Factors influencing kidney transplantation rates: a study from the ERA Registry

BACKGROUND

Large international differences exist in kidney transplantation (KT) rates. We aimed to investigate which factors may explain the total, deceased donor, and living donor KT rates over the last decade.

METHODS

KT experts from 39 European countries completed the Kidney Transplantation Rate Survey on measures and barriers and their potential effect on the KT rate in their country. In the analyses, countries were divided into low, middle, and high KT rate countries based on the KT rate at the start of study period in 2010.

RESULTS

Experts from low KT rate countries reported more frequently to have taken measures regarding staff, equipment and facilities to increase total KT rate compared with middle and high KT rate countries. For donor type specific KT, the largest international differences in measures taken were reported for deceased donor KT, with middle and high KT rate countries taking more measures, such as the use of expanded criteria donor kidneys, the presence of transplantation coordinators, and (inter)national exchange of donor kidneys. Once a measure was taken, experts' opinion on its success was similar across the low, middle and high KT rate countries. Experts from low KT rate countries more often reported potential barriers, such as patients' lack of knowledge and distrust in the health care system.

CONCLUSIONS

In particular in low KT rate countries, KT rate might be stimulated by optimizing staff, equipment, and facilities. In addition, all countries may benefit from deceased and living donor specific measures.

POS0253 PERSONALIZED RISK EVALUATION FOR OUTCOME PREDICTION IN ANCA ASSOCIATED VASCULITIS (AAV) USING LATENT CLASS ANALYSIS AND MACHINE LEARNING

Background

ANCA associated vasculitides (AAV) are a heterogeneous group of rare diseases with unknown etiology. In the most severe cases AAV can lead to end stage kidney disease or death. Since etiology and detailed pathogenesis of AAV is not known, the prediction of disease outcome at the time of diagnosis is challenging. Thus, there is an unmet need for tools to identify patients with the highest risk of organ dysfunction and death and apply effective personalized therapy.

Objectives

The aim of this work was to search for tools allowing outcome prediction at the time of AAV diagnosis. Early identification of patients, who are likely to develop severe organ dysfunction and death is crucial for appropriate disease management. Induction therapy in AAV relays on immunosuppressive drugs characterized by a high risk of severe side effects. Thus, their administration in high doses should be limited only to individual patients with an especially high risk of poor outcome.

Methods

We applied here two methods of identification of AAV patients at risk to develop severe organ dysfunction and death. First method (latent class analysis [LCA] followed by logistic regression) was meant to subcategorize patients and identify a subgroup at subjects at risk to develop chronic renal replacement therapy (CRRT) and death [1]. Second, served to assess individual poor outcome risk and was based on two machine learning (ML) classifiers, which by analyzing clinical information allow assigning computed risk for CRRT and death in an individual patient allowing to identify subjects with high risk of chronic replacement therapy (CRRT) and death. We have evaluated a number of different approaches to build the ML models (including logistic regression, support vector machines, random forests), and obtained the best results for the gradient boosting algorithm implementation called LightGBM [2]. It works as a sequential ensemble of so-called weak learners (decision trees) finally combined in a one prediction model. Both analyses were based on retrospective data from Polish national AAV registry (POLVAS) [3] including presently 565 GPA and 135 MPA patients. The parameters used were: demographic data and laboratory parameters, specific organ involvement, ANCA specificity and time between selected stages of the disease.

Results

LCA used on our AAV cohort identified four subphenotypes – three already previously proposed - and revealing a fourth clinically relevant subphenotype. This new subphenotype includes only GPA patients, usually diagnosed at a younger age as compared to other groups, and characterized by multiorgan involvement, high relapse rate, relatively high risk of death, but no end-stage kidney disease. Logistic regression analysis revealed significant differences in the risk of CRRT and death between those subphenotypes – the worst prognosis was found for severe MPO AAV. On the other hand, using ML approach we obtained an individual prediction model with potentially relevant clinical performance (ROC AUC of 0.85 for CRRT and 0.82 for death).

Conclusion

We consider results obtained encouraging. They may offer a new insight into AAV course based on data available at diagnosis, and create a solid foundation for potential clinical decision support system.

References

[1]Wójcik K et al. Subphenotypes of ANCA-associated vasculitis identified by latent class analysis. Clin Exp Rheumatol. 2021 Mar-Apr;39 Suppl 129(2):62-68.

[2]Ke G, at al. Light GBM: A Highly Efficient Gradient Boosting Decision Tree. Advances in Neural Information Processing Systems 30 (NIPS 2017), pp. 3149-3157.

[3]Wójcik K et al. Clinical characteristics of Polish patients with ANCA-associated vasculitides-retrospective analysis of POLVAS registry. Clin Rheumatol. 2019 Sep;38(9):2553-2563.

Acknowledgements

This work was supported by a grant from Polish National Science Center UMO-2018/31/B/NZ6/03898

Disclosure of Interests

None declared

AB0820 INFLUENCE OF ANCA ANTIBODIES ON DEMOGRAPHIC AND CLINICAL CHARACTERISTIC OF AAV

Background:

ANCA associated vasculitides (AAV) are a heterogeneous group of rare diseases with unknown etiology and the broad clinical spectrum ranging from life-threatening systemic disease, through single organ involvement to minor isolated skin changes. Unfortunately the clinical classification, ANCA specificity or genetic characteristics alone is not able to categorize AAV patients in a satisfactory manner. As a consequence advanced statistical techniques were used to identify and stratify AAV subphenotypes [1, 2]. Here we have analyzed influence of the ANCA type on clinical manifestations and demographic characteristics in various types of AAV, based on data from the POLVAS registry

Objectives:

We decided to retrospectively analyze a large cohort of Polish AAV patients deriving from several referral centers – members of the Scientific Consortium of the Polish Vasculitis Registry (POLVAS) – and concentrate on demographic and clinical characteristics of anti-PR3 and anti-MPO positive patients regardless of their clinical diagnosis.

Methods:

We conducted a systematic multicenter retrospective study of adult patients diagnosed with AAV between Jan 1990 and Dec 2016. Patients were enrolled by 9 referral centers. We analyzed dichotomous variables: gender; ANCA status – anti-PR3+ or anti-MPO+, ANCA negative; organ involvement - skin, eye, ENT, respiratory, heart, GI, renal, urinary, CNS, peripheral nerves and polytomous variable (number of relapses), supported by quantitative covariates (e.g., age at diagnosis, CRP at diagnosis, maximal serum creatinine concentration ever)[3].

Results:

MPO-positive patients (both GPA and EGPA phenotype) were older at the time of diagnosis with a substantial percentage diagnosed > 65 years of age, and with high rate of renal involvement. Interestingly, while in the whole group of patients diagnosed with EGPA male to female ratio was 1:2, the MPO+ EGPA patients showed M:F ratio of 1:1.

The analysis of ANCA negative AAV reveled significant differences in GPA, ANCA negative group is characterized with significantly lower frequency of renal involvement compared to rest GPA (11,5% vs 63,7%) p<0,05 what should be emphasized ANCA negative AAV never lead to ESRD (end stage renal disease) or even transient dialysis.

