Publications by authors named "Cem Tugmen"

28 Publications

  • Page 1 of 1

Immunological Results of Long-Term Use of Mammalian Target of Rapamycin (mTOR) Inhibitors and Its Effects on Renal Graft Functions.

Ann Transplant 2021 Sep 17;26:e932434. Epub 2021 Sep 17.

Department of Internal Medicine, SBU İzmir Tepecik Training and Research Hospital, İzmir, Turkey.

BACKGROUND Calcineurin inhibitor drugs (CNI), which are the basis of immunosuppression in kidney transplantation, contribute to renal graft loss, with increased morbidity and mortality due to their potentially harmful effects on the renal graft, cardiovascular system, and tumor pathology. For this reason, the mammalian target of rapamycin inhibitors (mTORi) such as sirolimus (SRL) and everolimus (EVE) has been preferred more frequently, as they are associated with fewer complications and longer graft function. MATERIAL AND METHODS We enrolled 89 adult renal transplant patients (37 patients on mTORi and 52 on CNI) who had similar age, sex, primary renal disease, dialysis type, post-transplant follow-up period, and donor type. We analyzed and compared the data between patients using mTORi for longer than 5 years and those using CNI regarding pre- and post-transplant panel reactive antibody (PRA), and donor-specific antibody (DSA), as well as post-transplantation and current graft functions. RESULTS Although those using mTORi for more than 5 years had significantly higher mismatch rates (P=0.024) than those using CNI, there was no significant change in PRA and DSA levels. Transplant time was longer in mTORi users (P=0.025). The switch time to mTORi in patients ranged from 0 to 19 years, but the average was 4 years. As expected, actual spot urine protein/creatinine was significantly higher in those using mTORi (P=0.009). Diabetes mellitus (DM) and BK virus nephropathy (BKVN) rates were significantly higher due to switching the regimen from CNI to mTORi. CONCLUSIONS Long-term use of mTORi does not appear to be an immunological problem.
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http://dx.doi.org/10.12659/AOT.932434DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8454254PMC
September 2021

Effect of preoperative skeletal muscle area and prognostic nutritional index values on postoperative morbidity and mortality in patients with gastric cancer: a single-center retrospective analysis.

Acta Chir Belg 2021 Sep 15:1-6. Epub 2021 Sep 15.

Department of General Surgery, University of Health Sciences Izmir Tepecik Training and Research Hospital, Turkey.

Introduction: The aim of this study was to determine the impact of preoperative prognostic nutritional index (PNI) value and skeletal muscle area (SMA) on short-term outcomes of patients with gastric cancer.

Patients And Methods: A total of 107 patients underwent gastrectomy due to gastric cancer between January 2016 and December 2019 were retrospectively analyzed. The patients were divided into groups according to the determined PNI and SMA cutoff values. Clinicopathological features and short-term results were compared.

Results: Overall morbidity was 29% ( = 31) in patients who underwent gastrectomy. Preoperative PNI value was ranged from 24.5 to 61.5 (median, 49.5). Preoperative SMA values were ranged respectively from 55.7 to 142 (median, 98.9) in women and 77.5 to 203.3 (median, 129.3) in men. It was observed that the risk of postoperative complications increased in patients with low PNI (OR 0.270 = .003). The average postoperative length of hospital stay was 12.1 days. The longer postoperative hospital stay was seen in lower PNI group (PNI ≤ 48, 15.1 days vs. PNI> 48, 10 days;  = .033). Clavien-Dindo classification was high in patients with low PNI and sarcopenia (PNI ≤ 48,  = .004 and Sarcopenia,  = .006). Likewise, mortality was significantly increased in patients with low PNI and sarcopenia (PNI ≤ 48, 20% vs. PNI > 48, 0%;  < .001 and Sarcopenia, 13.7% vs. Nonsarcopenia, 3.6%; OR 0.233,  = .053).

Conclusions: As a result, preoperative SMA and PNI values were found closely related to the postoperative hospital stay, morbidity and mortality results of patients with gastric cancer. Preoperative nutritional support may help to overcome longer hospital stay, higher mortality and morbidity rates in patients with gastric cancer.
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http://dx.doi.org/10.1080/00015458.2021.1977462DOI Listing
September 2021

A Management of Ureteral Obstruction After Lichtenstein Tension-Free Hernia Repair in a Kidney Transplant Recipient: A Case Report.

Transplant Proc 2021 May 21;53(4):1275-1278. Epub 2021 Apr 21.

Department of Transplantation and General Surgery, Tepecik Training and Research Hospital, Izmir, Turkey.

Background: The number of renal transplants has been increasing in recent years. Recent literature data show that abdominal operations performed on patients who undergo renal transplant have higher morbidity and mortality.

Case Presentation: A 49-year-old man who had received a renal transplant from a living donor 19 years ago underwent Lichtenstein tension-free hernia repair. Anuria was observed after the operation. Renal ultrasound demonstrated massive hydronephrosis and an elevated serum creatinine level (4.6 mg/dL). It was thought that the ureter may have been obstructed because of the operation, and, with the patient under local anesthesia, all sutures and polypropylene mesh were removed. Urine output was still not present, so a percutaneous nephrostomy catheter was inserted to normalize renal function. The patient underwent reoperation under general anesthesia 45 hours after the first operation. It was observed that the ureter was ligated during high ligation. The ureter was released, and no additional intervention was performed. The patient was discharged 6 days later with a return to basal creatinine level and a percutaneous nephrostomy catheter. The patient was hospitalized twice for severe urinary tract infection and urosepsis within 3 months and received appropriate treatment. The patient has had an uneventful postoperative course for 18 months.

