Associations of Pretransplant Serum Albumin with Post‐Transplant Outcomes in Kidney Transplant Recipients

The association between pretransplant serum albumin concentration and post‐transplant outcomes in kidney transplant recipients is unclear. We hypothesized that in transplant‐waitlisted hemodialysis patients, lower serum albumin concentrations are associated with worse post‐transplant outcomes. Linking the 5‐year patient data of a large dialysis organization (DaVita) to the Scientific Registry of Transplant Recipients, we identified 8961 hemodialysis patients who underwent first kidney transplantation. Mortality or graft failure and delayed graft function (DGF) risks were estimated by Cox regression (hazard ratio [HR]) and logistic regression (Odds ratio [OR]), respectively. Patients were 48 ± 13 years old and included 37% women and 27% diabetics. The higher pretransplant serum albumin was associated with lower mortality, graft failure and DGF risk even after multivariate adjustment for case‐mix, malnutrition–inflammation complex and transplant related variable. Every 0.2 g/dL higher pretransplant serum albumin concentration was associated with 13% lower all‐cause mortality (HR = 0.87 [95% confidence interval: 0.82–0.93]), 17% lower cardiovascular mortality (HR = 0.83[0.74–0.93]), 7% lower combined risk of death or graft failure (HR = 0.93[0.89–0.97]) and 4% lower DGF risk (OR = 0.96[0.93–0.99]). Hence, lower pretransplant serum albumin level is associated with worse post‐transplant outcomes. Clinical trials to examine interventions to improve nutritional status in transplant‐waitlisted hemodialysis patients and their impacts on post‐transplant outcomes are indicated.     

Preemptive kidney transplantation in systemic lupus erythematosus

Preemptive kidney transplantation is associated with superior outcomes. Patients who have kidney failure due to systemic lupus erythematosus (SLE) may not receive a preemptive kidney transplant because of the concern for risk of disease recurrence with shortened graft and patient survival. We identified 8001 patients in the United Network for Organ Sharing dataset who underwent kidney transplantation between October 1987 and February 2009 with kidney failure due to SLE. Seven hundred thirty patients received a preemptive kidney transplant with 7271 patients who were on dialysis before transplantation; their mean ages were 40.0 ± 11.6 years and 36.9 ± 11.7 years, respectively, (P < .01). Women constituted 82.5% of preemptive and 81.4% of non-preemptive groups (P = .47). Preemptive transplant recipients were more likely to receive a living donor kidney transplant (odds ratio [OR] = 3.6; 95% confidence interval [CI] = 3.3–4.5; P < .01). In unadjusted analyses, preemptive transplantation was associated with lower risk of recipient death (hazard ratio [HR] = 0.52; 95% CI = 0.38–0.70; P < .01). The difference remained significant after adjustment fr covariates (HR = 0.55; 95% CI = 0.36–0.84; P < .01). Graft survival was also superior among preemptive kidney transplant recipients in both unadjusted (HR = 0.56; 95% CI = 0.49–0.68; P < .01), and adjustment analyses (HR = 0.69; 95% CI = 0.55–0.86; P < .01). We concluded that preemptive kidney transplantation among patients with SLE was associated with superior patient and graft outcomes and should be considered when feasible.     

Differential Characteristics of Kidney Transplant Recipients According to 1‐Year Chronic Kidney Disease Stage 3a and Stage 3b Graft Function

The outcomes of transplantation have improved, but more than 50% of kidney transplantation (KT) recipients are still reported to have renal function of chronic kidney disease (CKD) stage 3 at 1 year after KT. We reviewed all 1235 patients who received a KT in our institution between 2008 and 2012. Among these recipients, 77 and 289 cases were included in the estimated glomerular filtration rate (eGFR) at 1 year after KT 30–44 (CKD stage 3b) group and eGFR 45–59 (CKD stage 3a) group, respectively. Longer duration of dialysis (odds ratio [OR] = 1.007, 95% confidence interval [CI], 1.000–1.014, P = 0.047), older donors (OR = 1.064, 95% CI, 1.031–1.098, P < 0.001), delayed graft function (OR = 3.601, 95% CI, 1.031–1.098, P < 0.001), BK virus infection (OR = 2.567, 95% CI, 1.242–5.305, P = 0.011), and pneumonia (OR = 4.451, 95% CI, 1.388–14.279, P = 0.012) were contributing factors to eGFR 30–44 mL/min. Especially, ureteral stricture occurred more frequently in eGFR 30–44 group of deceased donor KT. However, acute rejection was not a significant risk factor of lower eGFR. Graft survival was better in the eGFR 45–59 group. However, this difference was smaller in deceased donor KT. Infections and urologic complications are also important contributing factors of lower graft function in CKD stage 3. In addition, dividing CKD stage 3 into subgroups might be more useful in living donor kidney transplantation.     

