Maspin acts at the cell membrane to inhibit invasion and motility of mammary and prostatic cancer cells

Maspin, a novel serine protease inhibitor (serpin), inhibits tumor invasion and metastasis of mammary carcinoma. We show here that recombinant maspin protein blocks the motility of these carcinoma cells in culture over 12 h, as demonstrated by time-lapse video microscopy. Lamellopodia are withdrawn but ruffling continues. Both exogenous recombinant maspin and maspin expressed by tumor transfectants exhibit inhibitory effects on cell motility and cell invasion as shown in modified Boyden chamber assays. In addition, three prostatic cancer cell lines treated with recombinant maspin exhibited similar inhibition of both invasion and motility, suggesting a similar mode of maspin action in these two glandular epithelial cancers. When mammary carcinoma cells were treated with recombinant maspin, the protein was shown by immunostaining to bind specifically to the cell surface, suggesting that maspin activity is membrane associated. When pretreated with antimaspin antibody, maspin loses its inhibitory effects on both invasion and motility. However, when maspin is added to these cells preceding antibody treatment, the activity of maspin is no longer inhibited by subsequent addition of the antibody. It is concluded therefore that the inhibition of invasion and motility by maspin is initially localized to the cell surface.

Anterior tibialis tendon ruptures: an outcome analysis of operative versus nonoperative treatment

Ruptures of the anterior tibialis tendon are a rare clinical entity. Case reports in the literature reveal a total of 28 cases. Unfortunately, because of the limited discourse in the orthopaedic literature, there are few guidelines regarding the treatment for these injuries. This study analyzes the treatment of 16 anterior tibialis tendon ruptures. Eight patients in this group had operative treatment of their ruptures, and eight patients had nonsurgical treatment of their ruptures. The average follow-up for the operative and nonoperative patients were 6.68 years and 3.86 years, respectively. The Foot and Ankle Outcome questionnaire provided by the American Academy of Orthopaedic Surgeons and an outcome-based foot score described by Kitaoka et al. were used as the methods of analysis. Our outcome results show no statistically significant difference between operative and nonoperative treatment in anterior tibialis tendon ruptures. The lack of statistical difference between operative and nonoperative groups may be a reflection of the age bimodality present in this study. Elderly low demand patients were treated nonsurgically and young active patients were treated operatively. Therefore, despite a lack of statistical difference present in the outcome of both groups, we still maintain the need to repair/reconstruct anterior tibialis tendon ruptures in young active patients with high functional demands. The deficits present in the nonoperative group, we believe, would not be well tolerated in a young high functional demand patient. Nonsurgical management is an appropriate alternative in low demand elderly patients.

Tethered cord syndrome in low motor level children with myelomeningocele

The clinical presentation of tethered spinal cord and the results of tethered cord release were examined in a group of 30 low motor level (L3 and below) children with a history of myelomeningocele without concomitant CNS complications. Changes in orthopedic and/or neurologic status formed the basis of consideration for tethered cord release. Clinically, these patients presented with a new onset or recently progressing scoliosis, spasticity with or without contractures, decrease in motor function and low back pain at the site of closure. One or more of these findings was present in all cases and led to the suspicion of tethered spinal cord. The diagnosis of tethered cord was confirmed in all cases by MRI or CT myeolography. In order to isolate tethering as the etiology for the patients' clinical deterioration, patients with concomitant CNS complications, e.g. shunt dysfunction or hydromyelia were excluded from the study. Twenty-nine such patients, of an initial 59, who would have otherwise been considered, were excluded on the basis of this criteria of concomitant CNS complications. The results of release 1 year after the procedure were as follows: regarding scoliosis, in 75% of cases the curve either remained stable or decreased by more than 10 degrees, with 25% experiencing curve progression of > 10 degrees. The most recent follow-up in this group revealed that 11.8% experienced a decrease in curvature of >10 degrees; 47.1% remained stable, and 41.2% ultimately progressed 10 degrees. In the group with spasticity, 43.8% improved; 56.3% remained stable, and none worsened. Most (78.6%) of the children who had experienced a decline in motor function improved postoperatively, and all those with back pain experienced complete resolution. In conclusion, tethered cord release in symptomatic low lumbar and sacral level children with myelomeningocele appears to be of benefit, especially with respect to stabilization of scoliosis in selected patients, back pain at the site of closure, and prior decline in motor function. Results in the cases with spasticity were more equivocal.