Conclusion:

ANCA specificity is indispensable as a separate variable in any clinically relevant analysis of AAV subcategories. MPO+ group is characterized by older age at time of diagnosis, male to female ration 1:1, kidney involvement, and shows more homogenous clinical phenotype than PR3+ AAV patients. In our group ANCA negative AAV never lead to ESRD (end stage renal disease) or even transient dialysis.

References:

[1]Mahr A, Specks U, Jayne D. Subclassifying ANCA-associated vasculitis: a unifying view of disease spectrum. Rheumatol Oxf Engl 2019;58:1707–9. https://doi.org/10.1093/rheumatology/kez148.

[2]Wójcik K, Biedroń G, Wawrzycka-Adamczyk K, Bazan-Socha S, Ćmiel A, Zdrojewski Z et al. Subphenotypes of ANCA-associated vasculitis identified by latent class analysis. Clin Exp Rheumatol. 2020 Sep 1. Epub PMID: 32896241.

[3]Wójcik K, Wawrzycka-Adamczyk K, Włudarczyk A, Sznajd J, Zdrojewski Z, Masiak A, et al. Clinical characteristics of Polish patients with ANCA-associated vasculitides—retrospective analysis of POLVAS registry. Clinical Rheumatology. 1 wrzesień 2019;38(9):2553–63.

Disclosure of Interests:

None declared

POS0120 INCIDENCE OF MALIGNANCIES IN PATIENTS WITH GRANULOMATOSIS WITH POLYANGIITIS AND MICROSCOPIC POLYANGIITIS DIAGNOSED BETWEEN 1988 AND 2020

Background:

Antineutrophil cytoplasmic antibody-associated vasculitis (AAV) is a group of systemic necrotizing small vessel vasculitides. Microscopic polyangiitis (MPA) and granulomatosis with polyangiitis (GPA) are two most common types of AAV affecting mainly middle-aged and elderly people. Previous data indicated an increased occurrence of cancer in AAV patients [1], which has been mainly attributed to exposure to cyclophosphamide [2].

Objectives:

The purpose of this paper was to analyze cancer incidence in unselected patients with GPA and MPA treated in one academic center since 1988 with follow-up until 2020.

Methods:

With case record review, the baseline characteristics, outcomes and malignancy development in a cohort of 251 patients were assessed. Patients were followed up from time of diagnosis to their death or most recent hospital or outpatient’s assessment.

Results:

Twenty-eight of 251 patients with AAV (65 % cANCA, 26% pANCA, 9.0 % ANCA-negative) developed a total of 32 malignancies during a mean follow-up of 8.6 years. Patients characteristic is presented in table 1. Mean time since AAV onset to cancer diagnosis was 5.86±6.78 years. Of these malignancies, 2 melanoma, 6 were non-melanoma skin cancers, 4 gastrointestinal tract cancer (2 colon, 1 stomach, 1 liver), 3 bladder cancer, 2 breast cancer, 2 uterine cancer, 1 ovarian cancer, 2 prostate cancer, 1 testis cancer, 2 lung cancer, 6 haematological malignancies (1 lymphoma, 1 chronic myeloid leukemia, 4 monoclonal gammopathy of unknown significance), additionally 1 benign salivary gland tumor was found. Four of the 16 patients with renal transplants developed a total of 6 malignancies. There were no differences in the incidence of cancer by gender, age, severity and activity of the disease, ANCA status, smoking status, number of relapses and treatment. There was no association between cancer and cumulative dose of cyclophosphamide.

Conclusion:

In the AAV group, 11% of patients developed different type of cancer. The most common was non-melanoma skin cancer. The risk of developing malignancy increased with follow-up time. We found no association of tumor development and cumulative cyclophosphamide dose.

References:

[1]Rahmattulla et al. Incidence of malignancies in patients with antineutrophil cytoplasmic antibody-associated vasculitis diagnosed between 1991 and 2013. Arthritis Rheum. 2015;67(12):3270–3278.

[2]Faurschou M et al. Prolonged risk of specific malignancies following cyclophosphamide therapy among patients with granulomatosis with polyangiitis. Rheumatology (Oxford) 2015; 54:1345–1350.

Table 1.

Characteristics of the AAV patients included in the study.

Total sample (n=251)No malignancy occurrence (n=223)Malignancy occurrence (n=28)P valueAge at diagnosis, mean ± SD years53.0±15.952.4±16.457.9±9.45NSFemale, n (%)115 (45.8%)106 (47.5 %)9 (32.1 %)NSMean observation time (years)5.72±5.175.35±4.938.61±6.170.002BVASv318.9±8.4918.9±8.4618.6±8.90NSDEI7.03±2.867.04±2.906.96±2.62NSOrgan involvement, n (%) Upper respiratory tract170 (67.7 %)151 (67.7 %)19 (67.9 %)NS Lungs163 (64.9 %)142 (63.7 %)21 (75.0 %)NS Kidney171 (68.1 %)151 (67.7 %)20 (71.4 %)NS Skin62 (24.7 %)54 (21.5 %)55 (24.7 %)49 (22.0 %)7 (25.0 %)NS Eyes11 (4.4 %)11 (4.9 %)5 (17.9 %)NS Heart30 (12.0 %)24 (10.8 %)0 (0.0 %)NS Gastrointestinal tract34 (13.5 %)32 (14.3 %)6 (21.4 %)NSFollow-up 0–5 years145 (57.8 %)136 (61.0 %)9 (32.1 %)0.004 > 5–10 years62 (24.7 %)52 (23.3 %)10 (35.7 %)NS > 10 years44 (17.5 %)35 (15.7 %)9 (32.1 %)0.031Deaths, n(%)56 (23.0 %)45 (20.8 %)11 (39.3 %)0.029Renal transplantation, n(%)16 (6.4 %)12 (5.4 %)4 (14.3 %)NSCumulative Cyclophosphamide dose (g)14.7±30.014.5±30.816.6±23.6NS

Disclosure of Interests:

None declared

SAT0265 RISK FACTORS FOR INFECTIOUS COMPLICATIONS FOLLOWING RITUXIMAB TREATMENT – MULTICENTER POLISH EXPERIENCE

Background:

Rituximab (RTX) is a B cell depleting monoclonal antibody with proven efficacy in the treatment of ANCA-associated vasculitis (AAV). The infectious complications occur in 15-25%.

Objectives:

We aimed to assess the frequency and risk factors of infections in patients with AAV receiving RTX among Polish patients.

Methods:

7 tertiary referral centers experienced in the treatment of vasculitis completed a questionnaire regarding AAV patients treated with RTX.

