Prevalence of hepatitis C virus infection and related risk factors among Iranian haemodialysis patients

Hepatitis C virus (HCV) infection is common among patients undergoing haemodialysis, and liver disease is an important cause of morbidity and mortality in this population. Management of HCV-related liver disease is a major health concern in patients with end-stage renal disease (ESRD) undergoing haemodialysis. To investigate the prevalence of HCV infection in patients on haemodialysis and its associated risk factors, we conducted a prospective case series study of 838 patients on haemodialysis in Tehran, Iran. Patients were selected randomly (cluster sampling) and all were screened for anti-HCV antibodies, using ELISA 3rd generation and confirmed by using RIBA 2nd generation. We found that 111 patients (13.2%) were infected. By applying univariate analysis, longer duration on haemodialysis (P = 0.000), more weekly dialysis sessions (P = 0.03), history of blood transfusion (P = 0.03) and history of previous renal transplantation (P = 0.01) were found to be associated with a higher rate of HCV infection. Multivariate analysis revealed that only length of time on dialysis (P = 0.000) and history of blood transfusion (P = 0.02) were significantly associated with HCV infection. The more the units transfused, the higher the rate of HCV infection. Our results suggest that early transplantation and avoidance of blood transfusion, as much as possible, are the two most important practical interventions to reduce the HCV exposure rate in our patients on haemodialysis.

Renal allograft in a professional boxer

Significant health benefits result from regular physical activity for kidney transplant recipients. Nevertheless, some adverse effects also have been shown to be associated with highly intensive exercises. We report a kidney transplant professional boxer whose kidney allograft has remained in good health, despite his violent sport activities.

Outcome of kidney transplantation in type 1 and type 2 diabetic patients and recipients with posttransplant diabetes mellitus

INTRODUCTION

We aimed to assess the effects of different types of diabetes mellitus (DM) on patients receiving living donor kidney allografts.

MATERIALS AND METHODS

A total of 111 kidney transplant patients with DM and 111 randomly selected kidney transplant recipients without DM were enrolled in the study. The characteristics of the kidney allograft recipients and the allograft and patient outcomes were assessed and compared between 4 groups of kidney recipients without DM and patients with type 1 DM, type 2 DM, and posttransplant DM.

RESULTS

Of the 111 patients with DM, 36 (32.4%), 20 (18.0%), and 55 (49.6%) had been diagnosed with type 1 DM, type 2 DM, and posttransplant DM, respectively. Diabetic patients had significantly higher rates of rejection episodes (P = .049) and suffered more frequently from delayed graft function (P = .03) compared to the kidney recipients in the control group. Patient and allograft survival rates were significantly lower in the patients with DM (regardless of their DM type) compared to the nondiabetic patients (P = .03 and P = .04, respectively). Prominently, type 1 DM had significantly adverse effects on patient and allograft survival. Patients with posttransplant DM had a relatively better patient survival compared to those with type 1 DM and type 2 DM.

CONCLUSION

We found that kidney recipients with DM, especially preexisting DM, had worse patient and graft survival rates compared to the nondiabetics. These findings suggest that kidney transplant patients presenting with any type of DM should be more closely followed.

Invasive fungal infections following renal transplantation: a review of 2410 recipients

BACKGROUND

Organ transplant recipients, on long-term graft preserving immunosuppressive therapy, are at increased risk for life threatening opportunistic fungal infections.

MATERIAL/METHODS

In order to evaluate the incidence of invasive fungal infections (IFIs) and to identify the most common fungal pathogens, we conducted a retrospective study on 2410 ESRD cases undergone living kidney transplantation in three transplant centers between 1998 and 2008.

RESULTS

IFIs developed in 21 recipients (0.87%), 17 male and 4 female. Their immunosuppression was cyclosporine based. The mean age of patients was 48+/-10 (ranged from 32 to 67) years. Diagnosis was made by radiological findings, positive blood or bronchoalveolar lavage (BAL) cultures and tissue biopsies. Mucormycosis was the most common cause of IFIs in population studied (n=11), followed by disseminated candidiasis (n=4), aspergillosis (n=3), nocardiasis (n=2) and histoplasmosis (n=1). Pulmonary involvement was dominant (47.6%). The treatment was successful in only 10 patients and the rest died.