Discussion: Inguinal hernia repair is seen as a safe surgical procedure, but the risk of emerging urological complications is higher in patients with renal transplant. Imaging before surgery to identify the anatomy of the kidney and ureter may be useful. Delicate dissection of the extraperitoneal area during the operation will reduce surgical complications.
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http://dx.doi.org/10.1016/j.transproceed.2021.03.005DOI Listing
May 2021

Isolated Metastasis of Pancreas due to Endometrial Carcinoma.

J Coll Physicians Surg Pak 2020 Dec;30(12):1362-1363

Department of General Surgery, University of Health Sciences, Tepecik Training and Research Hospital, Turkey.

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http://dx.doi.org/10.29271/jcpsp.2020.12.1362DOI Listing
December 2020

Corticosteroid associated lupus pancreatitis.

Rev Assoc Med Bras (1992) 2020 Oct;66(10):1414-1416

University of Health Sciences, Tepecik Training and Research Hospital, Department of General Surgery, İzmir, Turkey.

The relationship between acute pancreatitis and the administration of glucocorticoids is unclear because most reported cases have been diagnosed with systemic vascular diseases, such as systemic lupus erythematosus, which may be responsible for pancreatitis. A 22-year-old woman with eye involvement of a newly diagnosed systemic lupus erythematosus was admitted to our hospital. Pulse intravenous methylprednisolone therapy was given at 1mg/kg day for 3 days, and oral prednisolone at 40 mg/day thereafter. During pulse steroid therapy, she had abdominal pain, back pain, distention, nausea, and vomiting. Her physical examination was compatible with acute abdomen and peritonitis. Abdomen Computerized Tomography scan revealed diffuse liquid perihepatic and perisplenic area with heterogeneity around the mesentery. Due to the symptoms of acute abdomen, explorative laparotomy was performed. There was diffuse free fluid in the abdomen and edematous changes were observed around the pancreas. Amylase and lipase from intraabdominal fluid were studied and found to be high. The postoperative prednol dose was reduced carefully. On the sixth postoperative day, the drain was removed, and the patient was discharged without any problem. Physicians should keep in mind that acute pancreatitis may also be a cause of differential diagnosis of newly developed abdominal pain in patients receiving pulse steroid therapy with a normal level of serum amylase and lipase.
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http://dx.doi.org/10.1590/1806-9282.66.10.1414DOI Listing
October 2020

Anastomotic leakage treatment with endoscopic stent after small bowel transplantation in an infant.

Turk J Gastroenterol 2020 09;31(9):667-670

Department of Organ Transplantation and General Surgery, SBU Tepecik Training and Research Hospital, İzmir, Turkey.

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http://dx.doi.org/10.5152/tjg.2020.19292DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7577416PMC
September 2020

Outcome of Children With Intestinal Failure Due to Waardenburg Syndrome From an Intestinal Transplant Center: A Case Series.

Exp Clin Transplant 2020 Sep 17. Epub 2020 Sep 17.

From the Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Izmir Katip Celebi University, SBU Tepecik Training and Research Hospital, Izmir, Turkey.

Waardenburg syndrome is a genetic disease characterized by hearing loss and pigmentation abnormalities. Waardenburg syndrome type 4 is very rare, and children with Waardenburg syndrome type 4 present with intestinal aganglionosis. The associated findings and severity of Waardenburg syndrome type 4 may also differ significantly between cases. Intestinal insufficiency is probable and creates difficulties in terms of treatment; intestinal transplant may be required. In this case report, we present 4 cases of patients with Waardenburg syndrome who have intestinal issues, 2 of whom underwent small bowel transplant. Appropriate surgical and nutritional management should be provided for patients with Waardenburg syndrome type 4 who have gastrointestinal manifestations.
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http://dx.doi.org/10.6002/ect.2020.0166DOI Listing
September 2020

Symptomatic cholelithiasis may be the first sign of sarcoidosis.

Rev Assoc Med Bras (1992) 2020 Aug;66(8):1018-1020

. University of Health Sciences Tepecik Training and Research Hospital, Department of General Surgery, Izmir, Turkey.

Sarcoidosis is a multisystemic noncaseating granulomatous disease that rarely affects the gastrointestinal system. The initial diagnosis of sarcoidosis with gallbladder/gallbladder-associated lymph node involvement is a very rare condition in the literature. Herein, we aimed to report a case of newly diagnosed sarcoidosis with lymph node involvement associated with the gallbladder.
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http://dx.doi.org/10.1590/1806-9282.66.8.1018DOI Listing
August 2020

Ectopic ureter associated with Zinner's syndrome in a kidney recipient: case report and literature review.

Rev Assoc Med Bras (1992) 2020 May 3;66(5):692-695. Epub 2020 Jul 3.

Department of General Surgery, Tepecik Training and Research Hospital, Izmir, Turkey.

