Hospitalized psychoses after renal transplantation in the United States: incidence,risk factors,and prognosis

Although it is recommended that renal transplant (RT) candidates routinely undergo screening for mental health-related conditions, national statistics for psychoses after RT have not been reported. This is a historical cohort study of 39,628 renal transplant recipients in the United States Renal Data System between July 1, 1994, and June 30, 1998, and followed until December 31, 1999. Adjusted hazard ratios (AHR) for time to hospitalization for both a primary and secondary discharge diagnosis of psychoses (ICD-9 codes 290.x-299.x) after RT and mortality/graft loss after psychosis were assessed by Cox Regression. In addition, rates of psychosis were compared with 178,986 patients with Medicare as their primary payer who started chronic dialysis from April 1, 1995, to June 29, 1999. The incidence of psychoses was 7.5/1000 person-years (PY) after RT compared with 7.2/1000 PY for all patients on chronic dialysis and 9.6/1000 PY for dialysis patients aged 65 yr or younger. Among RT recipients, graft loss (AHR, 2.97; 95% CI, 2.19 to 4.02), allograft rejection, and cadaveric donation were independently associated with psychosis, which was associated with an increased risk of both death (AHR, 2.09; 95% CI, 1.71 to 2.56; P < 0.001) and graft loss (AHR, 1.79; 95% CI, 1.15 to 2.78; P = 0.01). Graft loss due to noncompliance was significantly more common after psychosis (9.0% versus 3.7% in patients not hospitalized for psychosis; P < 0.001). The incidence of hospitalized psychosis was not substantially higher after RT compared with chronic dialysis patients. Psychoses were independently associated with increased risk of death and graft loss after renal transplantation, possibly mediated through medical non-adherence.     

New-onset gout after kidney transplantation: incidence, risk factors and implications

BACKGROUND: Although cyclosporine use has been associated with an increased risk of new-onset gout after renal transplantation, the incidence and risk factors for new-onset gout have not been reported in the era of modern immunosuppression. METHODS: We conducted a retrospective cohort study of Medicare primary renal transplant patients reported in the United States Renal Data System (USRDS), using Medicare claims data to determine the incidence of new-onset gout. Cox regression analysis was used to calculate adjusted hazard ratios (AHR) for cyclosporine (including separate analysis of Neoral) compared directly with tacrolimus, for the risk of new-onset gout, adjusted for baseline demographic factors and posttransplant renal function. RESULTS: The cumulative incidence of new-onset gout was 7.6% at 3 years posttransplant. The following factors were independently associated with an increased risk of new-onset gout: use of Neoral (vs. tacrolimus, AHR 1.25, 95% CI 1.07-1.47) at discharge, recipient male sex (AHR 1.44, 95% CI 1.25-1.67), older age, higher body mass index, and more recent year of transplant. No other immunosuppressive medications were associated with new-onset gout. Diabetes was associated with a significantly lower risk of new-onset gout. The development of new-onset gout was independently associated with decreased patient survival (AHR 1.26, 95% CI 1.08-1.47) as well as death-censored graft survival. CONCLUSIONS: Cyclosporine is an independent risk factor for new-onset gout after transplantation. The incidence of new-onset gout appears to be increasing even while the use of cyclosporine is decreasing, and the development of new-onset gout was an independent predictor for death and graft loss in this population.     

Early renal insufficiency and hospitalized heart disease after renal transplantation in the era of modern immunosuppression

