Erectile dysfunction in liver transplant patients

The objectives of the study were to determine the frequency of erectile dysfunction (ED) after liver transplantation (LT) and discuss potential risk factors. Of 123 eligible LT men, 98 (79.7%) responded to a questionnaire about sexual function at a mean time posttransplant of 5.4 +/- 4.0 years (1.0-21). Erection was evaluated using the five-question international index for erectile function score, and sexual satisfaction by the patient-baseline treatment-satisfaction status (TSS) score. Questions also focused on patient perception of changes overtime. We found that after LT, the proportion of sexually inactive men decreased from 29% to 15% (p = 0.01), but the proportion of men with ED remained unchanged. The absence of sexual activity was associated with pretransplant sexual inactivity (p = 0.001), age (p = 0.008), cardiovascular disease (p = 0.03), use of diuretics (p = 0.04), anticoagulants (p = 0.001), statins (p = 0.01) and treatment for diabetes (p = 0.03). Cardiovascular disease (p = 0.05), posttransplantation diabetes (p = 0.04), alcohol abuse (p = 0.03), antidepressants (p = 0.05) and angiotensin II receptor blockers (p = 0.05) were associated with having ED after LT. Having a low TSS score was associated with a history of endocrine disease (p = 0.03), antidepressants (p = 0.04) and diuretics (p = 0.03). In conclusion, LT improves sexual activity, but ED is multifactorial and remains a long-term condition in the majority of patients.

Acute hepatitis E in south-west France over a 5-year period

BACKGROUND

Hepatitis E was found in people living in industrialized countries who had not travelled to highly endemic areas.

OBJECTIVES

To study the cases of acute hepatitis E confirmed thanks to viral genomic detection over a 5 years period in south-west France.

STUDY DESIGN

62 cases of hepatitis E were identified between 2003 and 2007. Their demographic, clinical, and virological features were analyzed.

RESULTS

Cases of acute hepatitis E occurred regularly throughout this period. No seasonal variation was found. Patients, usually male (sex ratio=1.95), were adults living in both urban and rural areas. Sixty (96.8%) patients had not travelled abroad during the 6 months before diagnosis. Clinical manifestations ranged from asymptomatic infection to severe hepatitis. HEV was genotyped in 55 specimens. All the patients who had not travelled abroad were infected with genotype 3.

CONCLUSION

The incidence of hepatitis E in south-west France was stable from 2003 to 2007, 96.8% of the cases were autochthonous. There was an age-related increase in the disease and patients tended to be men. The predominant genotype and subtype was 3f. However, contaminations pathways involved in hepatitis E in our area remain to clarify.

Hepatitis E virus-related cirrhosis in kidney- and kidney-pancreas-transplant recipients

Hepatitis E virus (HEV) infection was thought to be responsible for acute hepatitis that did not become chronic. However, we have recently reported that HEV infection can evolve to chronic hepatitis, at least in solid-organ transplant patients. We report on two cases of rapidly progressive of HEV-related cirrhosis that occurred in two organ-transplant patients. Case 1: A kidney-pancreas-transplant patient developed acute HEV hepatitis 60 months after transplantation, which evolved to chronicity as defined by persisting elevated liver-enzyme levels and positive serum HEV RNA. At 22 months after the acute phase, she presented with cirrhosis and portal hypertension, that is ascites and esophagus varices. Case 2: A kidney-transplant patient developed acute hepatitis 36 months after transplantation, which persisted and remained unexplained for 38 months. Then, HEV RNA was searched for in their serum and stools, and was found to be positive in both. Retrospective analysis of available stored serum, mainly the serum obtained at the acute phase, confirmed the diagnosis of chronic hepatitis E. In both cases, a liver biopsy showed cirrhosis. We conclude that HEV infection cannot only evolve to chronic hepatitis, but can also be responsible for rapidly progressing cirrhosis in organ-transplant patients.

