Correlation between Plasma Carnitine, Muscle Carnitine and Glycogen Levels in Maintenance Hemodialysis Patients

Chronic hemodialysis (HD) may lead to losses of carnitine from plasma and muscle. Plasma carnitine does not reflect the body content of carnitine. The purpose of this study was the evaluation of total and free plasma and muscle carnitine concentrations (TPC, FPC, TMC, FMC), muscle glycogen and the relationship between plasma and tissue carnitine content and the basic indices of lipid metabolism in HD patients. The studies were conducted in two groups: the first one consisted of 37 HD patients (19 F, 18 M), the second one served as the control and was composed of 29 (10 F, 19 M) patients with healthy kidneys. Tissue specimens in HD patients were taken during surgery on arterio-venous fistula from brachioradial muscle. Carnitine and glycogen measurements were performed using enzymatic methods according to Cederblad and Huijng respectively. Total cholesterol (CH), HDL-CH, and triglycerides were assayed by enzymatic commercial test system (Boehringer-Mannheim, Germany). To summarise, we found the following phenomena in our HD patients in comparison with the controls: 1) In plasma: similar TPC but decreased FPC levels and FPC/TPC ratio which may suggest free carnitine deficiency. 2) In muscle: significantly lower TMC and FMC levels but normal FMC/TMC ratio. 3) Negative correlation between TMC and FMC levels and duration of dialysis treatment. 4) No correlation between plasma and muscle carnitine concentration. 5) Significantly higher concentration of muscle glycogen which could be explained by the changes in the structure of muscle fibres in HD patients and/or lower physical activity. 6) A positive correlation between FPC/APC or FPC/TPC ratio and HDL-CH in HD patients which may suggest that an appropriate proportion between free and acylcarnitines may influence HDL-CH levels in that population. (Int J Artif Organs 2000; 23: 90–6)

Evaluation of Gore-Tex Graft Patency in Hemodialysis Access

Aim

The purpose of this retrospective study was to analyze the patency and complications of Gore-Tex grafts used in hemodialysis (HD) access.

Methods

In the last 16 years, 1649 surgical procedures were performed on 655 patients to ensure and maintain permanent HD access. The study group consisted of 64 HD patients on whom 81 vascular synthetic PTFE Goretex grafts were performed. There were 28 males and 36 females, 3 of them were children (4.7%). Mean age was 54.2 years (range 15–77). Two types of Gore-Tex prosthesis were used: Diastat and Stretch. All grafts were implanted in the upper extremities. Kaplan-Meier survival curves were calculated to determine primary and secondary patency. Log-rank analysis was used to determine differences between curves.

Results

Primary and secondary patency at 12 months was 52.5% and 67.5%, and at 18 months respectively 41.5% and 58.2%. The Diastat graft had a lower primary and secondary patency compared with the Stretch graft (respectively p = 0.02 and p = 0.008). Factors such as gender, coexisting diabetes and hypertension did not determine graft patency. Thrombosis was one of the most frequent complications. The remaining complications included stenosis, pseudoaneurysms, infection, steal syndrome and seroma.

Conclusion

On the basis of our experience Stretch grafts appear a better option for creating vascular access for HD than Diastat grafts.

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.

Interrelationship between Cardiac Structure and Function and Incidence of Arrhythmia in Peritoneal Dialysis Patients

Cardiovascular complications in patients with end-stage renal disease requiring dialytic therapy are frequent and account for approximately 40% of all deaths in these patients. The aim of this study was to analyze the occurrence of cardiac arrhythmia in peritoneal dialysis (PD) patients with respect to the changes in left ventricular structure and function. To determine characteristics of arrhythmia in patients on PD for chronic renal failure, 30 patients (18 male and 12 female; aged 54.1±13.8 years) underwent twice (interval of 20±4.1 months) ambulatory 24 hour Holter ECG monitoring. At the same time all the patients were analyzed by echocardiography and pulsed Doppler echocardiography to estimate cardiac structure and function. Ventricular arrhythmias were seen in 9 patients (30%) during the first examination and in 13 patients (43.3%) on the second. Ventricular arrhythmias were observed only in patients with left ventricular hypertrophy (LVH). Supraventricular arrhythmias were seen in 12 (40%) and 17 (56.7%) patients. The majority of these patients also had LVH, with 11/12 (91.7%) patients at the first examination and 15/17 (88.2%) at the second respectively. We conclude that the incidence of arrhythmia is primarily dependent on the presence of LVH in PD patients. It appears that peritoneal dialysis does not provoke or aggravate arrhythmia.