CONCLUSIONS

In our large series of kidney transplant recipients, mucormycosis was found to be the most common cause of invasive fungal infection. Prompt diagnosis and treatment are necessary to avoid the life threatening complications and may greatly improve prognosis.

Posttransplantation lymphoproliferative disorders in renal transplant recipients: report of over 20 years of experience

INTRODUCTION

Despite the benefits of immunosuppressive medications to improve graft function, they have several adverse effects, such as development of neoplasms in renal transplant recipients. Posttransplantation lymphoproliferative disorders (PTLDs) are not uncommon complications, so we conducted a study to evaluate the characteristics of affected patients.

METHODS

We enrolled 2117 kidney recipients from June 1984 to March 2004 in order to find pathological and clinical evidence of neoplasms. We collected and analyzed all data on PTLD patients.

RESULTS

Overall there were 46 recipients with different types of neoplasms, among which the most common types were diseases of the skin (24 cases, 52.2%), Kaposi's sarcoma (15 cases, 32.6%), and PTLD (14 cases, 30.4%). The mean (+/- SD) age of PTLD patients at the time of transplantation was 37.86 +/- 9.67 years and 42.8% were women. Median and mean (+/- SD) time interval to PTLD diagnosis were 38.5 and 50.35 +/- 41.7 months, respectively (range 1 to 146 months). Types of PTLD in these patients were kidney lymphoma (14.3%); gastrointestinal (14.3%); brain lymphoma; tonsils; palatine; Hodgkin's lymphoma, large cell lymphoma, and acute lymphoblastic lymphoma (each 7.1%), with 28.6% unspecified types. The 1-, 5-, and 10-year patient survival rates after transplantation were 71.4%, 51.4%, and 44.3%, respectively. Despite discontinuing immunosuppressive therapy in PTLD patients, five of six surviving had graft function up to a mean time of 105.4 +/- 57.6 months after transplantation.

CONCLUSION

Our findings showed that the prevalence of PTLD was 0.66%, which was less than reports from Western countries. The fact that there were surviving grafts for a considerable time despite discontinuing immunosuppressive therapy is of great importance.

Renal transplantation in patients with Bardet-Biedl syndrome

BACKGROUND

Bardet-Biedl syndrome is an autosomal recessive disorder characterized by obesity, polydactyly of hands and feet, retinitis pigmentosa, hypogenitalism, various degrees of intellectual impairment and renal anomalies. Other clinical features include speech disorder, brachydactyly, developmental delay, polyuria/polydipsia, ataxia, poor coordination/clumsiness, diabetes mellitus, left ventricular hypertrophy, hepatic fibrosis, and renal hypoplasia/dysplasia. If spasticity and mental retardation present, it fulfills the criteria for Laurence-Moon-Bardet-Biedl syndrome.

METHODS

Between July 1985 and January 2005, 2,282 kidney transplantations were performed at Labbafinejad Medical Center, of whom 262 were children under 15 years of age (61% males). Among children, five (four females) had Bardet-Biedl syndrome who were transplanted preemptively. Kidneys were taken from living unrelated donors.

RESULTS

All five patients had retinitis pigmentosa and obesity with body mass index up to 39.33 kg/m(2). The cause of end-stage renal failure was reflux nephropathy in one, neurogenic bladder in one, and renal hypoplasia/dysplasia in three patients. The mean age at transplantation was 11 years (range: 6-17 years). Immunosuppressives administered were prednisolone, cyclosporine, and mycophenolate mofetil. All of them suffered at least one episode of acute rejection shortly after transplantation but reversed with methylprednisolone pulses; in the last follow-up, the mean creatinine was 1.2 (range: 0.6 - 2.3 mg/dL). The mean glomerular filtration rate before transplantation was 10 mL/min/1.73 m(2); in the last follow-up it was 79 (range: 38-137).

CONCLUSION

Renal transplantation is a safe and successful procedure and renal replacement therapy of choice in patients with Bardet-Biedl syndrome and end-stage renal failure, but special attention should be paid to body mass index and steroid-free immunosuppression if other suitable drugs, such as sirolimus and basiliximab are affordable.

Posttransplant malignancies and their relationship with human leukocyte antigens in kidney allograft recipients

INTRODUCTION

Kidney transplant recipients are at increased risk of cancers, most frequently skin cancers, and in some regions, Kaposi sarcoma and non-Hodgkin lymphoma. We sought to investigate the associate of the most frequent malignancies among our patients with human leukocyte antigens (HLAs).

