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Background Cirrhotic patients have impaired hemostasis with variable incidence of hypersplenism necessitating splenectomy. Rotation thromboelastometery (ROTEM) facilitates diagnosis and guides management. This study evaluates perioperative effects of desflurane versus propofol on hemostasis in cirrhotic patients undergoing splenectomy guided by ROTEM and laboratory hemostatic tests. Methods Thirty hepatic Child A patients, ASA II- III, of either sex, aged 25–55 years, undergoing splenectomy were randomly allocated into two equal groups: Group D; anesthetized with desflurane 1 MAC (6%) and Group P; with propofol Target Controlled Infusion 2–5 µg/ml. Six blood samples were collected; preoperatively, after splenic artery ligation, immediately, first, third postoperative day then one month later. The samples were handled to measure complete blood picture, liver and kidney functions, screening coagulation tests (INR, PT and PTT), specific hemostatic factors (P-Selectin/CD62P, fibrinogen and D-dimer) as well as ROTEM criteria; clotting time (CT), clot formation time (CFT) and maximum clot firmness (MCF) via EX-TEM, IN-TEM and FIB-TEM commercial kits. Results This study displayed postoperative hemoglobin reduction; however, platelet and WBCs as well as CT, CFT and MCF increased versus baseline. Screening and specific hemostatic factors as all other changes were within reference range and comparable between both groups. Conclusions The current study concluded comparable effects of desflurane and propofol anesthesia on coagulation parameters within acceptable range as monitored by ROTEM and laboratory coagulation tests in cirrhotic patients with hypersplenism. Thus both anesthetics are considered safe in such patients who have high incidence of coagulopathy.

Background Dexmedetomidine is an α-2 adrenoceptor agonist with sedative and analgesic properties. Desflurane is the most rapidly washed volatile anesthetic agent allowing rapid recovery with minimal metabolism. Having a MAC of 6 vol % made it important to look for an adjuvant that would minimize its consumption. This study was undertaken to analyze desflurane consumption when combined with dexmedetomidine infusion guided by bispectral index as well as calculating intraoperative fentanyl requirements and recording hemodynamic changes associated with this technique. Methods Forty adult patients ASA class I and II of either sex scheduled for elective laparoscopic cholecystectomy were included in this study. Patients were randomized to one of two groups: Group ‘D’ (Dexmedetomidine group) receiving 1μg/kg over 10 minutes followed by an infusion at 0.5 μg/kg/hr and Group ‘P’ (Placebo group) who received same volumes of normal saline. Desflurane was started at a concentration of 6% then adjusted to keep BIS level within the range of 40-50. Desflurane consumption, fentanyl requirements as well as hemodynamics were either calculated or recorded. Results Desflurane consumption and total fentanyl usage were significantly lower in group D versus group P with P value P P Conclusions Continuous intravenous administration of dexmedetomidine resulted in significant reduction of desflurane consumption and intraoperative fentanyl requirements with attenuation of hemodynamic response to intubation, pneumoperitoneum and extubation.

Background: This study compared haemodynamics of continuous Wiley Spinal® anaesthesia with continuous epidural anaesthesia in elderly patients undergoing transurethral resection of prostate (TURP). Methods: After Institutional Review Board approval, thirty elderly male patients undergoing TURP classified as ASA physical status II or III were assigned into either the following: Continuous Epidural Anaesthesia group (Group CEA) receiving fentanyl 50 μg with plain bupivacaine 0.5% in 5 ml boluses or Wiley Spinal® Anaesthesia group (Group WSA) receiving fentanyl 5 μg with plain bupivacaine 0.5% given as 0.5 ml boluses until reaching sensory level of T10. Sensory and motor block onset and recovery, haemodynamics, time to first analgesia and adverse events were documented. Results: On reviewing WSA and CEA groups, onset of T10 sensory block [2 (1–8) vs. 5 (3–20) min], and motor block [9 (2–25) vs. 12 (5–40) min], with sensory recovery [161.7 ± 28.3 vs. 253.3 ± 52.7 min] and motor block duration [100.0 ± 27.4 vs. 130.7 ± 19.5 min] respectively (P

BackgroundLaparoscopic surgery produces measurable effects on cardio-circulatory, respiratory and metabolic systems. Total intravenous anesthesia with propofol using target-controlled infusion technique guided by Bispectral Index monitoring ensures an optimum level of anesthesia. This study was designed to evaluate the hemodynamic changes with the use of BIS-guided TCI with propofol-fentanyl during either laparoscopic or open cholecystectomy.MethodsTwenty-four ASA class I-II patients, scheduled for cholecystectomy under general anesthesia using BIS-guided TIVA with propofol-fentanyl delivered by TCI pump, were divided surgically into laparoscopic surgery group (LS group, n=12) and open surgery group (OS group, n=12). Hemodynamic data as well as stress hormones were measured at various time intervals.ResultsWithin LS, there was rise of both cardiac output after abdominal insufflation (p