Beneficial Clinical Effects of Ozonated Autohemotherapy in Chronically Dialysed Patients with Atherosclerotic Ischemia of the Lower Limbs - Pilot Study

Ozonated autohemotherapy is a controversial but successful method of treatment, used in particular in European countries. There are many fields in which medical ozone could be of value: treating different infections, immunodeficiency syndromes, neoplasms. Encouraging results have also been achieved in the treatment of atherosclerotic ischemia of the lower limbs. In this preliminary study, the influence of blood ozonation on the intensity of symptoms of ischemia of the lower extremities was analysed among dialysed patients with chronic renal failure. We examined 5 hemodialyzed patients and 7 patients treated with peritoneal dialysis immediately before and after 14 sessions of ozonated autohaemotherapy. Eleven patients (91.6 %) reported a subjective decrease in perceived intensity of ischemic pains, or observed prolongation of intermittent claudication distance. During march tests performed on a treadmill, we found significant prolongation of intermittent claudication distance in all examined patients – 65.6% (mean value, p (≤0.01). Patients treated with peritoneal dialysis achieved much greater improvement than did hemodialyzed patients (165% vs. 42%). We concluded that autohemotherapy with ozone, in a concentration of 34.4 mcg/ml of blood, is safe, easily applied and may be useful In the therapy of atherosclerotic ischemia of lower extremities among dialyzed patients. It could also be a complement to current treatment, especially in cases where the latter has failed.

The Role of Automated Peritoneal Dialysis in Peritoneal Dialysis Programme: One Centre Experience

The results of the Automated Peritoneal Dialysis (APD) therapy in adult patients in the Department of Nephrology in Gdansk during the years 1995–98 are presented. Seventeen patients (8-M, 9-F) aged 25–86 years (mean age 55.3 years), including 7 diabetics, were treated with different forms of APD. The most common indication for APD therapy was patients' loss of ability to perform Continuous Ambulatory Peritoneal Dialysis due to progressive blindness, leg amputation related to diabetic foot complications or cerebrovascular episodes (8 pts). The cumulative therapy period was 231.5 patient-months.

During the observation 4 patients died, 1 received kidney transplant and 12 were still treated with APD at the end of the study. No patient was transferred to long-term hemodialysis. The peritonitis rate in the APD group was 1/57.5 patient-months. Most patients reached adequacy targets, the mean Kt/V value was 1.97 (range 1.17 - 2.36). To achieve this, 12–19 litres of dialysate were used per day (mean 14.6 L/d). There were significant differences between CCPD and NPD groups with respect to dialysis adequacy, body weight and dialysis fluid volume. We conclude that APD may be used with success in patients in whom continuation of CAPD or HD therapy is very difficult due to its complications or comorbid conditions.

Comparison of the Quality of Life in Hemodialysed (HD) and Peritoneally Dialysed (CAPD) Patients using the EORTC QLQ-C30 Questionnaire

Background

The aim of the paper was to assess reliability and validity of the QLQ-C30 questionnaire in studying the quality of life in dialysed patients, and then to compare the life quality in patients on hemodialysis (HD), continuous ambulatory peritoneal dialysis (CAPD) and healthy controls. The present study included 65 HD patients, 22 CAPD patients and a group of 76 healthy volunteers.

Methods

Quality of Life Questionnaire (QLQ-C30), Hospital Anxiety and Depression Scale (HADS), Cantrill ladder.

Results

The EORTC QLQ-C30 questionnaire appeared to be a reliable and valid tool for assessing the quality of life in dialysis patients. HD patients had significantly poorer quality of life in the areas of physical, social, cognitive and emotional functioning in comparisons to the controls. CAPD patients were not significantly different life quality-wise from controls, except for their social and professional life.

Aortic Valve Replacement and Perioperative Management in Hemodialyzed Patient wth Antiphospholipid Syndrome

Antiphospholipid syndrome is characterized by the presence of antiphospholipid antibodies, hypercoagulability, and prolonged phospholipid-dependent coagulation indices such as activated clotting time (ACT). Perioperative thrombotic complications are frequent among patients with antiphospholipid syndrome submitted to cardiac surgery, therefore, in these patients, heparin-protamine titration for anticoagulation monitoring is particularly recommended. We demonstrate a case of 42-year-old hemodialyzed patient with antiphospholipid syndrome, submitted to the replacement of stenotic aortic valve. In our patient celite ACT and heparin concentration during cardiopulmonary bypass did not correspond to each other. Anticoagulation based on heparin concentration assessment resulted in safe perioperative hemostatic management.