Renal insufficiency has been identified as a risk factor for graft loss and death after renal transplantation but has not been consistently linked to early, nonfatal, hospitalized heart disease (HHD). With the United States Renal Data System database, 29,597 patients who received a kidney transplant between January 1, 1996, and July 31, 2000, with Medicare as the primary payer, and were monitored until December 31, 2000, were studied. Cox proportional-hazards regression models were used to calculate the association of recipient estimated GFR (eGFR) at 1 yr after renal transplantation, as determined with the Modification of Diet in Renal Disease formula, with hospitalization for treatment of acute coronary syndromes (ACS) (International Classification of Diseases, version 9, code 410.x or 411.x) or congestive heart failure (CHF) (code 428.x) 1 to 3 yr after renal transplantation. Rates of ACS and CHF were 2.2 and 4.9%, respectively, for patients with eGFR of <44.8 ml/min per 1.73 m(2), compared with 1.2 and 1.4% for patients with eGFR of >69.7 ml/min per 1.73 m(2). Reduced eGFR (<44.8 ml/min per 1.73 m(2), compared with >69.7 ml/min per 1.73 m(2)) at the end of the first 1 yr after transplantation was independently associated with increased risks of both ACS (adjusted hazard ratio, 2.16; 95% confidence interval, 1.39 to 3.35) and CHF (adjusted hazard ratio, 2.95; 95% confidence interval, 2.24 to 3.90). It was concluded that early renal insufficiency (approximately stage 3 chronic kidney disease) was associated with higher rates of HHD 1 to 3 yr after kidney transplantation. Preservation of renal function after renal transplantation may reduce the rates of HHD, and renal transplant recipients with reduced eGFR should be considered at high risk of developing cardiovascular disease.     

Hospitalized Atrial Fibrillation After Renal Transplantation in the United States

Renal transplant recipients have a high incidence of hypertension, a known risk factor for atrial fibrillation (AF), as well as factors that could increase their risk of AF. However, the incidence of, risk factors for, and mortality associated with AF after renal transplantation have not been reported. We present a historical cohort study of 39 628 renal transplant recipients in the United States Renal Data System between 1 July 1994 and 30 June 1998. Data source: USRDS files through May 2000. Associations with hospitalizations for a primary diagnosis of AF (ICD-9 codes 427.31) after renal transplant were assessed by Cox Regression analysis. Tacrolimus was not approved for use by the FDA during the time-frame of the study. The incidence of AF after renal transplantation was 5.8 episodes/1000 person-years. In Cox Regression analysis, recipients who were older age, experienced graft loss, rejection, had higher body mass index, renal failure due to hypertension, and cyclosporine use (vs. tacrolimus use) were associated with increased risk of hospitalized AF. Atrial fibrillation was not uncommon after renal transplantation, and was associated with increased risk of mortality, primarily from cardiovascular disease. The strongest risk factors for AF after renal transplantation were older age, allograft rejection, graft loss and obesity.     

Hospitalized gastrointestinal bleeding and procedures after renal transplantation in the United States

The risk of hospitalized gastrointestinal bleeding (GIB) in renal transplant recipients has not been studied in a national renal transplant population. Therefore, 42,906 renal transplant recipients in the United States Renal Data System (USRDS) from 1 July 1994 - 30 June 1998 were analyzed in an historical cohort study of hospitalizations with a primary discharge diagnosis of GIB (ICD9 Code 578.9x) using Cox regression analysis. The 1997 National Hospital Discharge Survey was used to obtain rates of GIB for the general population. Renal transplant recipients had a cumulative incidence of hospitalizations for GIB of 334 events/100,000 person-years. In 1997, compared to the general population, renal transplant recipients had an age-adjusted rate ratio for GIB of 10.69 at one year of follow-up. The strongest risk factors for GIB in Cox regression analysis were graft loss (adjusted hazard ratio, 4.28 (2.84-6.47) and African American recipients who experienced allograft rejection (AHR, 3.04, 95% CI, 1.45-6.37). GIB was associated with increased all-cause mortality (hazard ratio 1.78, 95% CI, 1.39-2.28). GIB is significantly more common in renal transplant recipients than in the general population, and the strongest risk factors are graft loss and African Americans who experience rejection.     

Effect of Donor Factors on Early Graft Survival in Adult Cadaveric Renal Transplantation

Previous studies of the effect of donor factors on renal transplant outcomes have not tested the role of recipient body mass index, donor/recipient weight ratios and age matching, and other factors. We analyzed 20,309 adult (age 16 or older) recipients having solitary cadaveric renal transplants from adult donors from 1 July 1994 to 30 June 1998 in an historical cohort study (the 2000 United States Renal Data System) of death censored graft loss by the Cox proportional hazards models, which corrected for characteristics thought to affect outcomes. The only independently significant findings in Cox Regression analysis were a high donor/ recipient age ratio (> or = 1.10, e.g. a 55-year-old donor given to a recipient age 50years or younger, adjusted hazard ratio (AHR) 3.22, 95% confidence interval (CI) 2.36-4.39) and African American donor kidneys (AHR 1.64, 95% CI, 1.24-2.17). African American recipients and older donors were not at independently increased risk of graft failure in this model. Among donor factors, older donor kidneys given to younger recipients and donor African American kidneys were independently associated with graft loss in recipients of cadaver kidneys. The task for the transplant community should be to find the best means for managing all donor organs without discouraging organ donation.     

