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Background: The only treatment in patients developing liver failure is liver transplantation. According to the Ministry of Health, the number of patients waiting for a liver transplantation is 2141, the average waiting period for liver transplantation is approximately 5 years, and 15-18% of these patients lose their life while waiting for transplantation. In these patients, limitations in daily activities and depression-anxiety are commonly found. The aim of this study was to analyze life quality, depression symptoms, and existence of sexual functional disorders of patients waiting for liver transplantation., Methods: A total of 74 patients, who were registered in Başkent University Hospital between 2015 and 2018, were included into the study. Short Form-36, Beck Depression Inventory, and Arizona Sexual Experiences Scale were applied to 56 patients who approved study., Results: Most of the patients were male (64.3%), and the mean age was 46 (18-64). Short Form-36 scores were low in all patients. The mean Beck Depression Inventory score of patients was found as 18.4 ± 11.3, and they were suffering from moderate depressive symptoms. According to Arizona Sexual Experiences Scale, total mean scores of males was found as 16.3 ± 5.5, and for females, it was 19.5 ± 5.3 with a statistically significant difference (P < .05). It was found that sexual dysfunction mostly had moderate to mild., Conclusion: Depression and sexual dysfunction are common in patients with chronic liver diseases, and their life qualities deteriorate significantly. It is anticipated that evaluation of these patients in terms of psychological issues and sexual dysfunction will increase their quality of life during the organ waiting period and affect their well-being post-transplant.

Objective: To determine the frequency of neuropathic pain (NeP) and potentially related new factors including fibromyalgia, vitamin D and medication use in ankylosing spondylitis (AS) patients., Methods: In total, 102 patients with AS were prospectively enrolled in this study and evaluated for pain severity (visual analog scale, VAS), disease activity (the Bath Ankylosing Spondylitis Disease Activity Index, BASDAI), fibromyalgia and current medication use The presence of NeP was also assessed using the painDETECT questionnaire Blood samples were taken from all patients to analyze serum 25-hydroxyvitamin D and inflammatory marker levels., Results: NeP component 32 (21 [20.6%]; clearly NeP and 11 [10.8%]; mixed NeP) was present in patients with AS Compared to those without NeP, they had significantly higher VAS and BASDAI scores (p=0.022 and 0.003, respectively) In addition, there was a highly significant difference of frequency of fibromyalgia between patients with and without NeP (50.0% vs 5.7%, p<0.001) Vitamin D status and medication use were comparable for patients with and without NeP Logistic regression analysis revealed that only fibromyalgia was a significant predictor of NeP., Conclusion: This study confirmed that about one-third of AS patients have the NeP component In addition, NeP was found to be associated with the frequency of fibromyalgia However, no relation was found between NeP and vitamin D status and medication use in AS., Competing Interests: CONFLICT OF INTEREST No potential conflict of interest relevant to this article was reported., (Copyright © 2021 by The Korean College of Rheumatology. All rights reserved.)

Objectives: Primary abdominal wound closure is performed at the completion of liver transplant in most patients. However, this is not always possible in pediatric recipients. The shortage of size-matched donor organs for pediatric patients means that occasionally it is necessary to use whole livers that are larger than can be accommodated comfortably in the child's abdomen. The present report outlines our experience with temporary patch closure after pediatric liver transplant of the abdominal wall., Materials and Methods: Our team performed the first liver transplant in Turkey in 1988. Since 1988, we have performed 629 liver transplant (336 adult and 293 pediatric) procedures at our center. We evaluated data of 191 liver transplants performed in recipients who were under 10 years of age. Left lateral lobe grafts were used in 169 patients (88%), and whole grafts were used in 22 patients (12%)., Results: Temporary closure with the Bogota bag patch was necessary in 31 transplant procedures (16.2%), 3 of which involved whole livers and 28 of which involved left lateral lobe grafts. The age range of recipients was 5 months to 10 years (median, 30 mo). The temporary abdominal closure technique was preferred in 22 patients because the abdomen could not be closed during surgery., Conclusions: In pediatric patients with difficult abdominal closure after liver transplant, temporary patch closure is the treatment of choice. Our preference has been reinforced silicone sheeting, which allows minimal adhesion formation between the patch and abdominal viscera; in addition, the transparent nature of the material provides a window for inspection of the donor liver.

Objectives: Kidney transplant started at Başkent University Konya Hospital in July 2016. In this study, we compared the causes of brain death and the organ donation rates in our center between 2013 and 2016 versus between 2016 and 2019., Materials and Methods: Patient files and records were analyzed retrospectively. Age, biologic sex, cause of brain death, and organ donation rates of patients diagnosed with brain death were examined and compared., Results: The number of patients who were diagnosed with brain death and became deceased donors at our center increased 4-fold during the period from 2016 to 2019 compared with that shown from 2013 to 2016. In addition, organ donation rates increased to 71.4%, which is much higher than the average in Turkey (24%-28%). Between 2013 and 2016, trauma was the leading cause of brain death (42.8%), whereas between 2016 and 2019 cerebral hemorrhages rose to first place with a rate of 89.3%. In 2018 and 2019, there were 199 and 62 brain deaths, respectively, reported in our organ donation coordination region with an approximate organ donation rate of 25%. In our center, 12 patients were diagnosed with brain death in 2018 and 8 of these patients (66.7%) became donors; 6 brain deaths were diagnosed in 2019, and 4 patients (66.7%) became donors. Since we started kidney transplant at our center in 2016, the number of patients diagnosed with brain death has increased significantly., Conclusions: Establishing a healthy communication with relatives of patients and having a dedicated organ transplant center are important reasons for our much higher organ donation rates compared with the general rate in Turkey. A healthy communication is the most effective way to establish trust with next-of-kin and the general public.

