of virus C is known to interfere with chaperones in the hepatocytes, results in an endoplasmic reticulum (ER) stress. In this study HCV positive liver transplanted patients were evaluated, whether there are correlations among chaperone expression, recurrence and viral titer. Patients were enrolled after surviving the first month following OLT. Sera were collected regularly, and biopsies were taken on demand following OLT. The diagnosis of recurrent HCV was proven by Knodell-Ishak scoring. In this case ribavirin+interferon were initiated, and maintained for one year. All chaperones were upregulated in the transplanted liver graft showing recurrent hepatitis C disease. ATF6, GP96, GRP78, CNX and CLR chaperones were upregulated significantly compared to their levels in normal livers. Except for one chaperone, the level of upregulation did not correlate with the serum's HCV-RNA titre: the only difference between Group1 and 2 (RNA titre above and below 8.78 106 respectively) was that the level of ATF6 was 1.6 times higher in Group1 compared to Group2. The expression of all chaperones was reduced, and some even became downregulated after the interferon treatment. In accordance with the literature our results suggest that hepatitis C might induce apoptosis through ER-stress. Those cells exposed to a high C viral load, had a lower chance to be eliminated.

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Authors: Balázs Nemes, É. Toronyi, K. Rajczy, A. Szakos, B. Somlai, A. Doros, R. Chmel, F. Derner and L. Kóbori

Abstract

Malignant diseases are considered as great challenges in clinical transplantation. It is well known that the incidence of malignancy is higher in the transplanted population if compared with the normal population. It is important to distinguish between neoplastic diseases originating from pre-existing lesions in the transplanted organs and de novo graft tumours. Post-transplant malignancy of donor origin is a rare complication of organ transplantation, most likely transmitted as micrometastases within the parenchyma of the donor organ or from circulating tumour cells contained within the organ. Malignant melanoma, although its incidence is rather low, is one of the most common donor-derived tumour inadvertently transplanted, comprising 28% of donor transmitted tumours. Malignant melanoma in the graft without dermatological localisation is extremely rare. We report a case of de novo melanoma occurring in the allograft, where transmission from the donor was excluded by DNA (desoxyribonucleic acid) investigation. We did not find any data in the literature where a malignant melanoma occurred after transplantation in the transplanted kidney without any skin lesions and the donor origin was excluded. We draw attention to the importance of the DNA typing in case of tumours occurring in immunosuppressed patients.

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Authors: Balázs Nemes, P. Sótonyi, G. Lotz, A. Heratizadeh, F. Gelley, C. Doege, M. Hubay, Zs. Schaff and B. Nashan

Abstract

In chronic liver rejection lymphocyte mediated processes lead to chronic inflammation, necrosis and repair mechanisms. The aim of the present study was to investigate the expression of apoptosis related proteins (FAS/APO-1, FAS-L, Bcl-2, Bax, TNF-α, and INF-γ). ApopTag reaction and immunohistochemistry were performed on liver samples of chronically rejected allografts and compared with normal donor livers. In chronic rejection, apoptosis was detected in pericentral hepatocytes and in the biliary epithelium. Bcl-2 was strongly expressed on lymphocytes around the bile ducts, but not on the biliary epithelium itself. Bax, FAS, TNF-α and INF-γ were present in pericentral areas. T-cells showed up around bile ducts, whereas macrophages around pericentral areas. In pericentral areas apoptosis seems to be fostered through TNF-α and INF-γ and by the lack of Bcl-2. Based on these results both downregulation and upregulation of apoptotic proteins can be observed in chronic liver allograft rejection: FAS is upregulated in biliary epithelium and zone 2, protein levels of FASL remain unchanged, BAX is upregulated in zone 3, BCL2 is downregulated in both biliary epithelium and zone 1 and both TNFa and IFN are upregulated in zone 3. Our results suggest that the balance between pro- and antiapoptotic patterns was shifted to the proapoptotic side, mainly in the centrilobular area of the hepatic lobule, and in the bile ducts. According to these findings in chronic rejection the predictive sites of apoptosis are the biliary epithelium and the pericentral areas.

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Authors: Attila Nemes, Marcel L. Geleijnse, Osama I. I. Soliman, Wim B. Vletter, Tamás Forster and Folkert J. ten Cate

A klinikai tapasztalat azt mutatja, hogy a jelenleg elérhető kritériumok alapján kiválasztott szívelégtelen betegek közel egyharmada a kardiális reszinkronizációs terápia (CRT) ellenére nonreszpondernek bizonyul, vagyis az optimális kezelés ellenére klinikai állapotukban javulás nem észlelhető. Ez a tény vezetett ahhoz a kutatási irányhoz, hogy találjunk olyan, noninvazív képalkotó diagnosztika (például echokardiográfia) során mérhető és/vagy számítható értéket, amely alkalmas a diszszinkrónia megítélésére és jobban segíti kiválasztani a CRT-re alkalmas betegeket. Ennek az áttekintő közleménynek a célja a legújabb noninvazív echokardiográfiás módszer, a real-time háromdimenziós echokardiográfia lehetséges szerepének bemutatása lenne az elérhető irodalom alapján.