INTRODUCTION Zinner's Syndrome is a triad of mesonephric duct anomalies comprising unilateral renal agenesis, seminal vesicle cyst, and ejaculatory duct obstruction. In this study, we present a kidney recipient with ectopic ureter associated with Zinner's syndrome and a literature review. CASE PRESENTATION A 59-year-old male with a history of chronic kidney disease and left renal agenesis underwent deceased donor kidney transplantation. After securing optimal renal functions, the patient underwent abdominal computed tomography (CT) scan for the seroma that occurred under the incision. The final diagnosis was an ectopic distal ureter ending in the seminal vesicle cyst's wall and ipsilateral renal agenesis. The patient was discharged without any complications and the clinical follow up was uneventful. DISCUSSION AND CONCLUSION Congenital seminal vesicle disorders are usually associated with ipsilateral urinary duct anomalies stemming from the same embryonic structure. To our knowledge, this is the first case report that describes kidney transplantation in a patient with ipsilateral renal agenesis and ectopic ureter ending in the seminal vesicle cyst. In patients with renal agenesis, during the ipsilateral urinary tract anastomosis, the possibility of ectopic ureter should be kept in mind otherwise graft loss can occur with a high morbidity rate.
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http://dx.doi.org/10.1590/1806-9282.66.5.692DOI Listing
May 2020

Impact of Subclinical Rejection on Kidney Graft Function.

Transplant Proc 2019 Dec 13;51(10):3304-3308. Epub 2019 Nov 13.

Kent Hospital, Department of General Surgery, Izmir, Turkey.

Background: In kidney transplant recipients with borderline infiltration, protocol biopsy results demonstrated the relationship with chronic injury. The purpose of this study was to evaluate the effect of subclinical rejection (SCR) on 6-month protocol biopsy results in long-term renal function in renal transplant recipients with stable graft function.

Material And Methods: Transplant protocol biopsies performed in 45 patients with stable renal function were included in this study at 6 months. Biopsy specimens were evaluated for SCR. Study groups were divided into patients with and without SCR. Renal functions were compared with pathologic evaluation. The effect of immunosuppressive regimens on renal function were evaluated in patients with SCR RESULT: The median age of patients was 32 years (range, 18-64 years). The median follow-up was 56 months (range, 24-84 months). According to the 6-month protocol biopsy results, 20 of 45 patients (44.4%) met SCR criteria based on Banff 07 parameters. There was not a statistically significant difference in renal function with SCR.

Conclusion: The presence of SCR on the 6-month protocol biopsy results in renal transplant recipients with a stable graft function does not cause deterioration in the long-term graft function.
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http://dx.doi.org/10.1016/j.transproceed.2019.08.036DOI Listing
December 2019

Assessment and outcome of pediatric intestinal pseudo-obstruction: A tertiary-care-center experience from Turkey.

Turk J Gastroenterol 2019 Apr;30(4):357-363

Department of Pediatric Surgery, Izmir Katip Çelebi University - SBU Tepecik Training and Research Hospital, İzmir, Turkey.

Background/aims: Pediatric intestinal pseudo-obstruction (PIPO) is a severe disorder of gut motility. In this rare and difficult-to-manage disease, complex treatment method, such as intestinal transplantation, is sometimes needed. This study evaluated the management and follow-up results of patients with PIPO who received treatment at our center.

Materials And Methods: The cases of 13 patients with PIPO were reviewed retrospectively. Demographic data, clinical features, etiologies, pharmacological and surgical treatments, nutritional support, anthropometric findings, small bowel transplantation (SBT), and survival rates were assessed.

Results: Two of the patients were diagnosed at 1 and 5 years of age, while other patients were diagnosed during neonatal period. The etiological cause could not be identified for 5 patients. Pharmacological treatment response was observed in 38.4% of patients. Post-pyloric feeding was applied in 4 patients, but no response was observed. Gastrostomy decreased the clinical symptoms in 3 patients during the abdominal distension period. Total oral nutrition was achieved in 38.4% of the total-parenteral-nutrition (TPN)-dependent patients. It was observed that anthropometric findings improved in patients with total oral nutrition. Liver cirrhosis developed in 1 patient. Venous thrombosis developed in 4 patients. The SBT was performed on 3 patients. One of these patients has been followed up for the last 4 years.

Conclusion: Pediatric intestinal pseudo-obstruction is a rare disease that can present with a wide range of clinical symptoms. While some patients require intestinal transplantation, supportive care may be sufficient in others. For this reason, patients with PIPO should be managed individually.
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http://dx.doi.org/10.5152/tjg.2019.18287DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6453653PMC
April 2019

Outcomes of patients with advanced stage ovarian cancer with intestinal metastasis.

Ginekol Pol 2017 ;88(10):537-542

Objectives: The aim of this study is to evaluate the results of advanced stage (stage IIIB-IVB) ovarian cancer (OC) patients with intestinal metastasis, and to investigate the factors that affect survival.

