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Early ileocolonoscopy with biopsy for the evaluation of persistent post-transplantation diarrhea

World Journal of Gastroenterology 2010年第30期16卷 3834-3840页

作者： Giorgos Bamias john boletis Theodoros Argyropoulos Chrysanthi Skalioti Spyros I Siakavellas Ioanna Delladetsima Irene Zouboulis-Vafiadis George L Daikos Spiros D Ladas Gastroenterology Division 1st Department of Internal MedicinePropaedeuticMedical SchoolUniversity of Athens"Laikon" Hospital11527AthensGreece Department of Nephrology and Renal Transplantation Unit "Laikon" Hospital11527AthensGreece 1st Department of Pathology University of Athens"Laikon"Hospital11527AthensGreece

AIM: To investigate the signifi cance of ileocolonoscopy with histology in the evaluation of post-transplantation persistent diarrhea (PD). METHODS: We retrospectively reviewed all records of renal transplant patients with PD, over a 3-year period. All patients were referred for ileocolonoscopy with biopsy, following a negative initial diagnostic work up. Clinical and epidemiological data were compared between cases with infectious or drug-induced diarrhea. RESULTS: We identif ied 30 episodes of PD in 23 renaltransplant patients (1-3 cases per patient). There were 16 male patients and the mean age at the time of PD was 51.4 years. The average time from transplantation to a PD episode was 62.3 ± 53.2 mo (range 1-199 mo). Ileocolonoscopy detected mucosal abnormalities in 19 cases, whereas the intestinal mucosa appeared normal in 11 cases. Histological examination achieved a specific diagnosis in 19/30 cases (63.3%). In nine out of 11 cases (82%) with normal endoscopic appearance of the mucosa, histological examination of blinded biopsies provided a specif ic diagnosis. The etiology of PD was infectious in 11 cases (36.6%), drug-related in 10 (33.3%), of other causes in three (10%), and of unknown origin in six cases (20%). Infectious diarrhea occurred in significantly longer intervals from transplantation compared to drug-related PD (85.5 ± 47.6 mo vs 40.5 ± 44.8 mo, P < 0.05). Accordingly, PD due to drug-toxicity was rarely seen after the f irst year post-transplantation. Clinical improvement followed therapeutic intervention in 90% of cases. Modif ication of immunosuppressive regimen was avoided in 57% of patients. CONCLUSION: Early ileocolonoscopy with biopsies from both affected and normal mucosa is an important adjunctive tool for the etiological diagnosis of PD in renal transplant patients.

关键词： Endoscopy Post-transplantation diarrhea Histology Enteric infections Mycophenolate mofetilcolitis

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Hepatitis B in renal transplant patients

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World Journal of Hepatology 2017年第25期9卷 1054-1063页

作者： Smaragdi Marinaki Kyriaki Kolovou Stratigoula Sakellariou john N boletis Ioanna K Delladetsima Department of Nephrology and Renal Transplantation Unit Medical SchoolNational and Kapodistrian University of AthensLaiko General Hospital First Department of Pathology Medical SchoolUniversity of Athens

Hepatitis B virus(HBV) poses a significant challenge for both dialysis patients and kidney transplant recipients despite its decreasing rates, especially in developed countries. The best preventive method is vaccination. Patients with chronic renal disease should ideally be vaccinated prior to dialysis, otherwise, reinforced vaccination practices and close antibody titer monitoring should be applied while on dialysis. HBV infected dialysis patients who are renal transplant candidates must be thoroughly examined by HBV-DNA, and liver enzyme testing and by liver biopsy. When needed, one must consider treating patients with tenofovir or entecavir rather than lamivudine. Depending on the cirrhosis stage, dialysis patients are eligible transplant recipients for either a combined kidney-liver procedure in the case of decompensated cirrhosis or a lone kidney transplantation since even compensated cirrhosis after sustained viral responders is no longer considered an absolute contraindication. Nucleoside analogues have led to improved transplantation outcomes with both long-term patient and graft survival rates nearing those of HBs Ag(-) recipients. Moreover, in the cases of immunized HBs Ag(-) potential recipients with concurrent prophylaxis, we are enabled today to safely use renal grafts from both HBs Ag(+) and HBs Ag(-)/antiHBc(+) donors. In so doing, we avoid unnecessary organ discarding. Universal prophylaxis with entecavir is recommended in HBV kidney recipients and should start perioperatively. One of the most important issues in HBV(+) kidney transplantation is the duration of antiviral prophylaxis. In the absence of robust data, it seems that prophylactic treatment may be discontinued in selected stable, low-risk recipients during maintenance immunosuppression and should be reintroduced when the immune status is altered. All immunosuppressive agents in kidney transplantation can be used in HBV(+) recipients. Immunosuppression is intimately associated with increased