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Authors: L. Kóbori, T. Németh, B. Nemes, G. Dallos, P. Sótonyi Jr., I. Fehérvári, A. Patonai, M. J. H. Slooff, J. Járay and K. P. De Jong

Hepatic artery thrombosis is a major cause of graft failure in liver transplantation. Use of donor interponates are common, but results are controversial because of necrosis or thrombosis after rejection. Reperfusion injury, hypoxia and free radical production determinate the survival. The aim of the study was to create an 'ideal' arterial interponate. Autologous, tubular graft lined with mesothelial cells, prepared from the posterior rectus fascia sheath, was used for iliac artery replacement in eight mongrel dogs for six months under immunosuppression. Patency rate was followed by Doppler ultrasound. Eight grafts remained patent and another two are patent after one year. The patency rate was good (median Doppler flow: 370 cm/sec) and there was no necrosis, thrombosis or aneurysmatic formation. The grafts showed viable morphology with neoangiogenesis, appearance of elastin, smooth muscle and endothelial cells. Electron microscopy showed intact mitochondrial structures without signs of hypoxia. Tissue oxygenation was good in all cases with normal (< 30 ng/ml) myeloperoxidase production. In conclusion, this autologous graft presents good long-term patency rate. Viability, arterialisation and low thrombogenicity are prognostic factors indicating usability of the graft in the clinical practice without the risk of rejection. Further investigations such as cell cultures and standardisation are necessary.

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Authors: L. Kóbori, G. Dallos, Anette S. H. Gouw, Tamás Németh, B. Nemes, I. Fehérvári, A. M. Tegzess, M. J. H. Slooff, K. P. De Jong and F. Perner

Vascular complications in liver transplantation are a major cause of graft failure and mortality. The aim of the study was to create autologous vascular graft without risk of rejection. Posterior rectus fascia sheath lined with peritoneum was used for iliac artery replacement in seven mongrel dogs. The patency was followed by palpation and Doppler ultrasound. The grafts were removed after one month. Five grafts remained patent. The Doppler showed good, relatively increased flow (median flow rate: 383 cm/sec) after one month in all of the cases. Slight increase in diameter was present in all cases. By microscopy the five patent grafts showed viable morphology, fibroblasts, smooth muscle cells and thin fibrin layer in the wall. The grafts were lined partially with a neoendothelial monolayer and a thin fibrin layer. In conclusion, this graft presents an acceptable patency rate and low thrombogenicity, and could be useful in transplantation. Further investigations are needed to study the effect of immunosuppression and rejection on long-term morphology and patency of the grafts.

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Authors: A. Doros, B. Nemes, Z. Máthé, A. Németh, E. Hartmann, Á. P. Deák, Zs. F. Lénárd, D. Görög, I. Fehérvári, Zs. Gerlei, J. Fazakas, Sz. Tóth and L. Kóbori

Abstract

Introduction

Hepatic artery complication represents recognized sequel of liver transplantation that carries significant morbidity and mortality. Besides retransplantation, hepatic artery recanalization is provided surgically, or by percutaneous angioplasty and stent placement. This study provides an analysis of a single center experience comparing surgical and interventional treatments in cases of early hepatic artery complications.

Methods

In this retrospective single center study, 25 of 365 liver transplant recipients were enrolled who developed early hepatic artery complication after transplantation. Percutaneous intervention was performed in 10 cases, while surgical therapy in 15 cases. Mean follow-up time was not different between the groups (505±377 vs. 706±940 days, respectively).

Results

6 patients in the Intervention Group and 10 patients in the Surgery Group are alive. The retransplantation rate (1 and 3) was lower after interventional procedures, while the development of biliary complications was higher. The mortality rate was higher after operative treatment (2 and 5).

Conclusion

Interventional therapy is a feasible and safe technique for treatment of early hepatic artery complication after transplantation. Being less invasive it is an invaluable alternative treatment having results comparable to surgical methods.

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Authors: Attila Nemes, Marcel L. Geleijnse, Osama I. I. Soliman, Ashraf M. Anwar, Wim B. Vletter, Jackie S. McGhie, Miklós Csanády, Tamás Forster and Folkert J. Ten Cate

A hypertrophiás cardiomyopathia egy relatíve gyakori öröklődő betegség, amely sajátos kardiális morfológiai és funkcionális eltérésekkel jár együtt. Az echokardiográfia a cardiomyopathiás betegek noninvazív vizsgálatának egyszerű, könnyen kivitelezhető és megtanulható módszereként szolgál. Ennek az összefoglaló jellegű közleménynek a célja az egyik legújabb echokardiográfiás fejlesztés, a real-time háromdimenziós echokardiográfia lehetséges diagnosztikus szerepének bemutatása hypertrophiás cardiomyopathiában.

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