Margaret McMillan

Ultrasound changes in sclerosing peritonitis following continuous ambulatory peritoneal dialysis

Sclerosis of the peritoneum, with encapsulation of the small bowel is one of the most serious complications of continuous ambulatory peritoneal dialysis (CAPD), and carries a high mortality. The abnormalities seen on ultrasound are described for 14 patients and comprise increased small bowel peristalsis, tethering of the bowel to the posterior abdominal wall, intraperitoneal echogenic strands and, in the late stages of the disease, membrane formation. Optimal visualization of these features in the early stages of the disease was obtained by examining the patients with dialysis fluid present in the abdomen. Sclerosing peritonitis should be suspected in patients being treated by CAPD who develop abdominal pain and progressive loss of ultrafiltration and subsequent investigation should include the use of ultrasound.

Long-term outcome of a prospective randomized trial of conversion from cyclosporine to azathioprine treatment one year after renal transplantation.

BACKGROUND Since the introduction of cyclosporine (CsA), 1-year renal allograft survival has improved, but concern persists about the long-term adverse effects of CsA, especially with respect to renal function and blood pressure. This randomized controlled trial was set up to establish whether withdrawal of CsA would alter long-term outcome. METHODS Adult patients who, at 1 year after renal transplantation, had a stable serum creatinine of less than 300 micromol/L and who had not had acute rejection within the last 6 months were eligible for entry. Patients were randomized either to continue on CsA (n=114) or to stop CsA and start azathioprine (Aza, n=102). All patients remained on prednisolone. Median follow-up was 93 months after transplantation (range: 52-133 months). RESULTS There was no significant difference in actuarial 10-year patient or graft survival (Kaplan-Meier), despite an increased incidence of acute rejection within the first few months after conversion. Median serum creatinine was lower in the Aza group (Aza: 119 micromol/L; CsA. 153 micromol/L at 5 years after randomization, P=0.0002). The requirement for antihypertensive treatment was also reduced after conversion to Aza; 75% of patients required antihypertensive treatment at the start of the study, decreasing to 55% from 1 year after randomization in the Aza group and increasing to >80% in the CsA group (55% (Aza) and 84% (CsA) at 5 years after randomization, P<0.005). CONCLUSIONS Conversion from CsA to Aza at 1 year after renal transplantation results in improvement in both blood pressure control and renal allograft function, and is not associated with significant adverse effects on long-term patient or graft survival.

Randomized study comparing cyclosporine with azathioprine one year after renal transplantation-15-year outcome data

Background. The introduction of cyclosporine (CsA) improved 1-year graft survival and reduced the incidence of acute rejection episodes after renal transplantation compared to azathioprine (Aza). However, CsA has many side effects and reducing exposure of this drug after the first year may benefit long-term patient and graft survival. Methods. We report 15-year outcome data from a single center, randomized controlled study comparing CsA withdrawal and conversion to Aza with continuation of CsA 1-year posttransplant. Results. Two hundred sixteen patients who showed a serum creatinine less than 300 &mgr;mol/L with no acute rejection episodes in the preceding 6 months were enrolled (CsA 114, Aza 102). There was no difference in patient survival at 15 years: 62.4% in the CsA group and 64.4% in the Aza group (P=0.6). Fifteen-year transplant survival was 41.9% for the CsA group and 48.8% for the Aza group (P=0.8). Fifteen-year graft survival censoring for death with a functioning graft was 58% in the CsA group and 72% in the Aza group (P=0.5). Predictors of patient survival were younger recipient age (P<0.001) and lower systolic blood pressure at randomization (P=0.01). Predictors of graft survival were older recipient age (P<0.001) and better renal function at randomization (P=0.01). Assigned drug showed no effect on graft or patient survival. Patients assigned to CsA showed significantly worse renal function up to 10 years posttransplantation and required more anti-hypertensive treatment throughout the study period. Conclusion. In a selected group of patients, either Aza or low-dose CsA is safe and effective. Despite lower estimated glomerular filtration rate (eGFR) up to 10 years posttransplantation and increased use of anti-hypertensive agents, low-dose CsA was not associated with a worse patient or graft survival.

In vitro studies on lymphocyte Fcγ receptor blocking factors in human renal transplantation

Abstract In this study we have confirmed our earlier observation that the presence in pre-transplant serum of a high-molecular-weight lymphocyte Fcγ receptor blocking factor correlates with improved human renal allograft survival. This factor was found to bind preferentially to B cells and to impair B cell function in vitro.

