{"id":24906,"date":"2022-06-27T09:00:12","date_gmt":"2022-06-27T06:00:12","guid":{"rendered":"https:\/\/www.klimikdergisi.org\/?p=24906"},"modified":"2022-06-27T13:56:27","modified_gmt":"2022-06-27T10:56:27","slug":"kornea-donorlerinde-mikrobiyolojik-testler","status":"publish","type":"post","link":"https:\/\/www.klimikdergisi.org\/tr\/2022\/06\/27\/kornea-donorlerinde-mikrobiyolojik-testler\/","title":{"rendered":"Postmortem Kornea Don\u00f6rlerinde Transplantasyon \u00d6ncesi Yap\u0131lan Serolojik ve Molek\u00fcler Testler: 5 Y\u0131l\u0131n Retrospektif De\u011ferlendirilmesi"},"content":{"rendered":"

G\u0130R\u0130\u015e<\/h2>\n

Keratoplasti olarak da adland\u0131r\u0131lan kornea nakli ilk kez 1905 y\u0131l\u0131nda Eduard Konrad Zirm taraf\u0131ndan yap\u0131lm\u0131\u015f olup o zamandan bu yana en s\u0131k yap\u0131lan nakil t\u00fcr\u00fcd\u00fcr (1). Kornean\u0131n tam kal\u0131nl\u0131kta de\u011fi\u015ftirilmesini i\u00e7eren bir prosed\u00fcr olan penetran keratoplasti (PK), yar\u0131m y\u00fczy\u0131ldan fazla bir s\u00fcredir yayg\u0131n olarak uygulanmaktad\u0131r (2-4). Bununla birlikte baz\u0131 \u00e7al\u0131\u015fmalar, PK\u2019y\u0131 takiben uzun vadeli kornea greft sa\u011f kal\u0131m oranlar\u0131n\u0131n tatmin edici olmad\u0131\u011f\u0131n\u0131 g\u00f6stermi\u015ftir; bu durum esas olarak endotelyal imm\u00fcnolojik allogreft reddine ve don\u00f6r kornealar\u0131n\u0131n endotel h\u00fccrelerinin s\u00fcrekli kayb\u0131na ba\u011flanmaktad\u0131r (2-4). Bu nedenle son y\u0131llarda, \u00f6n lamellar keratoplastinin (ALK) yan\u0131 s\u0131ra \u00f6zellikle derin \u00f6n lamellar keratoplastini (DALK) daha fazla \u00f6ne \u00e7\u0131kmaktad\u0131r (5). ALK, endotelin etkilenmedi\u011fi keratopati vakalar\u0131nda sa\u011fl\u0131kl\u0131 kornea endotelini koruyarak endotel reddi riskini ortadan kald\u0131rabilmektedir (6).<\/p>\n

T\u00fcrkiye\u2019de ilk olarak 1963 y\u0131l\u0131nda Ankara E\u011fitim ve Ara\u015ft\u0131rma Hastanesi\u2019nin ard\u0131ndan 1993 y\u0131l\u0131nda \u0130stanbul T\u0131p Fak\u00fcltesi\u2019nde faaliyetlerine ba\u015flayan g\u00f6z bankalar\u0131 arac\u0131l\u0131\u011f\u0131yla y\u00fcr\u00fct\u00fclen keratoplasti i\u015flemlerinin say\u0131s\u0131 e\u011fitimler ve yaz\u0131l\u0131\/g\u00f6rsel medya zeminli bilgilendirmelerin katk\u0131s\u0131yla giderek artmaktad\u0131r (7). T.C. Sa\u011fl\u0131k Bakanl\u0131\u011f\u0131 verilerine g\u00f6re 2020 y\u0131l\u0131nda 1734 keratoplasti yap\u0131lm\u0131\u015ft\u0131r (8).\u00a0 <\/span>Bir\u00e7ok organ nakli bekleyen ki\u015fide oldu\u011fu gibi keratoplastide de uygun don\u00f6r bulmak olduk\u00e7a zordur.\u00a0 <\/span>Ayr\u0131ca, infeksiyonlar (viral infeksiyonlar ve septisemi), maligniteler, ge\u00e7irilmi\u015f g\u00f6z i\u00e7i cerrahi m\u00fcdahaleler ve hastal\u0131klar kornea naklinde kontrendike kabul edilmekte ve uygun olan dokunun imha edilmesine neden olmaktad\u0131r (9). Uluslararas\u0131 G\u00f6z Bankalar\u0131 Federasyonu (\u201cInternational Federation of Eye Banks \u2013 IFEB\u201d) ve Avrupa G\u00f6z Bankas\u0131 Birli\u011fi (\u201cEuropean Eye Bank Association \u2013 EEBA\u201d) taraf\u0131ndan kornea transplantasyonu \u00f6ncesi imm\u00fcnolojik (serolojik) testler zorunlu tutulmu\u015ftur (10). \u00dclkemizde de keratoplasti \u00f6ncesinde s\u00f6z konusu taramalar, Organ ve Doku Al\u0131nmas\u0131, Saklanmas\u0131, A\u015f\u0131lanmas\u0131 ve Nakli Hakk\u0131nda Kanun kapsam\u0131nda zorunlu k\u0131l\u0131nm\u0131\u015ft\u0131r (11, 12). Kornea transplantasyonu sonras\u0131 infeksiyon etkenlerinin bula\u015f\u0131 nadir olmakla birlikte infeksiyon etkenlerinin serolojik taramas\u0131n\u0131n yap\u0131lmas\u0131 ile reaktiflik\/pozitiflik saptanan postmortem kornea don\u00f6rlerinin belirlenmesi post keratoplasti s\u00fcreci i\u00e7in hem geli\u015febilecek infeksiyon hastal\u0131klar\u0131 hem de kornean\u0131n kullan\u0131m\u0131 y\u00f6n\u00fcnden \u00e7ok \u00f6nemlidir. Bu s\u00fcre\u00e7te en s\u0131k\u0131nt\u0131l\u0131 ve kafa kar\u0131\u015ft\u0131r\u0131c\u0131 problem, postmortem kornea don\u00f6rlerinde s\u0131k\u00e7a hemolize ba\u011fl\u0131 olarak g\u00f6zlenen d\u00fc\u015f\u00fck reaktiviteli, \u00f6zellikle antikor saptamaya y\u00f6nelik serolojik test sonu\u00e7lar\u0131d\u0131r. Postmortem kornea d\u00f6norlerindeki pre-op d\u00f6nemde d\u00fc\u015f\u00fck reaktiviteli serolojik test sonu\u00e7lar\u0131 ve algoritmalar\u0131 ile ilintili sorunlara d\u00f6n\u00fck ulusal d\u00fczeyde yap\u0131lan \u00e7al\u0131\u015fmalar\u0131n say\u0131s\u0131 az olup bu hususta farkl\u0131 merkezlerce yeni \u00e7al\u0131\u015fmalar\u0131n yap\u0131lmas\u0131 \u00f6nemlidir.\u00a0<\/span><\/p>\n

