Gastrointestinal complications in renal transplant recipients

Gastrointestinal complications are frequent in renal transplant recipients and can include oral lesions, esophagitis, peptic ulcer, diarrhea, colon disorders and malignancy. Oral lesions may be caused by drugs such as cyclosporine and sirolimus, by virus or fungal infections. Leukoplakia may develop in patients with Epstein-Barr virus (EBV) infection. The commonest esophageal disorder is represented by fungal esophagitis usually caused by candida. A number of patients may suffer from nausea, vomiting and gastric discomfort. These disorders are more frequent in patients treated with mycophenolate mofetil (MMF). Peptic ulcer is more rare than in the past. Patients with a history of peptic ulcer are particularly prone to this complication. Other gastroduodenal disorders are caused by cytomegalovirus (CMV) and herpes simplex infection. Diarrhea is a frequent disorder which may be caused by pathogen microorganisms or by immunosuppressive agents. The differential diagnosis may be difficult. Colon disorders mainly consist of hemorrhage, usually sustained by CMV infection, or perforation which may be caused by diverticulitis or intestinal ischemia. Colon cancer, anal carcinoma, and EBV-associated lymphoproliferative disorders are particularly frequent in transplant recipients. A particular gastric lymphoma called mucosa-associated lymphoid tissue (MALT) lymphoma may develop in renal transplant patients. It usually responds to the eradication of Helicobacter pylori.     

Dream anxiety in renal transplant recipients

Abstract

Objective: Although low quality of sleep has been reported in kidney transplant patients with functioning allografts, there are no previous studies investigating the dreams of these patients. We aimed to investigate the differences in dream anxiety level between renal transplant patients and healthy control subjects. We also planned to compare depression and anxiety symptoms, sleep quality and sleepiness level between these two groups. Methods: Twenty-two living-donor renal transplant recipients followed at an outpatient nephrology clinic and 22 healthy controls were enrolled in this observational cross-sectional study. Sociodemographic Data Collection Form, and the Van Dream Anxiety Scale (VDAS), the Pittsburg Sleep Quality Index (PSQI), the Insomnia Severity Index (ISI), Beck Depression and Anxiety Inventories were used for the assessment of the necessary features. Hemoglobin (Hb), blood urea nitrogen (BUN), creatinine (Cr) and glucose levels were measured. Results: There were no significant differences between the groups in terms of dream anxiety (p?=?0.45), depression (p?=?0.76), sleep quality (p?=?0.8), insomnia severity (p?=?0.08) and Hb (p?=?0.11) and glucose levels (p?=?0.14). Although, BUN (p?=?0.00) and creatinine (p?=?0.00) levels differed significantly between the two groups, both parameters were found to be within their normal range. Conclusions: In our study, chronic renal failure patients with a successful kidney transplant were found to be able to completely return to normal in terms of metabolic parameters, sleep quality and mood. Similar levels of dream anxiety are also consistent with these findings.     

Levofloxacin and rhabdomyolysis in a renal transplant patient.

Rhabdomyolysis can lead to fatal hyperkalaemia, acute renalfailure and compartment syndromes in renal transplant patients.The most common cause for rhabdomyolysis in these patients isa drug interaction between statins and ciclosporin A [1]. Statinsare known to be myotoxic [2], and their serum levels can beelevated with the concomitant use of ciclosporin A, as the metabolismof both drugs is dependent     

Comparison of peritoneal dialysis and haemodialysis after renal transplant failure