Tethered cord as a cause of scoliosis in children with a myelomeningocele

Scoliosis interferes significantly with the functional ability of most children with a myelomeningocele. While it is recognized that tethered cord at the repair site causes neurological deterioration, it has been controversial whether tethered cord causes scoliosis. The spinal cord was untethered in 30 children with progressive loss of function and scoliosis. Of 6 children with curves greater than 50 degrees only 1 improved. Of the other 24 children their curves were stable or improved at 1 year follow-up. At late follow-up, 2-7 years, 63% were stable or improved while 38% began to progress. Tethered cord causes scoliosis and stability or improvement can be anticipated following untethering. Close long-term follow-up is essential to identify those individuals with retethering of their cord.

Additional endoscopic procedures instead of urgent surgery for retained common bile duct stones

One hundred and twenty seven patients were treated by nasobiliary drainage, or stenting, to prevent biliary obstruction after endoscopic failure to clear stones from the common bile duct. At presentation, 91 (72%) patients were jaundiced and 39 (31%) had cholangitis. Placement of either a nasobiliary drain or stent was successful in 124 (98%) patients. One hundred and twenty one (95%) patients were followed up. Clearance was ultimately achieved endoscopically in 52 and surgically in 25 patients after (mean) 2.4 months. Thirty day mortality was 3%. There were no complications of nasobiliary drainage, but two of 39 patients treated by temporary stents developed cholangitis, both successfully managed by endoscopic duct clearance. Forty two patients unfit for surgery or further endoscopic attempts at duct clearance were followed with stents in situ for a mean 15.9 months (range 2.5-37.5). Cholangitis developed in four patients and was successfully managed by stent change. These results indicate that longterm stenting can be useful for poor risk surgical patients and that nasobiliary drainage or temporary stenting permits further elective rather than urgent endoscopic or surgical treatment.

Myelomeningocele: a review of the orthopaedic aspects of 206 patients treated from birth with no selection criteria

Two hundred and six consecutive children with spina bifida who have been treated since the first day of life were analysed in terms of walking ability, motor level, orthopaedic deformities, operative procedures and balance deficit. The authors found that: (1) ambulation was quite delayed compared with the normal population; (2) sitting balance was a useful predictor of future walking; (3) almost all patients with quadriceps function were able to walk and were community ambulators; and (4) a significant number of congenital and acquired orthopaedic deformities required surgical intervention.

Degradation of terbuthylazine, difenoconazole and pendimethalin pesticides by selected fungi cultures

Contamination of waters by xenobiotic compounds such as pesticides presents a serious environmental problem with substantial levels of pesticides now contaminating European water resources. The aim of this work was to evaluate the ability of the fungi Fusarium oxysporum, Aspergillus oryzae, Lentinula edodes, Penicillium brevicompactum and Lecanicillium saksenae, for the biodegradation of the pesticides terbuthylazine, difenoconazole and pendimethalin in batch liquid cultures. These pesticides are common soil and water contaminants and terbuthylazine is considered the most persistent triazine herbicide in surface environments. P. brevicompactum and L. saksenae were achieved by enrichment, isolation and screening of fungi capable to metabolize the pesticides studied. The isolates were obtained from two pesticide-primed materials (soil and biomixture). Despite the relatively high persistence of terbuthylazine, the results obtained in this work showed that the fungi species studied have a high capability of biotransformation of this xenobiotic, comparatively the results obtained in other similar studies. The highest removal percentage of terbuthylazine from liquid medium was achieved with A. oryzae (~80%), although the major biodegradation has been reached with P. brevicompactum. The higher ability of P. brevicompactum to metabolize terbuthylazine was presumably acquired through chronic exposure to contamination with the herbicide. L. saksenae could remove 99.5% of the available pendimethalin in batch liquid cultures. L. edodes proved to be a fungus with a high potential for biodegradation of pesticides, especially difenoconazole and pendimethalin. Furthermore, the metabolite desethyl-terbuthylazine was detected in L. edodes liquid culture medium, indicating terbuthylazine biodegradation by this fungus. The fungi strains investigated could prove to be valuable as active pesticide-degrading microorganisms, increasing the efficiency of biopurification systems containing wastewaters contaminated with the xenobiotics studied or compounds with similar intrinsic characteristics.