Retrospektif olarak ger\u00e7ekle\u015ftirilen \u00e7al\u0131\u015fmam\u0131zda; Cerrahpa\u015fa T\u0131p Fak\u00fcltesi Hastanesi G\u00f6z Bankas\u0131\u2019na keratoplasti i\u00e7in ba\u015fvuran olgular i\u00e7in, kornealar\u0131 haz\u0131rlanan postmortem kornea don\u00f6rlerinin transplantasyon \u00f6ncesi hepatit B virusu (HBV), hepatit C virusu (HCV), insan ba\u011f\u0131\u015f\u0131kl\u0131k yetmezli\u011fi virusu (HIV) ve Treponema pallidum<\/i> serolojik test sonu\u00e7lar\u0131n\u0131n ortaya konmas\u0131 ve \u00f6zellikle d\u00fc\u015f\u00fck reaktif\/pozitif test sonu\u00e7lar\u0131n\u0131 desteklemek veya do\u011frulamak i\u00e7in serolojik ve molek\u00fcler testlerle korelasyonunun saptanmas\u0131 ama\u00e7land\u0131. Ayn\u0131 zamanda, bu verilerle birlikte kornea hastal\u0131klar\u0131nda \u00f6nemli bir \u00e7\u00f6z\u00fcm yolu olan keratoplasti i\u015fleminde, serolojik test sonucu karma\u015fas\u0131ndan dolay\u0131 geli\u015febilecek kornea don\u00f6r kayb\u0131 sorununa d\u00f6n\u00fck olu\u015fturulacak tan\u0131sal algoritmalara bir katk\u0131 sunmay\u0131 hedefledik.\u00a0 \u00a0 \u00a0<\/span><\/p>\n