Results:

Among 49 patients included in the analysis (47 with GPA, 2 with MPA; 36/73% men; mean age at diagnosis 42,45±14,9 yrs., mean age on RTX initiation 46,14±14,72 yrs.,) at least one infection occurred in 20 patients (40.82%) after mean time of 16,65±16,01 weeks since the administration of RTX. Patients were followed for a mean time of 26,88±21,94 months. There were no differences in the incidence of infectious complications by gender, age, BMI, smoking status, severity of the disease, activity of the disease (BVAS), time from diagnosis to RTX initiation, carriage of staphylococcus aureus in the upper respiratory tract, total dose of CYC before RTX treatment. We didn’t observe severe hypogammaglobulinemia or neutropenia after RTX treatment. 40% of the observed infections occurred during the first month, 35% between second and sixth month of follow-up, while 25% were observed between 6 and 12 months after the RTX initiation. Of the 20 patients who developed infection, 12 (24.5%) had further infections. Antibiotic prophylaxis with trimethoprim–sulfamethoxazole was administered in 40 out of 49 (81.63%). Upper respiratory tract infection was the most common infectious complication (n=11), followed by lower respiratory tract (n=4), soft tissues (n=4) and urinary tract infections (n=4), lacrimal gland abscess (n=2) and abdomen (n=1). In cases with a positive microbial result Staphylococcus aureus (n=4), Klebsiella pneumoniae (n=2), Pseudomonas aeruginosa (n=1), Candida (n=1) and others (n=6) were identified. No fatalities were recorded and only 3 patients had severe infection with the necessity of prolonged treatment.

Conclusion:

Despite the high number of infections in our group treated with RTX, most of them were not severe. Upper respiratory tract was the most common site of infection.

Disclosure of Interests:

None declared

FRI0223 SUBPHENOTYPES OF ANCA ASSOCIATED VASCULITIS IDENTIFIED BY LATENT CLASS ANALYSIS

Background:

ANCA associated vasculitides (AAV) are a heterogeneous group of rare diseases with unknown etiology and the clinical spectrum ranging from life-threatening systemic disease, through single organ involvement to minor isolated skin changes. Thus there is an unmet need for phenotype identification especially among patients with granulomatosis with polyangiitis GPA, patients with microscopic polyangiitis MPA group seems to be more uniform. Recently, based on previous clustering analysis and clinical, histopathological, serological and prognostic aspects three subcategories of AAV have been proposed and named as: non-severe AAV, severe PR3-AAV and severe MPO-AAV [1].

Objectives:

In line with these attempts to subcategorize AAV we decided to use latent class analysis (LCA) on a large multicenter cohort of polish AAV patients from POLVAS [2] registry to identify potential new subphenotypes or confirm already proposed ones.

Methods:

Latent Class Analysis (LCA) approach was used as a model based clustering method of objects described by dichotomous (e.g., gender; ANCA status – cANCA, pANCA; organ involvement - skin, eye, ENT, respiratory, heart, GI, renal, urinary, CNS, peripheral nerves) and polytomous (number of relapses) variables supported by quantitative covariates (e.g., age at diagnosis, CRP at diagnosis, maximal serum creatinine concentration ever).

Results:

Results of LCA on our AAV group returned four class model of AAV subphenotypes, confirming existence of the previously proposed by Mahr at al. [1] and revealed fourth – previously not described clinically relevant subphenotype. To this fourth class - belong patients only with GPA, diagnosed at young age, with multiorgan involvement, high relapse rate and relatively high risk of death.

Table 1.

AAV subcategorization – summary of clinical characteristics and ANCA specificity

LCA Class 1LCA Class 2LCA Class 3LCA Class 4No of patients13019410297AAV typeMainly GPAMainly GPAmainly MPAOnly GPAAge at diagnosisMiddle ageMiddle ageOldYoungMale/female ratio1:22:11:11:1Main organ involvementENT, respiratory, eyeRenal, respiratory, ENTRenal, respiratory, skinMultiorgan involvementRelapse rateintermediateintermediatelowhighModified class description (based on ref. [1])Non severe AAVSevere PR3 AAVSevere MPO AAVSevere non-renalPR3 AAV

Conclusion:

Based on multiple clinical and serological variables LCA methodology identified 4-class subphenotypes model of AAV. Fourth-class is a new clinically important subphenotype including exclusively PR3-positive young AAV patients with multiorgan involvement, high risk of relapse and distinct mortality.

References:

[1]Mahr A, Specks U, Jayne D. Subclassifying ANCA-associated vasculitis: a unifying view of disease spectrum. Rheumatol Oxf Engl 2019;58:1707–9.https://doi.org/10.1093/rheumatology/kez148.

[2]Wójcik K, Wawrzycka-Adamczyk K, Włudarczyk A, Sznajd J, Zdrojewski Z, Masiak A, i in. Clinical characteristics of Polish patients with ANCA-associated vasculitides—retrospective analysis of POLVAS registry. Clinical Rheumatology. 1 wrzesień 2019;38(9):2553–63.

Disclosure of Interests:

Krzysztof Wójcik: None declared, Adam Ćmiel: None declared, Anna Masiak: None declared, Zbigniew Zdrojewski: None declared, Radoslaw Jeleniewicz: None declared, Maria Majdan Consultant of: Roche, Amgen, Speakers bureau: Roche, Amgen, Iwona Brzosko: None declared, Marek Brzosko: None declared, Piotr Głuszko: None declared, Małgorzata Stasiek: None declared, Małgorzata Wisłowska: None declared, Joanna Kur-Zalewska: None declared, Marta Madej: None declared, Anna Hawrot-Kawecka: None declared, Hanna Storoniak: None declared, Barbara Bułło-Piontecka: None declared, Alicja Dębska-Ślizień: None declared, Eugeniusz Kucharz: None declared, Katarzyna Jakuszko: None declared, Jacek Musiał: None declared

FRI0210 ORBITAL PSEUDOTUMOR AMONG PATIENTS WITH GRANULOMATOSIS WITH POLYANGIITIS – DATA FROM THE POLISH REGISTRY POLVAS

Background:

Orbital inflammatory masses have been described as the common manifestation of granulomatosis with polyangiitis (GPA) occuring in 7- 45% of patients.

Objectives:

Identification and characterization of patients with orbital pseudotumor among Polish patients based on the national vasculitis registry, POLVAS.

Methods:

Clinical presentation and management of all GPA patients fulfilling ACR criteria or Chapel Hill Consensus Conference definition included to the Polish registry POLVAS who developed orbital masses in the course of GPA were evaluated.

Results:

Ocular involvement was found in 114 (27%) of 417 GPA patients registered in POLVAS, 34 (8%) developed orbital masses. Mean patients’ age was 47.8 (range from 19-75) yrs., 23 (67%) were women. Forty four per cent of the patients developed tumor at the beginning of the disease, 56% during relapse. Patients’ characteristics on diagnosis of orbital mass: 24 cANCA, 2 pANCA, and 8 ANCA negative, 9% active smokers and 31% past smokers, 29% had localized disease, 21% early systemic and 50% systemic with organ involvement, 29% had other type of ophthalmological involvement before pseudotumor occurred, 88% had active paranasal sinus involvement, 41% lungs, 15% CNS, 15% skin and 6% heart manifestations. Thirty seven per cent of patients had positive nasal swabs cultures, 50% of which were positive for Staphylococcus aureus. In 65%, tumor occurred during steroid therapy (46% had prednisone more than 5mg/d) and 45% on immunosuppressive treatment (19% when treated with AZA, 16% MTX, 6,5% MMF and 3,5% CYC). Due to orbital mass 86.5% were treated with CYC and 13.5% with RTX. Twenty one per cent had complete remission of the pseudotumor, 76% partial remission and in 3% patients there was no response to the treatment; 43% developed visual impairment, 20% suffered from blindness.