MR imaging of osteoid osteoma

An osteoid osteoma was detected in a young boy with a classic history for this lesion. Plain radiography was not helpful but ultrasound and magnetic resonance imaging demonstrated the tumor nidus.

Impact assessment in living kidney donation: psychosocial aspects in the donor

BACKGROUND

Living donor kidney transplantation has a positive influence on graft survival and recipient quality of life (QoL). We assessed the psychosocial impact of donation to the donor.

METHODS

Before and after the procedure 32 living kidney donors (mean age 41 years) completed the Zung Self-Rating Anxiety and Depression Scales; a Sociodemographic, Short-Form 36 Health Survey (SF-36), and a Donation Perceptions Questionnaire.

RESULTS

Living kidney donors were siblings (62.5%), parents (34.4%), or a daughter (3.1%). Transplantation was not successful in two cases: one recipient death and one graft failure. No significant changes were observed in donor QoL except for the SF-36 social functioning subscale that showed significant improvement after donation (P = .038). A reduction in depression symptom frequency was verified after donation (from 65.6% to 46.9%). There was an almost significant decrease in depression scores (P = .077), which was in fact was significant when one considered only successful transplants (P = .021). There was no significant variation in anxiety scores among donors. Time since transplantation was inversely correlated with overall anxiety (r = .443, P = .011), and with somatic anxiety subscales (r = .357, P = .045). For most donors, the decision to donate was easy and spontaneous. Nearly all donors would donate again and strongly encourage others to donate.

CONCLUSIONS

Except for the social functioning scale that improved, no significant changes were observed in QoL of living kidney donors after the procedure. Depression scores significantly decreased after donation, but anxiety scores remained stable. Donors, who were mostly siblings, showed positive perceptions about donation, did not regret their decision, and strongly recommend it to others.

Impact of hepatitis C virus on renal transplantation: association with poor survival

Data concerning the effect of hepatitis C virus (HCV) infection on the long-term outcome of patient and allograft survival are conflicting. We performed a retrospective study including all renal transplant recipients who underwent the procedure at our center between July 1983 and December 2004. We compared HCV-positive (n = 155) versus HCV-negative (n = 1044) recipients for the prevalence of anti-HCV, patient/donor characteristics, and graft/patient survival. The prevalence of HCV-positive patients was 12%. The anti-HCV positive recipients displayed a longer time on dialysis (P < .001), more blood transfusions prior to transplant (P < .001), and a higher number of previous transplants (P < .001). There were no differences in the incidence of acute rejection between the two groups. Patient (P = .006) and graft survival (P = .012) were significantly lower in the HCV-positive than the HCV-negative group. Graft survival censored for patient death with a functioning kidney did not differ significantly between HCV-positive and HCV-negative recipients (P = .083). Death from infectious causes was significantly higher among the HCV-positive group (P = .014). We concluded that HCV infection had a significant detrimental impact on patient and renal allograft prognosis. Death from infectious causes was significantly more frequent among HCV-positive than the non-HCV population.

Depression and anxiety in living kidney donation: evaluation of donors and recipients

BACKGROUND

Psychosocial status of donors before and after living kidney donor transplantation has been an important concern. Investigations of psychosocial issues in related recipients are not frequent.

AIM

The aims of this study were to evaluate and compare psychopathologic dimensions in donors and recipients before and after transplantation.

METHODS

Thirty-five recipients and 45 donors completed a psychosocial evaluation before and after transplantation. We applied Pearson chi-square, McNemar, Fisher, Wilcoxon, and Mann-Whitney tests as well as linear and logistic regression statistical methods.