Determinants of survival in lung transplantation patients with idiopathic pulmonary fibrosis: a retrospective cohort study

Survival after lung transplantation (LTx) for idiopathic pulmonary fibrosis (IPF) is worse compared to other indications for LTx. We investigated the effect of several pretransplant variables including the use of pretransplant corticosteroids (CS) on post‐transplant graft and chronic lung allograft dysfunction (CLAD)‐free survival and functional testing (maximum inspiratory and expiratory pressure, six‐minute walk test, quadriceps and hand pinch force) in a small cohort of IPF patients. We retrospectively compared two groups of IPF patients (n = 36 on CS vs. n = 18 not on CS) who underwent LTx between 2000 and 2016. Analysis of 54 IPF‐LTx patients showed no significant effect on graft survival or functional tests except for maximum inspiratory pressure (P = 0.033) between these two groups (all LTx patients, CS vs. no CS). Regression analysis showed significant impact of procedure with a hazard ratio of 0.423 (CI 95% 0.194, 0.924) favoring sequential single LTx (SSLTx) compared to single lung transplantation (SLTx). When analyzing only the 40 SSLTx patients, corticosteroid‐free patients showed significantly better graft survival compared to patients on CS (P = 0.045) and CLAD‐free survival (P = 0.019). The possible detrimental effect of corticosteroid therapy before LTx was demonstrated in this cohort of SSLTx patients, which questions the use of corticosteroids in a pretransplantation setting.     

Long‐term evolution,secular trends,and risk factors of renal dysfunction following cardiac transplantation

Recent reports suggest that individuals who underwent heart transplantation in the last decade have improved post‐transplant kidney function. The objectives of this retrospective study were to describe the incidence and to identify fixed and time‐dependent predictors of renal dysfunction in cardiac recipients transplanted over a 25‐year period (1983–2008). To illustrate temporal trends, patients (n = 306) were divided into five groups based on year of transplantation. The primary endpoint was the estimated glomerular filtration rate (eGFR) at year 1. Secondary endpoints were time to moderate (eGFR <60 ml/min/1.73 m²) and severe renal dysfunction (eGFR <30 ml/min/1.73 m²). Risk factor analyses relied on multivariable regression models. Kidney function was mildly impaired before transplant (median eGFR=61.0 ml/min/1.73 m²), improved at discharge (eGFR=72.3 ml/min/1.73 m²; P < 0.001), decreased considerably in the first year (eGFR = 54.7 ml/min/1.73 m²; P < 0.001), and deteriorated less rapidly thereafter. At year 1, 2004–2008 recipients exhibited a higher eGFR compared with all other patients (P < 0.001). Factors independently associated with eGFR at year 1 and with moderate and severe renal dysfunction included age, gender, pretransplant eGFR, blood pressure, glycemia, and use of prednisone (P < 0.05). In summary, kidney function worsens constantly up to two decades after cardiac transplantation, with the greatest decline occurring in the first year. Corticosteroid minimization and treatment of modifiable risk factors (hypertension, diabetes) may minimize renal deterioration.     

Allograft outcome following repeat transplantation of patients with non‐adherence‐related first kidney allograft failure: a population cohort study

Nonadherence is an important risk factor for premature allograft failure after kidney transplantation, but outcomes after re‐transplantation remain uncertain. Using data from the Australian and New Zealand Dialysis and Transplant registry, the associations between causes of first allograft failure and acute rejection‐related and non‐adherence‐related allograft failure following re‐transplantation were examined using competing risk analyses, treating the respective alternative causes of allograft failure and death with functioning graft as competing events. Fifty‐nine of 2450 patients (2%) lost their first allografts from nonadherence. Patients who lost their first kidney allograft from nonadherence were younger at the time of first kidney allograft failure but waited longer for a second allograft (>5 years: 54% vs. 20%, P < 0.001) compared with other causes. Compared with patients who lost their first allograft from causes other than nonadherence, the adjusted subdistribution hazard ratio (HR and 95% CI) for acute rejection‐related second allograft failure was 0.58 (0.08, 4.07; P = 0.582) for patients with allograft failure attributed to nonadherence and was 6.30 (1.34, 29.67; P = 0.020) for non‐adherence‐related second allograft failure. In this cohort of transplant recipients who have received second allografts, first allograft failure secondary to nonadherence was associated with a marginally greater risk of allograft failure attributed to nonadherence in subsequent transplantation.     