Conclusion:

Orbital inflammatory mass was not common manifestation of GPA among our patients. The mass developed at the beginning or in the course of the disease, even during immunosuppressive treatment. Orbital masses have been resistant to therapeutic interventions and were accompanied by high risk of visual impairment.

Disclosure of Interests:

Anna Masiak: None declared, Marcin Ziętkiewicz: None declared, Krzysztof Wójcik: None declared, Katarzyna Wawrzycka-Adamczyk: None declared, Radoslaw Jeleniewicz: None declared, Marta Madej: None declared, Joanna Kur-Zalewska: None declared, Katarzyna Jakuszko: None declared, Małgorzata Wisłowska: None declared, Hanna Storoniak: None declared, Michał Komorniczak: None declared, Barbara Bułło-Piontecka: None declared, Iwona Brzosko: None declared, Małgorzata Stasiek: None declared, Eugeniusz Kucharz: None declared, Alicja Dębska-Ślizień: None declared, Maria Majdan Consultant of: Roche, Amgen, Speakers bureau: Roche, Amgen, Jacek Musiał: None declared, Zbigniew Zdrojewski: None declared

Islet Transplantation - perspective from Poland

The article describes impact of advanced research in the USA and collaborative approach of US scientists and clinicians on development of the field of islet transplantation in Poland and all over the world. At the same time, it presents negative consequences of islet regulation by FDA as a biological drug leading to decline and extinction of the field in the US, while it is on the rise worldwide.

Assessment of Cardiovascular Risk in Renal Transplant Recipients: Preliminary Results

BACKGROUND

Cardiovascular (CV) diseases are the most common cause of death in patients with chronic kidney disease, including patients after kidney transplantation. The aim of the study was to do a retrospective analysis of CV risk in renal transplant recipients (RTRs).

METHODS

The analysis of CV risk was based on the following scales: QRISK2, Framingham (assessment of development of CV disease), PROCAM (assessment of any CV incident), and Pol-SCORE (assessment of CV death) within a 10-year period. Out of 150 RTRs transplanted in 2007-2009, 100 RTRs (65 male/35 female) with an average age of 48.4 years were enrolled in the study. Coronary heart disease and diabetes mellitus were diagnosed in 7% and 15% of participants, respectively. Coronarography was performed in 38% of patients. Hypertension was diagnosed in 98% of participants, myocardial infarction was diagnosed in 6% of participants, and stroke was diagnosed in 2% of participants.

RESULTS

High and very high risk of CV endpoint according to QRISK2, PROCAM, Framingham, and Pol-SCORE scales was found in 41%, 8%, 10%, and 41% of patients, respectively. After 5 years of follow-up, a total of 13 CV events (myocardial infarction and stroke) were observed in 11 patients. Among these patients, the highest risk of endpoint according to QRISK2, PROCAM, Framingham, and Pol-SCORE scales was found in 36%, 9%, 18%, and 45% of patients, respectively.

CONCLUSIONS

The QRISK2 and Pol-SCORE scales seem to be the most predictive in assessing CV risk in RTRs.

Clinical Consequences of Diabetes Mellitus in Patients After Kidney Transplantation: A Paired Kidney Analysis

BACKGROUND

Diabetes mellitus (DM) has been acknowledged as the most common disorder leading to end-stage renal failure in adults. Diabetic patients show higher survival rates after kidney transplantation (KTx) compared with dialysis therapy. The aim of the study was to evaluate follow-up after KTx in patients with DM as a reason of end-stage renal disease (ESRD), or with long-lasting diabetes before transplantation, compared with patients without DM.

METHODS

We retrospectively analyzed the clinical consequences of DM in patients after KTx performed at the Gdansk Transplantation Centre between 2000 and 2016. To minimize donor bias, a paired kidney analysis was applied.

RESULTS

The incidence of DM (types 1 and 2) was 13%; 145 patients with DM had pairs of nondiabetic patients, who received kidneys from the same donor and were included to the analysis. The DM group was older. The incidence of AR was similar among the 2 groups, DGF was observed more often in patients with diabetes. Kidney graft function 1 month after transplantation was equal in both groups (mean serum creatinine concentration 1.4 mg/dL). Five-year patient survival was better in the non-DM group (96.7% vs 81.5%). Kaplan-Meier survival curves did not differ significantly between the DM and non-DM groups. DM was not associated graft loss. In the univariate analysis age was the only factor associated with death.

CONCLUSION

Diabetic patient survival after KTx seems to be worse than in patients without diabetes, but generally the follow-up among diabetics is good, with graft survival similar to that observed in patients without DM.

External Validation of the Newly Developed BETA-2 Scoring System for Pancreatic Islet Graft Function Assessment

BACKGROUND

BETA-2 score using a single fasting blood sample was developed to estimate beta-cell function after islet transplantation (ITx) and was validated internally by a high ITx volume center (Edmonton). The goal was to validate BETA-2 externally, in our center.

METHODS

Areas under receiver operating characteristic curves (AUROCs) were obtained to see if beta score or BETA-2 would better detect insulin independence and glucose intolerance.

RESULTS

We analyzed values from 48 mixed meal tolerance tests (MMTTs) in 4 ITx recipients with a long-term follow-up to 140 months (LT group) and from 54 MMTTs in 13 short-term group patients (ST group). AUROC for no need for insulin support was 0.776 (95% confidence interval [CI] 0.539-1, P = .02) and 0.922 (95% CI 0.848-0.996, P < .001) for beta score and 0.79 (95% CI 0.596-0.983, P = .003) and 0.941 (95% CI 0.86-1, P < .001) for BETA-2, in LT and ST groups, respectively, and did not differ significantly. In LT group BETA-2 score ≥ 13.03 predicted no need for insulin supplementation with sensitivity of 98%, specificity of 50%, positive predictive value (PPV) of 93%, and negative predictive value (NPV) of 75%. In ST group the optimal cutoff was ≥13.63 with sensitivity of 92% and specificity, PPV, and NPV 82% to 95%. For the detection of glucose intolerance BETA-2 cutoffs were <19.43 in LT group and <17.23 in ST group with sensitivity > 76% and specificity, PPV, and NPV > 80% in both groups.

CONCLUSION

BETA-2 score was successfully validated externally and is a practical tool allowing for frequent and reliable assessments of islet graft function based on a single fasting blood sample.

Efficacy and Safety of Mammalian Target of Rapamycin Inhibitor Use-Long-term Follow-up of First Tuberous Sclerosis Complex Patient Treated De Novo With Sirolimus After Kidney Transplantation: A Case Report

Mammalian target of rapamycin inhibitors (mTORI) are increasingly used in the treatment of tuberous sclerosis complex (TSC) and as immunosuppressants after organ transplantation. In TSC patients, mTORI are the treatment of choice after kidney transplantation. It is still under debate if benefits from long-term mTORI use will not be limited by side effects.

MATERIALS AND METHODS

We report long-term follow-up data of the first TSC patient after kidney transplantation treated with sirolimus de novo. In 2005, a female patient was transplanted with a kidney graft after bilateral nephrectomy due to angiomyolipoma. Initial immunosuppressive treatment consisted of antithymocyte globulin, methylprednisolone, tacrolimus, and, due to TSC diagnosis, sirolimus. Creatinine level at discharge was 1.2 mg/dL.