RESULTS

Before transplantation 100% of the recipients presented total anxiety, compared with 64.4% of donors, with higher anxiety levels in all dimensions (P < .001). Also, 38.7% of recipients and 16.3% of donors had moderate/serious depression (P = .029). Men showed higher levels of cognitive anxiety before transplantation (odds ratio [OR] = 4.3; P = .008). After versus before transplantation central nervous system and cognitive anxiety had diminished in recipients (P = .031; P = .035, respectively); there were higher levels of cognitive anxiety than among the donors (P = .007). Depression showed no significant changes in recipients or donors; the differences were no longer significant. There were less severely depressed recipients but an increase among severely depressed donors. Male recipients and donors showed greater cognitive anxiety (P = .02; P = .04, respectively) at both times. Female recipients presented with more severe depression (P = .036).

CONCLUSIONS

Anxiety is an important symptom. Surgery had a positive impact to lower anxiety in recipients. Most protagonists displayed little or no depression; it was more prevalent among recipients. Donors and recipients maintained some psychopathologic symptoms after surgery. We defined vulnerable groups among these cohorts.

Independent ambulators with high sacral myelomeningocele: the relation between walking kinematics and energy consumption

The aims of this study were to determine the relation between gait kinematics (center of mass excursions) and measures of oxygen consumption and oxygen cost. Fourteen independent ambulating children with myelomeningocele (nine females, five males; mean age 8 years 7 months) and thirteen children with no history of neuromuscular disorder were evaluated. At their comfortable walking speed all patients exhibited oxygen cost and oxygen consumption values that exceeded the normal level by more than 1 SD. Pelvic obliquity demonstrated the strongest relation with oxygen cost which suggests that ultimately hip abductor strength may play a key role in energy demands during gait. Despite the exaggerated pelvic kinematics, vertical and horizontal center of mass excursions of the trunk and whole-body during the gait cycle were not significantly greater than normal (p>0.05). Decreased self-selected walking velocity at which many of these children consider comfortable and stable may be predicated on an optimal center of mass movement that approximates the magnitude observed in normal gait. The slower walking velocity decreases walking efficiency. Conversely, the increased center of mass movement that would accompany a faster gait would probably impose intolerable oxygen consumption levels. Strengthening programs that focus on the gluteus medius and maximus to decrease compensatory trunk and pelvic motions, allowing the patients to adopt a faster gait without exacerbating kinematic and center of mass motions and which enabled more efficient walking hold promise for these patients.

The influence of forearm crutches on pelvic and hip kinematics in children with myelomeningocele: don't throw away the crutches

Gait analysis was performed on 16 children with high-sacral-level myelomeningocele who walked with and without crutches to evaluate the influence of crutches on their unique walking pattern. All of the patients used solid ankle-foot orthoses (AFOs). Deviations in coronal and transverse planes improved with assisted walking. The timing of stance phase pelvic depression and the magnitude of stance phase hip abduction improved with crutch walking. Pelvic rotation, which was seven times the normal range of motion during no-crutch walking, decreased to four times normal with crutches. Walking velocity was not significantly different between conditions. The results demonstrated that deviations in pelvic and hip kinematics are related to muscle weakness and improve with crutch use. Crutches enable the patient to transfer some weight bearing to their upper extremities which decreases the demand on weak lower-extremity musculature. This allows them to maintain functional ambulation with a closer to normal gait pattern.

Cyclosporine versus tacrolimus in kidney transplantation: are there differences in nephrotoxicity?

Cyclosporine and tacrolimus, two calcineurin inhibitors, show different side effects and toxicities. The data concerning their nephrotoxicity are few and conflicting. A retrospective study was performed in 2 groups of renal transplant recipients treated with cyclosporine or tacrolimus to evaluate graft function and side effects. All patients had completed at least 6 months of follow-up before inclusion in the study. Group I included 10 patients who were converted from cyclosporine to tacrolimus, due to cosmetic problems or due to chronic graft dysfunction with creatinine values <3 mg/dL. After conversion, there was a significant reduction in creatinine values (from 2.43 +/- 1.21 to 1.86 +/- 0.72 mg/dL; P =.023) and an improvement in creatinine clearance (from 47.5 +/- 19.2 to 56.1 +/- 18.9 mL/min; P =.047). The lipid profile did not change, but there was a trend to better blood pressure control with less antihypertensive drugs. Group II compared 2 subgroups of patients receiving kidneys from the same donor, one treated with cyclosporine and the other with tacrolimus. Tacrolimus patients showed better renal function; namely, creatinine was 1.15 +/- 0.27 versus 1.44 +/- 0.33 mg/dL (P =.029) and creatinine clearance was 87.7 +/- 27.1 versus 60.3 +/- 25.9 mL/min (P =.043). Lipid and blood pressure values were not different between the 2 subgroups, but tacrolimus patients tended to need a lower number of antihypertensive medications. The incidence of de novo diabetes mellitus was approximately 20% among patients using tacrolimus. We concluded that tacrolimus may be less nephrotoxic than cyclosporine. Tacrolimus patients showed better graft function and easier blood pressure control, but a high incidence of posttransplantation diabetes mellitus.

