A. De Vecchi

Cutaneous Lesions in 67 Cyclosporin-Treated Renal Transplant Recipients

Sixty-seven out of 100 kidney transplant recipients treated with cyclosporin and methylprednisolone were evaluated for the presence of dermatological manifestations. Only 2 patients had no dermatological lesions; 80% had iatrogenic lesions, 38% infectious, 13% miscellaneous, 3% cancerous lesions, while 28% had cutaneous manifestations related to previous uremic state. Most of the lesions concerned the pilosebaceous unit: hypertrichosis (60%), epidermal cysts (28%), pilar keratosis (21%), acne (15%), folliculitis (12%) and sebaceous hyperplasia (10%). Among infectious manifestations, viral lesions were the most frequent and were very severe in the first month after transplantation. Two patients developed a squamous-cell epithelioma and a probable cutaneous lymphoma, respectively.

Lipid Disorders in Renal Transplant Recipients

Plasma cholesterol, triglyceride, lipoprotein and phospholipid levels were higher in 76 transplant recipients than in normal age-matched controls. 22 patients exhibited a normal lipid pattern; 12 a type IIa, 12 a type IIb, and 30 a type IV hyperlipidemia. Lipid abnormalities were not related to serum creatinine, parathyroid hormone (PTH), serum albumin, plasma glucose, transplant age, relative body weight or steroid administration schedule. Only plasma triglyceride level was related to mean prednisone dosage. In order to reduce the apparent cardiovascular risk posed by these changes in plasma lipid concentration, hypocaloric diet was administered to 16 patients with hypertriglyceridemia or mixed hypertriglyceridemia and hypercholesterolemia. With these dietary measures, plasma lipid concentrations returned to normal and remained stable during the period of observation (6--18 months).

Cutaneous Manifestations in Renal Transplant Recipients

Out of 105 renal transplant recipients 100 had skin lesions: 55% iatrogenic, 74% infectious, 12% precancerous or cancerous and 4% miscellaneous. Many of these lesions were at least in part transient, and steroid-related skin lesions became less frequent as years progressed. The more frequent infections were the fungal ones, followed by viral and bacterial infections with different patterns of onset. All the precancerous lesions appeared late and were almost exclusively represented by actinic keratoses; 2 evolved into squamous cell epitheliomata. 2 patients died due to Kaposis sarcoma and melanoma. The high incidence of skin cancers in transplanted patients and the rapid evolution of dyskeratoses into spinaliomas warrants close dermatological surveillance.

A randomized trial comparing triple-drug and double-drug therapy in renal transplantation

This is the 7-year update of a randomized trial comparing triple (TT) and double (DT) immunosuppressive therapy in renal transplantation. At 7 years, patient survival rate was 85% in DT vs. 87% in TT (P=NS); graft survival rate was 73% in DT and 68% in TT (P=NS); pure graft survival was 86% in DT vs. 77% in TT (P=0.096). The 7-year graft survival rate was 67% for cadaver graft recipients vs. 92% for living-related graft recipients (P=0.044). No difference in the slopes of plasma creatinine between the two groups was observed. Ten DT and 13 TT patients changed their original therapy: statistical analysis, however, was carried out according to intention to treat. Both CsA levels and doses were significantly higher in DT than in TT group (P<0.001) at any time point up to the 7th year. At univariate analysis, a living-related donor kidney (P=0.044) and immediate recovery of renal function (P<0.001) were the only two parameters associated with graft survival at 7 years. At multivariate analysis, only early graft function recovery was correlated with late graft survival (RR=10.480). Thus, even in the long-term, there is no difference between DT and TT, either in patient or in graft survival: at the doses we used, TT had a lower prevalence of late side effects than DT, however, long-term pure graft survival was better, although not significantly, in DT than in TT. The possibility of a safe shift from one regimen to the other one makes the two treatments complementary rather than alternatives.

High Prevalence of Silent Gallstone Disease in Dialysis Patients

Gallstone disease was detected in 28% of 119 patients on regular dialysis treatment. The disease was silent in 82% of the patients. Stones were radiolucent in 88% of the cases, radioopaque in 8% and mixed in 4%. Among 49 variables considered, increasing age was the only variable that correlated significantly with increasing prevalence of gallstone disease. Since no relationships were found between gallstones and age or modes of dialysis, it is conceivable that some mechanism(s) linked with the preexisting chronic nephropathy might have been involved in the development of cholelithiasis. End-stage renal disease could be another so far unrecognized risk factor for cholelithiasis.

