Antihypertensive agents and renal transplantation

Hippokratia 2007;11(1):3-12

G Vergoulas
Organ Transplant Unit, Hippokratio Hospital, Thessaloniki, Greece

Abstract

Advances in the field of kidney transplantation have led to a significant increase in the life of renal allograft with 1 - year graft survival rates of 93% to 99%.This increase in early graft survival has made it possible to observe the long term morbidities that accompany renal transplantation. Studies correlating the reduction of arterial blood pressure with patient and graft survival as well as the risk of cardiovascular disease do not exist. The recommendations come from the general population and from comparative studies of hypertensive and normotensive kidney graft recipients. It is known that in the general population hypertension is a risk factor for chronic kidney disease but at the same time a risk factor for death, ischaemic heart disease, chronic heart failure and left ventricular hypertrophy. We must always have in mind that there are many similarities between a kidney graft recipient and a patient with chronic kidney disease. Renal transplant recipients represent a patient population with a very high risk for development of cardiovascular disease which has been identified as the leading cause of death in these patients. Of 18,482 deaths among renal allograft recipients, 38% had functioning renal allografts. Successful renal transplantation (Rt) can result in partial regression of left ventricular hypertrophy (LVH) if it is associated with hypertension (HTN) remission or if HTN is controlled by medications. Frequently post transplant HTN is associated with failure of LVH to regress. Transplant clinicians must choose antihypertensive agents that will provide their patients with maximum benefit from renal allograft and cardiovascular perspective. The target must always be long term patient and graft survival and acceptable quality of life. The antihypertensive drugs usually used after kidney transplantation are diuretics, calcium channel blockers, angiotensin converting enzyme inhibitors, angiotensin II receptor blockers and b - blockers. Most emphasis is given lately to ACEIs/ARBs and b - blockers because of their cardioprotecive effect.

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Preoperative evaluation and preparation for anesthesia and surgery

Hippokratia 2007; 11(1): 13-21

A Zambouri
4th Dpt Anesthesiology, Hippokratio Hospital, Thessaloniki, Greece

Abstract

The ultimate goals of preoperative medical assessment are to reduce the patient?s surgical and anesthetic perioperative morbidity or mortality, and to return him to desirable functioning as quickly as possible. It is imperative to realize that perioperative risk is multifactorial and a function of the preoperative medical condition of the patient, the invasiveness of the surgical procedure and the type of anesthetic administered. A history and physical examination, focusing on risk factors for cardiac and pulmonary complications and a determination of the patient?s functional capacity, are essential to any preoperative evaluation. Laboratory investigations should be ordered only when indicated by the patient?s medical status, drug therapy, or the nature of the proposed procedure and not on a routine basis. Persons without concomitant medical problems may need little more than a quick medical review. Those with comorbidity should be optimized for the procedure. Proper consultations with appropriate medical services should be obtained to improve the patient?s health. These consultations should ideally not be done in a ?last second? fashion. The preoperative preparation involves procedures that are implemented based on the nature of the expected operation as well as the findings of the diagnostic workup and the preoperative evaluation.

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Interventional Nephrology a new subspecialty of Nephrology

Hippokratia 2006, 11(1):22-24

G Efstratiadis, I Platsas, P Koukoudis, G Vergoulas
Nephrology Department, Aristotle University of Thessaloniki, Hippokratio Hospital
Organ Transplant Unit, Aristotle University of Thessaloniki, Hippokratio Hospital


Abstract

Interventional Nephrology is a new and emerging ubspecialty of Nephrology that mainly deals with ultrasonography of kidneys and ultrasound guided renal biopsy, insertion of peritoneal dialysis catheters, tunneled dialysis catheters as a vascular access for patients undergoing hemodialysis as well as percutaneous endovascular procedures performed to manage dysfunction of arteriovenous fistulas or grafts in end stage renal disease patients. Traditionally, these procedures have been delegated to a variety of specialists with resultant delays in diagnosis and initiation of therapy. To avoid the delays nephrologists have taken the initiative to perform these procedures themselves. Indeed, recent data have emphasized that nephrologists can safely and successfully perform these procedures with excellent results. The success of the nephrologis role in Interventional Nephrology insures the ideal management of renal patients with effectiveness, safety and lower cost for the Public Health System. Certainly nephrologists must have adequate training and develop the necessary skills in the new fields as a prerequisite for the success of the concept.