Earlier Is Not Necessarily Better in Preemptive Kidney Transplantation

While preemptive (before chronic dialysis) transplantation is associated with improved graft survival, it is unclear whether higher versus lower pretransplant kidney function is associated with even better graft survival after preemptive transplantation. We examined 671 first, preemptive, kidney‐only transplantations at Hennepin County Medical Center and the University of Minnesota Medical Center 1984–2006. We estimated pretransplant glomerular filtration rate (eGFR, mL/min/1.73 m²) using the Modification of Diet in Renal Disease (MDRD) equation with Group 1: <10.0 (7.3 ± 1.7, N = 324), Group 2: 10.0–14.9 (12.0 ± 1.4, N = 217) and Group 3: ≥15.0 (21.1 ± 10.0, N = 130). The mean difference in eGFR for Group 1 versus 3 was 13.8 pretransplant, 16.3 on day 1 and 13.9 on day 2 posttransplant. By week 1 and year 1 posttransplant, the differences between Groups 1 and 3 reduced to 6.3 and 4.5 mL/min/1.73 m², respectively. The adjusted relative risk (RR; Cox analysis) for graft failure was not significantly lower with higher pretransplant eGFR (reference eGFR <10.0); RR = 0.99 (95% confidence interval = 0.68–1.44, p = 0.9432) for eGFR 10.0–14.9; RR = 1.35 (0.89–2.05, p = 0.1588) for eGFR ≥15. Thus, early preemptive transplantation with higher eGFR does not necessarily improve graft survival after kidney transplantation, compared to preemptive transplantation with lower pretransplant eGFR.     

Functional status of hemodialysis arteriovenous fistula in kidney transplant recipients as a predictor of allograft function and survival

There is no accepted policy for preserving or ligating arteriovenous fistula (AVF) after successful kidney transplantation. The aim of this study was to compare kidney graft function and survival between patients with a functional AVF at 1 year after-transplantation with those having a nonfunctional AVF. This historical cohort study included 311 kidney transplant recipients between January 2000 and December 2008 with a functional AVF at the time of transplantation. Patients were divided into 2 groups according to functional status of AVF at 1 year after transplantation. Graft function was assessed at 1 year by serum creatinine and estimated glomerular filtration rate (eGFR) using the 4-variable Modification of Diet in Renal Disease formula. Kaplan-Meier and Cox proportional hazards analyses were used to assess the relationship between the functional status of the AVF and graft survival. The 311 recipients had a mean age of 47 ± 11 years (range, 14 to 70) with 188 (60.5%) males. Patients with functional AVF at 1 year (n = 239) showed higher serum creatinine and lower eGFR values than those with nonfunctional AVF (n = 72): namely 110 ± 38 μmol/L and 69 ± 21 mL/min/1.73 m² versus 99 ± 30 μmol/L and 74 ± 19 mL/min/1.73 m², respectively (P < .05). Persistence of a functional AVF at 1 year after transplantation was associated with a greater incidence of eGFR <60 mL/min/1.73 m² compared with nonfunctional AVF: 36.8% versus 23.6% (odds ratio, 1.885; 95% confidence interval [CI], 1.031–3.450; P = .038). The 5-year allograft survival rates were 60% among patients with a functional AVF versus 75% among those with a nonfunctional AVF (P = .045). The adjusted analyses revealed the persistence of a functional AVF to be associated with an increased risk for future allograft loss (hazard ratio, 1.336; 95% CI, 1.018–1.755; P = .037). In conclusion, the persistence of a functional AVF was associated with a lower eGFR at 1 year after-transplantation and an increased risk for future allograft loss.     

Clinical outcomes of hepatitis C treatment before and after kidney transplantation and its impact on time to transplant: A multicenter study

Waitlist time for kidney transplantation is long but may be shortened with the utilization of hepatitis C positive allografts. We retrospectively reviewed the course of 36 hepatitis C positive patients awaiting kidney transplantation at 2 large centers within the same health system, with near‐identical care delivery models with the exception of timing of hepatitis C treatment, to determine the impact of timing of hepatitis C treatment on access to transplant, waitlist time, and treatment efficacy and tolerability. The majority of patients had hepatitis C genotype 1a or 1b, and all received direct acting antiviral therapy with 100% treatment response. One patient underwent transplantation in the pretransplant treatment group. The 1‐year transplantation rate was 12.5% vs 67.9% (P = .0013) in those treated posttransplantation. The median waitlist time in the posttransplant group was 122 (interquartile range [IQR] 21.5, 531.0) days, which was significantly shorter than the center’s regional and national wait time. Pathologic review revealed no difference in allograft quality. Overall treatment related adverse events were not different between the 2 groups. A strategy of posttransplant hepatitis C treatment increased access to transplant and reduced waitlist time. Delaying treatment until after transplant did not appear to adversely affect recipients’ kidney allograft or overall survival.     