Y\u00d6NTEMLER<\/h2>\n

\u00c7al\u0131\u015fmam\u0131z, Ocak 2015-Aral\u0131k 2020 tarihleri aras\u0131nda Cerrahpa\u015fa T\u0131p Fak\u00fcltesi G\u00f6z Hastal\u0131klar\u0131 Anabilim Dal\u0131, Kornea Poliklini\u011fi\u2019ne ba\u015fvurmu\u015f ve keratoplasti endikasyonu alan hastalar i\u00e7in hastanemizin g\u00f6z bankas\u0131 taraf\u0131ndan temin edilen kornea don\u00f6rlerinde transplantasyon \u00f6ncesi yap\u0131lan serolojik testlerin retrospektif olarak taranmas\u0131n\u0131 kapsamaktad\u0131r. Kornea dokular\u0131n\u0131n temininde IFEB ve EEBA taraf\u0131ndan belirlenen ko\u015fullar g\u00f6z \u00f6n\u00fcnde tutuldu (10). Bu do\u011frultuda \u00f6ncelikle; nedeni bilinmeyen \u00f6l\u00fcm, tan\u0131s\u0131 konulmam\u0131\u015f n\u00f6rolojik hastal\u0131klardan \u00f6l\u00fcm, Creuzfeldt-Jacob hastal\u0131\u011f\u0131, subakut sklerozan panensefalit, progresif multifokal l\u00f6koensefalit, konjenital rubella, Reyes sendromu, intrinsik g\u00f6z hastal\u0131klar\u0131 gibi sistemik durumlardan herhangi birini i\u00e7eren don\u00f6rlerden kornealar\u0131 al\u0131nmad\u0131. \u00c7al\u0131\u015fmam\u0131zda de\u011ferlendirilen 424 postmortem kornea don\u00f6r\u00fcn\u00fcn demografik ve serolojik test bilgilerine, Cerrahpa\u015fa T\u0131p Fak\u00fcltesi Hastanesi\u2019nin ISHOP sistemi Elisa Laboratuvar\u0131 verilerinden ula\u015f\u0131ld\u0131. Seroloji \u00fcnitesine g\u00f6nderilen 424 postmortem kornea don\u00f6r serumunda; HBV, HCV, HIV ve T. pallidum<\/i> i\u00e7in pre-op tarama testleri olarak HBsAg, Anti-HCV, HIV Ag\/Ab, RPR ile TP-Ab IgG testleri ger\u00e7ekle\u015ftirildi ve d\u00fc\u015f\u00fck reaktiflik saptanan don\u00f6rlerde do\u011frulama testi olarak RT-PCR kiti (\u0130ontek, \u0130stanbul T\u00fcrkiye) kullan\u0131ld\u0131. \u0130lintili y\u00f6ntemlerin de\u011ferlendirilmeleri taraf\u0131m\u0131zca belirlenmi\u015f olup d\u00fc\u015f\u00fck (1-9.99), orta (10.00-19.99) ve y\u00fcksek (>20.00) d\u00fczey [S\/CO (\u201csignal\/cut-off\u201d)] aral\u0131klar\u0131 Tablo 1\u2019de verilmi\u015ftir.\u00a0<\/span><\/p>\n

\"\"<\/a>

Tablo 1.<\/strong> Mikrobiyolojik Olarak \u0130ncelenen Etkenlere Y\u00f6nelik Tarama, Do\u011frulama Testlerinde \u201cCut-Off\u201d ve De\u011ferlendirme Aral\u0131k D\u00fczeyleri<\/p><\/div>\n

Merkezimizde, Ocak 2014-Haziran 2016 tarihleri aras\u0131nda serolojik sifilis tan\u0131s\u0131 i\u00e7in konvansiyonel algoritma izlenmi\u015f olup t\u00fcm serum \u00f6rneklerine non-treponemal tarama testi olarak RPR (\u201crapid plasma reagin\u201d) (Spinreact, Girona, \u0130spanya) uygulanm\u0131\u015ft\u0131r (13). Temmuz 2016\u2019dan itibaren ise konvansiyonel algoritma de\u011fi\u015ftirilmi\u015f olup ABD Hastal\u0131k Kontrol ve Korunma Merkezleri (\u201cCenters for Disease Control and Prevention \u2013 CDC\u201d) (14) ve Avrupa Hastal\u0131k \u00d6nleme Kontrol Merkezi (\u201cEuropean Centre for Disease Prevention and Control –\u00a0 <\/span>ECDC\u201d) (15) \u00f6nerileri do\u011frultusunda ters algoritma uygulanmaya ba\u015flam\u0131\u015ft\u0131r. 2016-2018 y\u0131llar\u0131 aras\u0131nda Tp-Ab IgG (Abbott, Illinois, ABD), 2019\u2019da Elecsys\u00ae Syphilis (Roche Diagnostics, Basel, \u0130svi\u00e7re), 2020 itibariyle ise tekrar Tp-Ab IgG Abbott (Abbott, Illinois, ABD) kullan\u0131larak kemil\u00fcminesans imm\u00fcnoessey (CIA) y\u00f6ntemi uygulanm\u0131\u015ft\u0131r (13) (Tablo 1).<\/p>\n

\u00c7al\u0131\u015fma i\u00e7in, \u0130stanbul \u00dcniversitesi Cerrahpa\u015fa T\u0131p Fak\u00fcltesi Klinik Ara\u015ft\u0131rmalar Etik Kurulu\u2019dan 06 Temmuz 2021 tarih ve A-66 karar numaras\u0131 ile onay al\u0131nm\u0131\u015ft\u0131r.<\/p>\n

BULGULAR<\/h2>\n
\"\"<\/a>

Tablo 2.<\/strong> \u00c7al\u0131\u015fmaya Dahil Edilen Kornea Don\u00f6rlerinin Demografik Verileri<\/p><\/div>\n

\"\"<\/a>

Tablo 3.<\/strong> Serolojik Olarak Pozitiflik\/Reaktiflik Saptanan Kornea Don\u00f6rlerinin Ya\u015f ve Cinsiyete G\u00f6re Da\u011f\u0131l\u0131m\u0131<\/p><\/div>\n