Material And Methods: Patients who underwent cytoreductive surgery (CS) for FIGO stage IIIB-IVB OC with metastasis in the intestinal system, at Tepecik Research and Treatment Hospital between 2008-2014, were analyzed retrospectively. Patients with borderline ovarian tumor; those who had previously undergone radiation therapy and/or hysterectomy and patients having secondary or tertiary cytoreduction were excluded and 49 patients were included and analyzed in this study. Hysterectomy, bilateral salpingo-oopherectomy, pelvic and para-aortic lymph node sampling, resection of bulky lymph nodes and omentectomy were performed. Optimal cytoreduction was accepted as that which left residual tumor ≤ one cm maximum size.

Results: The risk factors affecting OS interval were investigated according to Cox' regression analysis. Optimality of the primary CS (P = 0.008 and HR = 5.202) and cancer stage (P = 0.016 and HR = 6.083) were found to be statistically significant factors.

Conclusions: Achieving optimal CS is the most important aim for the general surgeon carrying out an intestinal resection procedure. Although resection procedures are superior in providing the desired optimal results when compared to excision surgery, their higher complication rates and subsequent lower quality of life must be taken into consideration when choosing either resection or excision methods; surgical intervention should always be kept to the minimum possible.
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http://dx.doi.org/10.5603/GP.a2017.0098DOI Listing
July 2018

Nonmelanoma Skin Cancers After Kidney Transplant: Our 15 Years of Experience With Mammalian Target of Rapamycin Inhibitors.

Exp Clin Transplant 2017 02;15(Suppl 1):236-239

Department of General Surgery, Izmir Bozyaka Education and Research Hospital, Izmir, Turkey.

Objectives: We evaluated patients with nonmelanoma skin cancer after kidney transplant and the effects of immunosuppression reduction and switching to a mammalian target of rapamycin inhibitor drugs.

Materials And Methods: Kidney transplant recipients were evaluated retrospectively from patient medical records (between January 2000 and December 2014). A 30% increase in serum creatinine was accepted as indicating renal failure progression.

Results: Of 18 patients included (mean follow-up 98 ± 66 mo), 7 (38.8%) had squamous cell carcinoma, 7 (38.8%) had Kaposi sarcoma, and 4 (22.2%) had basal cell carcinoma. At cancer diagnosis, average serum creatinine was 1.6 ± 0.7 mg/dL and proteinuria was 410 ± 766 mg/d. Immunosuppression regimen was changed in 15 patients (83.3%), with new regimen being a single-drug (only prednisolone) in 4 patients, double-drug in 6 patients, and triple-drug protocol in 8 patients. Eight patients were switched to a mammalian target of rapamycin inhibitor-based double (4 patients) or triple (4 patients) regimen. During follow-up after starting new treatment (average 46 ± 50 mo), 6 patients (33.3%) had progressive kidney failure (0 were receiving triple regimen). Those that progressed were using mammalian target of rapamycin inhibitor-based drugs relatively less (33% vs 50%), although often receiving a single-drug immunosuppression treatment (50% vs 8.3%). Three patients (33.3%) had acute rejection (2 receiving double and 1 receiving single immunosuppression treatment). Five patients (27.7%) had local recurrence of the primary tumor. Mammalian target of rapamycin inhibitor use was relatively less common in patients with tumor relapse (20% vs 46%). One patient died (heart failure), and 1 with chronic rejection returned to dialysis.

Conclusions: Mammalian target of rapamycin inhibitorbased drugs could reduce local recurrence rate in kidney transplant recipients with nonmelanoma skin cancers. Aggressive reduction and/or cessation of immunosuppressive drugs after skin cancer can lead to graft rejection.
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http://dx.doi.org/10.6002/ect.mesot2016.p112DOI Listing
February 2017

Pediatric small bowel transplantation: A single-center experience from Turkey.

Turk J Gastroenterol 2016 Sep;27(5):428-432

Department of Organ Transplantation and General Surgery, Sağlık Bilimleri University İzmir Tepecik Training and Research Hospital, İzmir, Turkey.

Background/aims: Small bowel transplantation (SBTx) is a treatment option for patients with serious parenteral nutrition-related problems in intestinal failure. İzmir Tepecik Training Research Hospital Organ Transplantation Center is still the only pediatric intestinal transplant center in Turkey.

Material And Methods: This study was approved by the local ethics committee. Patients' data were analyzed from the medical charts and the hospital digital database. Seven isolated SBTxs were performed in six children between 2010 and 2016.

Results: One jejunal segment and six partial jejuno-ileal segments were used for seven transplants. All grafts were retrieved from deceased donors (one child and six adult donors). The six recipients had a mean age of 8.8±6.9 years (9 months to 17 years; M: 4, F: 2). The mean follow-up period of patients was 727±848 (34 to 1950) days. Acute cellular rejection (ACR) rates were 57% (n: 4) in the first 2 months. Graft loss due to severe ACR was seen in one patient. Central line-associated fungal (n: 3, 42%) and bacterial infections (n: 3, 42%) were seen in the first 2 months. Two Epstein-Barr virus (EBV) infections were recorded between 3 and 8 months in two patients. Our 1-year patient and graft survival rates were 71% and 71%, respectively.

Conclusion: SBTx has become a treatment modality for patients with intestinal failures. Management of ACR and infections are still challenging problems in SBTx. Appropriate-sized cadaveric donors are very limited in Turkey for pediatric intestinal transplantation candidates. Although the number of SBTxs performed was small, this study shows promising results.
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http://dx.doi.org/10.5152/tjg.2016.16385DOI Listing
September 2016

Delayed Graft Function in Kidney Transplantation: Risk Factors and Impact on Early Graft Function.

