New Recipes With Known Ingredients: Combined Therapy of Everolimus and Low-dose Tacrolimus in De Novo Renal Allograft Recipients

BACKGROUND

Calcineurin inhibitors (CNIs) are the cornerstones of immunosuppressive management in renal allograft recipients even though their nephrotoxicity may contribute to a reduced long-term graft survival. This has created a great interest in improving immunosuppressive strategies in the early post-transplantation period. Proliferation signal inhibitors (PSIs), such as everolimus, are promising alternatives, although their side effects may have a drawback in de novo renal transplant recipients, for instance, delaying renal function in the presence of renal ischemia/acute tubular necrosis and predisposing to lymphocele development.

STUDY AND METHODS

A retrospective study was developed to compare the combined therapy of low-dose tacrolimus and everolimus (study group) with mycophenolate mofetil/mycophenolic acid and standard-dose tacrolimus (control group) in the first 3 months post-transplantation. The study's end-points concerned renal graft function, proteinuria, incidence of biopsy-proven acute rejection, surgical complication rates, and incidence of new-onset diabetes after renal transplantation.

RESULTS

There was no more delayed graft function in the study group and graft function distribution was similar between groups. Median serum creatinine and eGFR were comparable as well as proteinuria levels. Generally, adverse events were rare in both groups and there were no significant statistical differences between them in terms of biopsy-proven acute rejection, surgical complication, and new-onset diabetes after renal transplantation rates.

CONCLUSION

Despite the slightly lower tendency for serum creatinine in the study group, renal allograft function wasn't statistically different between groups. Moreover, there weren't more metabolic or surgical complications in the study group. Everolimus may be a choice in tacrolimus-sparing strategies, but a larger study and a longer follow-up are still required.

Human Bone Marrow Mesenchymal Stem Cell Behaviors on PCL/Gelatin Nanofibrous Scaffolds Modified with A Collagen IV-Derived RGD-Containing Peptide

OBJECTIVE

We introduce an RGD (Arg-Gly-Asp)-containing peptide of collagen IV origin that possesses potent cell adhesion and proliferation properties.

MATERIALS AND METHODS

In this experimental study, the peptide was immobilized on an electrospun nanofibrous polycaprolactone/gelatin (PCL/Gel) hybrid scaffold by a chemical bonding approach to improve cell adhesion properties of the scaffold. An iodine-modified phenylalanine was introduced in the peptide to track the immobilization process. Native and modified scaffolds were characterized with scanning electronmicroscopy (SEM) and fourier transform infrared spectroscopy (FTIR). We studied the osteogenic and adipogenic differentiation potential of human bone marrow-derived mesenchymal stem cells (hBMSCs). In addition, cell adhesion and proliferation behaviors of hBMSCs on native and peptide modified scaffolds were evaluated by 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay and 4',6-diamidino-2-phenylindole (DAPI) staining, and the results compared with tissue culture plate, as the control.

RESULTS

FTIR results showed that the peptide successfully immobilized on the scaffold.MTT assay and DAPI staining results indicated that peptide immobilization had a dramatic effect on cell adhesion and proliferation.

CONCLUSION

This peptide modified nanofibrous scaffold can be a promising biomaterial for tissue engineering and regenerative medicine with the use of hBMSCs.

Renal transplantation with donors older than 70 years: does age matter?

PURPOSE

The need for organs for renal transplantation has encouraged the use of grafts from increasingly older donors. Studies of transplantation results with donors older than 70 years are sparse. The main purpose of this study is to compare the results of transplantation with donors older and younger than 70 years old.

METHODS

This retrospective study included 1233 consecutive deceased-donor renal transplantations performed between January 1, 2001, and December 31, 2011. We compared outcomes of grafts from donors older than 70 years (group ≥ 70; n = 82) versus donors younger than 70 years (group < 70; n = 1151).