Objectives: Our aim was to evaluate the influence of the localization of right posterior bile duct anatomy relative to portal vein of the donors on posttransplant bile duct complications., Materials and Methods: We retrospectively investigated 141 patients who had undergone living donor liver transplant using right hemiliver grafts. The patients were classified based on the pattern of the right posterior bile duct and divided into infraportal and supraportal types. Clinical donor and recipient risk factors and surgical outcomes were compared for their relationship with biliary complications using logistic regression analyses., Results: The 2 groups were similar according to demographic and clinical features. The biliary complication rate was 23.7% (9/38) in the infraportal group and 47.4% (37/78) in the supraportal group (P = .014). An analysis of risk factors for the development of anastomotic bile leak using logistic regression showed that a supraportal right posterior bile duct anatomy was a statistically significant positive predictor, with odds ratio of 18.905 (P = .012; confidence interval, 1.922-185.967). The distance of the right posterior bile duct from confluence was significantly lower in patients with biliary complications than in those without (mean of 7.66 vs 0.40 mm; P = .044). According to receiver operating characteristic analyses, the cut-off point for the length of right bile duct to right posterior bile duct from the hepatic confluence was 9.5 mm regarding presence of complications., Conclusions: Factors influencing bile duct anastomosis leakage were supraportal-type donor bile duct anatomy and length of the right main bile duct from biliary confluence. Hepatic arterial complications were similarly a risk factor for biliary strictures. Because of the multiple factors leading to complications in living donor liver transplant, it is challenging to group these patients by operative risk; however, establishing risk models may facilitate the prediction of complications.

Objectives: Ureteral complications remain a major source of morbidity and occasional mortality in renal transplant. Among all ureteral complications, leaks are the most frequently encountered in the early posttransplant period. The routine use of a double-J ureteric stent remains controversial, with reported increased incidence of urinary tract infection. Here, we retrospectively compared the efficacy of a double J stent in kidney transplant patients to investigate ureteral complication incidence in our center., Materials and Methods: Our study included 382 kidney transplant patients. At 5 weeks after transplant, the double J stent was removed under sedation. Patients were divided into 2 groups: 125 patients with double J stent placement (group 1) and 257 patients without double J stent placement (group 2)., Results: We observed no significant demographic differences between the 2 groups with regard to patient age (median patient age of 30 y [range, 2-73 y] for group 1; median patient age of 33 y [range, 4-69 y] for group 2), patient sex (30.2% females in group 1, 32.4% females in group 2), and body mass index (median of 25.1 vs 24.9 kg/m2 in groups 1 and 2, respectively). Cold and warm ischemia time for donor organ, delayed graft function, and episodes of acute rejection did not differ significantly between the groups. Urinary tract infection was observed in 25/125 (20.4%) and 50/257 patients (19.2%) in groups 1 and 2, respectively. Urinary leak was present in 8/125 group 1 (6.4%) and 6/257 group 2 patients (2.3%)., Conclusions: A double J stent in ureteral anastomosis was not likely to decrease the frequency of leakage but is likely to reduce the gravity of the complication and the need for reoperation. In addition, the use of a double J stent was not associated with increased urinary tract infections in renal transplant recipients.

Background: In this study, we aimed to investigate the factors causing conversion from laparoscopic appendectomy (LA) to open appendectomy (OA) in patients with acute appendicitis and to investigate the role of preoperative C reactive protein (CRP) and neutrophil ratio in this conversion and determine a cut-off point for these parameters., Methods: Records of patients who underwent LA due to acute appendicitis at our general surgery department between January 2011 and January 2017 were retrospectively evaluated. The preoperative American Society of Anesthesiology (ASA) scores, Alvarado scores, white blood cell count, C-reactive protein level, and neutrophil ratio were evaluated., Results: LA was performed in 394 patients with an initial diagnosis of acute appendicitis. A conversion to OA (cOA) was performed in 17 patients (4.31%). A CRP value of ≥108.5 mg/L and a neutrophil ratio of ≥81.5% were found to be statistically significant for the cOA (p<0.001)., Conclusion: Our study results showed that male gender, age, elevated neutrophil ratio, and CRP value were the main risk factors for cOA in patients who were scheduled for LA due to acute appendicitis.

Objectives: Wilson disease is an autosomal, recessive, inherited disorder of copper metabolism that results in the accumulation of copper in many organs and tissues. This disease is mainly characterized by dysfunction due to copper accumulation in the liver, kidney, brain, cornea, bone, heart, and blood cells. The clinical spectrum is broad in Wilson disease. Asymptomatic Wilson disease may be present, but findings related to the involvement of an individual organ or multiple organ failure can be seen. These findings can include neurologic and neuropsychiatric complications. Our aim here was to examine the neurologic complications and our clinical experience in patients who underwent liver transplant for Wilson disease in our clinic., Materials and Methods: We retrospectively reviewed the medical records of transplant patients with Wilson disease who were seen at Baskent University Faculty of Medicine Transplantation Science between 2005 and 2017. Patient demographics, neurologic complaints, findings from neurologic examinations, and imaging findings were recorded. We also recorded the presence of the Kayser-Fleischer ring, serum ceruloplasmin, 24-hour copper urine levels, and levels of dry copper in liver in each patient., Results: Our study included 19 patients who ranged in age range from 18 to 44 years (mean age of 26 years). Seven of 19 patients (36.8%) had neurologic symptoms, including epileptic seizures in 2 patients (10.5%), encephalopathy in 1 patient (5.2%), tremor in 3 patients (15.7%), and headache in 1 patient (5.2%). The cause of these long-term neurologic complications was the immunosuppressive drugs. Patients with epileptic seizures were provided with seizure control medication (levetiracetam). Tremor did not need treatment., Conclusions: In Wilson disease, neurologic complications can be severe. The most common complication seen in our patients was tremor. Early diagnosis and treatment may slow down neurologic disability.

