J. Sańko-Resmer

Assessment of Health-Related Quality of Life of Patients after Kidney Transplantation in Comparison with Hemodialysis and Peritoneal Dialysis

BACKGROUND The quality of life may determine the efficacy of renal replacement therapy (RRT). The purpose of the study was to compare the health-related quality of life (HRQOL) of end-stage renal disease (ESRD) patients depending on RRT method. MATERIAL/METHODS The studies were conducted on 120 patients divided into 3 groups depending on RRT method: 30 peritoneal dialysis (PD) patients, 40 hemodialysis (HD) patients, and 47 post-kidney transplantation (KTx) patients. The following research tools were used: (1) Medical Outcomes Study 36 - the Short Form (SF-36 v.1); (2) Kidney Disease Quality of Life Short Form (KDQOL-SF™ v.1.3); and (3) disease history. The relevance level was p<0.05. RESULTS The evaluation of PCS by HD and PD patients is poorer compared to patients in the 3rd and 12th month after KTx (34.7 ± 7.4 vs. 37.51 ± 10.63 vs. 45.01 ± 9.43 vs. 45.55 ± 8.62; p<0.05; respectively). PCS statistically significantly correlated with the following: SBP (r=-0.54; p<0.05), DBP (r=-0.58; p<0.05), and creatinine concentration (r=0.46; p<0.05) in the 12(th) month after KTx. CONCLUSIONS HRQOL of ESRD patients differed depending on the RRT method: top values were shown by post-KTx patients, lower by PD patients, and the bottom ones by HD patients. Along with patient age, increased BP, and BMI, a drop in value of HRQOL in post-Tx or PD patients was observed. When choosing RTT method, patients may use the results of the evaluation of quality of life. A preferred lifestyle, and predominantly the work status and quality of social interaction, should decide the choice of treatment.

Renal function after liver transplantation: calcineurin inhibitor nephrotoxicity

Renal failure, mainly due to calcineurin inhibitor (CNI) nephrotoxicity, is the most common complication following orthotopic liver transplantation (ltx). The aim of this study was to evaluate the incidence and course of renal failure in adult ltx patients. Severe acute renal failure in early postoperative period due to impaired hemodynamics and CNI nephrotoxicity, occurred in 14 patients, 3 of whom required dialysis. The creatinine clearance after ltx showed a tendency to decrease, but there was no statistically significant difference (P >.05) in the change in serum creatinine clearance levels between patients treated with tacrolimus (TAC) versus Cyclosporine (CsA) during the first 2 years of follow-up. Fourteen patients required conversion of their regimen because of CNI nephrotoxicity namely, dose reduction (n = 7) or discontinuation of CNI therapy with the replacement by mycophenolate mofetil (MMF) (n = 5) or SRL (n = 5). Dose reduction or CNI withdrawal significantly improved the creatinine clearance (P <.05) without affecting lives graft function. No episode of acute rejection was observed after conversion. Neither conversion of CsA to TAC nor the reverse maneuver significantly influenced the serum creatinine level (P >.05). Reduction of the CNI dose or CNI discontinuation or replacement with MMF or SRL in patients with stable liver but impaired renal function is safe, resulting in a significant improvement in renal function.

1000 liver transplantations at the Department of General, Transplant and Liver Surgery, Medical University of Warsaw--analysis of indications and results.

THE AIM OF THE STUDY was to analyze indications and results of the first one thousand liver transplantations at Chair and Clinic of General, Transplantation and Liver Surgery, Medical University of Warsaw. MATERIAL AND METHODS Data from 1000 transplantations (944 patients) performed at Chair and Clinic of General, Transplantation and Liver Surgery between 1994 and 2011 were analyzed retrospectively. These included 943 first transplantations and 55 retransplantations and 2 re-retransplantations. Frequency of particular indications for first transplantation and retransplantations was established. Perioperative mortality was defined as death within 30 days after the transplantation. Kaplan-Meier survival analysis was used to estimate 5-year patient and graft survival. RESULTS The most common indications for first transplantation included: liver failure caused by hepatitis C infection (27.8%) and hepatitis B infection (18%) and alcoholic liver disease (17.7%). Early (< 6 months) and late (> 6 months) retransplantations were dominated by hepatic artery thrombosis (54.3%) and recurrence of the underlying disease (45%). Perioperative mortality rate was 8.9% for first transplantations and 34.5% for retransplantations. Five-year patient and graft survival rate was 74.3% and 71%, respectively, after first transplantations and 54.7% and 52.9%, respectively, after retransplantations. CONCLUSIONS Development of liver transplantation program provided more than 1000 transplantations and excellent long-term results. Liver failure caused by hepatitis C and B infections remains the most common cause of liver transplantation and structure of other indications is consistent with European data.