Background. A growing number of patients are returning to dialysisafter renal transplant failure. The aim of this study is todetermine whether peritoneal dialysis (PD) is a safe and goodtreatment option for these patients. Methods. All patients returning to PD or haemodialysis (HD)after renal transplant failure before 1 October 2002 at theUniversity Hospital Gasthuisberg, Leuven, Belgium, were evaluated.Data were collected until death, retransplantation (reTx), transferto HD or PD or until 1 January 2003. Results. Twenty-one patients starting PD (PDpostTx-group) and39 patients starting HD (HDpostTx-group) after renal transplantfailure were included in the study. There were no significantdifferences in age, sex, serum albumin- and CRP-levels at baseline.The total time on renal replacement therapy at transplant failureand time to transplant failure did not differ between the twogroups either. Furthermore, the baseline comorbidity was similarin both groups. During follow-up, the outcome did not differsignificantly between the two groups. However, there was a tendencytowards higher patient survival and reTx tended to be more frequentin the PDpostTx-group. Moreover, patients in the HDpostTx-grouptended to accrue more new comorbidity. The incidence of peritonitisand the evolution of dialysis adequacy (renal and peritonealKt/V and creatinine clearances) with time in the PDpostTx-groupwas similar to that seen in our centre's PD patients who hadnever undergone transplantation before. Conclusions. This study suggests that the outcome in patientsstarting PD after renal transplant failure is at least as goodas the outcome in those starting HD. Although these observationalfindings warrant further confirmation, PD therefore can be regardedas a safe and good treatment option for patients returning todialysis after renal transplant failure.     

Gout in renal transplant recipients

AIMS: The aims of the present audit were to determine the prevalence of gout in renal transplant recipients in Canterbury, New Zealand, to identify risk factors for gout, and to assess the range of treatments used, their efficacy and complications. In addition, the authors wished to assess the impact of post-renal transplant gout on the patient. METHODS: Patients with post-transplantation gout were identified from the Christchurch Hospital Nephrology database. For each patient with gout a post-renal transplantation recipient without gout post transplant was found matched for age, sex and date of transplant. Case notes were audited and patients interviewed. RESULTS: In total, 47/202 (23%) living renal transplant recipients had gout post transplant. Those patients with gout were more likely to be taking a loop diuretic (68%vs 34%, P < 0.001), to have a higher serum urate and impaired renal function and to have had gout prior to the transplant. Of those patients who developed gout post transplant 70% had an attack at least every 3 months. Of those who returned to work post transplant 48% required time off work because of gout. CONCLUSION: out is an important problem in the post-transplant population causing significant morbidity and time off work. Diuretics, impaired renal function, gout prior to transplantation and hyperuricaemia are important risk factors. The need for diuretic therapy should be kept under review in these patients. Hypouricaemic therapy should be considered early in those who develop gout post renal transplantation. Further studies are required to determine whether treatment for asymptomatic hyperuricaemia is justified.     

Recurrence from primary and secondary glomerulopathy after renal transplant

Glomerulonephritis is the primary cause of end-stage renal failure in 30-50% of kidney transplant recipients and recurrence of the initial disease is an important determinant of long-term graft outcome after transplantation. Although renal transplantation remains the best treatment option for patients with end stage renal diseases in most cases, diagnosis and management of recurrences of glomerulopathies are critical for the optimization and improvement of long-term kidney transplant graft survival and provide a unique opportunity to explore the pathogenesis of native kidney disease. This review aims to update knowledge for a large panel of recurrent primary and secondary glomerulonephritis after kidney transplantation, excluding diabetic nephropathy including primary focal and segmental glomerulosclerosis, membranous nephropathy, IgA nephropathy, membranoproliferative glomerulonephritis, lupus, vasculitis but also less usual secondary nephropathy related to sarcoidosis, AA and AL amyloidosis, monoclonal immunoglobulin deposition disease, and fibrillary glomerulonephritis.     

Improving survival in the very young renal transplant recipient

Sixty-one patients ranging in age from 6 weeks to 30 months have undergone renal transplantation over a 19-year period. The overall survival is 80% with a 90% survival in those patients transplanted since 1980 (41 patients). Seventy-five percent of the original allografts have survived with 83% of the last 41 allografts surviving. The unique challenges presented by the very young renal transplant recipient are outlined along with those aspects of management felt to be most important in ensuring a successful outcome.     