RESULTS

Univariate analysis of pretransplantation data showed statistically significant differences (P < .05) among the following variables for the group < 70 and group ≥ 70, respectively: recipient age (46 ± 13 versus 61 ± 5 years), donor age (44 ± 16 versus 73 ± 3 years), donor male gender (69.4% versus 47.6%), use of antibody induction immunosuppression (51.7% versus 70.7%), and HLA compatibilities (2.4 versus 2). The group ≥ 70 showed increased postoperative minor complications: bleeding (8.5% versus 3.4%; P = .017), lymphocele formation (3.7% versus 0.5%; P = .011), and incisional hernia (2.4% versus 0.2%; P < .001). Regarding transplantation results, we observed that mean serum creatinine was significantly lower among group < 70, at 1, 3, 6, 12, 24, and 60 months after transplantation (P < .05). Cumulative graft survival at 1, 3, and 4 years was 90%, 85%, and 83% in the group < 70 versus 87%, 79%, and 72% in the group ≥ 70. In the subgroup of recipients younger than 60 years, we did not verify statistically significant differences in allograft survival between group ≥ 70 and group < 70. Using Cox regression for survival analysis, we verified that donor age was not an independent risk factor for graft failure.

CONCLUSIONS

The group of patients who received kidneys from donors younger than 70 years achieved better transplantation outcomes. Nevertheless, kidneys from older donors represent an excellent alternative for older recipients.

New-onset diabetes after transplantation: assessment of risk factors and clinical outcomes

BACKGROUND

New-onset diabetes after transplantation (NODAT) is a serious complicatin of kidney transplantation (KT) with adverse impacts on graft and patient survivals. This study aims assess potential risk factors for development of NODAT and compare clinical outcomes of KT recipients with versus without NODAT.

METHODS

We retrospectively evaluated 648 patients who underwent KT between 2005 and 2009. From the 83 (12.8%) subjects who developed NODAT, we selected 47 for comparison with controls free of diabetes.

RESULTS

The diagnosis of NODAT was made at 4.3 ± 8.5 months after transplantation in 47 patients, including 76.6% males, with an overall mean age of 54.5 ± 10.8 years. Patients with NODAT presented higher pretransplantation fasting plasma glucose levels (P < .001) as well as cyclosporine and tacrolimus trough levels (P = .003 and P < .001, respectively). On multivariate analysis, higher pretransplantation fasting plasma glucose and higher tacrolimus, but not cyclosporine concentrations were independent predictors of NODAT. No differences were found for other potential risk factors. Upon follow-up at 6, 12, 24, 36, 48, and 60 months, renal function (estimated Glomerular Filtration Rate using Modification of Diet in Renal Disease), 24 hour proteinuria and proportions of patients with hypertension were similar between groups. Patients with NODAT showed comparable numbers of hospitalizations and infections, as well as acute rejection episodes and acute cardiovascular events as their counterparts. Event-free survival (loss of graft function/death with functioning graft) was similar between the groups (P = .418; K-M).

DISCUSSION

In our population, higher pretransplantation fasting plasma glucose levels and higher tacrolimus concentrations were independent predictors of NODAT. During a mean follow-up of 3 years, NODAT was not associated with worse clinical outcomes.

Conversion to everolimus in kidney transplant recipients: to believe or not believe?

INTRODUCTION

Immunosuppression with calcineurin inhibitors (CNI) in renal transplantation is associated with chronic graft dysfunction, increased cardiovascular risk, and malignancies. Everolimus (EVR) appears to permit a CNI-sparing regimen among stable kidney recipients.

AIM

The aim of this study was to analyze the efficacy and safety of conversion from CNI to EVR.

