Soluble Complement Component 1q Receptor 1 (sCD93) Is Associated with Graft Function in Kidney Transplant Recipients

Cluster of differentiation 93 (CD93), also known as complement component 1q receptor 1 is a transmembrane glycoprotein expressed in endothelial and hematopoietic cells and associated with phagocytosis, cell adhesion, angiogenesis and inflammation. The extracellular part, soluble CD93 (sCD93), is released to body fluids in inflammation. Data on sCD93 in kidney diseases are limited. Our aim was to evaluate serum sCD93 in long-term kidney transplant recipients as a marker of inflammation and endothelial dysfunction that may be potentially useful in early recognition of graft dysfunction. Seventy-eight adult patients with functioning kidney graft and stable clinical state were examined at least one year after kidney transplantation. Serum sCD93 was measured by enzyme immunosorbent assay. Estimated glomerular filtration rate (eGFR) and albuminuria or proteinuria were assessed at baseline and over one-year follow-up. Increased sCD93 was associated with lower baseline eGFR independently of the confounders. Moreover, sCD93 was negatively associated with eGFR during one-year follow-up in simple analysis; however, this was not confirmed after adjustment for confounders. Baseline sCD93 was positively associated with baseline albuminuria and with increased proteinuria during the follow-up. Serum sCD93 was not correlated with other studied inflammatory markers (interleukin 6, C-reactive protein, procalcitonin and C3 and C4 complement components). To the best of our knowledge, this is the first report regarding the concentrations of sCD93 in kidney transplant recipients and one of the first reports showing the inverse association between sCD93 and renal function. Serum sCD93 should be further evaluated as a diagnostic and prognostic marker in renal transplantation.

Urinary NGAL Measured after the First Year Post Kidney Transplantation Predicts Changes in Glomerular Filtration over One-Year Follow-Up

Currently, serum creatinine and estimated glomerular filtration rate (eGFR) together with albuminuria or proteinuria are laboratory markers used in long-term monitoring of kidney transplant recipients. There is a need for more sensitive markers that could serve as early warning signs of graft dysfunction. Our aim was to assess the urinary concentrations of neutrophil gelatinase-associated lipocalin (NGAL) as a predictor of changes in kidney transplant function after the first year post-transplantation. We prospectively recruited 109 patients with functioning graft at least one year after the transplantation, with no acute conditions over the past three months, during their control visits in kidney transplant ambulatory. Urinary NGAL measured on recruitment was twice higher in patients with at least 10% decrease in eGFR over 1-year follow-up compared to those with stable or improving transplant function. Baseline NGAL significantly predicted the relative and absolute changes in eGFR and the mean eGFR during the follow-up independently of baseline eGFR and albuminuria. Moreover, baseline NGAL significantly predicted urinary tract infections during the follow-up, although the infections were not associated with decreasing eGFR. Additionally, we assessed urinary concentrations of matrix metalloproteinase 9-NGAL complex in a subgroup of 77 patients and found higher levels in patients who developed urinary tract infections during the follow-up but not in those with decreasing eGFR. High urinary NGAL in clinically stable kidney transplant recipients beyond the first year after transplantation may be interpreted as a warning and trigger the search for transient or chronic causes of graft dysfunction, or urinary tract infection.

Comparison of Kidney Transplant Function, Lipid Metabolism Disorders, and Glucose and Hemoglobin Concentration in Transplant Patients Treated With Proliferation Signal Inhibitor (Everolimus) or Calcineurin Inhibitor (Tacrolimus)

INTRODUCTION

After kidney transplantation (KTx) in patients with diagnosed cancers, calcineurin inhibitor tacrolimus (TAC) is replaced by sirolimus or everolimus (EV).

OBJECTIVE

The objective of the study was to compare the lipid metabolism parameters, KTx function, and glucose and hemoglobin (Hgb) levels in patients treated with EV to those on TAC.

MATERIAL AND METHODS

The retrospective study included 114 patients: 54 (17 women and 37 men) aged 57.6 years (18-77 years) treated with EV and 60 (18 women and 42 men) aged 49.6 years (20-77 years) treated with TAC as a control group. Their total cholesterol (TC), triglycerides (TG), fasting glucose (FG), serum creatinine (SCr), Hgb, and estimated glomerular filtration rate (eGFR) were assessed. In the patients treated with EV, the above values were evaluated before conversion, as well as 12 and 24 months following the switch and were evaluated once in the group treated with TAC.

RESULTS

In the EV-treated group, the mean preconversion values after 12 and 24 months were as follows: TC 5.06, 6.59, and 5.98 mmol/L; TG 1.90, 2.48, and 2.20 mmol/L; FG 94.95, 97.85, and 104.05 mg/dL; SCr 1.46, 1.44, and 1.56 mg/dL; Hgb 12.46, 12.83, and 13.36 g/dL; and eGFR 50.3, 50.6, and 50.5 mL/min/1.73 m². In the patients on TAC, the authors obtained the following values: TC 4.6 mmol/L; TG 1.87 mmol/L; glucose 104.13 mg/dL; SCr 1.51 mg/dL; Hgb 13.96 g/dL; and eGFR 56.6 mL/min/1.73 m².

CONCLUSIONS

After conversion from TAC to EV, increased values of TC and TG were observed after 1 year, while the increased values of TC, TG, SCr, Hgb, and FG were observed after 2 years.