\"\"<\/a>

Tablo 4.<\/strong> Y\u0131llara g\u00f6re HBV, HCV, HIV ve T. pallidum Reaktiflik\/Pozitiflik S\u0131kl\u0131\u011f\u0131<\/p><\/div>\n

\"\"<\/a>

Tablo 5.<\/strong> Serolojik Olarak Pozitiflik\/Reaktiflik Saptanan Kornea Don\u00f6rleri ve Do\u011frulama Test Sonu\u00e7lar\u0131<\/p><\/div>\n

424 don\u00f6re ait demografik veriler Tablo 2\u2019de yer almaktad\u0131r. Postmortem kornea don\u00f6rlerinin 161 (%37.7)\u2019i kad\u0131n iken 263 (%62.03)\u2019\u00fc erkektir. En az postmortem kad\u0131n don\u00f6r say\u0131s\u0131 10 (%6.21) olup 17-26 ya\u015f aral\u0131\u011f\u0131ndad\u0131r; \u00e7o\u011funlukta olan 71 (%44.1) kad\u0131n don\u00f6rse 56 ya\u015f ve \u00fczerindedir. En az postmortem erkek don\u00f6r say\u0131s\u0131 ise 22 (%8.36) olup 17-26 ya\u015f aral\u0131\u011f\u0131ndad\u0131r; \u00e7o\u011funlukta olan 111 (%42.21) erkek don\u00f6rse 56 ya\u015f ve \u00fczerindedir. Erkek ve kad\u0131n don\u00f6r say\u0131lar\u0131n\u0131n k\u0131yaslamas\u0131na y\u00fczdelik olarak bak\u0131ld\u0131\u011f\u0131nda en fazla don\u00f6r\u00fcn 56 ya\u015f ve \u00fczerindeki kad\u0131nlar [71 (%44.1)] oldu\u011fu g\u00f6r\u00fclmektedir.\u00a0<\/span><\/p>\n

Pozitiflik\/reaktiflik saptanan don\u00f6rlerin ya\u015f ve cinsiyete g\u00f6re da\u011f\u0131l\u0131m\u0131 Tablo 3\u2019te verilmi\u015ftir. HBsAg pozitifli\u011fi saptanan 13 don\u00f6r\u00fcn 10 (%76.92)\u2019u erkek ve 3 (%23.07)\u2019\u00fc kad\u0131n olup ya\u015f ortalamas\u0131 55.23\u2019t\u00fcr. Anti-HCV reaktifli\u011fi olan 23 don\u00f6r\u00fcn 10 (%43.47)\u2019u erkek ve 13 (%56.52)\u2019\u00fc kad\u0131n olup ya\u015f ortalamas\u0131 35.69\u2019dur. Anti-HIV 1\/2 reaktifli\u011fi olan 19 don\u00f6r\u00fcn 11 (%57.89)\u2019i erkek ve 8 (%42.10)\u2019i kad\u0131n olup ya\u015f ortalamas\u0131 35.63\u2019t\u00fcr. Tp-Ab IgG reaktifli\u011fi olan 2 don\u00f6r\u00fcn ise tamam\u0131 (%100) kad\u0131n olup ya\u015f ortalamas\u0131 64.5\u2019tir.\u00a0<\/span><\/p>\n

Postmortem kornea don\u00f6rlerinin; HBV, HCV, HIV ve T. pallidum<\/i> reaktiflik\/pozitiflik s\u0131kl\u0131\u011f\u0131n\u0131n y\u0131llara g\u00f6re da\u011f\u0131l\u0131m\u0131 ise Tablo 4\u2019te verilmi\u015ftir. Be\u015f y\u0131ll\u0131k d\u00f6nemde incelenen 424 don\u00f6r\u00fcn; 13 (%3.06)\u2019\u00fcnde HBsAg pozitifli\u011fi, 23 (%5.42)\u2019\u00fcnde Anti-HCV reaktivitesi, 19 (%4.48)\u2019unda anti-HIV 1\/2 reaktivitesi ve 2 (%0.47)\u2019sinde ise Tp-Ab IgG reaktivitesi saptanm\u0131\u015ft\u0131r. HBsAg pozitifli\u011fine 2015- 2016 y\u0131llar\u0131 aras\u0131nda rastlanmazken en fazla pozitiflik 4 don\u00f6rle 2018-2019 y\u0131llar\u0131nda tespit edilmi\u015ftir. Anti-HCV reaktifli\u011fi 2020 y\u0131l\u0131nda g\u00f6r\u00fclmemi\u015f; en fazla reaktiflik 8 don\u00f6rle 2017 y\u0131l\u0131nda bildirilmi\u015ftir. Anti-HIV 1\/2 reaktifli\u011fi bir don\u00f6rle en az olarak 2015 y\u0131l\u0131nda bildirilirken 8 don\u00f6rle en fazla reaktiflik 2017 y\u0131l\u0131ndad\u0131r. Tp-Ab IgG reaktifli\u011fi 2 don\u00f6rle sadece 2020 y\u0131l\u0131nda bildirilmi\u015ftir. Toplamda, Ocak 2015-Aral\u0131k 2020 y\u0131llar\u0131 aras\u0131nda etkenlerin varl\u0131\u011f\u0131 y\u00f6n\u00fcnden 57 reaktiflik\/pozitiflik saptanm\u0131\u015ft\u0131r.<\/p>\n