Influence of pretransplant midodrine use on outcomes after kidney transplantation

Evaluation of potential kidney transplant recipients is important to identify and treat conditions that may influence graft or patient survival after transplantation. We performed a single‐center, observational cohort study to determine whether pretransplant midodrine use influences outcomes after kidney transplantation. We analyzed graft and patient outcomes for adult patients who underwent a kidney‐only transplantation at Barnes‐Jewish Hospital from January 1999 to December 2015. We quantified adjusted associations of pretransplant midodrine use with post‐transplant complications by multivariable Cox regression. Among the 2621 kidney transplant recipients analyzed, 37 (1.4%) were taking midodrine immediately prior to transplantation. Midodrine users were more commonly older (56.5 vs 50.4 years) and obese (67.6% vs 33.6%). Midodrine users were also more likely to be on hemodialysis (86.5% vs 59.2%), to have a longer duration of dialysis dependence (646 months vs 577 months), and to have higher levels of sensitization (peak panel reactive antibody >20%, 32.4% vs 15.8%) compared to nonusers. Pretransplant midodrine users had significantly higher rates of delayed graft function (DGF) (32.4% vs 6.7%, P < 0.001). No difference in the incidence of DGF was observed based on the midodrine dosing regimen. After multivariable adjustment for recipient and donor characteristics, pretransplant midodrine use was independently associated with graft failure at 1 year (adjusted hazard ratio, 5.11; 95% confidence interval, 2.09‐12.49).     

1,25-dihydroxyvitamin D(3) therapy is protective for renal function and prevents hyperparathyroidism in renal allograft recipients

1,25-Dihydroxyvitamin D(3) (calcitriol) therapy has been extensively used for posttransplant osteoporosis. Beside its effect on bone metabolism, calcitriol has an important immunomodulatory effect. We evaluated the effects of oral calcitriol therapy on allograft function and parathyroid hormone levels after renal transplantation. The patients were retrospectively selected from a renal transplant patient population who received calcitriol (group 1, n = 59, 36 male/23 female, follow-up: 52.8 +/- 12.2 months) compared with group (group 2, n = 52, 42 male/9 female, follow-up: 62.0 +/- 24.4 months) without calcitriol therapy after renal transplantation. Calcitriol therapy was started 24.0 +/- 19.1 months posttransplantation. All patients were under three-drug immunosuppression. The pretransplant and posttransplant data were studied retrospectively. Additionally, creatinine levels before and after the initiation of calcitriol therapy were recorded at 6 months intervals for 3 successive years. Our results were analyzed according to the first and third year on therapy data. According to the first year data, there were no differences in patient groups in terms of creatinine and iPTH levels. In the third year, the patients in group 1 showed significantly lower creatinine (P = .01) and iPTH (P < .04) levels and needed lower pulse steroid doses (P < .04). According to a Friedman repeated measures variance test, the creatinine level was significantly lower among group I (P < .04) at 3-year follow-up. In conclusion, even a delayed start of calcitriol therapy after renal transplantation exerts a protective effect on renal allograft function and prevents the development of hyperparathyroidism.     

Intact parathyroid hormone levels in renal transplant patients with normal transplant function

Bleskestad IH, Bergrem H, Leivestad T, Gøransson LG. Intact parathyroid hormone levels in renal transplant patients with normal transplant function.
Clin Transplant 2011: 25: E566–E570. © 2011 John Wiley & Sons A/S. Abstract: Introduction: Chronic kidney disease mineral and bone disorder (CKD‐MBD) is common in patients who have undergone kidney transplantation. There is limited information on the extent to which patients with normal renal function after transplantation have persistent disturbances in their mineral metabolism. Aim: The aim of the study is to investigate the prevalence of elevated intact parathyroid hormone (iPTH) levels at least one yr after transplantation in patients living with a first renal transplant with normal transplant function. Methods: A retrospective, observational study of 607 patients was collected from the Norwegian Renal Registry. Of these, iPTH was recorded for 360 patients. Results: One hundred and eighty‐eight patients (52%) had elevated iPTH levels. Twenty‐six patients (7%) had iPTH levels >2.5 times the upper limit of normal (ULN). Patients with a pre‐emptive transplant were significantly younger than the patients who had received treatment with dialysis (p < 0.0001). The prevalence of iPTH > ULN was significantly higher in patients with a pre‐emptive transplant (p = 0.037). Conclusions: In post‐transplant patients with normal transplant function, our data indicate that more than 50% have elevated levels of iPTH more than one yr after transplantation. If elevated iPTH level is associated with mortality in this patient population, it may have major impact on clinical treatment guidelines.     

