Federico Cofán

Renal transplantation in HIV-infected patients: 2010 update

The prognosis of human immunodeficiency virus (HIV) infection has improved in recent years with the introduction of antiretroviral treatment. While the frequency of AIDS-defining events has decreased as a cause of death, mortality from non-AIDS-related events including end-stage renal diseases has increased. The etiology of chronic kidney disease is multifactorial: immune-mediated glomerulonephritis, HIV-associated nephropathy, thrombotic microangiopathies, and so on. HIV infection is no longer a contraindication to transplantation and is becoming standard therapy in most developed countries. The HIV criteria used to select patients for renal transplantation are similar in Europe and North America. Current criteria state that prior opportunistic infections are not a strict exclusion criterion, but patients must have a CD4+ count above 200 cells/mm(3) and a HIV-1 RNA viral load suppressible with treatment. In recent years, more than 200 renal transplants have been performed in HIV-infected patients worldwide, and mid-term patient and graft survival rates have been similar to that of HIV-negative patients. The main issues in post-transplant period are pharmacokinetic interactions between antiretrovirals and immunosuppressants, a high rate of acute rejection, the management of hepatitis C virus coinfection, and the high cardiovascular risk after transplantation. More studies are needed to determine the most appropriate antiretroviral and immunosuppressive regimens and the long-term outcome of HIV infection and kidney graft.

URODYNAMIC EVALUATION IN SIMULTANEOUS INSULIN- DEPENDENT DIABETES MELLITUS AND END STAGE RENAL DISEASE

PURPOSE We evaluated the urodynamic changes produced by insulin-dependent diabetes mellitus with end stage renal disease. MATERIALS AND METHODS A urodynamic evaluation was performed on 51 young patients (mean age plus or minus standard deviation 35 +/- 6 years) with long-term diabetes mellitus (average 21 +/- 6 years) and end stage renal disease (86% on dialysis). RESULTS The urodynamic study was abnormal in 84% of the patients. The bladder was hypersensitive in 39% and hyposensitive in 30% of the cases, and maximum vesical capacity was greater than 600 ml. in 33%. An acontractile detrusor was noted in 6% of the patients, while 4% had detrusor hyperreflexia and 35% had bladder outlet obstruction. CONCLUSIONS A high frequency of vesical alterations was observed, which were modified by association of progressive vesical dysfunction and diabetes mellitus. In diabetes mellitus dialysis protects against detrusor hypocontractility but predisposes the patients to have bladder obstruction.

Toxoplasma gondii primary infection in renal transplant recipients. Two case reports and literature review

Toxoplasmosis after solid organ transplantation is a complication associated with high morbidity and mortality. Universal prophylaxis with trimethoprim–sulfamethoxazole (TMP‐SMX) is effective to prevent post‐transplant toxoplasmosis. We report two cases of renal transplant recipients with negative antibodies against Toxoplasma gondii pretransplant who developed toxoplasmosis after TMP‐SMX discontinuation. We have also performed a review of published cases of primary toxoplasmosis after renal transplantation. Of 20 cases reviewed, 11 were male and the mean age was 37.8 years (SD = 13.8). Donor serology for T. gondii was determined in 15 donors, two of them (13%) with negative immunoglobulin (Ig)G and four (27%) with positive IgG and IgM antibodies. Fever was present in 85% of primary toxoplasmosis and hematologic abnormalities were observed in 69% of the cases. Ten patients died (50%). All patients with fatal outcomes had clinical evidence of toxoplasmosis during the early post‐transplant period (first 90 days), while no patient with late toxoplasmosis died (P = 0.003). Primary toxoplasmosis is associated with high mortality rates and TMP‐SMX prophylaxis can delay the onset of symptoms resulting in an improvement of prognosis.

Dialysis and Renal Transplantation in HIV-Infected Patients : a European Survey

Objectives:To determine prevalence and characteristics of end-stage renal diseases (ESRD) [dialysis and renal transplantation (RT)] among European HIV-infected patients. Methods:Cross-sectional multicenter survey of EuroSIDA clinics during 2008. Results:Prevalence of ESRD was 0.5%. Of 122 patients with ESRD 96 were on dialysis and 26 had received a RT. Median age was 47 years, 73% were males and 43% were black. Median duration of HIV infection was 11 years. Thirty-three percent had prior AIDS; 91% were receiving antiretrovirals; and 88% had undetectable viral load. Median CD4+T-cell count was 341 cells per cubic millimetre; 20.5% had hepatitis C coinfection. Most frequent causes of ESRD were HIV-associated nephropathy (46%) and other glomerulonephritis (28%). Hemodialysis (93%) was the most common dialysis modality; 34% of patients were on the RT waiting list. A poor HIV control was the reason for exclusion from RT waiting list in 22.4% of cases. All the RT recipients were all alive at the time of the survey. Acute rejection was reported in 8 patients (30%). Functioning graft was present in 21 (80%). Conclusions:This is the first multinational cross-sectional study of ESRD among European HIV population. Low prevalence of ESRD was found. Two-thirds of patients were excluded from RT for non-HIV/AIDS-related pathologies. Most patients had a functioning graft despite a high acute rejection rate.

