Patient and Graft Survival after Renal Transplantation

Hippokratia 2004; 8(2):51-56

G.V Vergoulas
Organ Transplant Unit, Hippokratio General Hospital, Thessaloniki, Greece

Abstract

Patients with end stage renal disease have poor overall survival compared with age - matched individuals in the general population and even compared with individuals with other chronic illnesses. One of the goals of renal replacement therapy is to provide patients with the life expectancy as near to normal as possible. Renal transplantation is the form of renal replacement therapy that restores the greatest degree of normal renal function and achieves cadaveric graft survival rates 90%, 60-70% and 30-40% in the first, fifth and 10th posttransplant year respectively and reduces the mortality of patients with end stage renal disease, with 81.3% and 62.2% patient survival 5 and 10 years after cadaveric renal transplantation. The main causes of graft loss after the 1st posttransplant year are chronic allograft nephropathy, death with functioning allograft, recurrence of the original disease, and noncompliance.
A renal transplant must be able to sustain a number of injuries in order to be successful in the long - term. Estimates exist of 3% to 5% graft loss and 5% mortality in the first year in the best programs for cadaver transplantation and less for live donor transplantation. After the first posttransplant year the average GFR decline is about 1.2 to 2.5 ml/min. From this point of view allograft failure remains a significant factor for initiating dialysis.

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Access of Persons with Special health Care needs to quality dental services in Greece

Hippokratia 2004; 8(2):57-61

P. Thanoulis, I Basli
Dental Dpt, Hippokratio General Hospital, Thessaloniki, Greece

Abstract

The individuals with special medical needs hardly seek for dental care and their access to the dental health services is compromised. The obstacles that they meet in the use of dental services can be divided in three categories: Barriers from the users themselves and the carers. Barriers from the professionals that offer the services. Barriers from the shortage of government programs and services for the oral health of people with special needs.
An absence is observed in dental services with complete functional status, program and strategy in Greece for the protection and the promotion of oral health of people with special needs. For this reason it is essential that a Central Specialised Dental Service for the oral health care of the disabled to be founded with peripheral Dental Health Services in local or perhaps in Prefectoral level under the Ministry of Health.
Aim and objective of these Dental Services are: Recording of the number of persons with special needs. Organising of education and training programs in dental prevention for parents or carers. Program of prevention. A mobile dental unit and Units of dental care in Hospitals.
Thus is determined the form, which we can apply in our country in order to activate us in offering to individuals with special medical needs comfortable and free access to quality dental services.

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Influence of clinical Parameters on five year patient and graft survival after first renal transplantation

Hippokratia 2004; 8(2):62-68

E. Koutlas, L. Nikolaidou-Tokalaki, G. Zacharakis
Organ Transplant Unit, Hippokratio General Hospital, Thessaloniki, Greece

Abstract

Background: Survival after renal transplantation is the most important outcome measure when transplantation results are analysed. The determinators of patient and graft survival after renal transplantation are incompletely known and conflicting results have been reported. The purpose of this study was to evaluate the effect of common clinical parameters on patient and graft survival.
Material and Methods: Three hundred sixty three patients (pts), 235 men and 128 women, 39 years old (range 16-69), who received a first renal transplantation (Rt) from 1.1.1987 to 31.12.96, were studied. The influence of graft origin (LR or CD donor), method of dialysis (HD, PD), donor and recipient hypertension (DH, RH) before transplantation, delayed graft function (DGF), acute rejection (AR), recipient and donor sex on patient and graft survival was investigated. The methods Kaplan Meier, Log Rank, Breslow and Tarone Ware were used for statistical analysis.
Results: One and 5 year patient survival of the whole sample was 96.14% and 90.63% respectively. Pts with LRD or CD presented 1 and 5 survival 97.84%-95.24% and 93.13%-82.44% respectively (p:0.00005). Pts on HD or PD before Rt had 97.31%-92.59% and 90.74%-85.19% 1 and 5 year survival respectively (p:0.03). Pts with RH or not before Rt had 96.26%-90.37% and 98.39%-96.77% 1 and 5 year survival respectively (p:0.02). Pts with DH or not had 95.29%-83.33% and 98.92%-96.77% 1 and 5 year survival respectively (p:0.0015). One and 5 year graft survival (gs) of the whole sample was 87.33% and 68.60% respectively. Grafts from LRD or CD had 1 and 5 year survival 91.34%-72.73% and 80.94%-61.83% respectively (p:0.03). Grafts from DH or not had 1 and 5 year survival 88.10%- 64.29% and 96.77%-84.41% respectively (p:0.001). Grafts with DGF or not had 1 and 5 year survival 73.02%-55.56% and 91.67%-73.26% respectively (p:0.0001). Grafts with AR or not had 1 and 5 year survival 82.98%-48.94% and 89.52%-76.61% respectively (p:0.00005).
Conclusions: In conclusion better 5-year survival had pts with a LRD, previously on HD, without hypertension before Rt or a normotensive donor. Better survival presented grafts coming from a normotensive donor, a LRD, without DGF or AR.