BACKGROUND This prospective, randomized, double blinded, controlled study was designed to compare effects of intravenous co-administration of clonidine, magnesium, or ketamine on anesthetic consumption, intraoperative hemodynamics, postoperative analgesia and recovery indices during Bispectral Index (BIS) guided total intravenous anesthesia (TIVA). METHODS After ethical committee approval and written informed consent, 120 adult patients ASA I and II scheduled for open cholecystectomy were randomly assigned to one of 4 equal groups. Group CL received clonidine 3 µg/kg and maintained by 2 µg/kg/h. Group MG received magnesium sulphate 50 mg/kg and maintained by 8 mg/kg/h. Group KET received racemic ketamine 0.4 mg/kg and maintained by 0.2 mg/kg/h. Control group (CT) received the same volume of isotonic saline. Anesthesia was induced and maintained by fentanyl, propofol and rocuronium. Propofol infusion was adjusted to keep the BIS value between 45-55. Intraoperative hemodynamics, induction time, anesthetic consumption, recovery indices, and PACU discharge were recorded. RESULTS Induction time, propofol requirements for induction and maintenance of anesthesia, intraoperative fentanyl and hemodynamic values were significantly lower with Groups CL and MG compared to Groups KET and CT (P < 0.05). Patients in Group MG showed significantly lower muscle relaxant consumption, delayed recovery and PACU discharge than other groups (P < 0.05). First, analgesic requirement was significantly longer and total postoperative analgesic consumption was significantly lower in the adjuvant groups versus Group CT (P < 0.05). CONCLUSIONS Clonidine, magnesium, and ketamine can be useful adjuvant agents to BIS-guided TIVA. Pharmacokinetic studies of such drug combinations were recommended to investigate their interaction.

Severe resistant hypertension in end-stage renal disease patients has traditionally been an indication for bilateral nephrectomy (BN) before kidney transplantation. Nevertheless the influence of BN on successful control of hypertension has not been well documented. We sought to clarify the effect of BN on blood pressure patterns and control in renal transplant patients. Materials and Methods We retrospectively reviewed 28 patients who underwent BN between November 2003 and May 2009 before or after kidney transplantation. Nineteen of them were under treatment with 4 or 5 antihypertensives according to the international guide lines; they had BN for resistant hypertension. They were considered as group 1 (G1). Nine patients operated for indications other than resistant hypertension; they constitute group 2 (G2) and considered as a control group. All patients received triple immunosuppresion according to our local protocol. BN was done either before, simultaneously or after transplantation. Antihypertensives were recorded before and after BN. We evaluated our patients at 3 months, 1 year, and 3 years. Acute rejection episodes and calcinurein nephrotoxicity were reported. Results In G1, the mean age was 30.2 years (range, 10–62). In G2, the mean age was 33.6 years (range, 11–61). Before BN, G1 patients used antihypertensive drugs (3.6 ± 1.05 drugs per day; mean ± SD), which was significantly higher than in G2 patients (2.0 ± 1.65 drugs per day; P = .02). Three months after BN, G1 patients used 2.6 + 0.9 drugs per day, with gradual reduction in number of antihypertensives to 1.4 ± 1.3 drugs per day at 3 years (P = .008). In G2, there was reduction in antihypertensive drug number per day, which was insignificant during the follow-up period. No difference was noted between G1 and G2 drug administered after BN. We conclude that BN is effective to help blood pressure control, in resistant hypertension in renal transplant patients, but it starts to show up 3 months after surgery, and continues to work for a year and more.

