P. Troncoso

Factors That Predict Duration of Delayed Graft Function in Cadaveric Kidney Transplantation

INTRODUCTION We have previously shown that the duration of delayed graft function (DGF) is a significant predictor of serum creatinine concentration at 1 year posttransplantation, which may be a surrogate marker for kidney survival after renal transplantation. OBJECTIVE To identify donor and recipient characteristics that influence the duration of DGF in a 2-center study. PATIENTS AND METHODS This retrospective analysis of 212 consecutive cadaveric renal transplant procedures examined the following variables: donor and recipient age and sex, cause of death (cerebrovascular accident or trauma), donor creatinine and sodium concentrations, multiorgan or kidney-only donor use, type of vasoactive drugs, cold ischemia time, percent reactive antibodies, and HLA mismatch. RESULTS Overall, 30.5% of recipients experienced DGF with a mean (SD) duration of 4.4 (8) days. At univariate analysis, the use of norepinephrine in the donor and increased cold ischemia time were associated with longer DGF duration. However, at multivariate analysis, none of the factors studied was significant. CONCLUSIONS The duration of DGF may be associated with longer cold ischemia time, which emphasizes the need to shorten this period insofar as possible to improve long-term results. The association of use of norepinephrine and prolonged DGF should be observed carefully because it may be that use of this drug is related to worse hemodynamics in the donor and not to deleterious effects of the drug per se.

Renal Vein Extension Using Gonadal Vein: A Useful Strategy for Right Kidney Living Donor Harvested Using Laparoscopy

INTRODUCTION Vascular management of the right renal vein during laparoscopic living donor nephrectomy is still an unsolved problem. This short vessel has limited the use of right kidneys. However, the right kidney should be harvested in some instances. Based on experience in open donor nephrectomy, our unit has used the donor gonadal vein to obtain a longer renal vein in this setting. METHODS Four consecutive living related donors with the indication for laparoscopic right nephrectomy underwent this procedure. Three donors were females and the overall average age was 48.5 years. The renal vein was controlled with a 30-mm stapler and we included 5-6 cm of the ipsilateral gonadal vein during the harvest. The donor kidney was perfused and renal vessels prepared under cold conditions. The gonadal vein was opened longitudinally and sutured to the donor right renal vein as a wide tube in 3 cases and as a spiral tube in 1 case with 6-0 monofilament suture. RESULTS This procedure extended the bench work between 25 to 40 minutes permitting an 2.5- to 3.5-cm extension of the donor vein. The transplantations were performed in the usual mode and the vein enlargement enormously facilitated the implantation surgery. All recipients displayed immediate graft function; no complications were observed with this strategy. CONCLUSIONS Vein extension with the gonadal vein was a simple, safe method to enlarge the renal vein among right living donor kidneys procured using laparoscopy.

Prophylaxis and treatment of Chagas disease in renal transplant donor and recipient: case report.

Chagas disease is a prevalent zoonosis in Latin America, caused by the protozoa Trypanosoma cruzi and transmitted by Triatoma infestans. Part of the infectious cycle consists of chronic subclinical parasitemia, causing in the long term end-organ damage. Amastigotes have been isolated from various organs including native and allograft renal parenchyma; thus, transplantation plus immunosuppression therapy is another mode of disease transmission and reactivation. Herein, we report 2 successful kidney transplantations cases in which either infection or reactivation was averted using prophylactic nitroderivates.

Abbreviated AUC Monitoring of Cyclosporine More Adequately Identified Patients at Risk for Acute Rejection During Induction of Immunosuppressive Therapy After Kidney Transplantation Than Recommended C2 Concentration Values

OBJECTIVE Monitoring of cyclosporine (CsA) is critical during the induction of immunosuppressive therapy. Although most centers have incorporated C2 levels, our unit still uses an abbreviated AUC model which includes concentrations at C1, C2, and C6 post-dose (AUC(1-6)). The objective of this study was to compare both strategies of CsA monitoring during the first 30 days after kidney transplantation. PATIENTS AND METHODS The study included 89 recipients induced with CsA microemulsion and steroids. AUC(1-6) profiles were performed around days 3, 10, and 30 after transplantation with a target of 5500 to 6000 ng*h/mL considered therapeutic. For comparison purposes, a value of C2 >/= 1500 ng/mL was also considered therapeutic. Mean C2 and AUC(1-6) values were low dated with biopsy-proven acute rejection episodes (BPAR) during the study period. RESULTS Twenty patients received living donor kidneys and overall there were 46 females. During this period, 253 AUC(1-6) were performed including 44 (17.4%) below the therapeutic range. When the analysis included only C2, 171 (67.6%) were below the therapeutic target (P < .001). Five patients experience BPAR and only AUC(1-6) at day 10 discriminated rejectors versus nonrejectors (5645 +/- 1390 and 8221 +/- 2502, respectively; P = .008). C2 was not significantly different at any time in either group. CONCLUSIONS In this study, abbreviated AUC monitoring more adequately identified patients at risk for acute rejection than C2. Recommended C2 concentration levels need to be redefined in our patients.