Objectives: Solid-organ transplant recipients are at an increased risk of developing skin cancer; this risk is due to long-term graft-preserving immunosuppressive therapy, and excessive sun exposure is a major contributing factor to this process. The aim of this study was to evaluate the skin cancer awareness and sun-protective behavior of solid-organ transplant recipients., Materials and Methods: In all, 70 consecutive solid-organ transplant recipients were evaluated regarding knowledge of their increased skin cancer risk and regarding the influence of this knowledge on their sun-protective practices, by applying a questionnaire during their routine check-up visits., Results: Of 70 solid-organ transplant recipients, 38 (54.3%) stated knowledge of hazardous consequences of sun exposure; however, only 28 (40%) had the knowledge of causal relationship between sun and skin cancer development. There were 31 patients (44.3%) who were unable to recall anybody giving any information to them about sun protection, and 40 patients (57.1%) had never visited a dermatology clinic. The 10 solid-organ transplant recipients (14.3%) who used sunscreen creams daily had been undergoing regular dermatologic examination. Regarding sun-protective clothing, only 8 patients (11.4%) had been wearing a suitable hat, long sleeves, and sunglasses when outdoors. There was a statistically significant difference between the groups who had visited a dermatology clinic versus those who had not regarding knowledge of sun protection, the causal relationship between sun exposure and skin cancer, the use of sunscreens, and use of sun-protective clothing (P < .05)., Conclusions: Our data showed that dermatologic examination and education of patients about skin cancer development and sunscreen measures improved the sun-protective habits of solid-organ transplant recipients. Therefore, orderly visits once or twice a year should be strongly advised for this patient population by their medical care providers.

Traumatic external iliac artery dissection after renal transplant is a rare complication, but it should be urgently managed due to its devastating effects on graft and lower limb circulation. External iliac artery dissection is seen more in recipients with diabetes mellitus and comorbid disease. Recipients with external iliac artery dissection should be treated immediately by percutaneus angioplasty or surgical reconstruction. In this study, we reported the management of 2 kidney transplant cases with external iliac artery dissection due to vascular clamping of the artery. External iliac artery dissection was diagnosed by ultrasonography in both cases. After failed percutaneous interventional angioplasty, we reconstructed the external iliac artery dissection surgically and replaced the external iliac artery with polytetra-fluoroethylene grafts in both patients. Both patients were discharged with normal functioning grafts showing 0.9 and 0.8 mg/dL serum creatinine levels at month 3 posttransplant. Close monitoring of recipients after transplant is mandatory for early diagnosis and early management of external iliac artery dissection to prevent graft loss and preserve lower limb circulation. Routine Doppler ultrasonography is an inexpensive and useful tool for early diagnosis in cases of sudden cessation or decrease in urine. In cases of failed percutaneous interventional angioplasty, reconstruction with synthetic vascular grafts can be safely applied in external iliac artery dissection.

Objectives: Although the incidence of bile stones after liver transplant is rare (2%-6%), various complications can occur, including recurrent cholangitis, biliary strictures, graft loss, and patient mortality., Materials and Methods: We retrospectively evaluated bile stone incidence, pathogenesis, and treatment in 352 liver transplant recipients, comparing demographics, transplant indication, blood lipid profile, bile reconstruction technique, postoperative complications, time of diagnosis, and treatment regimens., Results: Of 352 recipients, 18 had bile stones, with 13 of these patients (72.2%) receiving duct-to-duct bile reconstruction, 17 having biliary complications before bile stone development, 7 (38.9%) having biliary stricture, 6 (33.3%) having biliary leakage, 4 (22.2%) having biliary strictures secondary to biliary leakage, and 7 (38.9%) having hepatic artery complications early posttransplant. Previous biliary complications and recurrent cholangitis significantly increased bile stones. Incidence in patients with triglyceride levels > 250 mg/dL was significantly different from those with levels at < 250 mg/dL. Cold ischemia time was significant in those with and without bile stones (P = .001). Three patients (16%) were treated by endoscopic tools, with others (15/18, 84%) treated via percutaneous procedures., Conclusions: Bile stone risk can be greater in those with previous biliary complications, hepatic artery problems, long cold ischemia time, and high cholesterol levels. It can be successfully treated by endoscopic and percutaneous techniques.

DUSG is a useful diagnostic tool for the follow-up of renal transplant recipients. The measurement of intrarenal arterial RI by DUSG has been proven to predict short-term AF. The aim of the study was to evaluate the predictive value of DUSG performed during the early after RTx on long-term AF. Seventy patients were enrolled into study. DUSG was performed at third and seventh days after RTx. Patients were divided into two groups according to rate of recovery of graft function as patients with normal graft function and abnormal graft function. Although the RI values were correlated with the AF early after transplantation, they were not correlated with long-term AF. However, the rate of recovery of graft function at early period after RTx was correlated with creatinine level at first year and with glomerular filtration rate at first year and last visit. Although the RI has no predictive value for long-term AF, the rate of recovery of graft function at early post-transplantation period has predictive value for long-term AF; patients with higher RI values early after RTx should be followed carefully for the development of chronic allograft injury., (© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Since the first successful organ transplant conducted between twins in 1954, kidney transplant has evolved considerably over the past 50 years. Kidney transplant plays an important role in the treatment of end-stage kidney disease to improve the quality of life and prolong the life of patients. Despite significant advances, postoperative medical and surgical complications still represent important causes of morbidity and mortality. Many problems can be avoided through prophylactic correction of abnormalities detected during the preoperative evaluation; however, it is critical that technical mishaps at all stages of the transplant process (donor nephrectomy, benchwork preparation, and implant) be prevented and that careful postoperative monitoring be carried out, including thorough examination by attending physicians. However, despite these advances, surgical complications still present serious problems in kidney transplant recipients.

Ankylosing spondylitis (AS) is a chronic inflammatory disorder that mainly affects the sacroiliac joints and axial skeleton. The aim of this study was to assess serum prolidase level (SPL) and its association with disease activity in patients with AS. This prospective study included 75 AS patients. Thirty age- and gender-matched healthy controls were enrolled. AS patients were considered as active if BASDAI score was ≥4 or inactive if BASDAI score was <4. There were 34 AS patients in the active group and 41 AS patients in the inactive group. Anti-TNF-monoclonal antibody treatment was started in patients in the active group. These active patients were reassessed 6 months later. BASDAI, ASDAS, visual analogue scale, short-form-general health survey questionnaire, C-reactive protein, erythrocyte sedimentation rate and SPL were measured in all AS patients before and after treatment. The SPL was significantly lower in inactive AS patients than in control group, and also, SPL was significantly lower in active AS patients than in inactive patients. All activity parameters were successful in separating active and inactive AS patients. However, the only parameter that could distinguish active patients from inactive patients was prolidase. The optimum cutoff point of SPL to identify patients with active AS was 23.13 ng/mL with sensitivity, specificity, positive predictive value and negative predictive value of 100 %. Serum prolidase level was successful in measuring disease activity and had as high sensitivity and specificity as BASDAI and was superior to other activity parameters.