Posttransplantation diabetus mellitus under calcineurin inhibitor

BACKGROUND The development of postransplantation diabetes mellitus (PTDM) is a serious complication of kidney transplantation. PTDM has a major impact on quality of life decreasing rates of patient and graft survival. It is well known that some currently used immunosuppressants are diabetogenic. Greater diabetogenicity of FK-506 has been reported in multicenter trials. We initiated a study of conversion from tacrolimus (FK-506) to cyclosporine (CsA) among kidney allograft recipients presenting with PTDM to evaluate whether this maneuver would ameliorate a diabetic state. METHODS This analysis of 20 adult, renal allograft recipients presenting with PTDM assumed the need for insulin therapy or oral hypoglycemics before and after conversion of the immunosuppressive regimen. The criteria for evaluating the outcome were as follows: dose reduction of insulin or oral hypoglycemic agents, adequacy of glucose control, C-peptide levels, and insulin concentration. RESULTS During the follow-up, we observed an improvement in the control of blood glucose in the converted group. In 13 patients, satisfactory glucose control was obtained without insulin or any other agent. In 3 patients a significant dose reduction of required insulin was possible. In another 2 patients who were insulin-dependent, the switch to oral hypoglycemic treatment was clinically possible after conversion. After conversion we observed significantly lowered fasting blood glucose levels and increased C-peptide levels. CONCLUSIONS The conversion from a tacrolimus to a CsA-based immunosuppressive regimen resulted in better glucose metabolism. We demonstrated a positive effect of conversion on the diabetic state of patients with PTDM.

Anemia treatment with erythropoietin in pregnant renal recipients.

Pregnancies in renal transplant patients are considered to be high risk. Anemia is one of the major complications of pregnancy occurring among 65% to 85% of cases in this setting, especially since these patients carry additional risk factors. Herein we have presented five renal transplant recipients who were women who were treated with human recombinant erythropoietin due to severe anemia that developed during pregnancy. Hemoglobin levels below 9 g/dL after 3 weeks of oral iron administration were assumed to be qualifying criteria for erythropoietin treatment. No complication was observed to be associated with the treatment. Two of the five patients required blood transfusions despite erythropoietin administration. Two cases delivered small for gestational fetus age. Erythropoietin therapy in pregnant kidney transplant recipients should be considered to be a safe method to reduce the need for blood transfusions.

Evolution Of The Results Of 1500 Liver Transplantations Performed In The Department Of General, Transplant And Liver Surgery Medical University Of Warsaw.

UNLABELLED Liver transplantation is a well-established treatment of patients with end-stage liver disease and selected liver tumors. Remarkable progress has been made over the last years concerning nearly all of its aspects. The aim of this study was to evaluate the evolution of long-term outcomes after liver transplantations performed in the Department of General, Transplant and Liver Surgery (Medical University of Warsaw). MATERIAL AND METHODS Data of 1500 liver transplantations performed between 1989 and 2014 were retrospectively analyzed. Transplantations were divided into 3 groups: group 1 including first 500 operations, group 2 including subsequent 500, and group 3 comprising the most recent 500. Five year overall and graft survival were set as outcome measures. RESULTS Increased number of transplantations performed at the site was associated with increased age of the recipients (p<0.001) and donors (p<0.001), increased rate of male recipients (p<0.001), and increased rate of piggyback operations (p<0.001), and decreased MELD (p<0.001), as well as decreased blood (p=0.006) and plasma (p<0.001) transfusions. Overall survival was 71.6% at 5 years in group 1, 74.5% at 5 years in group 2, and 85% at 2.9 years in group 3 (p=0.008). Improvement of overall survival was particularly observed for primary transplantations (p=0.004). Increased graft survival rates did not reach the level of significance (p=0.136). CONCLUSIONS Long-term outcomes after liver transplantations performed in the Department of General, Transplant and Liver Surgery are comparable to those achieved in the largest transplant centers worldwide and are continuously improving despite increasing recipient age and wider utilization of organs procured from older donors.

The impact of experience of a transplantation center on the outcomes of orthotopic liver transplantation

The so-called learning factor has been disregarded for many years in analyzing the causes of surgical complications and post-operative mortality; it is also the case for OLT. In our center until April 2003, 209 OLT were performed in 196 patients. We evaluated the impact of experience of the transplantation team on the outcomes of liver transplantation. Thirty-four patients died (mortality rate, 16%) and 1-year survival rate, 64%. Mortality rates varied during different periods of observation due to increasing experience of the transplantation team. The causes of mortality were assessed for a series of 34 patients: it was 75% at the beginning of transplantation procedures while recent deaths have not recently exceeded 10% of cases.