MATERIALS AND METHODS

We performed a retrospective study on 44 kidney allograft recipients who had posttransplant malignancy and 44 kidney allograft recipients without malignant lesions (control group). All of the patients had been treated by immunosuppressive regimens including cyclosporine plus prednisolone or cyclosporine, prednisolone, and mycophenolate mofetil. Data on HLA typing were achieved from their transplant records.

RESULTS

There were 15 patients (34.1%) with Kaposi sarcoma; 13 (29.6%) with non-Hodgkin lymphoma, 6 (13.6%) with skin cancer, 2 (4.5%) with ovary cyst adenocarcinoma, and 8 (18.2%) with other tumors. The mean interval from transplantation to diagnosis of malignancy was 15.3 month. Twelve patients died of cancer during the follow-up (mean, 12.3 years). No significant difference was noted in the age, sex, and time of transplantation between these patients and those in the control group. Kaposi sarcoma was associated with HLA-CW4 (P = .03) with an odds ratio of 4.96 (95% confidence interval, 2.90 to 8.12).

CONCLUSIONS

We found HLA-CW4 as a risk factor of Kaposi sarcoma in kidney allograft recipients. Screening for malignancies after kidney transplantation sounds very important with special attention to the specific environmental and genetic factors in each population.

Sun protection in Iranian kidney transplant recipients: knowledge, attitude and practice

BACKGROUND

Kidney transplant recipients (KTR) are at increased risk of developing skin cancer. The purpose of this study was to evaluate the knowledge, attitude, and practices of KTRs regarding skin cancer after transplantation and to identify the role of education in motivating these patients to practice sun-protective behaviours.

METHODS

Two hundred and fifty KTRs in a referral hospital were interviewed using a questionnaire. All patients received a skin cancer information booklet after completion of the questionnaire. Six months later, these patients were invited and interviewed again about their skin cancer-prevention practices.

RESULTS

The patients consisted of 153 men and 97 women patients with a mean age of 35.9 +/- 14.2 years and mean of 49.7 +/- 53.1 months after their transplantation. A total of 102 patients (40.8%) mentioned receiving skin care advice after transplantation. Nonetheless, the majority of patients did not have appropriate skin cancer-prevention practices. Patients who had received advice on skin care after transplantation were significantly more likely to do skin self-examination (chi-squared test; P < 0.001) and have less sun exposure daily (Mann-Whitney test; P = 0.019) than those who did not. Half of the patients (125 patients) participated in the second part of the study 6 months after the first interview and providing skin care instruction booklet. Although regular skin self-examination and sunscreen use was significantly increased (P = 0.006 and P = 0.001, respectively), but daily sun exposure was not changed significantly (P = 0.64).

CONCLUSIONS

Post-transplantation education does not necessarily lead to patients' awareness about their increased risk of skin cancer, and subsequent motivation to practice effective sun protection. Health professionals and dermatologists in particular need to establish better methods of dissemination of information, repeatedly and at the proper time.

An established rat model of inducing reversible acute tubular necrosis

INTRODUCTION

Acute tubular necrosis (ATN) is a challenging problem that still requires to be studied in animal models. Our aim was to prepare an established experimental model of inducing reversible ATN in rats by determining the optimum duration of ischemia induction to the kidney.

MATERIALS AND METHODS

Twenty-four hour after nephrectomy of the right kidney and clamping the pedicle of the left kidney for durations ranging from 10 to 55 minutes, the kidney function and the histologic changes were evaluated. Accordingly, the optimum duration of clamping was determined and in the next step, it was considered for induction of reversible ATN in another group of rats. This group was followed up for 14 days and the pathologic course and function of the kidney were observed.

RESULTS

Reversible ATN developed by 47-minute clamping of the renal pedicle. Blood urea nitrogen and serum creatinine levels were elevated up to threefold within 24 hours after the induction of ischemia and they decreased to their reference ranges after 12 and 6 days, respectively. In the histologic study of the kidneys, the least extend of injury was noted by the 14th day following the ATN induction. Even on the 14th day of the follow-up, some signs of ATN remained indicating that the tissue regeneration was not complete yet.

CONCLUSIONS

To integrate the experimental models of ATN, a rat model with 47-minute clamping of the renal pedicle for induction of ischemia seems appropriate. The resultant ATN remains for a long duration, while kidney function is alleviated.