Introduction Laparoscopic donor nephrectomy (LDN) has been adopted rapidly as it offers less postoperative pain, early recovery, and better cosmetic results compared with the open approach. This prospective study investigated the results of the first 80 LDN performed between May 2005 and May 2006, with regard to donor morbidity and effect on graft function. Patients and Methods LDN was attempted in 80 donors by one surgical team. Donors included 68 men and 12 women, ages 22 to 53 years, with body mass indices of 17.9 to 42.4. According to computed tomographic angiography, left nephrectomy was planned in 75 donors and right nephrectomy in 5. Results LDN was completed successfully in 74 (92.5%) and converted to open in 6 (7.5%) secondary to technical difficulties and operative bleeding. The mean operating time for LDN was 186.16 minutes (range, 95–260 minutes). Mean warm ischemia time (WIT) was 5.7 minutes (range 2–16 minutes). Mean hospital stay was 5.28 days (range, 3–14 days). Two donors (2.5%) were reexplored for postoperative bleeding. Renal function in all donors was satisfactory within 3 months of surgery. Immediate diuresis occurred in 76 (95%) recipients. Acute cellular rejection was diagnosed in 1 recipient. No association was observed between WIT, graft function, development of acute tubular necrosis (ATN), or rejection. Plasma creatinine normalization was clearly associated with donor age. Conclusions LDN was found to be a safe procedure with low postoperative morbidity and short recovery time for donors. It can potentially increase the donor pool.

Introduction Invasive fungal sinusitis is a rare but often fatal infection in immunocompromised patients. Aggressive antifungal treatment is mandatory, but is not without risk. Caspofungin, an antifungal agent that is a member of the echinocandin family, an inhibitor of glucan synthesis in the fungal wall, is active against Aspergillus and Candidae infections. Although it works on the fungal wall, it does not affect mammalian cells; hence, its toxicity is minimal. Case Summary This report describes a case of invasive Aspergillus sinusitis in a kidney transplant recipient with diabetes mellitus. The infection involved the apex of the right orbit causing optic nerve compression. The patient was treated with transnasal endoscopic decompression of the optic nerve and intravenous AmBisome (liposomal amphotericin B) for 2 weeks without clinical improvement. The combination of caspofungin and AmBisome administered for another 2 weeks yielded partial improvement. The AmBisome had to be discontinued due to deterioration of renal and hepatic function, but the patient completed a further 7-week course of caspofungin alone. Retro-orbital biopsy confirmed a complete response to treatment; the patient’s renal and hepatic function returned to normal. Conclusion This case indicates that caspofungin is effective to treat invasive Aspergillus sinusitis in kidney transplant recipients. This agent is well tolerated and safe with respect to renal and hepatic function.

Objective. The area under the concentration-time curve of cyclosporine microemulsion is the best measure of the absorption and beneficial effects in renal transplant recipients. We sought to determine the best method of monitoring cyclosporine levels in these patients. Methods. Prospective evaluation of peak cyclosporine blood levels and area under the curve monitoring were performed for 1 year in 65 renal transplant recipients (study group). Cyclosporine trough levels and peak cyclosporine blood levels were correlated with the calculated area under the curve. Cyclosporine trough levels were monitored in equal numbers of matched controls. Results. There were no significant differences in the incidence of acute rejection, cyclosporine nephrotoxicity, proteinuria, serum creatinine levels, or graft and patient outcomes between the groups (P = .1). Peak cyclosporine blood levels guided by calculating the area under the curve were found to be 27% to 32% lower than previously reported. The correlation coefficient was 90% for peak cyclosporine blood levels (P

Background. Cytomegalovirus (CMV) is one of the serious viral infections after organ transplantation, especially in patients receiving anti-lymphocyte antibodies. Prevention of the infection using antiviral chemotherapy (ganciclovir) has gained interest in the transplant community due to the availability of quantitative methods for viral detection and monitoring. Methods. Forty-six CMV seropositive kidney transplant recipients were assigned to receive induction immunosuppression with anti-thymocyte globulin (ATG, Fresenius). Prophylactic intravenous ganciclovir was administered for 2 weeks at a dose of 5 mg/kg/d (adjusted to kidney function) starting from the day of surgery. Patients were monitored regularly for CMV infection or disease over 1 year posttransplant. The time to CMV manifestation, the number of antigenemia assay-positive cells, the clinical severity of infection, the incidence of acute rejection, the graft function, and the duration of hospital stay were evaluated. This group was compared to a historical matched control cohort (n = 37) transplanted earlier who did not receive prophylactic ganciclovir. Result. The incidence of CMV disease was significantly less among the prophylaxis than the control group (6/46 patients [13%] vs 16/37 patients [43.2%], P =