Hospitalizations for bacterial endocarditis after renal transplantation in the United States.

PURPOSE: The national rate of and risk factors for bacterial endocarditis in renal transplant recipients has not been reported. METHODS: Retrospective registry study of 33,479 renal transplant recipients in the United States Renal Data System (USRDS) between 1 July 1994 and 30 June 1997. Hospitalizations for a primary diagnosis of bacterial endocarditis (ICD-9 codes 421.x) within three years after renal transplant were assessed. RESULTS: Renal transplant recipients had an unadjusted incidence ratio for endocarditis of 7.84 (95% confidence interval 4.72-13.25) in 1996. In multivariate analysis, a history of hospitalization for valvular heart disease (adjusted odds ratio (AOR), 25.81, 95% confidence interval 11.28-59.07), graft loss (AOR, 2.81, 95% CI 1.34-5.09), and increased duration of dialysis prior to transplantation were independently associated with hospitalizations for bacterial endocarditis after transplantation. Hospitalization for endocarditis was associated with increased patient mortality in Cox Regression analysis, hazard ratio 4.79, 95% CI 2.97-6.76. CONCLUSIONS: The overall incidence of bacterial endocarditis was much greater in renal transplant recipients than in the general population, although it is still relatively infrequent. Independent risk factors for bacterial endocarditis in the renal transplant recipients were identified, the most significant of which was valvular heart disease. Endocarditis substantially impacts renal transplant recipient survival.     

Mycobacterium Tuberculosis Infection Incidence in Hospitalized Renal Transplant Patients in the United States, 1998–2000

The incidence, risk factors, and prognosis for Mycobacterium tuberculosis (MTB) infection have not been reported in a national population of renal transplant recipients. We performed a retrospective cohort study of 15,870 Medicare patients who received renal transplants from January 1, 1998 to July 31, 2000. Cox regression analysis derived adjusted hazard ratios (AHR) for factors associated with a diagnosis of MTB infection (by Medicare Institutional Claims) and the association of MTB infection with survival. There were 66 renal transplant recipients diagnosed with tuberculosis infection after transplant (2.5 cases per 1000 person years at risk, with some falling off of cases over time). The most common diagnosis was pulmonary TB (41 cases). In Cox regression analysis, only systemic lupus erythematosus (SLE) was independently associated with TB. Mortality after TB was diagnosed was 23% at 1 year, which was significantly higher than in renal transplant recipients without TB (AHR, 4.13, 95% CI, 2.21, 7.71, p < 0.001). Although uncommon, MTB infection is associated with a substantially increased risk of mortality after renal transplantation. High-risk groups, particularly those with SLE prior to transplant, might benefit from intensified screening.     

Renal Allograft Survival in Transplant Recipients with Focal Segmental Glomerulosclerosis

Previous literature suggests that the recurrence of focal segmental glomerulosclerosis (FSGS) after renal transplantation is more common in recipients who have received an HLA-identical living-related (LRD) transplant. To address the question if FSGS patients can safely receive a 6-antigen match LRD kidney transplant, we analyzed death-censored renal allograft survival data of FSGS patients from the United States Renal Data System database (USRDS). Using the USRDS and the U.S. Scientific Renal Transplant Registry between the years 1988-97, we found 19259 adult primary renal transplant recipients, of which 2414 patients had FSGS as their primary diagnosis as compared to 16845 patients who had other types of glomerulonephritis (GN). A Cox proportional hazard model was used to estimate death-censored graft survival among FSGS patients with a zero mismatch LRD kidney transplant. The model included a triple interaction term comparing FSGS vs. GN vs. living donation (LD) vs. cadaveric donation (CAD) vs. zero mismatch (six antigen or HLA-identical) vs. mismatch. Annually adjusted death censored graft loss rates per 1000 patients (ADGL) were calculated. Focal segmental glomerulosclerosis patients receiving a zero mismatch LRD kidney transplant had the lowest ADGL rate, losing 10.5 grafts per 1000 patients per year. Not significantly different but higher (14.3) was the ADGL rate for LD, zero mismatch GN recipients. The ADGL rate was significantly higher in FSGS recipients who received a LD, mismatched transplant (36.5). Focal segmental glomerulosclerosis patients who received a CAD, zero mismatched graft (44.1), or CAD, mismatched graft (63.2), had significantly higher ADGL rates. Zero mismatch LRD kidney transplants are not a risk factor for graft loss in FSGS patients but are associated with significantly better death-censored graft survival as compared to CAD 6-antigen match or mismatched donations.     

