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Due to organ shortage and difficulties for availability of cadaveric donors, living donor transplantation is an important choice for having allograft. Live donor surgery is elective and easier to organize prior to starting dialysis thereby permitting preemptive transplantation as compared to cadaveric transplantation. Because of superior results with living kidney transplantation, efforts including the usage of "Medically complex living donors" are made to increase the availability of organs for donation. The term "Complex living donor" is probably preferred for all suboptimal donors where decision-making is a problem due to lack of sound medical data or consensus guidelines. Donors with advanced age, obesity, asymptomatic microhematuria, proteinuria, hypertension, renal stone disease, history of malignancy and with chronic viral infections consist of this complex living donors. This medical complex living donors requires careful evaluation for future renal risk. In this review we would like to present the major issues in the evaluation process of medically complex living kidney donor. [ABSTRACT FROM AUTHOR]

Gorgulu N, Yelken B, Caliskan Y, Elitok A, Cimen AO, Yazici H, Oflaz H, Golcuk E, Ekmekci A, Turkmen A, Yildiz A, Sever MS. Endothelial dysfunction in hemodialysis patients with failed renal transplants. Clin Transplant 2009 DOI: 10.1111/j.1399-0012.2009.01160.x © 2009 John Wiley & Sons A/S. Endothelial dysfunction (ED) is a common precursor and denominator of cardiovascular events including development of atherosclerosis. In this cross-sectional study, we aimed to investigate ED, measured by coronary flow reserve (CFR) in hemodialysis (nHD) patients who were never transplanted and patients with failed renal transplants restarting hemodialysis (fTx-HD). Methods: Forty nHD (24 males, mean age 39 ± 9 yr) and 43 fTx-HD patients (27 males, mean age 36 ± 9 yr) were included in the study. Clinical and biochemical parameters, including high-sensitive C-reactive protein (hs-CRP) levels were determined. Also, CFR measurements were used to evaluate ED. Results: There were no significant differences regarding age, gender, smoking status, systolic and diastolic blood pressure levels, mean duration of HD treatment as well as Kt/V(urea) values between the two groups. Time spent on dialysis in the nHD group and dialysis duration following failure of renal allograft in the fTx-HD group were similar. Serum creatinine, hemoglobin, hematocrit, calcium and phosphorus levels were similar between the two groups as well. When compared to nHD group, serum total cholesterol (139 ± 3 vs. 154 ± 3 mg/dL, p = 0.045), serum albumin (3.8 ± 0.3 g/dL vs. 4.1 ± 0.2 g/dL, p < 0.0001) and CFR (1.60 ± 0.2 vs. 1.75 ± 0.3, p = 0.028) levels were significantly lower, while serum hs-CRP levels (11 ± 15 mg/L vs. 3 ± 4 mg/L, p = 0.001) were significantly higher in the fTx-HD group. Serum hs-CRP negatively correlated (r = −0254, p = 0.021), while serum albumin positively correlated (r = 0402, p = 0.001) with CFR values. Conclusion: ED is more prominent in fTx-HD than the nHD patients. Inflammation, caused by failed renal allograft can be responsible for this abnormality. [ABSTRACT FROM AUTHOR]

Background. In previous studies, the oral and dental health statuses were compared in hemodialysis (HD) and peritoneal dialysis (PD) patients without taking into account the effect of educational levels on oral health. Hence we aimed to make a comparison of these parameters based upon the subjects educational levels. Patients and Methods. 76 PD (33 males, 43 females-mean age: 44±12 years) and 100 HD (56 males, 44 females-mean age: 46 ± 14 years) patients were included. The number of decayed, missing and filled teeth were detected, DMFT index was calculated and plaque index (PI) values were assessed. Results. Significantly higher numbers of filled teeth (P < .001) and lower PI values (P < .01) in the PD group were detected with higher educational levels, whereas no significance was detected in the HD group. Higher DMFT index values were assessed in the lower educated and high school levels in PD than HD patients (P < .05). Higher numbers of filled teeth (P < .05) were detected in the secondary school level in PD patients. This difference was even more significant in the high school level (P < .001). Conclusion. We assume that PD patients, who were found to be in a higher educational level, are more caring for their oral health as compared to HD patients. [ABSTRACT FROM AUTHOR]