Erythrocyte Metabolism during Renal Anemia Treatment with Recombinant Human Erythropoietin

Recombinant human erythropoietin (epoetin) is widely used for the treatment of renal anemia. The aim of our study was to determine the influence of epoetin on erythrocyte metabolism. Thirty-six hemodialysis patients (22 men, 14 female), aged from 17 to 64 years (mean age 43) and 30 healthy volunteers (12 men, 18 female), aged from 25 to 65 years (mean age 40) were studied. Epoetin (Eprex, Janssen-Cilag) was administered subcutaneously with the starting dose of 2000 IU three times per week for twelve months (range from 75 to 133 IU/kg/week, mean dose 102±21 IU/kg/week). Laboratory markers of: hematological response, iron status and erythrocyte metabolism were measured before epoetin administration. Afterwards the markers were controlled every three months. During epoetin treatment a significant increase in hemoglobin concentration was observed (100% patients responded in a positive way to epoetin). The following changes in erythrocyte metabolism were noticed: 1) in glycolytic enzymes: a significant increase in the activity of hexokinase and that of lactate dehydrogenase, 2) in glycolytic intermediates: a significant increase in the 2,3-diphosphoglycerate and adenosine triphosphate concentrations, 3) a significant increase sodium, potassium adenosine triphosphatase concentration, 4) the glucose uptake by erythrocytes significantly decreased while the lactate production remained stable.

During anemia treatment with epoetin in hemodialysis patients not only quantitative but also qualitative changes in erythrocytes were observed.

Natural Killer Cell Activity Unaffected by Ozonated Autohemotherapy in Patients with End-Stage Renal Disease on Maintenance Renal Replacement Therapy

Ozonotherapy is a complementary medical approach in the treatment of resistant infections, immune deficiency syndromes, orthopedic pathologies and vascular diseases. The criticism of this method is associated with potentially harmful effects of ozone on cells. The aim of this study was to investigate the influence of ozonated autohemotherapy (O3-AHT) on the cellular response of the immunologic system represented by cytotoxic activity of natural killer cells. 12 hemodialyzed patients (8 M, 4 F) aged 64.8±7.6 years with peripheral arterial disease as the main reason for the treatment with O3-AHT were examined in a prospective, placebo controlled, single blind study. They received 9 sessions of autohemotherapy without ozone exposure as a placebo-control and subsequent 9 sessions of O3-AHT. The procedures were performed 3 times a week, just before hemodialysis session. Ozone-oxygen gas mixture with ozone concentration of 50 μg/ml produced by ozone generator (ATO3, KrioMetrum, Poland) was used during O3-AHT. Natural killer cell activity was measured using lactate dehydrogenase release assay. There was no statistical difference between natural killer cell activity (%) at the baseline (16.78±8.07), after nine sessions of control autohemotherapy (15.98±6.67), and after nine sessions of O3-AHT (18.26±8.82). In conclusion, our findings showed that O3-AHT in a dose of 50 mg/mL does not have any significant influence on natural killer cell function in hemodialyzed patients.

Kaposi Sarcoma in the Genital Area in a Kidney Transplant Patient: A Case Report and Literature Review

BACKGROUND

Kaposi sarcoma (KS) is a cancer with an incidence in patients after transplantation (Tx) that is 500 times greater than that in the healthy population. The risk of KS increases significantly during therapy, especially when immunosuppressive therapy with cyclosporine A (CsA) is used. Most cases of KS develop during the first 2 years after transplantation. After a KS diagnosis, it is recommended to reduce the doses of immunosuppressive medications. Conversion of immunosuppressive treatment into mammalian target of rapamycin (m-TOR) inhibitors is strongly suggested.

PATIENTS AND METHODS

We present the case of a 65-year-old man with end-stage renal disease (ESRD) of unknown etiology, who had kidney transplantation in 2008. Immunosuppressive protocol was based on CsA, mycophenolate mofetil (MMF) and prednisolone (PRE). In 2011, during the dermatological consultation, on the penis glans a purple stain of uneven surface was noted. Histology study revealed the presence of KS. The treatment was modified. The patient was converted from CsA to everolimus. Before converting, the creatinine concentration was 1.79 mg/dl and proteinuria less than 0.3 g/day.

