Ana Fernández-Rodríguez

Achieving chronic kidney disease treatment targets in renal transplant recipients: results from a cross-sectional study in Spain.

Background. Kidney transplant recipients are considered to have chronic kidney disease (CKD) irrespective of glomerular filtration rate (GFR) or presence or absence of markers of kidney damage. The aim of this work was to investigate the prevalence of CKD-stages and whether the guidelines for general population (Kidney Disease Outcomes Quality Initiative) are routinely followed in kidney transplant in Spain. Patients and Methods. Two thousand one hundred sixty renal transplant recipients followed up at the outpatient clinics in 4 University Hospitals were included. The estimated GFR (eGFR) was calculated according to the abbreviated modification of diet in renal disease equation, and the patients were classified following the Kidney Disease Outcomes Quality Initiative stages. Results. Chronic kidney failure (eGFR <60 mL/min/1.73 m2) was present in 1505 patients (69.7%), 54.4% were 3T-stage (eGFR 30-59); 13.0% were 4T-stage (eGFR 15-30), and 2.3% were 5T-stage. The prevalence of severe anemia increased from 4.1% in 1T-stage to 44% in 5T-stage (P=0.000) as did the percentage of patients on erythropoiesis-stimulating agents from 1.3% to 68% (P=0.000). The intact parathyroid hormone levels increased as graft function declined and 45% of 5T-stage patients had intact parathyroid hormone levels more than 300. Calcium and vitamin D supplements were administered to 50% and 40% of patients, respectively. Hypertension was quite common and increased with the progression of CKD. The mean total cholesterol was 192±39 mg/dL, and the levels did not increase with the decline in graft function. Approximately 60% had suboptimal cholesterol despite 50% being on statins treatment. Conclusions. CKD and their complications were prevalent in renal transplant recipients. The control of some of these complications is far below targets established for nontransplant CKD patients despite a progressive intensification of therapy as graft function declines.

Long-term graft function changes in kidney transplant recipients

Background. Monitoring changes in glomerular filtration rate (GFR) is the recommended method for assessing the progression of kidney disease. The aim of this study was to assess the decline of graft function defined by the annualized change in GFR and the factors which affect it. Methods. Four thousand four hundred and eighty-eight patients, transplanted during the years 1990, 1994, 1998 and 2002 in 34 centres in Spain with allograft survival of at least 1 year, were included in the study. GFR was estimated using the four-variable equation of the Modification of Diet in Renal Diseases (MDRD) study. Linear mixed effects model was applied to determine the relation between the covariates and the annualized change in GFR after transplantation. Results. The average GFR at 12 months was 51.4 ± 18.9 mL/min/1.73 m2; most patients were in stage 3 of chronic kidney disease classification. The average patient slope, calculated in a linear model with varying-intercept and varying-slope without covariates, was −1.12 ± 0.05 mL/min/year (slope ± standard error). Some variables were related to both the 12-month GFR (intercept) and the slope: recipient gender, hepatitis C virus (HCV) status, estimated GFR (eGFR) at 3 months and proteinuria at 12 months. Some variables were only related to the slope of eGFR: time on dialysis, primary renal disease and immunosuppression. Others affected only the 12-month GFR: donor age, delayed graft function, acute rejection and systolic blood pressure at 12 months. Higher graft function at 3 months had a negative impact on the GFR slope. Cyclosporine-based immunosuppression had a less favourable effect on the rates of change in allograft function. Conclusions. There was a slow decline in GFR. Poor graft function was not associated with an increased rate of decline of allograft function. Immunosuppression with cyclosporine displayed the worst declining GFR rate.

Effects of the new immunosuppressive agents on the occurrence of malignancies after renal transplantation.