Objectives: Renal transplant is an important treatment option for end-stage renal disease. A successful kidney transplant improves the quality of life and reduces the mortality risk compared with maintenance dialysis in patients with end-stage renal disease. Several immunologic and nonimmunologic factors are responsible for graft outcomes in renal transplant patients. Our study was performed to evaluate the role of smoking on postoperative pulmonary complications and graft outcomes in renal transplant patients., Materials and Methods: Our study retrospectively analyzed 1740 patients who had renal transplants between 1987 and 2014 at Baskent University. Patients with smoking data were included in the study. Patient demographic, smoking status, comorbid diseases, postoperative pulmonary complications, graft outcomes, and clinical features were recorded. The relation between postoperative pulmonary complications and risk factors was investigated., Results: Our study included 131 adult renal transplant recipients who had smoking data. The incidence of postoperative pulmonary complications was 16% (21 patients) in the first month after surgery. Smoking history was found in 52 patients (39.7%). There was a statistically significant relationship between the presence of atelectasis and smoking history (P = .004). A positive and statistically significant correlation was detected between atelectasis and pack-years smoking (r = 0.424; P = .001). We evaluated graft rejection within 1 month after transplant regardless of being acute cellular or humoral rejection. The relation between smoking history and graft rejection within 1 month after transplant was significant (P = .011)., Conclusions: Renal transplant patients who are smokers have an increased risk for early postoperative pulmonary complications. Furthermore, cigarette smoking contributes to allograft loss in renal transplant patients. Smoking cessation before surgery can reduce the risk of early postoperative complications.

Objectives: Peritoneal dialysis, the preferred long-term renal replacement modality in the pediatric population, can also be used during the post transplant period. Although it is well known that peritonitis or other complications may occur related to the peritoneal dialysis catheter, less is known about complications related to the peritoneal dialysis during the posttransplant period. Our objective was to evaluate the complications related to use of a peritoneal dialysis catheter during the posttransplant period and to determine the optimum time for removal of the peritoneal dialysis catheter., Materials and Methods: We retrospectively analyzed 33 chronic peritoneal dialysis patients. Pretransplant and posttransplant demographics and clinical and laboratory data for each patient were recorded, including incidence of peritonitis and incidence of peritoneal dialysis catheter requirement after transplant., Results: Mean age of patients at transplant was 12.8 ± 4.0 years (range, 3.5-18.0 y). Mean catheter removal time was 81.1 ± 36.2 days (range, 22.0-152.0 d). The peritoneal dialysis catheter was used in 6 of 33 patients (18.2%); none of these patients developed peritonitis. In contrast, 2 of the 27 patients who did not use the peritoneal dialysis catheter developed peritonitis. Our data suggest that the need for catheter use occurs predominantly during the first month, and infectious complications usually happen later., Conclusions: Previously, the trend was to not remove the peritoneal dialysis catheter at the time of transplant. However, in light of recent literature and our present study, we recommend that the time of catheter removal should be modified and decided for each patient on an individual basis.

Primary hyperoxaluria type 1 is an autosomal recessive disorder that is responsible for the overproduction of oxalate and has an incidence of 1 in 120 000 live births. Indications for combined liver and kidney transplant are still debated. However, combined liver and kidney transplant is preferred in various conditions, including primary hyperoxaluria, liver-based metabolic abnormalities affecting the kidney, and structural diseases affecting both the liver and the kidney, such as congenital hepatic fibrosis and polycystic kidney disease. When compared with sequential liver and kidney transplant, the rejection rate of both liver and kidney allografts was reported to be lower than with combined liver and kidney transplant. With proper anesthesia management, the probable increased complications with combined liver and kidney transplant can be prevented. In this report, we present the anesthesia care of a 22-year-old patient with primary hyperoxaluria type 1 who had deceased-donor combined liver and kidney transplant.

Objectives: Neurologic complications occur frequently after liver transplants. Up to 43% of patients experience severe postsurgical neurologic complications. These complications are significantly associated with longer hospital stay, morbidity, and mortality. The aim of this retrospective study was to evaluate the type and incidence of neurologic complications after liver transplants in adult patients., Materials and Methods: We retrospectively evaluated the medical records of 176 adult patients who had undergone liver transplants between 1995 and 2013. We recorded the demographic data, type of neurologic complications, type, and level of immunosuppressive treatment, and cause of liver failure., Results: Our study sample consisted of 48 deceased-donor liver transplants and 128 living-donor transplants (n = 176). Fifty-three of the patients (30.1%) were female. The age range of the total sample was 18 to 66 years (mean age, 43.1 ± 13.7 y). As immunosuppressive treatment, most patients received tacrolimus alone (52%) or tacrolimus combined with mycophenolate mofetil (33%). Neurologic complications occurred in 74 of the patients (42%). The most common neurologic complications were diffuse encephalopathy (22.2%) and seizure (14.2%). Other neurologic complications were posterior reversible encephalopathy (1.7%), peripheral neuropathy (1.7%), cerebrovascular disease (1.1%), and central nervous system infection (1.1%). Age, cause of liver failure, and type of transplant were not associated with occurrence of neurologic complications., Conclusions: There was a high incidence of neurologic complications after liver transplants. Diffuse encephalopathy and seizure were common complications. Physicians should be aware of the high risk of neurologic complications after liver transplants. Factors such as immunosuppressive toxicity and metabolic imbalance that predispose patients to neurologic complications after liver transplants should be evaluated immediately, and treatment of postoperative neurologic complications should be initiated as early as possible.