Prog Transplant 2016 Jun 6;26(2):172-7. Epub 2016 Apr 6.

Tepecik Training and Research Hospital, Department of Transplantation and General Surgery, Izmir, Turkey.

Context: Although kidney transplantations are routinely performed at many centers in Turkey, the incidence and risk factors associated with delayed graft function (DGF) here have not yet been well defined.

Objective: The aim of this study is to evaluate the incidence and risk factors of DGF and its impact on early graft function.

Design: The medical charts of 154 adult patients who underwent deceased donor kidney transplantation between 2000 and 2014 in a single center were reviewed retrospectively.

Setting: Delayed graft function-related risk factors for donors, recipients, and the transplant surgery itself were analyzed, and their relation with graft function was evaluated.

Main Outcomes Measures: The median recipient age was 39 years. The median cold ischemia time (CIT) was 840 minutes (14 hours). The incidence of DGF and acute rejection were 57.8% and 8.4%, respectively. Higher serum creatinine levels at 3, 6, and 12 months were observed in patients with DGF compared to other patients without DGF (P < .05). Patients with DGF had poor graft function (glomerular filtration rate ≤ 50) at 3 and 6 months (P < .05), but these correlations were not seen at 12 months (P = not significant).

Results: This study showed that DGF was a common and serious problem associated with poor graft functions at 3, 6, and 12 months after transplantation. Extra effort to shorten CIT as an independent risk factor for DGF could have protective effect on graft functions.
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http://dx.doi.org/10.1177/1526924816640978DOI Listing
June 2016

Natural Killer-Like T-Cell Lymphoma Localized to the Terminal Ileum: Case Report.

Turk Patoloji Derg 2016 ;32(1):40-3

Departments of Pathology, Tepecik Training and Research Hospital, İZMİR, TURKEY.

Intestinal intraepithelial lymphocytes are non-organized lymphoid populations that are composed of heterogeneous subsets with diverse ontogeny and phenotypes, and the differential diagnosis is crucial. A 43-year-old male patient underwent an emergency laparotomy due to a perforated mass of the terminal ileum. A right hemicolectomy plus small bowel resection was performed. Histopathological examination showed medium to large cells with vesicular nuclei, including marked nucleoli with large, colorless cytoplasm. No signs of celiac disease were found in the adjacent mucosa. The tumor cells were immunohistochemically CD45+, CD3+, CD4+, CD8+, CD56+, Pan-Cytokeratin-, CD20-, CD79a-, CD5- and CD30-. Endomysial antibody and antigliadin antibody, IgM and IgG tests; and anti-Ebstein Barr virus latent membrane protein all proved negative. Finally, the histopathological diagnosis of tumor mass was natural killer-like T-cell lymphoma. Primary intestinal cytotoxic natural killer-like T-cell lymphoma is a rare entity, which is difficult to distinguish from other T-cell lymphomas. In addition to microscopic evaluation, immunohistochemical analysis and serological tests are essential to reach a definitive diagnosis.
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http://dx.doi.org/10.5146/tjpath.2014.01251DOI Listing
January 2017

The DESCARTES-Nantes survey of kidney transplant recipients displaying clinical operational tolerance identifies 35 new tolerant patients and 34 almost tolerant patients.

Nephrol Dial Transplant 2016 06 12;31(6):1002-13. Epub 2016 Jan 12.

Department of Translational Medicine, Amedeo Avogadro University, AOU Maggiore della Carità di Novara, Novara, Italy.

Background: Kidney recipients maintaining a prolonged allograft survival in the absence of immunosuppressive drugs and without evidence of rejection are supposed to be exceptional. The ERA-EDTA-DESCARTES working group together with Nantes University launched a European-wide survey to identify new patients, describe them and estimate their frequency for the first time.

Methods: Seventeen coordinators distributed a questionnaire in 256 transplant centres and 28 countries in order to report as many 'operationally tolerant' patients (TOL; defined as having a serum creatinine <1.7 mg/dL and proteinuria <1 g/day or g/g creatinine despite at least 1 year without any immunosuppressive drug) and 'almost tolerant' patients (minimally immunosuppressed patients (MIS) receiving low-dose steroids) as possible. We reported their number and the total number of kidney transplants performed at each centre to calculate their frequency.

Results: One hundred and forty-seven questionnaires were returned and we identified 66 TOL (61 with complete data) and 34 MIS patients. Of the 61 TOL patients, 26 were previously described by the Nantes group and 35 new patients are presented here. Most of them were noncompliant patients. At data collection, 31/35 patients were alive and 22/31 still operationally tolerant. For the remaining 9/31, 2 were restarted on immunosuppressive drugs and 7 had rising creatinine of whom 3 resumed dialysis. Considering all patients, 10-year death-censored graft survival post-immunosuppression weaning reached 85% in TOL patients and 100% in MIS patients. With 218 913 kidney recipients surveyed, cumulative incidences of operational tolerance and almost tolerance were estimated at 3 and 1.5 per 10 000 kidney recipients, respectively.

