Contrast-induced Nephropathy in Kidney Transplant Recipients: A Single-center Experience

INTRODUCTION

Data regarding contrast-induced nephropathy (CIN) in kidney transplant (KT) recipients are scarce despite the distinct risk factors such as the use of immunosuppressive agents, sympathetic denervation, glomerular hyperfiltration, and high prevalence of the cardiovascular disease. This study aimed to determine the prevalence of CIN in KT recipients who received low-osmolality iodine-based contrast material (CM) for radiological assessment.

METHODS

Between 2010 and 2020, 79 of the 3180 KT recipients followed at Hamed Al-Essa organ transplant center received low-osmolality iodine-based contrast for radiological assessment for various indications. Preventive measures including holding metformin, intravenous hydration, sodium bicarbonate and N-acetylcysteine were given before contrast administration. CIN was defined as an increase in serum creatinine of 25% from the baseline within 72 hours.

RESULTS

The enrolled patients were divided into two groups: those who developed CIN (n = 7) and those with no increase in serum creatinine level (n = 72). The mean age of the patients was 52.1 ± 12.3 years; 44 of them were males, and the cause of end-stage kidney disease was mostly diabetic nephropathy. The pre-transplant demographics were comparable between the two groups. Fortyseven cases received contrast for coronary angiography, and 32 received it for a CT scan. The graft function deteriorated in group 1, but no significant difference was found between the two groups at the end of the study.

CONCLUSION

CIN is not uncommon in KT recipients receiving CM, especially with ischemic heart disease. Risk stratification, optimizing hemodynamics, and avoiding potential nephrotoxins are essential before performing CM-enhanced studies in KT recipients.  DOI: 10.52547/ijkd.7165.

Better outcome of COVID-19 positive kidney transplant recipients during the unremitting stage with optimized anticoagulation and immunosuppression

INTRODUCTION

COVID-19 is an ongoing pandemic with high morbidity and mortality and with a reported high risk of severe disease in kidney transplant recipients (KTR).

AIM

We aimed to report the largest number of COVID-19-positive cases in KTR in a single center and to discuss their demographics, management, and evolution.

METHODS

We enrolled all the two thousand KTR followed up in our center in Kuwait and collected the data of all COVID-19-positive KTR (104) from the start of the outbreak till the end of July 2020 and have reported the clinical features, management details, and both patient and graft outcomes.

RESULTS

Out of the one hundred and four cases reported, most of them were males aged 49.3 ± 14.7 years. Eighty-two of them needed hospitalization, of which thirty-one were managed in the intensive care unit (ICU). Main comorbidities among these patients were hypertension in 64.4%, diabetes in 51%, and ischemic heart disease in 20.2%. Management strategies included anticoagulation in 56.7%, withdrawal of antimetabolites in 54.8%, calcineurin inhibitor (CNI) withdrawal in 33.7%, the addition of antibiotics in 57.7%, Tocilizumab in 8.7%, and antivirals in 16.3%. During a follow-up of 30 days, the reported number of acute kidney injury (AKI) was 28.7%, respiratory failure requiring oxygen therapy 46.2%, and overall mortality rate was 10.6% with hospital mortality of 13.4% including an ICU mortality rate of 35.5%.

CONCLUSION

Better outcome of COVID-19-positive KTR in our cohort during this unremitting stage could be due to the younger age of patients and early optimized management of anticoagulation, modification of immunosuppression, and prompt treatment of secondary bacterial infections. Mild cases can successfully be managed at home without any change in immunosuppression.