We are introducing a new continuous hydrostatic pressure system for identification and catheterization of epidural space in adults. One hundred and eight patients scheduled for elective endoscopic urological procedures were enrolled in this prospective randomized study. They were assigned to perform loss of resistance epidural technique by either the conventional saline-filled syringe (group C) or the new pressure technique (group P). The latter depends on observing passage of free flow of pressurized normal saline (50 mmHg) connected to epidural needle during its advancement, and then the epidural catheter was inserted to "float" easily while saline was flowing. Ten ml of bupivacaine 0.5 % with 50 μg fentanyl were injected. Time to identify epidural space, number of attempts, ease of catheterization, sensory and motor block by Bromage scale after 20 min, quality of anesthesia and any side effects were recorded. Significant reduction was found in group P versus group C concerning time to identify epidural space [20 (6-40) vs. 60.5 (23-75) s with p = 0.001], number of attempts [1 (1-2) vs. 1 (1-4) with p = 0.02] and motor block [1 (0-3) vs. 2 (0-2) with p = 0.02], respectively. No significant difference in epidural catheterization, sensory block, quality of anesthesia and incidence of side effects. We concluded that this new technique is an easy way to identify epidural space using available tools in the operating room.

CYTOMEGALOVIRUS (CMV) is one of the most frequent infections in renal transplant recipients. After primary infection the virus remains dormant in various cells/organs for years. There are many factors that may reactivate virus replication; among them, organ transplantation certainly is the most important one, often causing serious disease and often associated with decreased graft survival. Though treatment is available, its timing and dosage should be tailored according to the ongoing CMV disease. There are different approaches for the diagnosis of CMV infections. The “gold standard” is cell culture in which the virus can be isolated. However, it is a timeconsuming and expensive procedure. Though combining virus isolation with immunofluorescence technique reduces the time from weeks to days, it is still not enough to meet the demand of a rapid diagnosis. Polymerase chain reaction (PCR) may have a strong impact on the diagnosis of CMV infection, but there is a need for further standardization and simplification. Many of the kidney transplant recipients fail to produce antibodies due to immunosuppressive therapy, making serological diagnosis undependable in CMV infections. Recently, detection of a specific CMV replication-related antigen (CMV antigen pp65) directly in leukocytes of patients has shown a good correlation with the clinical condition of the patient. This, CMV antigenemia assay (AA) seems to provide not only a reliable, specific, and sensitive diagnostic tool, but also facilitates monitoring the effectiveness of antiviral therapy.

Background Immunosuppressed organ transplant recipients are more susceptible to cancer than are persons in the general population. If malignancies of the skin are excluded for geographic variation, a cancer incidence of 4% to 7% in transplant recipients is usual. Objectives We aimed to find the incidence, histopathological types, and outcome of malignancy in kidney transplant recipients in Kuwait. Patients and Methods Between 1972 and October 2004, more than 1500 kidney recipients were followed. After excluding recipients who left the country soon after transplantation, we reviewed the medical records of the remaining 1171 kidney recipients (724 male and 447 female patients of ages 3 to 76 years) at the time of transplantation. Kidney grafts were obtained from 968 living and 203 deceased donors. Records were retrospectively reviewed for the incidence, clinical presentation, histopathological patterns, and outcome of cancer. Results Fifty-six malignant lesions (4.8%) were diagnosed in 51 recipients (28 men and 23 women, aged 15 to 66 years), who had received grafts from 44 living and seven cadaveric donors. Malignancy was diagnosed 4 to 288 months after transplantation. The most commonest types were posttransplantation lymphoma and Kaposi’s sarcoma. Posttransplantation cancer presented earlier in female and in adult recipients and following decreased donor transplantation. Kaposi’s sarcoma appeared earlier than posttransplantation lymphoma or squamous cell carcinoma. Less than 40% of recipients with malignancy are alive.

Objectives. We sought to explore the incidence, risk factors, clinical presentation, management options, and outcomes of post renal transplant urologic complications. Patients and Methods. Between November 1993 and December 2005, we performed 646 renal transplantation procedures in 373 males and 273 females, of whom 81 were children. Kidney grafts were obtained from 461 living and 185 cadaveric donors. The medical records were retrospectively reviewed for urologic complications. Affected patients presented clinically with impaired kidney function: the diagnosis was confirmed by ultrasound scanning, isotope renal scanning, magnetic resonance urography, and/or antegrade urography. Ureteric stricture was managed by percutaneous antegrade ureteric dilatation and stenting, or by surgical reconstruction. Urine leak was treated by prolonged bladder drainage or surgical reconstruction. Renal stones were treated with extracorporeal shockwave lithotripsy. Results. Urologic complications were detected in 31 recipients (4.8%), including 21 males and 10 females, among whom 4 were children. They had received kidney grafts from 19 living and 12 cadaveric donors. Urologic complications were ureteric strictures in 15 (2.58%), urine leaks in 15 (2.58%), and ureteric stone in 1 (0.17%) recipients. There was no graft loss to urologic complications. Conclusions. The incidence of post-kidney transplant urologic complications was 4.8%. They were more common among male recipients and after cadaveric kidney transplantation. Although ureteric stricture presented late posttransplantation and was more common among children (4.23%), urine leak presented early and was more common in the elderly (4.69%). All urologic complications were successfully managed, with no graft loss.