Objectives: Varicella zoster virus (VZV) is an important pathogen after renal transplant. The aim of this study is to assess the outcome of disseminated Varicella zoster virus infection in renal transplant recipients and to determine potential risk factors for mortality., Materials and Methods: From January 2001 to January 2014, we performed 1614 renal transplants at our institution. Varicella zoster virus infection was diagnosed in 41 patients (2.5%). Median time of diagnosis of Varicella zoster virus was 5 years after transplant (range, 3 mo to 13 y)., Results: Thirty-seven patients (90%) had dermatomal distribution of Varicella zoster virus, 4 patients (10%) had disseminated Varicella zoster virus infection. After diagnosis of Varicella zoster virus immunsuppressive therapy was reduced and patients received acyclovir. Cutaneous lesions were healed with a scar in 7 cases (17%). Two patients (5%) developed postherpetic neuralgia. Seventy percent of cases were diagnosed within 5 years, and 92% were diagnosed within 10 years after transplant. Mortality due to Varicella zoster virus was 2% (n = 1). Visceral involvement found to be a risk factor for mortality. Profilactic acyclovir or gancyclovir therapy following transplantation reduced Varicella zoster virus infection. However, Varicella zoster virus seropositivity did not influence fatal outcome., Conclusions: Early initiation of antiviral therapy may prevent development of complication and visceral dissemination of disease. Active immunization should be applied for all seronegative patients before organ transplant.

Objectives: Primary hyperoxaluria, especially type 1, is a severe disease with multisystem morbidity and high mortality. We present 3 primary hyperoxaluria type 1 patients who underwent liver transplant, including living-donor liver transplant or combined liver and kidney transplant in our institution., Case Reports: Patients who underwent liver transplant or combined liver/kidney transplant at our institution were evaluated, retrospectively. Between January 2002 and 2013, there were 3 patients who underwent transplant for primary hyperoxaluria. All 3 patients had disease onset in childhood, and the definitive diagnosis was established at age < 1, 6, and 8 years. Although early diagnosis was made, primary hyperoxaluria resulted in end-stage renal disease in 2 patients, and hemodialysis was introduced before liver transplant. All 3 patients underwent living-donor liver transplant. Case 1 was a 10-year-old girl who had an uneventful course after living-donor liver transplant, and she received a living-donor kidney transplant from the same donor 4 months after living-donor liver transplant. Case 2 was a 7-yearold boy who was the younger brother of the first patient; he did not have end-stage renal disease or any renal disorder after successful living-donor liver transplant. Case 3 was a 3-year-old boy who was diagnosed at age 2 months with renal disorders; although he was discharged from the hospital after living-donor liver transplant, he was readmitted because of unconsciousness that developed 1 day after discharge, and he died because of intracranial hemorrhage 2 months after liver transplant, unable to receive a kidney transplant., Conclusions: Primary hyperoxaluria is a rare disorder that is difficult to diagnose until end-organ damage is severe. Outcomes may be improved with early and accurate diagnosis, aggressive supportive treatment, and correction of the enzyme defect by liver transplant before systemic oxalosis develops. However, kidney transplant or combined liver and kidney transplant is required in many primary hyperoxaluria type 1 patients because of the delayed diagnosis or long organ waiting time.

Objectives: Seizure is a common complication after liver transplant and has been reported to occur in up to 42% of patients in different case series. Multiple factors can trigger seizures, including immunosuppressive toxicity, sepsis, metabolic imbalance, and structural brain lesions. The aim of this retrospective study was to evaluate seizure types and associated factors in adult liver transplant patients., Materials and Methods: We retrospectively evaluated the medical records of 142 adult patients who received a liver transplant between 2005 and 2013. We recorded demographic data, immunosuppressive treatment, seizure type, cause, recurrence, and treatment., Results: Of the 146 patients, 23 (15.7%) had a seizure after the liver transplant. This group included 10 females and 13 males, with ages ranging between 18 and 63 (39.9 ± 14.8 y). Generalized tonic-clonic seizures were the most common, occurring in 20 patients (87%). We observed complex partial seizure and status epilepticus in 1 and 2 patients. Immunosuppressive drug-related seizure occurred in 8 patients (34.8%) with normal drug blood levels, and all but 1 of these patients experienced seizure within the first week after transplant. Multiple factors (26.1%), metabolic imbalance (17.4%), structural lesion (13%), and sepsis (8.7%) were the other factors identified as underlying conditions., Conclusions: In conclusion, seizure occurred in a significant proportion of patients who underwent liver transplant. Immunosuppressive drugs were the most common factor associated with seizure occurrence and drug cessation prevented seizure recurrence.

Objectives: Liver transplant is an established curative therapy for children with chronic end-stage liver disease or acute liver failure. In this study, we aimed to evaluate pediatric liver transplant in terms of outcomes, complications, and long-term followup results., Materials and Methods: Pediatric patients who had liver transplant in our institution were included. We retrospectively evaluated demographic features including body weight, Child-Pugh score, etiology of liver disease, graft source, perioperative outcomes, perioperative complications, postoperative complications, and long-term results. Outcomes of treatment of complications and revision transplant were evaluated., Results: Between September 2001 and December 2013, there were 188 pediatric liver transplants performed in our institution. Most grafts (90.9%) were obtained from living-related donors. There were 13 patients (6.9%) who had an intervention because of a hemorrhage postoperatively. Biliary leakage was observed in 33 patients (17.5%) and biliary stricture during follow-up was observed in 32 patients (17%). Thrombosis rates in the hepatic artery and portal vein were 12.3% and 0.5%. Revision transplant was performed in 11 patients (5.8%); reason for revision transplant was rejection in 50% patients. The remaining children were alive with good graft functioning after treatment of complications and revision transplant. The overall 5- and 10-year survival rates were 82.3% and 78.9%., Conclusions: The overall outcomes of pediatric liver transplant at our center are very promising. With improved care of younger children and the combined efforts of the parents and medical team, the number of the children receiving transplants will increase in the future.