Hospitalized avascular necrosis after renal transplantation in the United States

BACKGROUND: The national incidence of and risk factors for hospitalized avascular necrosis (AVN) in renal transplant recipients has not been reported. METHODS: This historical cohort study consisted of 42,096 renal transplant recipients enrolled in the United States Renal Data System (USRDS) between 1 July 1994 and 30 June 1998. The data source was USRDS files through May 2000. Associations with hospitalizations for a primary diagnosis of AVN (ICD-9 codes 733.4x) within three years after renal transplant were assessed in an intention-to-treat design by Cox regression analysis. RESULTS: Recipients had a cumulative incidence of 7.1 episodes/1000 person-years from 1994 to 1998. The two-year incidence of AVN did not change significantly over time. Eighty-nine percent of the cases of AVN were due to AVN of the hip (733.42) and 60.2% of patients with AVN underwent total hip arthroplasty (THA); these percentages did not change significantly over time. In the Cox regression analysis, an earlier year of transplant, African American race [adjusted hazard ratio (AHR), 1.65, 95% confidence interval (CI) 1.33 to 2.03], allograft rejection (AHR 1.67, 95% CI 1.35 to 2.07), peritoneal dialysis (vs. hemodialysis; AHR 1.44, 95% CI 1.15 to 1.81), and diabetes (AHR 0.41, 95% CI 0.27 to 0.64) were the only factors independently associated with hospitalizations for AVN. CONCLUSIONS: The incidence of AVN did not decline significantly over time in the renal transplant population. Patients with allograft rejection, African American race, peritoneal dialysis and earlier date of transplant were at the highest risk of AVN, while diabetic recipients were at a decreased risk.     

Effect of waiting time on renal transplant outcome

BACKGROUND: Numerous factors are known to impact on patient survival after renal transplantation. Recent studies have confirmed a survival advantage for renal transplant patients over those waiting on dialysis. We aimed to investigate the hypothesis that longer waiting times are more deleterious than shorter waiting times, that is, to detect a "dose effect" for waiting time. METHODS: We analyzed 73,103 primary adult renal transplants registered at the United States Renal Data System Registry from 1988 to 1997 for the primary endpoints of death with functioning graft and death-censored graft failure by Cox proportional hazard models. All models were corrected for donor and recipient demographics and other factors known to affect outcome after kidney transplantation. RESULTS: A longer waiting time on dialysis is a significant risk factor for death-censored graft survival and patient death with functioning graft after renal transplantation (P < 0.001 each). Relative to preemptive transplants, waiting times of 6 to 12 months, 12 to 24 months, 24 to 36, 36 to 48, and over 48 months confer a 21, 28, 41, 53, and 72% increase in mortality risk after transplantation, respectively. Relative to preemptive transplants, waiting times of 0 to 6 months, 6 to 12 months, 12 to 24 months, and over 24 months confer a 17, 37, 55, and 68% increase in risk for death-censored graft loss after transplantation, respectively. CONCLUSIONS: Longer waiting times on dialysis negatively impact on post-transplant graft and patient survival. These data strongly support the hypothesis that patients who reach end-stage renal disease should receive a renal transplant as early as possible in order to enhance their chances of long-term survival.     

Risk factors for hospitalizations resulting from pulmonary embolism after renal transplantation in the United States.