Individualized mycophenolate mofetil dosing based on drug exposure significantly improves patient outcomes after renal transplantation

Efficacy and safety of mycophenolate mofetil (MMF) may be optimized with individualized doses based on therapeutic monitoring of its active metabolite, mycophenolic acid (MPA). In this 12-month study, 137 renal allograft recipients from 11 French centers receiving basiliximab, cyclosporine A, MMF and corticosteroids were randomized to receive either concentration-controlled doses or fixed-dose MMF. A novel Bayesian estimator of MPA AUC based on three-point sampling was used to individualize doses on posttransplant days 7 and 14 and months 1, 3 and 6. The primary endpoint was treatment failure (death, graft loss, acute rejection and MMF discontinuation). Data from 65 patients/group were analyzed. At month 12, the concentration-controlled group had fewer treatment failures (p = 0.03) and acute rejection episodes (p = 0.01) with no differences in adverse event frequency. The MMF dose was higher in the concentration-controlled group at day 14 (p < 0.0001), month 1 (p < 0.0001) and month 3 (p < 0.01), as were median AUCs on day 14 (33.7 vs. 27.1 mg*h/L; p = 0.0001) and at month 1 (45.0 vs. 30.9 mg*h/L; p < 0.0001). Therapeutic MPA monitoring using a limited sampling strategy can reduce the risk of treatment failure and acute rejection in renal allograft recipients 12 months posttransplant with no increase in adverse events.

Linezolid-related pancytopenia in organ-transplant patients: report of two cases

Linezolid is a recent oral antibiotic used in drug-resistant Gram-positive cocci infection. We herein report on the first two cases of linezolid-related pancytopenia in organ-transplant patients. Both patients had methicillineresistant Staphylococcus aureus infections. Pancytopenia, i.e. aregenerative anemia, neutropenia and thrombopenia, developed 3 weeks and 5 weeks after initiating linezolid therapy at a conventional dosage (600 mg bid). There were no other confounding causes of pancytopenia, which resolved promptly after withdrawing linezolid. Because of the potential hazards of pancytopenia in immunosuppressed organ-transplant patients, we advocate the cautious use of linezolid for transplant patients.

Plasma concentrations of mycophenolic acid acyl glucuronide are not associated with diarrhea in renal transplant recipients

The aim of this study was to determine whether plasma concentrations of the acyl (AcMPAG) and phenolic (MPAG) glucuronide metabolites of mycophenolic acid (MPA) were related to diarrhoea in renal transplant patients on mycophenolate mofetil (MMF) with cyclosporine (CsA) or tacrolimus (TCL). Blood samples (0, 30, 120 min) were taken at days 3, 10, week 4, months 3, 6 and 12 for determination of MPA, MPAG and AcMPAG. MPA-AUC was estimated using validated algorithms. Two hour AUCs were calculated for MPAG and AcMPAG. Immunosuppressive therapy consisted of CsA/MMF (n= 110) and of TCL/MMF (n= 180). In 70/290 (24%) patients 86 episodes of diarrhoea were recorded during 12 months. Significantly more patients on TCL (31.1%) suffered from diarrhea compared to CsA (12.7%). MMF dose, MPA-AUC and the 2 h AUCs of MPAG and AcMPAG did not differ between patients with and without diarrhoea. Plasma AcMPAG and MPAG concentrations were substantially higher in patients on CsA compared with TCL, while MPA-AUC was lower in the former group. These data support the concept that CsA inhibits the biliary excretion of MPAG and AcMPAG, thereby potentially reducing the risk of intestinal injury through enterohepatic recycling of MPA and its metabolites.

Results of an international, randomized trial comparing glucose metabolism disorders and outcome with cyclosporine versus tacrolimus

DIRECT (Diabetes Incidence after Renal Transplantation: Neoral C(2) Monitoring Versus Tacrolimus) was a 6-month, open-label, randomized, multicenter study which used American Diabetes Association/World Health Organization criteria to define glucose abnormalities. De novo renal transplant patients were randomized to cyclosporine microemulsion (CsA-ME, using C(2) monitoring) or tacrolimus, with mycophenolic acid, steroids and basiliximab. The intent-to-treat population comprised 682 patients (336 CsA-ME, 346 tacrolimus): 567 were nondiabetic at baseline. Demographics, diabetes risk factors and steroid doses were similar between treatment groups. The primary safety endpoint, new-onset diabetes after transplant (NODAT) or impaired fasting glucose (IFG) at 6 months, occurred in 73 CsA-ME patients (26.0%) and 96 tacrolimus patients (33.6%, p = 0.046). The primary efficacy endpoint, biopsy-proven acute rejection, graft loss or death at 6 months, occurred in 43 CsA-ME patients (12.8%) and 34 tacrolimus patients (9.8%, p = 0.211). Mean glomerular filtration rate (Cockcroft-Gault) was 63.6 +/- 20.7 mL/min/1.73 m(2) in the CsA-ME cohort and 65.9 +/- 23.1 mL/min/1.73 m(2) with tacrolimus (p = 0.285); mean serum creatinine was 139 +/- 58 and 133 +/- 57 mumol/L, respectively (p = 0.005). Blood pressure was similar between treatment groups at month 6, but total cholesterol, LDL-cholesterol and triglyceride levels were significantly higher with CsA than with tacrolimus (total cholesterol:HDL remained unchanged). The profile and incidence of adverse events were similar between treatments. The incidence of NODAT or IFG at 6 months post-transplant is significantly lower with CsA-ME than with tacrolimus without a significant difference in short-term outcome.

