David C. Dahl

Risk factors for fractures in kidney transplantation.

Background. Risk factors for fracture after kidney transplantation need to be identified to target patients most likely to benefit from preventive measures. Methods. Medical records were reviewed for 1572 kidney transplants done at a single center between February, l963 and May, 2000 with 6.5±5.4 years of follow-up. Results. One or more fractures occurred in 300 (19.1%), with multiple fractures in 101 (6.4%). After excluding fractures of the foot or ankle (n=130 transplants, 8.3%), avascular necrosis (n=86, 5.5%), and vertebral fractures (n=28, 1.8%), there were one or more fractures in 196 (12.5%), with a cumulative incidence of 12.0%, 18.5%, and 23.0% at 5, 10, and 15 years, respectively. In multivariate Cox proportional hazards analysis, age had no effect on fractures in men. Compared with men and younger women, women 46–60 and >60 years old were, respectively, 2.11 (95% confidence interval 1.43–3.12, P =0.0002) and 3.47 (2.16–5.60, P <0.0001) times more likely to have fractures. Kidney failure from type 1 and 2 diabetes increased the risk by 2.08 (1.47–2.95, P <0.0001) and 1.92 (1.15–3.20, P =0.0131), respectively. A history of fracture pretransplant increased the risk by 2.15 (1.49–3.09, P <0.0001). Each year of pretransplant kidney failure increased the risk by 1.09 (1.05–1.14, P <0.0001). Obesity (body mass index >30 kg/m2) was associated with 55% (17–76%, P =0.0110) less risk. Different immunosuppressive medications, acute rejections, and multiple other factors were not independently associated with fractures. Conclusions. The population of transplant patients at high risk for fracture can be identified using age/gender, pretransplant fracture history, diabetes, obesity, and years of pretransplant kidney failure.

A randomized trial comparing cyclosporine induction with sequential therapy in renal transplant recipients

Abstract Calcium antagonists may reduce the nephrotoxicity of cyclosporine (CsA), allowing CsA to be introduced immediately after renal transplantation and thereby obviating the need for sequential induction therapy with a monoclonal or polyclonal antibody. To test this hypothesis, in a pilot feasibility trial 100 cadaveric or one-haplotype-mismatched living-related renal transplant recipients were randomized to either (1) sequential therapy with antithymocyte globulin (ATG) (ATGAM; Upjohn, Kalamazoo, MI) 20 mg/kg/d for 7 to 14 days until renal function was established and CsA (Sandimmune; Sandoz, East Hanover, NJ) was started, or (2) CsA 8 mg/kg/d begun immediately before surgery with diltiazem (Cardizem; Marion Merrell Dow, Kansas City, MO) 60 mg sustained release twice daily. Acute rejection episodes during the first 90 days were not different with ATG versus CsA induction (42% v 28%; P = 0.142 by chi-square analysis). Graft failures (10% v 16%; P = 0.372) and the incidence of delayed graft function (28% v 34%; P = 0.516) were also similar with ATG compared with CsA. ATG caused lower platelet counts (138 ± 59 × 103v 197 ± 75 × 103 at 7 days; P

Human Granulocytic Ehrlichiosis Presenting with Acute Renal Failure and Mimicking Thrombotic Thrombocytopenic Purpura

We present the case of an elderly female patient presenting with recurrent acute renal failure, fever, altered mental status, abdominal pain, thrombocytopenia and a small number of fragmented red cells on peripheral smear mimicking recurrent thrombotic thrombocytopenic purpura (TTP). Eventually, however, she was diagnosed to have human granulocytic ehrlichiosis (HGE), and after treatment for HGE her clinical and laboratory abnormalities resolved. Ehrlichiosis mimicking TTP, diagnosed at postmortem examination, has been described in a single prior case. As illustrated in this case, there are potential difficulties in diagnosing HGE after plasma exchange, blood transfusion and immunosuppressive therapy. Ehrlichiosis, a potentially curable disease, should be considered in the differential diagnosis of thrombotic microangiopathic disorders.

A Randomized Trial Comparing Cyclosporine Induction With Sequential Therapy in Renal Transplant Recipients

Calcium antagonists may reduce the nephrotoxicity of cyclosporine (CsA), allowing CsA to be introduced immediately after renal transplantation and thereby obviating the need for sequential induction therapy with a monoclonal or polyclonal antibody. To test this hypothesis, in a pilot feasibility trial 100 cadaveric or one-haplotype-mismatched living-related renal transplant recipients were randomized to either (1) sequential therapy with anti-thymocyte globulin (ATG) (ATGAM; Upjohn, Kalamazoo, MI) 20 mg/kg/d for 7 to 14 days until renal function was established and CsA (Sandimmune; Sandoz, East Hanover, NJ) was started, or (2) CsA 8 mg/kg/d begun immediately before surgery with diltiazem (Cardizem; Marion Merrell Dow, Kansas City, MO) 60 mg sustained release twice daily. Acute rejection episodes during the first 90 days were not different with ATG versus CsA induction (42% v 28%; P = 0.142 by chi-square analysis). Graft failures (10% v 16%; P = 0.372) and the incidence of delayed graft function (28% v 34%; P = 0.516) were also similar with ATG compared with CsA. ATG caused lower platelet counts (138 +/- 59 x 10(3) v 197 +/- 75 x 10(3) at 7 days; P < 0.001) and lower white blood cell counts (9.6 +/- 4.6 x 10(3) v 12.3 +/- 4.9 x 10(3) at 7 days; P = 0.003). Diltiazem reduced the dose of CsA required to maintain target blood levels (479 +/- 189 mg/d v 576 +/- 178 mg/d at 14 days; P = 0.015). There were no statistically significant differences between the groups in serum creatinine levels at days 1, 3, 5, 7, 14, 28, 60, or 90. The results of this pilot feasibility trial suggest that prophylactic treatment with CsA and diltiazem may be equally effective and less toxic than ATG induction after renal transplantation.