M. Almeida

Bone mineral density after simultaneous kidney-pancreas transplantation: four years follow-up of 57 recipients.

Bone disease and an high risk of fractures are major problems in transplantation. Among diabetic patients undergoing simultaneous kidney-pancreas (SKP) transplantation, there are few studies assessing long-term effects on bone mass. The aim of this study was to evaluate bone mineral density (BMD) over 4 years follow-up after SKP transplantation. Fifty-seven patients had 22.8 +/- 5.3 years of prior diabetes, 65% were female, and the overall mean age was 24.3 +/- 5.93 years. At the time of transplantation, the lumbar spine and femoral neck T-scores were -1.75 +/- 1.05 and -1.95 +/- 0.73, respectively; 28% of subjects had evidence of osteoporosis. One year after transplantation, 77.6% of patients displayed improved lumbar T-scores to -1.33 +/- 0.94 (P = .044) with stable femoral neck T-scores. Bone densitometry enhanced gradually through the 4 years follow-up: lumbar T-score to -1.04 +/- 0.67 (P = .004) and femoral neck T-score to -1.69 +/- 0.49 (P = .12). At year 4, no osteoporosis cases were detected but 86.7% of patients did not receive steroids in the immunosuppressive regimen. The graft function remained stable (serum creatinine, 1.2 mg/dL; fasting glucose, 87.7 mg/dL). During the follow-up, BMD improved more significantly at cortical sites. Our study reports a reduced prevalence of fractures (8.7%) compared with the literature, which could be related to a steroid-sparing protocol and/or aggressively treatment of osteoporosis.

Effect of Different Sensitization Events on HLA Alloimmunization in Kidney Transplantation Candidates

BACKGROUND HLA alloimmunization is caused by sensitization events (SEs), such as transfusion, pregnancy, or previous organ transplantation, and the effects of particular SEs have not been thoroughly studied. Our aim was to evaluate how each SE affected HLA alloimmunization by considering Luminex assays. METHODS Sera from 722 kidney transplantation candidates were screened per protocol by means of Luminex assays to determine the presence of anti-HLA class I/II antibodies; positive sera underwent single-antigen assay to determine the presence of specific antibodies against HLA A, B, C, DR, DQ, DP loci (positivity if median fluorescence intensity values were >1,000). The effect of each SE was analyzed considering only patients exposed to 1 kind of sensitization. RESULTS In the 453 candidates with ≥1 SE, anti-HLA class I positivity rates were significantly higher in patients with previous transfusion (18.9%; P = .014), pregnancy (38.3%; P < .001) or transplant (75%; P < .001) compared with those with no SE (similar results for class II). The strength (median fluorescence intensity) of specific antibodies was significantly higher in patients with previous transplantation than in those with previous transfusion for HLA-A (8,017 vs 2,302; P = .02), HLA-B (7,765 vs 2,901; P = .018), and HLA-DR (9,835 vs 2,060; P = .003). Other anti-HLA antibody strengths were similar between patients with previous pregnancy or transplantation. CONCLUSIONS Presence of any SE analyzed was associated with a higher prevalence of anti-HLA antibodies for class I ± II compared with nonsensitized patients. Transplantation had the strongest immunization effect on both classes, followed by pregnancy and then transfusion.

