Paradigm shifts in multiple sclerosis management: Implications for daily clinical practice

Multiple sclerosis (MS) is the most common chronic inflammatory neurological disease. The emergence of disease-modifying therapies (DMTs) has greatly improved disease activity control and progression of disability in MS patients. DMTs differ in their mode of action, route of administration, efficacy, and safety profiles, offering multiple options for clinicians. Personalized medicine aims at tailoring the therapeutic strategy to patients' characteristics and disease activity but also patients' needs and preferences. New therapeutic options have already changed treatment paradigms for patients with active relapsing MS (RMS). The traditional approach consists in initiating treatment with moderate-efficacy DMTs and subsequently, escalating to higher-efficacy DMTs when there is evidence of clinical and/or radiological breakthrough activity. Recent real-world studies suggest that initiation of high-efficacy DMTs from disease onset can improve long-term outcomes for RMS patients. In this article, we review different treatment strategies and discuss challenges associated with personalized therapy.

CONFISEP: Impact of the Covid-19 pandemic lockdown on patients with multiple sclerosis in the north of France

We performed an online survey to assess lockdown impact in 176 patients with multiple sclerosis (PwMS) in the north of France. Access to healthcare was reduced for 38% of PwMS, mainly in physiotherapy, general practitioners and neurologists. 49.2% have implemented self-rehabilitation programs. Medical support was maintained for 39.2% through teleconsultations. 76.2% reported a negative impact of lockdown related to worsen disability. 45.5% expressed beneficial effects like strengthening family relationships, and reduced fatigue. Previous studies have found the same results on disability and discontinuation of care. However, even if this period has been challenging for PwMS, most of them have shown excellent adaptability.

High-fidelity laser-free universal control of trapped ion qubits

Universal control of multiple qubits-the ability to entangle qubits and to perform arbitrary individual qubit operations¹-is a fundamental resource for quantum computing², simulation³ and networking⁴. Qubits realized in trapped atomic ions have shown the highest-fidelity two-qubit entangling operations^5-7 and single-qubit rotations⁸ so far. Universal control of trapped ion qubits has been separately demonstrated using tightly focused laser beams^9-12 or by moving ions with respect to laser beams^13-15, but at lower fidelities. Laser-free entangling methods^16-20 may offer improved scalability by harnessing microwave technology developed for wireless communications, but so far their performance has lagged the best reported laser-based approaches. Here we demonstrate high-fidelity laser-free universal control of two trapped-ion qubits by creating both symmetric and antisymmetric maximally entangled states with fidelities of [Formula: see text] and [Formula: see text], respectively (68 per cent confidence level), corrected for initialization error. We use a scheme based on radiofrequency magnetic field gradients combined with microwave magnetic fields that is robust against multiple sources of decoherence and usable with essentially any trapped ion species. The scheme has the potential to perform simultaneous entangling operations on multiple pairs of ions in a large-scale trapped-ion quantum processor without increasing control signal power or complexity. Combining this technology with low-power laser light delivered via trap-integrated photonics^21,22 and trap-integrated photon detectors for qubit readout^23,24 provides an opportunity for scalable, high-fidelity, fully chip-integrated trapped-ion quantum computing.

Assessment of the role of afucosylated glycoforms on the in vitro antibody-dependent phagocytosis activity of an antibody to Aβ aggregates

The terminal sugars of Fc glycans can influence the Fc-dependent biological activities of monoclonal antibody therapeutics. Afucosylated N-glycans have been shown to significantly alter binding to FcγRIIIa and affect antibody-dependent cell-mediated cytotoxicity (ADCC). Therefore, in order to maintain and ensure safety and efficacy for antibodies whose predominant mechanism of action (MOA) is ADCC, afucosylation is routinely monitored and controlled within appropriate limits. However, it is unclear how the composition and levels of afucosylated N-glycans can modulate the biological activities for a recombinant antibody whose target is not a cell surface receptor, as is the case with ADCC. The impact of different types and varying levels of enriched afucosylated N-glycan species on the in vitro bioactivities is assessed for an antibody whose target is aggregated amyloid beta (Aβ). While either the presence of complex biantennary or high mannose afucosylated glycoforms significantly increased FcγRIIIa binding activity compared to fucosylated glycoforms, they did not similarly increase aggregated Aβ uptake activity mediated by different effector cells. These experiments suggest that afucosylated N-glycans are not critical for the in vitro phagocytic activity of a recombinant antibody whose target is aggregated Aβ and uses Fc effector function as part of its MOA.

Efficacy of Follow-up Care System of Living Kidney Donors in Monitoring of Residual Kidney Function

BACKGROUND

The possibility of an increased risk of end-stage renal disease is a major concern associated with living kidney donation. Therefore, monitoring of residual kidney function becomes most essential.

METHODS

A data analysis of 156 living kidney donors (LKDs) was conducted. The efficacy of the long-term care system with regard to monitoring residual kidney function was evaluated.

RESULTS

The analyzed group consisted of 102 (65.4%) women. The mean follow-up period was 5.44 years. The rise in value of mean serum creatinine concentration after donation was observed, but it was within the range of normal during the observation period. Despite its initial decline after nephrectomy, mean glomerular filtration rate (GFR) remained >60 mL/min/1.73 m². A MDRD (Modification of Diet in Renal Disease) GFR in the range of 45-60 mL/min/1.73 m² was observed in 53 donors (33.97%). It was found to be <45.0 mL/min/1.73 m² in 15 cases (9.6%). No patient developed end-stage renal disease. Only 25.0% of those analyzed had their CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) GFR estimated on 45-60 mL/min/1.73 m² and 4.49% were found to have levels of <45 mL/min/1.73 m² (down to 33.7 mL/min/1.73 m²). Mean postdonation CKD-EPI GFR was estimated at 69.99% of its predonation value.