Hyperlipidemia After Renal Transplantation and Its Relation to Graft and Patient Survival

INTRODUCTION

Hyperlipidemia is a multifactorial event that frequently develops following renal transplantation and may worsen the patient's prognosis. The aim of this study was to evaluate the incidence and concomitant factors for hyperlipidemia.

METHODS

We studied 687 renal transplant recipients from 1988 to 2004 using a cross-sectional design to determine the frequency of hypercholestrolemia and hypertriglyceridemia before and 1 month to 1 year after renal transplantation, to evaluate its relation to patient and graft prognosis in two medical centers in Iran. Cyclosporine was the constant part of immunosuppressive treatment in all study subjects.

RESULTS

One and 5-year graft survival times were 94.23% and 81.34%, respectively. The prevalence of hypercholestrolemia after transplantation was 59.9%. Mean (+/- 2 SE) serum cholesterol levels before and after transplantation were 161.15 +/- 3.81 and 213.83 +/- 4.53 mg/dL respectively (P=.000). Triglycerides levels, were 159.99 +/- 13.08 and 196.28 +/- 19.6 mg/dL respectively. There was no significant correlation between cyclosporine dose, graft and patient survivals, and severity of hyperlipidemia (determined by cholesterol and triglyceride levels).

CONCLUSIONS

Lipid metabolism abnormalities observed in this study were similar to other reports. There was no correlation with patient or graft survival. In addition, there may routes for development of hyperlipidemia other than adverse complications of immunosuppressive drugs.

Calcium and Phosphorus Metabolism Disturbances After Renal Transplantation

INTRODUCTION

Several studies have noted that, despite beneficial correction of abnormalities of mineral metabolism after successful renal transplantation, renal functional recovery is incomplete. Also, persistence of hyperparathyroidism and metabolic acidosis among patients with chronic impairment of graft function together with the use of loop diuretics and immunosuppressive drugs with adverse effects may alter mineral metabolism. We determined calcium and phosphorus levels in recipients.

METHODS

This cross-sectional study enrolled 398 recipients in 2 medical centers in Iran from 1988 to 2004 to evaluate serum calcium and phosphorus levels after 1 month in relation to graft and patient survivals. Cyclosporine was the constant part of the immunosuppressive treatment in all study subjects.

RESULTS

The median follow-up time was 8 months (range, 1-180 months). One and 10-year survival rates of patients were 97.9% and 91.1%. Mean (SD) serum calcium levels before and after transplantation were 8.79 (1.26) and 8.50 (1.39) mg/dL, respectively (P=.020). The mean (SD) phosphate levels before and after transplantation were 6.43 (2.42) and 3.64 (1.71) mg/dL, respectively (P=.000). There was no significant difference in survival considering changes in serum calcium and phosphorus levels. There was no correlation between serum calcium and phosphorus level changes among study patients.

CONCLUSIONS

Despite reports suggesting hypercalcemia as a posttransplantation finding, we did not observe this condition, but, consistent with other reports in this field, we observed a significant decrease in serum phosphorus levels showing correction of this mineral level.

Cyclosporine Trough (C0) and 2-Hour Postdose (C2) Levels: Which One Is a Predictor of Graft Loss?

BACKGROUND

Compared with conventionally measured trough level (C0), cyclosporine 2-hour postdose (C2) concentrations show a better correlation with the area under the curve and acute graft rejection.

OBJECTIVES

We evaluated the relationships of C0 and C2 with long-term graft survival among kidney transplant recipients.

METHODS

In a case-control design, we selected 215 adult kidney recipients. Inclusion criteria were more than 18 years of age at transplantation and at least 6 months of follow-up. The case group consisted of patients with graft loss (n=17) and a control group, patients with functioning grafts (n=198). The C0 and C2 levels for the first 6 months posttransplantation, along with demographic and clinical data, were compared between the two groups using univariate analysis. P<.05 was considered to be significant.

RESULTS

The mean age at transplantation was 40.5 +/- 16.5 years. The mean follow-up duration was 18 +/- 14 months. The mean C0 values for the case and control groups were 257.8 +/- 126.5 and 248.5 +/- 104.4 mumol/L, respectively (P>.05). The values for C2 were 712.7 +/- 273.2 and 886.2 +/- 266.9 mumol/L, respectively (P=.01).