Successful Pregnancy Outcome in a Recipient With Simultaneous Kidney and Pancreas Transplant Who Underwent Posttransplant Metabolic Surgery

Although chronic kidney disease decreases fertility, kidney transplantation provides restoration of fertility in women, enabling them to get pregnant. Data available from registries have shown that pregnancy is feasible in solid-organ transplant recipients without significant impact on long-term graft function. Despite these reassuring data, some studies have reported that one-third of female transplant recipients are still actively being counseled against pregnancy. Here, we present a patient who received a simultaneous deceased-donor kidney and pancreas transplant and who had a favorably evolved pregnancy. The 36-yearold kidney-pancreas transplant recipient conceived 5 months after her marriage. The patient was closely followed during pregnancy by a multidisciplinary team that included a nephrologist, gynecologist, and endocrinologist. Renal function and blood glucose levels remained within normal limits. She delivered her baby normally at 31 weeks of pregnancy (1.3-kg male baby). Currently, both mother and baby are doing well. Pregnancy in combined kidney and pancreas transplant recipients with stable graft functions is feasible but remains risky. Proper planning, modification of immunosuppressive drugs, and close monitoring are the keys to optimized maternal, fetal, and graft outcomes.

Successful Management of Late-Onset Cytomegalovirus-Induced Hemophagocytic Lymphohistiocytosis in Kidney Transplant Recipient After Coronary Artery Bypass Graft Surgery

Hemophagocytic syndrome combines febrile hepatosplenomegaly, pancytopenia, hypofibrinemia, and hepatic dysfunction. It is characterized by bone marrow and organ infiltration of activated, nonmalignant macrophages that phagocytize blood cells. It is rare among renal transplant recipients. Here, we present the successful management of late-onset cytomegalovirusinduced hemophagocytic lymphohistiocytosis in a kidney transplant recipient after coronary artery bypass graft surgery. In 2012, our patient had end-stage kidney disease due to diabetic nephropathy and underwent related living-donor renal transplant. He was also hypertensive and hyperuricemic and had heart ischemia for which percutaneous coronary intervention for triple vessel disease was performed before transplant. In March 2017, he underwent successful aortic valve replacement and coronary artery bypass graft surgery; however, the patient had persistent thrombocytopenia. Heparin-induced thrombocytopenia was negative. His bone marrow showed hemophagocytosis possibly due to cytomegalovirus. Moreover, antiglycoprotein IIb/IIIA autoantibodies were positive. A positron emission tomography scan was negative for malignancy. He started treatment for cytomegalovirus with modifi cation of his immunosuppressive regimen (pulse steroid). Antiplatelet therapy was held and only resu med if platelet count exceeded 30000/L. Moreover, he received intravenous immunoglobulin and romiplostim treatment with partial response. Throughout treatment, he had stable kidney graft function with improving platelet count. A multi disciplinary approach is needed to treat patients with hemophagocytic syndrome, especially renal transplant recipients. Late-onset cytomegalovirus is an important cause for this syndrome.

Thymoglobulin-Resistant T-Cell-Mediated Acute Rejection in a Pregnant Renal Transplant Recipient: Case Report and Review of the Literature

To avoid graft rejection during pregnancy, frequent monitoring of serum drug levels is recommended. Pregnancy induces hyperfiltration in transplanted kidneys, as in native kidneys; therefore, detection of rejection can be difficult when monitoring by serum creatinine. If rejection is suspected, ultrasonographguided graft biopsy can be done; once proven, it can be treated with pulse steroids, but data are scarce regarding other agents. Here, we present a 28-year-old pregnant female patient with resistant acute rejection but with successful pregnancy outcome. Our patient had end-stage kidney disease secondary to lupus nephropathy and underwent living-donor renal transplant in May 2013 after hemodialysis support for 1 year. She received thymoglobulin as induction therapy and was maintained on prednisolone, mycophenolate mofetil, and tacrolimus. She had normal renal graft function without proteinuria. After she received counseling, she became pregnant in February 2015. In June 2015, she presented with acute graft dysfunction with serum creatinine level of 365 μmol/L. Her abdominal ultrasonography showed mild hydronephrosis and viable fetus. She received empirical pulse steroids with partial response, and her graft biopsy showed acute T-cell-mediated rejection and negative C4d. Intravenous immunoglobulins and minipulse steroids were administered but without response. After gynecologic counseling and informed consent, she received 5 doses of thymoglobulin. She was dialysis dependent until premature vaginal labor, which resulted in birth of a viable 2-kg boy. We suggest that successful pregnancy outcomes could occur with close monitoring and daily dialysis in female kidney transplant patients with resistant rejection.

