Alessia Giaquinta

Age is an important predictor of kidney transplantation outcome

BACKGROUND Donor and recipient age may have an impact on the renal transplant outcome. Kidney transplantation from older donors may result in a worse outcome, and the survival benefit of kidney transplantation compared with dialysis may be reduced. The aim of this study was to evaluate the impact of donor and recipient age on kidney transplant outcome. MATERIALS AND METHODS Two hundred and twenty-three recipients of kidney transplants performed at our institution between 2002 and 2007 were analysed. The role of donor and recipient age matching on survival rate were investigated performing the Kaplan-Meier survival time analysis by decades, considering the donors age of 60 and 70 years. The Cox proportional hazard uni- and multivariate regressions were also performed. Finally, Kaplan-Meier survival time analysis was performed to assess survival rates of patients transplanted stratified by donor age compared with wait-listed renal transplant candidates. RESULTS Elderly recipients had a significant lower graft and patient survival as well as a significantly higher risk of graft loss and patient death. Recipients younger and older than 65 years of age were at higher risk of graft loss if they received grafts from donors>65 years [hazard ratio (HR)=2.59, 95% confidence interval (CI): 1.12-6 and HR=5.65, 95% CI: 2.31-13.79, respectively]. Elderly recipients displayed a worse survival compared with transplant candidates on the waiting list. CONCLUSIONS Age is an important predictor of kidney transplantation outcome. Kidney transplantation does not offer a significant survival benefit in the intermediate term, compared to the waiting list, to elderly recipients transplanted with grafts from older donors. However, it cannot be excluded that it is still possible that there is a long-term benefit of transplantation over dialysis in this group of patients.

Surveillance of Human Papilloma Virus Infection and Cervical Cancer in Kidney Transplant Recipients: Preliminary Data

INTRODUCTION Development of cancer after transplantation has rapidly became one of the leading causes of death in kidney transplant recipients with functioning grafts. Anogenital malignant neoplasms may occur with a 14-fold increased incidence, and human papilloma virus (HPV) infection has been recently identified as the leading cause of cervical carcinoma. We report the preliminary findings of a prospective study that evaluated the incidence of HPV infection and cervical carcinoma in a population of kidney transplant recipients. PATIENTS AND METHODS The study included 35 female recipients of a deceased donor kidney with at least 6 months of follow-up. All patients underwent a cervicovaginal brushing, an HPV DNA test, and a Papanicolaou test. RESULTS Twenty-two patients (62.8%) were positive for HPV DNA. Thirteen of 22 HPV DNA-positive recipients (59%) demonstrated a high-risk HPV genotype. No cytologic anomalies were detected in Papanicolaou smears. CONCLUSIONS These preliminary data demonstrated a high incidence of HPV infection in renal transplant recipients. Most of our recipients exhibited a high-risk HPV genotype, which suggests higher aggressiveness of such infection in immunosuppressed patients. The HPV test is useful to monitor patients at higher risk of anogenital malignant neoplasms by identifying the cytologic anomalies at an earlier stage. This ongoing study will investigate the rate of progression of HPV infection and the clinical patterns of HPV-positive cytologic anomalies in renal transplant recipients.

Low-intensity body building exercise induced rhabdomyolysis: a case report

IntroductionRhabdomyolysis is a severe and debilitating condition that promotes muscle breakdown and is a relatively rare, not always diagnosed cause of acute renal failure (ARF) with an 8–20% reported incidence. Exertional rhabdomyolysis only appears in adult patients 24–48 h after strenuous activities as military basic training, weight lifting, and marathon running.Case presentationA 30-year-old man was admitted to our department because of weakness and painful swelling of the muscles as well as dark urine appearing 24 h after carrying out a body-building exercises of low intensity. The development of an acute exertional rhabdomyolysis was confirmed by the increased serum enzyme levels and myoglobinuria. The patient was treated with intravenous sodium chloride, and sodium bicarbonate. The nephrotoxicity of myoglobin was decreased by forced alkaline diuresis.ConclusionThe reported case emphasizes the occurrence of acute rhabdomyolysis even in those who underwent a low-intensity exercise. A proper treatment is mandatory to avoid a sudden worsening of clinical conditions eventually evolving to acute renal failure.