CONCLUSION

A reliable qualification process could minimize the probability of kidney donation by someone with an increased risk of chronic kidney failure. The CKD-EPI formula seems to be more precise than the MDRD for estimatation of LKDs' GFR, as their loss of GFR is a result of nephrectomy and not kidney or systemic disease. Using the MDRD formula may lead to inappropriate diagnosis of CKD in some cases.

Patient preferences for topical treatment of actinic keratoses: a discrete-choice experiment

BACKGROUND

The treatment of actinic keratosis (AK) is a potentially effective strategy for the prevention of cutaneous squamous cell carcinoma (cSCC). However, the patient perspective on potential benefits of AK treatment in terms of skin cancer reduction has received little attention to date.

OBJECTIVES

(i) To investigate patient preferences for topical treatments for AK using a discrete-choice experiment (DCE); (ii) to evaluate patient willingness to trade between clinical benefit and medical burden.

METHODS

The DCE was conducted as part of a study to establish the feasibility of a phase III randomized controlled trial evaluating the prevention of cSCC using currently available topical interventions. Preferences were elicited by asking patients to make a series of choices between treatment alternatives with different hypothetical combinations of attribute levels. Willingness to trade between treatment attributes was estimated using a flexible-choice model that allows for the heterogeneity of patient preferences.

RESULTS

A total of 109 patients with AK completed the DCE. The majority of patients who expressed valid preferences were willing to accept some reduction in both prophylactic and cosmetic efficacy to reduce the burden of the treatment regimen, the severity of skin reaction and other adverse effects. Patients may reject treatment if the perceived therapeutic benefit is outweighed by the subjective burden of treatment.

CONCLUSIONS

Evidence of significant variation in the perceived utility of treatments across patients highlights the importance of taking individual patient preferences into account to improve AK treatment acceptability and adherence.

Psychological Aspects of Living Kidney Donation in Poland: Experience of One Center

BACKGROUND

Living kidney transplantation is the optimal treatment of end-stage renal disease. The benefits for recipients are obvious. The psychological consequences for living kidney donors in Poland are not known.

OBJECTIVE

The objective of the study was to evaluate the psychological aspects of living kidney donation in Poland.

PATIENTS AND METHODS

A total of 66 living donor open nephrectomies were performed in our institution between 1995 and 2005. The psychological aspects were assessed in 40 donors after nephrectomy. The study applied the Satisfaction With Life Scale (SWLS), the Situation Assessment Questionnaire, the Health Behaviors Survey, and our own questionnaire. The mean observation period was 65.6 months.

RESULTS

There was a trend toward better life satisfaction in living kidney donors compared to Polish adults. Donor life satisfaction was significantly lower when the recipient was dead than when the recipient was alive. Most donors perceived the kidney donation as a challenge in cognitive judgment. The mean score of the Health Behaviors Survey was not significantly different than in the general population in Poland. The mean pain score after donation was 3.2 in a 5-item scale (1 = severe pain, 5 = mild pain). The mean time of return to work was 3.5 months. No donors regretted their decisions about kidney donation.

CONCLUSION

Living kidney donation in Poland has a positive impact on donors' quality of life. Among living kidney donors, the sense of danger concerning the risk of donation depends on the degree of the relationship with the recipient.

Effect of Selective Antibiotic Pressure on the MLS-B Phenotype in Methicillin-Resistant Staphylococcus aureus Strains Originating From Patients From Transplantation Wards: 24 Years of Observations

INTRODUCTION

Staphylococcus aureus infection, and health care-associated-methicillin resistant S aureus (HA-MRSA) in particular, is a serious risk for patients treated with organ transplantation. The frequent combined resistance of these bacteria to macrolides, lincosamides, and streptogramin-B (MLS-B) limits the use of these drugs in therapy.

AIM

Evaluation of the mechanism of MLS-B resistance among HA-MRSA strains derived from patients treated in surgical-transplantation wards, over a 24-year period, and assessment of correlation of clindamycin use and resistance phenotype.

MATERIALS AND METHODS

One hundred and twelve HA-MRSA strains from patients in surgical-transplantation wards (clinical hospital, Warsaw), hospitalized in the period from 1991 to 2014. Methicillin-resistance was determined using phenotypic and genetic methods by detecting the mecA gene. Erythromycin/clindamycin resistance was determined by E-test, the iMLS-B (inductive) and cMLS-B (constitutive) phenotypes by the D-test method. The number of defined daily doses (DDD), statistically per 1000 person-days, was calculated in accordance with the WHO guidelines.

RESULTS

Resistance to erythromycin/clindamycin in MRSA strains increased from 1991 to 2004-2007 from 64.7/11.8% to 100/76.9%, respectively. The frequency of the cMLS-B phenotype in the years 1991/2010-2011/2012 was 5.9%/76.9%/69.7%, respectively, and correlated with the increased use of clindamycin in the examined wards. In 2012, the percentage of MLS-B-sensitive isolates increased from 3.9 to 21.7%, while constitutive resistance decreased to 69.7%, which correlated with a decrease in the use of clindamycin.

CONCLUSIONS

The proportion of cMLS-B to iMLS-B phenotypes in HA-MRSA is related to the amount of clindamycin used in hospital wards. Limiting the selection pressure of antibiotics can lead to complete loss of resistance or return to the inductive mechanism of its regulation.

Does Low Birthweight Have an Impact on Living Kidney Donor Outcomes?

