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PubMed2000

Patients on chronic peritoneal dialysis for ten years or more in North America.

Thirty-six patients on peritoneal dialysis (PD) for more than ten years in six North American centers were analyzed retrospectively. In the six centers, the percentage of patients surviving for more than ten years varied between 0.8% and 7.3%. The study group included 27 females and 9 males aged 38.6 +/- 14.2 years [mean +/- standard deviation (SD)] at the start of treatment. Of the 36 patients, 28 were Caucasian. The most common cause of end-stage renal disease (ESRD), present in 12 patients, was chronic glomerulonephritis. Only 4 patients had diabetes. At the beginning of the study, 19 patients had hypertension (the most common comorbid condition); 11 had no comorbid conditions at the start. Creatinine clearance at the start was 4.12 +/- 3.5 mL per minute, and the mean duration to anuria was 51 +/- 25 months. Mean initial body weight was 55 +/- 9 kg, and mean body surface area was 1.5 +/- 0.2 m2. Serum albumin levels showed an increase from 33.8 +/- 3.6 g/L at the start of the study to 38.2 +/- 3.9 g/L at the end. Hospitalization rate was low at 0.5 +/- 0.3 admissions per patient-year, and duration of hospitalization was 4.8 +/- 3.7 days per patient-year. Peritonitis was the most common cause of hospitalization. The mean peritonitis rate was 1 episode every 52 +/- 48 patient-months. There were 36 catheter changes in 18 patients; 16 patients had a single PD catheter throughout the period of study. Autonomous hyperparathyroidism was the most common long-term complication. At the end of the study period, 11 patients were still on PD, 9 had died, 5 had been transferred to hemodialysis (HD), 1 was alive with a functioning allograft, and 1 was lost to follow-up. We conclude that patients who survive longer than ten years on PD are most likely to be young Caucasian females, small in body size, who are non diabetic, with few comorbid conditions. These long-term survivors have few hospitalizations, and their peritonitis rate is low. In this group of patients, severe autonomous hyperparathyroidism is the most common long-term complication.

Adolescent↗

PubMed2000

[Transplantation surgery and immune regulation].

Although transplantation has revolutionized care for patients with end-stage organ failure due to the development of new immunosuppressive drugs, significant problems persist with treatments designed to prevent acute graft rejection. There is a real need for improved methods to maintain allograft function by preventing immune-mediated rejection. Accumulating evidence suggests that the inhibition of T cell costimulation may promote antigen-specific tolerance of transplants. In particular, blockade of the CD28 and CD40 costimulatory pathways has shown great promise in preventing transplant rejection in rodents and nonhuman primates. This paper discusses the human immune system, costimulatory pathways, and new therapeutic agents that regulate so-called costimulatory second signaling to maintain transplant function without general suppression of the immune system.

Animals↗

PubMed2000

Laparoscopic live donor nephrectomy: the University of Maryland 3-year experience.

PURPOSE: We determined whether laparoscopic living donor nephrectomy decreases the morbidity of renal donation for the donor, while providing a renal allograft of a quality comparable to that of open donor nephrectomy. MATERIALS AND METHODS: In a 3-year period laparoscopic donor nephrectomy was performed via the transperitoneal approach. We evaluated donor and recipient medical records for preoperative donor characteristics, intraoperative parameters and complications, and postoperative recovery and complications. RESULTS: Of the 320 laparoscopic donor nephrectomies performed the left kidney was removed in 97.5%. Intraoperative complications, which developed in 10.4% of cases, tended to occur early in the experience and required conversion to open nephrectomy in 5. Average operative time was 31/2 hours and warm ischemia time was 21/2 minutes. As the series progressed, blood loss as well as laparoscopic port size and number decreased but extraction site size remained constant at 7 cm. Urinary retention, prolonged ileus, thigh numbness and incisional hernia were the most common postoperative complications. Postoperative analgesic requirements were low and average hospitalization was 66 hours. CONCLUSIONS: Laparoscopic donor nephrectomy appears to be safe and decreases morbidity in the renal donor. Allograft function is comparable to that in open nephrectomy series. The availability of laparoscopic harvesting may be increasing the living donor volunteer pool.

