The evolution of weight and body composition in renal transplant recipients: Two-year longitudinal study

Previous series have reported weight gain after kidney transplantation. However few studies have investigated the body composition after kidney transplantation, particularly during longitudinal follow-up. In this prospective study, we assessed the changes in body composition after kidney transplantation. We also analyzed the effect of steroid withdrawal from the immunosuppressive regimen on weight gain and body composition.

METHODS

Thirty-eight cadaveric kidney transplant recipients were followed for 2 years posttransplant. Total and segmental body composition were measured by dual energy X-ray absorptiometry (DEXA) at the time of transplantation as well as 3, 6, 12, and 24 months later.

RESULTS

In 28 patients (group A), prednisone was stopped by month 6, whereas, in 10 patients (group B), it was continued throughout the study. In the overall patient group, there were no significant changes in body weight. However, a trend to increased weight was observed in group B. In this group, patients showed an early increase in total body fat with a central accumulation of fat mass that was maintained during the follow-up period. On the other hand, total lean mass increased significantly in group A but did not change significantly in group B.

CONCLUSION

In summary, overall the group showed no major changes in body weight during the 2 years after transplantation. Steroid withdrawal in kidney transplant recipients may have a significant positive effect on body composition.

[Prevention of malnutrition in peritoneal dialysis patients]

Malnutrition is a frequent and serious problem for patients treated by peritoneal dialysis. Patients' survival depends on their nutritional status at the initiation of the dialysis treatment. Main malnutrition factors are inflammation, insufficient dialysis dose, peritoneal glucidic absorption and protein loss within the dialysate. These patients show a relationship between malnutrition, inflammation and cardiovascular diseases. To prevent malnutrition, it is necessary to reduce inflammation by improving dialysis solutions' biocompatibility and optimising the sodium regulation. The peritoneal membrane exposure to both glucose and its degradation products must also be reduced. In order to restrict protein losses, especially when peritoneal hyper permeability occurred, dialysis solutions containing amino acids can be used. Early dialysis treatment and a progressive increase of the dialysis dose corresponding to the decrease of the residual renal function can also be recommended.

[Distal vascular access for chronic hemodialysis in patients over 65 years of age. Surgical results]

OBJECTIVE

To evaluate the results of vascular accesses for chronic haemodialysis in elderly patients.

MATERIAL AND METHODS

56 consecutive vascular accesses for haemodialysis were performed from November 1993 to December 1995 in patients over the age of 65 years. The policy adopted was to prefer distal accesses: only forearm accesses, primary arteriovenous fistula (AVF) or radio-M venous bioprosthesis shunt (AVS) were performed. Surgical or interventional radiological reoperation rates and abandonment rates were evaluated.

RESULTS

13 AVF (mean age: 74.5 years) and 43 AVS (mean age: 73.8 years) were analysed. The mean number of reoperations was significantly higher in the shunt group. 1 out of 13 AVF was abandoned versus 9 out of 43 AVS (no significant difference).

DISCUSSION

AVS gave poor results in terms of reoperation rate, inducing a high cost and impairment of the quality of life of these patients. Their survival in this population was comparable to that of AVF. Several teams prefer to perform first-line humero-cephalic or humero-basilic arteriovenous fistulas whenever a simple fistula in the forearm cannot be performed. They appear to give better results, but their use in the elderly is poorly evaluated. Peritoneal dialysis may be preferable to haemodialysis in the elderly. As vascular accesses are increasingly performed in elderly subjects with a reduced life expectancy, protection of the proximal venous capital does not appear to be a sufficient argument to justify the use of AVS in this population.

CONCLUSION

This study encouraged us to abandon the use of prostheses in the forearm in favour of direct accesses in the arms.