Strategies for prevention of cytomegalovirus infection in renal transplant patients.

OBJECTIVE Cytomegalovirus (CMV) constitutes the principal viral infection in renal transplant patients. The indirect consequences of CMV infection increase the risks for acute and chronic rejection, secondary infections, lymphoproliferative disorders, atherosclerosis, and cardiovascular deaths. The direct effects depend on the affected organ. There have been strategies to prevent CMV disease: prophylaxis and preemptive strategy. The aim of this study was to compare the incidences of disease and infection due to CMV among our patients. PATIENTS AND METHODS We performed a retrospective analysis of all our renal transplant patients between January 2000 and January 2008. RESULTS Four groups were identified among 94 patients: without any preventive strategy; brief prophylaxis; formal prophylaxis; and preemptive treatment. There were no significant differences among the groups in the incidences of CMV disease, acute renal rejection, or survival. The greatest number of infections was registered in the group with brief prophylaxis (P = .006); 50% of the registered infections occurred before 150 days posttransplantation. CONCLUSIONS We concluded that the preemptive strategy is appropriate for the low-risk patient, while prevention with antiviral drugs should be reserved for intermediate- and high-risk patients. A brief treatment for prevention is an alternative to prevent CMV disease, but it needs to be followed with serial, long-term evaluation of antigenemia for >150 days posttransplantation.

Hemorrhagic Cystitis Secondary to Adenovirus Infection in a Kidney Transplant Recipient: Case Report

Increasingly potent immunosuppressive agents have reduced the incidence of rejection of transplanted organs while increasing patient susceptibility to opportunistic infections and cancer. Adenoviruses are increasingly recognized as contributors to morbidity and mortality in stem cell and solid-organ transplant recipients. Clinical findings range from asymptomatic viremia to respiratory and gastrointestinal disease, hemorrhagic cystitis, and severe disseminated illness. We describe the first case in Chile of hemorrhagic adenovirus cystitis after renal transplantation in an adult.

Factors That Affect Concentrations of Cyclosporine During the Induction Period of Kidney Transplantation: Multivariate Analysis

OBJECTIVE The pharmacokinetics of cyclosporine (CsA) depend on numerous factors over the transplantation course. The aim of this study was to evaluate the impact of several clinical variables on CsA concentrations during the induction period after kidney transplantation. METHODS Potential variables were contrasted with CsA concentrations at 2 hours postdose (C(2)) and with the area under the concentration curve of CsA (AUC) at days 3 and 10 after transplantation. Evaluated variables were: recipient age, gender, body mass index (BMI), type/duration of previous dialysis, pretransplant serum creatinine (sCr), donor type, CsA dose, cold ischemia time, reduction of sCr, and use of other immunosuppressive drugs. RESULTS This series included 112 patients who displayed an average age of 43 ± 13 years, including 62 men and 31 recipients of living donor organs. The induction dose of CsA was 8.36 ± 1.53 mg/kg. On day 3, the C(2) was related to the reduction of sCr (P = 0.034) and to the BMI (P = 0.033). There was an inverse correlation with pretransplant sCr (P = 0.012). The AUC correlated with BMI (P = 0.027) and living donor category (P = .002). Patients receiving rapamycin or a locally procured kidney showed a trend toward higher AUC values. On day 10, the CsA dose and use of rapamycin showed a trend to higher values of C(2); the AUC was related to the CsA dose (P = .034). None of the other variables showed significant effects. Analysis between variables showed that time on dialysis correlated with the pretransplant sCr (P = .002) and that the CsA dose was negatively associated with BMI (P = .009). CONCLUSION Pretransplant sCr, BMI, living donor kidney category, better functional recovery, and the dose of CsA were predictors of CsA concentrations of clinical interest during this induction period. The effect of BMI was not related to higher doses of CsA.