Post-transplant Lymphoproliferative Disorder in a Patient After Kidney Transplant, 5-Year Follow-up: A Case Report

INTRODUCTION

Post-transplant lymphoproliferative disorder (PTLD) is a serious, life-threatening complication in organ transplant patients receiving immunosuppressive therapy. The risk factors include Epstein-Barr virus infection and a cumulative dose of the immunosuppression.

CASE REPORT

We present a 5-year follow-up case of a 28-year-old patient with PTLD in the gastrointestinal tract. In the ninth month after kidney transplant, the patient was hospitalized for pain in the abdomen and diarrhea. Physical examination demonstrated tenderness in the area of the cecum, and colonoscopy revealed ulcerations in the large intestine. Polymorphic lymphoma (PTLD) was found in the collected samples. The patient received monotherapy treatment with anti-CD20 antibodies, resulting in complete remission of disease, confirmed by computed tomography scan and colonoscopy.

CONCLUSION

PTLD may have a different clinical course and should be considered in the differential diagnosis of patients after organ transplant.

Beneficial effect of kidney transplantation from a deceased donor on severe chronic refractory intradialytic hypotension - a case report

BACKGROUND

Chronic refractory hypotension (IDH, intradialytic hypotension) is a rare but serious problem encountered in patients on hemodialysis. Patients with chronic hypotension are often disqualified by transplant teams from renal transplantation. This is due to the possibility of an enormous risk of ischemic complications.

CASE PRESENTATION

We describe a 44-year old female patient with severe refractory hypotension (mean BP 60/30 mmHg, the lowest 48/28 mmHg), which appeared after bilateral laparoscopic nephrectomy of the infected kidneys. The kidney transplantation from a deceased donor, with infusion of the two pressor amines (dopamine, dobutamine) was performed without technical complications and the blood pressure measurements were 100-120/70-80 mmHg. The immunosuppression regimen was tacrolimus (TAC) + mycophenolate mophetil (MMF) and steroids (GS). Pressor amines were discontinued on the 18th day after the transplantation. Because of delayed graft function, 4 hemodialysis treatments were performed. The patient was discharged from the hospital on the 22nd day with good function of the transplanted kidney (the concentration of serum creatinine 117 μmol/l). During one-year follow-up, the patient has been remaining stable with a very good graft function (serum creatinine 84 μmol/l) and normal blood pressure (115/70 mmHg).

CONCLUSIONS

Proper preparation and adequate perioperative treatment allowed for safely performing kidney transplantation in the patient with severe IDH.

A Cluster of Fatal Tick-borne Encephalitis Virus Infection in Organ Transplant Setting

Background

Tick-borne encephalitis virus (TBEV) infection has become a major health problem in Europe and is currently a common cause of viral brain infection in many countries. Encephalitis in transplant recipients, althrough rare, is becoming a recognized complication. Our study provides the first description of transmission of TBEV through transplantation of solid organs.

Methods

Three patients who received solid organ transplants from a single donor (2 received kidney, and 1 received liver) developed encephalitis 17-49 days after transplantation and subsequently died. Blood and autopsy tissue samples were tested by next-generation sequencing (NGS) and reverse transcription polymerase chain reaction (RT-PCR).

Results

All 3 recipients were first analyzed in autopsy brain tissue samples and/or cerebrospinal fluid by NGS, which yielded 24-52 million sequences per sample and 9-988 matched TBEV sequences in each patient. The presence of TBEV was confirmed by RT-PCR in all recipients and in the donor, and direct sequencing of amplification products corroborated the presence of the same viral strain.

Conclusions

We demonstrated transmission of TBEV by transplantation of solid organs. In such a setting, TBEV infection may be fatal, probably due to pharmacological immunosuppression. Organ donors should be screened for TBEV when coming from or visiting endemic areas.

[Recovery of renal function and comorbidities in patients with acute kidney injury in the course of severe cardiovascular complications]

INTRODUCTION

Acute kidney injury (AKI) is a frequent, serious and sometimes unreversable complication in patients with cardiovascular disease. The aim of the study was to evaluate the frequency of recovery renal function and commorbidities in patients with AKI complicating severe cardiovascular diseases.

MATERIAL AND METHODS

A retrospective analysis of 246 patients (157 men and 89 women aged 67.9 ± 14.8 years) with AKI in the course of severe cardiovascular diseases, hospitalized in intensive care units and words of nephrological profile in years 2000-2011 were performed. Analysis was based on surveys data collected by regional consultant on the field of nephrology. Based on these data precise information about recovery of renal function was present in 143 documents.

RESULTS

In the studied group of 143 patients recovery of renal function was observed in 39 subjects (27.3%). Kidney dysfunction before AKI was observed in 116 patients from the whole study group (47.2%). Such commorbidities like: myocardial infarction, sudden cardiac arrest, diabetes, arterial hypertension, chronic obstructive pulmonary disease or performed operations and grade of biochemical disturbances had no significant influence on recovery of renal function. Complications observed during AKI and anemia negatively influenced on recovery of renal function (p<0.001 and p = 0.007). Patients staying longer at hospital has more frequent recovery of renal function (p = 0.014).

CONCLUSIONS

Probability of renal function recovery in patients with AKI in the course of severe cardio-vascular complications is low.