Efficacy and Safety of Enteric-Coated Mycophenolate Sodium in De Novo Renal Transplant Recipients: Pooled Data From Three 12-Month Multicenter, Open-Label, Prospective Studies

BACKGROUND

The myfortic Prospective Multicenter Study (myPROMS) utilizes a core protocol in which renal transplant patients receive enteric-coated mycophenolate sodium (EC-MPS) and cyclosporine microemulsion. Substudies investigate specific aspects of the immunosuppressive regimen.

METHODS

A pooled analysis of three 12-month myPROMS substudies in de novo renal transplant patients was undertaken. Patients in the US01 and DE01 substudies were randomized to higher or lower cyclosporine C(2) target ranges; patients in FR01 were randomized to early or delayed introduction of cyclosporine. All patients received steroids and interleukin-2 receptor antagonist induction.

RESULTS

In total, 456 patients were included in the pooled analysis. Treatment failure (biopsy-proven acute rejection, graft loss, or death) occurred in 118 patients (25.9%) by month 12, with biopsy-proven acute rejection reported in 101 patients (22.1%). Fourteen patients (3.1%) lost their graft, and six patients died (1.3%). Median calculated creatinine clearance was 62.9 mL/min at month 12 (median serum creatinine, 138 +/- 51 mumol/L). Gastrointestinal (GI) adverse events were reported in 354 patients (77.6%); these were mild or moderate in 323 patients. Within 12 months, 16.2% of patients required EC-MPS dose changes for GI adverse events. GI disorders led to EC-MPS discontinuation in only 10 patients (2.2%). Over the 12-month study, mean EC-MPS dose was 1352 +/- 230 mg/d (94% of recommended dose).

CONCLUSION

Cyclosporine, EC-MPS, and steroids with interleukin-2 antagonist induction offers effective and well-tolerated immunosuppression following renal transplantation. Graft survival was excellent and renal function was stable. High EC-MPS dosing was sustained throughout (>90% recommended dose) and dose modifications due to EC-MPS-related adverse events or infections were infrequent.

An unusual cause of acute renal failure in a kidney transplant recipient: Salmonella enteritidis post-infectious glomerulonephritis

BACKGROUND

Salmonella enteritidis-associated acute renal failure has often been described and is usually a result of dehydration or of rhabdomyolysis. A few cases of acute renal failure with glomerular syndrome, caused by S. enteritidis infection, have been reported in the literature, but none have been proven by histological findings.

METHODS

Herein, we report on a case of S. enteritidis-related glomerulonephritis that occurred in a 42-year-old male transplant recipient. He was admitted with fever, signs of urinary infection, diarrhea, and nephritic syndrome, i.e. edema, hypertension, increase in serum creatinine, microscopic hematuria, proteinuria. His urine culture tested positive for S. enteritidis.

RESULTS

Under light microscopy, the graft biopsy showed proliferative and exudative endocapillary glomerulonephritis. In addition, there was polymorphonuclear infiltration of the interstitium, and extra-capillary proliferation in one glomerulus. Immunofluorescence showed granular deposits of C3 in the mesangium. Electron microscopy showed electron-dense deposits typical of humps. He fully recovered on a double antibiotic therapy that included ofloxacin and amikacin.

CONCLUSION

Although acute renal failure related to non-typhoidal Salmonella infections are often related to dehydration or rhabdomyolysis, this case report shows that it might also be related to immune complex-mediated glomerulonephritis manifesting as nephritic syndrome.

Prospective evaluation of BK virus DNAemia in renal transplant patients and their transplant outcome

BACKGROUND

After renal transplantation, the prevalence of BK virus (BKV) viruria, viremia, and nephritis (BKVAN) has been estimated at 30%, 13%, and 8%, respectively.