Effect of Different Sensitization Events on HLA Alloimmunization in Kidney Transplantation Candidates

BACKGROUND

HLA alloimmunization is caused by sensitization events (SEs), such as transfusion, pregnancy, or previous organ transplantation, and the effects of particular SEs have not been thoroughly studied. Our aim was to evaluate how each SE affected HLA alloimmunization by considering Luminex assays.

METHODS

Sera from 722 kidney transplantation candidates were screened per protocol by means of Luminex assays to determine the presence of anti-HLA class I/II antibodies; positive sera underwent single-antigen assay to determine the presence of specific antibodies against HLA A, B, C, DR, DQ, DP loci (positivity if median fluorescence intensity values were >1,000). The effect of each SE was analyzed considering only patients exposed to 1 kind of sensitization.

RESULTS

In the 453 candidates with ≥1 SE, anti-HLA class I positivity rates were significantly higher in patients with previous transfusion (18.9%; P = .014), pregnancy (38.3%; P < .001) or transplant (75%; P < .001) compared with those with no SE (similar results for class II). The strength (median fluorescence intensity) of specific antibodies was significantly higher in patients with previous transplantation than in those with previous transfusion for HLA-A (8,017 vs 2,302; P = .02), HLA-B (7,765 vs 2,901; P = .018), and HLA-DR (9,835 vs 2,060; P = .003). Other anti-HLA antibody strengths were similar between patients with previous pregnancy or transplantation.

CONCLUSIONS

Presence of any SE analyzed was associated with a higher prevalence of anti-HLA antibodies for class I ± II compared with nonsensitized patients. Transplantation had the strongest immunization effect on both classes, followed by pregnancy and then transfusion.

Evaluation of residual clubfoot deformities using gait analysis

Gait analysis was used to evaluate 15 patients who had previously undergone clubfoot surgery. Because six patients had had bilateral surgery, 21 feet had undergone previous clubfoot surgery. Three of the operated feet had no residual deformity. In the remaining 18 feet, the reason for referral was intoeing in 13, calcaneovalgus in three, hindfoot varus in one, and supination/adduction in one. Clinical assessment and information from the gait analysis were used to establish a treatment plan. Satisfactory treatment outcome was achieved in 13 patients, one result was unsatisfactory, and one result was undetermined.

CT evaluation of the shoulder in children with Erb's palsy

The majority of children with traumatic injuries of the brachial plexus recover with only minor sequelae. Some patients develop residual deformity, however. This deformity may consist only of internal rotation contractures, but in some patients subluxation of the humeral head may be present. CT is useful in the evaluation of: the presence or absence of subluxation, deformity of the glenoid and the proper placement of the humeral head in plaster or orthotic devices.

Hyperuricemia in adult renal allograft recipients: prevalence and predictors

BACKGROUND

Hyperuricemia is a common complication after kidney transplantation that may adversely affect graft survival.

OBJECTIVE

Our aim was to determine the prevalence of hyperuricemia in a sample of adult kidney graft recipients and to investigate its predictors.

METHODS

A total of 302 patients were included in the study. We used univariate analyses to compare clinical characteristics between the hyper-and normouricemic groups. We used multivariate adjusted logistic regression to detect independent predictors of hyperuricemia. Hyperuricemia was defined as serum uric acid ≥6.5 mg/dL in women and ≥7.0 mg/dL in men or allopurinol use.