[Fatty acid profile in phospholipids fraction with regard to blood pressure control in the kidney transplant patients]

INTRODUCTION

Hypertension is diagnosed in over 50% of renal transplant patients, and its presence is associated with significantly increased risk of cardiovascular complications. The pathogenesis of hypertension in this group of patients is complex. The use of immunosuppressive drugs is among the most important risk factors due to their hypertension-inducing properties. It is also suspected, that fatty acids may play an important role in the development of the disease; however, the mechanism of its formation has not yet been fully elucidated.

AIM

Evaluation of fatty acid profile in phospholipids fraction in the blood serum of patients after renal transplantation, with respect to the blood pressure and immunosuppressive drug used.

MATERIALS AND METHODS

The study included 65 kidney transplant patients treated with immunosuppressants: 24 patients received CsA (9 women, 15 men) and 41 were treated with Tac (15 women, 26 men). Blood pressure level was estimated by taking an average value of the last 3 measurements in an outpatient setting. Blood pressure exceeding 140/90 mmHg was considered as abnormally high. The number of antihypertensive drugs administered was based on the analysis of patients’ records and direct interviews with patients. The concentration of each fatty acid was determined using gas chromatography. Statistical analysis was performed using Statistica 10.

RESULTS

There were no statistically significant differences between both: systolic blood pressure (136.16 vs. 133.31 mmHg, p=0.499) and diastolic blood pressure (80.62 vs 80.76; p=0.962) in patients treated with CsA compared to those taking Tac. Patients treated with CsA, received – on average – more antihypertensive drugs, compared to the group of patients taking Tac (2.64 vs 2.17), but this difference was also not statistically significant (p=0.174). The profile of fatty acids in renal transplant recipients treated with CsA was similar in both with normal blood pressure and with elevated blood pressure. In case of patients treated with Tac, significantly lower concentrations of C14 (p=0.015), C16:1 (p=0.039), C18:1 (p=0.043) and MUFA (monounsaturated fatty acids; p=0.049) were found in patients with higher values of blood pressure, compared to the ones whose blood pressure was within the norm. A significantly higher concentration of fatty acids: C14 (p=0.029), C16:1 (p=0.049) and C20:5 (p=0.029) was found in patients with normal blood pressure, treated with Tac as compared with treated with CsA. In contrast, regardless to the immunosuppressive drug used, no statistically significant differences were found between the patients’ groups with elevated blood pressure values.

CONCLUSION

The prevalence of hypertension in renal transplant recipients treated with CsA and Tac is similar. The fatty acid profile in phospholipids fraction depends on the blood pressure and the immunosuppressant used.

[Risk factors of death occurrence in patients with acute kidney injury in the course of severe cardio-vascular complications]

INTRODUCTION

Acute kidney injury (AKI) is a frequent and serious complication in patients with cardiovascular disease. The aim of the study was to evaluate the risk of death in patients with AKI complicating severe cardiovascular diseases.

MATERIAL AND METHODS

A retrospective analysis of 246 patients surveys (157 men and 89 women aged 67.9 ± 14.8 years) with AKI in the course of severe cardiovascular diseases, hospitalized in intensive care units and words of nephrological profile in years 2000-2011 were performed.

RESULTS

The majority of patients (95.9%) with AKI required hemodialysis treatment. The mortality rate in the study group was high and amounted to 69.5% and the recovery of renal function was observed in 39 patients (27.3%). Kidney disease before the onset of AKI was observed in 116 patients (47.2%). Patients with arterial hypertension have more frequently oligoanuria (p = 0.001), needs more hemodialysis sessions (p = 0.029) and stay longer in hospital (p = 0.012). In multivariate analysis, the occurrence of death depend on such factors as: the lack of recovery of renal function, bleeding from gastrointestinal tract, urinary tract infections, and other infectious and noninfectious complications.

CONCLUSIONS

No recovery of renal function and comorbidity while AKI in the course of severe cardiovascular diseases increase the risk of death.

Location of nonmelanoma skin cancers in patients after kidney transplantation

INTRODUCTION

Long -term use of immunosuppressant therapy makes kidney transplant recipients particularly susceptible to infections and skin cancers.

OBJECTIVES

The aim of the study was to evaluate the type and location of nonmelanoma skin cancers (NMSCs) in patients after kidney transplantation.

PATIENTS AND METHODS

The study included 486 patients (296 men and 190 women; mean age, 46.1 ±13.1 years) after deceased -donor kidney transplantation, most of whom received triple immunosuppressive therapy. Patients underwent skin examination. All suspicious lesions were thoroughly described in terms of their type, size, and location. Only patients with histologically confirmed malignancy were included in the study.

RESULTS

Of all 486 patients, 25 were diagnosed with 53 NMSCs, including 39 basal cell carcinomas, 13 squamous cell carcinomas, and 1 case of Bowen's disease. The lesions were observed on the face (n = 34), upper limb (n = 8), neck (n = 6), and trunk (n = 5).

CONCLUSIONS

Most NMSCs were located on the sun -exposed areas, emphasizing the effect of ultraviolet radiation on the pathogenesis of skin cancers. The presence of lesions on the skin that had not been exposed to the sun indicates that a physical examination of the entire skin is necessary.