INTRODUCTION

Because nearly 30,000 people worldwide become living kidney donors each year, donor safety is of the utmost importance. Recent studies have shown that living kidney donation is associated with an increased relative risk for end-stage renal disease (ESRD). It is essential to determine which donors will be more likely to develop ESRD. One of the risk factors for ESRD in living kidney donors is hypertension and, because there are studies demonstrating that low birthweight is a risk factor for developing hypertension in adult life, we hypothesized that donors with low birthweight may be at higher risk of developing renal disease after donation.

METHODS

Seventy-three living kidney donors were examined. Donors were divided into 2 cohorts: a group with low birthweight and group with normal birthweight. We checked whether the donor birthweight has an impact on the outcome of donor renal function and on the development of hypertension.

RESULTS

Hypertension was observed statistically more frequent in the group with low birthweight (P = .003).

CONCLUSION

Glomerular filtration rate before kidney donation was found to be lower in the low-birthweight group.

Endoscopic Islet Autotransplantation Into Gastric Submucosa-1000-Day Follow-up of Patients

BACKGROUND

Total pancreatectomy and autologous transplantation of pancreatic islets is a treatment option for patients with severe pain due to chronic pancreatitis. In the standard procedure, pancreatic islets are isolated and subsequently administered into the portal vein. In the case of patients with a history of thrombosis or at risk of thrombosis, this route of administration is not viable. Animal studies conducted in our department led to the development of a technique of endoscopic islets transplantation into the gastric submucosa. In 2013 and 2014, the first human autologous transplant procedures were performed. The objective of this study was to present the results of a 3-year follow-up of these patients.

METHODS

Two pancreatectomies were performed in our department, the first in 2013 and another in 2014, along with subsequent autologous transplantation of pancreatic islets into the gastric submucosa.

RESULTS

Both patients had been diagnosed previously with diabetes, and both had endogenous islet activity detected. Peptide C concentration after pancreatectomy and before pancreatic cell transplantation was 0.1 ng/mL. After the transplantation, peptide C concentrations for the 2 patients were 0.8 and 0.5 ng/mL on day 7, 1.2 and 0.6 ng/mL on day 30, 1.3 and 0.8 ng/mL on day 180, 1.1 and 0.7 ng/mL on day 360, and 3.0 and 0.6 ng/mL at 3 years, respectively, after transplantation. The pain symptoms resolved in both cases.

CONCLUSION

Pancreatic islets may survive in the gastric wall. Endoscopic submucosal transplantation may present an alternative for the management of patients who cannot undergo a classic transplantation procedure.

Islets Allotransplantation Into Gastric Submucosa in a Patient with Portal Hypertension: 4-year Follow-up

BACKGROUND

Islets transplantation is an established treatment method for patients suffering from brittle diabetes with hypoglycemia unawareness. The standard implantation technique is through the portal vein into the liver. In case of liver diseases or portal hypertension, finding an extra-hepatic site is recommended. There have been attempts to perform islets transplantations into muscles and into the gastric submucosa.

OBJECTIVE

The aim of this study is to show a 4-year follow-up of allotransplantation into gastric submucosa in a case of portal hypertension observed during the procedure of islets infusion.

PATIENTS AND METHODS

A 36-year-old woman with complicated diabetes for over 30 years was selected to receive simultaneous islets and kidney transplantation. The patient underwent an unsuccessful simultaneous pancreas and kidney transplantation 2 years earlier in another transplantation center. The patient's daily insulin requirement was 60 IU, which corresponded to 1.15 IU/kg of body weight. The HbA1c level was 7.4%. C-peptide levels, both fasting and stimulated, were 0.01 ng/mL. On December 7, 2013, the patient received transplanted kidney and islets procured from the same donor. Only 124,000 islets equivalents (IEQ) were isolated (2400 IEQ/kg body weight). Islets were suspended in 300 mL of Ringer's solution along with albumin, antibiotics, and heparin. After infusing 100 mL of the islets suspension into the portal vein, pressure in portal vein increased from 5 mm Hg to 23 mm Hg. Despite stopping the infusion, pressure did not drop after 30 minutes. The decision was made to transplant the reminder of the islets (200 mL) into the gastric wall.

RESULTS

No complications were observed after the procedure. Serum creatinine level was 1.6 mg/dL on day 10 and 1.5 mg/dL 4 years after the transplantation. Fasting C-peptide levels were 1.7, 0.65, 0.55, 0.69, 0.68, and 0.2 ng/mL at 1, 3, 6, 12, 18, and 36 months after the transplantation, respectively. HbA1c levels were 5.2, 6.4, 4.7, 5.2, and 5.9% at 3, 6, 12, 18, and 36 months, respectively. The patient's insulin requirement dropped to 15 U/day immediately after transplantation and equaled 20 and 27 U/day at 18 and 48 months after the simultaneous islet and kidney transplantation, respectively.

CONCLUSION

Allotransplantation of islets into the gastric wall may be a safe alternative in cases of contraindications for transplantation into the portal vein.