The assessment of coronary flow reserve (CFR) by trans-thoracic echocardiography has recently been introduced into clinical studies. Impairment of coronary microvascular functions and decreased CFR detected by trans-thoracic Doppler harmonic echocardiography (TTDE) has recently been reported in hemodialysis (HD) patients, but there is no comparative study between HD patients and renal transplant recipients. Methods: The aim of our study was to evaluate coronary microvascular circulation in chronic HD patients and renal transplant recipients. Forty-eight chronic HD patients, 27 renal transplant patients and 39 normotensive healthy controls were studied for the assessment of CFR by TTDE. The carotid artery intima media thickness (IMT) and areas of focal plaque formation were also evaluated in all subjects. Results: CFR values were significantly lower in both the HD and renal transplant groups than in the control group (p = 0.00). CFR values (1.57 ± 0.32 vs. 1.89 ± 0.50, p = 0.01) were also significantly lower in the HD group than in the renal transplant group. In 43 of 48 (89.6%) HD patients, CFR was <2.0; however, in 16 of 27 (59.3%) renal transplant recipients it was <2.0 (p = 0.00). When the HD and renal transplant groups were divided into two subgroups, according to CFR measurements (CFR < 2 and ≥2), no significant differences were found with respect to coronary risk factors and left ventricular echocardiographic measurements. The IMT of the control group (0.586 ± 0.163 mm) was significantly lower than the HD (0.799 ± 0.218 mm) and renal transplant groups (0.681 ± 0.148 mm; p = 0.00). The IMT of the HD patients (0.799 ± 0.218 mm) was significantly higher than the renal transplant recipients (0.681 ± 0.148 mm; p = 0.01). Conclusions: Renal transplant and HD patients had lower CFR values detected by TTDE, which may be regarded as an early finding of an affected cardiovascular system. CFR is more impaired in HD patients than renal transplant recipients. Uremia-associated microvascular disease may be responsible for CFR impairment in HD patients. [ABSTRACT FROM AUTHOR]

Oflaz H, Pusuroglu H, Genchallac H, Demirel S, Bugra Z, Sever MS, Yildiz A. Endothelial function is more impaired in hemodialysis patients than renal transplant recipients. Clin Transplant 2003: 17: 528–533. © Blackwell Munksgaard, 2003 Endothelial dysfunction (ED) is a common precursor and denominator of cardiovascular events including development of atherosclerosis. In this cross-sectional, controlled study, we aimed to investigate ED measured by ischemia-induced forearm vasodilatation in chronic hemodialysis (HD) patients and renal transplant recipients (rTX). Thirty-nine HD patients, 39 rTX and 38 normotensive healthy controls were included. There was no difference in age and gender distribution among the study groups. The mean time spent on dialysis and transplantation were 74 ± 46 and 68 ± 39 months. Serum high sensitive C-reactive protein (hs-CRP) and plasma fibrinogen levels were measured. Endothelium dependent post-ischemic vasodilatation of brachial artery was used to evaluate ED. The hs-CRP and plasma fibrinogen levels were significantly increased in HD patients when compared with rTX. On high resolution ultrasonographic examination, post-ischemic vasodilatation values in HD patients (9.55 ± 6.47%) were significantly lower than rTX (14.39 ± 8.06%, p = 0.007) and controls (20.42 ± 6.10%, p < 0.001). Renal transplant recipients also had significantly lower post-ischemic vasodilatation values than controls (p = 0.001). The hs-CRP levels were negatively correlated with endothelium-dependent dilatations in TX (r = −0.59, p = 0.001), however, this correlation was not detected in HDp. Patients with end-stage renal disease have ED. Endothelial function is more impaired in HD patients than rTX. Different mechanisms might be responsible for ED in HD patients and rTX. [ABSTRACT FROM AUTHOR]

