The influence of simultaneous pancreas-kidney transplantation on the evolution of diabetic foot lesions and peripheral arterial disease

PURPOSE

Simultaneous pancreas-kidney transplantation (SPKT) remains the best treatment option in patients with type 1 diabetes and chronic kidney failure. There are only a few studies addressing the potential ischemic deterioration of peripheral arterial disease (PAD) due to blood diverting from the iliac artery to the kidney graft. We aimed to evaluate diabetic foot lesions and PAD evolution in SPKT recipients and investigate if they are more frequent in ipsilateral lower limb of kidney graft.

METHODS

We developed a retrospective cohort, including patients submitted to SPKT in our tertiary center, between 2000 and 2017. Diabetic foot lesions and PAD frequencies were compared in the period before and after transplantation.

RESULTS

Two hundred and eleven patients were included, 50.2% (n = 106) female, with a median age at transplantation of 35 years (IQR 9). After a median follow-up period of 10 years (IQR 7), patient, kidney, and pancreatic graft survival were 90.5% (n = 191), 83.4% (n = 176), and 74.9% (n = 158), respectively. Before transplant, 2.8% (n = 6) had PAD and 5.3% (n = 11) had history of foot lesions. In post-transplant period, 17.1% (n = 36) patients presented PAD and 25.6% (n = 54) developed diabetic foot ulcers, 47.6% (n = 35) of which in the ipsilateral and 53.3% (n = 40) in the contralateral lower limb of the kidney graft (p = 0.48). Nine patients (4.3%) underwent major lower limb amputation, 3 (30%) ipsilateral and 7 (70%) contralateral to the kidney graft (p = 0.29).

CONCLUSIONS

Diabetic foot lesions were not more frequent in the ipsilateral lower limb of the kidney graft, therefore downgrading the 'steal syndrome' role in these patients.

Effects of supplements containing different additives on nutritional and productive performance of beef cattle grazing tropical grass

A grazing trial was carried out to evaluate the inclusion of three feed additives in supplements (crude protein, CP 230 g/kg dry matter, DM) on the performance, voluntary intake, and digestibility of beef heifers grazing Brachiaria decumbens (CP 81 and neutral detergent fiber, NDF 615 g/kg DM). Thirty-five Nellore heifers (21 months of age and 383 ± 6.29 kg of body weight, BW) were used in a completely randomized design. The treatments were as follows: no supplement (control); supplement fed at 1 kg/animal/day without additives (S); supplement with monensin (S + M); supplement with yeast culture (S + YC); and supplement with enzyme complex (S + EC). All of the supplemented heifers had greater (P < 0.1) average daily gain (∼0.186 kg/day) compared to the control treatment (0.014 kg/day). Average daily gain and final BW were similar (P > 0.1) among supplemented heifers. Monensin inclusion in the supplement decreased (P < 0.1) forage DM (expressed as g/kg BW) and NDF intake (expressed as kg/day and as g/kg BW). All of the feed additive inclusions decreased (P < 0.1) NDF digestibility. In conclusion, the heifers' performance was improved by concentrate supplementation. However, the inclusion of additives did not enhance this effect.

Conversion From Twice-Daily to Once-Daily Tacrolimus in Stable Kidney Graft Recipients

INTRODUCTION

Immunosuppression has a pivotal role in kidney transplantation. The new prolonged-release formulation of tacrolimus was developed to provide a more convenient once-daily dosing to improve patient adherence.

METHODS

We selected 60 stable kidney transplant recipients who underwent tacrolimus conversion in our unit. Conversion was made on a 1 mg:1 mg basis in 66.7% of patients (n = 40) and on a 1 mg:1.1 mg basis in the remaining 33.3% (n = 20). Clinical and analytical data at conversion and postconversion was analyzed retrospectively to evaluate the efficacy and safety of conversion from tacrolimus twice-daily to once-daily formulation.

RESULTS

A significant reduction in tacrolimus blood levels requiring an increase in tacrolimus daily dose was observed postconversion. Postconversion tacrolimus blood level reduction >25% was significantly higher in the conversion group 1 mg:1 mg basis (P = .004). In patients converted 1 mg:1 mg, female sex and higher tacrolimus level at conversion were significant risk factors for a reduction >25% in tacrolimus blood levels after conversion. No significant change was detected between mean glomerular filtration rate at conversion (57 mL/min) and at 3, 6, and 9 months postconversion.

CONCLUSIONS

Once-daily tacrolimus at similar doses to the twice-daily formulation is an efficient and safe treatment option. Conversion made on 1 mg:1.1 mg basis seems advantageous at least in some patients.

