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Background. Polyoma BK virus nephropathy (BKVN) is one of the important causes of graft failure and loss among renal transplant patients. Reduction of immunosuppression is the most important preferred treatment approach; however, there is no agreed protocol for additional treatments. Objective. Our aim was to investigate the effects on graft survival of intensive treatment protocols for BKVN among renal transplant patients. Methods. 214 patients were included in the study. All patients underwent investigation for the presence of BKV in plasma samples every 3 months starting from the third month after transplantation. Biopsies were obtained upon detection of graft dysfunction or viremia. If BKVN was positive, viremia was investigated monthly. Results. Plasma plus biopsy-proven BKVN were detected in 19 patients (8.9%), whose mean age was 45.8 12.0 years; 68.4% (n 13) were male and 94.7% (n 18) were recipients of a living-donor kidney. There were 5.2% (n 1) diabetic subjects, and the mean time prior to dialysis was 39.6 44.8 (3–125) months. BKVN was observed at a mean of 6.8 2.9 (4 –14) months after the transplantation. It positively correlated with the baseline serum creatinine level (r 0.159; P .02), application and cumulative dose of antithymocyte globulin (r 0.177; r 0.165; respectively; P .01), mean tacrolimus dose (r 0.303; P .001), and hepatitis B virus positivity (r 0.169; P .01). Immunosuppression was decreased in all patients who developed BKVN. In addition, leflunomide was applied in 68%, intravenous immunoglobulin in 74%, and cidofovir in 32% of patients. Acute rejection rates did not increase significantly after lowering immunosuppression (P .05). Conclusion. BKVN is one of the important problems in renal transplant patients. Intensive treatment of BKVN with heterogeneous regimens, including combined treatment with leflunamide IVIG together with immunosuppressive dose reduction, was an effective approach to prolong graft survival.

Chronic renal failure (CRF) patients are at increased risk of tuberculosis. Detecting latent tuberculosis infection is essential before transplantation. The tuberculin skin test is the only validated method for the diagnosis of latent tuberculosis infection and for screening for hypersensitivity. The aim of this study was to assess the tuberculin test status (5 Todd units tuberculin) of 164 asymptomatic transplant candidates and correlate it with anamnestic data and laboratory values of patients awaiting transplantation. Skin test positivity was higher among older age subjects (r = .294, P = .0001). The cumulative prevalence rates of tuberculin positivity and anergy were 42.1% (69 patients) and 43.3% (71 patients), respectively. Only 14.5% of the positive patients had a previous tbc history; 15.9% had a family history of tbc. Among peritoneal dialysis (PD) patients, the rate of anergic skin tests was higher, while positivity was higher among patients who were preparing for preemptive renal transplantation (P = .009). In conclusion, there was a high prevalence of tuberculin positivity and anergy among asymptomatic pretransplant CRF patients. CRF patients who are awaiting transplantation especially should meet evaluations for previous tbc anamnesis and family history. Elderly subjects showed a higher risk for purified protein derivate positivity.

Chronic allograft nephropathy (CAN) represents the cumulative and incremental damage to nephrons by time-dependent immunologic and nonimmunologic causes. Hyperlipidemia is one nonimmunologic mechanism that promotes injury and poor function in a renal transplant. The aim of our study was to determine the effect of lipid profiles on CAN among renal transplant recipients. We retrospectively evaluated 53 renal transplant recipients who were classified according to the presence of CAN: CAN+ = 28 (18 males, 10 females) constituted the study group, whereas those with stable graft function CAN− = 25 (14 males, 11 females) were the control group. Biochemical parameters included serum urea, creatinine, total cholesterol, triglyceride, HDL cholesterol, LDL cholesterol, apolipoprotein A1 (ApoA1), apolipoprotein B (ApoB), lipoprotein (a), homocysteine, and high-sensitive CRP (hs CRP). Angiotensin-converting enzyme inhibitor (ACEI) and/or angiotensin receptor blocker (ARB) use was significantly greater among the CAN+ group compared with the controls (P = .02, P = .04). Also, higher serum creatinine levels were observed in the CAN+ group (1.49 vs 1.22 mg/dL, P = .002), whereas serum levels of total cholesterol, triglyceride, hs CRP, and albumin were similar in both groups. The levels of ApoA1, ApoB, and lipoprotein (a) were similar, whereas the LDL/HDL cholesterol ratio and homocysteine levels were significantly higher in the CAN+ group (P = .04, P = .04). In conclusion, the LDL/HDL ratio may have a positive impact on CAN and may be used as a parameter during patient follow-up.