MATERIAL AND METHODS

This was a retrospective registry-based study of all kidney transplant recipients converted from CNI to EVR between 2006 and 2010. One hundred fifty-one patients, including 69.5% males and with an overall mean age of 50.2 ± 12.7 years, underwent conversion to EVR at 37.0 ± 49.8 (16) months after transplantation with 33.7% during the first 6 months. Reasons for conversion included: CNI nephrotoxicity prevention (54.3%), chronic graft dysfunction (25.8%), malignant tumors (10.6%), CNI-adverse reactions (6.6%), and biopsy-proven CNI nephrotoxicity (2.6%). During a follow-up of 17.9 ± 9.9 months (range, 6-58.5), 18 patients (11.9%) were reconverted to CNI, 2 died with functioning grafts, and 2 lost kidney function.

RESULTS

We observed a significant (P < .001) increase in estimated glomerular filtration rate-Modification of Diet in Renal Disease (eGFR-MDRD) by 11.3% within 6 months: 56.7 ± 22.1 to 64.1 ± 23.4 mL/min/1.73 m(2). At final evaluation it was 13.7%, namely, to 65.5 ± 23.0 mL/min/1.73 m(2). At the end of follow-up the proportion of patients with >300 mg/d proteinuria increased from 7.9% to 23.3% (P = .001). Dyslipidemia prevalence increased from 69.5% to 77.5% (P = not significant [NS]) and arterial hypertension increased from 49% to 65.9% (P < .001) at the end of follow-up. Other reported side effects included oral ulcers (2.6%), edema (5.3%), interstitial pneumonitis (1.3%), and toxic hepatitis (1.3%), some of them leading to EVR discontinuation.

CONCLUSION

In our population, renal function improved significantly after conversion from CNI to EVR. Although side effects were common, most were mild, withdrawal of EVR was necessary in a low percentage of cases. EVR appears to be an effective, safe alternative to CNI for maintenance therapy in selected kidney transplant recipients.

Does multiorgan versus kidney-only cadaveric organ procurement affect graft outcomes?

INTRODUCTION

The majority of kidney grafts in most European countries still come from deceased donors who provide other organs. We analyzed whether multiorgan procurement portends a worse functional outcome compared with kidney-only harvesting.

METHODS

We performed a retrospective analysis of 1043 consecutive brain-dead donor kidney transplantations performed at a single academic institution from September 2002 to June 2011. The graft outcomes using kidney-only donors (n = 243) were compared with multiorgan donor grafts (n = 800) analyzing donor age, gender, cause of death, duration of mechanical ventilation, renal function, and cold ischemic interval. We compared delayed graft function and serum creatinine values at 1, 3, 6, and 12 months posttransplantation as well as graft survivals. This methodology was also applied to the subset of expanded criteria donors: 179 kidney-only versus 474 multiorgan. The influence of donor variables on graft survival was also analyzed in a Cox regression model. Immunosuppressive regimens and preservation solutions were similar in both groups.

RESULTS

Kidney-only donors were older than their multiorgan counterparts (53.1 versus 44.8, P < .0005) and predominantly male (76.5% versus 62.6% male donors, P < .0005). Other donor variables were comparable. Kidney-only donor grafts showed a slightly higher incidence of delayed function (27.2 versus 21.1%, P = .049), but the mean serum creatinine values were similar at all intervals. No differences were observed in 7-year graft survival: 80.7% versus 79.9%. Expanded criteria donor grafts showed overlapping results, except for a higher rate of donor oligoanuria and a lower 1-month mean creatinine among kidney-only donors. Multivariate analysis revealed that the number of harvested organs did not influence graft survival.

DISCUSSION

Immediate and long-term outcomes of kidney grafts did not correlate with the number of organs harvested from the donor. The longer explantation time associated with multiorgan procurement did not seem to affect graft function.

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.

Do intraoperative hemodynamic factors of the recipient influence renal graft function?

PURPOSE

To assess the importance of intraoperative management of recipient hemodynamics for immediate versus delayed graft function.

METHODS

The retrospective study of 1966 consecutive renal transplants performed in our department between June 1980 and December 2009 analyzed several perioperative hemodynamic factors: central venous pressure (CVP), mean arterial pressure (MAP) as well as volumes of fluids, fresh frozen plasma (FFP), albumin, and whole blood transfusions. We examined their influence on renal graft function parameters: immediate diuresis, serum creatinine levels, acute rejection, chronic transplant dysfunction, and graft survival.