Peritoneal ultrafiltration and refractory congestive heart failure

This prospective nonrandomized study enrolled 16 patients with congestive heart failure [NYHA (New York Heart Association) III and IV] refractory to a maximal well-tolerated drug therapy. The aims were to evaluate if peritoneal ultrafiltration (PUF) could improve clinical conditions and to determine morbidity secondary to resistant congestive heart failure (RCHF) and PUF. There were 16 patients (12 male, 4 female) with a mean age of 65.4 years (56-81 years) and follow-up of 15.6 months (4-33 months). Thirteen patients had RCHF without end-stage renal disease. Patients were classified as NYHA class IV (n = 11) or class III (n = 5). One anuric patient had been on previous hemodialysis and switched to APD. PUF was obtained with a 2-L hypertonic dialysis solution, once a day (n = 7) or every 2 days (n = 4). Clinical improvement was obtained for all the patients. Weight decreased from 72.2 to 66.7 kg with a weekly ultrafiltration of 3.74 L (2.2-6.5 L). Sodium removal was 79 mmol/day (urinary 43%, peritoneal transport 57%). During the follow-up period, 2 patients received a cardiac transplant since 7 died due to cardiac reasons. Mean hospitalization time was 4.4 and 1.20 per patient per day before and after PUF, respectively. Hospitalization was in keeping with either RCHF (36%), dialysis complications (16%), or miscellaneous causes (48%). Our experience showed that a functional improvement and a better quality of life were achieved for all these patients with a low rate of hospitalization.

[Rheumatoid purpura during pregnancy]

We report the case of a 26 year old woman who presented a Henoch Schönlein purpura at 13 weeks' gestation. IgA glomerulonephritis without pejoratif feature was confirmed by renal biopsy. Corticosteroid therapy was unsuccessful on nephrotic syndrome. At 25 weeks' gestation foetal death occurred followed by a rapid development of end stage renal failure.

[Quantitative detection of pp65 intraleukocyte cytomegalic antigen in renal transplantation]

OBJECTIVE

To assess the clinical value of quantitative assay of leukocyte cytomegalovirus antigen (LCA) in the management of immunodepressed patients.

METHODS

Thirty-three kidney transplant recipients followed a weekly follow-up protocol during the first 3 months after transplantation. LCA was compared with cytomegalovirus (CMV) detection in blood using fibroblast cell culture and with serology tests. LCA was expressed in number of positive cells per 2.10(5) leukocytes, detected by immunofluorescence with a specific monoclonal antibody directed against the pp65 antigen. The standard culture method and a rapid centrifuge method were used for blood samples. The serum level of anti CMV antibodies was determined by ELISA.

RESULTS

CMV infection defined as positive viraemia and/or positive serology tests was diagnosed in 22 of the 33 patients. LCA was detected in 20 patients, including all those with clinical signs of infection. Serology was the only method giving a positive diagnosis in 2 patients and was negative in 3 infections positive for LCA. Viraemia was negative in 2 patients positive for LCA. LCA was detected in 60 of the 65 blood samples with a positive viraemia test and in 46 of the 165 negative samples (sensitivity 92% and specificity 72%). Quantitatively, LCA in samples taken from patients with clinical signs was higher than that in samples taken from asymptomatic patients (51 +/- 5 versus 20 +/- 2, p < 0.001). In addition, LCA was detected a mean 7.6 +/- 4 days before significant changes in serology tests, 2.2 +/- 1.6 days before the viraemia and 7.1 +/- 1 days before clinical manifestations.

CONCLUSION

Leukocyte cytomegalovirus antigen gives a sensitive means of early positive diagnosis. The quantified level illustrates the patient's risk of infection. This new method is a very helpful tool in following renal transplantation recipients.

[Role of peritoneal dialysis in the treatment of terminal chronic renal insufficiency. Survival of patients and method]

Chronic peritoneal dialysis, especially continuous ambulatory peritoneal dialysis, is now a modality of treatment for patients with end stage renal failure. The proportion of patients varies considerably from country to country. Non medical considerations seem to be the main reason for the limited development of the treatment modality. Most of available reports point out no difference in patient or technique survivals on hemodialysis or peritoneal dialysis. Age, diabetes mellitus, cardiovascular diseases, infections complications (peritonitis and exit-site infections) impact on mortality and morbidity (number of hospital days per patient per year). The probability of death or dropout is much higher for patients with diabetes and patients in older age groups. Most patients with end stage renal failure, especially those waiting for a kidney transplant, are suitable for peritoneal dialysis.

