g-Hsu Chen

Mycobacterium tuberculosis infection following renal transplantation in Taiwan

Abstract: Background. Tuberculosis (TB) is one of the major causes of morbidity and mortality worldwide. Post‐transplant (post‐Tx) TB is a problem in successful long‐term outcome of renal transplantation recipients. It is a life‐threatening opportunistic infection that is frequently encountered, but the diagnosis is often delayed. With the emergence of newer potent immunosuppressive regimens and an increased incidence of TB in the general population, post‐Tx TB among transplant recipients can be anticipated. Our objective was to describe the pattern and risk factors of TB infection, and the prognosis in an endemic area.

Lower Variability of Tacrolimus Trough Concentration After Conversion From Prograf to Advagraf in Stable Kidney Transplant Recipients

Backgrounds. Variability of blood trough concentration (C0) in immunosuppressant leads to rejection and graft loss after kidney transplantation. Methods. The aim of this study is to prospectively investigate the change of within-patient variability among stable kidney transplant recipients with conversion from twice-daily Prograf to the same milligram-for-milligram daily dose of once-daily Advagraf. Results. The mean age of 129 patients was 51.3±12.1 years. The conversion to Advagraf was administrated at 6.3±4.8 years after transplantation. The daily dose was changed from 4.7±2.0 mg to 4.9±2.1 mg after conversion. Only six patients increased daily dose by 16.7% to 25% to maintain target levels. The whole blood C0 of tacrolimus before conversion was 5.9±1.7 ng/mL. The mean C0 was significantly reduced after conversion to Advagraf; it was 4.9±1.5 ng/mL on the seventh day (P<0.001) and 5.4 to 5.5 ng/mL at 1 to 6 months (P<0.05). Forty-one (31.8%) patients have reduced C0 of more than 25% on the seventh day. The percent coefficient of variation of tacrolimus C0 more than 22.5% before conversion is associated with higher risk of reduced C0 after conversion (P<0.05). Compared with before conversion, less kidney transplant recipients have percent coefficient of variation more than 22.5% after conversion (3.1% vs. 17.4% with P<0.01). Conclusions. The results support that conversion from Prograf to Advagraf among kidney transplant recipient leads to a significantly lower C0 and within-patient variability of tacrolimus C0. The within-patient variability of C0 before conversion influences C0 on the sevent day after conversion to Advagraf.

High Risk of Renal Failure in Stage 3B Chronic Kidney Disease is Under-recognized in Standard Medical Screening

Background: The objective of this study was to determine the risk of renal failure in patients with under‐recognized chronic kidney disease (CKD) in the self‐pay standard medical screening program of health management centers. Methods: The abbreviated Modification of Diet in Renal Disease equation was used to calculate the estimated glomerular filtration rate (eGFR) of study subjects. Study subjects with eGFR less than 60 mL/min/1.73m2 but with normal results of routine assessment, including serum creatinine, blood urea nitrogen, urinalysis and kidney ultrasound, were defined as having under‐recognized CKD. Episodes of renal failure requiring dialysis within 2 years in subjects with stage 3 to stage 5 CKD were evaluated. Results: A total of 15,817 subjects were recruited and 28.4% of subjects were identified by routine assessments as having a kidney problem. The prevalences of CKD 3A, 3B, 4 and 5 were 8.3%, 1.9%, 0.3% and 0.2%, respectively. All subjects with stages 4 and 5 CKD had abnormal serum creatinine levels, but 48.7% of 1,507 subjects with stage 3 CKD (stage 3A, n = 713; stage 3B, n = 21) had normal routine assessments. Subjects with under‐recognized stage 3B CKD had the highest risk (20%) of developing renal failure compared to subjects with stages 3‐5 CKD and abnormal results of routine assessments. Conclusion: Identifying subjects with CKD stage 3 by the eGFR equation, especially in stage 3B, is advantageous in detecting the risk of renal failure over the routine clinical assessment that is currently carried out by health management institutions in Taiwan.

Outcome of Kidney Transplantation Using Organs from Executed Prisoners: Is It Justified Beyond the Ethical Issue?

Background: Kidney transplantation using organs from executed prisoners is a subject of controversy from the viewpoint of ethics. However, few reports have addressed the clinical outcome beyond the ethical issue. Methods: Between January 1990 and September 2004, a total of 435 kidney transplant recipients (group M) who underwent transplantation in 26 different hospitals in China were followed up at our hospital. It is believed that all the organs came from executed prisoners. The clinical data were retrieved and compared to those of 200 kidney transplant recipients (group T) who underwent transplantation in our hospital during the same period. Results: There was no significant difference between these 2 groups (T vs. M) in terms of hepatitis B virus infection (10.5% vs. 12.1%) or surgical complication rate (6.5% vs. 5.6%). The 1st‐year acute rejection rate was significantly lower in group M (31.1% vs. 24.5%, p = 0.015). The 1‐year, 5‐year, and 10‐year patient survival rates were 94.3%, 89.5%, and 85.2%, respectively, for group T and 92.6%, 83.6%, and 76.7%, respectively, for group M (p > 0.05); the corresponding graft survival rates were 91.4%, 82.6%, and 66.9%, respectively, for group T and 91.6%, 80.0%, and 61.4%, respectively, for group M (p > 0.05). When patients were stratified according to the year of transplantation, patients who underwent transplantation between 2000 and 2004 had significantly better graft survival rates in both groups. Conclusion: We conclude that kidney transplantation using organs from executed prisoners had a clinical outcome similar to that of transplantation performed in our hospital during the same period.

Infectious Alopecia in a Dog Breeder After Renal Transplantation

Tinea capitis rarely occurs in renal transplant recipients. We report this living-related renal transplant patient receiving cyclosporine-based therapy who initially presented with severe exfoliation of the scalp with yellowish-white scales and marked hair loss. The lesions extended to the frontal area and both cheeks, resulting in several skin ulcers with perifocal erythematous inflammatory changes, and palpable cervical lymph nodes. A biopsy of a skin lesion revealed fungal infection and culture yielded Microsporum canis. The patient mentioned an outbreak of ringworm in her breeding dogs during this period. After adequate treatment of the patient and her infected animals with griseofulvin and disinfection of the environment, her skin lesions resolved dramatically, with regrowth of hair.

Uremia Secondary to Nephronophthisis in a Girl with Ellis-van Creveld Syndrome

Ellis-van Creveld (EvC) syndrome, a chondral and ectodermal dysplasia characterized by short ribs, polydactaly, growth retardation, ectodermal and heart disorder, is a rare autosomal recessive disorder. In previous English studies, the association between renal insufficiency and EvC syndrome has not been well described. We herein report a 9-year-old girl with typical EvC syndrome diagnosed since infancy and presented with renal insufficiency during her childhood. The initial presentations were hypertension, heavy proteinuria and impaired renal function. Histopathological findings from biopsy specimen were indicative of nephronophthisis. Progressive renal failure and uremia occurred in months and she received peritoneal dialysis. At 11 years old, she received cadaveric renal transplantation. The post-transplantation course was uneventful with fair renal function and no episode of rejection. The serum creatinine level after renal transplantation for two years is 0.9 mg/dL. In spite of its rarity, we suggested that nephronophthisis with subsequent renal insufficiency may be presented in patients with EvC syndrome.