Management of Chronic Active Antibody-Mediated Rejection in Renal Transplant Recipients: Single-Center Experience

OBJECTIVES

Data on the management of chronic antibody-mediated rejection after kidney transplantation are limited. We aimed to assess the impact of treatment of biopsy-proven chronic active antibodymediated rejection with combined plasma exchange, intravenous immunoglobulin, and rituximab treatment versus intravenous immunoglobulin alone or conservative management on the evolution of renal function in renal transplant recipients.

MATERIALS AND METHODS

In this retrospective study, we compared patients diagnosed with chronic active antibody-mediated rejection who were treated with standard of care steroids, intravenous immunoglobulin, plasma exchange, and rituximab (n = 40) at our center versus those who received intravenous immunoglobulin only or just intensified maintenance immunosuppression (n = 28). All patients were followed for 12 months clinically and by laboratory tests for graft and patient outcomes.

RESULTS

The two groups were matched regarding mean recipient age (41.9 ± 15.4 vs 37.8 ± 15.5 y in patients with conservative versus combined treatment), recipient sex, mean body weight, and the cause of end-stage kidney disease. Most patients and their donors were males. Glomerulonephritis represented the most common cause of end-stage kidney disease in both groups followed by diabetic nephropathy. The type of induction and pretransplant comorbidities were not different between groups (P > .05) except for the significantly higher number of chronic hepatitis C infections in patients who received conservative treatment (P = .007). Mean serum creatinine values before and after treatment of chronic active antibodymediated rejection were comparable between groups (P > .05). Active treatment with heavier immunosuppression (rituximab and plasma exchange) was associated with posttreatment viral (cytomegalovirus and BK virus) and bacterial infections that necessitated more hospitalization (P > .05). However, graft and patient outcomes were significantly better in the active treatment group than in patients with conservative treatment (P = .002 and .028, respectively).

CONCLUSIONS

Combined treatment of chronic active antibody-mediated rejection with plasma exchange, intravenous immunoglobulin, and rituximab can significantly improve outcomes after renal transplant.

Screening for BK Viremia/Viruria and the Impact of Management of BK Virus Nephropathy in Renal Transplant Recipients

OBJECTIVES

The prevalence of BK-induced nephritis in renal transplant recipients is estimated to be 1% to 10%; the rate of graft loss within 1 year is 30% to 65%. We conducted this study to evaluate screening of BK virus in blood and/or urine among renal transplant recipients and to assess the effects of different therapeutic modalities in renal transplant recipients with BK nephropathy.

MATERIALS AND METHODS

Kidney transplant recipients were screened at the time of transplant and then at 1, 2, 3, 6, 9, 12, 18, and 24 months posttransplant. Fiftynine patients were diagnosed with BK virus viremia. Patients were divided into 2 groups according to treatment: group 1 (n = 29) received an active treatment and group 2 (n = 30) received minimized immunosuppression.

RESULTS

Most patients required graft biopsies to confirm diagnosis (86.2% in group 1 vs 50% in group 2; P = .03). Both groups were comparable regarding demographic data. Initial posttransplant graft function was significantly better in group 1 (P = .017); ultimately, there was no significant difference between both groups regarding graft survival (P= .51). Fifty percent of patients had biopsy-proven acute T-cell-mediated rejection before BK virus-associated nephropathy diagnosis (significantly higher in group 1). Serum creatinine levels were significantly better in group 2 at 3, 4, and 5 years after BK nephropathy (P = .001, .017, and .003, respectively).

CONCLUSIONS

The prevalence of BK nephropathy in our renal transplant recipients was 5.9% with a rate of graft loss ranging from 43% to 51%. Regular screening, less intensive immunosuppressive therapy, and early intervention by reduction of immunosuppressive medications are advisable to obtain early diagnosis and to have better outcomes of BK virus-associated nephropathy with antiviral agents.

Elderly Kidney Transplant Recipients: Single-Center Experience in the Middle East

OBJECTIVES

The number of renal transplants in elderly patients is increasing as age per se does not constitute a contraindication to transplant. We compared renal transplant outcomes in elderly recipients versus a group of middle-aged patients.