PATIENTS AND METHODS

The aim of this prospective study was to assess the occurrence of BKV DNAemia during the first year after renal transplantation and to determine the prevalence of BKVAN, in the absence of immunosuppression alteration, following positive BKV DNA. BKV DNAemia was assessed systematically in 104 renal transplant patients on postoperative days 60, 90, 135, 180, 270, and 360.

RESULTS

Of the 104 patients, 7 (6.7%) presented with at least 1 episode of BKV DNAemia. Those with positive BKV DNAemia had a cumulative steroid dose administered from days 0 to 7 which was higher than those without BKV DNAemia (2.13 +/- 0.6 vs 1.6 +/- 0.4; P = .024). The first BKV DNAemia occurred at 170 (30-460) days posttransplantation. Of the 7 patients who experienced at least 1 BKV DNAemia, 3 had 1 occurrence, but the other 4 had repeated occurrences. These 4 patients developed overt BKVAN at 1 (2 cases) to 2 weeks (2 cases) after the first occurrence of BKV DNAemia. These 4 patients were withdrawn from mycophenolate mofetil, which was in all cases replaced by leflunomide. With a follow-up ranging from 14 to 24 months after the first episode of BKV DNAemia, patient and graft survivals were both 100%. Current serum creatinine ranges from 97 to 173 micro mol/L for those who had only 1 episode of BKV DNAemia, and from 144 to 240 micro mol/L for those who had overt BKVAN.

CONCLUSION

Although BKV DNAemia is a rare event after renal transplantation, it is often associated with BKVAN, which may be treated successfully by the alleviation of immunosuppression and leflunomide therapies.

Treatment of focal segmental glomerular sclerosis with rituximab: 2 case reports

BACKGROUND

Primary focal segmental glomerular sclerosis (FSGS) recurs in 20 - 40% of patients after kidney transplantation. Rituximab has been used to treat several glomerular diseases.

PATIENTS AND RESULTS

We treated two renal-transplant patients with recurrence of FSGS with rituximab. Despite a prophylactic perioperative therapy of plasmapheresis (PE) and i.v. cyclosporine A, Patient 1 developed significant proteinuria, at 1 day after his first kidney transplantation. After two infusions of rituximab (375 mg/m2) he had complete remission. A second relapse, which occurred on Day 40, was also successfully treated by PE and one additional infusion of rituximab. 10 months after transplantation, he still has complete remission from recurrent nephrotic syndrome. Patient 2 also developed significant proteinuria, but 1 day after a second kidney transplantation. Nephrotic syndrome persisted despite 27 sessions of PE and cyclophosphamide therapy. At 13 months after transplantation, he received four infusions of rituximab (375 mg/m(2)), but this was ineffective.

CONCLUSION

There is a need to demonstrate whether or not rituximab therapy is of interest to prevent and to treat nephritic syndrome in renal-transplant patients who suffer from FSGS.

Tolerability of enteric-coated mycophenolate sodium to 1 year in combination with cyclosporine and corticosteroids in renal transplant recipients

Enteric-coated mycophenolate sodium (EC-MPS) is therapeutically equivalent to mycophenolate mofetil, but delays release of mycophenolic acid until it reaches the small intestine. De novo renal transplant patients taking part in a 12-month, multicenter, randomized study received cyclosporine microemulsion (CsA-ME, early or delayed to day 6), EC-MPS, steroids, and interleukin-2 antagonist induction. Tolerability data relating to EC-MPS are reported. Ninety-seven patients were randomized to early CsA-ME and 100 patients to delayed CsA-ME. Median daily dose of EC-MPS was 1440 mg at all time points throughout the 12-month period. The most frequently reported adverse events were constipation, anemia, urinary tract infection, abdominal pain, leukopenia, and cytomegalovirus infection; there were four malignancies. Fifty patients (24.6%) discontinued EC-MPS prematurely by 12 months, including 42 patients (84%) who discontinued owing to adverse events. No patient discontinued treatment because of gastrointestinal adverse events. Two-thirds of patients (137 [67.5%]) maintained full EC-MPS dose throughout the 12-month study and did not require any dose reduction or dose interruption. EC-MPS is well tolerated in de novo renal transplant recipients when administered in combination with CsA-ME and steroids, with low rates of dose reductions or interruptions. Gastrointestinal adverse events were responsible for dose reduction or interruption in only 5% of patients.

