Kidney allograft and patient survival in type I diabetic recipients of cadaveric kidney alone versus simultaneous pancreas kidney transplants: a multivariate analysis of the UNOS database

Simultaneous pancreas-kidney transplant (SPK) is now a common treatment for insulin-dependent diabetic patients with end-stage renal disease. Renal graft survival rates after SPK have been less well studied. This study compared the kidney survival results for 3642 SPK and 2374 cadaveric renal transplants (CRT) in type I diabetic patients at 112 US transplant centers reported to UNOS during 1994 through 1997. The analysis included follow-up information through September 2000. The kidney graft survival rates were significantly lower among recipients of CRT compared with SPK recipients (P < 0.001). Patients who received SPK were younger, less often sensitized, transplanted after shorter periods on dialysis, and less often black. The donors of SPK organs were younger, more often died from head trauma, were less often female, and more often black. SPK renal grafts were transplanted with a shorter cold ischemia time to more poorly HLA-matched recipients. After adjustment of these and other factors, whether a patient was recipient of CRT or SPK was not associated with increased risk of kidney graft failure or patient death. SPK recipients experienced half the rate of delayed kidney function (11% versus 23%) but nearly double the rate of rejections during the initial hospitalization (15% versus 9%) compared with CRT recipients. SPK was associated with better renal allograft survival compared with CRT, despite a higher rate of renal allograft rejection. This observation was explained by favorable donor and recipient factors in the SPK group. After controlling for these factors, SPK provided no protective or detrimental effect on short-term renal allograft or patient survival.

Posttransplantation lymphoproliferative disorder presenting as a unilateral leg mass 10 years after kidney transplantation

Epstein-Barr virus (EBV)-associated lymphoproliferative disorder is a well-known complication of solid organ transplantation. The risk factors include type and degree of immunosuppression and EBV status of the donor and recipient before transplantation. The manifestations of posttransplantation lymphoproliferative disorders are myriad, from subtle findings such as tonsillar hypertrophy to fulminant manifestations such as hepatocellular failure and death. Here we report an unusual presentation of posttransplantation lymphoproliferative disorder as unilateral leg swelling in a 68-year-old man 10 years after kidney transplantation. The patient had detectable EBV-DNA by polymerase chain reaction in the peripheral blood and EBV messenger RNA by in situ hybridization in biopsy tissue. The patient's tumor did not respond to reductions in immunosuppressive medication, intravenous immunoglobulin, ganciclovir, and rituximab. Eventually the patient responded to CHOP (cyclophosphamide, Oncovin [vincristine, Eli Lilly, Indianapolis, IN], prednisone, and doxorubicin) therapy. He is currently 2 years posttreatment, with a serum creatinine of 0.8 mg/dL, on no immunosuppression.

Hepatitis C therapy with long term remission after renal transplantation

Hepatitis C virus infection (HCV) is common in patients with end-stage renal disease (ESRD) and long observation periods have shown the detrimental effect of HCV infection on patient and graft survival after renal transplantation. At present, interferon is the most important agent for the treatment of hepatitis C in ESRD; however, limited information exists concerning the long-term response of patients who undergo renal transplantation after successful antiviral therapy. We describe the evolution of HCV infection in a dialysis patient with hepatitis C who was successfully treated with interferon alpha and then underwent renal transplantation. He received aggressive immunosuppression during the induction phase and for allograft rejection; however, regular screening showed complete absence of biochemical and virological relapse of HCV over a 6-year post-transplantation period. We conclude that interferon can offer excellent response in selected dialysis patients with hepatitis C. Alternative strategies with newer antiviral agents are currently under active investigation.

Transplanting kidneys from donors with prior hepatitis B infection: one response to the organ shortage

While the number of cadaveric organ donors remains relatively stable, the number of patients awaiting transplantation continues to increase, creating a shortage of donor organs. To address this imbalance, there is interest in transplanting organs formerly considered marginal or undesirable. Thus, more organs are currently transplanted from living donors, older donors, hemodynamically unstable donors, non-heart-beating donors and donors with markers of prior hepatitis B virus (HBV) infection. A large number (up to 93.8%) of liver transplant seronegative recipients from anti-HBc antibody positive donors have acquired HBsAg after liver transplantation in the absence of immunoprophylaxis. Based on experience in liver transplantation programs, transmission of HBV from donors without HBsAg but with antibody to HBV core antigen (anti-HBc), although conventionally defined as evidence of resolved infection, can have adverse consequences on both graft and recipient. On the contrary, HBV appears to be in-frequently transmitted from HBsAg negative/anti-HBcAb positive kidney donors: the incidence of de novo HBsAg seropositivity after renal transplantation ranges between 0 and 5.2%. A significantly higher incidence of anti-HBc antibody seroconversion (without developing HBsAg) after renal transplantation with anti-HBc antibody positive donors was seen. However, anti-HBc antibody positive renal allografts should be considered, especially for recipients who have been successfully immunized with HBV vaccine. Prospective long-term studies are in progress to assess the risk of de novo HBV infection (HBsAg seroconversion) in renal transplant recipients who have not been successfully immunized with vaccine against HBV.