[Reccurent Clostridium difficile infection in patient after kidney transplantation on rituximab therapy due to PTLD (Post-Transplant Lymphoprolipherative Disorder). First experience with Fidaxomicin use--case report]

Clostridium difficile infection (CDI) is an increasingly problem in everyday clinical practice. The most important risk factor of this infection is antibiotics use. The incidence of Clostridium difficile associated diarrhea (CDAD) in patients after renal transplantation is estimated to be about 6% in the early postoperative period. Due to the applied immunosuppression and frequent infections requiring intensive, broad spectral antibiotics, the later prevalence of CDAD may remain at a similar level. Massive diarrhea caused by Clostridium difficile may lead to fluctuations in immunosuppressive drugs concentration, in renal transplant patients. The authors present a case study of a 23-year old patient after kidney transplantation from deceased donor, with diagnosed polymorphic PTLD (Post-Transplant Lymphoproliferative Disorder). During biological treatment with rituximab in this patient 4 recurrences of CDI were observed. In this article the clinical manifestation of recurrent CDAD are presented. The authors discuss therapeutic procedure with fidaxomicin use, its results and influence on immunosuppressive drugs concentration.

[Risk factors of non melanoma skin cancers in kidney transplant patients]

Non melanoma skin cancers (NMSC) represent a major challenge within the ever growing group of different organs recipients. The aim of the study was to evaluate risk factors influencing on frequency appearance of NMSC in patients after kidney transplantation. The clinical dermatological examination was performed in 486 patients after kidney transplantation consisted of 296 man (60.9%) and 190 woman (30.1%) in the mean age 46.1 +/- 13.1 (18-74 years) with median time after transplantation 74.3 +/- 52.1 months. Most of them (80.7%) before transplantation were treated by maintenance hemodialysis. Patients after kidney transplantation were checked by dermatologist for all skin abnormalities based on iniciated skin cancers screening program. All discovered abnormalities were described, their type, size, localization and results of histopathological examination were collected. The obtained results were analyzed based on t-Student's, Mann-Whitney's, chi-square and Fisher tests. Out of 486 studied patients, 53 NMSC were diagnosed in 25 kidney recipients including 39 basal cell carcinoma (BCC), 13 squamous cell carcinoma (SCC) and 1 Bowen's disease. The proportion of BCC to SCC was 2.79. NMSC occurred more often on sun skin exposure area, especially on the face. Almost all (96.2%) of the cancers were diagnosed in patients older than 50 years of age. Patients with NMSC comparing with those without were significantly older (52.8 +/- 7.8 vs. 41.0 +/- 7.8; p < 0.0001), have longer post-transplant period and have more frequent positive anamnesis of this cancer. There was no significant relationship between NMSC appearance and sex, cause of kidney failure, HLA mismatch, blood group as well as Rh factor.

CONCLUSIONS

Older age of patients while transplantation, longer time of immunosuppressive therapy and previous NMSC are independent predictors of new skin cancers appearance.

Cutaneous viral infections in patients after kidney transplantation: risk factors

INTRODUCTION

 Infectious skin lesions are a common complication in renal transplant patients receiving immunosuppressive therapy.

OBJECTIVES

 The aim of this study was to assess the prevalence and factors contributing to the development of viral skin infections in kidney transplant patients.

PATIENTS AND METHODS

 The study included 486 patients, 296 men (60.9%) and 190 women (39.1%), aged 46.1 ±13.1 years, 74.3 ±52.1 months post‑transplantation, who remained mostly on triple immunosuppressive therapy. All skin lesions detected during the dermatological examination were described in detail, and the type, size, exact location, dependence on age, sex, and the used immunosuppressive therapy were established. Patients were followed for 5 years.

RESULTS

 Infectious skin lesions of viral origin were diagnosed in 189 of 486 patients (38.9%). The most frequent infections were viral warts (38.5%), which were more common in older patients (47.6 vs. 45.0 years, P <0.033). Viral warts were observed more often in men (P <0.031). Lesions of viral origin occurred more often in patients treated with immunosuppressive drugs for a longer period of time (53 vs. 37 months; P <0.021) and those who received azathioprine and cyclosporine A (P <0.001). In a multivariate logistic regression analysis, therapy with azathioprine was the only factor associated with increased risk of these complications (P <0.007).

CONCLUSIONS

 Older age, male sex, and longer duration of immunosuppressive therapy affect the incidence of infectious skin lesions in patients after kidney transplantation. Treatment with cyclosporine A and azathioprine promotes the development of infectious viral warts.

[The evaluation of cost-effectiveness and cost-utility of valganciclovir for the prophylaxis of cytomegalovirus disease to 200 days after kidney transplantation]

Standard procedure for cytomegalovirus disease (CMV) prophylaxis in kidney transplant patients was the administration of valganciclovir for up to 110 days after organ transplant. This prophylaxis has been extended up to 200 days in Poland since 2011. The decision was based on the results of clinical trials which showed significant clinical benefit in case of prolonged administration of the drug. The aim of the analysis was to provide the economic evaluation of extending the CMV prophylaxis with co-financed from public funds Valcyte (valganciclovirum; 60 tab. a 450 mg; Roche Polska Sp. z o.o.) from 110 to 200 days, in the high risk patients group after kidney transplant (seronegative recipient and infected donor, D+/R-). The analysis was performed from the Polish healthcare payer's perspective.