Pharmacokinetics of rilmenidine in patients with chronic renal insufficiency and in hemodialysis patients

The pharmacokinetics of rilmenidine (1 mg orally) was studied in 3 groups of patients with stable chronic renal insufficiency. This was an open, single-blind study following a single administration, and after 15 days of treatment. Group 1 included 11 patients with a creatinine clearance between 15 and 80 mL/min. Group 2 included 17 patients with a creatinine clearance < 15 mL/min. Group III included 10 hemodialysis patients. In patients with chronic renal failure, total plasma clearance and renal clearance of rilmenidine decreased; terminal half-life was 30-42 hours, which is clearly longer than previous values achieved in healthy volunteers. After repeated administration (1 mg daily in group 1, 1 mg every other day in group 2, 1 mg at the end of each dialysis session in group 3), the area under the curve was significantly increased, corresponding to drug accumulation. The steady state was reached after 6 days in patients in group 1 and after 8 days in patients in group 2. The pharmacokinetics of rilmenidine was linear since the terminal elimination half-life and renal clearance were not significantly different after single and repeated administration of rilmenidine. A positive correlation was found between rilmenidine total plasma clearance and creatinine clearance, and between rilmenidine renal clearance and creatinine clearance. Mean rilmenidine hemodialysance was 85 mL/min, that is, 26% of the rilmenidine renal clearance value achieved in healthy volunteers (330 mL/min). Thus, the following dosage schedule can be proposed. In patients whose creatinine clearance ranges between 15 and 80 mL/min, a 1 mg dose every day can be recommended.(ABSTRACT TRUNCATED AT 250 WORDS)

Pharmacokinetics of fluconazole in patients undergoing continuous ambulatory peritoneal dialysis

The pharmacokinetics of fluconazole given orally (100 mg) or intraperitoneally (50 and 150 mg) were determined in 15 patients with chronic renal failure who were undergoing continuous ambulatory peritoneal dialysis. The half-life (72 to 85 hours) was intermediate between values obtained in healthy volunteers and in patients with renal insufficiency studied during an interhaemodialysis period. The peritoneal clearance, 0.26 to 0.33 L/h, led to an 18% recovery of administered drug in the dialysates after 48 hours. The peritoneal absorption was slow (time to peak plasma concentration 7 hours) but the peritoneal bioavailability was excellent at 87 +/- 5%. The mean concentrations of fluconazole up to 24 hours were 770 and 1900 micrograms/L after single intraperitoneal doses of 50 and 150 mg, respectively. The volume of distribution (40 to 60 L) did not differ from that determined in patients with normal renal function. In the case of fungal peritonitis essentially attributed to Candida spp., a 6-hour intraperitoneal infusion of fluconazole 150 mg every 2 days appears to be a good regimen to rapidly exceed minimum inhibitory concentrations and treat infection without risk of systemic dissemination of fungi or toxicity.

Foscarnet nephrotoxicity: mechanism, incidence and prevention

Foscarnet is a pyrophosphate analogue that has been successfully used in severe cytomegalovirus (CMV) infections. Little is known of the incidence and mechanisms of foscarnet-induced nephrotoxicity as most data comes from recipients of renal allografts or from patients with severe underlying disease or with other nephrotoxic drugs. We have retrospectively analyzed the evolution of renal function after 56 courses of foscarnet. In addition, we have prospectively studied the protective effects of hydration on foscarnet nephrotoxicity (2.5 liters of saline/day during the night before the foscarnet therapy and throughout the course of treatment). Foscarnet-induced acute renal failure was defined as a rise in serum creatinine of at least 25% from the basal value. An increase in serum creatinine occurred in 37 cases out of the 56 courses of foscarnet (66%). The mean serum creatinine prior to foscarnet was 80.5 +/- 3.3 mumol/l and the mean increase was 190 +/- 28.3 mumol/l (range 80-1,000). Peak serum creatinine was higher than 200 and 300 mumol/l in 16 and 13 patients, respectively. Kidney obtained at autopsy from a 30-year-old male with AIDS, CMV pneumonitis and acute renal failure secondary to foscarnet administration showed an extensive tubular necrosis. In the group which was prospectively hydrated only 1 patient had an acute renal failure. The mean serum creatinine at the peak (96 +/- 4 mumol/l) and at the end of the treatment (83 +/- 4 mumol/l) was significantly lower (p less than 0.05) than in non hydrated patients. In conclusion, foscarnet is a highly nephrotoxic drug which induces acute tubular necrosis.(ABSTRACT TRUNCATED AT 250 WORDS)