Hepatitis C virus (HCV) infection is the main cause of chronic liver disease after renal transplantation, which represents a risk factor for graft loss and patient death. Hepatitis C (+) kidney transplant candidates who remain on the waiting list show a greater risk of mortality than those who are transplanted, a risk that escalates with time. The aim of this study was to examine the impact of HCV infection on patient and allograft survival in our transplant population. Among 90 renal transplant patients transplanted between 1991 and 2002 who were retrospectively analyzed, 45 were HCV-positive and 45 HCV-negative by serology. All positive patients had shown positive HCV antibody and/or positive HCV RNA. The mean ages of the patients were 36.2 ± 9 years among the HCV (+) and 38 ± 10 years among the HCV (−) patients ( P = .31). Eighteen HCV (+) patients and 14 HCV (−) patients received their grafts from deceased donors. The immunosuppressive protocols were similar in both groups. The number of acute rejection episodes were 13 (30%) in HCV (+) and 6 (13%) in the HCV (−) group ( P = .006). Diabetes mellitus developed in 10 (23%) HCV (+) and 7 (16%) HCV (−) patients ( P = .04). Cytomegalovirus disease occurred in 5 (16%) HCV (+) and 2 (6%) HCV (−) patients ( P = .32). The mean serum creatinine was 1.85 ± 1.1 mg/dL in HCV (+) and 1.8 ± 1 mg/dL in HCV (−) group ( P = .82). The mean graft survivals were 97.1 ± 52 months in the HCV (+) and 81.1 ± 37 months in the HCV (−) group ( P = .04). Seven HCV (+) patients (16%) and three HCV (−) patients (6%) lost their grafts ( P = .04). Advanced cirrhosis developed in three HCV (+) patients (6%). One patient died in the HCV (+) group. Patient survivals were 98% in the HCV (+) and 100% in the HCV (−) cohorts. In this study, the rate of graft loss was higher in HCV (+) patients, whereas the patient survival was similar.

Purpose Taking in consideration the opinion of our team, which necessitates obligation of a relative relation between donors and recipients (genetic or matrimonial), we performed donor exchanges as an ethical alternative in living donor transplantations. We reviewed the outcomes of our exchange series. Methods Between July 2003 and August 2010 we performed 110 exchange donor transplantations in four hospitals: one four-way, two three-way, and 100 two-way cases. Donors were mostly spouses ( n = 71) or mothers ( n = 15). The mean age of the donors was 48.8 (range = 23–69) and the recipients 41.4 years (range = 5–66). Two were transplanted preemptively and the others had a mean dialysis duration of 43 months (range = 1–120). Results Among 110 patients, three compatible pairs joined the group voluntarily; 71, due to ABO incompatibility and 36, due to crossmatch positivity. Induction therapy was used in 92 patients. HLA mismatches (MM) were: one MM in three; two MM in three; three MM in 18, four MM in 36; five MM in 34; and six MM in 18. Among 90 patients tested for panel-reactive antibodies PRA, five showed class I and 10, class II positivity. In 11 patients, B-cell positivity was detected by flow cytometry. Delayed graft function ( n = 2), acute rejection ( n = 11), BK virus infection ( n = 1), and cytomegalovirus infection ( n = 3) were seen postoperatively. Three (2.7%) patients died due to sepsis. Five patients returned to dialysis program due to interstitial fibrosis tubular atrophy (IFTA) ( n = 2), renal vein thrombosis ( n = 1), de novo glomerulopathy ( n = 1), or primary nonfunction ( n = 1). The 1- and 5-year patient and graft survival rates were 96% and 96%, 95% and 89%, respectively. Conclusion We believe that exchange donor transplantation is as successful as direct transplants; it is a good, ethical alternative to unrelated living transplantations.