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Use of amifostine in the treatment of recurrent solid tumours in children

Hippokratia 2007; 11 (1):25-29

V Sidi, G Arsos, E Papakonstantinou, E Hatzipantelis, I Fragandrea, N Gombakis, E Koliouskas
Dpt Paediatric Oncology, Hippokratio Hospital, Thessaloniki, Greece
Dpt Nuclear Medicine, Aritotle University, Thessaloniki, Greece
1st Paediatric Dpt, Aristotle University, Thessaloniki, Greece

Abstract

Aim: Preclinical and clinical evaluation of amifostine (AMI) administration in conjunction with systemic chemotherapy supports its role as a cytoprotective agent of normal tissues without loss or impairing the antitumour effectiveness of chemotherapeutic agents. Since only a limited number of clinical studies have been performed using AMI in paediatric patients with malignancies we investigated the protective effect of AMI against carboplatin-induced myelotoxicity and nephrotoxicity in a paediatric group of patients.
Material and results: AMI was administered in 18 / 28 paediatric patients with reccurent solid tumours along with ICE (ifosfamide, carboplatin, etoposide) chemotherapy. A significant (p less than 0.05) decrease in GFR was observed in the control group whereas it was maintained at pre - treatment levels in the AMI-treated group. Leukopenia and neutropenia were significantly (p less than 0.05) less in the AMI-group. No protective effect of AMI was shown concerning thrombocytopenia.
Conclusions: AMI was generally well tolerated at the dose of 740 mg / m2. Side effects including nausea, vomiting, hypotension, flushing and rigors were moderate and reversible and the interruption of infusion was never required.

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Angina pectoris and intensive intravenous iron treatment in hemodialysis patients

Hippokratia 2007; 11 (1): 30 34

P Malindretos, A Sioulis, E Avgeriou, A Michalaki, V Roma, D Grekas
1st Dpt Internal Medicine, Renal Unit, AHEPA University Hospital, Thessaloniki, Greece

Abstract

Background: Intravenous iron and erythropoietin are commonly used for the treatment of anemia in end stage renal disease (ESRD) patients. Even though i.v. iron is proven to be very effective, there is great concern regarding its possible toxic effects. The aim of our study was to evaluate the possible correlation between iron administration and the incidence of angina pectoris in hemodialysis patients.
Methods: The study sample consisted of 10 stable coronary heart disease patients, receiving chronic hemodialysis treatment. The patients followed consecutively three different i.v. iron dose regimens according to their needs. Their standard monthly laboratory measurements were correlated with the incidence of angina pectoris and i.v. iron treatment.
Results: Hematocrit, ferritin, serum iron and mean rhEPO dose were related to the total amount of administered iron. Angina pectoris was related to intensive iron treatment, age and platelet count. Total white blood cell count were related to hemodialysis duration, platelet count and serum triglycerides.
Conclusion: It is suggested that the intensive intravenous iron treatment (300 mg / week) is associated with the increased incidence of angina pectoris in stable coronary heart disease patients receiving hemodialysis.

