P. Pereira

Eculizumab Treatment of Acute Antibody-Mediated Rejection in Renal Transplantation: Case Reports

The occurrence of acute antibody-mediated rejection (AMR), especially in more severe cases, continues to be associated with a poor prognosis for implant survival. Here, we have reported the results of treatment of two patients who developed AMR associated with thrombotic microangiopathy immediately after transplantation. We used a single dose of eculizumab at an early stage jointly with conventional modalities of steroid boluses, plasmapheresis, intravenous immunoglobulin, and rituximab. In both cases, the clinical course was favorable. Eculizumab, a monoclonal antibody with a high affinity for complement protein C5, prevents generation of the final membrane attack complex, blocking this cascade. To date, there are a few reports of the usefulness of eculizumab in AMR. Eculizumab can help to stop endothelial damage, especially in severe cases that show a risk of progression to cortical necrosis, by providing a therapeutic window until the other modalities begin to control the immune response. In our experience, the use of eculizumab can be beneficial in the treatment of AMR.

High incidence of diabetes mellitus after kidney transplant in patients with hepatitis C.

Accessible online at: http://BioMedNet.com/karger Dear Sir, Hepatitis C, with or without cirrhosis, is associated with a high prevalence of diabetes mellitus [1, 2]. It has also been observed more frequently in diabetic patients in comparison to the general population [3]. Only recently has a greater incidence of insulindependent diabetes mellitus (IDDM) after liver transplantation been described for recipients with hepatitis C [4]. We have observed a higher prevalence of IDDM after kidney transplant in carriers of hepatitis C antibodies (HCV+). In order to quantify and statistically evaluate this clinical observation, we reviewed all our patients receiving a cadaveric kidney transplant with an organ functioning for more than 3 months, no history of diabetes prior to transplantation and treated with cyclosporine during the immediate postoperative period (n = 370), most patients (79%) receiving a quadruple sequential therapy with prednisone, azathioprine and antilymphocyte globulin. The determination of anti-hepatitis C antibodies (ELISA II, confirmed by RIBA) before or after the transplant was available in 362 cases (before the transplant in 340 cases, determined from frozen samples for cases prior to 1990). We considered as cases of IDDM those requiring the prolonged use of insulin, although control could be later achieved without insulin (after decreasing or withdrawing steroid therapy). The determination of anti-HCV antibodies was positive (HCV+) before and/or after transplantation in 106 patients (29.3%); 41 cases (11.3%) were classified as IDDM. The accumulated incidence of IDDM was 22.6% in HCV+ patients and 6.6% in HCV– patients ( ̄2, p ! 0.0001). The difference was slightly lower when referring to the pretransplant determination: 21.7% of IDDM in HCV+ patients and 9.2% in HCV– patients (p ! 0.004). The odds ratio of IDDM in relation to the HCV+ status was 4.11 (95% confidence interval: 2.1–8.9); when considering the pretransplant determination, the odds ratio was 2.73 (95% CI 1.35–5.53). When comparing the two groups of patients with IDDM, we demonstrated a lower mean age for the HCV+ group (45.6 vs. 52.2 years in the HCV– group; t Student, p = 0.041) and a greater duration on dialysis prior to surgery (55.6 B 36 vs. 32.4 B 15 months for the HCV– group, p = 0.017). There were no differences with regard to sex (female predominance in both groups vs. a greater frequency of males in the total group of transplanted patients), body mass index at transplantation or at the last visit, or in the follow-up period posttransplant (almost 5 years for both groups). With multivariant analysis by logistic regression, the following predictive independent factors of IDDM were found: age, female sex, body mass index at the time of transplantation and the HCV+ status before transplant (odds ratio: 3.16). Hepatitis C could lead to IDDM through different mechanisms: direct viral damage to the beta cells, autoimmune mechanisms against insulin or pancreatic tissue and, in the case of postransplantation, besides a greater intensity of the aforementioned, a greater toxicity of the immunosuppressive drugs. In any case, the induction of diabetes could represent a new way in which hepatitis C affects the survival of the patient and the transplanted organ.