Adult↗

PubMed2000

[Doppler echocardiography after heart transplantation].

Acute rejection, graft atherosclerosis and infections are the major causes of morbility and mortality after heart transplantation. Therefore clinical follow-up after heart transplantation is usually focused on the early diagnosis and treatment of these complications. The early recognition of acute rejection episodes in cardiac allograft recipients remains a major challenge during follow-up after heart transplantation. The standard method used to identify rejection is endomyocardial biopsy, but this technique shows some important inherent limitations. Even if noninvasive methods are generally considered inaccurate in the early diagnosis of acute rejection, echocardiography is routinely used in the surveillance of heart transplant recipients to monitor allograft function. Furthermore it may be used to screen significant acute rejection episodes, because it can identify several morphologic and functional changes that are related to acute rejection: increase in left ventricular myocardial thickness, changes in ultrasonic texture, pericardial effusion, systolic and diastolic dysfunction. In this setting it is very useful to perform serial echocardiographic examinations, because the changes of echocardiographic and Doppler parameters in comparison with previous examination in each individual patient can be accurate in detecting acute rejection and evaluating the response after immunosuppressive treatment. The development of coronary artery disease (CAD) is the major factor limiting long-term survival. Serial coronary artery angiography remains the only effective diagnostic tool for detecting CAD, while noninvasive tests commonly used in atherosclerotic heart disease are considered inaccurate, due to their low sensitivity. However several studies reported a high accuracy of dobutamine stress echocardiography in the diagnostic and prognostic assessment of CAD. Furthermore, rest wall motion abnormalities and left ventricular systolic dysfunction can identify patients with significant CAD and worse prognosis. In conclusion, echocardiography cannot supplant invasive methods for monitoring acute rejection and CAD, but it is a useful tool for surveillance after heart transplantation.

Acute Disease↗

PubMed2001

Indications, results, and complications of tacrolimus conversion in pediatric renal transplantation.

It is the practice of many pediatric renal transplant programs to 'convert' children taking cyclosporin A (CsA) to tacrolimus, although the indications for, outcome, and complications of this practice remain obscure. To better understand these aspects of tacrolimus 'conversion', a fax survey was sent to 119 North American pediatric renal transplant centers. Analyzable responses were received from 52 centers (44%), and included data from approximately 1,815 pediatric renal transplants performed between 1991 and 98. Strong indications for tacrolimus conversion were: antibody-resistant rejection, CsA-resistant rejection, and CsA intolerance (strong indication in 72%, 65%, and 52% of centers, respectively). Steroid-resistant rejection and cosmetic side-effects were considered strong indications less often. Initial anti-rejection therapy was usually increased corticosteroid dose (47/52 centers). Antibody therapy was most commonly used for steroid-resistant rejection (44 centers). For steroid- and antibody-resistant rejection, tacrolimus conversion was most common (33 centers). Tacrolimus conversion for antibody-resistant rejection led to improvement of serum creatinine (SCr) in 27% of patients, stabilization of SCr in 46%, worsening of SCr in 11%, and graft loss in 16%. Reported complications after tacrolimus conversion included hyperglycemia, hyperkalemia, lymphoproliferative disorder, infection, and neurologic problems. We conclude that the major indication for tacrolimus conversion in pediatric transplant programs appears to be rejection. Outcome after tacrolimus conversion appears good, with the majority of patients experiencing stable or improved allograft function. These data provide direction for further study, including timing of tacrolimus conversion and interaction with other therapies.

Child↗

PubMed2001

Dysplasia of tubular cells in a kidney- transplanted patient treated with recombinant human growth hormone.