Thrombotic microangiopathy in a sirolimus-treated renal transplant patient receiving gemcitabine for lung cancer

BACKGROUND

Many etiologies lead to thrombotic microangiopathy (TMA), amongst which are antineoplastic chemotherapies. Gemcitabine, a nucleoside analogue, has been approved for the treatment ofbladder and advanced non-small cell lung carcinomas (NSCLC). The reported incidence of gemcitabine-associated TMA in the literature is low, ranging from 0.015-0.31%.

METHODS

Herein, we describe the first reported case of gemcitabine-induced TMA in a renal transplant patient. This occurred in a 54-year-old male transplant recipient undergoing sirolimus-based immunosuppression. In February 2005, he was diagnosed to have NSCLC, for which he received dual chemotherapy, including carboplatin and gemcitabine. After the third cycle he developed TMA.

RESULTS

On admission, he presented with weakness, edema, normal blood pressure, leucopenia (2440/mm3), thrombopenia (11,000/mm3), hemolytic anemia with hemoglobin at 8 g/dl, schistocytes between 18-33% per hundred, increase in lactate dehydrogenase at 600 IU/l (N <380), and decreased haptoglobin at 0.29 g/l. Renal function was stable: serum creatinine was 1.3 mg/dl, albuminemia 30 g/l, proteinuria was present at 3 g/l in association with microscopic hematuria, and sirolimus trough level was 6.4 ng/ml. Treatment included infusions of fresh frozen plasma, withdrawal of sirolimus, which was replaced by mycophenolate mofetil, and suspension of chemotherapy. He fully recovered from TMA within 4 weeks. The concomitant use of sirolimus, which inhibits vascular endothelial growth factor, plus gemcitabine may have resulted in TMA.

Hépatite à syphilis et transplantation hépatique

We report a case of secondary syphilis hepatitis in a liver-transplant patient. This homosexual male patient presented, 15 years after orthotopic liver transplantation, with non-squamous papulomacular rash, mild cytolysis, and anicteric cholestasis. Laboratory tests showed syphilis seroconversion with a venereal diseases research laboratory (VDRL) titer of 1/256, a Treponema pallidum hemaglutination assay (TPHA) of 1/5120, and a positive IgM fluorescent Treponemal antibody absorbance (FTA-abs). A liver biopsy performed 13 months after the diagnosis showed low-grade hepatitis with a Metavir score of A1F1; it also showed non-specific portal moderate inflammation consisting primarily of neutrophils, with no evidence of cholestasis. He was given benzathine-penicillin at 2,400,000 IU with a transient increase in prednisolone doses. Cytolysis rapidly, and cholestasis progressively disappeared. IgM FTA-abs became negative, whereas VDRL and TPHA titers decreased slightly over time.

Predictive factors for cytomegalovirus infection after orthotopic liver transplantation using an ultrasensitive polymerase chain reaction assay

The predictive factors for cytomegalovirus (CMV) infection in de novo liver transplant patients were determined at 3 months posttransplantation. We included all consecutive patients except those who died or who had lost their graft within 1 month posttransplant. We recorded both donor (D) and recipient (R) data. Immunosuppression utilized tacrolimus, steroids, with or without mycophenolate mofetil, and/or induction therapy with anti-CD25 monoclonal antibodies. CMV prophylaxis was administered only to those at high risk of CMV infection, namely, D+/R- patients. These cases received intravenous ganciclovir at 500 mg/d for the first 2 weeks followed by oral ganciclovir at 500 mg for the following 3 months. The median time to CMV infection was 1 month. The significant predictive factors for CMV infection were D/R CMV status, (P = .002): D+/R+ versus other patients (P = .01), D-/R- versus other patients (P = .002), D+ versus D- (P = .009). In addition infection was associated with the original liver disease (hepatitis C virus infection or alcohol-related cirrhosis; P = .03), R+ vs. R- (P = .03), donor age (<45 or >45 years; P = .01), lymphocyte count at M2 (< or >1300/mm(3); P = .02), hemoglobin levels at 1 and 3 months, and platelet and white blood cell counts at day 7. The independent predictive factors were recipient CMV sero-status (R+ vs R-; odds ratio = 10.2), donor age >45 years (odds ratio = 11.4) and lymphocyte count at M2 <1300/mm(3) (odds ratio = 7.33). This study showed that the major factors associated with CMV infection were recipient CMV status, donor age, and lymphocyte count.