BACKGROUND: Risk factors for pulmonary embolism (PE) have been identified in the general population but have not been studied in a national population of renal transplant recipients. METHODS: Therefore, 33,479 renal transplant recipients in the United States Renal Data System from 1 July 1994-30 June 1997 were analyzed in a historical cohort study of hospitalized PE (ICD9 Code 415.1x). HCFA form 2728 was used for comorbidities. RESULTS: Renal transplant recipients had an incidence of PE of 2.26 hospitalizations per 1000 patient years at risk. In multivariate analysis, polycystic kidney disease (adjusted odds ratio, 4.44, 95% confidence interval, 2.31-8.53), older recipient age, higher recipient weight, cadaveric donation, history of ischemic heart disease, and decreased serum albumin were associated with increased risk of PE. Body mass index and hemoglobin were not significant. Kidney-pancreas transplantation was also not significant. In Cox Regression analysis PE was associated with increased mortality (hazard ratio 2.06, 95% CI 1.34-3.18). CONCLUSIONS: The most important risk factors for PE in this population were polycystic kidney disease, advanced age and increased weight. The reasons for the increased risk of polycystic kidney disease remain to be determined but were independent of hematocrit level at initiation of end stage renal disease, and may result from venous compression. Prospective studies of anatomical and hemostatic changes after renal transplantation in recipients with polycystic kidney disease are warranted.     

Hepatitis C, acute humoral rejection, and renal allograft survival

The effect of recipient hepatitis C virus (HCV) infection on renal allograft loss and acute rejection in kidney transplantation remains controversial. We studied 354 renal allograft recipients transplanted during 1996 to 2001 who had HCV antibodies (Ab) measured before transplantation. The primary outcome was death-censored allograft loss and the secondary outcome was acute humoral rejection (AHR). Compared with HCV Ab-negative patients, those with positive HCV Ab had longer time on dialysis before transplantation, higher percentage of panel-reactive antibodies (PRA), were more likely to receive a cadaveric transplant, and were more likely to develop delayed graft function (DGF). In univariate analyses, predictors of renal allograft loss included HCV, cadaveric graft, PRA >20%, HLA mismatch > or =5, retransplantation, DGF, induction therapy, and AHR. When adjusted for PRA >20%, HLA mismatch > or =5, and multiple transplant status, HCV was not a statistically significant predictor of allograft loss. HCV was also associated with AHR but lost significance when adjusted for PRA >20%. HCV Ab-positive patients were more likely to have longer duration of dialysis before transplantation prior to kidney transplants, higher PRA, and to receive cadaveric transplants. These characteristics likely resulted in more DGF and AHR after transplantation. After adjusting for these confounding factors, the association between HCV Ab positivity and renal allograft loss was notably attenuated and no longer statistically significant.     

Impact of renal transplantation on survival in end-stage renal disease patients with elevated body mass index

BACKGROUND: Cadaveric renal transplantation is associated with a survival advantage compared with dialysis patients remaining on the renal transplantation waiting list, but this advantage has not been confirmed in obese end-stage renal disease (ESRD) patients. METHODS: Using data from the USRDS, we studied 7521 patients who presented with ESRD from 1 April 1995 to 29 June 1999 and later enrolled on the renal transplantation waiting list with body mass indices (BMI) >or=30 kg/m(2) at the time of presentation to ESRD, and followed until 6 November 2000. Recipients of preemptive renal transplantation or organs other than kidneys were excluded. Cox non-proportional hazards regression models were used to calculate adjusted, time-dependent hazard ratios (HR) for time to death in a given patient during the study period, controlling for renal transplantation, demographics and comorbidities (Form 2728). RESULTS: The incidence of mortality was 3.3 episodes per 100 patient-years (PY) in cadaveric renal transplantation and 1.9/100 PY in living donor renal transplantation compared with 6.6 episodes/100 PY in all patients on the transplant waiting list. In comparison to maintenance dialysis, both recipients of solitary cadaveric kidneys (HR 0.39, 95% CI 0.33 to 0.47), and recipients of living donor kidneys (HR 0.23, 95% CI 0.16 to 0.34) had statistically significant improved survival. A benefit of cadaveric renal transplantation did not apply to patients with BMI >or=41 kg/m(2) (HR 0.47, 95% CI, 0.17 to 1.25, P = 0.13). CONCLUSIONS: Obese patients on the renal transplant waiting list had a significantly lower risk of mortality after renal transplantation compared with those remaining on dialysis.     