关键词： Hepatitis B virus(+) donor Hepatitis B virus(+) recipient Renal transplantation Viral reactivation Immunosuppression Nucleoside analogues Antiviral discontinuation Antiviral prophylaxis Hepatitis B

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Wireless capsule endoscopy in the investigation of patients with chronic renal failure and obscure gastrointestinal bleeding (preliminary data)

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World Journal of Gastroenterology 2006年第32期12卷 5182-5185页

作者： Stephanos Karagiannis Spyros Goulas Georgios Kosmadakis Petros Galanis Dimitrios Arvanitis john boletis Evangelos Georgiou Christos Mavrogiannis Academic Department of Gastroenterology Faculty of Nursing Athens UniversityGeneral Hospital of Athens "Helena Venizelou"Greece Department of Nephrology and Transplantation Center Laiko General Hospital AthensGreece Department of Nephrology A. Fleming General Hospital AthensGreece Medical Physics Department Medical School Athens UniversityGreece

瞄准：在小肠(SB ) 的察觉调查无线的囊内视镜检查法(WCE ) 的角色在有长期的肾衰竭(CRF ) 并且阴暗流血的病人的病理。方法：有阴暗流血的连续 CRF 病人有希望地被学习。有正常肾的功能并且阴暗流血的病人，与 WCE 在一样的时期期间调... 详细信息

瞄准：在小肠(SB ) 的察觉调查无线的囊内视镜检查法(WCE ) 的角色在有长期的肾衰竭(CRF ) 并且阴暗流血的病人的病理。方法：有阴暗流血的连续 CRF 病人有希望地被学习。有正常肾的功能并且阴暗流血的病人，与 WCE 在一样的时期期间调查了，被用于结果的解释。结果：十七个 CRF 病人(11 公开， 6 玄术流血) 并且 51 个病人(33 公开， 18 玄术流血) 与正常，肾的功能在这研究被注册。积极 SB 调查结果在 70.6% CRF 病人被检测(P < 0.05 ) 。SB angiodysplasia 在 47% CRF 病人被识别。Univariate 逻辑回归为 angiodysplasia 作为一个重要预兆的因素揭示了 CRF (P < 0.05 ) 。治疗学的措施与积极调查结果在 66% 病人被承担。结论：根据我们的初步的结果， SB angiodysplasia 与阴暗流血在 CRF 病人之中在增加的流行被发现。WCE 在胃肠的病理的诊断并且在计划适当治疗学的干预是有用的并且因此，应该在这组病人的病情的检查被包括。

关键词：内窥镜慢性肾疾病肾功能胃疾病肠疾病

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Hepatitis C in hemodialysis patients

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World Journal of Hepatology 2015年第3期7卷 548-558页

作者： Smaragdi Marinaki john N boletis Stratigoula Sakellariou Ioanna K Delladetsima Department of Nephrology and Renal Transplantation Unit Medical School University of Athens Laiko General Hospital First Department of Pathology Medical School University of Athens

Despite reduction of hepatitis C prevalence after recognition of the virus and testing of blood products, hemodialysis(HD) patients still comprise a high risk group. The natural history of hepatitis C virus(HCV) infection in dialysis is not fully understood while the clinical outcome differs from that of the general population. HD patients show a milder liver disease with lower aminotransferase and viral levels depicted bymilder histological features on liver biopsy. Furthermore, the "silent" clinical course is consistent with a slower disease progression and a lower frequency of cirrhosis and hepatocellular carcinoma. Potential explanations for the "beneficial" impact of uremia and hemodialysis on chronic HCV infection are impaired immunosurveillance leading to a less aggressive host response to the virus and intradialytic release of "hepatoprotective" cytokines such as interferon(IFN)-α and hepatocyte growth factor. However, chronic hepatitis C is associated with a higher liver disease related cardiovascular and allcause mortality of HD patients. Therapy is indicated in selected patients groups including younger patients with low comorbidity burden and especially renal transplant candidates, preferably after performance of a liver biopsy. According to current recommendations, choice of treatment is IFN or pegylated interferon with a reported sustained viral response at 30%-40% and a withdrawal rate ranging from 17% to 30%. New data regarding combination therapy with low doses of ribavirin which provide higher standard variable rates and good safety results, offer another therapeutic option. The new protease inhibitors may be the future for HCV infected HD patients, though data are still lacking.

关键词： Hemodialysis Hepatitis C infection Interferon Ribavirin Protease inhibitors

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Renal transplantation with expanded criteria donors: Which is the optimal immunosuppression?