After renal transplantation (Tx), children with growth retardation can be successfully treated with recombinant human growth hormone (rhGH). However, the impact of this treatment on kidney allograft function remains a source of concern. We report on one boy who received a cadaveric kidney transplant at 12 yr of age, after developing end-stage focal and segmental glomerulosclerosis and hyalinosis. The early post-transplant period was complicated by thrombosis of an arterial branch of the graft and two acute rejection episodes. Because of poor growth, the boy was treated with rhGH starting 22 months after the Tx. The renal function remained relatively stable for 22 months after initiation of rhGH therapy and then progressively deteriorated over a period of 10 months, with the patient ending up on dialysis. Several biopsies, performed for rejection episodes or before the start of rhGH, or to elucidate the deterioration of the renal function, were analyzed. Histologically, a progressive increase in the amount of hypertrophy of the tubules and of the glomeruli was seen after initiation of rhGH. Hyperplasia of the tubular epithelium with crowding of cells of the proximal tubules, hyperchromasia and irregularities in the shape of the nuclei, and abrupt changes of chromatism along the tubuli, were also observed. These lesions of tubular dysplasia are extremely unusual in transplanted kidneys and are unlikely to be caused by compensatory hypertrophy secondary to destruction of renal tissue. They may be an effect of rhGH treatment. The prognostic significance of these lesions is unknown but merits attention.

Child↗

PubMed2002

Donor-acquired sarcoidosis.

"Donor-acquired sarcoidosis" is defined as the development of sarcoidosis in presumably naïve (non-sarcoidosis) transplant recipients who have received tissues or organs from donors who were not known or suspected to have active sarcoidosis. In reviewing the literature up until September of 1999, we found four publications describing a total of eight organs or tissues donated by subjects with sarcoidosis. These are the basis for this review. We draw upon these cases to discuss etiologic considerations for sarcoidosis, and suggest that donor-acquired sarcoidosis strengthens the view that sarcoidosis is caused by a transmissible agent, perhaps of infectious origin. Since not all recipients of organs from donors with active sarcoidosis develop sarcoidosis, host factors also appear to be important in disease pathogenesis. Less credence is ultimately given to external or environmental factors. Issues underlying host tolerance as a possible explanation for the reported absence of mortality or loss of allograft function during the limited periods of observation are also discussed.

Adult↗

PubMed2002

Cardiovascular risk reduction in renal transplantation. Strategies for success.

One of the aims of transplantation is to restore the potential for a full life to individuals with ESRD. To obtain this strategies that allow better and longer allograft function and a reduction in adverse events that lead to premature death are required. To this end, the recommendations below showed reduce cardiovascular disease and help present and future transplant recipients live a full life. Focusing on traditional risk factors (hypertension, hyperlipidemia, discontinuation of smoking, and prevention and treatment of diabetes mellitus) in patients at risk and striving for the recommended targets will have the greatest clinical benefit. These strategies should begin in the pre-dialysis and dialysis phases in order to reduce the cumulative burden of disease. Failing this, early and hopefully pre-emptive transplantation should be the goal.

Arteriosclerosis↗

PubMed2002

Laparoscopic donor nephrectomy in Hawaii.

Laparoscopic donor nephrectomy for transplant is a minimally invasive, effective, and safe operation that also provides less post-operative pain and earlier return to pre-donation activity. In review of the first 10 cases, no major complications occurred and mean hospital stay was 3.7 days. All recipients of these kidneys displayed excellent allograft function (mean creatinine--1.5 mg/dL) and no ureteral problems. Successful use of this procedure has also resulted in a steady increase in the number of living transplants performed in Hawaii and perhaps this will impact the 330 patients currently awaiting renal transplant.

Adult↗

PubMed2002

[Urinary infections in patients with urologic complications after kidney transplantation].