RESULTS

Mean CVP was 9.23 ± 2.65 mm Hg and its variations showed no impact on graft function. We verified a twofold greater risk of chronic allograft dysfunction among patients with CVP ≥ 11 mm Hg (P < .001). Mean MAP was 93.74 ± 13.6 mm Hg; graft survivals among subjects with MAP ≥ 93 mm Hg were greater than those of patients with MAP < 93 mm Hg (P = .04). On average, 2303.6 ± 957.4 mL of saline solutions were infused during surgery. Patients who received whole blood transfusions (48%) showed a greater incidence of acute rejection episodes (ARE) (P = .049) and chronic graft dysfunction (P < .001). Patients who received FFP (55.7%), showed a higher incidence of ARE (P < .001). Only 4.6% of patients (n = 91) received human albumin with a lower incidence of ARE (P = .045) and chronic graft dysfunction (P = .024). Logistic binary regression analysis revealed that plasma administration was an independent risk factor for ARE (P < .001) and chronic dysfunction (P = .028). Volume administration (≥ 2500 mL) was also an independent risk factor for chronic allograft dysfunction (P = .016). Using Cox regression, we verified volume administration ≥ 2500 mL to be the only independent risk factor for graft failure (P < .001).

CONCLUSION

MAP ≥ 93 mm Hg and perioperative fluid administration <2500 mL were associated with greater graft survival. Albumin infusion seemed to be a protective factor, while CVP ≥ 11 mm Hg, whole blood, and FFP transfusions were associated with higher rates of ARE and chronic graft dysfunction.

C4d deposits in acute "cell-mediated" rejection: a marker for renal prognosis?

BACKGROUND

Accumulation of C4d along peritubular capillaries (PTC) of renal allografts is normally attributed to antibody-mediated rejection. The prognostic implication of these deposits associated with "cell-mediated" rejection on graft survival remains uncertain. Our study aims to evaluate the impact of C4d deposits along PTC of patients with acute cell- mediated rejection on graft function and survival.

METHODS

We retrospectively analyzed patients transplanted between 2005 and 2010 with histopathologic diagnosis of acute rejection (AR). Eleven patients with "pure" antibody-mediated rejection were excluded. The remaining 79 patients were divided into two groups according to type of AR by Banff 2003 criteria: type I (69.6%) versus type II (30.4%). In each group, comparisons were made between C4d-negative (-) and C4d-positive (+) biopsies.

RESULTS

Fifty-five patients presented with type I AR: 35 (63.6%) C4d- and 20 (36.4%) C4d+. Twenty-four patients presented with type II AR: 13 (54.2%) C4d- and 11 (45.8%) C4d+. In the type I AR group, graft survival at the first and second years was similar in C4d- and C4d+ patients (94% and 91% versus 75% and 75%, respectively, log-rank P = .26). No differences were encountered in estimated glomerular filtration rate (eGFR) between subgroups at the first, second, and final years of follow-up. Graft loss occurred in 14.7% of C4d- patients versus 25% in C4d+ patients (P = NS). In the type II AR group, graft survival at the first and second years was similar in C4d- and C4d+ patients (85% and 85% versus 72% and 61%, respectively, log-rank P = .50). No differences were encountered in eGFR between subgroups at the first, second, and final years of follow-up. Graft loss occurred in 30.8% of C4d- patients versus 45.5% in C4d+ patients (P = NS).

CONCLUSION

Our results suggest that detection of C4d staining in acute "cell-mediated" rejection does not imply a worse renal prognosis.