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World Journal of Transplantation 2016年第1期6卷 103-114页

作者： Vassilis Filiopoulos john N boletis Department of Nephrology and Transplantation Unit Laiko University Hospital

The growing gap between demand and supply for kidney transplants has led to renewed interest in the use of expanded criteria donor(ECD) kidneys in an effort to increase the donor pool. Although most studies of ECD kidney transplantation confirm lowerallograft survival rates and, generally, worse outcomes than standard criteria donor kidneys, recipients of ECD kidneys generally have improved survival compared with wait-listed dialysis patients, thus encouraging the pursuit of this type of kidney transplantation. The relative benefits of transplantation using kidneys from ECDs are dependent on patient characteristics and the waiting time on dialysis. Because of the increased risk of poor graft function, calcineurin inhibitor(CNI)-induced nephrotoxicity, increased incidence of infections, cardiovascular risk, and malignancies, elderly recipients of an ECD kidney transplant are a special population that requires a tailored immunosuppressive regimen. Recipients of ECD kidneys often are excluded from transplant trials and, therefore, the optimal induction and maintenance immunosuppressive regimen for them is not known. Approaches are largely center specific and based upon expert opinion. Some data suggest that antithymocyte globulin might be the preferred induction agent for elderly recipients of ECD kidneys. Maintenance regimens that spare CNIs have been advocated, especially for older recipients of ECD kidneys. CNI-free regimens are not universally accepted due to occasionally high rejection rates. However, reduced CNI exposure and CNI-free regimens based on mammalian target of rapamycin inhibitors have shown acceptable outcomes in appropriately selected ECD transplant recipients.

关键词： Expanded-criteria donors Outcomes Kidney transplantation Immunosuppression Survival

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Kidney transplantation in patients with systemic lupus erythematosus

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World Journal of Transplantation 2014年第3期4卷 176-182页

作者： Sophia Lionaki Chrysanthi Skalioti john N boletis Nephrology Department and Transplantation Unit Laiko Hospital 11527 Athens Greece

Despite improvements in overall prognosis in lupus nephritis, 10%-30% of patients with proliferative renal involvement progress to end stage renal disease, according to the severity of the disease and associated socioeconomic factors. Kidney transplantation has been recognized as the most appropriate treatment for those patients, but several issues remain after renal function restoration in a lupus recipient. Among these are the fear of lupus nephritis recurrence in the graft,the choice of immunosuppressive therapy in cases of recurrent lupus for a patient who has already received a toxic and prolonged immunosuppressive course, and finally, the management of comorbidities to reduce associated morbidities in the long term. All the above topics are examined in this review, with the hope of providing a clear picture of data as illustrated in the current literature.

关键词： Kidney transplantation Lupus Recurrence

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Excellent long term patient and renal allograft survival after ABO-incompatible kidney transplantation:Experience of one center

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World Journal of Transplantation 2015年第4期5卷 329-337页

作者： Christina Melexopoulou Smaragdi Marinaki George Liapis Chrysanthi Skalioti Maria Gavalaki George Zavos john N boletis Nephrology Department and Renal Transplantation Unit Laiko Hospital 1st Department of Pathology Medical School National and Kapodistrian University of Athens Blood Transfusion Center-National Reference Center for Congenital Haemorrhagic Disorders Laiko Hospital Renal Transplantation Unit Laiko Hospital

AIM: To investigate the long-term results of ABOincompatible(ABOi) kidney transplantation in a single center in ***: Thirty consecutive ABOi kidney transplantations were performed from June 2005 to December 2013. All patients received rituximab one month prior to transplantation. Immunoadsorption therapy was performed for the removal of anti-A/B Ig G antibodies until the titer was ≤ 1:16. Additional apheresis sessions were performed post-operatively. Intravenous immunoglobulin and oral immunosuppression consisting of tacrolimus(TAC) in combination with either everolimus or mycophenolate acid was administered. We compared the long term results of our ABOi group to those of a matched group of 30 ABO compatible(ABOc) living kidney recipients with similar baseline characteristics. The ABOc recipients received an immunosuppressive regimen consisting of TAC and mycophenolate acid. All patients in both groups received induction therapy with Basiliximab or Daclizumab, whereas corticosteroids were instituted on the day of surgery. During the followup period, indication biopsies were performed and interpreted by an experienced nephropathologist. The parameters we analyzed included the following: Donor/recipient age, gender, blood type, human leukocyte antigen mismatches, panel reactive antibodies, primary cause of renal failure, mean time on dialysis, immunosuppressive regimen, patient survival, graft outcome, incidence of rejections, surgical and infectious ***: The mean follow-up period was 6 years(range 1 to 9 years). A mean of 5.0 ± 3.0(range 0-14) pre-transplant immunoadsorptions were required in order to reach the target titer. Patient survival in ABOi group in comparison to ABOc group at 1, 3, 5 and 8 years did not differ significantly(100% vs 100%, 96% vs 100%, 92% vs 100% and 92% vs 100%, P = ns). Additionally, graft survival was similar in the two groups at the same time points(100% vs 100%, 96% vs 96%, 92% vs 96% and 81% vs 92%, P = ns)

关键词： ABO-incompatible Kidney Transplantation Renal transplant Everolimus Immunoadsorption

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