MATERIALS AND METHODS

Our retrospective casecontrolled study compared elderly transplant recipients (n = 252; > 60 y old) with a matched cohort of younger adult recipients (n = 710; between 40 and 60 years old) who underwent renal transplant at the Hamed Al-Essa Organ Transplant Center of Kuwait between 2000 and 2014. Demographic characteristics, comorbidities, complications after transplant, and graft and patient outcomes were compared between groups.

RESULTS

There were 252 elderly kidney transplant recipients (mean age of 65.5 ± 4.8 y; 59.52% males) and 710 younger adult patients (mean age of 49.3 ± 5.5 years; 61.4% males). Most donors were males in their thirties. Deceased donors predominated in the younger adult group, whereas living unrelated donors predominated in the elderly group (P < .05). Diabetes represented the most common cause of endstage kidney disease. Younger patients tended to receive heavier induction therapy but comparable maint enance immunosuppression. Posttransplant diabetes was higher in younger patients; however, there were more elderly patients with micro- and macroangiopathies (P < .05). No significant differences were shown between groups with regard to patient or graft survival (P > .05). This could be attributed to a significantly higher number of patients with cardiovascular risks, less rejection episodes, and higher number of malignancies in the elderly group (P < .05).

CONCLUSIONS

Due to relatively less potent immunosuppression, elderly patients experienced lower rejection rates and better graft survival; however, patient survival was lower due to higher cardiovascular risk factors. Older patients should not be discouraged from living-donor renal transplant. Targeted research studies on protocols for the elderly are needed.

Role of Diabetes Education Program in Controlling Posttransplant Diabetes in a Recent Renal Transplant Bodybuilder: Case Report and Review of the Literature

Posttransplant diabetes is a common complication of solid-organ transplantation. We present the possible role of diabetes education in improvement of posttransplant diabetes in a 36-year-old bodybuilder who was a kidney transplant recipient. The patient had been abusing some medications to help in bodybuilding. He underwent living unrelated-donor renal transplant with thymoglobulin induction and was maintained on steroids, tacrolimus, and mycophenolate mofetil. Posttransplant diabetes was confirmed by blood tests. His blood sugar was partially controlled by 3 oral agents. The patient participated in our structured diabetes education program. This program was created to cover different items related to diabetes control, including diet, proper exercise, blood sugar monitoring, sick day management, and pathophysiologic roles of diabetes medications. Within 4 months of participation in this program, the patient's blood sugar became well controlled and his diabetes medications started to be minimized. He presently has stable graft function with hemoglobin A1c level around 5.6% on only diet management. Bodybuilders are at risk of deterioration of their kidney function. A proper diabetes education program is recommended to help renal transplant recipients with early posttransplant diabetes mellitus to control their disease. Success requires close evaluation and a multidisciplinary approach.

Kidney Transplant in a Patient With Factor VII Deficiency: Case Report

Organ transplant in patients with congenital bleeding disorders is a challenge requiring an integrated approach of various specialists. Inherited factor VII deficiency is the most common of the rare bleeding disorders, with a wide set of hemorrhagic features. Although a kidney allograft is the most frequent type of solid-organ transplant, it is rarely performed in individuals with congenital hemorrhagic disorders. Here, we highlight the course of a patient with coagulation factor VII deficiency who underwent successful kidney transplant without significant coagulopathy. Our patient was a 19-year-old man with end-stage kidney disease and congenital coagulation factor VII deficiency. Perioperative bleeding was successfully prevented by administration of recombinant factor VII, confirming its safety in solid-organ transplants. Success requires evaluation of doses and therapeutic schedules, as well as a multidisciplinary approach.

Successful Cost-Effective Prevention of Cytomegalovirus Disease in Kidney Transplant Recipients Using Low-Dose Valganciclovir

OBJECTIVES

Low-dose valganciclovir prophylaxis is still under investigation in renal transplant procedures. Our aim was to assess the cost effectiveness of 450 mg versus 900 mg valganciclovir prophylaxis in kidney transplant recipients.