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Left ventricular hypertrophy and coronary heart disease in patients with metabolic syndrome and arterial hypertension.

Hippokratia 2004; 8(2):69-72

S Voyaki, A Efstratopoulos, T Gialernios, A Hatzis, A Baltas, L Mourgos, S Siasiakou, V Lekakis
Hypertension Unit & 3rd Medical Dpt of General Hospital of Athens, Athens, Greece

Abstract

Background: Metabolic syndrome is considered as a situation associated with cardiovascular complications, obesity, hypertension and diabetes. Aim of the present study was the investigation of the prevalence of cardiac complications in patients suffering from metabolic syndrome (MS) and hypertension.
Methods: Patients with a follow up in our Hypertension Unit, with hypertension and fulfilling at least 3 of the 5 risk criteria of NCEP / ATP-III, namely: abdominal obesity (waist circumference of > 102 cm for men, and > 88 cm in women), triglycerides > 150 mg/dl, HDL-C < 40 mg/dl for men and < 50 mg/dl in women, blood pressure > 130/85 mmHg, and fasting glucose >110 mg/ dl, were included in the study. All patients were evaluated by recording past history for coronary heart disease (CHD), office and home blood pressure as well as 24-h-ABPM, ECG, M-Mode echocardiography and fasting plasma glucose to insulin ratio (FPG/FPI). No one patient was under antihypertensive or antilipidemic therapy. As left ventricular hyperrophy (LVH) characterized a left ventricular mass index (LVMI) of >125 gm/m2 for men and > 110 gm/m2 for women, using the criteria of Penn convention.
Results: From the 143 studied patients ( 82 M/ 61 F, aged 17-81 years), 11 patients (5%) had CHD and 65 (45.5%) LVH. The left ventricular wall thickness (LVWT) was found to be significantly related to pulse pressure (p<0.003) and significantly inversely related to FPG/FPI ratio (insulin sensitivity index). Multiple regression analysis with these relationships together and confounding factors age, sex, BMI waist, and duration of hypertension as independent variables showed FPI to be the only significant variable explaining 41% of the variation in LVWT, while duration of hypertension was the main determinant for the presence of CHD (p= 0.0044).
Conclusions: We conclude that LVH was present in about 46% of hypertensives with metabolic syndrome and the main determinant was the fasting plasma glucose to insulin ratio, while duration of hypertension was also a significant factor for the development of CHD.

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The role of regulatory factor for the determination of dosage of digoxin and other drugs in patients with renal dysfunction

Hippokrtia 2004; 8(2):73-77

A Efstratopoulos, N Ioakimidis, N Marougas, D Dimou, Th Gialernios, N Karbouniaris
3rd Medical dpt & Hypertension Unit, General Hospital of Athens "Gennimatas', Athens, Greece

Abstract

Background: In cases of chronic renal dysfunction, the dose of drugs that are excreted mainly from the kidneys should be adjusted according to the level of renal function. In such cases, the use of a regulatory factor (RegF) is of clinical importance. In the present work a RegF was calculated from the glomerular filtration rate (GFR) of the patient (Gault -Cockroft method), in relation to normal GFR (120 ml/min/l.73m2 of body surface area), taking into account the body weight, age, sex of the patient and the renal (%) excretion of the drug. The dose based on calculation of RegF was estimated by either the division of the daily dosage or the multiplication of the interval of administration. In our study we used the RegF to estimate the proper dose of digoxin in patients with heart failure or atrial fibrillation, in order to achieve therapeutic plasma levels.
Patients and Methods. A total of 29 patients (14 M / 15 F, 52-92 years-old) with either heart failure or atrial fibrillation, were included in the study. In every patient, digoxin plasma levels were measured initially (following the initial dosage of the drug) and later, after dosing adjustment based on RegF. In every patient, serum creatinine, body weight, GFR and blood pressure were determined. One-way analysis of variance (ANOVA) was used to compare responses following dosing modification due to regulatory factor.
Results: The initial plasma digoxin levels (i.e. plasma levels obtained from the initial dosage) ranged from 0.56 to 3.88 ng/mL (1.63±0.18 ng/mL, M±SE), while, the normal plasma levels ranged from 0.7 to 2.0 ng/mL. Plasma digoxin levels after dosage adjustment according to calculation of the regulatory factor ranged from 0.75 to 2.0 ng/mL (1.17±0.076), (in relation to the initial plasma levels, P: 0.02). Following the initial dosage, 7 patients had toxic digoxin plasma levels, 3.06±0.24, (range 2.14 - 3.88), whereas, after dosage modification, nobody from this study group had toxic plasma levels (i.e. > 2.0 ng/mL) (p < 0.001).
Conclusions. We conclude that the use of RegF to determine the appropriate dosage of digoxin leads to the proper therapeutic plasma levels of digoxin, avoiding the unwanted higher plasma levels of digoxin in patients with heart failure or atrial fibrillation.