Infectious complications in 159 consecutive kidney transplant recipients

INTRODUCTION The incidence of infections has decreased in kidney transplant (KT) recipients owing to advances in the surgical techniques and clinical management of this population. Nevertheless, these complications continue to occur and the causes seem to be changing, in part because of the prophylactic strategies used. METHOD Prospective, observational study investigating infections occurring during the first 2 years post-transplantation in KT recipients who underwent surgery between July 2003 and December 2005 at Hospital Universitario Virgen del Rocío. Univariate and multivariate regression analysis was performed to determine risk factors associated with the development of infection. RESULTS The incidence of infection was 1.11 episodes per patient over 510+/-234 days. The most common infections were urinary tract infection (UTI) (46.6%), cytomegalovirus (CMV) infection (22.7%), and surgical site infection (8%). The causes were bacterial (50.4%), viral (45.9%), and fungal (3.6%) agents. The most frequent pathogens were CMV (36%), Escherichia coli (28%), extended-spectrum beta-lactamase (ESBL)-producers (26%), and coagulase-negative staphylococci (6.3%). Seventy-nine percent of infection episodes occurred in the 4 months following KT. One recipient died 30 days after the infection episode. In the infection group, patient and graft survival at the end of follow-up was 98% and 89%, respectively. CONCLUSIONS The most frequent syndromes were UTI, CMV infection and surgical site infection. The infections were mainly produced by bacteria, in particular gram-negative rods, and there was a high rate of ESBL E. coli.

Complicaciones infecciosas en 159 receptores de trasplante renal consecutivos

INTRODUCTION The incidence of infections has decreased in kidney transplant (KT) recipients owing to advances in the surgical techniques and clinical management of this population. Nevertheless, these complications continue to occur and the causes seem to be changing, in part because of the prophylactic strategies used. METHOD Prospective, observational study investigating infections occurring during the first 2 years post-transplantation in KT recipients who underwent surgery between July 2003 and December 2005 at Hospital Universitario Virgen del Rocío. Univariate and multivariate regression analysis was performed to determine risk factors associated with the development of infection. RESULTS The incidence of infection was 1.11 episodes per patient over 510+/-234 days. The most common infections were urinary tract infection (UTI) (46.6%), cytomegalovirus (CMV) infection (22.7%), and surgical site infection (8%). The causes were bacterial (50.4%), viral (45.9%), and fungal (3.6%) agents. The most frequent pathogens were CMV (36%), Escherichia coli (28%), extended-spectrum beta-lactamase (ESBL)-producers (26%), and coagulase-negative staphylococci (6.3%). Seventy-nine percent of infection episodes occurred in the 4 months following KT. One recipient died 30 days after the infection episode. In the infection group, patient and graft survival at the end of follow-up was 98% and 89%, respectively. CONCLUSIONS The most frequent syndromes were UTI, CMV infection and surgical site infection. The infections were mainly produced by bacteria, in particular gram-negative rods, and there was a high rate of ESBL E. coli.

Infectious diseases in 159 consecutive kidney transplant recipients.

INTRODUCTION The incidence of infections has decreased in kidney transplant (KT) recipients owing to advances in the surgical techniques and clinical management of this population. Nevertheless, these complications continue to occur and the causes seem to be changing, in part because of the prophylactic strategies used. METHOD Prospective, observational study investigating infections occurring during the first 2 years post-transplantation in KT recipients who underwent surgery between July 2003 and December 2005 at Hospital Universitario Virgen del Rocío. Univariate and multivariate regression analysis was performed to determine risk factors associated with the development of infection. RESULTS The incidence of infection was 1.11 episodes per patient over 510+/-234 days. The most common infections were urinary tract infection (UTI) (46.6%), cytomegalovirus (CMV) infection (22.7%), and surgical site infection (8%). The causes were bacterial (50.4%), viral (45.9%), and fungal (3.6%) agents. The most frequent pathogens were CMV (36%), Escherichia coli (28%), extended-spectrum beta-lactamase (ESBL)-producers (26%), and coagulase-negative staphylococci (6.3%). Seventy-nine percent of infection episodes occurred in the 4 months following KT. One recipient died 30 days after the infection episode. In the infection group, patient and graft survival at the end of follow-up was 98% and 89%, respectively. CONCLUSIONS The most frequent syndromes were UTI, CMV infection and surgical site infection. The infections were mainly produced by bacteria, in particular gram-negative rods, and there was a high rate of ESBL E. coli.