The presence of IgG antibodies in the pretransplant cross-match (XM) test results in hyperacute rejection, but IgM antibodies are inconsequential. The XM should be able to differentiate between IgG and IgM antibodies. This study evaluated 3 methods. This study was based on 500 patients for whom XM were performed between 2004 and 2006 with all 3 techniques. Two patient sera were used: normal serum and heat inactivated serum, which was prepared by incubating patient serum at 63 degrees C for 10 minutes to destroy IgM antibodies. The efficiencies of flow cytometry XM (FC-XM), dithiothreitol complement-dependent microlymphocytotoxicity (DTT/CDC-XM), and heat inactivation (HI-CDC-XM) to differentiate between IgG and IgM were evaluated by using both sera. Patients with positive XM, and negative HI-CDC-XM were reported as negative XM. During the study period, there were 70 patients with positive B-cell XM. Forty-nine became negative after HI-XM, and 21 remained positive. Only 34 cases became negative after DTT-CDC-XM and 36 remained positive. HI-CDC-XM was comparable to FC-XM; all patients testing negative with this technique experienced successful renal transplantations without hyperacute, accelerated, or acute rejection episodes. Our study showed that HI-CDC-XM was effective at exclude donor-specific IgM antibodies, a result which was comparable to FCXM to detect only IgG antibodies. HI is simple and rapid and does not involve any extra equipment or cost.

Background Hyperinfection strongyloidiasis is a potentially fatal syndrome associated with conditions of depressed host cellular immunity. A high degree of suspicion is required to detect cases early and thereby avoid a fatal outcome. Patients and Methods Three consecutive cadaveric kidney transplant recipients died within 2 months from hyperinfections with strongyloides. All members of the transplant team were involved in a campaign to localize the source of infection, identify and treat affected patients, and provide adequate prophylaxis to other transplant recipients. We reviewed cadaveric donor files and screened 61 hospital personnel, 27 hospital inpatients, and the 87 hospital outpatients transplanted in a year’s time before that event for a possible source. The screening test included analysis of fresh stool samples on 3 consecutive days for strongyloides larvae. The anti-helminthic drug albendazol was administered to all patients during screening. They were followed for possible development of the disease during the infectivity period. Results The first 2 recipients received their kidneys from 1 cadaveric donor, while the third received it from a different donor. Both donors came from areas endemic for strongyloidiasis. The 3 recipients were on tacrolimus-based immunosuppression. The twin recipient of the second kidney was on cyclosporine and did not manifest a disease. All stool samples taken for screening were negative for the infective larvae. None of the other recipients developed the disease. Conclusions Cadaveric donors were the possible source for this outbreak. Cyclosporine probably has a protective effect against strongyloides. In our setting, screening of cadaveric donors for strongyloides is mandatory before accepting them for donation, and oral prophylaxis is required for all recipients.

Introduction Lymphedema is an increasingly observed complication of sirolimus (SIR) therapy. In this report, we describe four renal recipients with SIR-induced lymphedema of varying severity. Cases Reports Patient 1, a 38-year-old man developed lymphedema of the left upper limb after being exposed to SIR for 30 months (mean daily Rapamune dose, 3 mg; trough level, 10–18 ng/mL). Venography and duplex ultrasound were normal. Lymphangiography was showed delayed lymphatic drainage. SIR was replaced with Prograf with significant improvement in the lymphedema over the next 6 months. Patient 2, a 26-year-old woman, developed lymphedema of the left lower limb at 24 months after starting SIR (mean daily dose, 3 mg; trough level, 10–15 ng/mL). Lymphangiography showed delayed drainage of lymphatics in the left lower limb. The patient was shifted to Prograf and there was some improvement over the next 4 months. Patient 3, a 28-year-old man, developed lymphedema of the left upper limb at 24 months after the start of SIR (mean daily dose, 2 mg, trough level, 6–15 ng/mL). Lymphangiography showed evidence of lymphatic obstruction. SIR was changed to cyclosporine with only mild improvement in lymphedema over the next 6 months. Patient 4, a 46-year-old man, developed lymphedema of the right upper limb at 7 months after starting SIR (mean daily dose, 6 mg; trough level, 10–16 ng/mL). Lymphangiography showed complete blockage of the lymphatic channels. SIR was changed to cyclosporine and there was mild improvement in lymphedema over the next 8 to 10 months. Conclusion The exact mechanism of SIR-induced lymphedema is unknown. The absence of other demonstrable etiologies and spontaneous improvement after discontinuation of SIR suggest that this drug was the responsible factor in these four patients. It occurred 7 to 30 months after transplantation. This is the fourth such report in the literature to the best of our knowledge.