CONCLUSIONS

We observed that C2, but not C0, in the first 6 months posttransplantation were a predictor of long-term graft survival. The findings here in supported the results of other studies that have proposed cyclosporine concentration monitoring by C2 rather than C0 measurements.

Associations of Human Leukocyte Antigen (HLA) haplotypes with risk of developing lymphoproliferative disorders after renal transplantation

BACKGROUND

Genetic susceptibility to lymphomas associated with human leukocyte antigens (HLA) has been broadly reported for many years. In this study, we aimed to evaluate the potential impact of various HLA antigens on the incidence of lymphoproliferative disorders in renal allograft recipients.

MATERIAL/METHODS

In this retrospective cross-sectional study, we analysed data of PTLD patients from two of the major Iranian transplant centers and compared them with 1155 normal kidney recipients. Potential impact of previously reported relevant HLA antigens was assessed. For assessing independent impact of various factors, we used a multivariate proportional hazard analysis using Cox regression.

RESULTS

Patients in the two groups were similar in their age at transplantation. PTLD group was significantly female predominated (61% vs. 33%). chi(2) showed a higher frequency of HLA-BW22 in the PTLD group. HLA-A2, HLA-A11, HLA-B5 and HLA-B35 concomitant with azathioprine based immunosuppression were significantly associated with PTLD occurrence.

CONCLUSIONS

Our findings can further alert us toward the initial signs of PTLDs in high risk kidney allograft recipients. Future prospective studies with larger patient population seem necessary for confirming our findings.

Atherosclerosis after kidney transplantation: changes of intima-media thickness of carotids during early posttransplant period

INTRODUCTION

The aim of this study was to evaluate atherosclerotic changes in the carotid artery following kidney transplantation.

MATERIALS AND METHODS

Twenty-six nonsmoker kidney allograft recipients who did not have cardiovascular disease or diabetes mellitus were enrolled in the study. The carotid intima-media thickness (IMT) was measured at 12 points using B-mode ultrasonography. The mean of the measured values was considered as the patient's IMT. We followed the patients and changes in the carotid IMT were evaluated every 2 months up to the 6th posttransplant month.

RESULTS

The mean age of the patients at transplantation was 41.5 +/- 11.1 years. The mean baseline IMT was 0.84 +/- 0.22 mm. During the follow-up period it reached 0.85 +/- 0.22 mm, 0.87 +/- 0.23 mm (P = .01), and 0.88 +/- 0.24 mm (P = .002) after 2, 4, and 6 months, respectively. The IMT measures significantly correlated with the age and body mass index. Using the IMT cutoff points of 0.75 mm for stroke and 0.82 mm for MI, we found that 57.7% and 68% of the patients were at the risk of stroke at baseline and 6 months after transplantation (P < .001). Also, 46.2 % of the patients were at the risk of MI at baseline that rose to 53.8% at the end of the study (P < .001).

CONCLUSION

Atherosclerosis is an early event after kidney transplantation even in asymptomatic patients and those without major risk factors such as cardiovascular disease, diabetes mellitus, and smoking. Early diagnosis and treatment of atherosclerosis is of utmost importance.

Is preemptive kidney transplantation preferred? Updated study

INTRODUCTION

For eligible patients with end-stage renal disease, the dialysis stage could be bypassed by preemptive kidney transplantation (PKT), when the organ is available. We compared this treatment option with kidney transplantation in patients with pretransplant dialysis (PTD).

MATERIALS AND METHODS

We retrospectively studied on 300 patients who received PKT between 1992 and 2006 from living donors. They were compared with 300 kidney recipients with PTD matched for the time of transplantation that had been on hemodialysis for at least 6 months. Episodes of rejection, graft function, and graft and patient survivals were compared between the two groups.

RESULTS

No significant differences were noted in the sex of the recipients, age and sex of the donors, donor source, and posttransplant immunosuppressive therapy, but posttransplant follow-up was longer (P < .001) and the recipients were older (P < .001) in the PTD group. Seventy-one patients (23.7%) in the PKT group and 64 (21.3%) in the PTD had at least 1 rejection (P = .49). The kidney allografts were functional in 272 (90.7%) kidney recipients in the PKT group and 278 (92.7%) in the PTD group during their follow-ups (P = .30). Five-year graft and patient survival rates were slightly higher in the PTD group, which were not statistically significant (P = .06 and P = .07, respectively).