MATERIAL AND METHODS

All methods used in the following study were consistent with the Requirements of the Polish HTA Agency (AHTAPOL). The cost-effectiveness and the cost-utility analysis were performed on the basis of a randomised study which was identified as a result of the systematic search of the medical databases, comparing 200 days valgancyclovir administration with 100 days drug use as a prophylaxis of CMV disease in the patients group mentioned above. The Markov model was developed, simulating the disease evolution over time considering a high risk patient after kidney transplant treated with valgancicloviras the CMV disease prophylaxis. The disease period was divided into health states that are the most probable for this condition and the transitions probabilities between them were identified and assigned. Based on the clinical trial results, registry database of health conditions usability and experts' opinion, all health states (i.e. death, kidney transplant, CMV disease) were attributed with utilities and costs. The direct costs, important from the Polish healthcare payer's perspective, were included in the analysis. Extension of the proposed model in the series of one month time cycles made it possible to assess long-term (assumed time horizon was median patient's life expectancy--23,5 years) costs and clinical effects of the compared technologies.

RESULTS

The Incremental Cost-Effectiveness Ratio (ICER) was 39 669 008 PLN and The Incremental Cost-Utility Ratio (ICUR) was 48 008 PLN in the specified time horizon. The result is well below the accepted threshold of profitability in Poland (assuming tripled GDP per capita cost-utility threshold, i.e. 99 543 PLN), which means that the therapy is cost-effective.

CONCLUSIONS

The results of the analysis confirmed that the 200 days use of valganciclovirin the prevention of CMV disease compared to standard 110 days therapy is economically justified from the Polish healthcare payer's perspective.

[Comparison of the prevalence frequency of infectious skin changes in dialyzed patients and after kidney transplantation]

Due to graft preserving immunosuppressive therapy, renal transplant recipients are predisposed to the development of a variety of skin infections and skin cancers. The aim of the study was to compare prevalence frequency of infective skin changes among patients after kidney transplantation and the dialyzed population. Clinical dermatological examination was performed in 486 patients after renal transplantation. The group consisted of 296 men (60.9%) and 190 women (30.1%), of mean age 46.1+/-13.1 (18-74 years) with median time after transplantation of 74.3+/-52.1 months. Most of the patients (80.7%) before transplantation were treated by maintenance hemodialysis. The most frequent immunosuppression regiments were combination of cyclosporine A (CsA) with mycofenolate mofetil (MMF) and steroids (GKS)-207 patients (42.5%); tacrolimus (TAC) with MMF and GKS-102 (20.9%) and CsA with azathiopine and GKS-53 patients (10.9%). The group of 112 dialyzed patients consisted of: 57 males (50.9%) and 55 females (49.1%), aged 57.4+/-15.4 years without history of immunosuppressive therapy and were on maintenance dialysis for 63.2+/-74.0 months. Most of this group (77.7%) was on maintenance hemodialysis, while the remaining 22.3% on peritoneal dialysis. The obtained results were analyzed based on t-Student's, Mann-Whitney's, chi-square and Fisher tests. It was shown that infective skin changes were significantly more frequent in the group of patients after kidney transplantation as compared with the dialyzed population. They were observed in 53.9% and 9.8% of the studied populations, respectively (p<0.0001). In the studied group after kidney transplantation the most frequent were viral changes (38.9%). Fungal infection was observed in 25.9% of these patients, while bacterial in 1.2% of this study group. In the dialyzed population fungal infections were diagnosed in 8.9%, while viral in 3.6% of patients. No bacterial changes were observed in this group. Acne was observed in 16.5% of patients after kidney transplantation.

CONCLUSIONS

1. In the group of patients after kidney transplantation receiving immunosuppressive therapy viral, fungal and bacterial infective skin changes were significantly more frequent as compared with the dialyzed patients. 2. The most frequent skin changes observed in patients after kidney transplantation were viral warts.

[Factors influencing on the prevalence frequency of infectious skin changes of bacterial and fungal origin in patients after kidney transplantation]

Infective skin changes are frequent complications in patients after kidney transplantation receiving immunosuppressive therapy. The aim of the study was to evaluate factors influencing on frequency and type of skin infections of bacterial and fungal origin in patients after kidney transplantation. The study was performed in 486 patients, 296 male (60.9%) and 190 female (39.1%) aged 46.1 +/- 13.1 years (18-74 years) 74.3 +/- 52.1 months after kidney transplantation remain mainly on triple immunosupresive therapy. Type, size and localization of skin changes revealed during dermatological evaluation were described according age, sex, and applied immunosuppression. The obtained results were analyzed based on t-Student's, Mann-Whitney's, chi-square and Fisher tests. It was shown that fungal infective skin changes in patients after kidney transplantation are more frequent in older population (48.4 +/- 11.8 vs. 45.2 +/- 13.4 years; p < 0.017). The significant differences concern interdigitale mycoses 49.7 +/- 11.1 vs. 45.4 +/- 13.3 years; p < 0.009, nail mycoses 51.5 +/- 10.4 vs. 45.5 +/- 13.2 years; p < 0,004 and foot mycoses 51.8 +/- 10.7 vs. 45.5 +/- 13.2 years; p < 0.0005. In male more frequent as compare with female were also fungal infections (30.7% vs. 18.4%; p < 0.002) including pityriasis versicolor 37.0% vs. 9.5%; p < 0.016 and interdigitale mycoses 18.6% vs. 9.0%; p < 0.004.