Abstract: Background: In this prospective-controlled study, we aimed to investigate the effect of changes in insulin resistance and anthropometrical parameters on serum leptin levels (SLL) after renal transplantation (Tx). Patients and methods: Thirty-four patients (M/F: 19/15, mean age: 29 ± 9 yr) and 30 age and sex-matched healthy controls (C) were included. Body weight, subscapular, suprailiac, periumbilical, biceps and triceps skinfold thicknesses, neck, wrist, hip and waist circumferences, as well as body mass index and body fat mass were measured as anthropometrical parameters. In order to measure the serum glucose, insulin and SLL, blood samples were obtained before and 1 wk, 1 and 6 months after Tx. Homeostasis Model Assessment (HOMA) values were calculated as an index of insulin resistance. Results: Serum leptin levels (SLL) of the patients at pre-Tx were significantly higher than C (21.5 ± 3.5 vs. 7.8 ± 0.9 ng/mL, p = 0.002) and decreased at first week after Tx (from 21.5 ± 3.5 to 8.4 ± 1.5 ng/mL, p < 0.001). Thereafter, it gradually increased to 12.8 ± 2.1 ng/mL in the first month and to 14.4 ± 2.1 ng/mL in the sixth month after Tx. Serum leptin levels at sixth month were significantly higher than C (p = 0.005). Serum insulin and HOMA values changed similar to SLL after Tx. Correlations between SLL and HOMA persisted during the study period [pre-Tx (r: 0.40) and at first (r: 0.38) and sixth (r: 0.47) months]. In linear regression analysis, HOMA and fat mass were found as independent variables for predicting SLL at the sixth month after Tx. Conclusion: Serum leptin levels dramatically decreased immediately after Tx and significantly correlated with serum insulin levels and HOMA during the entire study. Increase in SLL at sixth months was probably because of increase in fat mass, insulin resistance and steroid use in renal transplant recipients. [ABSTRACT FROM AUTHOR]

Background. Chronic allograft dysfunction (CAD), the major cause of the failure of kidney allografts, may be caused by immunological and non-immunological haemodynamic factors. Renin–angiotensin system has been implicated in the development of intraglomerular hypertension and has a central role on progression in chronic renal disease. Polymorphism in 16th intron of the ACE gene has been reported to predict the circulating angiotensin II levels. The aim of this study was to investigate the effect of the both recipient and donor angiotensin converting enzyme (ACE) genotype on the development of CAD in renal allograft recipients. Patients and methods. A total of 143 renal transplant recipients (95 male, 48 female, mean age 32 ± 10 yr) were included. In order to exclude the effect of cold ischaemia, only patients transplanted from living donors were selected. Factors analysed in the development of CAD were donor and recipient age, past history of acute rejection, presence of hypertension and hypercholesterolaemia, serum uric acid level and ACE gene polymorphism. Results. Forty of the patients (28%) had CAD. Homozygous deletion type ACE gene polymorphism was detected in 59 renal transplant recipients (42%) and in 31 donors of the patients (37%). On comparing patients with and without CAD, donor age, rate of acute rejection and hypertension and serum uric acid levels were significantly higher in CAD (+) groups. Neither recipient nor donor ACE genotype was associated with time to CAD. Cox regression analysis revealed donor age (p < 0.001), presence of hypertension (p=0.002) and serum uric acid levels (p=0.009), but neither donor nor recipient ACE genotype as independent factors for predicting development of CAD. Conclusion. Donor age, presence of hypertension and serum uric acid levels was independent factors. Donor and recipient ACE genotype seemed to have no influence on the development of CAD in living donor transplanted patients. [ABSTRACT FROM AUTHOR]

SUMMARY: In this controlled study, systolic time intervals (STI) and diastolic functions were investigated in haemodialysis patients (HDp) with ejection fraction (EF) within normal limits. Echocardiographic findings in 86 HDp (M: F, 47:39, mean age 36 ± 13 years) and 51 healthy controls (M: F, 22:29, mean age 37 ± 10 years) were compared for STI parameters (prejection period (PEP), left ventricular ejection time (LVET) and STI index (PEP/LVET)) and diastolic dysfunction (isovolumetric relaxation time (IVRT) and E/A ratio and deceleration time). The pre-ejection period (114 ± 21 vs 94 ± 4 msec, P < 0.001) and STI index (0.41 ± 0.11 vs 0.34 ± 0.02, P < 0.001) were higher in the HDp compared with controls. Increased STI index and prolonged PEP in HDp were independent of left ventricular (LV) hypertrophy and hypertension. Diastolic dysfunction was present in 61% of the patients. The IVRT were also found to be longer in HDp compared with controls (97 ± 16 vs 75 ± 16 msec, P < 0.001), independent of the presence of LV hypertrophy or hypertension. Diastolic dysfunction indicated by IVRT > 100 msec and latent systolic dysfunction (STI index > 0.4) were randomly distributed, with nearly half (48%) of the patients with prolonged IVRT having an STI index within the normal limits and the other half of the patients with deteriorated STI index having a normal IVRT. The combined systolic and diastolic dysfunction was observed in 30% of the patients. It was concluded that STI indexes deteriorate before an overt systolic dysfunction (normal EF), and that systolic and/or diastolic dysfunction of the myocardium may appear singly or simultaneously because of a common pathogenetic mechanism of myocardial fibrosis. [ABSTRACT FROM AUTHOR]