M. Kharrat

Sirolimus for the Treatment of Kaposi Sarcoma After Renal Transplantation: A Series of 10 Cases

The incidence of Kaposi sarcoma (KS) has substantially increased among immunocompromised patients, suggesting a role for immunosuppressive drugs. The aim of this study was to evaluate the incidence, features, and outcome of KS among 307 kidney transplantation patients at our center between January 1994 and June 2010. During the study period, the 10 patients who developed KS (3.25%) showed a mean age at transplantation of 35.8 ± 8.7 years (range, 22 to 49 years). The mean interval between transplantation and occurrence of KS was 24.7 ± 21.36 months (range, 6 to 64 months). The mean time of antithymocyte globulin induction was 9.5 days (range, 6 to 13 days). KS was restricted to the skin in 7 cases, among which, one presented with associated Hodgkin lymphoma. Visceral involvement (one lung and one colon) was observed in two cases. One patient presented with a gastric KS without skin lesions. Immunosuppressive treatment was reduced, then withdrawn in three cases, resulting in regression of KS a few weeks later, but with graft loss requiring hemodialysis at 1, 3 and 4 months. Among the remaining 7 cases, we stopped mycophenalate mofetil (MMF) and switched from calcineurin inhibitors to sirolimus. Allograft function remained stable after the switch. Only one patient who already had allograft dysfunction due to biopsy-proven chronic allograft nephropathy. Deteriorated progressively, undergoing hemodialysis at 2 years after KS diagnosis. In conclusion, we observed a relatively high incidence of KS among our cases. The introduction of sirolimus resulted in complete regression of KS lesions with preserved graft function.

Secondary oxalosis due to excess vitamin C intake: a cause of graft loss in a renal transplant recipient.

Renal oxalate deposition can be seen with primary hyperoxaluria, malabsorptive states, ethylene glycol toxicity and, rarely, with excessive vitamin C ingestion. We report a case of secondary hyperoxaluria in which the diagnosis was not considered initially because there was no past history of urinary calculi and no evidence of nephrocalcinosis on plain X-ray of the abdomen and ultrasonography. The disease was detected and diagnosed only after kidney transplantation. Secondary oxalosis can cause graft loss or delayed graft function. Biopsy of the allograft should be carefully examined for oxalate deposits even in the absence of a family history. When oxalosis is diagnosed, intensifying hemodialysis (HD) to eliminate calcium oxalate can help in the recovery of renal function in some cases. Systematic vitamin C supplementation in HD patients should be avoided as it can be a cause of secondary oxalosis.

Alport syndrome and diffuse leiomyomatosis

Review on Alport syndrome and diffuse leiomyomatosis, with data on clinics, and the genes involved.

Living and cadaver donor transplant programs in the Maghreb.

In the Maghreb, organ failure constitutes a major public health problem, especially given the increasing number of patients with chronic renal failure and the high cost of care. In this study, we attempted to seek the recommendations, through a questionnaire, of various officials related to organ transplantation as well as leaders of ethics committees and religious groups in different countries of the Maghreb. The objective was to improve the rate of organ donation and transplantation. We received 36 replies (62%) within the prescribed time limit. In our survey, 83% of the respondents felt that living donor transplantation should be promoted initially, followed gradually by measures to increase cadaver donor transplantation to achieve a target of about 30 transplants with cadaver kidney donors per million inhabitants. To expand the donor pool, 83% of the respondents proposed to expand the family circle to include the spouse and in laws. To improve the cadaver donation activity, one should improve the organizational aspects to ensure at least 50 renal transplantations per year (100%) and provide material motivation to the treatment team proportional to the activity of organ donation and transplantation. Finally, 93% of the respondents suggested suitable moral motivation of the donors.

Pulmonary Nocardiosis in a Kidney Transplant Recipient: A Case Report and Review of the Literature

Nocardiosis is a life threatening disease in solid organ transplant recipients. It is an uncommon but important infection for these patients. We report a case of 37- year-old kidney recipient who developed pulmonary nocardiosis that was successfully treated with intravenous imipenem and tetracyclines in conjunction with a reduction in immunosuppressive therapy. Four years later, graft function remains stable with complete regression of radiological abnormalities and absence of relapses. This case emphasizes the role of new potent immunosuppressants and diabetes in the occurrence of opportunistic infections. Nocardiosis should be suspected in the presence of pulmonary symptoms with unusual radiological presentation.