Association of self-reported passive smoking in pregnant women with cotinine level of maternal urine and umbilical cord blood at delivery

Passive smoking during pregnancy leads to adverse effects on mother and infant. The present investigation was designed to evaluate the association between maternal reported passive smoking with the cotinine concentration of maternal urine and umbilical cord blood at delivery and to determine the accuracy of maternal reporting of exposure to cigarette smoke during pregnancy. This was a cross-sectional study. From the 108 non-smoker pregnant women who were referred for delivery, 54 were passive smokers. Urine samples were collected from the mothers in the delivery room and blood samples after birth were taken from the umbilical cord. Passive smoking was evaluated through questionnaire and cotinine level of urine and umbilical cord blood. The geometric mean cotinine concentration of the maternal urine and the umbilical cord serum were, respectively, 27.4 ± 29.96 ng/mL and 3.71 ± 1.22 ng/mL in the exposed group (P < 0.001) and 0.75 ± 2.29 and 0.40 ± 0.63 in the non-exposed group (P < 0.001). There was a statistically significant correlation between maternal urinary and umbilical cord serum level of cotinine (P < 0.001, r = 0.58). Significant associations were shown between maternal reports of exposure to cigarette smoking with cotinine level of urine (kappa = 96%) and umbilical cord (kappa = 98%) (P < 0.001). This study shows that the pregnant woman's report of passive smoking during pregnancy in Iran is accurate. The questionnaire is an appropriate method to evaluate smoke exposure and could replace cotinine measurement.

Cytomegalovirus retinitis in an immunocompromised infant: a case report and review of the literature

Purpose

To describe a case of bilateral cytomegalovirus retinitis (CMVR) in an immunocompromised infant.

Methods

A 4-month-old male infant with severe combined immunodeficiency syndrome was examined for the presence of CMVR. Ocular involvement was recorded and monitored by digital imaging.

Results

The child had bilateral CMVR, with a fine granular pattern, present both in the peripheral retina and posterior pole. There was no vitritis. The active areas of retinitis progressively resolved with intravenous ganciclovir treatment. At the 3-month follow-up examination, no recurrence was observed.

Conclusion

Ganciclovir treatment was effective in this case. The prognosis depends on rapid institution of effective antiviral therapy and on a patient's systemic immunocompetence.

Renal transplantation in recipients over 65 years old

BACKGROUND AND PURPOSE

Older patients on hemodialysis have become candidates for renal transplantation, particularly in the period of increasing numbers of marginal donors. The purpose of this study was to evaluate short-term and long-term results of renal transplantation among recipients ≥65 years old for comparison with these in younger patients.

PATIENTS AND METHODS

We retrospectively studied 1,796 renal transplantations performed between June 1991 and May 2010, dividing the sample into 2 groups: ≥65 years old (n = 89) versus <65 years old (n = 1,707).

RESULTS

The mean ages were 42.17 and 67.45 years for the younger and older groups, respectively. Time of pretransplantation dialysis was significantly greater among the older group (52.76 vs 47.69 mo). There were no differences between the 2 groups regarding donor age, donor renal function, or cold ischemia times. After a mean follow-up of 73.37 versus 39.73 months for the younger versus older groups, respectively, we observed differences in initial graft function, with a greater rate of delayed graft function in the ≥65 group (28.1% vs 17.8%), and in acute rejection rate, which was higher among the younger group (19.4% vs 10.1%). Initial creatinine was better for the older group (1.71 vs 2.10 mg/dL), but similar between the groups at 10 years. Graft and patient survivals at 1, 5, and 10 years were lower among the older group. When analyzing graft survival censored for death with a functioning kidney, there were no differences between the younger and older groups: It was at 1, 5, and 10 years, namely 93.6% versus 90.6%, 87% versus 80.8%, and 76.7% versus 70.1%, respectively.

CONCLUSIONS

Selected recipients ≥65 years of age show good outcomes of transplantation.

Pretransplantation overweight and obesity: does it really affect kidney transplantation outcomes?

OBJECTIVE

The objective of this study was to compare kidney transplant outcomes among pretransplantation overweight and obese patients with those with normal weight.