RESULTS

The patients had a mean age of 49.6 ± 13.4 years, a median posttransplantation time of 7.6 years, and a mean estimated glomerular filtration rate (eGFR) of 51.9 ± 18.46 mL/min. The prevalence of hyperuricemia was 42.1% (n = 127). Hyperuricemic patients were predominately male (P = .004), older (P = .038), and with lower eGFR (P < .001). They also had a higher prevalence of hypertension (P = .001), dyslipidemia (P = .004) and proteinuria (P = .001). Multivariate adjusted regression model showed as significant predictors of hyperuricemia: male gender (odds ratio [OR], 2.46; P = .002); impaired renal function (OR 1.33 for every 10 mL/min reduction in eGFR; P < .001), higher body weight (OR 1.09 for every 1 kg/m(2) increase of body mass index; P = .044), prednisolone use (OR 2.12; P = .035), and cyclosporine versus tacrolimus use (OR 2.44; P = .039).

CONCLUSIONS

The prevalence of posttransplant hyperuricemia was high, particularly in patients with classical cardiovascular risk factors and lower eGFR. However, our findings suggest that modifiable immunosuppression options could play a role in its management.

EULID project: European living donation and public health

The choice of transplantation from a living donor offers advantages over a deceased donor. However, it also carries disadvantages related to donor risks in terms of health and safety. Furthermore, there are several controversial ethical aspects to be taken into account. Several national and international institutions and the scientific community have stated standards that have great influence on professional codes and legislations. Living organ donation and transplantation are to some extent regulated by parliamentary acts in most European countries. It is necessary to take a step forward to develop a legal framework to regulate all of these processes to guarantee the quality and to prevent illegal and nonethical practices. It is also necessary to develop and implement living donor protection practices not only in terms of physical health, but also to minimize potential impacts on the psychological, social, and economic spheres. Finally, an additional effort should be made to create a database model with recommendations for registration practices as part of the standardized follow-up care for the living donor. The European Living Donation (EULID) project's (http://www.eulivingdonor.eu/) main objective was to contribute to a European consensus to set standards and recommendations about legal, ethical, and living donor protection practices to guarantee the health and safety of living donors.

The influence of HLA mismatches and immunosuppression on kidney graft survival: an analysis of more than 1300 patients

New immunosuppressive drugs used in kidney transplantation decreased the incidence of acute rejection. It was hypothesized that, with their power, the importance of HLA matching was decreased. To evaluate the influence of HLA matching, immunosuppression, and other possible risk factors, we analyzed data of 1314 consecutive deceased donor kidney transplantation. We divided the patient population into 4 cohorts, according to the era of transplantation: era 1, before 1990, azathioprine (Aza) and cyclosporine (Csa) no microemulsion; era 2, between 1990 and 1995, Csa microemulsion; era 3, between 1996 and 2000, wide use of mycophenolate mofetil (MMF) and anti-thymocyte globulin (ATG); and era 4, after 2000, marked by sirolimus and tacrolimus (TAC) use. Multivariate analysis compared death-censored graft survival. Using as reference the results obtained with 0 HLA mismatches, we verified, during era 1 and era 2, an increased risk of graft loss for all of the subgroups with HLA mismatch >0. However, during era 3 and era 4, the number of HLA mismatches did not influence graft survival. Although acute rejection and delayed graft function, which decreased in the later periods, remained as prognostic factors for graft loss. Considering the immunosuppressive protocol with Csa+Aza+Pred as reference, protocols used after 1995 with Pred+Csa+ATG, with Pred+Csa+MMF, and with Pred+Tac+MMF presented better survival results. Results showed that the significance of HLA matching decreased while the results improved with the new immunosuppressant drugs. These observations support the hypothesis that the weakened importance of HLA matching may be a consequence of the increasing efficacy of the immunosuppression.

Renal Transplantation in Patients Over 60 Years of Age: A Single-Center Experience