Background. Hepatitis B virus (HBV) and hepatitis C virus (HCV) infections are the most important causes of chronic liver diseases among end-stage kidney disease patients. Our aim was to evaluate the influence of HBV and HCV infections on patient and allograft outcomes after successfull kidney transplantation. Patients and Methods. We retrospectively analyzed 592 kidney transplantations performed between December 2008 and August 2010. We compared patient and graft survivals as well as age, gender, immunosuppression status, pretransplant dialysis duration, chronic allograft dysfunction, and causes of death. Results. Thirty-two patients (5.4%; group 1) were positive for HCV antibody, whereas 16 (2.7%) were positive for hepatitis B surface antigen (HBsAg) (group 2). Two patients (0.3%) were positive concurrently for both HCV antibody and HBsAg. Five hundred forty-two patients (91.6%; group 3) were negative for both. Patients were divided into groups with respect to viral infection. The groups were analyzed for age, gender, immunosuppression, pretransplant dialysis duration, chronic allograft dysfunction, and causes of death, as well as patient and graft outcomes. There were no differences in patient and graft survivals among the groups. None of the patients showed signs of hepatic failure. No patient or graft loss was observed among hepatitis groups when compared with disease-free patients. Conclusion. Graft and patient survivals were not influenced by HBV and/or HCV infections. HBV and HCV infections are not contraindications for kidney transplantation.

Sirolimus (SRL) is a new, potent immunosuppressive agent. More recently, proteinuria has been reported as a consequence of sirolimus therapy, although the mechanism has remained unclear. We retrospectively examined the records of 25 renal transplant patients, who developed or displayed increased proteinuria after SRL conversion. The patient cohort (14 men, 11 women) was treated with SRL as conversion therapy, due to chronic allograft nephropathy (CAN) (n = 15) neoplasia (n = 8); Kaposi’s sarcoma, Four skin cancers, One intestinal tumors, One renal cell carsinom) or BK virus nephropathy (n = 2). SRL was started at a mean of 78 ± 42 (15 to 163) months after transplantation. Mean follow-up on SRL therapy was 20 ± 12 (6 to 43) months. Proteinuria increased from 0.445 (0 to 1.5) g/d before conversion to 3.2 g/dL (0.2 to 12) after conversion (P = 0.001). Before conversion 8 (32%) patients had no proteinuria, whereas afterwards all patients had proteinuria. In 28% of patients proteinuria remained unchanged, whereas it increased in 68% of patients. In 40% it increased by more than 100%. Twenty-eight percent of patients showed increased proteinuria to the nephrotic range. Biopsies performed in five patients revealed new pathological changes: One membranoproliferative glomerulopathy and interstitial nephritis. These patients showed persistently good graft function. Serum creatinine values did not change significantly: 1.98 ± 0.8 mg/dL before SRL therapy and 2.53 ± 1.9 mg/dL at last follow-up (P = .14). Five grafts were lost and the patients returned to dialysis. Five patients displayed CAN and Kaposi’s sarcoma. Mean urinary protein of patients who returned to dialysis was 1.26 (0.5 to 3.5) g/d before and 4.7 (3 to 12) g/d after conversion (P = .01). Mean serum creatinine level before conversion was 2.21 mg/dL and thereafter, 4.93 mg/dL (P = .02). Heavy proteinuria was common after the use of SRL as rescue therapy for renal transplantation. Therefore, conversion should be considered for patients who have not developed advanced CAN and proteinuria. The possibility of de novo glomerular pathology under SRL treatment requires further investigation by renal biopsy.

Kidney transplantation has become the treatment of choice for end-stage renal disease. However, its application is limited due to inadequate organ supply, mainly because many dialysis patients do not have suitable living donors. The increasing discrepancy between organ supply and demand has forced many transplant centers to consider using organs procured from marginal donors. The aim of this study was to investigate whether utilization of kidneys from living related elderly donors is safe for the recipients in the long term. We analyzed the clinical results of 296 consecutive recipients of living related renal transplants, among whom 44 recipients received kidneys from donors over 60 years of age. By the end of 12 months, the mean serum creatinine level of the recipients who were transplanted from the older donors was higher (1.55 +/- 0.45 mg/dL) than that from other donors (1.21 +/- 0.3 mg/dL), but the difference was not significant (P = .08). In the long term (60 months), the graft function was similar (1.88 +/- 0.55 vs 1.52 +/- 0.38) for both groups. The similarity in outcomes of ideal versus older donors as shown less in the present series has encouraged us to utilize elderly living donors. We concluded that transplantations performed from the elderly donors yielded similar results to those of conventional donors. The long waiting list for transplantation, the treatment of choice for end-stage renal disease, should encourage us to be more flexible about donor selection.