Association of MYH9 rs3752462 and rs5756168 Polymorphisms With Transplanted Kidney Artery Stenosis

Allelic variants of the MYH9 gene, encoding myosin nonmuscle heavy chain type IIA, have been shown to correlate with diminished glomerular filtration rates and end-stage kidney disease in individuals of Caucasian ancestry. Myosin nonmuscle heavy chain type IIA is expressed during development as well as in injured vessels and kidney structures. We hypothesized that MYH9 risk variants may correlate with kidney artery injury and dysfunctional healing, such as transplant renal artery stenosis (TRAS). Our study aimed at evaluating the association of MYH9 risk allelic variants (rs4821480, rs4821481, rs3752462, rs11089788, rs136211, rs5756168, rs2032487, and rs2239784) with TRAS, defined as >50% renal artery lumen reduction. Genotyping was performed with the use of custom Taqman genotyping assays on DNA samples (n = 295) from white deceased-donor kidney transplant recipients and genomic DNA from the corresponding donors. Statistical analysis was performed with the use of Kaplan-Meier estimates, log-rank tests, and proportional hazard Cox models. Recipients carrying TT in rs5756168 experienced diminished risk of TRAS (hazard ratio [HR], 0.31; P < .009), whereas organs carrying CC in rs3752462 were exposed to excessive TRAS risk (HR, 2.54; P < .047). In multivariate stepwise analysis TRAS was 10.9-fold increased in kidneys originating from rs3752462 CC, whereas the risk was decreased 3.45-fold (adjusted HR, 0.29) in recipients carrying rs5756168 TT (P < .007 and P < .033, respectively). Intracranial bleeding or trauma compared with other mechanisms of donor death diminished TRAS risk by 87% and 91%, respectively (P < .030 and P < .017). Our study is the first to identify genetic predisposition to transplant renal artery stenosis.

Renal Tumor in Allogeneic Kidney Transplant Recipient

BACKGROUND

Malignancies will be a leading cause of mortality in renal transplant recipients in the next 20 years. Renal cell cancer (RCC) is the most common urologic cancer in kidney transplant recipients. The risk of RCC development in kidney transplant recipients is 15-100 times higher than in the general population. The purpose of the current retrospective study was to assess the frequency of nephrectomies performed because of renal tumors in the native kidneys in kidney transplant recipients in the Department of General and Transplantation Surgery at the Medical University of Warsaw between 2010 and 2014 year; the identification of kidney recipients diagnosed with RCC; and epidemiologic, clinical, and histopathological aspects associated with RCC.

PATIENTS AND METHODS

A total of 319 nephrectomies were performed in the Department of General and Transplantation Surgery at the Medical University of Warsaw between 2010 and 2014 year. Renal tumors were diagnosed in 25 renal transplant recipients.

RESULTS

Among malignant tumors, 13 cases of RCC and 1 case of post-transplant lymphoproliferative disorder (PTLD) were observed. There was no significant difference between age and duration of pretransplantation dialysis in patients with RCC and patients with benign tumors (P = .14 and P = .91, respectively). Body mass index was significantly higher in patients with RCC than in patients with benign tumors (P = .04).

CONCLUSIONS

Renal cell cancer is more common among male kidney recipients. There is a good Polish screening system allowing detection of kidney cancer in native kidney. We recommend performing periodic screening for kidney cancers to obtain an early diagnosis.

Urinary Tract Infections in Kidney Transplant Recipients Hospitalized at a Transplantation and Nephrology Ward: 1-Year Follow-up

INTRODUCTION

The aim of this study was to investigate risk factors for urinary tract infections (UTI), the causative organisms of UTI and also their management and treatment. In addition, we evaluated the effects of UTI on renal graft function.

METHODS

This analysis included 107 kidney transplant recipients (64% women) with a diagnosis of UTIs confirmed by positive results on urine culture. Type of pathogens, sensitivity to drugs, risk factors for infection, incidence of urosepsis, hospitalization period, treatment methods, and recurrence rates were analyzed. Statistical analysis was performed by using Pearson's χ(2) test, Yates' χ(2) test, the Student t test, Welch's t test, the Mann-Whitney U test, Fisher's exact test, and the Shapiro-Wilk normality test.

RESULTS

The most common species isolated from urine samples included Escherichia coli (42%), Klebsiella pneumoniae (15%), and Enterococcus faecalis (10%). The percentage of multidrug-resistant strains was 31%, and urosepsis was diagnosed in 16% of patients. Recurrences developed in 76% of infected patients. Bricker ureterointestinal anastomosis was performed in 11% of patients. Risk factors for severe infections included: pre-transplantation urinary tract surgery (P = .02), double-J stent insertion (more common in men) during KTx (N = 34; 32%), (P = .021), reoperations following transplantation (P = .36), elevated tacrolimus levels at the time of infection (P = .024). Severe infections were diagnosed in patients with lower eGFRs, were associated with a need for longer hospitalization (P = .04) and escalation of antibacterial treatment. Carbapenems were used in 22 patients (20.5%).

CONCLUSIONS

UTIs were more common in women, in patients with impaired function of the kidney transplant, and in those with a history of urinary tract interventions. Severe infections were associated with a risk of urosepsis, longer hospitalization, and a need for escalation of antibiotic treatment.

Comparison of Staphylococcal Flora in Denture Plaque and the Surface of the Pharyngeal Mucous Membrane in Kidney Transplant Recipients

BACKGROUND

Biofilm occurring on removable prostheses is a reservoir of bacterial flora, consisting of both physiological and pathogenic multidrug-resistant microorganisms. Patients undergoing dialysis and organ transplantation are particularly prone to bacterial infections, which can have its source in denture plaque. This study was a comparison of the composition of staphylococcal flora within the surface of the pharyngeal mucous membrane as well as denture plaque in kidney transplant recipients.

METHODS

The study included 44 subjects with removable prostheses who reported for a kidney transplant procedure. Swab samples were collected from prostheses and the pharyngeal wall. Isolated strains were identified and investigated for drug resistance.