MATERIALS AND METHODS

In this prospective trial, 201 kidney transplant patients were randomized (1:1) to receive 450 mg/d (group 1, n = 100) or 900 mg/d (group 2, n = 101) valganciclovir prophylaxis for the first 6 months after transplant. Patients were studied for incidence of cytomegalovirus disease, leucopenia episodes, rejection episodes, and graft outcomes along with associated costs over 1 year. Costs (in US dollars) of treatment of rejection were also analyzed.

RESULTS

Demographic features of the studied groups were comparable. We found that the cost of cytomegalovirus care in group 1 patients was significantly lower (by 50% at 6 months; P < .001), with less leukopenia episodes (P = .04), lower doses of granulocyte colony-stimulating factor (by 30% at 6 months; P = .03), higher doses of mycophenolate mofetil (P = .04), and less rejection episodes (P = .01) compared with group 2. In group 2, there were more episodes of cytomegalovirus infection (P = .052) and BK virus nephropathy (P = .04). Graft and patient outcomes were satisfactory in both groups.

CONCLUSIONS

Low-dose valganciclovir for cytomegalovirus prophylaxis after renal transplant is safer, effective and without breakthrough infection, and less costly than using the usual dose.

Sirolimus-Induced Combined Posterior Reversible Encephalopathy Syndrome and Lymphocytic Pneumonitis in a Renal Transplant Recipient: Case Report and Review of the Literature

The mammalian target of rapamycin inhibitor sirolimus was introduced into clinical transplant practice in 1999. Dose-related myelosuppression and hyper lipidemia are the most common adverse effects. Pulmonary toxicity has been reported since 2004 and can cause interstitial pneumonitis, organizing pneumonia, and alveolar hemorrhage. Moreover, it can occasionally induce posterior reversible encephalopathy syndrome, as documented in scarce reports. To our knowledge; this is the 1st report of combined posterior reversible encephalopathy syndrome and lymphocytic pneumonitis to be induced by sirolimus. Here, we present a renal transplant recipient with reversible sirolimus-induced brain lesions who was diagnosed after exclusion of infections (viral, bacterial, and fungal), tumors, sarcoidosis, and autoimmune disorders. Both brain lesions and pneumonitis resolved completely after sirolimus discontinuation with excellent patient and graft outcome. Early and gradual sirolimus withdrawal can reverse posterior reversible encephalopathy syndrome and lymphocytic pneumonitis with preservation of stable graft function.

Bariatric Surgery in Renal Transplant Patients

OBJECTIVES

The idea of transplanting organs is not new, nor is the disease of obesity. Obese transplant recipients have greater risk of early death than their cohorts, which is not due to increased rejection but due to obesity-related complications, including arterial hypertension, diabetes, and delayed graft function. Here, our aim was to evaluate the effects of bariatric surgery versus lifestyle changes on outcomes of moderate to severely obese renal transplant recipients.

MATERIALS AND METHODS

Twenty-two morbidly obese patients with stable graft function who underwent bariatric surgery were compared with 44 obese patients on lifestyle management (control group). Both groups were evaluated regarding graft and patient outcomes.

RESULTS

The studied groups were comparable demographically. In the bariatric study group versus control group, we observed that the mean body mass index was 38.49 ± 9.1 versus 44.24 ± 6 (P = .024) at transplant and 34.34 ± 7.6 versus 44.38 ± 6.7 (P = .002) at 6 months of bariatric surgery. Both groups received a more potent induction immunosuppression, but this was significantly higher in the obese nonbariatric control group (P < .05). There were more patients with slow and delayed graft functions in the same nonbariatric group. The 2 groups were comparable regarding new-onset diabetes after transplant, total patients with diabetes, and graft outcomes (P > .05).

CONCLUSIONS

Bariatric surgeries are feasible, safe pro cedures for selected obese renal transplant recipients.

Early Versus Late Acute Antibody-Mediated Rejection Among Renal Transplant Recipients in Terms of Response to Rituximab Therapy: A Single Center Experience

OBJECTIVES

There are no comparable trials concerning the use of rituximab among renal transplant recipients with acute antibody-mediated rejection. Here, we compared early and late acute antibody-mediated rejection in renal transplant recipients in terms of response to rituximab therapy.