INTRODUCTION The risk of malignancies in renal transplant recipients is considerably greater than in the general population. The purpose of the present study was to investigate the effects on the appearance of malignancies of 3 immunosuppressive periods: azathioprine (AZA), cyclosporine (CsA), and tacrolimus (TAC). PATIENTS AND METHODS This study included 1029 first renal transplant recipients of mean age at transplantation of 44.6±14.9 years with a mean follow-up of 95.6±84.2 months. Initial immunosuppression was AZA-based (n=198), CsA-based (n=524), and TAC (n=307). A total of 280 recipients were also treated with mycophenolate mofetil or mycophenolic acid. RESULTS There were 157 patients (15.3%) who displayed≥1 malignancy; there were 95 skin (9.2%) and 74 (7.8%) non-skin malignancies with presentations at 74±62 and 107±77 months, respectively (P=.003). The skin malignancies included squamous cell carcinomas (n=41), basal cell carcinomas (n=41), Kaposi sarcomas (n=7), and melanomas (n=4). Among the solid tumors, lymphoproliferative disorders (n=15), digestive tract (n=14), kidney and urinary tract (n=11), lung (n=10), and breast (n=3) carcinomas. The cumulative incidences at 5, 10, and 15 years were 6%, 10%, and 18% for skin and 3%, 7%, and 14% for non-skin malignancies, respectively. Multivariate analysis showed that age at transplant in years (P=.000) and male gender (P=.000) were the only variables associated with skin malignancies; age at transplant in years (P=.004) and treatment with OKT3 (P=.000) were associated with non-skin malignancies. Malignancies were the cause of death in 18% of recipients who died with functioning grafts. CONCLUSION Malignancies are an important cause of morbidity and mortality among renal transplant recipients. The new immunosuppressive agents do not increase the risk of malignancies. Special surveillance is needed for older, male recipients.

Are low levels of 25-hydroxyvitamin D a risk factor for cardiovascular diseases or malignancies in renal transplantation?

BACKGROUND Observational studies in healthy people suggest an inverse relationship between 25-hydroxy-vitamin D (25(OH)D levels) and cardiovascular diseases and malignancies. We performed an observational prospective study in renal transplant recipients to investigate the effects of vitamin D deficiency on cardiovascular and malignancy risks. METHODS From 389 renal transplant recipients, 331 with a functioning graft at 12 months were included in the study. Mineral metabolism parameters were measured at 1, 3, 4 and 12 months. Information regarding the cardiovascular events and malignancies were collected from an electronic database. RESULTS According to the 1-year mean of 25(OH)D levels, 75 recipients (22.7%) had a normal vitamin D status, 161 (48.6%) had insufficiency and 95 (28.7%) had deficiency in vitamin D levels. During the follow-up, 80 recipients presented at least one cardiovascular event. The total cardiovascular diseases included: 27 patients with coronary diseases, 25 with cardiac failure, 18 with arrhythmia, 11 with acute cerebrovascular events and 19 with peripheral vascular disease. Cardiovascular events were not associated with 25(OH)D levels or vitamin D status, and the 10-year cumulative incidence was 29.3% for normal vitamin D status and 31.6% for insufficiency and 51.9% for deficiency (P = 0.216). Furthermore, Cox univariate analysis showed no association between cardiovascular events and vitamin D levels or vitamin D status. In addition, 53 recipients presented at least one malignancy: 33 non-melanoma skin malignancies and 20 non-skin malignancies (5 prostate, 3 kidney and urinary tract, 2 colon, 2 lung, 2 lymphoma, 2 breast and 4 from other locations). The cumulative incidence of malignancies was 21.3% for normal vitamin D status, 22.7% for insufficiency and 16.7% for deficiency (P = 0.818). CONCLUSIONS Our data suggested that low vitamin D levels were not associated with an increased risk of cardiovascular diseases or malignancies. However, due to the small number of patients and events, the results should not be considered as definitive. Additional studies with a higher number of patients are required to elucidate the true impact of vitamin D status on cardiovascular and malignancy risks.

Bone fractures and lumbar mineral density after renal transplantation. A long‐term cross‐sectional study

The purpose of this work was to investigate the association of vertebral and peripheral fractures 10 yr after grafting with bone metabolic markers and body mass density (BMD).