Impact of Simultaneous Kidney–Pancreas Transplant and Timing of Transplant on Kidney Allograft Survival

Since 1988 over 10 000 simultaneous cadaveric pancreas-kidney transplants (SPK) have been performed in the United States among patients with end-stage renal disease due to Type 1 diabetes (T1DM). The two aims of this study were to assess the impact on kidney allograft survival of (i) SPK versus transplantation of a kidney alone (KA), and (ii) SPK prior to versus after initiation of chronic dialysis. This retrospective, non-concurrent cohort study examined registry data collected from 8323 patients waitlisted in the United States for an SPK and transplanted with either an SPK or a KA during January 1, 1990 - October 31, 2002. SPK recipients had an adjusted hazard ratio for kidney allograft loss of 0.63 (95% CI: 0.51-0.77, p < 0.001) compared to transplantation without pancreas allograft. SPK recipients who received their allografts prior to beginning chronic dialysis had a lower rate of kidney allograft loss than SPK recipients who received their transplant after initiation of chronic dialysis (adjusted hazard rates (HR) = 0.83, 95% CI: 0.69-0.99, p = 0.042). Simultaneous transplantation of pancreas-kidney compared to kidney transplantation alone and SPK prior to the initiation of chronic dialysis compared to SPK after initiation of dialysis were both associated with longer kidney allograft survival.     

Weekend effect on early allograft outcome after kidney transplantation‐ a multi‐centre cohort study

Weekend surgery may be associated with a higher risk of early complications, but the effect of the timing of kidney transplant surgery on early allograft outcome remains uncertain. The aim of this study is to evaluate whether the association between weekend transplant surgery and allograft failure was modified by prevalent vascular disease. Using data from the Australia and New Zealand Dialysis and Transplant registry, we examined the association between weekend status and 90‐day and 1‐year allograft failure in deceased donor transplant recipients between 1994–2012. Two‐way interaction between vascular disease and weekend status was examined. Of 6622 recipients, 1868 (28.2%) received transplants during weekends. Compared with weekday transplants, weekend transplants were associated with an adjusted hazard ratio (HR) for 90‐day and 1‐year allograft failure of 0.99 (0.78–1.25; P = 0.917) and 0.93 (0.76–1.13, P = 0.468), respectively. There was a significant interaction between prevalent vascular disease and weekend status for 90‐day allograft failure (P_interaction = 0.008) but not at 1‐year, such that patients with vascular disease were more likely to experience 90‐day allograft failure if transplanted on weekend (versus weekdays), particularly failures secondary to vascular complications. Timing of transplantation does not impact on allograft outcome, although those with vascular disease may benefit from more intensive post‐transplant follow‐up for potential vascular complications.     

Outcomes of en bloc simultaneous liver‐kidney transplantation compared to the traditional technique

Simultaneous liver‐kidney transplantation (SLKT) is indicated for patients with end‐stage liver disease (ESLD) and concurrent renal insufficiency. En bloc SLKT is an alternative to traditional separate implantations, but studies comparing the two techniques are limited. The en bloc technique maintains renal outflow via donor infrahepatic vena cava and inflow via anastomosis of donor renal artery to donor splenic artery. Comparison of recipients of en bloc (n = 17) vs traditional (n = 17) SLKT between 2013 and 2017 was performed. Recipient demographics and comorbidities were similar. More recipients of traditional SLKT were dialysis dependent (82.4% vs 41.2%, P = .01) with lower baseline pretransplant eGFR (14 vs 18, P = .01). En bloc SLKT was associated with shorter kidney cold ischemia time (341 vs 533 minutes, P < .01) and operative time (374 vs 511 minutes, P < .01). Two en bloc patients underwent reoperation for kidney allograft inflow issues due to kinking and renal steal. Early kidney allograft dysfunction (23.5% in both groups), 1‐year kidney graft survival (88.2% vs 82.4%, P = 1.0), and posttransplantation eGFR were similar between groups. In our experience, the en bloc SLKT technique is safe and feasible, with comparable outcomes to the traditional method.     