Psychopathological aspects of kidney transplantation: Efficacy of a multidisciplinary team

Renal transplantation is a well established treatment for end-stage renal disease, allowing most patients to return to a satisfactory quality of life. Studies have identified many problems that may affect adaptation to the transplanted condition and post-operative compliance. The psychological implications of transplantation have important consequences even on strictly physical aspects. Organ transplantation is very challenging for the patient and acts as an intense stressor stimulus to which the patient reacts with neurotransmitter and endocrine-metabolic changes. Transplantation can result in a psychosomatic crisis that requires the patient to mobilize all bio-psycho-social resources during the process of adaptation to the new foreign organ which may result in an alteration in self-representation and identity, with possible psychopathologic repercussions. These reactions are feasible in mental disorders, e.g., post-traumatic stress disorder, adjustment disorder, and psychosomatic disorders. In organ transplantation, the fruitful collaboration between professionals with diverse scientific expertise, calls for both a guarantee for mental health and greater effectiveness in challenging treatments for a viable association between patients, family members and doctors. Integrated and multidisciplinary care should include uniform criteria and procedures for standard assessments, for patient autonomy, adherence to therapy, new coping strategies and the adoption of more appropriate lifestyles.

Primary balloon angioplasty of small (≤2 mm) cephalic veins improves primary patency of arteriovenous fistulae and decreases reintervention rates

PURPOSE The purpose of this study was to evaluate the effect of primary balloon angioplasty (PBA) of cephalic veins with diameter≤2 mm on patency and maturation time of autogenous radiocephalic arteriovenous fistulae (AVF) for hemodialysis. METHODS Forty patients, all candidates for distal AVF, with a cephalic vein≤2 mm, were randomized to two different surgical procedures: (1) PBA of a long segment of the cephalic vein from the wrist up to the elbow (n=19); and (2) hydrostatic dilatation (HD) of a short venous segment (5 cm) at the level of the anastomosis (n=21). PBA was performed using a standard balloon 4×150 mm. Primary end points were primary patency and reintervention rates. Secondary end points were maturation time and the rate of working AVF. Follow-up included physical and duplex ultrasound (DUS) examinations at 1,4, and 8 weeks, and every 3 months thereafter. RESULTS Risk factors were homogeneously distributed between the two groups. Mean vein diameter was 1.8±0.2 mm for the PBA group and 1.7±0.2 mm for HD. Immediate success rate was 100% for PBA and 67% for HD groups (P=.04). Causes of failure in the HD group included early vein thrombosis in seven patients (33%). Mean fistula maturation time was 32 days in the PBA group and 55 days in the HD group (P=.04). During the mean follow-up of 7 months, three patients underwent drug-eluting balloon angioplasty for failure of AVF to mature due to stenosis (1 in the PBA group and 2 in the HD group). Six-month reintervention rate was significantly lower in the PBA group (5%) compared with the HD group (43%) (P=.02). At 6 months, primary patency rates were 95% in the PBA group and 57% in the HD group (P=.01). Working AVF rate was 100% in the PBA vs 90% in the HD group. CONCLUSIONS PBA of very small cephalic veins during the creation of a distal AVF for hemodialysis is a safe and feasible procedure. This technique assures excellent primary patency, maturation time, and dramatically decreases reintervention rate.

Quality of Life in Kidney Transplantation From Marginal Donors

OBJECTIVE Enhancement of the subjective components, recognition of overall needs, and careful consideration of subjectively perceived quality of life among dialysis and/or transplanted patients appear to be key objectives to promote optimized adherence to treatment and active cooperation of the patient. This study explores the relationship between self-rated health among recipients of kidney transplantations from deceased marginal donors (age older than 55 years) in relation to gender, age, time on dialysis, years after transplantation, and donor age. PATIENTS AND METHODS Posttransplant quality of life was assessed with the Complete Form Health Survey (SF-36) in 70 recipients of kidney transplantations from marginal deceased donors. RESULTS Donor age did not negatively influence health status perceived by the subjects. The vitality and mental health seemed to increase with greater donor ages, but the status of perceived health, vitality, social activities, and mental health were negatively influenced by the age of the transplant. CONCLUSIONS Our study shows that good general health and social well-functioning can be achieved also among recipients of organs from older donors. Thus, age alone should not be a barrier to organ donation, providing that the organ function is normal and that specific disease is absent in the organ.