Aim This retrospective report analyzed the demographic features of kidney transplant outpatients grafted in Turkey and in different regions of the world. Methods The patients were divided into 4 groups: 1 functional grafts (n = 432) 2 graft losses (n = 218) 3 deaths (n = 135) 4 lost to follow-up (n = 70) Every cohort was subgrouped as either receiving a cadaveric (CT) or a live donor transplant (LT) performed in our institute (ICT, n = 147, ILT, n = 304), other institutions in Turkey (TCT, n = 16, TLT, n = 86), or in a foreign country (FCT, n = 66, FLT, n = 154). Results Among the patients with functional grafts, FLT transplantations, of which the vast majority were paid transplantations, constituted the second largest group (n = 105) following ILT (n = 214). In the ILT group, 5- and 10-year graft survival rates were 76% and 50%, respectively, and patient survival rates were 88% and 78%, respectively. Considering the FLT group, 5- and 10-year graft survival figures were 70% and 42%, respectively, while patient survival rates in these periods were 81% and 69%, respectively. Patients with paid donor transplantations were characterized by a high risk of unconventional infectious complications in the early period, while midterm patient and graft survival was somewhat better than expected considering the high rate of complications in the early period. Conclusions Paid organ transplantation should be discouraged. Organ donation should be stimulated by every means to avoid potentially fatal unconventional infections after transplantation from paid donors. If patients receive a paid transplant, however, they should be closely followed for these complications, since, if they survive the early period the midterm and long-term outcomes are quite reasonable.

FAMILIAL Mediterranean fever (FMF) is an autosomal recessive disorder, common in some ethnic groups such as Sephardic Jews, Armenians, Turks, and Arabs. The disease is characterized by recurrent attacks of fever associated with serositis affecting the pleura, peritoneum, and/or large joints as well as systemic amyloidosis of the AA type causing nephropathy and end-stage renal failure (ESRF). There is a wide variation in the reporting of this disease as a cause of ESRF. Among the member countries of European Dialysis and Transplantation Association (EDTA), amyloidosis was responsible 1.6% of all ESRF patients. In 76% of these patients, chronic inflammatory diseases were the underlying etiology for amyloidosis, and FMF was the second cause. Most of the FMF patients were localized to Egypt, Israel, and Turkey. Even a lower incidence (0.3%) of amyloidosis as a cause of ESRF has been reported from the United States; however the underlying etiology of these cases was not defined in this report. In contradistinction, amyloidosis represents a more common cause of chronic renal failure among patients from the Middle East and the Mediterranean countries; and FMF has been identified as the most frequent underlying cause for the disease in these groups. Indeed, FMF amyloidotic patients represent 6% of the candidates for renal transplantation in Israel. In Turkey 4.2% of ESRF patients suffer from amyloidosis, although the underlying etiology was not identified in this report. Thus, at least in some countries, amyloidosis is an important etiologic factor for ESRF. As most of the patients with renal amyloidosis progress to ESRF, the selection of the renal replacement therapy modality (ie, hemodialysis, peritoneal dialysis, or renal transplantation) is a major concern. It has been reported that amyloidotic patients maintained on chronic hemodialysis experience higher rates of morbidity and mortality when compared to dialysis patients whose causes of ESRF were due to other diseases. There is not enough information regarding the patients on chronic peritoneal dialysis; because the effects of repeated peritoneal inflammation on peritoneal permeability has not been well defined. Considering kidney transplantation, many authors have concerns, because amyloidosis is a generalized disorder and most patients show systemic manifestations of the disease. There are four concerns when considering these patients for transplantation.

Hormonal abnormalities in male patients with end-stage renal diseases are primarily organic and related to uremia as well as the other comorbid factors that frequently contribute to chronic renal failure and concomitant drug administration. The restoration of hormonal profiles after successful renal transplantation is still controversial. Immunosuppressive drugs may influence hormonal profiles. Our cross-sectional study of 37 male kidney transplant recipients investigated two groups according to their calcineurin inhibitor therapy, namely 21 cyclosporine versus 16 tacrolimus patients. The two groups were matched for age, graft function, mean duration of dialysis before transplantation, and duration of follow-up after transplantation. There was no statistical significant difference in baseline circulating levels of follicle-stimulating hormone (FSH), luteinizing hormone (LH), testosterone (TTE), and prolactin (PRL) between the two groups. We found that calcineurin inhibitors have favorable effects on sexual hormone levels of male renal transplant patients and that there is no difference in baseline hormone levels between cyclosporine- and tacrolimus-treated male patients.