R. Alves

Renal transplantation with expanded criteria donors: the experience of one portuguese center

BACKGROUNDnThe shortage of kidneys available for transplantation has led to enlarged criteria donors (ECD): namely, donors older than 60 years or aged between 50 and 59 years with 2 of the following characteristics-hypertension, predonation serum creatinine level higher than 1.5 mg/dL or cerebrovascular disease as the cause of death. The aim of this study was to analyze renal transplants using ECD compared with standard criteria donors (SCD) concerning the incidences of delayed graft function (DGF), acute rejection episodes (ARE), and patient and graft survivals.nnnMATERIALS AND METHODSnThis retrospective study of 409 cadaveric renal transplants over the last 4 years identified ECD in contrast with SCD.nnnRESULTSnOf the transplants, 24.4% used ECD. The baseline characteristics of recipients of ECD versus SCD kidneys were similar, except for age and cold ischemia time. Comparing ECD and SCD, we observed an higher incidence of DGF (35% vs 18%), occurrence of ARE (34.4% vs 16.6%), average serum creatinine levels at 6 (1.87 vs 1.4 mg/dL), and 12 months (1.88 vs 1.43 mg/dL) as well as lower graft survival at 1 (82% vs 91%) and 3 years (75% vs 84%) after transplantation. Recipient survival at 1 year was not different. Multivariate analysis identified recipient age, cold ischemia time, ARE, and DGF as risk factors for graft failure.nnnCONCLUSIONSnRenal transplantation with grafts from ECD shows significantly worse outcomes with higher rates of DGF and ARE, worse graft function, and lower graft survival.

Kidney Transplantation Using Donors Over 70 Years Old: Are the Criteria for Organ Allocation Too Expanded?

BACKGROUNDnThe scarcity of organs available for transplantation has led to the use of kidneys from old deceased donors including those ≥70 years of age. The results of kidney transplants performed using such limit organs warrent further study.nnnMETHODSnWe retrospectively evaluated all cadaveric heart-beating renal transplants performed from September 1996 to June 2010 using expanded-criteria donors: Group 1 included 302 transplants performed with kidneys from expanded-criteria donors aged 50-69 years; group 2 included 60 recipients of kidneys from donors aged ≥70 years. All patients were prescribed an immunossupressive regimen based on mycophenolate mofetil or mycophenolic acid, a calcineurin inhibitor, and corticosteroids, with or without monoclonal/polyclonal antibodies.nnnRESULTSnThe baseline recipient characteristics were similar except for age, which was higher in group 2; history of previous transplantation was absent in group 2, and there was more use of induction with monoclonal or polyclonal antibodies in group 2 (65% vs 49%; P = .02). There was no significant difference in the rate of nonfunctioning grafts, delayed graft function, or acute rejection episodes in the first 6 months. There was no significant difference between groups regarding graft or patient survival.nnnCONCLUSIONSnThe use of kidneys from donors aged ≥70 older than or years yielded generally satisfactory results.

The Prognostic Value of Pre-implantation Graft Biopsy on the Outcomes of Renal Transplantations

INTRODUCTIONnThe pre-implantation graft biopsy is an important tool for the selection of donors, providing objective information about graft function outcomes. The degree of histological lesions is related to the incidence of delayed graft function (DGF) and long-term survival of the graft.nnnMATERIALS AND METHODSnWe analyzed 30 graft biopsy specimens by a semi-quantitative evaluation of chronic lesions. We evaluated the clinical characteristics of recipients, the presence of DGF, and the renal function in the immediate posttransplantation period, as well as month 3 and month 6 after transplantation.nnnRESULTSnHistological evaluation showed glomerulosclerosis score 0 in 77% versus score of 1 in 23%; fibrosis score 0 in 46.5% versus score 1 in 46.5% and score 2 in 7%; tubular atrophy score 0 in 53.5% versus score 1 in 36.5% and score 2 in 10%; vascular score 0 in 17% versus score 1 in 50% and score 2 in 33%. Approximately 33% of patients displayed DGF and 13% acute rejection episodes. There was a positive correlation between the presence of interstitial fibrosis and serum creatinine values at 3 (P = .01) and 6 months (P = .02). No correlation was observed between graft function and the presence of tubular atrophy, glomerulosclerosis, and vascular changes.nnnCONCLUSIONnWe observed that a large number of graft biopsy specimens (83%) displayed vascular changes related to the age of the donor. Only a minor degree of interstitial fibrosis, was related to better graft function. The presence of tubular atrophy, vascular changes, and glomerulosclerosis showed no impact on short-term graft function.

Induction With Basiliximab in Renal Transplantation

INTRODUCTIONnThe use of monoclonal antibodies in renal transplantation for induction therapy has been associated with a marked reduction in acute rejection rates with an impact on graft and patient survivals.nnnOBJECTIVEnWe sought to evaluate the efficacy of renal transplant induction protocols using Basiliximab based on the rates of acute rejection episodes (ARE) and delayed graft function (DGF) of infectious complications in the first 6 months posttransplant, as well as patient and graft survivals.nnnMETHODSnWe retrospectively evaluated all renal transplants performed between 2000 and 2008 that were primary grafts from cadaveric heart-beating donors, into recipients with a panel reactive antibody titer <5% and who were treated with an immunosuppression scheme based on cyclosporine, mycophenolate mofetil/mycophenolic acid plus corticosteroids, with (group 1) or without basiliximab (group 2).nnnRESULTSnWe enrolled 52 recipients in group 1 (induction with basiliximab) and 189 in group 2 (without basiliximab). The baseline characteristics were similar among the groups, except for time on dialysis which was longer in group 1 and the number of HLA matches, which was lower in group 1. The ARE rate was lower among group 1 (7.8% vs 27.8%; P = .001); rates of DGF and infectious complications were similar. There was no significant difference in graft and patient survivals.nnnCONCLUSIONnIn this study, induction with basiliximab was associated with a reduced rate rate of ARE, despite a lower number of HLA matches and a longer previous time on dialysis. The use of this induction modality was not associated with a greater rate of infectious complications.