The impact of reduced immunosuppression on graft outcomes in elderly renal transplant recipients

Abstract: Optimal immunosuppression (IS) for elderly kidney transplant recipients is unknown. We conducted a retrospective cohort study of recipients aged 60 yr or older to examine the impact of reduced IS on graft outcomes. Group 1 patients (n = 101) were initiated on mycophenolate mofetil 2 g/d and tacrolimus, target level 10–12 ng/mL; Group 2 patients (n = 88) with 1 g/d and 8–10 ng/mL, respectively. Dose adjustments were made as required. The groups were comparable except for diabetes, end‐stage renal disease duration, and induction. Mycophenolate mofetil dose was reduced in 62% and 38% of the patients, respectively (p < 0.01). Patients were followed for 23.8 ± 14.2 and 21.3 ± 11.8 months post‐transplant (p = 0.2). Twenty‐seven cases in Group 1 (26.7%) and eight in Group 2 (9.1%) lost their grafts (p = 0.01); 19 (18.8%) and 7 (8.0%) cases in each group because of death, respectively (p = 0.09). Sixteen patients in Group 1 (15.8%) and 18 in Group 2 (20.5%) experienced acute rejection (p = 0.36). Patients in Group 2 had a lower risk of graft loss compared with those in Group 1 [adjusted hazard ratio (HR): 0.27, p = 0.006, 95% CI: 0.11–0.69]. There were no significant differences between the groups regarding graft function, BK virus nephropathy, and CMV infection. Our results suggest that reduction in overall IS in this group was associated with improved graft and patient survival.     

Predictive factors for adverse pregnancy outcomes after renal transplantation

Several predictive factors associated with adverse pregnancy outcomes in female renal recipients have been suggested. Our study aimed to determine the most important factor for prediction of adverse pregnancy outcomes in female renal recipients. We studied 41 pregnancies in 29 female renal recipients retrospectively. We reviewed pregnancy outcomes and possible predictive factors including pre‐pregnancy serum creatinine (SCr), pre‐pregnancy glomerular filtration rate (GFR), pre‐pregnancy hypertension, pre‐pregnancy proteinuria, transplantation‐pregnancy interval and type of immunosuppressants. We defined an adverse pregnancy‐related outcomes index (APOI) that included the following conditions: (i) preeclampsia; (ii) fetal growth restriction (FGR); (iii) prematurity before 34 wk of gestation; (iv) fetal loss (v) graft dysfunction during pregnancy or within three months from delivery. The cutoff of pre‐pregnancy serum creatinine and GFR was determined by receiver operating characteristics curves for the prediction of each adverse outcome and APOI. Only pre‐pregnancy serum creatinine was associated with adverse pregnancy outcome, and 1 mg/dL was determined to be a useful cutoff for the prediction of each adverse outcomes. Pre‐pregnancy SCr ≥ 1 mg/dL was associated with 7.7 times increased risk of preeclampsia and 6.9 times increased risk of APOI. Pre‐pregnancy serum creatinine is the most powerful predictive factor for adverse pregnancy outcomes, and <1 mg/dL may be used as a screen for successful pregnancy outcome.     

Cost-minimization study comparing Simulect vs. Thymoglobulin in renal transplant induction

PURPOSE: Based on the data of clinical trial CHI-F-02 comparing the efficacy and safety of basiliximab (Simulect) vs. anti-thymocyte globulin (Thymoglobulin) in renal transplant induction, we carried out an economic evaluation. METHOD: This pharmacoeconomic study was a cost-minimization study, i.e. given the equivalent efficacy of the products, the strategy that minimized the cost of care was considered better. The cost of care was analyzed from the hospital perspective. MATERIAL: This 'piggyback' study of 100 patients estimated the direct medical costs incurred over 6 months of use of two strategies for renal transplant induction therapy. Direct medical costs are those of utilized medical resources: medications, hospital stays, dialysis, and physician visits and investigations not scheduled in the protocol. RESULTS: In the Simulect arm, significant reductions were found in the initial hospital stay duration and number of infectious episodes. Therefore, although the average cost of treatment was slightly higher with Simulect) than with Thymoglobulin (2964 vs. 2298 Euros), the cost of the initial hospitalization was significantly lower in the Simulect arm (10 907 vs. 11 967 Euros; p = 0.02). Furthermore the mean cost of infectious episodes was significantly lower in the Simulect arm (1056 vs. 1790 Euros, p = 0.03). Cytomegalovirus infection accounted for a significantly smaller proportion of this cost in the Simulect arm than in the Thymoglobulin arm (30% vs. 53%, p = 0.001). CONCLUSION: This study showed direct medical cost savings of 1159 Euros per patient in the Simulect arm, which more than compensated for the higher price of this immunosuppressive drug.     