RESULTS

The change in the scheme of immunosuppresion from CsA to everolimus was performed to treat the Kaposi sarcoma. Gradually, within a year, the KS was cured. However, the graft function deteriorated, and the graft was lost in one-years' time.

CONCLUSION

We present the first documented case of KS in the genital area of a kidney patient. The reduction in the strength of immunosuppression, and the introduction of an m-TOR inhibitor, may have contributed to the deterioration of kidney function, however it was substantial in the treatment of KS.

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.

Influence of Body Mass on Kidney Graft Function in Patients After Kidney Transplantation

BACKGROUND

Increasing evidence shows that body mass may play a role in complications after kidney transplantation and influence graft and patient survival. The aim of this study was to analyze the association between graft function and both the body mass and adipokines (leptin, visfatin, adiponectin) in kidney transplant recipients.

METHODS

We studied 183 kidney transplant recipients from the Department of Nephrology, Transplantology and Internal Disease, Medical University of Gdansk. Anthropometry and body composition examinations were performed using an electronic scale, hand grip dynamometer, and BCM - Body Composition Monitor (Fresenius, Germany). Obesity, overweight, and underweight were defined according to body mass index (BMI) classification. Blood urea nitrogen, creatinine, blood morphology, lipidogram, albumin, and C-reactive protein were measured. Estimated glomerular filtration rate (eGFR) was calculated according to the Chronic Kidney Disease Epidemiology Collaboration formula. Leptin, visfatin, and adiponectin were measured by ELISA methods.

RESULTS

Underweight was found in 16 (8.7%) KTR, overweight and obesity were observed in 68 (37.1%) and 26 (14.2%) patients, respectively. No relation between BMI and eGFR in all groups was noted, but in the early period after transplantation a correlation between BMI and creatinine and eGFR was observed. In all studied patients (also patients in the early posttransplantation period), eGFR significantly correlated with leptin and visfatin. Multiple regression analysis confirmed an association between eGFR and leptin and visfatin in all studied populations and between eGFR and BMI in the group examined shortly after transplantation.

CONCLUSIONS

Sarcopenic overweight and obesity prevail in KTR. In the short-term but not long-term period after transplantation, worse graft function was associated with high BMI. An association between graft function and leptin and visfatin was noted.

Homogeneity and elemental distribution in self-assembled bimetallic Pd-Pt aerogels prepared by a spontaneous one-step gelation process

Multi-metallic aerogels have recently emerged as a novel and promising class of unsupported electrocatalyst materials due to their high catalytic activity and improved durability for various electrochemical reactions. Aerogels can be prepared by a spontaneous one-step gelation process, where the chemical co-reduction of metal precursors and the prompt formation of nanochain-containing hydrogels, as a preliminary stage for the preparation of aerogels, take place. However, detailed knowledge about the homogeneity and chemical distribution of these three-dimensional Pd-Pt aerogels at the nano-scale as well as at the macro-scale is still unclear. Therefore, we used a combination of spectroscopic and microscopic techniques to obtain a better insight into the structure and elemental distribution of the various Pd-rich Pd-Pt aerogels prepared by the spontaneous one-step gelation process. Synchrotron-based extended X-ray absorption fine structure (EXAFS) spectroscopy and high-angle annular dark-field (HAADF) scanning transmission electron microscopy (STEM) in combination with energy-dispersive X-ray spectroscopy (EDX) were employed in this work to uncover the structural architecture and chemical composition of the various Pd-rich Pd-Pt aerogels over a broad length range. The Pd80Pt20, Pd60Pt40 and Pd50Pt50 aerogels showed heterogeneity in the chemical distribution of the Pt and Pd atoms inside the macroscopic nanochain-network. The features of mono-metallic clusters were not detected by EXAFS or STEM-EDX, indicating alloyed nanoparticles. However, the local chemical composition of the Pd-Pt alloys strongly varied along the nanochains and thus within a single aerogel. To determine the electrochemically active surface area (ECSA) of the Pd-Pt aerogels for application in electrocatalysis, we used the electrochemical CO stripping method. Due to their high porosity and extended network structure, the resulting values of the ECSA for the Pd-Pt aerogels were higher than that for a commercially available unsupported Pt black catalyst. We show that the Pd-Pt aerogels possess a high utilization of catalytically active centers for electrocatalytic applications based on the nanostructured bimetallic framework. Knowledge about the homogeneity and chemical distribution of the bimetallic aerogels can help to further optimize their preparation by the spontaneous one-step gelation process and to tune their electrocatalytic reactivity.