Uncommon Cause of Chest Pain in a Renal Transplantation Patient With Autosomal Dominant Polycystic Kidney Disease: A Case Report

Autosomal dominant polycystic kidney disease (ADPKD) is a common cause of end-stage renal disease (ESRD) and, because of its intrinsic systemic involvement, its treatment can be a medical and surgical challenge. This condition is often associated with the presence of hepatic cysts and their prevalence generally increases with age. Most patients remain asymptomatic, but some of these will develop complications associated with enlargement and infection of their cysts. Chest pain is a rare manifestation of these complications and, after exclusion of more common cardiovascular and pulmonary causes, should raise the suspicion of an infected hepatic cyst in these patients. We report the case of a 62-year-old male who underwent a kidney transplantation from a cadaveric donor in 1997 (etiology of the ESRD was ADPKD), and was admitted to the emergency department with complaints of chest pain radiating to both shoulders and the interscapular region. An echocardiogram was showed compression of the right atrium by a large liver cyst without associated ventricular dysfunction. Computer tomography-guided drainage of the cyst was performed and an Enterobacter aerogenes sensitive to carbamapenemes was isolated from respective cultures. The patient presented a favorable clinical outcome with prolonged administration of antibiotic therapy according to the antibiotic susceptibility testing. There was no need for surgical intervention.

Long-Term Outcomes of Kidney Transplantation From Expanded-Criteria Deceased Donors: A Single-Center Experience

BACKGROUNDnOrgan shortage has prompted the use of expanded-criteria donors (ECDs). Our objective was to compare long-term outcomes of kidney transplants from ECDs with those from concurrent standard-criteria donors (SCDs). In addition, we evaluated variables associated with graft survival in both groups.nnnMETHODSnWe retrospectively reviewed all 617 deceased-donor kidney transplantations performed from 2005 to 2009 in our department. The population was divided according to donor status into ECD or SCD. Patients were followed until 5 years after transplantation, death, graft failure, or loss to follow-up.nnnRESULTSnWe transplanted 150 deceased-donor kidneys from ECDs and 467 from SCDs. ECD were older, more frequently women, had a lower pre-retrieval glomerular filtration rate, and more frequently died due to cerebrovascular accident. ECD recipients were older, presented a lower proportion of black race, more frequently were on hemodialysis, and presented a higher rate of first kidney transplants. Mean glomerular filtration rate was consistently lower in the ECD group. Patient and graft survivals were lower in the ECD group, but statistical significance was present only in graft survival censored for death with a functioning graft at 3 years and graft survival noncensored for death with a functioning graft at 5 years. Younger recipient ages, longer time on dialysis, acute rejection episodes, and glomerular filtration rate at 1 year after transplantation were independent risk factors for lower graft survival.nnnCONCLUSIONSnTransplantation with the use of ECD kidneys provide quite satisfactory patient and graft survival rates despite their poorer long-term outcomes.

Kidney transplantation and posttransplantation diabetes: nutritional evaluation.

The prevalence posttransplanta-tion diabetes in our center is 9.8% (1997), demandingcareful attention to the nutritional and metabolic state ofthese individuals.The purposes of this study were to evaluate a group ofpatients who have undergone kidney transplantation withposttransplantation diabetes according to their body massindex (BMI) when submitted to the first intervention anddiscern the most common nutritional errors among thisgroup during a nutritional, therapeutic, and educationalintervention.

Kidney transplantation and diabetes: Posttransplantation malignancy

THE DEVELOPMENT of de novo malignancies in kidney transplant recipients represents a major problem. The reported prevalence is between 1% and 16% in Western countries and 1% to 3% in Asian countries. In our Center, the overall prevalence of 7.13% was reported in 1997 by Arnaldo et al. The most prevalent cancers are squamous cell carcinomas and basal cell carcinomas of the skin with an increasing cumulative incidence with longer survival of the patient. Epidemiological data show several risk factors, including pigmentary characteristics, solar irradiation, viral warts, type and doses of long-term immunosuppressants, presence of an oncogenic virus (EpsteinBarr), with age, with time of dialysis, genetic factors and diabetes among other considerations. The posttransplantation lymphoproliferative diseases, lymphoma, and Kaposi’s sarcoma are associated with the immunosuppressive therapy and oncogenic viruses. Type 2 diabetes mellitus (DM2) has been related to the risk for colon, endometrial, pancreatic, and hepatic cancers as well as an increased risk of non-Hodgkin’s lymphoma. Until now there are no reports of similar correlations with type 1 diabetes mellitus (DM1). Posttransplantation diabetes mellitus is in some ways similar to DM2, including insulin resistance and the presence of an overweight or obesity situation, but there are no reports on the prevalence of malignancy in this group of patients. The aim of this study was to determine the prevalence of malignancy during follow-up of all patients with diabetes bearing a kidney transplant in our Center.