We attempt in this retrospective study to evaluate the incidence, clinical presentations, and outcome of lymphocele in renal transplant recipients. 528 patients (313 males and 215 females) have received renal allografts from 384 living and 144 cadaveric donors. Diagnosis of lymphocele was made basically by ultrasound examination, and symptomatic collections were drained either percutaneously or into the peritoneal cavity. There were 50 (9.5%) instances of lymphocele encountered between 2 weeks and 6 months after transplantation. The lymphocele presented clinically predominantly as a single pelvi-abdominal swelling in 28 (56%) cases or as a swelling associated with manifestations of utereric and/or venous compression in 18 (36%) cases, and it was more common after cadaveric transplantation. All the cases of lymphocele were successfully treated with no graft loss. Lymphocele is an uncommon complication after renal transplantation, and is formed during the early post transplantation period. If not treated, it could seriously affect the kidney function. Intraperitoneal drainage is the most effective method for the treatment of symptomatic lymphocele.

Introduction BK virus nephropathy (BKVN) is a significant cause of graft loss among renal transplant recipients. The treatment outcomes of BKVN have been variably reported in the literature. Patients and methods We prospectively investigated BKV infection and BKVN among a population of renal transplant recipients with suspected BKV infection. The 42 subjects who all had acute allograft dysfunction, were categorized in three groups: those with clinical, laboratory, and histological findings that did not suggest acute rejection, drug toxicity, or obstruction (group 1, n = 24); those with findings that suggested probable acute cellular rejection but did not respond to antirejection treatment (group 2, n = 10); and those whose renal histology suggested BKVN (group 3, n = 8). Polymerase chain reaction analysis was done to detect BKV DNA in urine and blood samples from each subject. BKV DNA was detected in 19 (45%) urine samples with 11 of these subjects (26.1% of total) having BK viremia as well. Results No evidence of BKVN was detected histologically in seven subjects with isolated BK viruria, while the others proved to be JC virus infections. Among the 11 subjects with BK viremia, eight had BKVN based on renal histology at the time of diagnosis with BKV infection, while the other three subsequently developed histological features of BKVN. BKVN developed after 5.3 ± 2.5 (2 to 44) months after transplantation. The serum creatinine at time of BKVN diagnosis was 158.9 ± 58 (87 to 285) μmol/L. All subjects were initially treated with a 50% reduction in immunosuppressive drug doses. Further decreases in immunosuppression were performed in all patients with close monitoring of renal function. All subjects were followed up for a of 18.2 ± 5 (12 to 26) months. Two grafts were lost not due to BKVN, and one patient was lost to follow-up during this period. The latest serum creatinine in eight recipients is 113 + 20 (81 to 138) μmol/L, which is better than the renal function at diagnosis. Conclusion The prevalence of BKVN in suspected BKV infection was 26%. Although the study period was short (30 months), BK viremia strongly correlated with BKVN, which seemed to be successfully treated with reduction in immunosuppression.

Immunosuppressed organ transplant recipients are more susceptible to cancer than are persons in the general population. If malignancies of the skin are excluded for geographic variation, a cancer incidence of 4% to 7% in transplant recipients is usual.We aimed to find the incidence, histopathological types, and outcome of malignancy in kidney transplant recipients in Kuwait.Between 1972 and October 2004, more than 1500 kidney recipients were followed. After excluding recipients who left the country soon after transplantation, we reviewed the medical records of the remaining 1171 kidney recipients (724 male and 447 female patients of ages 3 to 76 years) at the time of transplantation. Kidney grafts were obtained from 968 living and 203 deceased donors. Records were retrospectively reviewed for the incidence, clinical presentation, histopathological patterns, and outcome of cancer.Fifty-six malignant lesions (4.8%) were diagnosed in 51 recipients (28 men and 23 women, aged 15 to 66 years), who had received grafts from 44 living and seven cadaveric donors. Malignancy was diagnosed 4 to 288 months after transplantation. The most commonest types were posttransplantation lymphoma and Kaposi's sarcoma. Posttransplantation cancer presented earlier in female and in adult recipients and following decreased donor transplantation. Kaposi's sarcoma appeared earlier than posttransplantation lymphoma or squamous cell carcinoma. Less than 40% of recipients with malignancy are alive.

