Mycophenolate Mofetil in Transplantation

Hippokratia 2002, 6 (4): 163-166

G Vergoulas

Abstract

Mycophenolate mofetil (MMF) blocks the de novo pathway of purine production in the lymphocytes and more specifically the production of guanocine by inhibiting the action of inosine monophosphate dehydrogenase. The result of this action is the inhibition of Τ and Β lymphocyte proliferation and the inhibition of antibody production by Β lymphocytes.

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Large Serous urachal cyst in an adult

Hippokratia 2002, 6 (4): 167-170

G Frangandreas, N Flaris, D Tsantilas, Ch Spiridis, H. Pezikoglou, Th. Gerasimidis

Abstract

Lesions of the urachus are rarely manifested clinically in adulthood. They more commonly cause clinical problems in children. The urachus is obliterated in early infancy and its remains persist as the median umbilical ligament. The lumen of the lower part of the urachus may persist throughout life and communicate with the cavity of the bladder. Persistent urachal remnants are most likely a normal phenomenon and clinically important only when complicated by infection, neoplasia or cystic dilatation.We present an adult patient with an unusually large urachal cyst causing hydronephrosis of the right kidney.

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De novo membranous glomerulonephritis in a kidney graft recipient

Hippokratia 2002, 6 (4): 171-176

Gr Miserlis, G Vergoulas, M Leontsini, A Papagiannis, V Papanikolaou, D Gakis, D Takoudas, A Antoniadis

Abstract

In renal transplantation, chronic allograft nephropathy is the leading cause of long term graft losses, transplant glomerulopathy being its glomerular form. Differential diagnosis from recurrent or de novo glomerulonephritis should be enstablished. Whether hepatitis C virus is associated with glomerular damage in renal allograft recipients, as in native kidneys, is not known. The aim of this case report was to show the clinical course of a HCV-positive kidney graft recipient who four and a half years posttransplantation presented de novo allograft glomerulonephritis. He was a 45-year-old male kidney graft recipient who presented to the Outpatient Department of Organ Transplant Unit at Hippokratio General Hospital of Thessaloniki on 1999, for further clinical and laboratory evaluation because of bilateral lower extremity edema, proteinuria (24h urine protein: 1,5 g) and mild hypertension. He was a healthy hepatitis C carrier who had received a kidney allograft from his 42-years-old sister on 1995 and no specific treatment was given to him for the positive HCV test before kidney transplantation. He had repeated episodes of acute tonsillitis while he was six years old and he presented rheumatic fever symptoms at age of eight. Aortic and mitral valve deficiency were added at age of fifteen and proteinuria, microscopic hematuria and mild elevation of serum creatinine (Scr: 1,8 mg/dl) at age thirty two. He had two replacements of aortic valve while he was thirty three and thirty eight years old and one of mitral valve at age of thirty eight. The renal function deteriorated gradually and he commenced hemodialysis treatment at age of forty four. He became HCV-positive during the renal replacement treatment. On 13th post-transplant day he was discharged with normal kidney graft function. One month after renal transplantation he presented acute bronchitis which was treated successfully with antibiotics and concomitant reduction of immunosuppression, while four months later he was admitted to our department with acute cholecystitis due to chololethiasis. Sixteen months after kidney transplantation he underwent laparoscopic cholecystectomy but two months later the clinical and laboratory evaluation at the Outpatient Department revealed mild elevation of blood pressure (BP: 140/95 mmHg), microscopic hematuria of upper urinary system origin and microalbuminuria (24h urine protein: 150 mg). The kidney and the liver function tests remained within normal limits during the 2nd, 3rd and 4th post-transplantation year. Proteinuria of nephrotic type (24h urine protein: 1,5 g) and edema of the lower extremities were added to the clinical syndrome, four and a half years post-transplantation. The circulating immune complexes (CICs) were found above normal limits (CIC:75 ng/ml, normal range: 0,5-15 ng/ml) while at the same period the blood viral load of HCV by polymerase chain reaction ( HCV-RNA PCR) was greater than 106 copies/ml. Renal graft biopsy demonstrated de novo stage II membranous glomerulonephritis with mild arteriosclerosis. Valsartan was added to the treatment in order to reduce proteinuria and stabilize blood pressure and allograft function. Eight years after kidney transplantation there is no impairment either of kidney or liver function, his 24h urine protein is 750 mg, he has negative HCV-RNA PCR and normal serum concentrations of CICs. In conclusion, we have shown that in renal allograft recipients with a past rheumatic fever history, HCV infection may be rarely associated with de novo membranous glomerulonephritis. In this group of patients the angiotensin II type I receptor antagonists may play a useful role for the treatment of proteinuria and hypertension.