Renal Dysfunction in the Setting of HIV/AIDS

Antiretroviral therapy has been immensely successful in reducing the incidence of opportunistic infections and death after HIV infection. This has resulted in heightened interest in noninfectious comorbidities including kidney disease. Although HIV-associated nephropathy, the most ominous kidney disease related to the direct effects of HIV, may be prevented and treated with antiretrovirals, kidney disease remains an important issue in this population. In addition to the common risk factors for kidney disease of diabetes mellitus and hypertension, HIV-infected individuals have a high prevalence of other risk factors, including hepatitis C and exposure to antiretrovirals and other medications. Therefore, the differential diagnosis is vast. Early identification (through efficient screening) and prompt treatment of kidney disease in HIV-infected individuals are critical to lead to better outcomes. This review focuses on clinical and epidemiological issues, treatment strategies (including dialysis and kidney transplantation), and recent advances among kidney disease in the HIV population.

Compression of the ulnar nerve in Guyon's canal by uremic tumoral calcinosis.

Abstract We describe the case of a 70-year-old woman with chronic renal failure on haemodialysis presenting with an ulnar nerve compression in Guyon’s canal secondary to uremic tumoral calcinosis. Excision of calcium deposits and external neurolysis of the ulnar nerve were successfully performed. Simultaneously, the hyperphosphatemia and hypercalcemia were corrected. The pathogenesis of this condition is different from primary tumoral calcinosis. Clinical and radiological features and therapy are discussed. Uremic tumoral calcinosis is an unusual etiology of ulnar nerve compression in Guyon’s canal not previously reported in dialysis patients.

Human Herpesvirus 7 Primary Infection in Kidney Transplant Recipients

The aims of the study were to evaluate the incidence and the clinical implications of human herpesvirus (HHV)-7 primary infection in patients undergoing kidney transplantation and the probable interactions between the three beta-herpesviruses (cytomegalovirus [CMV], HHV-6, and HHV-7). Sixty kidney transplant recipients had sequential plasma and whole blood samples collected prior to transplantation and at 7, 14, 21, 28, 45, 60, 75, 90, and 180 days posttransplantation. We used indirect immunofluorescence assays to detect HHV-7 immunoglobulin (Ig) G antibodies in plasma and quantitative real-time polymerase chain reaction to assess CMV, HHV-6 and HHV-7 viral loads. Sixteen out of 60 patients (27%) did not show HHV-7 IgG antibodies prior to transplantation and they were selected for this study. Whereas 3 (18.75%) out of the 16 HHV-7 seronegative patients seroconverted after transplantation, only one patient (6%) had a high HHV-7 viral load from the seventh day posttransplantation in consecutive blood samples during follow-up without clinical manifestations. In our study, the incidence of posttransplant HHV-7 primary infection was low and asymptomatic.

Uremic tumoral calcinosis of the foot mimicking infection.

Uremic tumoral calcinosis is an uncommon, benign condition characterized by slow-growing calcified periarticular soft tissue masses of varying size. We describe two patients with chronic renal failure on hemodialysis presenting uremic tumoral calcinosis, one in the fifth toe of the right foot and the other in the dorsum of the left foot between the first and second metatarsals. Excision of the calcic masses and parathyroidectomy were successfully performed in both patients. These cases are unusual in their rapid onset, mimicking acute infection. Differential diagnosis, radiological features and therapy are discussed.

Incidence and outcome of early Candida peritonitis after liver and pancreas transplantation

Candida peritonitis is a potentially life‐threatening infection after abdominal transplantation, although there is scant information regarding its incidence and outcome. We analysed the incidence rate and outcome of Candida peritonitis in 717 liver or pancreas transplant recipients. Five cases of Candida peritonitis were diagnosed, representing the second most frequent cause of invasive fungal infection in the cohort. The incidence rate of Candida peritonitis during the first 30 days after transplantation was 6.5 cases/10 000 transplant days in pancreas recipients and 1.2 cases/10 000 transplant days in liver recipients (P = 0.035). Four of the five patients received an echinocandin in combination with other antifungal. All patients were alive and with good graft function at 1‐year follow‐up. In our series, Candida peritonitis in liver and pancreas transplant recipients was not uncommon and had a good prognosis.

Platelet procoagulant activity induced in vivo by muromonab-CD3 infusion in uremic patients.

BACKGROUND Muromonab-CD3 is a murine monoclonal antibody (MoAb) that is used in the prophylaxis and treatment of acute graft rejection. Activation of coagulation and fibrinolysis following anti-CD3 administration have been reported in some patients to lead to irreversible intragraft thrombosis. DESIGN AND METHODS We have studied the effect of muromonab-CD3 infusion on platelets using flow cytometry in six patients who received three daily doses of muromonab-CD3 as prophylaxis of rejection before receiving a living donor renal transplant. Samples were collected before, 15 and 60 min after muromonab-CD3 infusion. Immunolabeling of platelets was performed in whole blood using dual-color analysis. The following conjugated MoAb were used: anti-CD41a, -CD36, -CD42b, -CD62P, -CD63, -factor V/Va and nonspecific Ig. Samples were analyzed with a FACScan flow cytometer (Becton Dickinson, Mountain View, CA, USA). RESULTS After muromonab-CD3 infusion, an increase in the binding of MoAb anti-factor V/Va to platelets was seen, which was only statistically significant (2.2% vs. 12.8%, P=.04) after 15 min of the second dose. No significant changes were seen in the other MoAbs studied. No thrombotic complications were observed after transplantation. INTERPRETATION AND CONCLUSION In uremic patients receiving muromonab-CD3 infusion as prophylaxis of graft rejection, an increase in the binding of anti-factor V/Va, denoting an increased exposure of anionic phospholipids in platelets, was seen. This increase in platelet procoagulant activity might contribute to the appearance of thromboses within renal graft seen in some patients who received muromonab-CD3.