Great figures of Polish Nephrology - Participants of the Warsaw Uprising 1944

In 1944, during the World War II, many doctors and many medical students participated in the Warsaw Uprising. This group also comprised future nephrologists, professors of medicine, founders of Polish nephrology, dialysis and transplantology centers. We presented 3 of great polish nephrologists who participated in medical services in the Warsaw Uprising: Zygmunt Hanicki, Andrzej Manitius and Tadeusz Orłowski.

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.

Adipokines and nutritional status in kidney transplant recipients

BACKGROUND

Obesity and disturbances of adipokine concentrations are often recognized in kidney transplant recipients (KTRs). Leptin plays a key role in regulating energy intake and expenditure, including appetite and hunger, metabolism, and behavior. Adiponectin modulates certain metabolic processes, including glucose regulation and fatty acid oxidation, and exerts some weight-reduction effects. Visfatin has various functions, including the promotion of vascular smooth muscle cell maturation and inhibition of neutrophil apoptosis. It also activates insulin receptors and has insulin-mimetic effects, lowering blood glucose and improving insulin sensitivity. The aim of this study was to evaluate the prevalence of leptin, adiponectin, and visfatin and nutritional status abnormalities in stable KTRs.

METHODS

Eighty KTRs aged 52.4 ± 14.0 years participated in the study. Nutritional status was determined with the use of the 7-point Subjective Global Assessment (SGA), anthropometric measurements (bioimpedance analysis), and serum concentration. Concentrations of leptin, adiponectin, and visfatin were measured with the use of enzyme-linked immunosorbent assay.

RESULTS

Mean time after transplantation and estimated glomerular filtration rate (eGFR; Modification of Diet in Renal Disease formula) were 82.5 ± 56.5 months and 42.0 ± 15.0 mL/min/1.73 m(2), respectively; 29 (36.2%) of the KTRs, despite high body mass index (BMI ≥25 kg/m(2)), presented mild malnutrition (SGA ≤5). BMI, content of body fat, and leptin concentration correlated positively with time from transplantation and negatively with eGFR. Additionally, patients with BMI ≥25 kg/m(2) presented significantly higher leptin-to-adiponectin ratios compared with lean patients (3.5 vs 1.1, respectively; P < .05). KTRs with eGFR ≥60 mL/min/1.73 m(2) presented significantly lower leptin concentration and BMI.

CONCLUSIONS

Despite high BMI, mild malnutrition was present in one-third of KTRs. Increased BMI, abdominal obesity, and high leptin concentration were aggravated by time from transplantation and deterioration of graft function. Overweight/obesity and incorrect leptin-to-adiponectin ratio could increase cardiovascular risk in KTRs.

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.

A randomized study evaluating cinacalcet to treat hypercalcemia in renal transplant recipients with persistent hyperparathyroidism

Persistent hyperparathyroidism (HPT) after kidney transplantation (KTx) is associated with hypercalcemia, hypophosphatemia and abnormally high levels of parathyroid hormone (PTH). In this randomized trial, cinacalcet was compared to placebo for the treatment of hypercalcemia in adult patients with persistent HPT after KTx. Subjects were randomized 1:1 to cinacalcet or placebo with randomization stratified by baseline corrected total serum calcium levels (≤11.2 mg/dL [2.80 mmol/L] or >11.2 mg/dL [2.80 mmol/L]). The primary end point was achievement of a mean corrected total serum calcium value<10.2 mg/dL (2.55 mmol/L) during the efficacy period. The two key secondary end points were percent change in bone mineral density (BMD) at the femoral neck and absolute change in phosphorus; 78.9% cinacalcet- versus 3.5% placebo-treated subjects achieved the primary end point with a difference of 75.4% (95% confidence interval [CI]: 63.8, 87.1), p<0.001. There was no statistical difference in the percent change in BMD at the femoral neck between cinacalcet and placebo groups, p=0.266. The difference in the change in phosphorus between the two arms was 0.45 mg/dL (95% CI: 0.26, 0.64), p<0.001 (nominal). No new safety signals were detected. In conclusion, hypercalcemia and hypophosphatemia were effectively corrected after treatment with cinacalcet in patients with persistent HPT after KTx.