METHODS

We performed a retrospective analysis of a sample of 448 kidney transplantations performed between 1984 and 2008 in our institution. We compared of initial graft function, postoperative length of stay, surgical complications, acute and chronic rejection rates, creatinine serum levels, and patient and graft survival, between normal weight, overweight, and obesity groups.

RESULTS

Overweight was detected on 28.3% of the patients, and obesity on 5.8%. A male predominance was noted among the normal and overweight groups, and the opposite in the obesity group: namely, male:female ratios of 2.17:1, 3.37:1, and 0.37:1, respectively. Mean age was lower in the normal weight group (41.51 years) versus 48.36 and 46.08 years in the overweight and obesity groups, respectively. Compared with the normal weight group, recipient creatinine serum levels between 1 and 6 months were higher among the obese group, but not the overweight one. Both overweight and obese groups showed significantly higher incidences of delayed graft function (26.8% and 26.9%, respectively) versus 16.9% in the normal weight group (P = .028) and longer surgery times, ie, greater than 3 hours in 22.8% and 42.3%, respectively, versus 20.7% of the normal weight patients. Surgical complication rates were higher in both non-normal weight groups (17.3% and 26.9% vs 15.9% in the normal weight group), especially lymphocele formation and wound dehiscence (P = .031 and P < .0005, respectively). However, no differences were detected concerning postoperative length of stay, graft loss, acute or chronic rejection, and graft or patient survival.

CONCLUSION

Pretransplantation overweight and obesity did not seem to significantly affect kidney transplantation in the medium and long terms. The early posttransplantation period can however be disturbed by an increased incidence of surgical complications and reversible degradation of some graft functional parameters.

Donor cause of brain death in renal transplantation: a predictive factor for graft function?

PURPOSE

Our aim was to evaluate the influence of donor cause of brain death on the results of kidney transplantation.

METHODS

This retrospective study included 896 consecutive deceased-donor renal transplantations performed between January 1, 2000, and December 31, 2009. We compared outcomes of grafts from donors after cerebrovascular accident (CVA; n = 371) versus head trauma (HT; n = 525).

RESULTS

Univariate analysis of pretransplantation data showed statistically significant differences (P < .05): among the following variables for the HT versus CVA groups respectively: recipient age (43.63 ± 13.2 y vs 49.80 ± 12.5 y); donor age (36.06 ± 16.6 y vs 52.57 ± 13.2 y) and time on dialysis (50.67 ± 45.034 mo vs 59.39 ± 46.3 mo). Regarding transplantation results, we observed that mean serum creatinine was significantly lower among HT recipient, at 1, 3, 6, 12, and 24 months after transplantation (P < .05). Chronic allograft nephropathy (CAN) and delayed graft function were higher among the CVA group. HT group kidneys showed significantly longer mean survival times than CVA group kidneys (102.7 ± 3.9 mo vs 94.8 ± 5.6 mo; log rank: P = .04). Upon multivariate analysis donor cause of death was not identified as an independent risk factor for graft survival or occurrence of chronic allograft nephropathy.

CONCLUSIONS

Transplantation results were better among the HT group. However multivariate regression analysis indicated that donor cause of death was not an independent risk factor for graft survival or occurrence of chronic allograft nephropathy.

Reduction of secondhand smoke exposure among healthy infants in Iran: randomized controlled trial

INTRODUCTION

The objective of this study was to assess whether counseling both mothers and fathers reduces their infants' exposure to secondhand smoke (SHS).

METHODS

Participants were 130 nonsmoking children aged less than 1 year, exposed to their fathers' or mothers' smoking, and recruited from a health center in southern Tehran. Eligible families were randomly assigned to intervention or control group. Infant urine samples were collected, and parents were interviewed at baseline and at a 3-month follow-up in each of the 2 groups. Mothers of the intervention group were provided 3 counseling sessions, one of which was face to face and 2 of which were by telephone. Fathers were provided 3 counseling sessions by telephone. Parents were also given an educational pamphlet and a sticker depicting a smoke-free home. The control group received usual care. Changes in infant urinary cotinine levels, parental cigarette consumption in the presence of the child, and home- and car-smoking bans were assessed.