Objectives: Liver biopsy is a diagnostic tool for liver pathology after liver transplant. However, biopsy can cause life-threating complications. There is limited knowledge about efficacy and complications of liver biopsy after liver transplant. Our aim was to evaluate the risk and benefit of liver biopsy after liver transplant and quality of biopsy specimens., Materials and Methods: We retrospectively analyzed all liver biopsies performed after liver transplant between January 2000 and October 2014. All patients were monitored for minimum 24 hours after biopsy., Results: We performed 245 liver biopsies in 159 liver transplant patients. Fifteen biopsies (6%) were nondiagnostic. In the samples, there were 102 cases (41%) of acute rejection, 79 cases (35%) of cholangitis, and 49 cases (20%) of cholestasis observed. Complications after biopsy were seen in 23 patients (9%) and biopsies. There were 7 patients who had severe abdominal pain followed by fever. We diagnosed 4 patients who had intercostal/subcapsular bleeding and 12 patients who had vasovagal reaction. All patients were treated with analgesic agents and monitored for 24 hours. No blood transfusion or surgery was required., Conclusions: Liver biopsy after liver transplant is an invasive diagnostic tool for liver pathology. However, it can be used safely in experienced centers.

Objectives: Liver transplant currently is the best treatment option for end-stage liver disease. During liver transplant, there is major blood loss due to surgery and primary disease. By using a cell saver, the need for blood transfusion is markedly reduced. In this study, we aimed to evaluate the efficacy of cell saver use on morbidity and mortality in living-donor liver transplant., Materials and Methods: We retrospectively evaluated 178 living-donor liver transplants, performed from 2005 to 2013 in our center. Child-Turcotte-Pugh A patients, deceased-donor liver transplants, and liver transplants performed for fulminant hepatic failure were not included in this study. Intraoperative blood transfusion was done in all patients to keep hemoglobin level between 10 and 12 g/dL. Cell saver was used in all liver transplants except in patients with malignancy, hepatitis B, and hepatitis C., Results: We included 126 patients in the study. Cell saver was used in 84 liver transplants (66%). In 42 patients (34%), liver transplant was performed without a cell saver. In living-donor liver transplant with cell saver use, 10 mL/kg blood (range, 2-50 mL/kg blood) was transfused from the cell saver; in addition, 5 to 10 mL/kg allogeneic blood was transfused. In living-donor liver transplant without cell saver, 20 to 25 mL/kg allogeneic blood was transfused., Conclusions: During liver transplant, major blood transfusion is needed because of surgery and primary disease. Cell saver use markedly decreases the need for allogeneic blood transfusion and avoids adverse events of massive transfusion.

Objectives: To investigate the relationship between enthesitis and disease activity, functional status, fatigue, joint mobility, radiological damage, laboratory parameter and quality of life in patients with ankylosing spondylitis (AS)., Methods: A total of 421 patients with AS (323 male and 98 female) who were included in the Turkish League Against Rheumatism Registry were enrolled in the study. The Bath AS Disease Activity Index (BASDAI), fatigue, the Bath AS Functional Index (BASFI), the Bath AS Metrology Index (BASMI), the Maastricht AS Enthesitis Score (MASES), AS quality of life (ASQoL), the Bath AS Radiology Index (BASRI) and erythrocyte sedimentation rate (ESR) were evaluated., Results: Enthesitis was detected in 27.3% of patients. There were positive correlations between MASES and BASDAI, BASFI and fatigue (p < 0.05). MASES was not correlated with BASRI, BASMI, ASQoL and ESR. The mean MASES score was 1.1 ± 2.4. The most frequent regions of enthesopathies were right iliac crest, spinous process of L5 and proximal to the insertion of left achilles tendon, respectively., Conclusions: Enthesitis was found to be associated with higher disease activity, higher fatigue, worse functional status and lower disease duration. As enthesitis was correlated with BASDAI, we conclude that enthesitis can reflect the disease activity in patients with AS.

Objectives: We sought to assess the incidence of invasive fungal infections and identify the risk factors and outcome of invasive fungal infections in liver transplant recipient., Materials and Methods: A retrospective analysis was made of 408 patients who received a liver transplant between January 1990 to December 2012 at Baskent University in Ankara, Turkey. Only 305 of 408 patients were included. Demographic and clinical findings were reviewed, and these findings were compared between patients with or without invasive fungal infections., Results: Ten of 408 liver transplant patients (2.5%) developed invasive fungal infections. Aspergillus was the most common cause of invasive fungal infections (n=8), followed by Candida (n=1), and Cryptococcus neoformans (n=1). Pulmonary involvement was dominant in all patients (n=10), and only 1 patient had disseminated fungal infection (cryptococcosis). The mean time from transplant to invasive fungal infection diagnosis was 32 ± 19.2 days. Most patients with invasive fungal infection (9/10) died. Mean survival time between diagnosis of fungal infection and death was 24.2 ± 27.3 days in all 10 patients. Fungal infections occurred significantly more frequently in patients with older transplant age, diabetes mellitus, cytomegalovirus infection, renal insufficiency. In addition, other risk factors included long stays in the surgical intensive care unit, the overall length of stay in hospital, and having preoperative high creatinine level., Conclusions: Invasive fungal infections were associated with increased morbidity and mortality among liver transplant recipients, with Aspergillus spp. being the most common pathogen in our series. Because of its high mortality rate, it is important to follow up transplant patients for the development of invasive fungal infections.