Ceftazidima-avibactam en el tratamiento de infecciones urinarias por Klebsiella productora de carbapenemasa en trasplante renal

Enterobacteriaceae are an important cause of infections, and the infection recurred weeks after finishing the antibiotic cycle, which led to another hospitalisation. For this reason, we decided to initiate treatment with the recent antibiespecially in immunocompromised patients. The recent appearance of carbapenemase-producing enterobacteriaceae otic ceftazidime–avibactam (C–A) for 2 weeks at a dose of 1000/250 mg every 12 h, which achieved the definitive eradi-

Outcomes of Peritoneal Dialysis Catheter Left In Place after Kidney Transplantation

No clear consensus has been reached regarding the optimal time to remove the peritoneal dialysis catheter (PDC) after kidney transplantation (KT). This retrospective observational study, conducted in a single peritoneal dialysis (PD) unit including all PD patients who received a KT between 1995 – 2015, was undertaken to evaluate the clinical outcomes and potential complications associated with a PDC left in place after KT. Of the 132 PD patients who received a KT, 20 were excluded from the study. Of the remaining, 112 (85%) patients with functioning KT were discharged with their PDC left in place and had it removed in a mean interval of 5 ± 3 months after KT, after achieving optimal graft function. During this follow-up period, 7 patients (6%) developed exit-site infection and there were 2 cases (2%) of peritonitis; all of them were successfully treated. Delayed PDC removal after KT is associated with low complication rates, although regular examination is needed so that mild infections can be detected early and therapy promptly instituted.

Preserved Renal Function in Kidney Transplantation over a Thrombosed Aortobifemoral Bypass Graft: The Role of Retrograde Flow and Early Thrombolysis.

Aortobifemoral bypass (ABFB) thrombosis is not uncommon, and when the artery of a renal graft is implanted on a bypass the risk of graft loss is high. We report the case of a 48-year-old woman with a previous history of ABFB under antiplatelet therapy and a kidney allograft implanted on the vascular prosthesis, who presented with acute limb ischemia and severe renal impairment. Imaging techniques revealed a complete thrombosis of the proximal left arm of the ABFB. However, a faint retrograde flow over the graft was observed thanks to the recanalization of distal left bypass by collateral native arteries. This unusual situation not previously reported in a kidney transplant setting, together with an early diagnosis, allowed graft survival until an early local thrombolysis resolved the problem. Two years later, renal function remains normal.

Black esophagus in the early kidney post-transplant period

A 65-year-old man with end-stage renal disease secondary to nephroangiosclerosis on hemodialysis was admitted to undergo a cadaveric kidney transplant. He had a previous history of moderate-to-severe aortic stenosis. Twenty-four hours after surgery, the patient developed an acute pulmonary oedema followed by cardiac arrest. Advanced cardiopulmonary resuscitation and aggressive fluid removal through extracorporeal ultrafiltration were performed, resulting in a successful recovery and no apparent neurological consequences. A transesophageal echocardiography revealed the progression of the aortic stenosis to a critical stage. Balloon aortic valvuloplasty was performed as a bridge therapy to a transcatheter aortic valve replacement.

Bullous necrotizing cellulitis in kidney transplant recipient

The patient is a 68-year-old male with a history of chronic kidney disease of unknown cause. He received a kidney transplant 25 years ago and was treated with double immunosuppression therapy with everolimus and methyl-prednisolone. He also has a history of multiple tumours (skin and parotid). The patient presented to the emergency department with a 10-day history of fever associated with pain, swelling and erythematous lesions in the middle third of the right leg. The patient denied previous history of local trauma, abdominal pain and urinary symptoms. During admission, these lesions progressed to bullae with serum-haematic content, which subsequently formed necrotic background ulcers with irregular borders, exposing the underlying muscle tissue (Figure 1A and B). Blood and ulcer secretion cultures were performed, with isolation of Escherichia coli, initiating treatment with intravenous meropenem. The necrotic lesions were surgically debrided (Figure 1C), and free skin grafts were performed to correct the defects of the skin. Infectious process was controlled within 1 month of systemic antibiotic therapy and achieved complete cure of the lesions with discharge at 45 days after admission. Bullous necrotizing cellulitis is an infection caused in most cases by E. coli, mainly in immunocompromised patients. This serious complication has been previously described in childhood nephritic syndrome, diabetes mellitus and haemodialysis patients, but this is the first case described in a kidney transplant recipient. The estimated mortality of this entity is ∼50% and treatment consists of prolonged antibiotic therapy against gram-negative micro-organisms and occasionally surgical repair of necrotic tissues may be required. This kind of serious infectious complication must be taken into account in kidney transplant patients with torpid evolution cellulitis. Fig. 1. Skin lesions of bullous necrotizing cellulitis in a renal transplant recipient. A-B: Necrotic skin and exposure of the muscle fascia; C: Debridement of soft tissues and drainage of subcutaneous abscesses.