Authors:Balázs Nemes, D. Görög, I. Fehérvári, T. Mándli, E. Sárváry, L. Kóbori, A. Doros and J. Fazakas
Portal vein reconstruction might be a challenge in certain cases of liver transplantation. The problem usually arises due to small vessels in pediatric transplantation and/or living related donor and split liver transplantation, or as a result of extensive PVT in adult recipients. Authors report a case of a 60-year-old alcoholic cirrhotic patient with reverse portal flow. The standard end to end portal anastomosis did not work well, so a mesoportal shunt with a donor iliac vein conduit was performed first, followed by a cavoportal hemitransposition. After unsuccessful attempts of providing good portal flow, the donor umbilical vein and the iliac conduit was used for portal flow reconstruction as meso-Rex graft. The patient has been doing fine for eight months after her liver transplantation. Unusual types of portal reconstructions consist of meso-portal, umbilico-portal, renoportal anastomoses that are primarily used as rescue techniques. However, it is rare that one has to use them sequentially in the same patient.
Authors:Balázs Nemes, É. Toronyi, K. Rajczy, A. Szakos, B. Somlai, A. Doros, R. Chmel, F. Derner and L. Kóbori
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.
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.
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.
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
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.
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).
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).
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.
Authors:E. Hartmann, A. Németh, Gy. Juharosi, Zs. Lénárd, P. Á. Deák, V. Kozma, P. Nagy, Zs. Gerlei, I. Fehérvári, B. Nemes, D. Görög, J. Fazakas, L. Kóbori and A. Doros
Hepatocellular carcinoma, which has developed in liver cirrhosis is a disease where liver transplantation can provide a cure both for the tumour and the underlying liver damage. However, patients can only be transplanted when the tumour number and size do not exceed the Milan criteria. Tumour ablation methods — such as radiofrequency ablation — can provide a chance to make the patient eligible for transplantation. Among the 416 Hungarian liver transplanted patients there are 6 who had received different types of ablative therapy as bridging therapy in different institutions. On the basis of analysis of the patients' data we created a guideline for the treatment of cirrhotic patients with hepatocellular carcinoma with the aim of developing a uniform Hungarian approach.
Authors:Eniko Sarvary, D. Lee, J. Varadi, M. Varga, I. Gaal, R. Chmel, G. Beko, Z. Kanyo, B. Nemes, Zs. Gerlei, J. Fazakas, L. Kobori, Zs. Herold, S. Németh, I. Galoczi, J. Jaray and R. Langer
The value of urinary cytology in the diagnosis of different pathological conditions in renal transplantation is particularly important. Manual microscopic urinalysis is a high-volume procedure that currently requires significant labour.
Objective: To automate the sediment evaluation and to make this more accurate using the Iris Diagnostics Automated Urine Microscopy Analyzer (iQ200). Our goal was to compare the manual and automated microscopic data to apply iQ200 in renal function monitoring.
Method: The iQ200 uses digital imaging and Auto Analyte Recognition software to classify urine constituents into 12 analyte categories and quantitatively report.
Results: We determined cut-off values of urine particles in every category, which correlated well with manual microscopic results. The iQ200 was more sensitive for pathological casts than manual microscopic analysis. iQ200 helped the operator to differentiate between isomorphic and dismorphic erythrocytes and between lymphocytes and granulocytes, too. Every pathological constituent could be recognized, which is very important for early recognition of renal impairment, graft rejection and urinary tract infection.
Conclusions: The iQ200 system automatically classifies 12 particles, significantly reducing the need for additional sample preparation, manual microscopic review achieving a high degree of standardization in urinalysis.
Authors:Enikő Sárváry, Zs. Gerlei, E. Dinya, E. Tóth, M. Varga, R. Chmel, M. Molnar, A. Remport, B. Nemes, L. Kobori, D. Görög, J. Fazakas, I. Gaal, J. Járay, F. Perner and R. Langer
Patients on hemodialysis (HD) and renal transplant recipients (RT) have a high prevalence of HCV infection. The aim of our study was to determine the prevalence of HCV-RNA in the anti-HCV positive patients and to compare the biochemical parameters of PCR(+) and PCR(−) subgroups. Methods: The 525 sera were screened for anti-HCV. HCV-RNA was detected by polymerase chain reaction (PCR) and liver enzymes [SGOT, SGPT, GGT, α-glutathione S-transferase (GST)] were measured. Results: Active viraemia was found only in 187 of 289 (65%) seropositive HD patients in contrast to 53 of 53 (100%) of seropositive RT patients. Significantly increased (p<0.05) GST values (9.9 μg/l) were found in the PCR(+) subgroups compared to GST levels (2.7 μg/l) of the PCR(−) subgroups. Elevated GST concentration was found in 80% (208/251) of PCR(+) patients. The measured enzymes were not elevated in HCV infected patients. Six percent of HD and 11% of RT patients were screened before seroconversion. Diagnostic sensitivity (80%) and specificity (79%) of GST were calculated as good for early liver damage caused by HCV. In contrast, the sensitivity of the measurement of other liver enzymes were very weak (SGOT: 8%; SGPT: 10%; GGT: 42%). Conclusion: The significantly higher viraemia of the RT subgroup could be related to the immunosuppressive therapy. Increased GST level may be a useful indicator of tissue damage during HCV infection. If HCV infection is suspected, PCR and GST measurement should be performed, even if anti-HCV result is negative.