BACKGROUND: Urinary tract infections (UTI) are the most frequent infectious complications after renal transplantation (Tx). We tried to analyse whether the urinary tract infection was one of the factors which participated in the lower allograft survival rates and in the reduced allograft function in urologically complicated (UC) patients. METHODS AND RESULTS: We observed 77 patients after Tx whom 42 had urinary fistula, 32 had urinary tract dilatation a 3 suffered from both complications. They were observed from January 1992 through December 1999. 100 patients without urological complications represented a control group (N). Obtained data was statistically evaluated using t-test, chi 2-test, correlation analysis. Graft and patient survival rates were assessed using the Kaplan-Meier method. We have found that UC patients after Tx had worse renal function compared with patients not suffering from this complications. Using Kaplan-Meier methods we have found that graft survival rate in patients with UC is significantly lower than that in the control group (5-year graft survival 0.6 vs 0.82, p < 0.01). On the other hand there were no differences in the 5-year patients survival rate between the followed groups of patients (0.74 vs 0.83). There was no significant correlation between predicted creatinine clearance and followed indicators of UTI--total time of positive urine bacterial cultivation, number of infectious periods and total time of antibiotic therapy. There were no significant differences in graft survival during 5 years between patients with UTI and control group. CONCLUSIONS: Our results suggest that patients with UC are at increased risk of urinary tract infection. Our findings are in keeping with the assumption that UTI in patients with UC do not significantly participate in the decreased level of graft function and in the shorter graft survival rates.

Dilatation, Pathologic↗

PubMed2001

Center and other factor effects in recipients of living-donor kidney transplants.

1. LIVING DONOR KIDNEY TRANSPLANTS: Using 1996-2001 UNOS Registry data, we assessed the joint influence of center, 19 pre- and 5 posttransplant factors on renal allograft function in 21,830 patients transplanted with living donor kidneys. During an initial risk period, 21,033 recipients were projected to keep their grafts through one year (an average 96.4% one-year graft survival), and, in a second risk period, 17,775 recipients were projected to keep their grafts through 5 years (84.5% conditional 5-year graft survival after surviving one year posttransplant). 2. CENTER EFFECTS: Following multivariate log-linear analysis, 57.5% and 26.5% of assignable variation in one- and 5-year living-donor graft survival rates were due to the variation across 234 transplant centers. Center effect dominated other factors in influencing early outcomes among living kidney donor transplants. A program's size was associated with this center effect since all large centers (400+ living donor kidneys) had better-than-average one-year graft survival rates, whereas smaller centers (< or = 100 grafts) had wide ranges in short-term outcomes (87-100%). Center size did not play a role in explaining long-term variation, and the extent to which uniformity in care remains the responsibility of the original center needs to be investigated. 3. PRETRANSPLANT FACTOR EFFECTS: The impact of the 19 pretransplant cofactors on short-term outcomes among living donor transplants was clinically small--adjusted one-year graft survival rates across all categories exceeded 94%. However, their long-term effects were stronger and more typical of cadaveric results. The following 4 factors, each explaining > 10% of the assignable variation in conditional 5-year graft survival, were ranked and independently yielded poor results: 1) kidneys from parental donors; 2) grafts in male recipients; 3) teenage/adult recipients (> 12 years); and 4) black recipients. Recipient's original disease and body mass index, donor's race and age, and HLA matching were highly significant factors, but their impact on long-term graft survival was less than those observed previously in cadaveric renal transplants. 4. POSTTRANSPLANT FACTOR EFFECTS: Short- and long-term outcomes were relatively stable regardless of the maintenance drug initiated at hospital discharge. Living donor transplant outcomes were similar for Neoral versus Tacrolimus and for MMF versus azathioprine. Kidney graft survival among living donor transplants was strongly affected by delays in graft function or acute rejection episodes. 5. CONCLUSIONS: During the first year posttransplant, the benefits of receiving a living donor kidney (versus a cadaver kidney) mitigate negative cofactor risks of graft failure. Beyond one-year, recipients of living donor kidneys are subjected to the same deleterious effects from cofactors and early posttransplant events that impact the long-term graft survival following cadaveric transplantation.

Female↗

PubMed2002

[Prevention of skin complications from immunodepression in organ transplantation].