Long-term clinical results of percutaneous transluminal angioplasty in transplant renal artery stenosis.

Twenty-five patients with transplant artery stenosis were identified among 1141 renal graft recipients. Impaired graft function (9 patients), hypertension (4 patients) or both (12 patients) were the indications for arteriography. All were treated by percutaneous angioplasty (PTA). The immediate technical success rate was 88% and actuarial graft survival was 88% and 80% at 2 and 5 years respectively. The long-term success rate on graft function was 67% (median observation time 24 months) and on hypertension 63% (median observation time 23 months). Six patients needed rePTA (8 procedures) and in only one patient was surgical repair performed. No case of graft loss due to PTA was recorded and in only one case did occlusion of a segmental artery lead to impairment of graft function. Minor complications were recorded in four other cases and in no case was surgical intervention necessary. Based on these results we favour PTA as a first-line interventional procedure in transplant renal artery stenosis, and the need for surgical repair has been low.     

Isolated hydatid disease of the native kidney in a renal transplant recipient.

A 43-year-old male renal allograft recipient was admitted tothe hospital for annual check-up. He received a cadaveric renaltransplant 2 years previously. On admission his physical examinationdid not show any abnormalities. Abdominal ultrasonography ofthe patient revealed     

Tuberculosis in renal transplant recipients on various immunosuppressive regimens.

BACKGROUND: Mycophenolate mofetil (MMF) and tacrolimus (TAC) are more potent than conventional immunosuppressive drugs, i.e. azathioprine, cyclosporin and prednisolone, and may be associated with an increase in the incidence of infections in the post-transplantation (post-tx) period. The aim of this study was to determine if the use of either or both of MMF and TAC for immunosuppression in renal transplant recipients increases the prevalence or modifies the clinical presentation of tuberculosis (TB), when compared with conventional therapy. METHODS: The medical records of 443 adult patients who received a kidney transplant between 1994 and 2002 were reviewed retrospectively. Comparisons were made between patients who had conventional immunosuppressive treatments (cyclosporin, azathioprine and prednisolone) or an alternative regimen (including MMF, TAC or both). RESULTS: We found 20 patients (4.5%) to have post-tx TB. There were 13 cases of TB (age 38.9+/-10.6 years) among 328 patients who received conventional immunosuppressants (group I) (4.0%) and seven cases (age 24.2+/-7.4 years) among 115 (6.1%) who received an alternative immunosuppressive regimen (group II) (P>0.05). The patients in group II were younger than the patients in group I (P = 0.002). A significantly higher number of patients in group II developed TB within the first 6 months post-tx (P = 0.042). However, there was no significant difference between the two groups regarding clinical and radiographic presentations or outcomes. CONCLUSIONS: Immunosuppression with TAC or MMF is associated with the development of TB earlier in the post-tx period and in younger patients.     

Decreased renal transplant function after parathyroidectomy.