MATERIALS AND METHODS

Of 1230 kidney transplants performed at Hamed Al-Essa Organ Transplant Center (Kuwait) over the past 10 years, 103 recipients developed acute antibody-mediated rejections and were subcategorized into 4 groups according to the onset of rejection and rituximab treatment. All patients received the standard treatment for acute antibody-mediated rejection according to our protocol (plasma exchange and intravenous immunoglobulin). We added rituximab to the treatment regimen in 2 groups of patients: 27 patients with early rejection (group 1) and 38 patients with late rejection (group 2). Groups 3 and 4 represented nonrituximab groups, with 20 patients with early (group 3) and 18 patients with late rejection (group 4). We compared the 4 groups regarding graft and patient outcomes.

RESULTS

All patients were comparable regarding patient age, sex, pretransplant type of dialysis, viral profile, type of induction, donor criteria, and pretransplant comorbidities. We observed that delayed and slow graft function were significantly higher in groups 1 and 3 (P = .016); however, we found no significant differences in the 4 groups regarding new-onset diabetes after transplant, BK viral infection, and malignancy. Graft outcomes were significantly better in groups 1 and 2 than in groups 3 and 4 (P = .028). However, patient outcomes were comparable in the 4 groups (P > .05).

CONCLUSIONS

Early acute antibody-mediated rejection in renal transplant recipients had significantly better outcomes when rituximab was added to the standard treatment regimen.

Recurrent Urinary Tract Infection Among Renal Transplant Recipients: Risk Factors and Long-Term Outcome

OBJECTIVES

Urinary tract infection is the most common type of bacterial infection in kidney transplant procedures, with adverse effects on graft and patient survival. We aimed to evaluate the risk factors of recurrent urinary tract infection in renal transplant recipients and its impact on patient and graft survival.

MATERIALS AND METHODS

In a cohort of 1019 patients who were transplanted between 2000 and 2010 at Hamed Al-Essa Organ Transplant Center in Kuwait, 86% developed at least 1 episode of urinary tract infection, with only 6.2% of patients having recurrent infections. We compared patients with recurrent urinary tract infections (group 1) with those who had no recurrence (group 2) regarding their risk factors.

RESULTS

Patients in group 1 were significantly younger than those in group 2 (34.9 ± 23 vs 42.8 ± 16 y; P < .001), with female preponderance (P < .001). The percentage of patients with thymoglobulin induction (21.5%) was significantly higher in group 1. Patients with pretransplant urologic problems experienced significantly more recurrent urinary tract infections (P < .001). Hepatitis C infections were significantly more prevalent among group 1 (10.8% vs 3.8%; P = .008). Long-term graft outcome (functioning and failed) were 78.5% and 21.5% in group 1 versus 85.1% and 13.9% in group 2 (P = .18). Patient outcomes (living and deceased donors) were 98.4% and 1.6% in group 1 versus 95.7% and 4.3% in group 2 (P = .187).

CONCLUSIONS

Adult females, thymoglobulin induction, pretransplant urologic problems, and hepatitis C infection were the risk factors of recurrent urinary tract infection among our renal transplant patients. However, recurrence did not adversely affect graft or patient survival.

Hepatitis C Virus in the Renal Transplant Population: An Update With Focus on the New Era of Antiviral Regimens

Chronic hepatitis C virus infection is a global health problem, especially among renal transplant recipients. Herein, we present an overview of hepatitis C virus among renal transplant patients, with a focus on some updated aspects concerning types of viral genotypes, methods of diagnosis, the effects of renal transplant on hepatitis C virus infection, and summary of hepatitis C virus-related complications after renal transplant. We also discuss patient and graft survival rates and the present and future therapeutic options with special focus on new antiviral and possible interactions with immunosuppressive medications.