RESULTS

Long-term mTORI use resulted in skin lesion regression (angiofibromas, "confetti" skin lesions, shagreen patch) and disease stabilization in brain, abdominal, and chest magnetic resonance imaging/computed tomography scans. Pulmonary function tests showed improvement in restriction and slow deterioration in obstruction and diffusion parameters. Sirolimus related adverse reactions were hyperlipidemia and hypertriglyceridemia and respiratory and urinary tract infections. No gastrointestinal or hematologic symptoms occurred. Sirolimus concentrations ranged between 1.7 and 8.2 ng/mL (mean 4.01 ± 2.09 ng/mL). Since 2009 proteinuria and slow increase in creatinine level have been observed. No biopsy was performed to establish etiology and potential association with mTORI. In 2017 creatinine level was 2.2 mg/dL.

CONCLUSION

The case of the patient confirms clinical effectiveness and acceptable safety of long-term mTORI treatment. Long-term mTORI use requires meticulous patient observation to optimize dosage, achieve immunosuppressive effect, and improve TSC manifestations with minimal side effects.

Paired Analysis of Outcomes After Kidney Transplantation in Peritoneal and Hemodialysis Patients

BACKGROUND

The impact of dialysis modality before kidney transplantation (hemodialysis or peritoneal dialysis) on outcomes is not clear. In this study we retrospectively analyzed the impact of dialysis modality on posttransplant follow-up.

METHODS

To minimize donor bias, a paired kidney analysis was applied. One hundred thirty-three pairs of peritoneal dialysis (PD) and hemodialysis (HD) patients were transplanted at our center between 1994 and 2016. Those who received kidneys from the same donor were included in the study. HD patients were significantly older (44 vs 48 years), but the Charlson Comorbidity Index was similar (3.12 vs 3.46) in both groups. The groups did not differ significantly with respect to immunosuppressive protocols and number of mismatches (2.96 vs 2.95).

RESULTS

One-year patient (98% vs 96%) and graft (90% vs 93%) survival was similar in the PD and HD patient groups. The Kaplan-Meier curves of the patients and graft survival did not differ significantly. Delayed graft function (DGF) and acute rejection (AR) occurred significantly more often in the HD recipients. Graft vessel thrombosis resulting in graft loss occurred in 9 PD (6.7%) and 4 HD (3%) patients (P > .05). Serum creatinine concentration and estimated glomerular filtration rate (using the Modification of Diet in Renal Disease guidelines) showed no difference at 1 month, 1 year, and at final visit. On multivariate analysis, factors significantly associated with graft loss were graft vessel thrombosis, DGF, and graft function 1 month after transplantation. On univariate analysis, age, coronary heart disease, and graft loss were associated with death. Among these factors, only coronary heart disease (model 1) and graft loss were significant predictors of death on multivariate analysis.

CONCLUSION

The long-term outcome for renal transplantation is similar in patients with PD and HD. These groups differ in some aspects, however, such as susceptibility to vascular thrombosis in PD patients, and to DGF and AR in HD patients.

Dietary Intake of Vitamins in Different Options of Treatment in Chronic Kidney Disease: Is There a Deficiency?

BACKGROUND

The importance of diet in the management of kidney transplantation (KT), as well as other treatment options of chronic kidney disease (CKD), is generally acknowledged. However, data regarding vitamin intake are very limited. Vitamins are essential in maintaining good nutritional status and preventing many chronic complications. It is still not clear which treatment modality imposes the highest risk of dietary vitamin deficiency and whether successful KT reverses such a threat.

METHODS

We performed this observational study to assess dietary intake of vitamins in CKD patients: after successful KT, not yet dialyzed (ND), treated with hemodialysis (HD), and with peritoneal dialysis (PD). A total of 202 patients were recruited (45 KT, 50 ND, 45 HD, and 62 PD). Vitamin intakes were evaluated through the use of a 24-hour dietary recall and processed with the use of a computerized database. Each record was evaluated by a skilled dietitian. In general, vitamin intakes in all study groups were comparable, with KT and ND groups manifesting lower risk of deficiency than HD and PD groups.

RESULTS

The content of fat-soluble vitamins in diet was insufficient, with remarkably high prevalence of vitamin D deficiency. Mean intakes of water-soluble vitamins were close to recommended, with the exception of folic acid, which was profoundly deficient in all groups.

CONCLUSIONS

CKD patients are at risk of inadequate vitamin intake. Vitamin D and folic acid are universally deficient in diet. KT patients have the most satisfactory content of vitamins in their diet, whereas HD individuals are at highest risk of deficiency.

Psychological Well-Being in Patients After Preemptive Kidney Transplantation

BACKGROUND

Preemptive kidney transplantation (PKT) is associated with improved patient and graft survival as compared with transplantation in previously dialyzed patients. Complications related to dialysis are avoided in preemptively transplanted patients. Psychological functioning of those patients is still under investigation. The aim of the study was to evaluate the acceptance of illness, satisfaction of life, and anxiety in patients preemptively transplanted (PET) and transplanted after dialysis (PTD).

METHODS

The present study compares 23 pairs of PET and PTD patients after kidney transplantation from the same donor. Each patient completed a set of psychological questionnaires: Acceptance of Illness Scale, Satisfaction With Life Scale, and State-Trait Anxiety Inventory. Pairs were examined in the same moment, from 7 days to 5 years after transplantation. The PET and PTD groups did not differ significantly in respect to sex, underlying renal diseases, incidence of acute rejection, surgical complications, and graft function. More PTD patients had delayed graft function (P < .05).

RESULTS

The statistical analysis revealed a significant lower acceptance of illness as well as satisfaction with life in PET recipients (P < .05). The groups differed significantly in the trait of anxiety but not in the state of anxiety.

CONCLUSIONS

Although the medical benefits of PKT are widely known, numerous psychological problems may occur in patients who do not have difficulties of dialysis and who after transplantation are faced with unexpected discomfort, which influences psychological well-being. Further effort should focus on providing psychological support during qualification to the transplantation and in follow-up after surgery.

Outcomes in Renal Transplant Recipients With Lupus Nephritis-A Single-Center Experience and Review of the Literature

BACKGROUND

Renal transplantation is the renal replacement therapy of choice in patients with end-stage lupus nephritis (LN). The aim of this study was to evaluate the early and late outcomes of renal transplantation in LN patients in a single transplant center.

PATIENTS AND METHODS

This study analyzed the clinical data of patients who received a renal transplant (RTx) at Gdańsk Transplantation Centre between January 1999 and December 2014.

RESULTS

There were 1296 RTx performed between January 1999 and December 2014, including 21 RTx in 19 LN patients (mean age 40 ± 10 years, 89% female). During the follow-up period (between 1 month and 10.5 years), 1 patient died of urosepsis and 1 of pneumonia. Three RTx recipients with antiphospholipid syndrome lost 5 kidney allografts, including 3 due to acute rejection (AR) during the first posttransplantation month. Kidney allograft survival median was 64 months. Delayed graft function (DGF) and AR were observed in 48% and 33% vs 31% and 21% of LN patients and other RTx patients, respectively (P = .1 and P = .16 for DGF and AR, respectively). The most common early posttransplantation complications were AR (31%) and perirenal hematomas (29%), and late complications were urinary tract infections (75%). Recurrence of LN in renal allograft was observed in 1 patient and was successfully treated by increasing the basic immunosuppression.