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Cardiovascular risk factors in patients with chronic renal failure Nine months follow up for cardiovascular disease events

Hippokratia 2004; 8(2):78-80

A Lubomirova, E Andreev, M Stoyanova, N Stoyanova, A, Tzontcheva, R Djerassi, B Kiperova
Nephrology Clinic, University Hospital "Alexandrovska", Sofia, Bulgaria
Cardiology Clinic, University Hospital "Alexandrovska", Sofia, Bulgaria
Clinical Laboratory Dpt, University Hospital "Alexandrovska", Sofia, Bulgaria

Abstract

Background: Cardiovascular morbidity and mortality in patients with chronic renal failure (CRF) is higher than in general population. The consideration that this patients are a " higher risk" group for subsequent cardiovascular disease events is based on detection of multiple cardiovascular risk factors- "traditional" and unique for chronic renal failure.
Material and Methods: We evaluated cardiovascular risk factors (CVF) in patients with CRF and followed them for a 9 month period for clinical presentation of cardiovascular disease.
Seventeen pts were examined -10 F and 7 M, average age 49 years with glomerular filtration rate from 10 to 58 ml/min. Four pts were with primary glomerulonephritis (GN), 4- secondary GN, 2- I type diabetes, 1 -II type diabetes, 2 -chronic pyelonephritis, 2 with hypertensive nephropathy and 3 others - with interstitial nephritis, amyloidosis and Balkan endemic nephropathy each. Elevated blood pressure was detected in all pts. Immunosuppressive therapy was needed in 2 pts with GN.
We examined "traditional" CVF (age, gender, body mass index, smoke, blood pressure, hyperlipidemia, carbohydrate metabolism- diabetes or glucose intolerance) as well as related to CRF CVF (anemia, hyperphosphatemia, left ventricular hypertrophy, hyperhomocysteinemia, hyperinsulinemia, based on the values of IRI, proteinuria and need for pathogenic treatment with steroids.
Results: After 9 month period 7 pts (35%) had coronary incident: 1 -died from myocardial infarction; in 2-ischemic heart disease was manifested by arrhythmia; in other 3-ECG criteria for heart ischemia was detected. All of these patients had moderate or advanced renal failure, diabetes or hyperinsulinemia and were positive for all related to CFR CVF.
Conclusion: In patients with chronic renal disease a straight forward search and correction of the classical and uremia-related cardiovascular risk factors are necessary even at the earliest stages. Primary and secondary prevention of all risk factors will decrease the serious cardiovascular complications in patints with chronic renal failure and will prolong and better their lives.

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The socioeconomic impact of hemodialysis

Hippokratia 2004; 8(2):81-87

D Kaitelidou, P Ziroyanis, N Maniadakis, L Liaropoulos, M Theodorou
Center for Health Services Management & Evaluation, University of Athens, Nursing Division
Nephrology Dpt, "Gennimatas" General Hospital of Athens, Athens, Greece
University Hospital of Rio, Patras, Greece
Hellenic Open University, European Observatory on Health Care Systems of WHO, Greek Hub

Abstract

Background: Hemodialysis is the most widely approach to treat End Stage Renal Disease (ESRD) patients in Greece. The purpose of the paper is to provide a microeconomic evaluation for the cost of dialysis in a public hospital setting, along with an estimate of the loss of production for these patients. Methods: A socioeconomic prevalence-based analysis was performed attempting the micro-economic evaluation of the resources consumed in order to provide hemodialysis therapy for ESRD patients. The loss of production for the patient and family were estimated and the method used was the human capital approach.
Results: It was estimated that the healthsector cost for hemodialysis has surpassed €171 million. The potential years of productivity lost due to mortality were, according human capital approach, 2,046 years leading to a cost of € 9,9 million, in 2000. The total morbidity cost due to absence from work and early retirement was estimated to be more than €273 million.
Conclusions: Results indicate that the total direct cost of hemodialysis constituted approximately 2% of the national health expenditure in Greece, providing care for 0.05% of the population. In addition to the costs imposed on the National Health System, it was estimated that production losses due to mortality and morbidity from the disease are also very significant. Organ-donation campaigns, introduction of satellite units in Greece and telemedicine are some recommendations which may hold some promise for the future and prove more cost-effective and psychologically advantageous for patients.

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Haemopoietic growth factors; brief review

Hippokratia 2004; 8(2):88-92

D Maritsi, A Charalabopoulos, K Charalabopoulos
Physiology Dpt, Clinical Unit, Medical Faculty, University of Ioannina, Ioannina, Greece

Abstract

Circulating blood cells in humans originate from a common pool of multipotential haemopoietic stem cells found in the bone marrow. Multiple steps of cell division, differentiation and maturation are necessary before mature effector cells are released into the circulation. Haemopoietic growth factors stimulate the proliferation of progenitor cells being essential for their survival and contribute to the activation of mature cell function. In this review article we are dealing with some haemopoietic growth factors including stem cell factor (SCF), granulocyte macrophage colony stimulating factor (GM-CSF), macrophage stimulating factor (M-CSF), granulocyte stimulating factor (G-CSF), and interleukin-3 (IL-3). Some of their biochemical characteristics, their physiological role on the blood cell progenitors, their involvement in the genesis of certain diseases as well as their newly presented therapeutic use are discussed in brief.

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