CONCLUSION

In addition to comparable patient and grretroper aft survivals with the PKT and kidney transplantations after a period of dialysis, PKT eliminates hemodialysis costs and complications. We recommend PKT as a better choice for transplantation whenever possible.

Plasmapheresis in the treatment of early acute kidney allograft dysfunction

OBJECTIVE

To evaluate the efficacy of plasmapheresis (PP) in kidney transplant recipients with acute humoral rejection (AHR).

PATIENTS AND METHODS

A retrospective review was conducted of all kidney allograft recipients who had undergone PP rescue therapy for early acute allograft dysfunction diagnosed as AHR at Shaheed Labbafinejad Medical Center from 1995 to 2002.

RESULTS

Twelve patients (4 men and 8 women; median age, 32 years; age range, 15-68 years) with AHR were treated with PP. The median time from transplantation to AHR was 6 days (range, 2-7 days). PP was performed in 2 to 11 sessions (median, 8.5 sessions) in the patients studied. Eight patients responded to that treatment, and their creatinine value normalized. Those responders were monitored for a median of 162.5 weeks (range, 69.3-484.7 weeks), and all had a functioning allograft during the follow-up period except for 1 patient in whom the graft failed 154 weeks after transplantation. In the 4 remaining patients (nonresponders), the allograft failed within the first posttransplant month. The median time from the acute serum creatinine elevation to the initiation of PP was 6 days in responders and 18.6 days in nonresponders (P = .37).

CONCLUSIONS

We suggest that PP with or without other therapeutic measures may have a role in the salvage of grafts with early acute dysfunction that is resistant to conventional therapy. Our findings indicate that graft survival in patients with AHR who respond to PP can be comparable to that in other kidney recipients.

Living unrelated versus living related kidney transplantation: 20 years' experience with 2155 cases

PURPOSE

To compare the long-term results of kidney transplantation from living unrelated donors (LURDs) with that from living related donors (LRDs).

MATERIALS AND METHODS

From 1984 to 2004, we performed 2155 kidney transplantations of which 374 were from LRDs and 1760 from LURDs. We reviewed and compared the long-term data from these cases.

RESULTS

The LURD group included 64.2% men with an overall mean age of 33.46 +/- 14.61 (range 3 to 76) years. Laparoscopic donor nephrectomy was performed in 329 cases (18.7%) with mean follow-up of 45.68 +/- 46.80 months. The LRD group included 66.5% of male recipients with overall mean age of 28.97 +/- 9.58 (range 9 to 65) years. Laparoscopic donor nephrectomy was performed in 12 cases (3.2%) of LRDs with mean follow-up of 81.15 +/- 67.03 months. One-, 3-, 5-, 10-, and 15-year graft survivals among LRDs were 91.6%, 81.7%, 76.4%, 64.4%, and 48.4%; and for LURDs, 91.5%, 86.7%, 81.4%, 68.2%, and 53.2%, respectively (P = .07). Patient survivals for 1, 3, 5, 10, and 15 years in LRDs were 94.6%, 91.9%, 83%, 79.5%, and 73.9%, and in LURDs were 93.6%, 91.7%, 89.3%, 84%, and 76.4%, respectively (P = .14).

CONCLUSION

The results of living unrelated kidney transplantation upon long-term follow-up with a large number of cases were as good as living related kidney transplantation. The organ shortage can be alleviated by using living unrelated kidney transplantation. To our knowledge this is the largest experience with long-term follow-up reported from one center to date.

Erythrocytosis after renal transplantation: review of 101 cases

Posttransplant erythrocytosis is increasingly recognized as a complication of kidney transplantation. In a retrospective analysis of 500 recipients, we observed 101 patients (20.2%) with persistent elevation of hematocrit value. It was more frequent in men (82.2%) than women (17.8%). It occurred 2 to 50 months after engraftment (mean value was 11.2 +/- 8.9 months), but most often developed in the first 24 months (86%). Spontaneous remission of established erythrocytosis was observed in all cases within 3 to 93 months. It frequently occurred in patients with a well-functioning renal graft; in 82.2% of cases the serum creatinine concentration was less than 1.5 mg/dL. It was 1.5 to 2 mg/dL in 15.8% of patients. There was no correlation between diabetes mellitus and erythrocytosis, compared with a control group. It was more common in patients who received cyclosporine compared to those who were not on cyclosporine. Predisposing factors included male gender, retention of native kidneys, cyclosporine use, and a rejection-free course with a well-functioning renal graft. In conclusion, posttransplantation erythrocytosis, a frequent problem in renal transplant patients, is a self-limited complication that can result in thromboembolic disease.