Conclusions: In kidney transplantation, operational tolerance and almost tolerance are infrequent findings associated with excellent long-term death-censored graft survival.
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http://dx.doi.org/10.1093/ndt/gfv437DOI Listing
June 2016

De novo produced anti-human leukocyte antigen antibodies relation to alloimmunity in patients with chronic renal failure.

Genet Test Mol Biomarkers 2015 Jun 31;19(6):335-8. Epub 2015 Mar 31.

2 Tissue Typing Laboratory, Tepecik Training and Research Hospital , Izmir, Turkey .

Aims: Chronic renal failure causes patients to become dialysis dependent, which is exhausting for them both financially and psychologically. However, the definitive treatment of chronic renal failure is transplantation. One of the crucial factors affecting success in transplantation is the presence of anti-human leukocyte antigen (HLA) antibodies in patients. HLA alloimmunization is caused by various sensitization events such as blood transfusion, pregnancy, and transplantation. In this study, different sensitization events were compared to determine the effectiveness on the panel-reactive antibody status in female solid organ transplantation candidates based upon pregnancy.

Results: When results were evaluated in terms of alloimmunization rates, 62.8%, 73.4%, and 14.9% of the patients were found to have blood transfusion, pregnancy, and rejection history, respectively. Three hundred twenty-six of the 444 women had had at least one pregnancy. Panel-reactive antibody (PRA) (class I and/or II)-positive rates were significantly higher among patients with pregnancy and blood transfusion history (43.7%) than patients with only pregnancy history (27.5%) and pregnancy and transplantation history (40%). While transplantation history significantly affects class II anti-HLA levels, blood transfusion raises class I levels.

Conclusions: Solid organ transplantation appears to have the strongest HLA alloimmunization effect followed by pregnancy and blood transfusion, especially for class II HLA antigens. Patients who were sensitized by more than one sensitization event have a lower chance to have a solid organ transplantation. In this case, identification of donor-specific antibodies and the results of the cross-match tests play an important role both before and postrenal transplantation.
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http://dx.doi.org/10.1089/gtmb.2014.0294DOI Listing
June 2015

Renal tubular acidosis in renal transplant patients: the effect of immunosuppressive drugs.

Ann Transplant 2015 Feb 9;20:85-91. Epub 2015 Feb 9.

Department of General Surgery, Izmir Tepecik Research and Training Hospital, Izmir, Turkey.

Background: Renal tubular acidosis (RTA) is a non-anion gap metabolic acidosis and is generally mild and asymptomatic in kidney recipients. Calcineurine inhibitors (CNIs) increase the frequency of RTA but the frequency of RTA development in kidney transplant recipients receiving mammalian target of rapamycin inhibitors (mTORi) treatment remains unclear. In this study, we aimed to investigate the frequency of RTA in kidney transplant recipients on mTORi and CNI treatment and to compare both groups.

Material And Methods: We enrolled 137 adult renal transplant patients - 82 patients on mTORi and 55 patients on CNI who had similar age, sex, posttransplant follow-up period, and graft functions. We recorded the parameters of venous blood gas analysis, including serum pH value, serum bicarbonate (HCO3) concentration, presence of metabolic acidosis defined as low HCO3 (<22 mEq/L), and serum pH value (<7.35), as well as base excess and urine pH at last follow-up. RTA was defined to be metabolic acidosis with normal serum anion gap and positive urine anion gap.

Results: The mean age of our study population was 41.2±11.3 years. RTA frequency was 35% in the mTORi group and 41% in the CNI group. mTORi and CNI groups did not differ significantly in terms of the development of metabolic and renal tubular acidosis. Type I RTA was common in both groups. RTA was affected by duration of time since transplantation and graft functions in both groups.

Conclusions: The rates of RTA development in patients on long-term CNI and mTORi treatment were similar.
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http://dx.doi.org/10.12659/AOT.892320DOI Listing
February 2015

Relationship between epicardial adipose tissue, inflammation and volume markers in hemodialysis and transplant patients.

Ther Apher Dial 2015 Feb;19(1):56-62

Department of Nephrology, Tepecik Education and Research Hospital, Izmir, Turkey.

Cardiovascular (CV) diseases are still the most important cause of morbidity and mortality in both patients receiving hemodialysis (HD) treatment and individuals with renal transplantation (Rtx). Measurement of epicardial adipose tissue (EAT) thickness is an easily applied, cheap, and useful recent method predicting increased CV risk. We aimed to compare EAT changes in HD and Rtx patients and the association between EAT and inflammatory and CV volume markers in both groups. A total of 124 patients: 45 Rtx, 43 HD patients and 36 healthy controls were enrolled in the study. Laboratory parameters and inflammatory markers (interleukin-6 [IL-6] and high sensitive C-reactive protein [Hs-CRP]) were evaluated from venous blood samples after an overnight fast. EAT thickness was measured with transthoracic echocardiography. The levels of Hs-CRP, IL-6, systolic and diastolic blood pressures, left atrial (LA) diameter, left atrial index (LAI), left ventricular mass (LVM) and LVM index (LVMI) were significantly higher in the HD patients than in the other groups. EAT was positively correlated with age, body mass index (BMI), time on dialysis, serum creatinine, total cholesterol, Low density lipoprotein-cholesterol, and LVM in Rtx group and positively correlated with age, BMI, duration of dialysis, Hs-CRP, IL-6, LAI and LVMI and inversely correlated with inferior vena cava collapse index (IVC-CI) in HD group. EAT thickness of RTx patients (whose previous HD duration was similar to those in HD group) are similar to the healthy population and significantly thinner than patients on HD.
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http://dx.doi.org/10.1111/1744-9987.12276DOI Listing
February 2015

The effect of cold ischemia time on delayed graft function and acute rejection in kidney transplantation.