RESULTS

A total of 72 strains of Staphylococcus were isolated from the denture plaque and 53 from the pharynx. In the pharynx, the following species prevailed: Staphylococcus epidermidis, Staphylococcus warneri, and Staphylococcus aureus. The following species prevailed in denture plaque: S epidermidis, S aureus, and Staphylococcus haemolyticus. Among the pharyngeal strains, antibiotic resistance most commonly referred to natural penicillin (77%), constitutive macrolide-lincosamide-streptogramin B resistance (28%), and tetracycline (26.4%). In case of denture plaque, the highest percentage of strains demonstrated resistance to natural penicillin (60%), fosfomycin (32%), and cefoxitin (25%). In 10 subjects (48%), Staphylococcus-induced infections occurred in the first year after transplantation, 5 of which had the same bacterial strain as cultured previously from dentures.

CONCLUSIONS

The denture biofilm and surface of the pharynx differ in terms of bacterial composition and bacterial drug resistance profiles. Denture plaque constitutes a considerable reservoir of staphylococcal flora, which can be a potential source of infection in organ transplant recipients.

Renal Transplantation Using Kidneys Procured From Elderly Donors Older Than 70 Years

AIM

A major problem for the transplant society is a shortage of organs for transplantation compared with the number of patients on the waiting list. This study aimed to assess the results of the transplantation of kidneys procured from older donors.

PATIENTS AND METHODS

A total of 27 kidneys procured from donors age 70 years or older were transplanted between January 1, 2010, and April 25, 2015. These represented only 4.1% of the 657 kidneys transplanted from deceased donors during this period at the same center.

RESULTS

Delayed graft function (DGF) in the recipients of kidneys procured from donors age 70 or older occurred in 46.1% of patients, whereas the recipients of kidneys from younger donors showed DGF at a frequency of 32.7% (P = NS). The annual and 3-year survival rates of kidneys in the study group were 85% and 80%, respectively, and in the control group were 92.5% and 88.6%, respectively (P = NS). According to the Polish National Organ Procurement Organization (Poltransplant), the annual survival rate of a transplanted kidney in Poland stands at 89%, whereas the 3-year survival rate is 82%. We detected no significant posttransplantation differences in the serum creatinine concentration and in the estimated glomerular filtration rate between the study and control groups. The donor age and donor creatinine were the variables independently associated with DGF.

CONCLUSIONS

The results of transplantation of kidneys from elderly donors were comparable to those of transplantation from younger donors. Kidneys harvested from elderly donors should be used for a transplant after a preliminary assessment.

Living-Donor Versus Deceased-Donor Kidney Transplantation: Comparison of Psychosocial Consequences for Recipients

INTRODUCTION

Health benefits of a living-donor kidney transplantation are numerous and well known. There is, however, a dearth of knowledge on postoperative quality of life among the living-donor (LD) compared to deceased-donor (DD) transplant recipients.

MATERIALS AND METHODS

The study involved 89 patients after renal transplantation: 48 from LDs and 41 from DDs. Interview data indirectly indicated the patients' health, whereas physiological parameters directly pinpointed the patients' health and the graft function. All study participants completed questionnaires to measure quality of life and the specificity of emotional and cognitive functioning.

RESULTS

LD kidney recipients were younger than DD recipients (40 years vs. 49 years). LD and DD transplantation patients were similar in health status assessed by indirect methods (data from an interview) and direct methods (laboratory tests results). They, however, differed in their psychosocial functioning. LD patients had a greater sense of happiness (P < .01) and of self-efficacy (P = .07). Moreover, these patients were more actively involved in their social lives (P < .02) and were more satisfied with their social relationships (P = .07). LD recipients also had a higher quality of life in terms of mental functioning (P < .01) and satisfaction with their environments (P < .01). Additionally, there were significant correlations between quality of life and the quality of cognitive and emotional functioning in the group of LD recipients. The perceived impact of health on physical and professional activity and daily routines was similar in LD and DD groups.

CONCLUSIONS

LD post-transplantation patients may derive greater psychosocial benefits from this form of treatment. This effect is not dependent on somatic parameters (comparable data from an interview and laboratory tests results). This study suggests that patients should be assisted by a multidisciplinary healthcare team, and receive continuous support from relatives during the post-transplantation adaptation process. This facilitates the patients' postoperative quality of life.

Cardiovascular Risk Evaluated With the Use of Heartscore in Kidney Transplant Recipients-Three Years of Follow-up

BACKGROUND

Cardiovascular (CV) complications are the major cause of death in kidney transplant (KT) patients.

METHODS

During a 3-year follow-up, 112 KT recipients, from living (LD KTRs; n = 54), and deceased (DD KTRs; n = 58) donors, were assessed for 10-year risk of fatal CV events with the use of the Heartscore tool (www.heartscore.org). In post-KT months 6, 12, and 36, current and optimum (target) CV risks (CVRs) were estimated.

RESULTS

Current risk was lower in the LD KTRs and remained stable. In DD KTRs, the risk was at the highest level in months 6 and 12 of follow-up and decreased in month 36. Change in CVR, ie, the difference between the current and target risk, was the highest in DD KTRs in month 36 of follow-up (P = .014). In the increased-CVR group, recipients were older (P < .01), primarily male (P = .08), and more frequently smokers (P < .01) and had a higher systolic blood pressure (P < .05) despite taking more hypotensive medicines (P < .01), and had higher total cholesterol (P < .01) and low-density lipoprotein (P < .01) levels. In this group, body mass index (BMI) was higher (P < .01) and metabolic syndrome was diagnosed significantly more often (P < .01). The high-risk group (estimated CVR, ≥5) was different also in longer durations of pre-transplantation dialysis (P < .05) and higher rates of CV episodes before transplantation (P < .05). In logistic regression, higher BMI and lower estimated glomerular filtration rate (eGFR) were the parameters strongly correlated with higher CVR.