Kidney retransplantation in comparison with first kidney transplantation

INTRODUCTION

The aim of this study was to depict the outcome of second and third kidney allografts in comparison with first kidney allografts.

METHODS

Among 2150 kidney transplantations are 103 second and 5 third transplantations. Demographic characteristics and survivals of retransplanted patients were compared with a randomly selected group of first kidney recipients, consisting of two cases matched with each retransplanted patient for age, gender, and date of transplantation.

RESULTS

Retransplanted patients consisted of 78 men and 30 women of mean age 32.63 +/- 11.92 years. They had received kidneys from 91 living-unrelated and 17 living-related donors. Median followup was 27 months. One-, 2-, 3-, and 5-year graft survivals were 81.4%, 78.9%, 78.9%, and 73.7% among retransplants, versus 92.9%, 91.5%, 89.8%, and 85.3% in the control group, respectively (P = .0037). Patient survival was 96%, 94.6%, 92.4%, and 87.8% in the retransplant group versus 93.1%, 92.4%, 90.9%, 87.4% in the control group, respectively (P = .63). Also, graft survivals were slightly lower in female compared to male retransplant patients (P = .09). No significant difference in survival rates was seen in different age groups.

CONCLUSION

It seems that kidney retransplantation can yield desirable outcomes, albeit relatively lower graft survivals.

Concomitant nephrectomy of massively enlarged kidneys and renal transplantation in autosomal dominant polycystic kidney disease

OBJECTIVES

We compared perioperative and intraoperative data of patients with end-stage renal disease (ESRD) due to autosomal dominant polycystic kidney disease (ADPKD) who received a renal allograft without native nephrectomy with ADPKD patients who underwent concomitant native nephrectomy of massively enlarged kidneys and renal transplantation to determine whether the latter approach is reasonable and safe.

PATIENTS AND METHODS

From January 1987 to December 2003, 13 patients with ESRD due to ADPKD were stratified as 6 patients who underwent bilateral and 7 patients who underwent unilateral native nephrectomy in conjunction with renal transplantation (group A), versus 20 patients with ESRD due to ADPKD underwent renal transplantation without native nephrectomy (group B). Operative time, need for intraoperative transfusion, time to oral intake, duration of hospital stay, serum creatinine level on the day of discharge, readmission rate, and postoperative complications were compared for both groups.

RESULTS

Mean intraoperative duration was significantly longer for patients in group A, but there was no statistically significant difference in the findings between both groups.

CONCLUSIONS

Concomitant native nephrectomy of massively enlarged kidneys at the time of renal transplantation is reasonable and safe for patients with ESRD due to ADPKD.

Signs and symptoms of cytomegalovirus disease in kidney transplant recipients

PURPOSE

To investigate the range of clinical presentations of cytomegalovirus (CMV) disease in kidney transplant recipients.

MATERIALS AND METHODS

We retrospectively reviewed the records of hundred kidney recipients who developed CMV disease between 1984 and December 2002 for demographic characteristics, laboratory findings, and presenting signs and symptoms.

RESULTS

The most common presentations were elevated serum creatinine in 74 patients, fever in 71, thrombocytopenia in 43, nausea in 32, vomiting in 25, elevated alkaline phosphatase in 24, leukocytosis in 22, and leukopenia in 21. Tissue involvement was relatively rare, but six patients had pneumonia, two had conjunctivitis, and one had vascular dermatitis. Four percent of the patients had received intravenous ganciclovir prophylaxis, and 7% had received oral ganciclovir prophylaxis. Fever was associated with number of hospitalizations (P = .006), elevated creatinine (P = .006), nausea (P = .017), vomiting (P = .031), and previous posttransplantation infections (P < .001). All the patients with conjunctivitis, pneumonia, pulmonary symptoms, and abnormal heart sounds and most of those with arthralgia, nausea, and vomiting were febrile during their CMV disease course.

CONCLUSION

Our findings showed that leukocytosis should be considered as much as leukopenia when CMV disease is suspected. CMV-induced pneumonia is not common in renal transplant recipients compared to other organ transplant recipients. CMV invasion to other tissues is also rare. Finally, fever is a common symptom and important in assessing the severity and prognosis of the disease.