Saudi J Kidney Dis Transpl 2014 Sep;25(5):960-6

Department of General Surgery, Van Training and Research Hospital, Van, Turkey.

The objective of this study is to evaluate the impact of cold ischemia time (CIT) on delayed graft function (DGF) and acute rejection (AR) among deceased donor kidney transplant recipients. The medical records of 111 patients who underwent kidney transplantation from deceased donors between November 1994 and July 2009 were retrospectively analyzed. DGF was observed in 54% of the patients and the prevalence of AR in the first year after transplantation was 9.9%. The incidence of DGF was higher among patients with longer CIT. There was no correlation between CIT and AR episodes. Higher body weight of recipients and donors, history of prior blood transfusion and advanced donor age were related with DGF. Patients with DGF had higher serum creatinine levels at the first, third and fifth years. There was a negative correlation between recipient body weight and creatinine clearance at the first year. CIT has an important role in the development of DGF as a modifiable risk factor. Moreover, donors with advanced age and higher body weight as well as recipients with higher body weight and history of blood transfusions are at risk for the development of DGF. Prevention of DGF may help to improve graft function at the first, third and fifth years and shorten the hospital stay.
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http://dx.doi.org/10.4103/1319-2442.139865DOI Listing
September 2014

Mesenchymal stem cell therapy in patients with small bowel transplantation: single center experience.

World J Gastroenterol 2014 Jul;20(25):8215-20

Sait Murat Doğan, Selçuk Kılınç, Eyüp Kebapçı, Cem Tuğmen, Mustafa Ölmez, Cezmi Karaca, Organ Transplantation Center, SB Tepecik Teaching and Research Hospital, 35121 Izmir, Turkey.

Aim: To study the effects of mesenchymal stem cell (MSC) therapy on the prevention of acute rejection and graft vs host disease following small bowel transplantation.

Methods: In our transplantation center, 6 isolated intestinal transplants have been performed with MSC therapy since 2009. The primary reasons for transplants were short gut syndrome caused by surgical intestine resection for superior mesenteric artery thrombosis (n = 4), Crohn's disease (n = 1) and intestinal aganglionosis (n = 1). Two of the patients were children. At the time of reperfusion, the first dose of MSCs cultured from the patient's bone marrow was passed into the transplanted intestinal artery at a dose of 1000000 cells/kg. The second and third doses of MSCs were given directly into the mesenteric artery through the arterial anastomosis using an angiography catheter on day 15 and 30 post-transplant.

Results: The median follow-up for these patients was 10.6 mo (min: 2 mo-max: 30 mo). Three of the patients developed severe acute rejection. One of these patients did not respond to bolus steroid therapy. Although the other two patients did respond to anti-rejection treatment, they developed severe fungal and bacterial infections. All of these patients died in the 2(nd) and 3(rd) months post-transplant due to sepsis. The remaining patients who did not have acute rejection had good quality of life with no complications observed during the follow-up period. In addition, their intestinal grafts were functioning properly in the 13(th), 25(th) and 30(th) month post-transplant. The patients who survived did not encounter any problems related to MSC transplantation.

Conclusion: Although this is a small case series and not a randomized study, it is our opinion that small bowel transplantation is an effective treatment for intestinal failure, and MSC therapy may help to prevent acute rejection and graft vs host disease following intestinal transplantation.
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http://dx.doi.org/10.3748/wjg.v20.i25.8215DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4081695PMC
July 2014

S-shaped wide excision with primary closure for extensive chronic pilonidal sinus disease.

Case Rep Surg 2014 2;2014:451869. Epub 2014 Jun 2.

Department of General Surgery Clinic, Tepecik Teaching and Research Hospital, Izmir, Turkey.

Background. The management of complex pilonidal sinus disease (PSD) with multiple pits on and beside the natal cleft is variable, contentious, and problematic. Wide excision of the sinus and reconstruction of the defect using different flap techniques have become more popular in recent years. Case Report. We report a case with a complex chronic PSD to which we applied primary closure after S-shaped wide excision. The patient's postoperative course was uneventful, and at the end of one-year followup he is now disease-free and comes for routine checkups. Conclusion. The simplicity of the technique and the promising results support the applicability of the S-shaped wide excision in chronic bilaterally extended large PSDs. Further studies entailing large patient populations are needed to reach a definite conclusion.
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http://dx.doi.org/10.1155/2014/451869DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4060288PMC
July 2014

A retrospective analysis of long-term graft survival in 61 pediatric renal transplant recipients: a single-center experience.

Ann Transplant 2013 Sep 20;18:497-504. Epub 2013 Sep 20.

Tepecik Training and Research Hospital, Organ Transplantation, Izmir, Turkey.