Allograft nephrectomy: a single-institution, 10-year experience

INTRODUCTION

Allograft nephrectomy (AN) is associated with a high number of surgical complications. Some authors advocate that early nephrectomy (<1 year) is associated with fewer complications. Intracapsular (ICAN) and extracapsular AN (ECAN) might have a different impact on allosensitization and surgical outcomes. Our goal was to compare surgical outcomes between early and late AN in our institution and to compare ICAN and ECAN in terms of surgical outcomes and panel reactive antibodies (PRA) variation.

MATERIALS AND METHODS

Between January 2000 and October 2012, we performed 104 AN at our institution (32 early and 72 late). Comparisons between early and late AN, and, within the latter, between the 2 different techniques were sought. Statistical analysis was performed for sample description, group comparison and %PRA variation.

RESULTS

Among the 104 patients with a mean age of 47.9 ± 14.2 years, 54 were men. Age, gender, body mass index, and number of previous transplants were similar between early and late AN and between ICAN and ECAN patients. Late AN was associated with less blood loss (293.4 ± 229.0 vs 414.3 ± 349.5 mL; P = .03), shorter hospital stay (12.8 ± 14.5 vs 26.8 ± 26.5; P < .05), and fewer complications (22.2% vs 59.3%; P < .05). The chance of being relisted for transplantation was similar (50.0% in early vs 59.7% in late AN; P = .7). When comparing ICAN and ECAN, there was no difference in surgical outcomes. The %PRA variation between the 2 techniques was comparable (-1.2 ± 10.6 ICAN vs -0.5 ± 15.9 ECAN; P = .8), as was the chance of being relisted for transplantation (60.5% ICAN vs 58.6% ECAN; P = .8).

CONCLUSIONS

Early AN was associated with a greater number of surgical complications. Nevertheless, the number of AN patients returning to the active waiting list was similar between early and late AN groups. ICAN and ECAN had similar surgical and postoperative outcomes, although a bias may be present because some conversions from ECAN to ICAN occurred owing to technical issues. As in other studies, ICAN did not seem to affect allosensitization or jeopardize the chance of being relisted for transplant when compared with ECAN.

Nutritional evaluation of young bulls on tropical pasture receiving supplements with different protein:carbohydrate ratios

The objective of this work was to evaluate the nutritional parameters of young bulls supplemented with different ratios of protein: carbohydrate on tropical pastures from 4 until 18 months old. Fifty-five non-castrated beef calves (138.3±3.4 kg, 90 to 150 d of age) were used. The calves (young bulls) were subjected to a 430-d experimental period encompassing 4 seasons. The treatments were as follows: control, only mineral mixture; HPHC, high protein and high carbohydrate supplement; HPLC, high protein and low carbohydrate supplement; LPHC, low protein and high carbohydrate supplement; and LPLC, low protein and low carbohydrate supplement. The amount of supplement was adjusted every 28 d. Dry matter (DM) intake was higher in the dry-to-rainy transition and rainy seasons for all nutritional plans. Non-supplemented animals had lower intakes of DM and total digestible nutrients (TDN) than supplemented young bulls in all seasons. Although differences in DM intake were not observed between supplemented animals, the supplements with high carbohydrate (HPHC and LPHC) had lower forage intake during suckling (rainy-to-dry transition season) and in the rainy season. However, the HPHC treatment animals had higher intake and digestibility of neutral detergent fiber. It can be concluded that supplementation with high protein levels (supplying 50% of the crude protein requirement) provide the best nutritional parameters for grazing young bulls in most seasons, increasing intake and digestibility of diet, and these effects are more intense when associated with high carbohydrate levels level (supplying 30% TDN requirement).

Neutrophils have a protective role during early stages of Leishmania amazonensis infection in BALB/c mice

Neutrophils are involved in the early stages of immune responses to pathogens. Here, we investigated the role of neutrophils during the establishment of Leishmania amazonensis infection in BALB/c and C57BL/6 mice. First, we showed an accumulation of neutrophils between 6 and 24 h post-infection, followed by a reduction in neutrophil numbers after 72 h. Next, we depleted neutrophils prior to infection using RB6-8C5 or 1A8 mAb. Neutrophil depletion led to faster lesion development, increased parasite numbers and higher arginase activity during the first week of infection in BALB/c mice, but not in C57BL/6 mice. Increased susceptibility was accompanied by augmented levels of anti-L. amazonensis IgG and increased production of IL-10 and IL-17. Because IL-10 is a mediator of susceptibility to Leishmania infection, we blocked IL-10 signalling in neutrophil-depleted mice using anti-IL-10R. Interestingly, inhibition of IL-10 signalling abrogated the increase in parasite loads observed in neutrophil-depleted mice, suggesting that parasite proliferation is at least partially mediated by IL-10. Additionally, we tested the effect of IL-17 in inflammatory macrophages and observed that IL-17 increased arginase activity and favoured parasite growth. Taken together, our data indicate that neutrophils control parasite numbers and limit lesion development during the first week of infection in BALB/c mice.