Intravoxel incoherent motion imaging in monitoring the function of kidney allograft

Background Non-invasive alternatives to percutaneous renal biopsy are sought for follow-up of renal allografts. Purpose To evaluate the feasibility of intravoxel incoherent motion (IVIM) imaging in monitoring and predicting the function of renal allografts. Material and Methods Thirty-five kidney recipients were examined on a 1.5-T MR unit approximately three and 18 months after transplantation. Based on estimated glomerular filtration rate (eGFR), patients were divided into three groups: improved; declined; and stable graft function. Diffusion parameters were calculated with the use of monoexponential (total apparent diffusion coefficient [ADCT]) and biexponential (pure diffusion coefficient [D], perfusion fraction [Fp]) model and compared among and within study groups using Kruskal–Wallis, Mann–Whitney, and Wilcoxon matched pairs tests. Diffusion parameters were correlated with eGFR using Spearman’s rank correlation coefficients. Results of tests with P values < 0.05 were considered statistically significant. Results Values of diffusion parameters, especially Fp, were lower in patients with a declined graft function; however, statistically significant intergroup differences were observed only in a limited number of parameters at the time of follow-up magnetic resonance imaging (MRI). None of the diffusion parameters from the baseline MRI correlated with the change in eGFR over time. Flow-related diffusion parameters calculated with the IVIM model showed high variability. Conclusion We observed a trend toward a decrease in values of diffusion parameters in patients with a declined graft function. Further research is needed to verify a clinical usefulness of this observation.

Assessment of Volumetric Hemodynamic Parameters and Body Composition in Stable Renal Transplant Recipients

BACKGROUND Cardiovascular disease (CVD) has been associated with decreased graft survival and increased complications in renal transplant recipients (RTRs). The objectives of this study were to explore the relationship between body composition and hemodynamic parameters (cardiac index [CI] and systemic vascular resistance index [SVRI]) in RTRs. MATERIAL AND METHODS The study included 80 RTRs (mean age: 51±8 yrs) who had been admitted to our Nephrology and Transplantology Clinic at 0.5 to 28 years after KTx. The control groups consisted of the 40 patients receiving hemodialysis and 20 health-care professionals. A Cardioscreen 1000 monitor (Messtechnik, Ilmenau, Germany) was used to perform non-invasive hemodynamic measurements. Body composition was studied using a Tanita BC 418 body composition analyzer (Tanita Corp., Tokyo, Japan). Clinical and laboratory data were also analyzed. RESULTS One-way ANOVA confirmed statistically significant differences between RTRs, HD patients, and the control group in CI (2.8±0.3 vs. 3.1±0.7 vs. 3.5±0.6 L/min/m2, P<0.001, respectively) and SVRI (2619±492 vs. 2307±701 vs. 2012±452 d·s/cm-5/m², P<0.001, respectively). In RTRs with functioning AVF, our study revealed significantly higher CI (2.9±0.3 vs. 2.7±0.4 L/min/m², P=0.004) and significantly lower SVRI (2497±286 vs. 2729±605 d·s/cm-5/m², P=0.035). CONCLUSIONS In conclusion, our data indicate that cardiovascular manifestations in the RTRs group are mainly related to decreased CI and HR in addition to increased SVRI with high arterial blood pressure.

Structure of Post-Transplant Care in a Single Transplant Center

BACKGROUND The number of transplant surgeries across the globe has markedly increased in recent decades and is associated with improvement in outcomes. Factors that could improve the organization of post-transplant care are sought. The aim of our study was to evaluate the changes in post-transplant care in the largest Polish transplant center from 2010 to 2014. MATERIAL AND METHODS Analysis was performed in all transplant recipients followed up at our center. The following factors were evaluated: changes in patient inflow and outflow, changes in the number of ambulatory visits, causes of loss to follow-up of the patients, and changes in National Health Fund financing. All factors were measured in 5-year period from 2010 to 2014. RESULTS Stable year-to-year patient inflow increased by 31% in the total number of patients under follow-up within 5 years. In the same time, the total NHF spending increased by 32%, but spending per patient increased by only 11%. As a consequence, after the initial growth in the years 2010-2012, the number of ambulatory visits per patient per year tended to decline. CONCLUSIONS Our study revealed that the real challenge in long-term post-transplant care is the increasing number of patients and the increasing length of their follow-up. Potential risks related to financial expenditure discrepancy between short-term and long-term transplantation procedures were also found.