Background. Renal transplantation is associated with several nonimmunological problems. Although urologic complications may be serious and carry a high risk of graft loss, they are amenable to successful treatment if diagnosed early and treated properly. Their incidence in the literature varies from 2.5% to 15%. Objective. We sought to assess the incidence, pattern, management options, and outcomes of urologic complications in 560 consecutive renal transplantations performed at a single center between November 1993 and October 2004. Patients and methods. Twenty-one (16 male and 5 female) recipients developed posttransplantation urinary complications at 2 days to 76 months after renal transplantation. Their kidney grafts were obtained from 13 living and eight deceased donors. Complications included ureteric stricture in 11 and urine leak in 10 recipients. Ultrasonography and isotope renal scanning were the main diagnostic tools. Complications were treated either conservatively, by percutaneous dilatation and stenting, or by surgical reconstruction. Results. The incidence of urologic complications following renal transplantation in the present series was 3.7%. All cases were successfully treated with no graft loss secondary to these complications. Conclusions. Posttransplantation urologic complications are associated with a good prognosis if diagnosed early and properly treated. Percutaneous transluminal dilatation of ureteric stenosis in renal transplant patients has good initial success, low morbidity, few recurrences, and long-term effectiveness.

Background Prior to the establishment of the pediatric nephrology service in Kuwait in 1995, no accurate registry of end-stage renal disease in children was available due to management by various adult nephrologists. In this study we analyzed our experience with renal replacement therapy in children, as the only center in the country offering this service for the past 8 years. Subjects and methods The records included all children less than 16 years of age with end-stage renal disease treated in the pediatric nephrology unit over a period of 8 years (January 1995 to December 2002). Results Of the 48 children boys comprises 52% and the overall mean age at institution of dialysis was 94.4 months. Causes of renal disease included congenital structural anomalies in 52%, including obstructive uropathy in 16.6%, vesicoureteric reflux in 16.6%, and renal dysplasia/hypoplasia in 18.7%. Hereditary nephropathy was diagnosed in 35.4%, including primary hyperoxaluria in 10.4%, nephronophthisis in 2%, autosomal-recessive polycystic renal disease in 8%, and glomerulopathies in 14.5%. Other etiologies constituted 14%. Renal replacement therapy was necessary in 43 patients: 46% by peritoneal dialysis and 43% by hemodialysis. The mortality rate in the dialyzed group was 16%. Twenty-four patients received kidney transplants from, cadaveric donors in 19 cases. Conclusion Genetic factors contributed to the high incidence of end-stage renal disease, which is most likely due to the common practice of consanguineous marriages in our country.

Objective To assess the effect of intrathecal midazolam with bupivacaine-fentanyl in elderly patients undergoing endourologic procedures. Materials and methods This prospective, randomized, double-blind study involved 60 ASA physical status II-III patients aged over 60 years scheduled for elective endoscopic urologic procedures under spinal anesthesia with hyperbaric bupivacaine 0.5% (5 mg/ml). They were randomized into one of three equal groups of 20 patients each: the first group, control group (group C), received 7.5 mg hyperbaric bupivacaine 0.5% in a volume of 1.5 ml; the second group, fentanyl group (group F), received 7.5 mg hyperbaric bupivacaine 0.5% in a volume of 1.5 ml and 10 mg fentanyl (0.1 ml); and the third group, fentanylmidazolam group (group FM), received 7.5 mg hyperbaric bupivacaine 0.5% in a volume of 1.5 ml and 10 mg fentanyl (0.1 ml) plus 1.0 mg of midazolam (0.2 ml). Sensory and motor effects were assessed. Postoperative pain, sedation, and adverse effects were also recorded. Results The three studied groups were comparable in demographic and clinical characteristics. They were hemodynamically stable. There was no significant difference between the three groups in the onset of sensory ( P = 0.721) and motor block ( P = 0.342), duration of motor block ( P = 0.286), and sedation score ( P = 0.229). Duration of sensory block was prolonged in group F compared with the control group ( P P = 0.065). Time to first request of rescue analgesic was significantly longer in group F compared with the C group ( P = 0.033) and in FM compared with the F group ( P P = 0.547). Conclusion Adjuvant intrathecal midazolam resulted in intraoperative hemodynamic stability and safely potentiates postoperative analgesic effect of bupivacainefentanyl spinal anesthesia in elderly patients undergoing endourologic procedures.