HBsAg y\u00fcksek pozitifli\u011fi saptanan 13 don\u00f6r\u00fcn, Tp-Ab IgG y\u00fcksek reaktifli\u011fi olan iki don\u00f6r\u00fcn ve anti-HCV, anti-HIV 1\/2 test sonucunda d\u00fc\u015f\u00fck reaktivite saptanan toplam 42 don\u00f6r\u00fcn reaktifliklerinin minimum, ortalama ve maksimum de\u011ferleri Tablo 5\u2019te ayr\u0131nt\u0131l\u0131 olarak g\u00f6sterilmi\u015ftir. HBsAg y\u00fcksek pozitiflikte minimum de\u011fer 24 S\/CO iken maksimum de\u011fer 7519 S\/Co olarak saptanm\u0131\u015ft\u0131r. Tp-Ab IgG\u2019de ise y\u00fcksek reaktiflikte minimum de\u011fer 21 S\/CO iken maksimum de\u011fer 105.6 S\/CO olarak saptanm\u0131\u015ft\u0131r.\u00a0 <\/span>Bununla birlikte, yap\u0131lm\u0131\u015f olan do\u011frulama testi sonucu anti-HCV d\u00fc\u015f\u00fck reaktifli\u011fi bulunan 23 don\u00f6r\u00fcn 22 (%95.65)\u2019sinde anti-HIV 1\/2 d\u00fc\u015f\u00fck reaktifli\u011fi saptanan 19 don\u00f6r\u00fcn ise tamam\u0131nda (%100) RT-PCR sonucu negatif saptanm\u0131\u015ft\u0131r. 2018-2020 y\u0131llar\u0131 aras\u0131nda HBsAg pozitifli\u011fi saptanan 13 don\u00f6r\u00fcn, 2015 y\u0131l\u0131nda d\u00fc\u015f\u00fck reaktivite tespit edilen fakat HCV RT-PCR sonucu pozitif olan 30 ya\u015f\u0131ndaki bir kad\u0131n\u0131n ve 2019 y\u0131l\u0131nda Tp-Ab IgG test sonucu pozitif saptanan iki don\u00f6r\u00fcn kornealar\u0131 infeksiyon varl\u0131\u011f\u0131 nedeniyle g\u00f6z bankas\u0131 taraf\u0131ndan kullan\u0131lmam\u0131\u015ft\u0131r.\u00a0<\/span><\/p>\n

