Daniela Corona

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.

Pregnancy under everolimus-based immunosuppression.

The ability to give birth to a live child is one of the best success of kidney transplantation. While there are an increasing number of pregnancies reported in kidney transplant recipients treated with cyclosporine or tacrolimus, there is little evidence of pregnancy among kidney transplant recipients exposed to sirolimus or everolimus. We present the first successful delivery in an organ transplant recipient exposed to everolimus during the whole gestation. The absence of congenital anomalies in the child as well as the recipient’s successful renal outcome are promising, although pregnancy in renal transplant recipients exposed to everolimus should be considered at higher risk.

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.

Sirolimus in solid organ transplantation: current therapies and new frontiers

Sirolimus (SRL) is a mammalian target of rapamycin inhibitor, which provides an immunosuppressive effect by inhibiting cell cycle progression. The encouraging results of combined SRL-cyclosporine therapy paved the way to further immunosuppressant combinations. Although SRL is relatively non-nephrotoxic when administered as monotherapy, it pharmacodynamically enhances the toxicity of calcineurin inhibitors. Other side effects may include hyperlipidemia and myelosuppression and less commonly wound healing impairment, proteinuria, edema and pneumonitis. Surprisingly, SRL also showed encouraging properties as an antiatherogenic and antineoplastic, opening a large spectrum of new potential applications. Whether SRL can be used safely over the long term with low doses of calcineurin inhibitors requires further study. The use of SRL as a corticosteroid-sparing agent also remains to be proven in controlled trials.

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.

Cytomegalovirus and Clostridium difficile Ischemic Colitis in a Renal Transplant Recipient: A Lethal Complication of Anti-Rejection Therapy?

Intestinal ischemia is reported to be the most common gastrointestinal complication of renal transplantation and a potential cause of morbidity and mortality. The recent use of more potent immunosuppressive drug regimens has reduced the incidence of acute rejection, increasing the incidence of potentially fatal infectious complications, such as clinically important cytomegalovirus (CMV) infection. A 42-year-old kidney transplant recipient experienced on postoperative day 10 a dehiscence of the ureterovesical anastomosis, associated with a 7-cm longitudinal tear graft on the lower pole of the kidney and an ureteral ischemia. A graft biopsy demonstrated a mild acute rejection for which the patient received an unsuccessful administration of steroids, with progression of the rejection, so that 1 mg/kg/day antithymocyte globulin was administered. Two days later the patient presented with fever (39.5°C), diffuse abdominal pain with tenderness and bloody diarrhea, and diagnosis of CMV colitis was achieved; rectal samples were taken for histologic examination, and Clostridium difficile toxin was isolated. A subtotal colectomy with Hartmann’s procedure was performed, but the patient died 13 days later of a multiple organ failure. The risk of lethal CMV colitis is increased in patients being treated with anti-rejection therapy for severe acute rejection; the occurrence of simultaneous infection, such as pseudomembranous colitis, usually characterized by a favorable prognosis, increases the mortality rate in these patients.

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.

Role of socioeconomic conditions on outcome in kidney transplant recipients.

INTRODUCTION While deaths with a functioning graft have occurred more frequently in recent years, other nonimmunologic factors may have an important role in late allograft loss. These variables include socioeconomic and cultural status as risk factors for posttransplantation noncompliance with therapy. We examined the effect of socioeconomic and cultural status on graft and patient survival in a population of kidney transplant recipients. PATIENTS AND METHODS This retrospective study included 223 kidney transplantations performed between September 2000 and December 2006. RESULTS A significant improvement in graft and recipient survival was observed with increased educational achievement level. Subjects with a high school diploma or college degree demonstrated significantly better outcome. Recipients who had attended intermediate or technical schools were also significantly more likely to have a better outcome than the lowest educational group. Using the lowest socioeconomic class as a reference, a proportional hazard model demonstrated statistically significant benefit for better outcome in patients with skilled occupations. CONCLUSIONS Results of the present study showed a significant difference in kidney transplantation outcome between different socioeconomic and educational classes. These results could help physicians to educate patients with end-stage renal disease to better understand long-term recovery after transplantation.

Anaesthesiological implications of Kimura's disease: a case report

IntroductionKimuras disease is a chronic inflammatory condition belonging to the angio-lymphatic proliferative group of disorders, usually affecting young men of Asian race, but is rare in Western countries. It is a benign but locally injurious disease, of unknown aetiology, whose classical clinical features are a tumour-like swelling, usually in the head and neck, with or without satellite lymphadenopathy, often accompanied by eosinophilia and elevated serum IgE.Case presentationWe report the case of a 33-year-old Caucasian woman with an atypical localization of Kimuras disease, discussing the anaesthesiological implications and reviewing the current literature on Kimuras disease.ConclusionsThe diagnosis of Kimuras disease can be difficult and misleading, and anaesthesiological precautions could be ignored. Patients with this disease are often evaluated for other disorders: unnecessary diagnostic tests and investigations, or even surgery, may be avoided by just being aware of Kimuras disease.