Isolation and characterization of a high molecular weight lymphocyte Feγ receptor-blocking factor associated with renal allograft survival

We have confirmed our previous observation that improved human renal allograft survival is associated with the presence in pre‐transplant serum of a high molecular weight lymphocyte Fey receptor‐blocking factor. Serum fractionation studies suggest that this factor is a complex protein consisting of IgG together with an IgG‐binding protein which has an apparent molecular weight of approximately 60 kD.

Persistent dipstick haematuria following renal transplantation.

Abstract:  Despite widespread testing for dipstick haematuria following renal transplantation, there are no published series describing the prevalence and possible causes of this complication in an adult population. A cross‐sectional study of 640 renal transplant recipients under review at our follow‐up clinic was performed. Persistent haematuria was defined as a minimum of 1+ of blood on urinalysis stick testing detected at not fewer than 75% of clinic visits since its onset, or since the start of routine testing, present over a period of at least 4 weeks. The prevalence of persistent dipstick haematuria was 13.3%. Median serum creatinine was higher in patients with persistent haematuria but age, gender and length of time since transplantation were not significantly different. Potential explanations for persistent haematuria in 21 of 85 affected patients were chronic infection, ureteric stent without chronic infection, regular or intermittent self‐catheterization, persistent menstrual bleeding, anticoagulant therapy, graft calculus, and allograft renal cell carcinoma. Recurrent or de novo glomerular disease was confirmed by graft biopsy in 10 of 85 patients. Among the 41 recipients whose original cause of renal failure was IgA nephropathy (IgAN), the prevalence of persistent haematuria was 31.7% compared with 12% in the remaining patients (relative risk 2.6, 95% CI: 1.6–4.3). Persistent haematuria in IgAN patients was not associated with gender, age or time since transplantation. After 29 months of follow‐up, 20% of patients with haematuria had progressed to graft failure or death compared with 11.6% of the unaffected group (p = 0.029). However, despite the association with earlier graft failure, haematuria did not predict this endpoint independently of renal function.

The visual status of diabetics on renal replacement therapy (RRT).

The visual status of 48 patients with end-stage diabetic nephropathy who were undergoing treatment either by dialysis or transplantation was assessed. At the time of starting dialysis, the vision was good in 27 (56 per cent), impaired in 7 (15 per cent) and of navigating standard only in 12 (25 per cent) while the remaining 2 (4 per cent) had no useful vision. During the time on dialysis and/or following transplantation, vision improved in 6 patients (12 per cent), deteriorated in 9 (19 per cent) and remained unchanged in 33 (69 per cent). Changes in the degree of retinopathy in the 96 eyes resulting either from treatment of the renal failure or laser therapy were noted. The reasons for any changes in vision and the effect of ophthalmic treatment will be discussed.

Long-term outcomes of patients on the 1988 West of Scotland renal transplant waiting list.

Background The prevalent population with established renal failure continues to grow. Method Using the Renal Electronic Patient Record, we assess the long-term outcomes of the adult population in the West of Scotland who were awaiting kidney transplantation in 1988 (n = 219), and compare the demographics to the 2011 transplant waiting list (n = 409). Results Comparing the 2011 transplant waiting list, there are now more patients, but they are older, more likely to be female, and are more likely to have diabetes as a cause of renal failure. Seventy-four percent received a transplant; of these, 41% of the transplants ultimately failed and the patient returned to dialysis; 39% of patients died with a functioning graft and 20% remain alive with continuing transplant function. Life expectancy for those with renal failure was less than 60 years, significantly lower than the general population, though 29% survived for 20 years, half of these with a functioning kidney transplant and half having returned to dialysis. Conclusion As survival with a transplant improves, attention is required to reduce the causes of mortality, in particular cardiovascular disease, and malignancy and infection associated with immunosuppression.

Detection of lymphocyte Fcγ receptor-blocking factors by the EA rosette inhibition assay: Refinement of the conventional method and development of a novel flow-cytometric assay

Serum factors which interact with human peripheral blood lymphocyte Fc gamma receptors (Fc gamma Rs) may be detected in vitro by the EA rosette inhibition assay (EARIA). This assay has been used to detect circulating immune complexes and certain alloantibodies directed against cell surface antigens situated in close proximity to Fc gamma Rs. Three main types of FcR-blocking factor have been demonstrated by the EARIA in human serum following exposure to alloantigens. A strong correlation was observed between the presence of one of these FcR-blocking factors (FcBF1) and human renal allograft survival. This factor was previously shown to bind preferentially to CD32+ B cells and to inhibit antibody synthesis. In this study we have shown that detection of FcBF1 by the EARIA depends on the type of erythrocyte and on the amount of antibody used to sensitise the erythrocytes. Furthermore, we have developed a flow-cytometric version of the EARIA which is rapid, reproducible and, most importantly, objective. Inter-laboratory comparisons using this standardised EARIA should now be possible.