\u0130RDELEME<\/h2>\n

\u0130nsan hayat\u0131n\u0131 do\u011frudan etkileyebilecek keratoplasti \u00f6ncesi yap\u0131lan don\u00f6r se\u00e7iminde korneada hasar olup olmad\u0131\u011f\u0131n\u0131n tespiti i\u00e7in endotel h\u00fccre say\u0131m\u0131n\u0131n yan\u0131 s\u0131ra infeksiyon etkenlerinin varl\u0131\u011f\u0131na d\u00f6n\u00fck olarak yap\u0131lan taramalar da son derece \u00f6nemlidir. Ocak 2015-Aral\u0131k 2020 tarihleri aras\u0131nda yapt\u0131\u011f\u0131m\u0131z tarama sonucunda 424 don\u00f6r\u00fcn 13 (%3.06)\u2019\u00fcnde HBsAg y\u00fcksek pozitiflik, 23 (%5.42)\u2019\u00fcnde anti-HCV d\u00fc\u015f\u00fck reaktiflik, 19 (%4.48)\u2019unda anti-HIV 1\/2 d\u00fc\u015f\u00fck reaktiflik ve 2 (%0.47)\u2019sinde Tp-Ab IgG y\u00fcksek reaktiflik saptanm\u0131\u015ft\u0131r. Hindistan\u2019dan bildirilen bir ara\u015ft\u0131rmada Aral\u0131k 2012 – Haziran 2017 y\u0131llar\u0131 aras\u0131nda 509 kornea don\u00f6r\u00fcnde yap\u0131lan serolojik testler sonucu 12 HBsAg pozitif, bir anti-HCV reaktif don\u00f6r saptan\u0131rken anti-HIV 1\/2 ve sifilis IgG reaktifli\u011fine rastlanmam\u0131\u015ft\u0131r (16). S\u00f6z konusu \u00e7al\u0131\u015fman\u0131n sonu\u00e7lar\u0131n\u0131n kar\u015f\u0131la\u015ft\u0131r\u0131lmas\u0131 yap\u0131ld\u0131\u011f\u0131 zaman HBsAg verileri y\u00f6n\u00fcnden bizim \u00e7al\u0131\u015fmam\u0131zla benzer oldu\u011fu g\u00f6r\u00fclmektedir. G\u00fcney Brezilya\u2019da 2019 y\u0131l\u0131nda yap\u0131lan bir \u00e7al\u0131\u015fmada ise 4 y\u0131ll\u0131k bir retrospektif tarama sonucunda 4645 don\u00f6rden 9290 kornea al\u0131nd\u0131\u011f\u0131 fakat 2097 (%49.6) kornean\u0131n seropozitiflikten \u00f6t\u00fcr\u00fc kullan\u0131lamad\u0131\u011f\u0131 tespit edilmi\u015ftir (17). Alt\u0131nkurt ve arkada\u015flar\u0131 (18) taraf\u0131ndan 2020 y\u0131l\u0131nda 23 y\u0131ll\u0131k don\u00f6r verilerinin analizinin yap\u0131ld\u0131\u011f\u0131 bir \u00e7al\u0131\u015fmada, 2018 don\u00f6rden al\u0131nan toplam 3048 kornea dokusunun 206 (%5.35)\u2019s\u0131n\u0131n serolojik testlerin pozitifli\u011fi nedeniyle kullan\u0131lamad\u0131\u011f\u0131 bildirilmi\u015ftir.\u00a0 <\/span>Kocazeybek ve arkada\u015flar\u0131 (19) taraf\u0131ndan 229 kornea don\u00f6r\u00fcnde yap\u0131lan \u00e7al\u0131\u015fmada, 15 (%6.6.) don\u00f6rde HbsAg pozitifli\u011fi, 2 (%0.9) don\u00f6rde anti-HCV reaktifli\u011fi ve bir don\u00f6rde ise her iki etken i\u00e7in yap\u0131lan testler pozitif olarak saptanm\u0131\u015ft\u0131r (19). S\u00f6z konusu \u00e7al\u0131\u015fman\u0131n sonu\u00e7lar\u0131 HBsAg pozitifli\u011fi a\u00e7\u0131s\u0131ndan bizim bulgular\u0131m\u0131zla uyumlu olmakla birlikte zaman i\u00e7erisinde anti-HCV reaktifli\u011finde art\u0131\u015f oldu\u011fu ve bu art\u0131\u015f\u0131n yap\u0131lan molek\u00fcler do\u011frulama sonucunda yanl\u0131\u015f pozitiflikten kaynakland\u0131\u011f\u0131 g\u00f6sterilmi\u015ftir.\u00a0<\/span><\/p>\n