Conversion to Sirolimus Therapy in Kidney Transplant Recipients with New Onset Diabetes Mellitus after Transplantation

New-onset diabetes mellitus after transplantation (NODAT) may complicate 2–50% of kidney transplantation, and it is associated with reduced graft and patient survivals. In this retrospective study, we applied a conversion protocol to sirolimus in a cohort of kidney transplant recipients with NODAT. Among 344 kidney transplant recipients, 29 patients developed a NODAT (6.6%) and continued with a reduced dose of calcineurin inhibitors (CNI) (8 patients, Group A) or were converted to sirolimus (SIR) (21 patients, Group B). NODAT resolved in 37.5% and in 80% patients in Group A and Group B, respectively. In Group A, patient and graft survivals were 100% and 75%, respectively, not significantly different from Group B (83.4% and 68%, resp., P = 0.847). Graft function improved after conversion to sirolimus therapy: serum creatinine was 1.8 ± 0.7 mg/dL at the time of conversion and 1.6 ± 0.4 mg/dL five years after conversion to sirolimus therapy (P < 0.05), while in the group of patients remaining with a reduced dose of CNI, serum creatinine was 1.7 ± 0.6 mg/dL at the time of conversion and 1.65 ± 0.6 mg/dL at five-year followup (P = 0.732). This study demonstrated that the conversion from CNI to SIR in patients could improve significantly the metabolic parameters of patients with NODAT, without increasing the risk of acute graft rejection.

Contamination of preservation fluid in kidney transplantation: single-center analysis.

INTRODUCTION Contamination of preservation fluid is common, with a reported incidence of 2.2% to 28.0%, and may be a major cause of early morbidity after transplantation. Herein, we report our experience with routine examination of preservation fluid collected just before implantation, focusing on the rate of contamination and the clinical consequences to recipients. MATERIALS AND METHODS We analyzed 62 samples of preservation fluid for microbial and fungal contamination. RESULTS Twenty-four samples (38.7%) were contaminated with at least 1 organism. Bacterial contamination alone was observed in 18 samples; all patients received prophylactic treatment with intravenous piperacillin/tazobactam, 4.5 g/d for 10 days, without clinical sequelae. Six samples were contaminated with Candida species; all patients received prophylactic treatment with fluconazole, 100 mg/d for 3 months. One patient developed reversible acute renal failure due to ureteral obstruction by fungus balls at 30 days after transplantation. CONCLUSION Contamination of preservation fluid occurs frequently after kidney transplantation. Bacterial contamination evolved without symptoms in most patients treated with prophylactic antibiotic therapy. Fungal contamination may be potentially life-threatening. However, graft nephrectomy is not mandatory if the involved Candida species is identified correctly and appropriate antifungal therapy is rapidly prescribed.

Impact of conversion to a once daily tacrolimus-based regimen in kidney transplant recipients with gastrointestinal complications.

Background Gastrointestinal (GI) complications may affect up to 64% of kidney transplant recipients, with a higher incidence of symptoms in patients receiving tacrolimus-based immunosuppression. Tacrolimus extended release once-daily (OD) formulation offers the benefit of OD administration over standard tacrolimus, with a similar rate of GI complications when compared with the standard tacrolimus. We hypothesized that patients with tacrolimus-based immunosuppressive regimen with posttransplant gastrointestinal symptoms may benefit from a conversion to a tacrolimus OD regimen. Methods In this pilot study, 27 kidney transplant recipients with tacrolimus-related GI complications were converted to a tacrolimus OD regimen (group 1). This group was compared with a historical cohort of 30 patients on standard tacrolimus therapy with GI symptoms (group 2). Patients were followed up for 1 year after initial enrollment. Results Patients in group 1 reported a significant improvement in GI symptoms, as expressed by the change in the Gastrointestinal Symptom Rating Scale scores (1.7±0.3 vs. 1.2±0.2, P<0.001) and GI-specific health-related quality of life scores (87±26.3 vs. 97±24.6, P<0.05). After comparing changes in Gastrointestinal Symptom Rating Scale total scores and subscale scores at 12 months, patients in Group 1 scored better than patients in Group 2 in total scores (−0.5 vs. −0.12, P<0.0001), abdominal pain (P<0.001), diarrhea (P<0.001), and reflux (P=0.013). Conclusions Preliminary results from this study demonstrate that kidney transplant recipients experiencing tacrolimus-induced GI symptoms may benefit from a conversion to a tacrolimus OD regimen.

The Study of Personality in Renal Transplant Patients: Possible Predictor of an Adequate Social Adaptation?

BACKGROUND This study explored the personality characteristic traits within a sample of renal transplant patients, seeking to obtain predictive index for likely clinical impacts. PATIENTS AND METHODS The personality study was performed using the Structured Clinical Interview Axis II Personality Disorders for Diagnostic and Statistical Manual of Mental Disorders fourth edition, text revision in 60 recipients of kidney transplantations from deceased donors. RESULTS The personality trait that prevailed in the female gender was borderline, while in the male gender it appeared to be predominantly obsessive-compulsive personality trait. CONCLUSIONS The personality study proved to be a good index to predict effects on the level of social adjustment. In this way, patients who have shown pathologic personality traits can be identified early to provide adequate psychologic-psychiatric support and follow-up.