The prevalence of end-stage renal disease (ESRD) increases with advancing age. In most countries renal transplant recipients are getting older, too. Transplantation must be considered for ESRD patients older than 60 years; however, there are few data regarding outcomes in this population. We retrospectively reviewed the clinical course of recipients aged > or =60 years (n = 43) who underwent primary or repeated grafts from August 1988 to December 2004. We then compared recipient and donor characteristics as well as graft and patient survivals with recipients aged 18 to 59 years (n = 1058) who were transplanted during the same time. Donor age tended to be higher among the oldest recipient group (P < .001). Mean follow-up was significantly shorter in the group aged > or =60 years (P < .001), as our institution only recently has frequently accepted patients > or =60 years. Older recipients showed more frequent delayed graft function (P = .007), longer initial hospitalization (P = .005), and a significantly lower incidence of posttransplant acute rejection episodes (P = .015). Patient (P = .057), graft (P = .407), and death-censored graft (P = .649) survivals were not different between the two groups. Seven recipients aged > or =60 years died; the main cause of which was cardiovascular in origin. The loss of organs (n = 11) in the older patients was mainly due to death with a functioning kidney (54.5%). Our results confirm that renal transplant must be considered in selected patients older than 60 years as patient and graft survivals are similar to those of younger patients.

Simultaneous Pancreas-Kidney Transplantation: Five-Year Results From a Single Center

We report the 5-year results of our simultaneous pancreas-kidney transplantation (SPKT) program, started on May 2, 2000. Forty-two SPKT were performed on 42 type I diabetic patients with chronic renal failure. The procedure was performed with enteric diversion and vascular anastomosis to the iliac vessels. Immunosuppressive protocol included antithymocyte globulin, tacrolimus, mycophenolate mofetil, and steroids. The 24 women and 18 men had a mean age of 33.5 +/- 6.3 years and mean 22.8 +/- 14.2 years time of diabetes evolution. Forty patients had been on dialysis for 34.3 +/- 24.1 months, and two were preemptive transplantations. Acute rejection episodes were treated in eight patients (19.1%): in three cases they affected both organs; in two only the kidney was affected; and the other three were pancreas graft rejections. The incidence of postoperative complications requiring re-operation was 42.9%, mostly pancreas graft related. Two patients died, one due to cardiovascular disease; the other was transplant related. Three kidney grafts were lost, and the causes were immunologic, thrombosis, and patient death. Pancreas graft loss occurred in seven patients: thrombosis (n = 3); infection (n = 3); immunologic (n = 1). The patients with surviving grafts were doing well, with normal kidney and pancreas function: serum creatinine = 0.89 +/- 0.15 mg/dL; fasting blood glucose = 79 +/- 16 mg/dL; HbA1c = 4.7 +/- 1.1%. The 1-year patient, kidney, and pancreas survival rates were 97.3%, 94.6%, and 83.8% and 5-year values, 91.7%, 89.2%, and 78.7%, respectively. In conclusion, these results are similar to the most recent UNOS/IPTR reports, leading us to consider our experience with SPKT very positive.

Immunosuppression With Antithymocyte Globulin in Renal Transplantation: Better Long-Term Graft Survival

We analyzed the impact of antithymocyte globulin (ATG) in renal transplantation. We retrospectively studied 1217 recipients performed from July 83 to December 03. ATG-Fresenius-S (ATG-F) was used for induction therapy in 492 patients (40.4%; group I) and compared with group II, 725 patients (59.6%), without antilymphocyte induction. Groups were comparable in terms of recipient gender and race distribution; time on dialysis; cause of renal disease; number of human leukocyte antigen (HLA) mismatches; donor age, gender, and creatinine; and cold ischemia time. Patients with ATG-F were younger (35.8 +/- 13.8 vs 38.9 +/- 12.5 years, P < .001), more frequently hypersensitized (10% vs 3%, P < .001), and had more second transplants (15.7% vs 5.8%, P < .001). The incidence of acute rejection episodes was lower among ATG-F patients (23.6% vs 32.1%, P = .004). Admission time and incidence of delayed graft function (DGF) were similar in the two groups. Graft survival at 1, 5, 10, and 15 years was 88.9%, 80.7%, 71.3%, and 64.9% in group I and 86.4%, 77.4%, 60.7%, and 48.4% in group II (P = .003). The difference in patient survival over the same follow-up did not reach statistical significance. Multivariate analysis showed that the risk of graft failure was higher for those who did not receive ATG-F (HR = 1.51; 95% CI, 1.14 to 2.00; P = .004). Donor age and DGF were also independent predictors of graft failure. Our results showed a better long-term graft survival among patients who received ATG-F, despite their higher immunological risk. The absence of induction with ATG-F, donor age, and DGF were independent risk factors for graft failure.