Atypical Presentation of a Brown Tumor in a Kidney Transplant Recipient: A Case Report

Brown tumor is a rare complication of secondary hyperparathyroidism. It is exceptionally encountered after kidney transplantation. We here report on a 54-year-old male recipient who developed a brown tumor localized in the right forearm, and whose initial presentation was atypical, mimicking a bone tumor. Hence, diagnosis of brown tumors should be suggested by clinicians in a context of hyperparathyroidism.

BLOOD PRESSURE BALANCE IN CHRONIC KIDNEY DISEASE

Objective: Hypertension is common in chronic kidney disease (CKD) and is a major determinant of CKD progression. Ambulatory blood pressure monitoring (ABPM) has been proposed as a better method to evaluate blood pressure (BP) in real life conditions. The objective of our study is to better specify the characteristics of ABPM in patients with CKD compared to the rest of the hypertensive population. Design and method: We conducted a retrospective study including all patients who benefited from an ABPM between January 2014 and Juin 2017. The CKD was established based on the definitions of KDIGO 2012. We divided our patients into 2 groups: G1: patients with ckd and G2: patients without CKD. The comparison between the 2 groups was carried out by Chi-square test and one factor ANOVA. Results: The study included 241 cases with a sex ratio of 0,84. The prevalence of CKD was 81% including 33 % stage 2, 56 % stage 3; 10 % stage 4 and 1% stage 5. Patients with CKD were older (55 ± 16 years vs 42 ± 15 years; p < 0,001). There were no significant difference regarding sex (p = 0,07) and body mass index (p = 0,06). The mean blood pressure (BP) in consultation was 157/85 (G1) and 145/ 86 (G2) (p = 0,03; p = 0,5). The indications of ABPM were different in the two groups: unbalanced hypertension (G1: 67%, G2: 37,5%), borderline hypertension (G1: 13.4%, G2: 22,5 % (G1: 1.7%, G2: 3%) and the search for masked hypertension (G1: 20%, 40%) with a significant difference (p = 0.002). In the ABPM, there was no difference in systolic and diastolic BP, whereas the difference was significant comparing patients having satges 4 and 5 CKD with other patients (149/82 vs 136 /78; p = 0,016; p = 0,3).The mean number of antihypertensive drugs was greater in the presence of CKD (1,8 ± 1,3 vs 0.8 ± 0,9; p < 0.001). Conclusions: BP should be monitored closely in hypertensive patients with CKD. ABPM seems to be the appropriate method in detecting hypertension and monitoring adequacy of treatment in patients with CKD.

Optimization of therapeutic drug monitoring of vancomycin in patients with chronic hemodialysis .

PURPOSE To validate a simplified vancomycin monitoring algorithm in patients on chronic hemodialysis who required intravenous vancomycin for at least 3 weeks. MATERIALS AND METHODS In this prospective study, all hemodialysis patients who were admitted between April 1, 2013, and March 31, 2015, in our unit for suspected or confirmed methicillin-resistant Staphylococcus aureus infection that required vancomycin were enrolled. All patients were categorized into two groups. In group 1 (standard vancomycin dosing algorithm), the maintenance doses of vancomycin were adjusted according to the pre-hemodialysis vancomycin concentrations determined before each hemodialysis session. In group 2 (simplified vancomycin dosing algorithm), pre-dialysis vancomycin trough levels were taken before the 2nd and the 6th session of hemodialysis. Maintenance doses were adjusted according to the residual concentrations of vancomycin. RESULTS A total of 101 blood samples were collected, the average plasma concentration of vancomycin was 13.1 ± 3.8 µg/mL. 64 (63.4%) levels fell out of the therapeutic range. Seven (6.9%) of these exceeded the therapeutic range and 30 (29.7%) were lower. After the loading dose, the average plasma concentration was 11.2 ± 3.4 µg/mL. There were no statistically significant differences between the two groups with respect to the average plasma concentration of vancomycin and the proportion of vancomycin trough levels in the target range. CONCLUSION The vancomycin dosing algorithm using limited concentration monitoring for hemodialysis patients achieved drug concentrations comparable to those found with more frequent monitoring and resulted in significant cost savings.
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