CONCLUSIONS

Mean CVR applicable to all kidney transplant recipients was stable throughout the follow-up. Changes in the risk affected mainly DD KTRs. In months 6 and 12, CVR was the highest in this group and was substantially reduced in the 3rd year of follow-up, probably owing to medical interventions. In the high-CVR group, impaired function of the transplanted kidney was recorded. CVR scores in patients with renal conditions and after kidney transplantation should additionally account for eGFR.

Nephropathy Evolving Within the First Two Posttransplant Months With No Typical Cytopathic Lesions: Two Cases Presentation

BACKGROUND

We report 2 cases of polyomavirus-associated nephropathy (PyVAN) emerging within the initial 8 posttransplant weeks. These cases were characterized by intraepithelial BK virus replication without typical nuclear inclusions in epithelial cells.

METHODS AND RESULTS

A 70-year-old male recipient of a cadaveric kidney transplant had experienced unsatisfying graft function since the time of transplantation (Tx). One month after Tx, results of a graft biopsy revealed mild tubulointerstitial inflammation. No intraepithelial nuclear inclusions suggestive of viral infection were present at that time. The patient received intravenous methylprednisolone, and the dosage of tacrolimus was increased. Due to a further drop in the glomerular filtration rate, a subsequent kidney biopsy was performed during posttransplant week 10, which revealed lesions typical of PyVAN. Retrospectively performed SV40 staining revealed that intragraft polyomavirus replication was already present on posttransplant day 30. Basic immunosuppression reduction and ciprofloxacin administration were followed by BK viremia elimination, stabilization of graft function, and resolution of PyVAN. In another patient, a 62-year-old male recipient of a cadaveric renal graft, BK viremia was monitored from the time of Tx. Two months after Tx, the patient was found to have a BK viral load of 6 × 4 log(10)/mL. Results of the graft biopsy revealed fully preserved tubular epithelium, but SV40 staining was positive in some of these cells. After basic immunosuppression reduction and introduction of ciprofloxacin, the BK viral load dropped to 1 × log(10)/mL with graft function stabilization.

CONCLUSIONS

PyVAN may emerge as early as 4 weeks after Tx, with near-normal or acute rejection-like graft morphology. The early monitoring of plasma BK viral load, as well as SV40 staining, avoids misdiagnosis of this severe posttransplant complication.

Bacterial and fungal infections in the early post-transplant period after kidney transplantation: etiological agents and their susceptibility

BACKGROUND

Infections remain serious complications in solid-organ transplant recipients, despite professional medical care, the introduction of new immunosuppressive drugs, and treatment that decreases the risk of infections.

METHODS

The study covered 295 adult patients undergoing kidney transplantation (KTx) between September 2001 and December 2007. All the patients were followed prospectively for infections from the KTx date and during the first 4 weeks after surgery. Samples of clinical materials were investigated for microbiological cultures. The microorganisms were cultured and identified in accordance with standard bacteriological procedures. Susceptibility testing was carried out through the use of Clinical and Laboratory Standards Institute procedures.

RESULTS

From 295 KTx recipients, 1073 clinical samples were taken for microbiological examination. Positive cultures were 26.9% (n = 289) of all samples tested; 525 strains were collected. Gram-positive bacteria were isolated in 52.2% (n = 274), Gram-negative bacteria were isolated in 40.8% (n = 214), and fungal strains were isolated in 7% (n = 37). Urine specimens (n = 582) were obtained from 84.5% of 245 recipients during the first month after transplantation. Among the isolated bacterial strains (n = 291), the most common were Gram-negative bacteria (56.4%). Gram-positive bacteria comprised 35.7%; fungal strains were found in 23 cases (7.9%). In surgical site specimens (n = 309), Gram-positive bacteria (72.1%) were the most common. Gram-negative bacteria comprised 24.4%. In blood specimens (n = 138), Gram-positive bacteria (81.6%) were the most common. Gram-negative bacteria comprised 15.8%; fungi were isolated in 2.6%. In respiratory tract specimens (n = 13), among the isolated bacterial strains (n = 8), the most common were Gram-positive bacteria (57.1%). Gram-negative bacteria comprised 14.3%; fungi were isolated in 28.6%.

CONCLUSIONS

Urine samples were predominantly positive after KTx. Our study showed Gram-positive bacteria in 52.2% after kidney transplantation. The proportion of isolates of multi-drug-resistant bacterial strains (MRCNS, vancomycin-resistant strains, high-level aminoglycoside-resistant strains, extended-spectrum beta-lactamase producers, and high-level aminoglycoside-resistant strains) was increased. These data indicate the need for strict adherence to infection control procedures in these patients.

Impact of pretransplant body mass index on early kidney graft function

BACKGROUND

An increase in the number of obese patients on transplantation waiting lists can be observed. There are conflicting results regarding the influence of body mass index (BMI) on graft function.

METHODS

We performed a single-center, retrospective study of 859 adult patients who received a renal graft from deceased donors. BMI (kg/m(2)) was calculated from patients' height and weight at the time of transplantation. Kidney recipients were subgrouped into 4 groups, according to their BMI: Groups A (<18.5; n = 57), B (18.6-24.9; n = 565), C (25-29.9; n = 198) and D (>30; n = 39). Primary or delayed graft function (DGF), acute rejection (AR) episodes, and number of reoperations, graft function expressed by glomerular filtration rate (GFR) and serum creatinine concentration and number of graft loss as well as the recipient's death were analyzed. The follow-up period was 1 year.