Background: Although short-term renal allograft survival in children has improved over the years, long-term graft outcomes remain unclear. In this study we report the characteristics and other variables that impact long-term kidney graft survival in children.

Material And Methods: Records of 61 pediatric kidney transplant recipients (mean age: 14±3 years) performed at our institution between 1995 and 2011 were evaluated. Patients were divided into 2 groups (functional and non-functional grafts) to investigate the factors that impact graft survival. The groups were compared in terms of recipient characteristics, underlying disease, HLA status, immunosuppressive therapy, donor characteristics, acute rejection, and delayed graft function (DGF). Statistical significance was detected with the t and chi-squared tests (Pearson and Fisher's exact tests). Kaplan-Meier analysis was performed for graft survival.

Results: Overall graft survival at 1, 5, 10, and 15 years were 93%, 66%, 46%, and 41%, respectively. The median graft survival was 128.4 months (range: 3-188 months). Donor age, acute rejection, and DGF strongly predicted the chance of graft survival (p<0.05).

Conclusions: It appears that several modifiable risk factors can partially account for poorer graft survival in pediatric kidney transplant recipients.
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http://dx.doi.org/10.12659/AOT.889117DOI Listing
September 2013

Effective weight control and normalization of metabolic parameters after laparoscopic sleeve gastrectomy: a single center experience.

Hepatogastroenterology 2013 Mar-Apr;60(122):368-71

Third General Surgery Clinic, Tepecik Teaching and Research Hospital, Izmir, Turkey.

Background/aims: Obesity is one of the most serious public health problems. Laparoscopic sleeve gastrectomy (LSG), a type of bariatric surgery, is emerging as the new promising therapy for the treatment of morbid obesity.

Methodology: In the present study we aimed to assess the effects of LSG on body weight and other obesity related pathological conditions.

Results: A total of 19 obese subjects underwent LSG surgery. All patients underwent complete evaluation including anthropometric/clinical parameters and laboratory tests. Hypertension (HT), diabetes mellitus (DM), body mass index (BMI), and hyperlipidemia were significantly reduced after LSG.

Conclusions: Results of this study demonstrate that LSG induces stable weight loss and resolution of obesity-associated comorbidities.
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http://dx.doi.org/10.5754/hge12566DOI Listing
August 2013

The effects of mammalian target of rapamycin inhibitors on serum uric acid levels in renal transplant patients.

Int Urol Nephrol 2013 Apr 30;45(2):547-52. Epub 2012 Jun 30.

Division of Nephrology, Ege University, School of Medicine, 35100 Bornova, Izmir, Turkey.

Backgrounds/aims: Elevated uric acid (UA) levels are frequently observed after renal transplantation. We investigated the consequences of shifting from calcineurin inhibitors (CNI) to mammalian target of rapamycin inhibitors (mTORi) on UA levels and graft functions.

Methods: Ninety-six patients were enrolled. Main points of interest were changes in UA and glomerular filtration rate (GFR).

Results: Mean age of the whole population was 39 ± 11 years (18-73), and 64.2 % were male. Patients were stratified into two groups according to their CNI type prior to the switch as cyclosporin A (CsA) or tacrolimus (Tac). Patients that were switched from CsA had a mean GFR of 49 ± 18 ml/min and serum UA level of 7.4 ± 1.8 mg/dl at the pre-switch period. Mean GFR increased to 53 ± 22 ml/min (p = 0.03), and UA levels decreased to 6.2 ± 1.6 mg/dl at the final visit (p < 0.001). In the Tac group, pre-switch mean GFR was 59 ± 28 ml/min and serum UA level 6.6 ± 2.6 mg/dl. In this group, mean GFR increased to 63 ± 28 ml/min (p = 0.03) and UA levels decreased to 6.2 ± 2.1 at the last visit (p < 0.001).

Conclusion: Switch from CNI to mTORi-based regimen provides better control of UA levels and improves renal functions.
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http://dx.doi.org/10.1007/s11255-012-0214-0DOI Listing
April 2013

En-bloc pediatric kidney transplantation together with a partial bladder segment: a case report.

Pediatr Nephrol 2011 May 7;26(5):805-7. Epub 2011 Jan 7.

Department of Transplantation, Izmir Tepecik Teaching and Research Hospital, Izmir, Turkey.

There is a continuing debate about the techniques of kidney transplantation from small donors because of the high vascular thromboses and ureteric leak rates. Transplantation of en-bloc pediatric kidneys with a partial bladder segment has potential benefits over established techniques. We transplanted cadaveric en-bloc kidneys together with a partial bladder segment from a 1.5-year-old donor to a 12-year-old boy with end-stage renal disease due to vesicoureteral reflux (VUR) of a solitary kidney. En-bloc kidneys were transplanted together with both ureters and a partial bladder segment. Using donor bladder segment augmented the recipient bladder. Thereby, potential complications of bilateral ureteroneocystostomies of small ureters were avoided. During the following 12 months, the clinical course was normal and there was no evidence of VUR. In conclusion, the technique of using en-bloc pediatric kidneys together with a partial bladder segment is feasible and safe as well as an efficient procedure to preserve the natural anti-reflux mechanism in childhood.
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http://dx.doi.org/10.1007/s00467-010-1743-3DOI Listing
May 2011
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