Kan, Doku ve Organlar\u0131n G\u00fcvenli\u011fi Dan\u0131\u015fma Kurulu (\u201cAdvisory Committee on the Safety of Blood, Tissues and Organs \u2013 SaBTO\u201d), kornea don\u00f6rlerinde HCV taramas\u0131 a\u00e7\u0131s\u0131ndan anti-HCV testinin tek ba\u015f\u0131na yeterli olmad\u0131\u011f\u0131n\u0131; HIV antikor taramas\u0131n\u0131n ise tek ba\u015f\u0131na d\u00fc\u015f\u00fck duyarl\u0131l\u0131\u011fa sahip oldu\u011funu ve bu etkenlerin bir n\u00fckleik asit amplifikasyon testiyle (NAAT) RNA varl\u0131\u011f\u0131 a\u00e7\u0131s\u0131ndan taranarak do\u011frulanmas\u0131 gerekti\u011fini belirtmektedir (20). Bu do\u011frultuda, \u00e7al\u0131\u015fmam\u0131zda ger\u00e7ekle\u015ftirilen tarama testlerinde anti-HCV d\u00fc\u015f\u00fck reaktivite saptanan 23 don\u00f6r ve anti-HIV 1\/2 d\u00fc\u015f\u00fck reaktivite saptanan 19 don\u00f6r d\u0131\u015f merkezde do\u011frulama testine tabi tutulmu\u015f olup do\u011frulama testi sonucunda HCV ve HIV RNA saptanmayan 41 don\u00f6r\u00fcn kornealar\u0131 g\u00f6z bankas\u0131 taraf\u0131ndan kullan\u0131lm\u0131\u015ft\u0131r. Ger\u00e7ekle\u015ftirilen t\u00fcm serolojik ve molek\u00fcler testlerin sonucunda; toplam\u0131 16 olmak \u00fczere, HBV varl\u0131\u011f\u0131 saptanan 13, HCV varl\u0131\u011f\u0131 saptanan bir ve T. pallidum<\/i> varl\u0131\u011f\u0131 saptanan iki don\u00f6r\u00fcn kornealar\u0131 halk sa\u011fl\u0131\u011f\u0131 nedeniyle kullan\u0131lmam\u0131\u015ft\u0131r. \u00c7al\u0131\u015fmam\u0131zdaki baz\u0131 don\u00f6r serumlar\u0131nda d\u00fc\u015f\u00fck reaktiviteli HCV ve HIV saptanmas\u0131n\u0131n nedeni;\u00a0 <\/span>\u00f6l\u00fcm sonras\u0131 ge\u00e7en s\u00fcre (d\u00fc\u015f\u00fck HCV ve HIV reaktivitesi g\u00f6steren postmortem serumlar transplantasyondan \u00f6nce laboratuvar\u0131m\u0131za mikrobiyolojik \u00e7al\u0131\u015fmalar i\u00e7in minimum 12 saat, maksimum 36 saat ortalama 24 saat i\u00e7erisinde iletilmi\u015ftir), \u00e7evre \u015fartlar\u0131 ve antijen-antikor reaksiyonlar\u0131na ba\u011fl\u0131 olarak postmortem v\u00fccut s\u0131v\u0131lar\u0131ndaki biyokimyasal ve mikrobiyolojik inceleme sonu\u00e7lar\u0131n\u0131n de\u011fi\u015fmesi olabilir. Klinik \u00f6l\u00fcm\u00fcn ger\u00e7ekle\u015fmesi ile t\u00fcm organizmada h\u00fccre d\u00fczeyinde oksijen yetmezli\u011fi, karbondioksit birikimi, pH de\u011fi\u015fiklikleri, toksik \u00fcr\u00fcnlerin birikimi meydana gelmektedir (21-23). \u00d6l\u00fcm sonras\u0131 kanda ve di\u011fer v\u00fccut s\u0131v\u0131lar\u0131nda meydana gelen de\u011fi\u015fiklikler nedeniyle biyokimyasal ve mikrobiyolojik incelemeler h\u0131zla de\u011ferini yitirmektedir (21-23). Postmortem koagulum genellikle \u00f6l\u00fcmden 3-4 saat sonra hemolize olmaya ba\u015flar ve bu olay 24 saatte tamamlan\u0131r (21-23).\u00a0 <\/span>\u0130srail\u2019de yap\u0131lan bir \u00e7al\u0131\u015fmada, postmortem kornea don\u00f6rlerinde HCV antikor test sonu\u00e7lar\u0131n\u0131 etkileyebilecek en \u00f6nemli parametrenin \u00f6l\u00fcm saati oldu\u011fu; kornean\u0131n tedariki ile \u00f6l\u00fcm saati aras\u0131ndaki zaman aral\u0131\u011f\u0131n\u0131n anti-HCV reaktifli\u011fi i\u00e7in olduk\u00e7a \u00f6nemli bir risk fakt\u00f6r\u00fc oldu\u011fu bildirilmi\u015ftir. S\u00f6z konusu \u00e7al\u0131\u015fmada, 10 saatten az zaman aral\u0131\u011f\u0131 olan don\u00f6rlerde pozitif test sonu\u00e7lar\u0131n\u0131n oran\u0131 sadece %2.9 iken, 10 saatten uzun olanlarda %10 oldu\u011fu tespit edilmi\u015ftir (24). Bu durum yanl\u0131\u015f pozitifliklerin verilmesine ve sonucunda kornean\u0131n bu hatadan \u00f6t\u00fcr\u00fc kullan\u0131lamamas\u0131na neden olabilmektedir. Bununla birlikte, postmortem kanlar\u0131nda bak\u0131lan HBV, HCV, HIV ve T. pallidum<\/i> etkenlerinin imm\u00fcnolojik (serolojik) test sonu\u00e7lar\u0131nda, antijen-antikor aras\u0131 ba\u011flar\u0131n non-spesifik olarak ba\u011flanmas\u0131 ve hidrojen ba\u011flar\u0131 gibi van Der walls kuvvetlerinin zay\u0131f olu\u015fumu sonucu d\u00fc\u015f\u00fck reaktivite ya da yanl\u0131\u015f pozitiflik meydana gelebilir (21-23). Lee ve arkada\u015flar\u0131 (25) taraf\u0131ndan yap\u0131lan \u00e7al\u0131\u015fmada, bir y\u0131l boyunca Kanada G\u00f6z Bankas\u0131\u2019na gelen 1619 potansiyel postmortem kornea don\u00f6r\u00fc ilk olarak serolojik olarak taranm\u0131\u015f ve bunlar\u0131n 15\u2019inde anti-HCV reaktifli\u011finin saptand\u0131\u011f\u0131 belirtilmi\u015ftir. Ayn\u0131 \u00e7al\u0131\u015fmada yap\u0131lan molek\u00fcler temelli do\u011frulama testi ile kornea don\u00f6rlerinin 7\u2019sinde HCV RNA tespit edildi\u011fi belirtilmi\u015ftir. Bu sebeple, postmortem kornea don\u00f6rlerinde yap\u0131lan serolojik pre-op tarama testlerinin, do\u011frulama testleriyle desteklenmesi halk sa\u011fl\u0131\u011f\u0131 a\u00e7\u0131s\u0131ndan son derece \u00f6nemlidir.\u00a0<\/span><\/p>\n