RESULTS

Obese patients' grafts do not develop any function more frequently in comparison with their nonobese counterparts (P < .0001; odds ratio [OR], 32.364; 95% CI, 2.174-941.422). Other aspects of the procedure were analyzed to confirm that thesis: Cold ischemia time and number of HLA mismatches affect the frequency of AR (OR, 1.0182 [P = .0029] and OR, 1.1496 [P = .0147], respectively); moreover, donor median creatinine serum concentration (P = .00004) and cold ischemia time (P = .00019) are related to delayed graft function. BMI did not influence the incidence of DGF (P = .08, OR; 1.167; 95% CI, 0.562-2.409), the number of AR episodes (P > .1; OR, 1.745; 95% CI, 0.846-3.575), number of reoperations, GFR (P = .22-.92), or creatinine concentration (P = .09). Number of graft losses (P = .12; OR, 1.8; 95% CI, 0.770-4.184) or patient deaths (P = .216; OR, 3.69; 95% CI, 0.153-36.444) were not influenced.

CONCLUSION

Greater recipient BMI at the time of transplantation has a significant influence on the incidence of primary graft failure.

Bacterial and fungal infections in the early post-transplantation period after simultaneous pancreas-kidney transplantation: etiological agents and their susceptibility

OBJECTIVE

This study aims to evaluate the frequency of microbial isolates and their susceptibility profiles cultured from clinical samples obtained from 26 simultaneous pancreas-kidney transplant (SPK) recipients suspected of infections during the early post-transplantation period.

PATIENTS AND METHODS

Data on microbiologic culture of 26 adult patients undergoing SPK were collected prospectively from 2001 to the end of 2006. Isolation and identification of cultured micro-organisms were performed according to standard microbiological procedures and commercially available tests. Susceptibility of the strains to antibacterial agents was made by the Clinical and Laboratory Standards Institute guidelines.

RESULTS

All the patients were followed prospectively for the first 4 weeks after surgery. In total, 263 samples from clinical materials obtained from 26 SPK recipients were cultured. Bacterial cultures were positive in 29.3% (n = 77) clinical samples. Of these, 219 microbial strains were cultured. Gram-positive bacteria were found in 64% (n = 140), Gram-negative bacteria in 22.8% (n = 50), and fungal strains were isolated in 13.2% (n = 29). Incidence rate values for subsequent isolation of micro-organisms in the sub-periods of time for decreasing the SPK were Gram-positive bacteria (102.3-18.7; I versus IV), growing the Gram-negative bacteria (14-46.1 I versus III) IV were 14, decreasing to fungi (22.1-1.6, I versus IV). Until now this early post-transplantation period was considered homogeneous time after transplantation. This study shows that this period is actually heterogenous, with statistically significant differences being observed between results obtained in consecutive 4 weeks after transplantation.

CONCLUSIONS

The results of this study show that the incidence rate was elevated with increasing age in the SPK group of patients. In the SPK group, our data showed the highest rate of isolation of micro-organisms compared with recipients of kidneys or liver.

Characteristics of potential living kidney donors and recipients: donor disqualification reasons--experience of a Polish center

INTRODUCTION

Kidney transplantation is efficacious as a renal replacement, particularly pre-emptive living donation. In Poland, the rate of transplantation of living donor kidneys is only 3%. The aim of the study was to identify the most common reasons to disqualify a potential living kidney donor.

METHODS

We evaluated 124 kidney donor candidates for 111 potential recipients at 1 medical center for genders and ages of donor and recipient; thus relation, donor disqualification reasons, number of potential donors for a particular recipient, prior transplantations, and kidney vasculature.

RESULTS

The 111 recipients of ages 2-62 years had, 1, 2, or 3 potential donors were tested in 101, 1, and 7, cases respectively. We had 18.9% recipients referred for pre-emptive transplantation; 59.5% were on haemodialysis and 21.6% on peritoneal dialysis. In all, 89% recipients sought first kidney transplantations. Kidneys were procured from 49/124 (39.5%) of the initially evaluated donors. The full examination was completed by 92 potential donors with 68/124 donors disqualified early. Single and multiple renal arteries were detected in 56 and 36 potential donors, respectively. Donor disqualification was due to medical contraindications (39.7%), earlier transplantation from a deceased donor (25%), immunologic constraints (23.5%), donor consent withdrawn (6%) or psychological and social reasons (4.4%).

CONCLUSIONS

A considerable number of donor candidates are disqualified for medical reasons.

Uridine diphosphate glucuronosyltransferase 2B7 variant p.His268Tyr as a predictor of kidney allograft early acute rejection

BACKGROUND

Uridine diphosphate glucuronosyltransferase (UGT2B7) is responsible for conversion of mycophenolic acid to mycophenolic acyl-glucuronide (acylMPAG). Conflicting data exist regarding the role of UGT2B7 p.His268Tyr (802C>T, rs7439366) variant in the clinical course following organ transplantation.

STUDY AIM

The aim of this study was to reveal an association between UGT2B7 p.His268Tyr (802C>T, rs7439366) polymorphism and kidney transplantation outcome. STUDY DESIGN, PATIENTS, AND METHOD: Genomic DNA of 235 kidney transplant recipients was genotyped for UGT2B7 802C>T using TagMan single nucleotide polymorphism (SNP) genotyping assay. Maintenance immunosuppression used mycophenolate mofetil (MMF) and cyclosporine A (n = 137) or tacrolimus (n = 98). Primary end-point was biopsy-confirmed acute rejection within 3 and 12 post-transplantation months. Secondary end-points included gastrointestinal side effects, leukopenia, lymphopenia, neutropenia, and infections. Statistical analysis was performed with the aid of SAS System using kernel-smoothed estimates of acute graft rejection hazard function. The log-rank test and hazard ratio were used to reflect association between UGT2B7 802C>T variant and risk of acute graft rejection.