CONCLUSIONS

Infective skin changes frequency in patients after kidney transplantation on immunosuppressive therapy depends on advanced age, male sex, and applied immunosuppressive therapy.

[Evaluation of immunosuppressive treatment on homocystein levels in patients after kidney transplantation during a 2 year observation period]

The aim of the study was to evaluate the influence of the type of prescribed immunosuppression: cyclosporine A (CsA) vs. tacrolimus (Tac) on remote homocystein levels in patients (pts) after kidney transplantation (Ktx).

PATIENTS AND METHODS

The study included 51 pts (17 F, 34 M) aged 15 to 62 years (mean 38.1) after cadaver Ktx. The mean observation period equaled 21.2 months (6 -24); while total observation period was 90 personlyears. Before Ktx, 46 pts were treated with maintenance hemodialysis (HD), while 5 by peritoneal dialysis (PD). After Ktx, patients had immunosuppression prescribed according to the following schemes: prednisone (P) + CsA + azathioprine (AZA) - 12 pts; P + CsA + mycophenolate mofetil (MMF) -26 pts; P + Tac + MMF - 11 pts; and P + Tac + AZA - 2 pts. Hcy level was measured using high performance liquid chromatography (HPLC). Serum creatinine level was measured by standard method using the Hitachi 917 analyzer. Creatinine clearance was calculated based on the Cockcroft-Gault formula. Patient's blood was drawn before Ktx and 3, 6, 9, 12,15, 18, 21 and 24 months post procedure.

RESULTS

Delayed graft function (DGF) after Ktx was diagnosed in 29 pts (56.9%) and this group required from 4 to 28 HD sessions (mean 14 sessions). Hcy level did not significantly differ between pts requiring (29 pts) and not requiring (22 pts) HD treatment after Ktx. It was also noted that the number of performed HD sessions did not significantly correlate with Hcy levels 24 months after Ktx (R =0.04, p=0.81). No relationship was found (non-parametric Spearman test) between the drop in Hcy level 3 months after Ktx as compare with value before Ktx and ischemia time (R=0.09, p=0.49), number of compatible HLA A and B (R=0.07, p=0.63), and DR antigens (R=0.09, p=0.51). Decrease in Hcy level (before Ktx and 24 months after Ktx) did not significantly correlate with the above parameters, respectively: R=-0.14, p=0.40; R=0.06, p=0.73; R=0.12, p=0.45; R=0.11, p=0.50. Decrease in Hcy level (before Ktx and 3 months after) did not differ significantly when compared to pts receiving immunosuppressive therapy CsA vs. Tac (p=0.18). Even though notable differences were observed in the drop in Hcy level (immunosuppressive treatment scheme CsA vs. Tac) in measurements before Ktx and 24 months post (respectively: 27% and 57.6%), no statistical significance was noted (p=0.13). Using the Mann-Whitneys' Test, no statistical significance was noted (p=0.13) when comparing differences in creatinine clearance between the group of pts receiving CsA and Tac 24 months after Ktx. Patients treated with Tac achieved a higher creatinine clearance by 16.5% when compared with those receiving CsA. No significant differences were observed between these two groups (p=0.65) when serum creatinine levels were evaluated.

CONCLUSIONS

Incidence of DGF, as well as prescribed immunosuppressive therapy does not have an influence on remote Hey levels in pts after Ktx. Graft function seems to be the main predictor that influences Hcy levels after Ktx in this group of pts.

[Influence of elevated homocystein level and selected lipid parameters in kidney transplant patients on the progression of atherosclerotic changes assessed by intima-media thickness index (CCA-IMT)]

The aim of the study was to evaluate the influence of elevated homocystein (Hcy) level and selected lipid parameters on the progression of atherosclerotic changes in patients after kidney transplantation (KTx).

PATIENTS AND METHODS

The study included 51 pts (17 F, 34 M) aged 15-62 years (median 38.1) after cadaver KTx. The mean observation period equaled 21.2 months (6-24 months); while total observation period was 90 patients/ years. Hcy levels was measured using HPLC, Lp(a) and Apo-B levels using the nephelometric method and total cholesterol with its' HDL and LDL fractions, triglycerides and creatinine based on the Hitachi 917 analyzer. Patients' blood was drawn before renal transplantation and 3, 6, 9, 12, 15, 18, 21 and 24 months after KTx. Common carotid artery intima media thickness (CCA-IMT) was evaluated by ultrasound on 14 days, 12 and 24 months after KTx.

RESULTS

CCA-IMT correlated significantly with Hcy levels after 12 months (R=0.53; p=0.0009) and 24 months (R=0.38; p=0.0356) after KTx. Significant differences were found 12 and 24 months after KTx in CCA-IMT between patients with normal (<15 micromol/l) and increased (>15 micromol/ l) mean Hcy concentrations: p=0.0035 and p= 0.015, respectively. Analyzing changes in CCA-IMT, significant differences were noted when comparing the CCA-IMT increment after 12 and 24 months post KTx in patients with normal (< or =15 micromol/l) and increased (>15 micromol/l) homocystein concentrations: p=0.049 and p=0.0039, respectively. Increment of CCA-IMT 12 months after KTx, significantly correlated with mean total cholesterol level (R=0.35; p=0.0333), whereas 24 months after procedure correlated significantly with 0.0315).