Objective: To retrospectively review the long-term outcome of renal transplant in diabetics at Mubarak Al-Kabeer Hospital and Hamad Al-Essa Organ Transplant Center, Kuwait from 1983 to 1998. Methods: There were 631 renal transplant patients, comprising 79 (12.5%) patients with pretransplant diabetes mellitus (pre-TDM), 117 (18.5%) patients with post-transplant diabetes mellitus and 435 (69%) nondiabetics (ND). Subjects with post-transplant diabetes mellitus were excluded from the comparative analysis. Distribution of sex, source of donors and mode of immunosuppression were similar in pre-TDM and ND groups. Results: Fifty-three (67%) recipients in pre-TDM and 90 (20.5%) in the ND group (p < 0.01) were above 45 years of age. However, 26 (33.3%) pre-TDM and 345 (79.5%) ND were below age 45. Among those who died, coronary artery disease led to death in 36% of pre-TDM and 27% in ND. Hyperlipidemia requiring drug therapy was observed in 37% pre-TDM and 6% ND. The incidence of severe infections was nearly twice in pre-TDM over ND recipients (1.9 vs. 1.0 per patient, p < 0.001). Acute rejection episodes were more frequently seen in pre-TDM (43%) than ND (33%), however the difference was not statistically significant. The patient survivals at 1, 5, 10, 14 years were significantly lower in pre-TDM (84, 65, 58 and 58%, respectively) than in ND (97, 93, 86 and 82%, respectively). The major contributory factors were severe infections and coronary artery disease. The cumulative graft survival showed a similar pattern (52% in pre-TDM, 73% in ND at 10 years). However, when death is excluded, the 10-year pure graft survival probability was similar for the pre-TDM and ND groups (76% vs. 80%). Conclusion: Our study indicates poor patient survival in pre-TDM due to coronary artery disease and infections, whereas the pure long-term graft survival was equally good in pre-TDM and ND transplant recipients.

Post-transplant diabetes mellitus (PTDM) has been reported to occur in 5–15% of non-diabetic renal transplant recipients. During a 15-year period (January 1983–January 1998), 631 renal transplant recipients (TxR) were followed-up in our Centre of whom 79 (12.5%) had pre-transplant diabetes mellitus. Among the 552 TxR who were non-diabetic at pre-transplantation, 117 (21.2%) developed PTDM. The gender, native renal disease and the mode of pre-transplant dialysis did not differ in those with and without PTDM. Of the 117 TxR who developed PTDM, 63 (53.8%) were above the age of 45 years where as only 90 (20.7%) of the 435 who remained non-diabetic (NDM) were above this age (P

KIDNEY transplantation is the treatment of choice for patients with end-stage renal disease. Acute rejection (AR) episodes are still a major problem in renal transplant recipients (RTR), predisposing them for chronic allograft dysfunction and graft loss. The search for more specific immunosuppressive agents to prolong graft survival has recently led us to focus on anti-interleukin (IL)-2 receptor antibodies (anti-IL-2Rab) in induction therapy. Two anti-IL-2 Rab are now approved for clinical use. They are biologically engineered to contain more human gene regions and fewer murine-derived regions. These are basiliximab (Simulect; Novartis, Basel, Switzerland) and daclizumab (Zenapax; Hoffman-La Roche, Switzerland). Reports of successful clinical trials of these agents in induction treatment of RTR is already available in the literature. These authors found anti IL-2 Rab useful for prevention of AR episodes and reported good tolerability. This paper reports on a prospective study of use of basiliximab (Simulect) and daclizumab (Zenapax) in induction immunosuppression in mismatched first renal transplants in our unit.

MARKED improvement in recipient and graft survival as well as decreased mortality and morbidity rates have made renal transplantation the treatment of choice for end-stage renal disease. The incidence of urologic complications after renal transplantation has ranged from 2.5% to 14.7%, with a higher incidence in pediatric recipients reaching approximately 30%. Urologic complications represent an important cause of morbidity delaying normal functioning of the graft and in some cases leads to the loss of the graft and/or the death of the patient. Although not unanimously affirmed, the technique of uretroneocystostomy used does not seem to influence the incidence of complications. We report urologic complications in 151 consecutive renal transplantations.

A rare kind of obstructive jaundice caused by compression on the common bile duct due to an inflated Foley catheter balloon placed in the duodenum after Suguira surgery for bleeding esophageal vesicles secondary to portal hypertension is presented. After deflating the balloon, the obstruction was relieved. Tc-99m HIDA studies were helpful in the diagnosis of obstruction of the common bile duct and the response following the deflation.