Objectives: Acute renal injury is a common complication in liver transplant patients. Acute kidney injury is due to nephrotoxic drugs used after liver transplant, infections, and hemorrhage. Though it is generally reversible, it has effects on grafts and patients survival. In this retrospective observational study carried out at a single center, the effects of acute renal disease on liver recipient's survival were investigated., Materials and Methods: Liver transplant recipients of live-donor and deceased-donor transplants between January 2002 and May 2013 were included in this study; there were 310 liver transplant patients (mean age, 28 y; age range, 6 mo-62 y; 165 males, 145 females). The acute kidney disease diagnosis and staging was based on the nephrology department evaluation and daily serum creatinine levels. Patients with acute kidney injury before undergoing liver transplant and those undergoing a transplant for the second time were excluded. Kidney functions were evaluated by the nephrology department 1 week, 3 months, and 1 year after the liver transplant., Results: Acute kidney disease rates in these patients were 5%, 8%, and 12%. Four patients developed chronic kidney failure during follow-up. The mortality rate was higher (18%) in acute renal failure patients compared with those that did not have acute renal failure. The mortality rate was 11% in patients without acute renal failure., Conclusions: Acute renal injury is common after liver transplant and has an effect on mortality.

Objectives: The incidence of malignancy is higher in solid-organ transplant recipients compared with the general population. In the present study, we present our experience with de novo malignancies encountered after both deceased-donor and living-donor liver transplants., Materials and Methods: We retrospectively reviewed the medical records of 335 patients who underwent an orthotopic liver transplant at our institution between September 2001 and December 2012 to identify subjects with de novo malignancies., Results: Fourteen patients (4.1%) developed de novo malignancies after liver transplant. De novo malignancies included lymphoproliferative disorders after liver transplant in 7 patients (treated with chemotherapy), thyroid papillary carcinoma in 1 patient (treated with total thyroidectomy and radioactive iodine therapy), squamous cell carcinoma in 2 patients (treated with surgical resection), gastric stromal tumor in 1 patient (treated with surgical resection), ovarian carcinomas in 1 patient (treated with radical surgical resection and chemotherapy, who died within 1 year of diagnosis), lung cancer in 1 patient (treated with chemotherapy, but he had bone metastasis and died within 1 year of diagnosis), and neuroblastoma in 1 patient (treated with chemotherapy). In all patients, immunosuppression was changed to sirolimus., Conclusions: Transplant recipients generally have advanced stage cancers at the time of diagnosis with a poor prognosis. Because some neoplasms are common, early detection of cancer is important to decrease cancer-related mortality and morbidity.

Objectives: The overall incidence, causes, and treatment of posttransplant gastrointestinal bleeding, have been previously described. In this study, we examined the causes and treatment of postoperative gastrointestinal bleeding after orthotopic liver transplant., Materials and Methods: Clinical data of 335 patients who underwent an orthotopic liver transplant at our institution between September 2001 and December 2012 were analyzed retrospectively. The diagnosis and treatment of postoperative gastrointestinal bleeding after an orthotopic liver transplant were reviewed., Results: Gastrointestinal bleeding occurred in 13 patients (3.8%) after an orthotopic liver transplant. Five patients (38.4%) were adult and 8 patients (61.6%) were pediatric. The sites of the bleeding were Roux-en-Y anastomosis bleeding in 5 cases, peptic ulcer in 3 cases, erosive gastritis in 3 cases, gastric and esophageal varices in 1 case, and hemobilia in 1 case. These 13 patients with gastrointestinal bleeding were managed with conservative treatment, endoscopic treatment, radiologic interventional embolism, or exploratory laparotomy. No patients died because of gastro--intestinal bleeding. During follow-up, 4 patients died because of sepsis and 1 patient died of recurrence of hepatocellular carcinoma., Conclusions: Gastrointestinal bleeding after liver transplant and its incidence, causes, and treatment are not well-described in the literature. Diagnosis and management of gastrointestinal bleeding requires a multidisciplinary approach involving surgeons, hepatologists, advanced and experienced endoscopists, and interventional radiologists.

Objectives: Locoregional therapy may decrease the tumor stage and enable liver transplant in patients who have hepatocellular cancer. The purpose of the present study was to assess the relation between locoregional therapy and recurrence of hepatocellular carcinoma after transplant., Materials and Methods: In 50 patients who had liver transplant for treatment of end-stage liver disease from hepatocellular carcinoma and cirrhosis, outcomes were evaluated for associations with locoregional therapy before transplant and Milan criteria., Results: Most patients had locoregional therapy before transplant (31 patients [62%]: transarterial catheter radiofrequency ablation alone, 16 patients; chemoembolization alone, 10 patients; both transarterial catheter radiofrequency ablation and chemoembolization, 5 patients). Follow-up at median 90 months after transplant showed that 9 patients (18%) had recurrence at median 45 months (range, 120 ± 12 mo) (recurrence: locoregional therapy, 5 of 31 patients [16%]; no locoregional therapy, 4 of 19 patients [21%]; not significant). Locoregional therapy was associated with a significantly lower frequency of recurrence in patients who were outside the Milan criteria., Conclusions: In patients who have liver transplant for treatment of hepatocellular carcinoma, preoperative locoregional therapy may decrease recurrence in patients who are outside the Milan criteria.

Objectives: The purpose of this study was to evaluate the causes of kidney impairment associated with liver transplant in patients who had kidney biopsy before or after liver transplant., Materials and Methods: In 408 patients who had liver transplant from January 1990 to December 2012, there were 10 patients who had kidney biopsy (total, 19 kidney biopsies) for evaluation of kidney dysfunction. A retrospective review of clinical records and kidney biopsies was performed., Results: There were 7 male and 3 female patients (median age at liver transplant, 43 y; range, 10 to 62 y). The most frequent reason for liver transplant were hepatitis B virus cirrhosis (4 patients). There were 3 patients who had a kidney transplant before or concurrent with liver transplant. Increased serum creatinine level was the most common clinical finding at the time of kidney biopsy. The median interval from liver transplant to kidney biopsy was 495 days (mean, 1025 d; range, 10-4980 d). The most common pathology in the kidney biopsies was immune complex glomerulonephritis (total, 7 patients: IgA nephropathy, 4 patients; lupus nephritis, 2 patients; membranoproliferative glomerulonephritis, 1 patient). There were 4 patients who had allergic tubulointerstitial nephritis, 2 patients who had chronic calcineurin inhibitor nephrotoxicity, and 1 patient who had karyomegalic nephropathy. There were 7 patients who died at mean 34 months (range, 1-70 mo) after liver transplant. The other 3 patients were alive at mean 128 months (range, 67-193 mo) after liver transplant and had a functioning liver graft and chronic kidney disease., Conclusions: Chronic kidney disease after liver transplant has a major effect on mortality. The frequency of immune complex glomerulonephritis associated with liver transplant may be greater than previously recognized.