CONCLUSIONS

Hcy level is an independent risk factor for atherosclerosis development in patients after KTx. Elevated Hcy level as well as increased cholesterol and Lp(a) levels enhance the progression of atherosclerotic changes evaluated by CCA-IMT in KTx patients.

[Post transplant lymphoprolipherative disorder (PTLD) in patients after kidney transplantation--clinical manifestation, treatment and prognosis]

Post transplant lymphoprolipherative disorder (PTLD) is a very severe, life threatening complication after organ transplantation. In adults after kidney transplantation the frequency of this complication is 0.3-3%; whereas in children 0.4-10%. Epstein-Barr virus infection discovered in 90% of patients, as a result of immunosuppression, plays an important role in the PTLD etiology. There is a coincidence between heavy immunosuppression, especially its cumulative doses, and the increased risk of lymphoprolipherative disorder. The clinical manifestation of PTLD may present as: mononucleosis like syndrome (fever, pharyngitis, tonsillar enlargement, lymphadenopathy), or as a rapid progressive course presenting with severe acidosis, lymphadenopathy, dysfunction of graft and other internal organs, where infiltration may mimic tumour like appearance. The present paper discusses methods and effectiveness of PTLD treatment, which aims to restore effectiveness of the immunological system, elimination of neoplastic cells and EBV.

[Post transplant lymphoproliferative disorder (PTLD)--10 years follow-up]

PTLD is a very severe, life threatening complication after organ transplantation. A 17 years old female patient with kidney transplanted (KTx) 7th months ago on immunosuppression therapy: Tacrolimus (TAC), Cell Cept (MMF), Encorton (Enc) was described. She was admitted to the hospital due to: fever, abdominal pain, diarrhea and enlarged cervical and inguinal lymph nodes on palpation. Histopathological diagnosis revealed monomorphic PTLD; diffuse large B cell lymphoma, immunoblastic. Treatment of PTLD was started immediatly after the final diagnosis. MMF was stopped, dose of TAC was reduced (blood level 3-4 ng/ ml), Enc were continued. Anti-CD20 antibodies (Rituximab) were administered. After 7 days of treatment the patient developed signs of diffuse peritonitis. In the course of surgery, perforation in six sites of the small intestine and sigmoid colon were discovered. The Hartman's surgery was performed (sigmoidectomy) with formation of temporary sigmoideostomy. Resected parts of intestine and sigmoid colon were infiltrated by immnunoblasts and revealed diffuse necrosis - the same process was seen in lymph nodes. After the wounds healed, Rituksymab was continued (8 doses) and chemotherapy was started - CHOP - 6 cycles every month. Eight months after surgery, full remission was obtained, TAC was change to rapamycine (RAP) and closure of sigmoideostomy was performed. At present, almost 10 years after first symptoms of PTLD, the patient remains in full remission of the disease.

[Analysis of selected inflammatory markers in patients with stable renal graft (RTx) 36 months after transplantation]

Chronic inflammation is an inherent feature of chronic renal failure. Successful renal transplantation (RTx) is the only known renal replacement therapy sufficient to reverse most of the metabolic disturbances of chronic uremia, although still some of these abnormalities may be present or even new problems may occur (mostly as the side effects of immunosuppressive drugs). The aim of this study was to evaluate the level of inflammation in 20 patients (9 F, 11 M, aged mean 44.0 +/- 11.8 years) with well-preserved renal function 36 months after kidney transplantation, using serum levels of selected cytokines (IL-6, IL-18, TNFalpha and soluble receptor for TNF - sTNFRII), acute phase proteins (CRP, fetuin A) and hepatocyte growth factor (HGF). Procalcitonin was also assessed as the sensitive indicator of active infection. Obtained results were compared with the control group of healthy subjects in a respective age. Serum levels of IL-6, TNF-R and IL-18 were significantly higher, and HGF and fetuin A--significantly lower in patients vs. controls (p < 0.05 for all differences). Significant negative correlations were noted between glomerular filtration rate (GFR) and serum TNF, sTNFRII and IL-18 in RTx patients, whereas strong positive relationship between GFR and fetuin A was observed. Serum creatinine correlated with IL-6, IL-18, TNFalpha, sTNFRII and hsCRP levels and serum urea-with TNFalpha, sTNFRII, IL-6 and IL-18. Significant negative associations were also noticed between serum fetuin A and most of the tested inflammatory markers: sTNFRII (r = -0.77; p = 0.0005), IL-6 (r = -0.63; p = 0.009), hsCRP (r = -0.62; p = 0.009) and IL-18 (r = -0.60; p = 0.01). Obtained results permit us to conclude that the increased activity of inflammation can still be noticed in RTx patients 36 months after successful engraftment. This process is inversely associated with the level of kidney function. The role of fetuin A as the 'negative' acute phase protein was also demonstrated in this group of patients.