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Conversion from azathioprine to mycophenolate mofetil in patients with kidney transplantation taking triple drug immnosuppression

Hippokratia 2002, 6 (4): 177-185

G. Vergoulas, Miserlis, I Fouzas, G Trellopoulos, V. Papanikolaou, D. Gakis

Abstract

The purpose of this study was to evaluate the effect and safety of azathioprine (AZA) replacement with mycophenolate mofetil (MMF) in a triple drug immunosuppression protocol on kidney transplant recipients. Fifty patients (35 men), 34 year - old (range 15-60 years) were included in the study. The replacement of AZA with MMF was done 5.24 �2.43 years from transplantation (range 1.47 - 10.56 years) because of a serum creatinine rise and / or proteinuria. The patients had received triple or quadruple induction therapy with Cyclosporine A (CsA), methylprednizolone, AZA and antifymphocyte globulin. Forty patients had received a kidney graft from living related donor (LRD).Serum creatinine (Cr), total protein (Pt), SGPT levels, WBC, platelet count and Ht were recorded every two months for a period of one year before and one year after conversion. At the same time period infections were recorded. Proteinuria (12 patients) was recorded at the time of conversion and six months later. Statistical analysis was done with ANOVA for repeated measures and paired t test.Serum Cr was 1.31+0.35 mg/dl, 1.41±0.38 mg/ dl, 1.35±0.38 mg/dl, 1.37±0.35 mg/dl, 1.45±0.38 mg/dl, 1.45±0.38 mg/dl και 1.47±0.40 mg/dl 12, 10, 8, 6, 4, 2 and 0 months before the conversion respectively (p=0.0005), and 1.54±0.41 mg/dl, 1.50±0.41 mg/dl, 1.54v0.47 mg/dl, 1.60±0.49 mg/dl, 1.56±0.44 mg/dl, 1.66+0.57 mg/dl 2, 4, 6, 8, 10 and 12 months after conversion respectively (p=NS). Proteiuria was 0.59v0.64 g/24h before and 0.64±0.69 g/24h one year after conversion (p=NS). The infections per patient year were 0.44±0.54 before and 0.42v0.53 one year after the conversion (p=NS). WBC, platelets and Ht, the serum Pt and SGPT did not show significant difference during time before and after the conversion.In conclusion the shift from AZA to MMF retarded the graft function deterioration in patients with a history of acute rejection episode and/or chronic allograft nephropathy and allowed the lowering of cyclosporine dose in patients with cyclosporine toxicity and grafts from aged donors. This conversion was not accompanied by new acute rejection episodes, new cases of chronic allograft nephropathy and there was no patient or graft loss.

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Action of Statins upon thrombogenesis, Fibrinolysis and inflammation in Coronary patients

Hippokratia 2002, 6 (4): 186-192

Ap Efthimiadis, D Psirropoulos, I Efthimiadis, N Lefkos

Abstract

It has been established that the use of statins and application of a healthy modified diet and way of life have a favorable influence upon lipids, fibrinogen, PAI-l, t-PA, and C-reacting protein (CRP) in hyperlipidaemic patients with angina manifestations.We studied 206 hyperlipidaemic patients (phenotypes IIa and IIb, according to Fredricson) of both sexes (M=116, F=90, mean age 51.7+6.8 years) hospitalized in our department with angina manifestations. Group A consisted of 65 patients, 44 with stable angina (M=31, F=13) and 21 with unstable angina (M=12, F=9), treated with pravastatin 20 mg daily while Group Β consisted of 141 patients, 112 with stable angina patients (M=62, F=60) and 29 with unstable angina (M=13, F=16), treated with fluvastatin 40 mg daily. Patients with conditions affecting the acute inflammatory proteins were excluded from the study. All patients followed a specific diet for three months at the same time as antilipidaemic treatment was administered. At the end of the three months period, all patients underwent the same clinical, biochemical and electrocardiographic estimation as at baseline.The concurrent application of our healthy modified model of diet and living and antilipidaemic drug treatment for three months resulted to: 1) A statistically significant reduction of total-ch, triglycerides, LDL-ch levels and significant elevation of LDL-ch compared to those at baseline. 2) A reduction of fibrinogen levels: 7.9% in the fluvastatin group (p<0.05) and 4.8% in pravastatin group. 3) A statistically significant reduction of PAI-1 levels and a statistically significant elevation of t-PA levels compared to those at baseline. 4) A statistically significant elevation (p<0.001) of CRP levels at baseline in patients with unstable angina compared to those with stable angina and with normal values. 5) A greater reduction (p<0.05) of CRP levels after three months treatment with pravastatin compared to those with fluvastatin. 6) A good long-term outcome for all patients. Thirty-two patients from the group with unstable angina had a positive for CAD exercise test (Ex) performed one month after discharge whilst the remaining 8 had an uncertain or negative Ex. 24 of them underwent coronary angiography with stenotic lesions < 50% in one or two arteries. Drug treatment was continued and an appointment after six months was recommended. 7) A non-statistically significant elevation within normal levels of SGPT, SGOT, CpK-MB. The levels of serum glucose and the other biochemical parameters were not influenced. 8) Gastroenteritis in six patients which was managed without interruption in the administration of the antilipidaemic drug.The combination of a hypolipidaemic diet, regular exercise, cessation of smoking, loss of body weight and hydrophilic statins seems to act favorably on hyperlipidaemic coronary patients improving clinical status and anatomic lesions. This action is achieved by functionally improving the endothelium, suppressing the inflammation, reducing the thrombogenesis, supporting the fibrinolysis and decreasing the lipid levels.