Posttransplant Outcomes of Peritoneal Dialysis Versus Hemodialysis Patients

The impact of dialysis modality on posttransplant outcomes remains controversial. The authors have compared primary failure, delayed graft function (DGF), acute rejection episodes as well as patient and allograft survivals among patients undergoing renal transplantation between 2004 and 2009, according to the modality of hemodialysis (HD) versus peritoneal dialysis (PD). We studied 306 patients (268 HD and 38 PD) with a mean follow-up of 29 ± 16 months. The PD cohort included a predominance of females (68.4% vs 36.2%; P = .001), lower age at transplantation (38 ± 14 vs 46 ± 12 years; P = .004), shorter time on dialysis (33 ± 49 vs 59 ± 157 months; P = .043), and higher rate of living donor grafts (PD 31.6% vs HD 13.1%; P = .003). Donor age (PD 43 ± 13 vs HD 45 ± 14 years; P = .30), human leukocyte antigen mismatch (P = .17), panel reactive antibody values (HD 11 ± 22 vs PD 13 ± 26; P = .55), and hyperimmunized patients (HD 3.73%; PD 7.89%; P = .23) were not different. Primary graft failure (3.4% vs 0%; P = .025) and DGF (37.1% vs 13.1%; P = .037) were more frequent among HD patients, but incidences of acute rejection episodes were similar (HD 10.5% vs PD 5.3%; P = 0.19). Neither recipient survival at 1 (97% in PD and HD) or 3 years (HD 90% vs PD 94%; P = .657) nor allograft survival at 1 year (HD 94% vs PD 95%; P = .80) or 3 years: (HD 70%, vs PD 81%; P = .73) were different. Graft function was similar at 1 (HD 64.2 ± 25 vs PD 56.4 ± 24 mL/min; P = .17) and 3 years (HD 62.3 ± 21 vs PD 46 ± 23 mL/min; P = .16). In our study, HD patients showed an higher incidence of DGF and primary allograft failure, but there was no difference in acute rejection episodes, long-term survivals, or renal function.

A Case Series of De Novo Inflammatory Bowel Disease After Kidney Transplantation

Diarrhea, which is common after transplantation, may be due to infections and immunosuppressive therapy. Inflammatory bowel disease (IBD) de novo or as an exacerbation of pre-existent disease is a rare complication after kidney transplantation with pre-existing disease having a less aggressive clinical course than the de novo disease. Cytomegalovirus mismatch, prescription of tacrolimus instead of cyclosporine or mycophenolate mofetil rather than azathioprine as well as low-dose corticosteroid treatments have been linked to an increased incidence of IBD. This series of renal transplant recipients with de novo IBD showed a higher incidence and more aggressive course than that previously described, possibly related to increased use of tacrolimus with minimization of steroids.

New-Onset Lupus Nephritis in a Kidney Transplant Recipient With Cystinosis—Differential Diagnosis With Cysteamine-Induced Lupus: Case Report

A case of lupus nephritis in an adult female kidney transplant recipient with cystinosis under cysteamine therapy is reported. Previous reports of new-onset lupus in cystinotic patients have focused in a possible relationship of lupus with cysteamine therapy, but no obvious pathophysiological association has been disclosed. The authors present a case of a 19-year-old female kidney transplant recipient with cystinosis admitted for acute allograft dysfunction, with clinical and immunologic manifestations of lupus nephritis. Cysteamine was considered as a potential cause of drug-induced lupus, and we temporarily interrupted this drug. The clinical picture, the negativity of antihistone antibodies, the nondisappearance of antinuclear antibodies after discontinuation of the drug, and the clinical stability after resuming cysteamine therapy suggested that the underlying mechanism of lupus was unrelated to the drug. This may be the first report of new-onset lupus in a kidney transplant recipient with cystinosis. Clinicians should be aware of the association of autoimmune abnormalities in patients with cystinosis.

Advantages of kidney transplant precocity in graft long-term survival.

BACKGROUND Preemptive kidney transplantation (KT) or KT after a brief period on dialysis (<6 months) has been associated with better graft survival. Our study aimed to analyze the effect of an early KT on graft survival censored for patient death with functioning graft. METHODS A total of 1,373 kidney-only transplantations, from both living and deceased donors, performed from 1983 to 2010 were retrospectively studied. We defined 2 groups: those with early KT (preemptive or within 6 months after dialysis initiation; n = 131) and non-early KT (n = 1,242). Survival curves for each group were calculated by Kaplan-Meier analysis and compared by log-rank test. The independent effect of early KT on censored graft survival was analyzed by a multivariate-adjusted Cox proportional regression model. RESULTS The 5-, 10-, 15-, and 20-year censored graft survival rates were, respectively, 96%, 89%, 79%, and 79% among the early KT group, and 91%, 81%, 68%, and 49% among the non-early KT group (P = .024). Multivariate analysis showed the following to be independent predictors for censored graft failure: non-early KT (hazard ratio [HR] 2.58; P = .028), recipient age (HR 0.97; P < .001), donor age (HR 1.03; P < .001), recipient negative status for cytomegalovirus IgG (HR 1.44; P = .032), delayed graft function (HR 1.48; P = .013), and acute rejection event (HR 1.68; P = .002). CONCLUSIONS Our results show that early KT can be an approach for the improvement of long-term graft survival.