CONCLUSIONS

Secondary antiphospholipid syndrome has a major influence on the outcomes of RTx in LN patients. Recurrence of LN has no clinical significance.

Association Between HLA Type and Skin Cancer in Kidney Transplant Recipients

BACKGROUND

Organ transplant recipients (OTRs) are more susceptible to various diseases, among them cancers. Nonmelanoma skin cancers (NMSC) represent the most common malignancies in OTRs in Europe. Due to the significantly higher morbidity, aggressive and rapid progression, and poor prognosis of NMSC in the OTR population, these patients require a special oncological approach. Intensive attention should therefore be paid to factors predisposing OTRs to the development of cancer. The aim of this study was to establish the role of genetic factors in the pathogenesis of skin cancer in kidney transplant recipients (KTRs).

METHODS

This single-center study was performed in 39 KTRs with posttransplant NMSC. The frequency of particular types of HLA Class I (HLA-A and HLA-B) and Class II (HLA-DR) in each group were compared to establish the association between the HLA type and risk of skin cancer after renal transplantation.

RESULTS

HLA-DR15 were more commonly detected in patients with MNSC than in the control group of KTRs (P = .014) There was also a positive correlation between HLA-B18 and skin squamous cell carcinoma. The antigen was more often recorded in KTRs with squamous cell carcinoma than in KTRs without NMSC (P = .03) and in the general population (P = .002).

CONCLUSIONS

Patients who are positive for HLA-BR15 and HLA-B18 should be under special dermatologic surveillance due to the potentially high risk of skin cancer.

Vitamin B6 status, immune response and inflammation markers in kidney transplant recipients treated with polyclonal anti-thymocyte globulin

BACKGROUND/OBJECTIVES

Vitamin B6 status has an impact on the body's inflammatory and immune responses. Immunosuppressive therapy may influence vitamin B6 metabolism in kidney transplant recipients. Treatment with polyclonal anti-thymocyte globulin (ATG) is associated with long-term changes in inflammatory and immune parameters. It is not known if ATG therapy also may have an impact on vitamin B6 status in kidney transplant recipients. We aimed to analyze the impact of therapy with ATG on vitamin B6 status, immune response, and the profile of inflammatory cytokines.

SUBJECT/METHODS

This was a retrospective, observational study that included 44 kidney allograft recipients. Twenty patients received induction therapy with ATG (6 to 24 months before enrollment). Twenty-four patients constituted the control group, matched with respect to time since transplantation. The B6 vitamers, total lymphocyte count, CD3 percentage, interleukin (IL)-6, -7, and -10, transforming growth factor β, interferon γ, and chemokine ligand 21 were analyzed in a study group.

RESULTS

All indicators of vitamin B6 status were lower in the ATG group than in the control group. There were also significant differences with respect to immune response (significantly lower total lymphocyte count and CD3 in the ATG group) and inflammatory status (significantly higher IL-6 and IL-10 in the ATG group). Vitamin B6 vitamers and derivatives were not related to lymphocyte count and cytokine levels or to estimated glomerular filtration rate and age of the study population.

CONCLUSIONS

Vitamin B6 stores and active forms are lower in kidney transplant recipients treated with ATG. ATG therapy promotes CD3 and total lymphocyte depletion and increases indicators of inflammation. We found no associations between vitamers of B6, immune response cells, and inflammatory cytokines in study population.

Sebaceous carcinoma in patients receiving long-term immunosuppresive treatment: case report and literature review

BACKGROUND

Sebaceous carcinoma (SC) is a very rare and aggressive malignant skin cancer that appears to occur with a greater frequency in the clinical setting of chronic immunosuppression; however, it is not reported in the literature as frequently as is squamous cell carcinoma (SCC). We report 2 cases of SC in organ transplant patients from clinical and histopathological points of view.

METHODS

A 48-year-old patient after 3 renal transplantations (1986, 1986, and 1998) was presented to the Dermatology Department in 1999 because of a papillomatous lesion along her right upper eyelid. The lesion was excised. Histopathologically, it was diagnosed as a SC. There was no lymphovascular invasion and no metastasis; therefore no other treatment was included. No symptoms of recurrent disease were present 14 years since diagnosis. An 87-year-old patient after a renal transplantation in 1989 was referred to dermatologist in 1993 because of the lesion on his right temple. The lesion was excised; histopathologically, it was diagnosed as SC. Because of metastatic disease, he had a course of radiotherapy to the right side of the neck. The immunosuppressive drugs azathioprine and cyclosporine A were reduced. The patient died of metastatic disease 1 year later (3 years since diagnosis). Both patients had very high cumulative UV exposition during their lifetimes, and many skin cancers were diagnosed, especially SCC.

RESULTS

It is necessary to realize that this cancer occurs more frequently in organ transplant patients, and its correct diagnosis is an essential issue because it has significantly more aggressive behavior than does SCC. In the 2 presented patients, we observed very rapid progression of disease. Despite aggressive treatment and reduction of immunosuppressive drugs, the second patient died 3 years after diagnosis.

CONCLUSIONS

Regular dermatological follow-up is required in the population of organ transplant patients to identify all skin tumors in the early stage.

Skin Cancers as Contraindication to Organ Transplantation

The period of preparing patients for organ transplantation is a suitable time for dermatologic screening and examination that guarantee early diagnosis and easier treatment of precancerous states and skin cancers. In most cases, diagnosis of skin cancer in the pretransplantation period is not a contraindication to transplantation. Knowledge of risk factors and etiopathogenesis of skin cancers after transplantation make it easier to point out patients with increased risk of skin carcinogenesis. Patients with skin phototype I-III (Fitzpatrick classification) and with high cumulative doses of ultraviolet radiation have an increased risk of skin cancers. Patients who had skin cancers in the past should be carefully examined, and the skin cancer histopathology should be analyzed in detail. These examinations have to be done from the clinical, surgical, and histopathologic aspects. It helps dermatologists to estimate the risk and predict the patient's health after a possible organ transplantation. Basal cell carcinoma and squamous cell carcinoma that are present before transplantation indicate the possibility of similar cancer occurrence after transplantation; however, they are not a contraindication to transplantation after treatment of the primary foci. The waiting period to transplantation in the case of melanoma in situ takes 2 years, but in more serious forms of melanoma this time is prolonged to ≥ 5-10 years. Different skin cancers have a 3-year asymptomatic period to renewed indication for transplantation.