Diabetic kidney disease: world wide difference of prevalence and risk factors

Diabetic kidney disease - which is defined by elevated urine albumin excretion or reduced glomerular filtration rate (GFR) or both - is a serious complication that occurs in 20% to 40% of all diabetics. In this review we try to highlight the prevalence of diabetic nephropathy which is not uncommon complication of diabetes all over the world. The prevalence of diabetes worldwide has extended epidemic magnitudes and is expected to affect more than 350 million people by the year 2035. There is marked racial/ethnic besides international difference in the epidemiology of diabetic kidney disease which could be explained by the differences in economic viability and governmental infrastructures. Approximately one-third of diabetic patients showed microalbuminuria after 15 years of disease duration and less than half develop real nephropathy. Diabetic kidney disease (DKD) is more frequent in African-Americans, Asian-Americans, and Native Americans. Progressive kidney disease is more frequent in Caucasians patients with type 1 than type 2 diabetes mellitus (DM), although its overall prevalence in the diabetic population is higher in patients with type 2 DM while this type of DM is more prevalent. Hyperglycemia is well known risk factor for in addition to other risk factors like male sex, obesity, hypertension, chronic inflammation, resistance to insulin, hypovitaminosis D, and dyslipidemia and some genetic loci and polymorphisms in specific genes. Management of its modifiable risk factors might help in reducing its incidence in the nearby future.

Focal segmental glomerulosclerosis and kidney transplantation

The recurrence rate of focal segmental glomerulosclerosis after kidney transplantation is ranging between 20% and 40%. Focal segmental glomerulosclerosis is associated with poor graft survival. In this review, the etiology, pathogenesis, clinicopathological features, risk factors of recurrence, and updated lines of management are discussed.

Risk factors for steroid-resistant T-cell-mediated acute cellular rejection and their effect on kidney graft and patient outcome

OBJECTIVES

Acute rejection in renal transplant is considered a risk factor for short-term and long-term allograft survival. The expected reversal rate for the first acute cellular rejection, by steroid pulse, ranges between 60% and 100%, and lack of improvement within 1 week of treatment is defined as steroid-resistant rejection. This work sought to evaluate factors that lead to steroid-resistant acute cellular rejection among patients with first live-donor renal allotransplant and its effect on graft and patient survival.

MATERIALS AND METHODS

Patients with an improvement in serum creatinine levels were considered controls (group 1; n=100); while the others were considered an early steroid-resistant group (group 2; n=99). Both groups were matched demographically.

RESULTS

Patients with a target cyclosporine level below accepted therapeutic levels were significantly higher in group 2 (P = .02). We found no significant differences between the groups regarding posttransplant complications (P > .05). Mean hospital stay was longer in group 2 (P = .021). Living patients with functioning graft were more prevalent in group 1, while those alive on dialysis were more prevalent in group 2. The groups were comparable regarding long-term patient and graft survival despite significantly lower creatinine values in patients of group 1 at 6 months' follow-up (P ≤ .001).

CONCLUSIONS

Prebiopsy low cyclosporine trough levels and associated chronic changes among patients who were maintained on calcineurin inhibitor-based regimens represented the most-important risk factors for the early steroid-resistant group. Rescue therapies improve short-term graft outcome; however, they did not affect either patient or long-term graft survival after 5 years' follow-up.

Effective therapy for acute antibody-mediated rejection with mild chronic changes: case report and review of the literature

To reduce the long-term toxicities of immunosuppressant drugs, corticosteroid-sparing and calcineurin-inhibitor-sparing immunosuppression protocols have become increasingly popular in managing kidney transplant recipients. The most vexing clinical condition caused by antibodies in organ transplants is antibody-mediated rejection. Limitations of the current antibody-mediated rejection therapies include (1) antibody-mediated rejection reversal tends to be gradual rather than prompt, (2) expense, (3) rejection reversal rates below 80%, (4) common appearance of chronic rejection after antibody-mediated rejection treatment, and (5) long-term persistence of donor specific antibodies after therapy. Because these limitations may be due to a lack of effects on mature plasma cells, the effects of bortezomib on mature plasma cells may represent a quantum advance in antihumoral therapy. Our experiences represent the first clinical use of bortezomib as an antihumoral agent in renal allograft recipients in Kuwait. We present 2 cases with resistant-acute antibody-mediated rejection to the standard therapies that were managed successfully with bortezomib.