Long-Term Incidence of Peritonitis in CAPD Patients Treated by the Y Set Technique: Experience in a Single Center

Our experience of peritonitis in 156 patients over an 8-year period represents 186 episodes of peritonitis and 4,964 patient-months of CAPD. The incidence of peritonitis was significantly greater (1 episode every 8.6 patient-months) when the Oreopoulos technique was used and dropped to 1 episode every 43.3 patient-months when the Y set system was used. Of the 109 patients using the Y set system, 88 (80.7%) never had episodes of peritonitis, whereas only 7 (16.7%) of the 42 patients using the Oreopoulos technique were free of peritonitis. For 23 patients shifted from the Oreopoulos to the Y set technique, the incidence of peritonitis dropped from 1/9.8 to 1/35.2 episodes/patient-months.

Effect of incremental doses of folate on homocysteine and metabolically related vitamin concentrations in nondiabetic patients on peritoneal dialysis

The role of folate supplementation in reducing hyperhomocystinemia in patients on dialysis has been reported, but the optimal dose of folate is still unknown. The aim of the present study was to investigate whether greater than 5 mg/day folate supplementation provides any additional effect on plasma homocysteine (HCY) levels. The study was prospective, open, and had no control group. Of the 64 eligible nondiabetic patients on peritoneal dialysis with hyperhomocystinemia (>20 &mgr;mol/L), 56 were given oral folate (5 mg/day) for 3 months. When Hcy did not fall below 20 &mgr;mol/L, folate doses were increased by 5 mg every 3 months to up to 15 mg/day. With 5 mg/day supplementation, serum folate concentrations increased above the upper confidence limit in 23 patients and erythrocyte folate concentrations in 27 patients. Hcy levels decreased to less than 15 &mgr;mol/L in 6 cases and by more than 50% in 12 cases. Nineteen of the remaining patients were given 10 mg/day folate. After increasing the dose, serum and erythrocyte folate levels rose above the upper detection limit. In one patient, plasma Hcy concentrations decreased to less than 15 &mgr;mol/L. Ten patients were given 15 mg/day oral folate for an additional 3 months with no effect on homocystinemia. This study confirms that oral folate supplementation may improve hyperhomocystinemia even in patients on dialysis with normal serum or erythrocyte folate concentrations. In fact, serum and erythrocyte levels cannot predict the effect of supplementation on plasma Hcy levels. However, 5 mg/day folate supplementation normalized Hcy in 10% of cases and reduced Hcy levels in another 21%. Increasing the folate dose to greater than 5 mg/day had a minimal (10 mg/day) or no (15 mg/day) additional effect on Hcy concentrations. Despite the minimal effect of increasing folate doses, given the low cost, the absence of side effects, and the high cardiovascular risk for patients on peritoneal dialysis, a careful attempt to increase the dose of oral folate up to 10 mg/day might be suggested.

Controlled Trial of Two Different Methylprednisolone Doses in Cadaveric Renal Transplantation

In a controlled trial the effects of two different methylprednisolone (MP) schedules were studied in 100 cadaver kidney adult recipients followed for 18-46 months. Group A patients were given 160 mg/day i.v. for 3 days, then oral MP (0.8 mg/kg/day), which was tapered by 4 mg/week to a maintenance dose of 16 mg/day up to the 6th month. Group B patients were given 80 mg/day i.v. for 3 days followed by 0.4 mg/kg/day oral MP; the dose was reduced by 2 mg/week to 16 mg/day. In both groups, the dose was further reduced bimonthly to a final dose of 8 mg/day. No significant differences were evidenced between the two groups in patients and kidney survival or in the incidence of complications. The number of patients with at least one rejection episode was significantly higher in the lower dose group.

Continuous ambulatory peritoneal dialysis in patients after intra-abdominal prosthetic vascular graft surgery

The purpose of this study was to assess the feasibility of continuous ambulatory peritoneal dialysis (CAPD) after intra-abdominal prosthetic vascular graft surgery. We report 8 consecutive patients with end-stage renal disease, who previously underwent intra-abdominal prosthetic aortic graft replacement, treated by CAPD between November 1983 and November 1994. All patients received a peritoneal dialysis catheter without technical problems and were dialyzed for a total of 208 months. Six episodes of peritonitis occurred in 4 patients without clinical evidence of any abdominal aortic graft infection. Three patients developed intermittent claudication and 2 died of myocardial infarct. A similar peritonitis and cardiovascular complication rate was observed in a control group of age- and sex-matched CAPD patients with no aortic prosthesis. We conclude that CAPD is feasible in patients with abdominal aortic prosthesis.