Introduction: Paroxysmal nocturnal hemoglobinuria (PNH) is a clonal stem cell disorder of hematopoietic cells. Gastrointestinal complications of PNH are rare and mostly related with intravascular thrombosis or intramural hematoma., Presentation of Case: We describe a case of a man with PNH complicated by intramural duodenal hematoma initially treated with supportive care. Three months after his first admission; he was admitted to the emergency department with abdominal pain, nausea and vomiting. He had undergone to surgery because of duodenal obstruction was treated with duodenojejunal by-pass surgery., Discussion: Patients were healed from gastrointestinal complications could suffer from gastrointestinal strictures, which cause wide spread symptoms ranging from chronic abdominal pain and anorexia to intestinal obstruction., Conclusion: We report a rare intestinal obstruction case caused by stricture at the level of ligamentum Treitz with PNH. The possibility simply has to be borne in mind that strictures can be occurring at hematoma, ischemia or inflammation site of gastrointestinal tract., (Copyright © 2014 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Chronic periodontitis (CP) and rheumatoid arthritis (RA) appear to share many pathologic features. Oxygen metabolism has an important role in the pathogenesis of both CP and RA. The aim of this study is to evaluate the relationship between these two chronic inflammatory diseases with regard to antioxidant and oxidant status., Methods: A total of 80 participants were divided into four groups of 20 each: group RA-CP (patients with RA and CP), group RA (periodontally healthy patients with RA), group CP (systemically healthy patients with CP), and group C (periodontally and systemically healthy volunteers) were included in the study. After assessment of periodontal measurements, gingival crevicular fluid (GCF) samples were taken at one incisor, premolar, and molar tooth and stored with serum samples at -80°C for the antioxidant/oxidant assay., Results: Although all clinical measurements in groups RA-CP and CP were statistically higher compared to those of C and RA groups (P <0.001), there were no differences between CP and RA-CP groups (P >0.05). GCF total oxidant status (TOS) values of CP and RA-CP groups were higher than those of the RA group (P <0.05). GCF oxidative stress index (OSI) values of the RA-CP group were higher than those of the RA group (P <0.05). There were no differences among the groups in terms of serum TOS and OSI values (P >0.05)., Conclusions: Local OSI values in groups with patients with CP were higher, whereas systemic OSI values showed no difference among the groups. The presence of RA seems not to affect local and systemic OSI values in patients with CP.

A web-based application patient follow-up program was developed to create a registry of patients with ankylosing spondylitis (AS) by the Turkiye Romatizma Arastirma Savas Dernegi (TRASD) AS Study Group. This study describes the methodological background and patient characteristics. The patient follow-up program is a web-based questionnaire, which contains sections on socio-demographic data, anamnesis, personal and family history, systemic and musculoskeletal examination, laboratory and imaging data and treatment. Between October 1, 2007 and February 28, 2009, 1,381 patients from 41 centers were included in the registry (1,038 males [75.2%]; mean age 39.5 ± 10.7 years). Mean disease duration was 12.1 ± 8.5 years, and mean time from initial symptom to diagnosis was 5 ± 6.8 years (median 2 years). HLA-B27 positivity was detected in 73.7% of 262 patients tested. Manifestations of extraarticular involvement were anterior uveitis (13.2%), psoriasis and other skin and mucous membrane lesions (6%) and inflammatory bowel disease (3.8%). The prevalence of peripheral arthritis was 11.2%. In 51.7% of patients, the Bath AS Disease Activity Index was ≥4. But since our patients consisted of the ones with more severe disease who referred to the tertiary centers and needed a regular follow-up, they may not represent the general AS population. Disease-modifying anti-rheumatic drugs were being used by 41.9% of patients, with 16.4% using anti-TNF agents. TRASD-IP (Izlem Programi: Follow-up program) is the first AS registry in Turkey. Such databases are very useful and provide a basis for data collection from large numbers of subjects. TRASD-IP gives information on the clinical and demographic profiles of patients, and the efficacy and safety of anti-TNF drugs, examines the impact on quality of life, and provides real-life data that may be used in cost-effectiveness analyses.

Objectives: To evaluate quality of life (QoL) and related variables in patients with ankylosing spondylitis (AS), a chronic inflammatory disease of the spine., Methods: Nine-hundred and sixty-two patients with AS from the Turkish League Against Rheumatism AS Registry, who fulfilled the modified New York criteria, were enrolled. The patients were evaluated using the Assessment of SpondyloArthritis International Society core outcome domains including Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), fatigue (BASDAI-question 1), pain (last week/spine/due to AS), Bath Ankylosing Spondylitis Functional Index (BASFI), Bath Ankylosing Spondylitis Metrology Index (BASMI), Bath Ankylosing Spondylitis Radiology Index (BASRI), Maastricht Ankylosing Spondylitis Enthesitis Score (MASES) and two QoL questionnaires (the disease-specific ASQoL and generic the Short Form-36 [SF-36])., Results: The mean ASQoL score was 7.1 ± 5.7. SF-36 subscales of general health, physical role and bodily pain had the poorest scores. ASQoL was strongly correlated with disease duration, BASDAI, fatigue, BASFI, BASMI, BASRI, MASES, pain and SF-36 subscales (P < 0.001). SF-36 subscales were also strongly correlated with BASDAI and BASFI. Advanced educational status and regular exercise habits positively affected QoL, while smoking negatively affected QoL., Conclusions: In patients with AS, the most significant variables associated with QoL were BASDAI, BASFI, fatigue and pain. ASQoL was noted to be a short, rapid and simple patient-reported outcome (PRO) instrument and strongly correlated with SF-36 subscales.