Gene expression profiling in organ transplantation

Aim of Review. Huge effort is being made among the transplant community investigating novel biomarkers that enable transplant clinicians to identify patients at risk for allograft rejection or those who will develop tolerance so that immunosuppression could be safely minimized or even ideally withdrawn. Despite the important advances achieved in the identification of several potential biomarkers of tolerance, rejection, or both, validation and demonstration of their clinical utility still needs to be tested, which will need international cooperative networks. It is important to note that the reproducibility of differently expressed genes might be affected by many factors such as gene ranking and selection methods, inherent differences between types, and the choice of thresholds. However, because microarray analyses are expensive and time consuming and their statistical evaluation is often very difficult, gene expression analysis using the RTPCR method is nowadays recommended. Conclusions. In the field of organ transplantation, gene-expression-based decision might help in improving patient and graft outcome and there are a multitude of studies showing that gene-expression profiling is feasible.

Steroid avoidance reduce the cost of morbidities after live-donor renal allotransplants: a prospective, randomized, controlled study

OBJECTIVES

Steroids have had the main role in renal transplant for more than 4 decades. However, chronic use of steroids is associated with many comorbidities, owing to a lack of assessing cost-benefit of steroid avoidance in live-donor renal allotransplants. In this prospective, randomized, controlled study, we aimed to assess the cost-benefit of a steroid-free immunosuppression regimen among Egyptian live-donor renal transplants.

MATERIALS AND METHODS

One hundred patients were randomly allocated to receive tacrolimus, mycophenolate mofetil, and steroids for only 3 days (n=50 patients; study group) or tacrolimus, mycophenolate mofetil, and steroids on a maintenance basis (n=50 patients; control group). All patients received basiliximab (Simulect) induction, with median follow-up of 12 months.

RESULTS

Both groups showed comparable graft and patient survivals, rejection episodes, and graft functioning. Posttransplant comorbidities were significantly more prevalent in the steroid-maintenance group. Hypertension was detected in 4% of steroid-free group versus 24% in the steroid-maintenance group (P = .0009). Posttransplant diabetes mellitus, serious infections, and hyperlipidemia were significantly more prevalent in the steroid-maintenance group (P < .05). Associated hospitalization costs were 2.2-fold higher in the steroid-maintenance group than they were in the steroid-free group. One year after transplant, the cost of managing posttransplant comorbidities was significantly higher in steroid-maintenance group, despite comparable costs of immunosuppression.

CONCLUSIONS

In low, immunologic risk recipients of live-donor renal transplants, using basiliximab induction and maintenance with tacrolimus, mycophenolate mofetil, steroid avoidance was associated with lower first annual total costs despite comparable immunosuppression costs, which was attributed to lower costs of associated morbidities.

Kimura disease: a case report and review of the literature with a new management protocol

Kimura disease (KD) is a chronic inflammatory disorder with angiolymphatic proliferation, usually affecting young men of Asian race but is rare in other races. The etiology of KD is still unknown. It is often accompanied by nephrotic syndrome. Herein, we present an atypical manifestation of Kimura disease occurring in a Caucasian man with steroid-responsive early membranous glomerulonephritis. Kimura disease can present atypically in a middle-aged Caucasian man with secondary steroid-responsive nephrotic syndrome. Steroid, endoxan, and MMF can be used safely and successfully in such situation. The diagnosis of KD can be difficult and misleading, and patients with this disease are often evaluated using avoidable procedures by just not being aware of KD.

Spinal compression by brown tumor in two patients with chronic kidney allograft failure on maintenance hemodialysis

Brown tumors with non-neoplastic process are noticed in patients with end-stage renal disease suffering from a severe form of secondary hyperparathyroidism. Herein, we report a patient with chronic kidney allograft failure returned back to hemodialysis who experienced manifestations of cauda equina compression secondary to a lumbar brown tumor. Also, we had another patient on hemodialysis with a demineralized lesion affecting the cervical vertebrae. Although brown tumor is a rare complication, these two cases highlighted the importance of neurological symptoms in uremic patients. Spinal decompression surgery, in order to alleviate pressure on neurological structures, together with subtotal parathyroidectomy, were highly indicated.