As skin diseases after organ transplantation are often disabling and sometimes lethal, it is essential to develop preventive measures. The group "Skin and organ transplantation" of the French Society of Dermatology concentrated one's efforts on skin carcinomas and Kaposis's sarcoma. Skin carcinomas are the most frequent tumors observed in transplant recipients. Many factors participate to their pathogenesis such as genetic, environmental and iatrogenic. Their prevalence is very high in elderly transplant recipients with fair complexion, long time of immunosuppression, long time of sun exposure, multiple keratoses and warts. Preventive measures consist educational training, sun avoidance and treatment of keratoses. Transplant recipients who develop Kaposi's disease are all infected with Human Herpes Virus 8 (HHV-8). HHV-8 promoinfection occurred frequently before transplantation. Cofactors involved in the development of Kaposi' sarcoma will be probably identified by the results of an ongoing national prospective study of kidney transplant recipients. Immunosuppressive therapy should be tapered to the lowest possible level compatible with allograft function.

Humans↗

PubMed2002

Spirituality characteristics of women following renal transplantation.

End stage renal disease (ESRD) is a potentially terminal condition that causes patients to consider their mortality. Post research has shown that prayer and religious coping are associated with better posttransplant adjustment and that individuals with life-threatening illnesses have higher levels of spirituality than healthy individuals. Few studies, however, have examined the spirituality characteristics of kidney transplant recipients. This study examined the spiritual perspectives and spiritual well-being of 28 women who had a functioning allograft 18-24 months after receiving a first kidney transplant. Measurement by the Spiritual Perspective Scale (SPS) and Spiritual Well-Being (SWB) Scale scores indicated high levels of spirituality and moderate correlation between spiritual perspective and spiritual well-being. Although older participants had higher levels of spiritual perspective, there were no associations between age and spiritual well-being, nor difference in spiritual perspective and well-being by race, education, or employment status. Thus, particularly for the aging, spirituality may be a valuable psychological resource that should be supported in women posttransplant.

Adaptation, Psychological↗

PubMedDate not supplied

Angiotensin converting enzyme gene polymorphism and development of post-transplant erythrocytosis.

BACKGROUND: An increased activation of the renin-angiotensin system probably plays a major role in the development of post-transplant erythrocytosis (PTE). It is known that deletion type polymorphism (DD) in the angiotensin converting enzyme (ACE) gene is associated with higher circulating angiotensin II (AII) levels. The aim of this study was to investigate the effect of ACE gene polymorphism on development of PTE. METHODS: 86 PTE patients (male/female: 68/18, mean age: 32 +/- 10 years) and 68 consecutively transplanted non- PTE patients (male/female: 38/30, mean age: 31 +/- 10 years) were included; 140 patients (91%) had been transplanted from living donors; 92 patients (60%) had hypertension. ACE gene polymorphism was determined by polymerase chain reaction (PCR). RESULTS: The mean time to appearance of PTE was 8.8 +/- 7.9 (range of 1-53) months. DD genotype was detected in 65 patients. PTE patients had a higher prevalence of hypertension (70% vs. 46%, p=0.003) and a lower frequency of DD genotype (34% vs. 54%, p=0.014) as compared to non-PTE patients [OR: 2.2 (1.14-4.25, 95% CI)]. PTE developed more frequently in male patients (68/106: 64%) than females (18/48: 38%) (p=0.002). Patients with DD genotype had a significantly longer leading time to PTE in Kaplan-Meier survival analysis with log-rank (136 +/- 15 vs. 92 +/- 13 months, p=0.015). In Cox regression analysis, hypertension (p=0.002) and recipient ACE genotype (p=0.013) were retained as independent variables for predicting PTE development. CONCLUSIONS: PTE develops more frequently in male, hypertensive renal transplant recipients with good allograft function. DD-type ACE gene polymorphism seems to protect against PTE development.

Adult↗

PubMed2003

[BK virus-associated nephropathy].

BK virus was first detected more than 30 years ago, however its role long time was not exactly defined. The virus is usually acquired in childhood; seroprevalence rate in adults appears to be 60-80%. In most cases the infection is asymptomatic. After renal transplantation it may manifest as so-called BK virus-associated nephropathy by gradual decrease of allograft function or signs of acute rejection. There is no effective therapy of BK virus-associated nephropathy to date. Treatment with low-dose cidofovir is under investigation.

Adult↗

PubMed2004

[Prevention and therapy of ischemia-reperfusion injury in renal transplantation].