RESULTS

The intervention was effective in reducing infant urinary cotinine levels (1-tailed p = .029). There was a greater decrease in the total daily cigarette consumption in the presence of the child in the intervention group compared with the control group, and the differences between the 2 groups were statistically significant (1-tailed p = .03). While the differences between home-smoking bans in the 2 groups were statistically significant (1-tailed p = .049), the differences between car-smoking bans did not reach significance.

CONCLUSION

Counseling similar to that employed in other countries can reduce infant exposure to SHS, suggesting generalizability.

Development of disseminated superficial porokeratosis in a patient with complicated acute pancreatitis

Porokeratosis is a group of hereditary or acquired diseases with abnormal epidermal keratinization. A 71-year-old man was admitted to the Surgery Department after an attack of acute pancreatitis complicated with pancreatic necrosis, which required surgical resection. Three weeks after the admission, the patient was observed by our Dermatology department with sudden onset of a generalized eruption of asymptomatic flat papules with a hyperkeratotic rim, sparing the face, palms, soles, and mucous membranes. A skin biopsy was performed at the border of a leg lesion, which disclosed the presence of cornoid lamella, confirming the clinical diagnosis of disseminated superficial porokeratosis (DSP). The skin eruption spontaneously subsided about one month after pancreatic resection. The late onset of DSP in our patient may represent a type of immunosuppression-induced porokeratosis. Possibly, the pathologic clone of keratinocytes for porokeratosis was present, but remained latent until there was a decrease in the immunological status. It is possible that this relative and transient state of immunosuppression was the result of the concurrent necrotizing pancreatitis. This case represents an unusually good outcome of DSP. To the authors best knowledge, this is the first case of DSP related to severe acute pancreatitis.

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

BACKGROUND

The 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.

MATERIALS AND METHODS

This retrospective study of 409 cadaveric renal transplants over the last 4 years identified ECD in contrast with SCD.

RESULTS

Of 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.

CONCLUSIONS

Renal transplantation with grafts from ECD shows significantly worse outcomes with higher rates of DGF and ARE, worse graft function, and lower graft survival.

Impact of hepatitis B and C virus infections on kidney transplantation: a single center experience

OBJECTIVE

The impacts of hepatitis C virus (HCV) and hepatitis B virus (HBV) infections on patient and renal graft survivals are controversial. This study sought to evaluate the effects of pretransplantation HCV and HBV infections on renal transplant patients and their grafts at our center.

PATIENTS AND METHODS

We retrospectively examined 1224 renal transplantations performed between 1992 and 2006, including 28 HBsAg positive; 64, anti-HCV; 9, anti-HCV plus HBsAg positive; and 1123, negative for anti-HCV and HBsAg. The mean posttransplantation follow-up was 5.6 +/- 4.1 years.

RESULTS

The prevalences of HBV infection were 6.2% in 1994 and 2.3% in 2006 and those of HCV infection were 6.8% in 1998 and 5.2% in 2006. The rejection rate was higher among HBV+ (46.4%) and HCV+ (40.6%) groups than the negative groups (31.5%), but it was not significant. There were no significant differences in patient and graft survivals among the groups. The major cause of patient death was liver failure among patients with concomitant HBV+ and HCV+ infections and cardiovascular disease among HCV+ and negative patients.

CONCLUSIONS

There has been a decrease in the prevalence of recipients with hepatitis virus infections over the last 15 years. Patient and graft survivals were not affected by HCV or HBV infection.