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The correlation between hypertension and renal function, left venticular hypertrophy and renal structure in autosomal dominant polycystic kidney disease

Hippokratia 2002, 6 (4): 193-197

A Idrizi, M. Barbullushi, S Qirko, A Koroshi, E Petrela

Abstract

The aim of this study was to evaluate the frequency of hypertension in autosomal dominant polycystic kidney disease (ADPKD) patients and its correlation with renal function, renal structure and its influence in left ventricular wall.Two hundred patients were included in the study. The patients were divided in two groups: first group of 92 patients with normal renal function, and second group of 108 patients with chronic renal failure. All patients performed an abdominal ultrasound and a M-mode echocardiography.Hypertension was observed in 140 ADPKD patients (70%): 56 of first group (61%) and 84 of second group (79%). Subjects who developed hypertension before age 35 had worse renal survival than those who remained normotensive after age 35 (50 years vs. 62 years; ρ < 0.0001; risk ratio = 4.3). Hypertensive patients had significantly higher serum creatinine concentration than those without hypertension (p < 0.001). Left ventricular hypertrophy was present in 56 patients with hypertension (40%) and in 9 normotensive patients (16%) (p < 0.005). Patients with LVH had a worse renal survival than those without LVH (p < 0.001). Also, we have studied the role of renal cystic enlargement in initiating hypertension in ADPKD and on renal function. We conclude that hypertension is a common complication in our ADPKD patients, considering as an important factor of cardiac hypertrophy. LVH could be considered a more valid measure of blood pressure control than office blood pressure measurements. The blood pressure correlates with kidney size in ADPKD patients. More increased kidney volume, highest blood pressure is observed. These findings suggest that hypertension is a serious complication in ADPKD that may lead to both an increased incidence of cardiovascular complications and more rapid progression of renal functional impairment.

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Spiral CT findings in abdominal aortic aneurysms

Hippokratia 2002, 6 (4): 198-203

G. Grollios, K . Tsinoglou, G. Anastasiou

Abstract

Abdominal aortic aneurysms (AAAs) are a well studied clinical entity, mainly affecting older male adults (over the age of 60). In this article we present our experience of the use of spiral computed tomography (CT) in the detection and perioperative evaluation of abdominal aortic aneurysms. From January 2000 to April 2002, an abdominal spiral CT examination was performed in 112 patients (103 male, 9 female, mean age 64 years old) with suspected AAA. In every case, the examination revealed the presence of an AAA and provided a diversity of vital information regarding the extent and diameter of the aneurysm, its relationship with the renal arteries, the presence of mural thrombus or perianeurysmal fibrosis and potential complications such as rupture; moreover, spiral CT was performed postoperatively in 32 patients, in order to exclude the presence of stent-related complications such as perigraft leaks or renal compromise. Out of 112 patients studied, 108 had aneurysms situated below the origin of the renal arteries; 7 patients presented also aneurysms of the common iliac arteries; 7 patients had inflammatory abdominal aortic aneurysms; 7 patients had a ruptured abdominal aortic aneurysm, while imminent rupture of an aneurysm was found in 5 patients. Out of the 32 patients re-evaluated postoperatively, 9 presented peristent leaks, while no one had evidence of renal compromise. In conclusion, we find that spiral computed tomography is an indispensable modality for the evaluation of abdominal aortic aneurysms, as it provides accurate information regarding not only the anatomy of the aneurysm itself but also the potential complications, both preoperatively and postoperatively.

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