Elderly donor kidney transplant: factors involved in graft survival

PURPOSE: To evaluate whether control of risk factors associated with worse results has improved graft survival, with respect of renal function quality and other factors influencing graft survival: recipient age, immunosuppressive therapy, cold ischemia time, acute tubular necrosis (ATN), acute rejection episodes (ARE) and 1-month creatinine levels. MATERIALS AND METHODS: Retrospective review of 147 patients who underwent kidney transplant between 1995 and 2001. Inclusion criteria were donor and recipient age older than 60 years, first renal transplant, follow-up period longer than 12 months, donor creatinine clearance higher than 75 mL/min, and less than 20% glomerulosclerosis observed in donor renal biopsy. RESULTS: Graft survivals were 87%, 83%, 78%, and 70% at first, second, third, and fifth year after transplantation, respectively. Mean serum creatinine levels were 2.3 mg/dL and mean follow-up time, 46 months. Multivariate analysis using a Cox regression model identified donor age, ARE, and serum creatinine levels 1 month after surgery as independent variables affecting graft survival. Recipient age, immunosuppressive therapy, and serum creatinine levels at 1 month after surgery were predictive variables of recipient survival. DISCUSSION: Renal transplantation is an accepted therapeutic option in elderly patients with chronic renal insufficiency, if both donor and recipient are carefully selected.     

Hepatitis C antibody status and outcomes in renal transplant recipients

BACKGROUND: Hepatitis occurs frequently in patients with end-stage renal disease. In 1997, 0.7% of patients receiving a renal transplant were positive for hepatitis C antibodies. Concern has been raised as to whether these patients are at an increased mortality risk after renal transplantation compared with patients who are hepatitis C antibody negative. To help answer this question, we analyzed data from the United States Renal Data System from October of 1988 through June of 1998. METHODS: Primary study endpoints were patient death and death censored graft loss. Secondary study endpoints included cardiovascular, infectious, malignant, and infection-related death. Kaplan-Meier survival estimates as well as Cox proportional hazard models were used to evaluate the impact of hepatitis C antibody status on the study endpoints. RESULTS: A total of 73,707 patients were analyzed. Patient survival by Kaplan-Meier analysis was higher in hepatitis C-positive patients, whereas death censored graft survival trended lower in the very long term. By the Cox model, hepatitis C-positive adjusted patient survival is slightly superior to that of hepatitis C-negative patients. CONCLUSIONS: Renal transplant recipients who are hepatitis C antibody positive do not have an increased risk of death after transplantation compared with hepatitis C-negative recipients. The current policy of transplanting hepatitis C-positive patients without active liver disease seems to incur no excess mortality risk.     

The association between recipient alcohol dependency and long-term graft and recipient survival.

BACKGROUND: The causative role of alcohol consumption in renal disease is controversial, and its effect on renal graft and recipient survival has not been previously studied. METHODS: We analysed the association between pre-transplant [at the time of end-stage renal disease (ESRD) onset] alcohol dependency and renal graft and recipient survival. The United States Renal Data System (USRDS) records of kidney transplant recipients 18 years or older transplanted between 1 January 1995 and 31 December 2002 were examined. We used Kaplan-Meier analysis and Cox regression models adjusted for covariates to analyse the association between pre-transplant alcohol dependency and graft and recipient survival. RESULTS: In an entire study cohort of 60 523, we identified 425 patients with a history of alcohol dependency. Using Cox models, alcohol dependency was found to be associated with increased risk of death-censored graft failure [hazard ratio (HR) 1.38, P < 0.05] and increased risk of transplant recipient death (HR 1.56, P < 0.001). Subgroup analysis demonstrated an association of alcohol-dependency with recipient survival and death-censored graft survival in males (but not in females), and in both white and non-white racial subgroups. CONCLUSIONS: We concluded that alcohol dependency at the time of ESRD onset is a risk factor for renal graft failure and recipient death.     