[Urological complications in patient after kidney transplantation. Correction of ureter stenosis with consequent proper renal graft function]

Urological complications constitute significant problem following renal transplantation. Incidence ranges from 4 to 14% in graft recipients. The most important aspects concerning these complications are early diagnosis and prompt treatment, any delay in diagnosis and management may lead to deterioration of renal graft function or graft loss. The following case report discusses management of hydronephrosis in renal graft caused by ureter stenosis due to scarring and fibrosis of its distal end after remote kidney transplantation. The patient was a 33-year-old woman with previous history of end stage renal failure in the course of chronic glomerulonephritis. A triple drug immunosuppressive regimen consisting of Azathioprine (AZT), Cyclosporine A and Encorton (AZT + CsA + Encorton) was administered during a period of three years after kidney transplantation. At this time AZT administration was discontinued due to chronic viral hepatitis type B. Episodes of expansion sensation (discomfort) and graft pain were reported by the patient which after 3 days were followed by a period of oliguria and then anuria. The patient was admitted to the Department of Nephrology CMUJ, where ultrasound imaging revealed graft hydronephrosis. In the presence of such clinical and biochemical indications due to acute graft failure, one hemodialysis session, was performed. The patient was transferred to the Urological Department CMUJ where ureter exploration was attempted, but was unsuccessful. Subsequently percutaneous nephrostomy was performed which lead to immediate diuresis. Next, distal ureter stenosis (located by the urinary bladder) was surgically removed and reimplantation of the ureter was carried out. Due to early diagnosis and surgical reconstruction of the transplanted ureter, renal graft function returned to normal requiring only one hemo-dialysis session.

[Factors influencing prevalence and clinical course of cytomegalovirus (CMV) infection in kidney transplant patients]

In the paper the authors tried to identify factors influencing prevalence and clinical course of cytomegalovirus (CMV) infection in kidney transplant patients. The study was performed in the group of 100 patients after cadaveric kidney transplant followed up in the Chair and Department of Nephrology, Collegium Medicum, Jagiellonian University in Krakow. CMV infection was demonstrated to occur more frequently and significantly earlier in the patients administered prednisone, cyclosporin A and mycophenolate mofetil, compared to the group treated with standard triple-drug-therapy (prednisone, cyclosporin A, azathioprine) or double-drug-therapy (prednisone, cyclosporin A). Higher serum levels of cyclosporin A did not increase prevalence of the infection but urged its onset. Risk for CMV infection was however higher in the group of patients treated for acute rejection episodes, especially with antilymphocyte preparations. No differences were shown in the immunological matching within HLA-A, -B and -DR antigens between the patients without features of CMV Infection and those treated for its active form. The infection occurred significantly more frequently in the recipients with HLA-A1 antigen than in those with HLA-A9 and -DR7. In patients with delayed transplanted kidney functioning, time of the infection onset and a number of its episodes were similar to the remaining population, however severity of the clinical course positively correlated with the duration of acute tubular necrosis (ATN). CMV infection occurred slightly more frequently in patients requiring transfusions compared to those not administered blood preparations. Among patients with AB blood type, active CMV infection occurred statistically less frequently, whereas in those with other blood types percentage of patients with/without CMV infection were comparable.

[Results of kidney transplantation in Krakow in 1992-2000]

The aim of the study was an analysis of renal transplantation results in the Krakow Transplant Center during 1992-2000. The analysis concerned 94 cadaveric transplant recipients. The study group included 31 females aged 23 to 61 years (mean 40.4 years) and 63 males aged 16 to 60 years (mean 41.8 years). The time of pre-transplant renal replacement therapy ranged from 4 to 120 months (mean 32 months). The mean time of total ischaemia was 22 hours 20 minutes. The majority of the recipients had three identical antigens out of six typed. Most of the recipients were treated with three immunosuppressive drugs including: Cyclosporine A, Azathioprine and steroids. Immediately after kidney transplantation 25.6% of the patients had urine output and did not require dialysis. Acute renal failure (ARF) of the graft was observed in 73.2% recipients. The average number of hemodialysis sessions in patients presenting ARF was 10. Acute rejection was diagnosed in 41.5% of the patients. The most frequent complications were: CMV (cytomegalovirus) infection, UTI (urinary tract infection) and policytemia. In the study group 1-year survival rate of the patients was 97.8% and 1-year graft survival was 93.61%. The 5-year survival rates both in the patients and the grafts were very satisfactory (96.96% and 87.7% respectively).

Cytomegalovirus infection in kidney transplant patients: clinical manifestations and diagnosis

Cytomegalovirus (CMV) infection is an important cause of morbidity and mortality after solid organ transplantation. CMV infection after kidney transplantation was confirmed in 19 (54.3%) out of 35 patients. 16 of these (84.2%) developed CMV disease. CMV infection was diagnosed based on a fourfold or greater increase of anti-CMV IgG antibody titre, detection of CMV-IgM antibodies and/or virus isolation. Primary infection was observed in 3 patients, reactivation in 9 and an undefined type of infection in 7. In most patients (63%), infection was diagnosed in the first 2 months, and in 3 patients, after 3, 5 and 9 years following kidney transplantation. The most frequent symptoms of CMV disease were fever (58%), pneumonitis (26.3%) and enterocolitis (15.8%). In 53% of the patients, CMV infection co-occurred with other pathogens such as Candida albicans. Cryptococcus neoformans, bacteria or viruses (HBV, HCV, HSV). Treatment with polyvalent globulin (Sandoglobin) or hyperimmune globulin (Cytotect), in combination with ganciclovir in 7 patients, resulted in a regression of CMV disease.