Kidney transplantation with corticosteroid-free maintenance immunosuppression: a single center analysis of graft and patient survivals

The purpose of this study was to assess the impact of a corticosteroid-free maintenance immunosuppression on graft survival in kidney transplantation. We analyzed 79 patients who were transplanted between June 1, 2006 and May 31, 2007. We excluded hyperimmunized patients, second transplantations, living donors, and black recipients. Patients underwent induction with thymoglobulin or basiliximab, followed by treatment with mycophenolate mofetil (MMF), tacrolimus, and methylprednisolone. On the 5th day, the patients were divided into 2 groups: group A (n = 45) discontinued steroid therapy; group B (n = 34) continued prednisone therapy. We performed a comparative analysis of incidence of delayed graft function (DGF), acute rejection episodes (ARE), renal function at 6 and 12 months, graft and patient survivals, causes of graft loss, and mortality. The 2 groups were similar for donor, recipient, and graft characteristics. The incidences of DGF were 8.9% in group A and 14.7% in group B; those for ARE were 2.3% in group A and 13.8% in group B (P = .077). The mean serum creatinine levels at 6 and 12 months were similar. There were 8 graft losses: 3 in group A (3 deaths with functioning grafts) and 5 in group B (1 death, 3 vascular causes, 1 kidney nonfunction). The 4 deaths were due to infection (n = 3) or neoplasia (n = 1). Graft survivals at 1 year were 98% in group A and 85% in group B, and patient survivals were 98% and 97%, respectively. An immunosuppressive regimen using antibody induction and steroid-free treatment proved to be effective in low-risk patients.

Diagnosis and management of hyperprolactinemia: results of a Brazilian multicenter study with 1234 patients

OBJECTIVE

The aim of the study was to evaluate clinical and laboratorial features of 1234 patients with different etiologies of hyperprolactinemia, as well as the response of 388 patients with prolactinomas to dopamine agonists.

DESIGN, SETTING, AND PATIENTS

A total of 1234 hyperprolactinemic patients from 10 Brazilian endocrine centers were enrolled in this retrospective study.

MAIN OUTCOME MEASURE

PRL measurement, thyroid function tests, and screening for macroprolactin were conducted.

RESULTS

Patients were subdivided as follows: 56.2% had prolactinomas, 14.5% drug-induced hyperprolactinemia, 9.3% macroprolactinemia, 6.6% non-functioning pituitary adenomas, 6.3% primary hypothyroidism, 3.6% idiopathic hyperprolactinemia, and 3.2% acromegaly. Clinical manifestations were similar irrespective of the etiology of the hyperprolactinemia. The highest PRL levels were observed in patients with prolactinomas but there was a great overlap in PRL values between all groups. However, PRL>500 ng/ml allowed a clear distinction between prolactinomas and the other etiologies. Cabergoline (CAB) was more effective than bromocriptine (BCR) in normalizing PRL levels (81.9% vs 67.1%, p<0.0001) and in inducing significant tumor shrinkage and complete disappearance of tumor mass. Drug resistance was observed in 10% of patients treated with CAB and in 18.4% of those that used BCR (p=0.0006). Side-effects and intolerance were also more common in BCR treated patients.

CONCLUSION

Prolactinomas, drug induced hyperprolactinemia, and macroprolactinemia were the 3 most common causes of hyperprolactinemia. Although PRL levels could not reliably define the etiology of hyperprolactinemia, PRL values >500 ng/ml were exclusively seen in patients with prolactinomas. CAB was significantly more effective than BCR in terms of prolactin normalization, tumor shrinkage, and tolerability.

Rowell syndrome - case report and review of the literature

Rowell syndrome is a rare distinctive entity first described in 1963 by Rowell and coworkers. It consists in erythema multiforme-like lesions associated with lupus erythematosus. Zeitouni et al. recently redefined the major and minor diagnostic criteria. Major criteria are lupus erythematosus, erythema multiforme-like lesions and speckled pattern of antinuclear antibody. Minor criteria are chilblains, positive anti-La (SS-B) or anti-Ro (SS-A) antibody and reactive rheumatoid factor. We report a case of a 63-year-old woman, with no previous history of lupus erythematosus, who developed erythema multiforme-like lesions and laboratory findings consistent with Rowell syndrome.