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Our experience in open rhinoplasty

Hippokratia 2007; 11 (1): 35-38

I Petropoulos, K Karagiannidis, G Kontzoglou
ENT Dpt, Hippokratio Hospital, Thessaloniki, Greece

Abstract

Aim: The last decade the external approach has gained enormous popularity in rhinoplastic surgery and it is a relatively new technique in Greece for the correction of functional and aesthetic problems of the nose. We introduce our experience in open rhinoplasty, we describe the operative technique, its advantages.
Material-methods: In a period of two years (2003-2005), 98 patients underwent open rhinoplasty in our department. In 42 of them, breathing problems were existed in combination with nasal deformities. Eighty seven patients underwent septorhinoplasty under general anesthesia and the other 11 under local anesthesia.
Results: The postoperative course was uneventful, painless and without postoperative bleeding in all patients. Postoperative photo documentation was performed in all of them after 1, 3, 6, and 12 months. Only two patients needed to undergo revision surgery (the first patient due to ''polly beak'' deformity and the second one due to postoperative nasal valve stenosis). The scar of broken columella incision was invisible in all patients some weeks postoperatively.
Conclusion: In open approach rhinoplasty, as it provides a full exposure of the osseocartilaginous vault, is much easier to perform all the modern rhinoplasty techniques with sutures, biological and non biological materials, to modify the nasal tip deformities and asymmetries and to gain an aesthetic result balanced with the other facial components. Its disadvantages are minimal, that's why it becomes every day more popular all over the world.

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Inflammation and anaemia as predictors of cardiovascular mortality in hemodialysis patients

Hippokratia 2007;11(1): 39-43

G Selim, O Stojceva-Taneva, N Ivanovski, K Zafirovska, A Sikole, L Trajcevska, A Asani, M Polenakovic
Macedonian Academy of Sciences and Arts, Skopje, F.Y.R.O.M.

Abstract

Background: Cardiovascular diseases are the most common causes of death among hemodialysis (HD) patients, yet the risk factors for these events have not been well established. Our study objective was to determine predictors of cardiovascular mortality, considering the non-traditional disease-related and treatment-related cardiovascular risk factor in HD patients.
Material and Methods: Disease-related cardiovascular risk factors, such as anaemia, calcium-phosphate disorders, nutrition-inflammation and treatment / dialysis-related cardiovascular risk factors such as HD dose, using the index Kt/V were analyzed in 214 patients on HD. Mortality was monitored prospectively over a two year period.
Results: Fifty-three of the 214 HD patients died during the follow up period and the main cause of death was cardiovascular events (56.6%), followed by infection / sepsis (26.4%). The patients who died were significantly older than those alive, had significantly lower serum levels of hemoglobin (Hb), albumin and Kt/V. Serum levels of calcium, C-reactive protein (CRP) and fibrinogen were significantly higher in patients who died during the follow up period. Kaplan-Meier analysis showed that the all cause and cardiovascular mortality was considerably higher in patients with Hb less than 110 g/l, albumin less than 40 g/l, CRP more than 8 mg/l and spKt / V less than 1.2 (log rank, p=0.000 / p=0.000, p=0.000 / p=0.001, p=0.000 / p=0.000, p=0.000 / p=0.000), respectively. No difference in cardiovascular mortality was observed between the fibrinogen less than 4 g/l and more than 4 g/l levels. High CRP, low Hb levels and low spKt/V were significant predictors of all-cause mortality, but low albumin and high fibrinogen levels were not in the Cox proportional hazards analysis. When only cardiovascular mortality was entered into the Cox model, high CRP and low Hb levels were the only significant predictors for mortality.
Conclusions: It can be concluded that, inflammation (elevated CRP) and anaemia (decreased Hb), were identified as significant independent non-traditional, disease-related cardiovascular risk factors that predict cardiovascular mortality in HD patients.

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Delayed interval delivery in twin pregnancy: A case report

Hippokratia 2007;11(1):44-46

N Klearhou, A Mamopoulos, S Pepes, A Daniilidis, D Rousso, V Karagiannis
3rd Department of Obstetrics and Gynecology, Aristotle University, Thessaloniki, Greece

Abstract

We report a case of diamniotic, dichorionic pregnancy presented at 24 weeks with premature rupture of the first amnionic sac. Seven days later, premature labour and delivery of the first twin took place, with unfortunate outcome.
The second twin was left in utero. The management included combination of tocolytics, antibiotics and cervical cerclage. Caesarean section was performed 48 days later, at 32 weeks and we delivered a live male infant, successfully.

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