Características da carcaça e da carne de cordeiros Corriedale manejados em duas alturas de milheto

O objetivo deste estudo foi avaliar características de qualidade da carcaça e da carne de cordeiros Corriedale manejados em duas alturas de pastejo em milheto. A terminação dos cordeiros foi feita em pastagem anual de verão, milheto cultivar comum (Pennisetum americanum (L.) Leeke.). Os tratamentos consistiram de duas alturas de pastejo, 20 e 40 cm. Os animais foram abatidos baseando-se na condição corporal ao atingirem o índice entre 2 e 3 (1 a 5). Foram realizadas avaliações quantitativas e qualitativas da carcaça e da carne. A conformação apresentou alta relação com o estado de engorduramento. Não houve diferença entre as características subjetivas de textura e cor, já para o marmoreio houve efeito da altura do milheto (p

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.

Características in vivo e componentes corporais de cabritos naturalizados do alto camaquã, brasil

O principal objetivo do estudo foi avaliar as características in vivo, os componentes corporais, os custos de produção e calcular equações de regressão para as principais características de interesse comercial de caprinos. Para este estudo foram utilizados cabritos cruza Angorá, acom-panhados durante um ano e abatidos com 11-12 meses (lote 1, n=20). A partir dos resultados do lote 1, foi abatido um segundo lote (lote 2, n=14) com animais de 8-9 meses de idade. Ambos os lotes foram criados em sistema extensivo no território do Alto Camaquã (Estado do Rio Grande do Sul, Brasil). Os cabritos abatidos com idade de 11-12 meses apresentaram custos de produção de R$/US$ 0,93/0,53 kg/peso vivo e R$/US$ 1,86/1,06 kg/carcaça e atingiram o peso de abate já aos 6-7 meses de idade. As equações de regressão determinaram que o perímetro torácico é a melhor característica para estimar o peso em jejum, já a compacidade corporal é melhor estimada pelo peso em jejum. Os caprinos abatidos com 8-9 meses tiveram maiores valores para as principais características avaliadas, quando comparados aos abatidos com 11-12 meses. A maior parte dos componentes corporais dos lotes avaliados demonstrou comportamento isogônico. Os resultados indicam que cabritos criados em sistema extensivo no território do Alto Camaquã, devem ser abatidos no período que antecede o inverno e a idade ótima de abate é de 8-9 meses, com peso vivo ao redor de 22 kg para as características avaliadas.

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.

Conversion to Sirolimus in a Population of Kidney and Kidney-Pancreas Transplant Recipients

INTRODUCTION

Calcineurin inhibitors (CI) are associated with nephrotoxicity that might reduce long-term graft survival. We report our experience with sirolimus (SRL) conversion among a population of kidney and kidney pancreas transplant recipients.

METHODS

Thirty transplant recipients (6 women, 24 men; age 41 +/- 10.5 years old) were converted to SRL therapy at 25.97 +/- 32.5 months after transplantation. Indications for conversion were: intolerance to mycophenolate mofetil (n = 13), diabetes mellitus (n = 3), CI nephrotoxicity (n = 11), CI nephrotoxicity with chronic allograft rejection (n = 2), and side effects of azathioprine (n = 1). Follow-up after conversion is 3 to 45 months.

RESULTS

No significant changes were observed in the 3 months postconversion in renal function, hematological profile, and mean arterial blood pressure. In contrast there was a significant increase in cholesterol values (pre: 198.7 +/- 49.4, versus post 221.2 +/- 60.8, P = .018). At a follow-up of 15.2 +/- 9.9 months after conversion two patients (6.7%) died with functioning allograft (one because of infection and one to myocardial infarct) three kidney allografts (10.7%) have been lost: two chronic rejection; one infection. In two patients SRL therapy was discontinued (one infection, one refractory edema). Neither significant change in renal function nor episodes of acute rejection were observed.

CONCLUSIONS

Conversion to SRL was safe. There was no deterioration in renal function nor episodes of acute rejection. There was a significant increase in cholesterol values after conversion. The size of the sample and the time of follow-up may have determined our results.

[A myoelectric prosthesis for the forearm amputee]

The authors make a revision of the principles of action of the myoelectric prosthesis for the forearm amputees and describe their components. The indications and contra-indications (French law) are also referred. We can say as a conclusion that the great progress made in prosthesis in the last years were possible on account of synthetic materials and the use of electronics and miniaturised computers. However, their functional possibilities are remote when compared with the human hand. The high costs of this prosthesis are one limitation to its prescription.