The transplantation of vascularized organs requires discontinuation of the organ blood supply. Ischemia-reperfusion injury is a serious issue in organ transplantation, bearing the potential to shorten graft and patient survival. It can affect early and late posttransplant kidney allograft function and is caused by numerous factors, including reactive oxygen species generation, aberrations of intracellular calcium concentration, activation of mononuclear cells, endothelial cells damage, capillary obstruction and the no-reflow phenomenon. During this period, biochemical and inflammatory events occur within the tissue, leading to graft dysfunction. This multifactorial process can be targeted by therapeutic interventions. In this paper, current data on the therapy and prevention of ischemia-reperfusion injury in renal transplantation is presented. The use of antioxidants, enriched preservation solutions, calcium channel blockers, factors limiting lipid peroxidation, inhibition of neutrophil-mediated acute inflammation, and immunosuppressive agents, as well as ischemic preconditioning or pulsatile perfusion can be proposed to prevent graft damage.

Antioxidants↗

PubMed2004

Simultaneous pancreas-kidney transplantation with modified enteric drainage of exocrine pancreatic secretion.

BACKGROUND: As a valid therapeutic option for patients with type 1 diabetes mellitus (IDDM) and secondary diabetic nephropathy, simultaneous pancreas-kidney transplantation (SPK) remains more undeveloped than other solid organ transplantations due to the restrictions of surgical techniques especially the modes of exocrine pancreatic secretion. The aim of this paper was to summarize our single-center experience in SPK with modified enteric drainage (ED). METHODS: From June 2000 to July 2003, 10 patients with IDDM associated with uremia received SPK. The pancreatic allograft exocrine secretion was drained into the proximal jejunum via a side-to-side duodenojejunostomy without Roux-en-Y anastomosis. Quadruple immunosuppressive regimen consisted of induction of tacrolimus (TAC)/cyclosporine (CsA), mycophenolate mofetil (MMF), steroids and antibodies, which included antilymphocyte globulin (ALG) or anti-CD25 monoclonal antibody. RESULTS: ED-SPK without Roux-en-Y anastomosis was successful in all 10 patients without serious complications such as pancreatitis, graft thrombosis and pancreatic fistula. The patients regained immediate kidney allograft function and euglycemia with insulin-independence. Four patients survived over one year. Episodes of acute rejection were observed in 4 patients, 3 of whom showed reversion after treatment of OKT3 or insulin. Early postoperative complications included peritoneal infection (2 patients), wound infection (2) and renal hematoma (1). CONCLUSION: ED-SPK without Roux-en-Y anastomosis is safe and preferable to the patients with IDDM associated with uremia.

Adult↗

PubMedDate not supplied

Noninvasive methods of rejection diagnosis after heart transplantation.

For clinical follow-up and prognosis in heart transplant patients, it is important to understand accurately the presence and extent of cardiac allograft rejection. Since the introduction of endomyocardial biopsy, almost 40 different noninvasive diagnostic procedures for the recognition of myocardial rejection have been proposed. However, endomyocardial biopsy is invasive and not suitable for frequent monitoring. If the pattern of rejection shows a focal distribution, false-negative results can be expected. Discrepancies between biopsy findings and allograft function are obviously possible. State-of-the-art information will be given on the most reliable noninvasive methods for rejection diagnosis, which can be differentiated from electrophysiology (fast-Fourier-transformed electrocardiography and intramyocardial electrocardiography), echocardiography, immunologic methods (cytoimmunologic monitoring, transferrin receptors, and interleukin-2 receptors), various biochemical markers (neopterines, prolactin, urinary polyamines, and beta 2-microglobulins), radioisotopic techniques (antimyosin-monoclonal antibodies, thallium, technetium, and gallium scintigraphy and indium-labeled cells), as well as magnetic resonance imaging. Thus modified and patient-adapted antirejection therapy can be provided if the decision for or against antirejection therapy is not based on biopsy findings alone but rather is confirmed along with histologic, electrophysiologic, biochemical, immunologic, and functional parameters.

Diagnostic Imaging↗