RESULTS

Within 3 postimplantation months 38 (16.2%) patients experienced acute rejection; 33 were allele C carriers in UGT2B7 802C>T SNP and 5 were TT homozygotes (P < .0457). Allele C-associated risk of rejection was 2.50 and remained between 2.19 and 3.02 after adjustment for clinical confounders, ie, HLA mismatch, panel-reactive antibodies, donor age, repeated transplantation, induction therapy, donor type, delayed graft function, applied calcineurin inhibitor, or MMF dosing. We found no association between the polymorphism and gastrointestinal side effects, leukopenia, lymphopenia, neutropenia, and infections.

CONCLUSION

UGT2B7 802C>T genotyping may help identify patients with excessive early acute rejection risk.

Herpes encephalitis during natalizumab treatment in multiple sclerosis

In this case report we describe the first non-fatal herpes simplex virus encephalitis (HSE) case with natalizumab for multiple sclerosis (MS). A 36-year-old woman, previously treated with immunomodulatory and immunosuppressive drugs for MS, developed acute encephalitis after 6 monthly natalizumab perfusions. Brain imaging demonstrated suggestive bi-temporal lesions. Herpes simplex virus type-1 DNA was detected in cerebrospinal fluid. The patient improved gradually after a 21-day course of intravenous acyclovir, but neuropsychiatric changes remained 5 months later. Our non-fatal case of HSE and other reported cases of herpes infections provide evidence of an increased risk with natalizumab and point to the need for clinicians to maintain awareness.

Complications of transplantation of kidneys from expanded-criteria donors

BACKGROUND

Organ shortage is the primary barrier to kidney transplantation. To maximize organ use, organs from expanded-criteria donors (ECDs) have been used increasingly. Expanded-criteria donors are defined as individuals older than 60 years or older than 50 years with at least 2 of the following risk factors: hypertension, stroke as the cause of death, or serum creatinine concentration greater than 1.5 mg/dL.

OBJECTIVE

To assess the incidence of complications posttransplantation in ECD kidneys compared with kidneys from standard-criteria cadaveric donors (SCDs).

PATIENTS AND METHODS

One hundred seventy-two patients received cadaveric renal transplants between January 1, 2006, and August 31, 2008. Donor and recipient data were collected, as well as patient and graft survival and immediate, delayed, or slow graft function. Complication rates for lymphocele, urinary leak, thrombosis, hematoma, urinary tract infection, and cytomegalovirus infection were recorded. Follow-up was for 3 to 35 months, ending on November 30, 2008.

RESULTS

Overall, mean 1-year graft survival was 86.9%, and mean creatinine concentration was 1.58 mg/dL. One incidence of primary nonfunction (0.6%) was observed. More than 25% of transplanted kidneys were from ECDs. No significant differences were noted in postoperative complications between recipients of ECD or SCD organs.

CONCLUSION

The rate of complications in recipients of ECD and SCD kidneys is comparable.

Serum concentration of vitamin D and parathyroid hormone after living kidney donation

BACKGROUND

Metabolic consequences resulting from loss of renal mass in living kidney donors remain uncertain. There is recent focus on the changes in the active form of vitamin D because it is an agent for cancer regulation. The objective of the study was to measure serum concentrations of 1,25-dihydroxycholecalciferol, parathyroid hormone and insulin-like growth factor-1 (IGF-1) in living donors after kidney donation.

PATIENTS AND METHODS

Forty living kidney donors reported for follow-up visits. Their mean age was 46.14 years. They were women in 52.5% of cases. The mean observation period was 65.6 months. Serum 1,25(OH)2D3 and IGF-1 concentrations were measured by radioimmunoassay after extraction. Serum intact parathyroid hormone (PTH) was quantified using an enhanced chemiluminescence immunoassay system.

RESULTS

1,25-dihydroxycholecalciferol deficiency in 57.5% patients after nephrectomy was the most important change we noted. No correlation was observed between 1,25(OH)2D3 and PTH. A decreased serum IGF-1 concentration was observed in 17.5% of donors. However, decreases in both serum IGF-1 and 1,25(OH)2D3 concentrations were observed in 12.5% of donors.

CONCLUSION

Prospective studies may be essential to determine metabolic changes after nephrectomy among living kidney donors.

Molecular epidemiology of vancomycin-resistant Enterococcus faecalis among patients of transplantology wards

OBJECTIVE

Vancomycin-resistant enterococci (VRE) require epidemiological monitoring especially in transplantation wards. The aim of our work was to perform a molecular analysis of vancomycin-resistant Enterococcus faecalis (VREfl) strains among solid organ recipients during various years.

MATERIALS AND METHODS

Strains were examined for the presence of different genes determining vancomycin resistance: vanA, vanB, vanD, or vanG by polymerase chain reaction (PCR). Restriction fragment length polymorphism (RFLP)-pulsed field gel electrophoresis (PFGE) was performed on bacterial DNA digested with SmaI enzyme.

RESULTS

From 2003 to 2006, we isolated 12 strains of VREfl from 8 patients (2 liver and 6 kidney transplantations). All strains harbored the vanA gene. Among the strains, 5 displayed patterns similar to each other, despite being isolated from different patients, and were susceptible to ampicillin with high resistance to aminoglycosides.

CONCLUSIONS

These results suggested that a single strain of VREfl was present for 3 years in closely related hospital wards, but it disappeared in the following years.