Proteinuria as a Predictive Factor in the Evolution of Kidney Transplantation

IntroductionCertain factors can change the course of renal transplantation, such as acute rejection, ischemia time, and compatibility. Other donor and recipient factors may modify this evolution. Proteinuria modifies glomerular disease progression and may influence renal graft survival. In this study we analyzed proteinuria in patients who received a transplant since 2000 in Andalusia.Material and MethodsWe studied the Andalusian Renal Transplant Registry from January 2000 to March 2012, recording data on 1815 patients who had proteinuria, registered at the third month and first year after transplantation. Three groups were formed, including those with proteinuria <300 mg/24 h, those between 300 and 1000 mg/24 h, and those >1000 mg/24 h.ResultsAt the third month and the first year after transplantation, 65.7% and 71.6% of patients had proteinuria <300 mg/24 h, 29.6% and 24.1% had proteinuria between 300 and 1000 mg/24 h, and 4.7% and 4.4% had proteinuria >1000mg/24 h, respectively. We found differences between the three proteinuria groups in panel reactive antibodies (% PRA), serum creatinine at the third month and the first year, the etiology of the donor death, incidence of delayed renal function, and incidence of hypertension. The degree of proteinuria influenced graft and patient survival. In multivariate analysis, proteinuria was an independent risk factor for renal graft lossConclusionsThe degree of proteinuria at the third month and the first year after transplantation is predictive of graft and patient survival. The patients who had more proteinuria at the third and 12th month after transplantation had worse renal function and more hypertension. Proteinuria is an independent risk factor for renal graft loss.     

Epidemiology of posttransplant lymphoproliferative disorders in adult kidney and kidney pancreas recipients: report of the French registry and analysis of subgroups of lymphomas

A registry of posttransplant lymphoproliferative disorders (PTLD) was set up for the entire population of adult kidney transplant recipients in France. Cases of PTLD were prospectively enrolled between January 1, 1998, and December 31, 2007. Ten-year cumulative incidence was analyzed in patients transplanted after January 1, 1989. PTLD risk factors were analyzed in patients transplanted after January 1, 1998 by Cox analysis. Cumulative incidence was 1% after 5 years, 2.1% after 10 years. Multivariate analysis showed that PTLD was significantly associated with: older age of the recipient 47-60 years and >60 years (vs. 33-46 years, adjusted hazard ratio (AHR) = 1.87, CI = 1.22-2.86 and AHR = 2.80, CI = 1.73-4.55, respectively, p < 0.0001), simultaneous kidney-pancreas transplantation (AHR = 2.52, CI = 1.27-5.01 p = 0.008), year of transplant 1998-1999 and 2000-2001 (vs. 2006-2007, AHR = 3.36, CI = 1.64-6.87 and AHR = 3.08, CI = 1.55-6.15, respectively, p = 0.003), EBV mismatch (HR = 5.31, CI = 3.36-8.39, p < 0.001), 5 or 6 HLA mismatches (vs. 0-4, AHR = 1.54, CI = 1.12-2.12, p = 0.008), and induction therapy (AHR = 1.42, CI = 1-2.02, p = 0.05). Analyses of subgroups of PTLD provided new information about PTLD risk factors for early, late, EBV positive and negative, polymorphic, monomorphic, graft and cerebral lymphomas. This nationwide study highlights the increased risk of PTLD as long as 10 years after transplantation and the role of cofactors in modifying PTLD risk, particularly in specific PTLD subgroups.     

Death After Graft Loss: An Important Late Study Endpoint in Kidney Transplantation

Traditional study endpoints utilized in renal transplantation have included graft survival, and death with a functioning graft. We analyzed the risk factors for death after allograft loss (DAGL) among a total of 78564 primary renal transplants reported to the United States Renal Data System (USRDS) from 1988 to 1998. Cox models were used to investigate risk factors for DAGL. Of 15528 deaths, 10816 occurred before, and 4712 occurred after graft loss. Overall annual adjusted death rates were more than 3-fold higher after graft loss as compared to before graft loss (9.42% vs. 2.81%). By Cox model, dialysis for more than 2 years was associated with a more than 2-fold relative risk for DAGL (RR = 2.2, Cl = 1.88-2.53), while transplant time was not associated with DAGL. Infection related graft losses showed a strong association with DAGL (RR = 1.64, Cl = 1.31-2.07). Acute rejection and thrombosis as causes of graft loss were also significantly associated with the risk for DAGL (RR = 1.35, Cl = 1.23-1.47 and RR = 1.39, Cl = 1.39). Patient survival after graft loss is poor. The lack of association between DAGL and transplant time, as opposed to the strong relation to pretransplant dialysis time, would suggest the adverse effects of previous uremia-mediated damage may be contributing to this phenomenon, along with the adverse effects of loss of renal function.