Sonu\u00e7 olarak, yap\u0131lan bu retrospektif tarama; kornea transplantasyonu \u00f6ncesinde, seropozitif vericilerdeki HBV, HCV, HIV ve T. pallidum<\/i>\u2019un al\u0131c\u0131 sa\u011fl\u0131\u011f\u0131 a\u00e7\u0131s\u0131ndan olduk\u00e7a \u00f6nemli bir risk oldu\u011funu, transplantasyon \u00f6ncesi bu taramalar\u0131n ve do\u011frulamalar\u0131n titizlikle yap\u0131lmas\u0131n\u0131n gereklili\u011fini bir kez daha g\u00f6stermi\u015ftir. Ayr\u0131ca, kornea transplantasyonu \u00f6ncesi mikrobiyolojik bula\u015fmalar\u0131 \u00f6nlemek i\u00e7in mikrobiyoloji laboratuvarlar\u0131nda kullan\u0131lan test ve kitlerin optimize, duyarl\u0131\u011f\u0131 ve \u00f6zg\u00fcll\u00fc\u011f\u00fc y\u00fcksek olmas\u0131 olduk\u00e7a \u00f6nemlidir. Postmortem kornea don\u00f6rlerinin k\u0131s\u0131tl\u0131 ba\u011f\u0131\u015flardan dolay\u0131 yeterince bulunamamas\u0131 g\u00f6z \u00f6n\u00fcne al\u0131narak don\u00f6rlerde saptanabilecek d\u00fc\u015f\u00fck pozitif\/reaktif sonu\u00e7lar\u0131n kornealar\u0131n kullan\u0131lamamas\u0131na neden olmamas\u0131 i\u00e7in her laboratuvar\u0131n belirli bir algoritmas\u0131n\u0131n olmas\u0131 gerekmektedir.\u00a0 <\/span>B\u00f6ylelikle d\u00fcnyada s\u0131k nakledilen bir doku olmas\u0131na ra\u011fmen T\u00fcrkiye\u2019de halen istenilen d\u00fczeyde olmayan kornea transplantasyonunun serolojik taramalar sonucu yanl\u0131\u015f pozitifli\u011fe\/reaktifli\u011fe ba\u011fl\u0131 kullan\u0131lamamas\u0131n\u0131n \u00f6n\u00fcne ge\u00e7ilebilece\u011fini d\u00fc\u015f\u00fcn\u00fcyoruz. Ayr\u0131ca, ulusal d\u00fczeyde bu t\u00fcr taramalar\u0131n ve \u00e7al\u0131\u015fmalar\u0131n art\u0131r\u0131lmas\u0131n\u0131n yan\u0131 s\u0131ra ortak ve \u00f6zellikle d\u00fc\u015f\u00fck reaktiviteli sonu\u00e7lara y\u00f6nelik bir pre-op tarama ve tan\u0131 algoritmas\u0131n\u0131n tekrar g\u00f6zden ge\u00e7irilmesi gerekti\u011fi kanaatindeyiz. Elde etti\u011fimiz veriler neticesinde kornea transplantasyonu \u00f6ncesinde postmortem don\u00f6rlerde HCV, HIV ve HBV i\u00e7in do\u011frulama testi olarak RT-PCR\u2019\u0131n, T. pallidum<\/i> i\u00e7inse RPR testlerinin uygulanmas\u0131n\u0131n etkin oldu\u011funu tespit ettik.<\/p>\n","protected":false},"excerpt":{"rendered":"

G\u0130R\u0130\u015e Keratoplasti olarak da adland\u0131r\u0131lan kornea nakli ilk kez 1905 y\u0131l\u0131nda Eduard Konrad Zirm taraf\u0131ndan yap\u0131lm\u0131\u015f olup o zamandan bu yana en s\u0131k yap\u0131lan nakil t\u00fcr\u00fcd\u00fcr (1). Kornean\u0131n tam kal\u0131nl\u0131kta de\u011fi\u015ftirilmesini i\u00e7eren bir prosed\u00fcr olan penetran keratoplasti (PK), yar\u0131m y\u00fczy\u0131ldan fazla bir s\u00fcredir yayg\u0131n olarak uygulanmaktad\u0131r (2-4). Bununla birlikte baz\u0131 \u00e7al\u0131\u015fmalar, PK\u2019y\u0131 takiben uzun vadeli […]<\/p>\n","protected":false},"author":4,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"footnotes":""},"categories":[5129],"tags":[5458,5459,5163,5457,5460],"class_list":["post-24906","post","type-post","status-publish","format-standard","hentry","category-ozgun-arastirma","tag-hbv-2","tag-hcv-2","tag-hiv-2","tag-kerotoplasti","tag-treponema-pallidum-2"],"acf":[],"_links":{"self":[{"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts\/24906","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/users\/4"}],"replies":[{"embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/comments?post=24906"}],"version-history":[{"count":4,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts\/24906\/revisions"}],"predecessor-version":[{"id":25140,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts\/24906\/revisions\/25140"}],"wp:attachment":[{"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/media?parent=24906"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/categories?post=24906"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/tags?post=24906"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}