Candida arteritis in kidney transplant recipients: case report and review of the literature

Multi-organ procurement is a risk factor for contamination of preservation fluid with intestinal flora including fungi (e.g., Candida). Transmission of fungal species to the graft vessel can cause mycotic arteritis. This is a very rare but life-threatening complication of renal transplantation. We present 2 cases of renal transplant recipients from the same multi-organ donor. Both recipients suffered from severe hemorrhages from renal graft anastomosis and renal artery pseudoaneurysm due to Candida albicans arteritis (CAA). The culture of the preservation fluid revealed growth of Escherichia coli, but neither preservation fluid nor multiple routine blood cultures performed before hemorrhagic complications revealed fungal growth (media non-selective for fungal growth were applied). The first recipient suffered from sudden severe hemorrhage in the area of graft anastomosis on day 10 post surgery (without any preceding clinical or radiological symptoms). This led to urgent surgery and graftectomy, which was complicated by cardio-respiratory arrest with resuscitation in the operating room; despite resuscitation, irreversible brain damage, and subsequent death occurred in the intensive care unit (ICU) 2 weeks later (on day 24 after transplantation). The second patient underwent urgent vascular surgery on day 22 (after transplantation), because of hemorrhage from a pseudoaneurysm of the graft artery. She required repeated vascular operations, extended antimicrobial and antifungal therapy, and ICU monitoring and, despite these interventions, she died on day 80 after transplantation as a result of Pseudomonas aeruginosa sepsis. Arteritis of the renal artery in both patients was caused by C. albicans. This was confirmed by histopathology: infiltration of renal artery with budding yeast forming pseudohyphae (Case 1), and the presence of C. albicans in the culture of the renal artery and surrounding tissue (Case 2). We conclude that organ preservation solution should be cultured with use of media selective for fungal growth. As soon as the positive culture is detected, appropriate measures protecting patients against CAA should be undertaken.

Dobutamine stress echocardiography in the diagnosis of asymptomatic ischemic heart disease in patients with chronic kidney disease--review of literature and single-center experience

BACKGROUND

Coronary artery disease (CAD) may be present in kidney transplant (KT) candidates without the presence of CAD clinical symptoms. This study joins an ongoing discussion about appropriate noninvasive diagnostic approaches for ischemic heart disease (IHD) assessment and patient selection for revascularization procedures. The aim of this study was to evaluate the role of dobutamine stress echocardiography (DSE) in IHD diagnosis in initially asymptomatic maintenance hemodialysis (HD) patients.

METHODS

Forty HD patients aged 52.4 ± 2.0 years, were studied for 2.5 years. At inclusion, they were free of both symptoms and history of IHD. Standard electrocardiography (ECG), chest X-ray, standard echocardiography, DSE, 24-hour Holter ECG, and Doppler ultrasonography (carotids and lower extremities) were performed. Results were analyzed according to a predefined diagnostic algorithm.

RESULTS

DSE yielded negative results in all patients. Left ventricular (LV) ejection fraction ≤ 60%, LV hypertrophy, and Holter ECG silent ischemia features were noticed in 15%, 70%, and 10% of patients, respectively. Atherosclerotic lesions in lower extremities and carotid arteries were present in 50% and 37.5% of patients, respectively. During the follow-up, 9/40 patients died, including 6 cardiovascular (CV) deaths: 2 with intermediate and 4 with high CV risk according to the proposed algorithm.

CONCLUSIONS

In asymptomatic KT candidates, not only DSE, but also other noninvasive tests (eg, echocardiography and Doppler ultrasonography of the carotid and peripheral arteries) along with a detailed profile of the remaining CV risk factors should be performed and analyzed. Defined composition of risk factors and particular changes in noninvasive tests may be an indication for coronary angiography.

Preemptive kidney transplantation: analysis of kidney grafts from the same donor

BACKGROUND

From November 2003 to December 2012, in the Gdańsk Center, 64 patients received preemptive transplantation (PET). PET comprised 8% of 794 kidney transplantations performed during this time. The benefits for individual patients and for the health care system are discussed.

METHODS

This study compares the outcomes of these PET patients who had their kidney pairs transplanted after a variable duration of dialysis (PTD), a total of 51 pairs.

RESULTS

The mean Charlson comorbidity index was 2.57 vs 3.04 (P > .05) for the PET and PTD groups, respectively. Both groups did not differ significantly with respect to 1-year patient and graft survivals, and incidences of acute rejection. Five (9.8%) PET patients and 20 (39%) PTD patients experienced delayed graft function (P < .05). The graft function (serum creatinine/4p MDRD) 1 year after transplantation was similar in both groups (1.42/53.7 vs 1.43/57.4; mg/dL/mL/min/1.73 m(2)). More PET patients continued normal professional activities or education before and after transplantation (P < .05).

CONCLUSIONS

Our single-center results confirmed that for both medical and socioeconomic reasons, PET is an optimal mode of renal replacement therapy.

Assessment of cardiovascular risk during peritransplant period in renal transplant recipients

BACKGROUND

Cardiovascular (CV) diseases are the leading cause of death among patients with chronic kidney disease, including patients on dialysis and after kidney transplantation. The aim of study was the retrospective assessment of CV risk in renal transplant recipients during the peritransplant period.

MATERIAL AND METHODS

Evaluation of CV risk was made using the Revised Cardiac Risk Index (RCRI). One hundred kidney transplant recipient (60 males/40 females) participated in the study. In 82 recipients (82%), the RCRI index was 2 points, which was associated with a 6.6% risk of cardiac events. The remaining 18 patients (18%) had ≥3 RCRI points, which was associated with an 11% risk. The median RCRI score in the study group was 2.26, which was related to a risk of 7.39%.

RESULTS

In the perioperative period, there were no CV events. The study group was observed for 5 years after transplantation, and during this time, 11 CV incidents occurred. Most of CV incidents occurred during the first 25 months after transplantation. Among patients, who underwent a CV incident, the RCRI was 3 and 2 points in 4 and 5 patients, respectively. Significant correlations were found between RCRI and both age and time spent on dialysis (P < .001).

CONCLUSIONS

Patients who qualify for a transplant are at a significant risk of having a CV incident in the peri- and postoperative periods. CV incidents did not occur in the perioperative period, although as many as 6% of patients experienced CV incidents within 2 years after transplant. Four (44%) of the 9 patients who experienced CV incidents after transplantation had a very high RCRI. This indicates the need for a very thorough long-term cardiologic supervision of transplanted patients.

The modification of diet in renal disease and chronic kidney disease epidemiology collaboration formulas versus measured or estimated creatinine clearance in kidney transplant recipients

BACKGROUND

Estimation of glomerular filtration rate (eGFR) after renal transplantation is performed with the use of methods that are standardized for a population of nontransplantation patients with chronic kidney disease. The aim of the study was to compare the performance of GFR estimation formulas in renal transplant recipients.

METHODS

The Modification of Diet in Renal Disease (MDRD) and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formulas were compared with measured creatinine clearance or clearance estimated by the Cockroft-Gault (C-G) formula. The influence of age, body mass index, and eGFR on the relative performance of these formulas also was studied by subgroups analysis.

RESULTS

Mean measured or estimated creatinine clearance overestimates the values of GFR calculated using the MDRD or CKD-EPI equation. This was statistically significant (P < .05) in whole-study population and in subgroups of patients at age above 25 years, with body mass index above 25, and in a subgroup with eGFR-MDRD <50 mL/min/m(2). The mean bias from creatinine clearance was 7.46 mL/min for MDRD, 4.4 mL/min for CKD-EPI and -1.65 mL/min for C-G formula. There was a statistically significant (P < .05) negative correlation between eGFR value and bias from creatinine clearance for all 3 methods of estimation. The correlation coefficient was -0.4 for MDRD, -0.36 for CKD-EPI, and -0.46 for C-G clearance.