Pregnancy in Kidney Transplant Recipients

PURPOSE

Our aim was to investigate kidney allograft, obstetric, and maternal outcomes in pregnant women undergoing kidney transplantation in our center.

METHODS

Retrospective data on 74 pregnancies in 60 patients were reviewed and completed through phone interviews were compared with information on a control group of female kidney recipients.

RESULTS

Mean age of patients at transplantation was 26.55 +/- 4.72 years and the median interval between transplantation and pregnancy was 27.5 months. Gestational period was 8 months. Live birth was the outcome in 43.2% of pregnancies; 9.5% led to still birth, 24.3% were aborted, and obstetrical data of the remaining were unavailable. Among the 11 patients who became pregnant within 12 months after transplantation, we observed seven live births and four abortions. None of pregnancies that were accompanied by acute rejection episodes (ARE) were successful. Twenty-six patients experienced at least one ARE versus 23 patients of the control group (P = NS). However, the first ARE occurred later in the pregnant group (P = .028). Chronic rejection and graft loss were seen in 24 and 18 study group cases and 17 and 17 control cases, respectively (P = NS). One-, 3-, 5-, and 10-year graft survivals were 100%, 96.5%, 94.5%, and 77.1% in the pregnant group versus 93.2%, 85.7%, 81%, and 64.7% in the control group, respectively (P = .07).

CONCLUSION

Pregnancy in kidney recipients seems to be safe for kidney allograft recipients even within the first year posttransplant. Nonetheless, the outcomes of pregnancy in this group of patients is not always favorable, especially when rejection occurs simultaneously.

Outcome of Kaposi’s Sarcoma and Graft Following Discontinuation of Immunosuppressive Drugs in Renal Transplant Recipients

PURPOSE

Owing to the use of immunosuppressive drugs, renal transplant recipients are at risk for malignancies including Kaposi's sarcoma (KS). Following the diagnosis, physicians tend to decrease the doses of immunosuppressive drugs to lower tumor progression rate. On the other hand, those who receive lower doses of immunosuppressive drugs are at a higher risk for acute rejection. In this study, we evaluated the outcome of KS on renal allografts following discontinuation or decrease in the doses of drugs.

METHODS

Since 1984, 14 (nine men and five women) among 2000 cases of renal transplantation have been diagnosed as KS. In 11 patients, cyclosporine was completely discontinued, the dosage was decreased to half of the initial dose in other cases. Except one case, we discontinued either azathioprine or mycophenolate mofetil.

RESULTS

During 57 months of follow-up on average, the serum creatinine level remained normal in 10 but increased in four cases. Kidney function deteriorated in two of these four patients at the beginning of study. Three patients died with normal serum creatinine levels. Discontinuation of immunosuppressive drugs caused complete remission of KS in all patients except one who received chemotherapy.

CONCLUSION

Discontinuation of immunosuppressants following the diagnosis of KS caused complete remission of this cancer in almost all patients and seemed to be relatively safe for kidney graft function.

Renal Allograft Accumulation of Technetium-99m Sulfur Colloid as a Predictor of Graft Rejection

Differentiation between rejection (the most common cause) and many other possibilities for detrimental effects on graft function represents a difficult issue to diagnose the cause of renal allograft dysfunction. This study was designed to determine whether technetium-99m sulfur colloid (TSC) accumulation predicted graft rejection. We prospectively studied 54 episodes of allograft dysfunction in 53 kidney transplant recipients who underwent TSC scintiscanning and graft biopsy. Visual analysis of TSC uptake compared uptake, in the allograft with that in the marrow of the fifth lumbar vertebra (L5). A 3+ result meant that allograft uptake was greater than L5 marrow uptake; 2+, the same; 1+, less and finally 0, no allograft uptake. Transplant accumulation of 2+ or more was considered consistent with rejection (P = .01). Allograft biopsies interpreted based on the Banff Working Classification showed rejection in 45 of 54 renal biopsies with 42 the biopsy-proven rejection episodes showing at least 2+ graft uptake. Furthermore, this nuclear medicine technique had a sensitivity of 93.3%, a specificity of 44.4%, a positive predictive value of 89.3%, a negative value of 57.1% and an efficiency of 83.3% for the diagnosis of renal allograft rejection.