Treatment of active cytomegalovirus disease with oral ganciclovir in renal allograft recipients: monitoring efficacy with quantitative cytomegalovirus polymerase chain reaction

Treatment regimens of patients with active cytomegalovirus (CMV) disease require 2-3 weeks of intravenous ganciclovir (GCV) with/without CMV hyperimmune globulin. Oral GCV is effective as a prophylactic agent in prevention of CMV disease. Here we explored the utility of oral GCV as a treatment of active CMV disease. Fifteen renal allograft recipients (CMV donor+/recipient- [53%], CMV donor+/recipient+ [40%] or CMV donor-/recipient+ [7%]) developed active CMV disease. Cytomegalovirus polymerase chain reaction (CMV-PCR) tests were performed at the time of presentation and patients were treated with oral ganciclovir 1 g tid (adjusted for renal function). Patients were monitored for efficacy of treatment by assessment of clinical symptoms and CMV-PCR. Treatment was continued until the CMV-PCR copy number was negative and symptoms resolved. The mean CMV-PCR copy number at the time of diagnosis was 580 copies/microg DNA (nl: < 5 copies/microg DNA). After 5-7 days of treatment, the mean copy number was 65 copies/microg DNA. Fourteen of 15 patients responded well to oral ganciclovir, with complete resolution of clinical symptoms and eradication of CMV-PCR positivity. One patient did not respond to oral ganciclovir therapy due to probable noncompliance. Our data suggest that oral ganciclovir treatment, coupled with careful CMV-PCR monitoring, may be a reasonable alternative to long-term intravenous ganciclovir.

Treatment of parvovirus B-19 (PV B-19) infection allows for successful kidney transplantation without disease recurrence

Parvovirus B 19 (PV-B19) has emerged as a cause of glomerulopathy in native and transplanted kidneys. Disease recurrence is less well described. The clinical and pathological spectrum of PV-B19 infection can be quite variable and therefore easily missed. There are no data regarding the safety of transplantation in PV-B19-infected patients. We diagnosed a kidney transplant patient with recurrent PV-B19 infection and collapsing glomerulopathy (CG) on renal biopsy. Retrospective analysis of stored serum showed that PV-B19 DNA was present prior to the transplant. The patient was treated with intravenous immunoglobulin (IVIG), and eventually the virus was successfully eradicated after allograft loss and discontinuation of immunosuppressive medications. The patient subsequently received her fourth kidney transplant. Polymerase chain reaction (PCR) for PV-B19 DNA was negative on multiple occasions for approximately 1 year prior to her transplant. The patient is now 22 months post transplantation, quarterly serum PCRs continue to be negative for PV-B19 DNA despite reinstitution of immunosuppressive therapy. The patient's renal function remains stable with a serum creatinine of 0.9 mg/dL and a serum albumin of 4.2 g/dL. Successful diagnosis and treatment of PV-B19 viremia appears to allow for successful transplantation without evidence of disease recurrence. Since PV-B19 can cause significant morbidity post transplant, it is important to screen potential transplant candidates at risk for PV-B19 infection pre transplant. Careful surveillance post transplantation is necessary to identify disease recurrence so that early treatment can be initiated.

Impact of hepatitis B core antibody status on outcomes of cadaveric renal transplantation: analysis of United network of organ sharing database between 1994 and 1999

BACKGROUND

Organ shortage continues to be a major problem in transplantation. The use of organs from marginal donors who are hepatitis B surface antigen (HBsAg) negative and hepatitis B core antibody (anti-HBc Ab) reactive (+), could increase the donor pool substantially. Little information is available about the effects of anti-HBc Ab (+) donor status on viral transmission, and graft and patient survival. To address these issues, an analysis was performed using the United Network of Organ Sharing cadaveric kidney transplant database between 1994 to 1999.

METHODS

All cadaveric kidney transplants performed between 1994 to 1999 with negative HBsAg serology were evaluated. Viral transmission, and graft and patient outcomes were measured. The analysis included follow-up information in the United Network of Organ Sharing database through September 2000. A multivariate analysis was performed, using known confounding factors that may affect the outcomes in donors and recipients who were designated as (+) or (-) (D+/R+, ++D+/R-, D-/R-, and D-/R+) according to their anti-HBc Ab status.

RESULTS

Univariate analyses showed that graft and patient survival rates were statistically significantly lower in D+/R- compared with those who were D-/R-. However, multivariate regression analyses showed that neither donor nor recipient anti-HBc Ab status influenced the risk of graft failure or patient death after adjustment for other factors. Anti-HBc Ab (+) kidneys resulted in a higher incidence of anti-HBc antibody seroconversion but this was not associated with a higher incidence of HBsAg detection.

CONCLUSION

We conclude that renal allografts from anti-HBc Ab (+) donors should be considered for transplant especially in successfully immunized recipients.

Comorbidity assessment in hemodialysis and peritoneal dialysis using the index of coexistent disease

The purpose of this paper is to describe the ICED, summarize outcomes of prior studies in which it was used, and describe the adaptations that have lead to the present instrument. We will then demonstrate its use in quantifying the burden of comorbid conditions in a sample of hemodialysis and peritoneal dialysis patients from our center, and show the relationship between ICED levels and outcomes in peritoneal dialysis patients.

The role of cytokines and cytokine gene polymorphism in T-cell activation and allograft rejection

INTRODUCTION

Cytokines are largely responsible for the regulation of immunoregulatory events and therefore play an important role in transplantation immunology. Recent advances in genetics have made it possible to study the role of cytokine gene polymorphisms in allograft rejection.

METHODS

This review describes studies that have analysed genetic variants in relation to renal disease and transplantation.

RESULTS AND CONCLUSION

Polymorphism of cytokine gene promoters can significantly influence the level of cytokine production, which in turn affects the amount of immunosuppression needed. It is possible that in future, genotyping of transplant recipients with respect to their cytokine gene polymorphisms may help determine their risk of allograft rejection, and thus, provide a guide to individualised immunosuppression in the post-transplant period.