CONCLUSIONS

Measured and estimated creatinine clearance overestimate values of eGFR calculated by the MDRD or CKD-EPI formula in a population of kidney transplant recipients, especially in subjects with obesity and worse renal function. Accuracy of analyzed GFR estimation formulas decreases with deterioration of renal graft function.

Open prospective study to evaluate cardiovascular risk factors and renal function in 2 dosage regimens of tacrolimus combined with mycophenolate mofetil and steroids in renal transplant patients: 5-year results

BACKGROUND

Cyclosporine and tacrolimus (TAC) are the most potent immunosuppressants. TAC is considered less nephrotoxic, but may be an important factor in chronic graft dysfunction. The aim of the study was to evaluate kidney function and cardiovascular risk profile in 2 groups of low immunological risk kidney allograft recipients receiving 2 TAC dosages.

MATERIALS AND METHODS

Patients were randomly assigned to 2 TAC-based treatments (group I [n = 14], standard dose; group II [n = 15], reduced dose). Patient and graft survival, graft function, occurrence of cardiovascular events (cardiac death, myocardial infarction, stroke), incidence of new-onset diabetes mellitus after transplantation, and cardiovascular risk factors were assessed over a 5-year period.

RESULTS

Patient demographics and transplant characteristics were not statistically different between groups. TAC trough levels were significantly higher in group I for 24 months post transplant. Patient survival did not differ, but there were more acute rejection episodes and graft losses in group II. There were no significant differences in the rate of cardiac events. Graft function measured as serum creatinine levels and calculated glomerular filtration rate did not differ between groups. The same applies to new-onset diabetes mellitus after transplantation incidence. Office blood pressures were numerically higher in group I up to 24 months but this difference did not reach significance at any time. Similar results were obtained for serum lipids.

CONCLUSIONS

Immunosuppression based on low doses of tacrolimus seems to be safe in the group of low immunological risk patients but in the 60-month follow-up does not offer any clear benefits in terms of potential nephrotoxicity or cardiovascular risk.

Generic formulation of mycophenolate mofetil (Myfenax) in de novo renal transplant recipients: results of 12-month observation

BACKGROUND

The aim of this study was to show the preliminary outcomes of transplantation in patients treated with the generic formulation of mycophenolate mofetil (Myfenax, Teva).

MATERIALS AND METHODS

Over the past 4 years, 60 patients received generic mycophenolate mofetil (Myfenax) after renal transplantation at the Gdansk Transplantology Center. During the same time period, another 273 kidney transplantations were performed in our department, and these patients were treated with other formulations of mycophenolate (CellCept [Roche], Myfortic, or mycophenolate mofetil-Apotex) as a part of the immunosuppressive plan. Thirty of the Myfenax patients received a pair of kidneys from the same donor and received original mycophenolate mofetil CellCept with observation for at least 12 months.

RESULTS

The outcomes of the renal transplantations in both groups (Myfenax vs pair) were good, with satisfactory function of grafts. One case of graft loss was reported in the Myfenax group (renal vein thrombosis, graftectomy 5 days after transplantation). There was no difference in the incidence of acute renal graft rejection in either group. Moderate adverse reactions to immunosuppression were observed in both groups. On the other hand, a comparison between the 60 patients with Myfenax and the 273 other patients with other formulations of mycophenolate revealed no differences in the incidence of acute renal graft rejection, delayed graft function, graft loss, and death.

CONCLUSIONS

There were no differences in the incidence of acute renal graft rejection, delayed graft function, graft loss, and death in patients with Myfenax vs original CellCept and other formulations of mycophenolate. To confirm its complete biological and pharmacokinetic equivalence with the reference medicine, long-term, randomized observations carried out on larger renal transplant patients groups are needed.

Urinary tract infections in renal transplant recipients

INTRODUCTION

Urinary tract infections (UTIs) are most common infections in renal transplant recipients and are considered a potential risk factor for poorer graft outcomes.

AIM

To evaluate incidence, clinical manifestations, microbiology, risk factors for UTIs, and the influence of UTIs on long-term renal graft function.

PATIENTS AND METHODS

We analyzed urine cultures with reference to clinical data of patients who received a renal transplantation from January to December 2009 with a 12-month follow-up.

RESULTS

The 1170 urine cultures were correlated with clinical data from 89 renal transplant recipients, including 58.4% males and on overall mean age of 48±14 years. The 151 episodes in 49 patients consisted of asymptomatic bacteriuria (65%, n=98); lower UTIs (13%, n=19); and upper UTIs (22%, n=34), as well as five cases of bacteremia. Nearly 48% of UTIs were diagnosed during the first month posttransplantation. The most frequently isolated uropathogens were Enterococcus faecium (33%, n=24) and Escherichia coli (31%, n=23). Beginning from the second month, most frequently found bacterium in urine cultures was E coli (65% n=51). Risk factors for posttransplant UTIs were female gender and a history of an acute rejection episode and/or a cytomegalovirus (CMV) infection. All patients with vesicoureteral reflux of strictures at the ureterovesical junction suffered recurrent UTIs (n=7). The evolution of renal graft function did not differ significantly between patients with versus without UTIs.

CONCLUSIONS

UTIs a frequent problem after kidney transplantation most commonly exist as asymptomatic bacteriuria. E coli and E faecium are ther predominant pathogens. Exposure to intensified immunosuppression due to acute rejection episodes or CMV infections represents a risk factor for UTIs. Vesicoureteral reflux or strictures at the ureterovesical junction are risk factors for recurrent UTIs. UTIs did not impair 1-year graft function.

HLA-B27 is a potential risk factor for posttransplantation diabetes mellitus in autosomal dominant polycystic kidney disease patients

The aim of this work was to investigate HLA phenotype predisposition to posttransplantation diabetes mellitus (PTDM) in kidney transplant recipients stratified according to kidney failure etiology. Ninety-eight transplant recipient pairs with kidney grafts from the same cadaveric donor were qualified for the study. In each pair, 1 kidney was grafted to an individual with autosomal dominant polycystic kidney disease (ADPKD group) and 1 to recipient with a different cause of kidney failure (non-ADPKD group). All class II HLA antigens were determined with the PCR-SSP molecular method. To identify class I HLA molecules we used both molecular and serologic methods. Diabetes was diagnosed according to the American Diabetes Association criteria. The posttransplantation observation period was 12 months. In the ADPKD group, HLA-B27 was more common in PTDM than non-PTDM patients; 31.6% versus 11.4% (P = .069). The difference achieved significance when comparing insulin-treated with non-insulin-treated patients (44.4% vs 12.4%; P = .029). In the non-ADPKD group, HLA-A28 and HLA-B13 were observed more frequently in patients with PTDM than in recipients without diabetes (22.2% vs 2.5% [P = .0099] and 22.2% vs 3.8% [P = .020]). All of these associations were significant upon multivariate analysis. HLA-B27 allele is a factor predisposing ADPKD patients to insulin-dependent PTDM. Antigens predisposing to PTDM among kidney graft recipients without ADPKD include HLA-A28 and B13.