BACKGROUND: Persistent secondary hyperparathyroidism after renal transplantation may require parathyroidectomy (PTX). Clinical experience suggests that these patients commonly develop decreased renal function thereafter. METHODS: To test this notion, we evaluated 76 transplant patients who underwent pararhyroidectomy between 1997 and 2003. RESULTS: In half the patients (47%), creatinine clearance decreased >20% (before vs after PTX, 57 +/- 21 vs 38 +/- 17 ml/min, P = 0.001). The patients with decreased creatinine clearance had higher parathyroid hormone (PTH) concentrations before and lower values after PTX compared with those who did not (594 +/- 392 vs 447 +/- 234 pg/ml before PTX, P = 0.03; 35 vs 123 pg/ml thereafter, P = 0.002). They also had lower serum calcium concentrations after PTX (2.0 vs 2.2 mmol/l, P = 0.005) and they required more calcium and vitamin D analogues. These patients also more commonly underwent total PTX with autotransplantation, compared with subtotal (75 vs 50%, P = 0.03). However, in multivariate analysis, only the delta PTH decline (%) after PTX was a significant predictor of deteriorating renal function (P = 0.005) and was correlated with the creatinine clearance decrease (R = 0.369, P = 0.001). Prospectively measured inulin and para-amino-hippuric acid (PAH) clearance decreased significantly after PTX in a subgroup of 19 patients (inulin before vs after PTX 67 vs 55 ml/min/1.73 m(2), P = 0.001; PAH 360 vs 289 ml/min/1.73 m(2), P = 0.001). Transplant biopsies revealed calcification in 70% of biopsied cases. CONCLUSION: Since PTH has a known positive regulatory effect on renal perfusion and glomerular filtration rate, we conclude that relative hypoparathyroidism after PTX is the main mechanism contributing to decreased renal function in these patients. There was no difference in 10-year-graft survival between the deteriorating and the non-deteriorating group.     

Outcomes in renal transplant recipients with lupus nephritis: experience at a single center

Background: The long-term prognosis of renal transplant recipients with systemic lupus erythematosus is still controversial. The outcome of these patients depends on the population studied, race/ethnicity, socioeconomic conditions, donor-related factors and recurrent lupus nephritis (LN), among other factors. Objective: This study was conducted to evaluate kidney transplantation outcomes for adult Brazilian patients with LN at a single center. Subjects and method: The archival records of all patients with LN who had received a kidney transplant at Santa Casa of Sao Paulo Hospítal were reviewed. Kaplan–Meier method was used to determine the survival rate. Results: We identified 18 patients with LN subjected to 22 kidney transplants during the 20-year interval. Two patients received three renal grafts. The majority of the patients were female, with 33.7 ± 10 years at the time of the transplantation, and half of them were African descendants or mixed. Sixteen transplants were performed from deceased donors and six from living-related donors. The patient survival rate was 90%, and graft survival was 68% at 10 years. Chronic allograft nephropathy was the major cause of graft loss. Two patients developed extra-renal manifestations of lupus. There was no clinical or histological evidence of recurrent LN. Conclusion: Renal transplantation is a method which can provide a long-term survival for patients with SLE and end-stage renal disease.     

Tuberculous infection in southern Chinese renal transplant recipients

A retrospective study of the prevalence and pattern of tuberculosis among renal transplant patients in a single centre in southern China was performed. Twenty-three cases of tuberculosis were diagnosed among 440 patients between January 1991 and December 2002. There were 18 men and five women. The mean age of the patients was 39.3 +/- 13.4 yr. There were 13 living-related and 10 cadaveric renal transplants. The interval between renal transplantation and the development of tuberculosis ranged from 3 to 127 months with a median of 46 months. There were 18 cases of pulmonary tuberculosis, two cases of pulmonary plus laryngeal tuberculosis, two cases of disseminated tuberculosis, and one case of tuberculosis involving the urinary tract. Diagnosis was established by positive culture for Mycobacterium tuberculosis in 21 patients and response to empirical anti-tuberculosis treatment in two patients. The duration of symptoms before the diagnosis of tuberculosis was 27 +/- 12 d. The patients were treated with standard anti-tuberculosis drugs for 11 +/- 3 months. The anti-tuberculosis treatment was in general well-tolerated. Five patients developed transient hepatitis, three patients developed thrombocytopenia and five patients developed gouty arthritis. One patient died 2 months after initiation of anti-tuberculosis therapy. All other patients completed anti-tuberculosis treatment. No recurrence of tuberculosis was observed after a median follow-up of 90 months. We concluded that (i) tuberculosis is prevalent among southern Chinese renal transplant recipients; (ii) high index of suspicion for tuberculosis among renal transplant recipients is warranted to ensure early diagnosis and prompt initiation of treatment; and (iii) treatment with standard anti-tuberculosis drugs for an extended period of time is well-tolerated and is associated with favourable outcome.