Postoperative surgical‐site hemorrhage after kidney transplantation: incidence,risk factors,and outcomes

Studies investigating the incidence, risk factors, and outcomes of surgical‐site hemorrhage after kidney transplantation are limited. Patients who underwent a kidney transplant from 1 January 2000 to 30 September 2012 (followed until 31 December 2012) at Toronto General Hospital were included in this study. Postoperative surgical‐site hemorrhage was defined as a drop in hemoglobin ≥20 g/l over a 24‐hour period within 3 days of transplantation, followed by an ultrasound indicating a significant hematoma/collection. A total of 59 of 1203 (4.9%) kidney transplant recipients had postoperative surgical‐site hemorrhage. Most cases (89.8%) occurred within 1 day after transplantation. Living donor transplants [OR 0.30 (95% CI: 0.16, 0.55)] and higher recipient BMI [OR 0.54 per 10 kg/m² increase in BMI (95% CI: 0.30, 0.99)] were associated with a significantly lower risk of bleeding. Chronic preoperative anticoagulant usage led to an increased risk of bleeding but was not statistically significant [OR 1.75 (95% CI: 0.52, 5.88)]. Postoperative hemorrhage was associated with a higher risk of graft loss or death [HR 1.62 (95% CI: 1.01, 2.60)]. While the incidence of postoperative surgical‐site hemorrhage in kidney transplantation is relatively low, it may be associated with an increased risk of graft loss or death.     

Plasma adiponectin before and after kidney transplantation

The role of plasma adiponectin (ADPN) in patients with impaired kidney function and following kidney transplantation (Tx) is debated. We aimed to: (i) determine whether pretransplant ADPN level is an independent risk factor for deterioration of glucose tolerance including development of new‐onset diabetes mellitus after Tx, (ii) describe which parameters that influence the ADPN concentration before and after Tx. Fifty‐seven nondiabetic kidney allograft recipients and 40 nondiabetic uraemic patients were included. The Tx group was examined at baseline and 3 and 12 months after Tx. The uraemic control group was examined twice, separated by 12 months. ADPN levels declined significantly following Tx (P < 0.0001), while estimated glomerular filtration rate (eGFR) increased (P < 0.0005). eGFR, BMI and insulin sensitivity index were independently associated with ADPN in a multivariate regression analysis, whereas an ordinal logistic regression analysis revealed no predictive characteristic of ADPN for aggravation of the glucose tolerance after Tx. In conclusion, kidney transplantation is accompanied by a significant reduction in ADPN concentration. Several factors determine the ADPN concentration before and after Tx including kidney function, insulin resistance, use of immunosuppressive agents and BMI. Pretransplant ADPN level did not predict development of new‐onset diabetes mellitus or even deterioration of the glucose tolerance following Tx.     

Morphologic patterns and treatment of transplant glomerulopathy: A retrospective analysis

Transplant glomerulopathy is mainly due to chronic antibody‐mediated rejection and actually represents a major cause of long‐term allograft failure. The lack of effective treatment remains a serious problem in transplantation. A retrospective and uni‐center study was performed in 48 kidney allograft recipients with transplant glomerulopathy between January 2010 and December 2015. Median time for diagnosis was 7.1 (3.6‐11.8) years post‐transplant. Light microscopy showed severity of transplant glomerulopathy in the majority of patients (cg1=10.4%; cg2=20.8%; cg3=68.8%). Moderate microvascular inflammation was present in 56.3% (g+ptc≥2), and almost half of recipients (51.1%) were C4d positive in immunofluorescence. Female gender (P=.001), age (P=.043), renal dysfunction (P=.002), acute rejection episodes (P=.026), and anti‐HLA class II antibodies (P=.004) were associated with kidney allograft failure. Treatment of transplant glomerulopathy was performed in 67.6% of patients. The histologic and laboratory features that led to a therapeutic intervention were score ptc (P=.021), C4d (P=.03), and the presence of anti‐HLA antibodies (P=.029), whereas score ah (P=.005) was associated with conservative measure. The overall cumulative kidney allograft survival at 10 years was 75%. Treatment of transplant glomerulopathy was ineffective to improve long‐term kidney allograft survival.     

Sorafenib therapy for hepatocellular carcinoma prior to liver transplant is associated with increased complications after transplant

This study compared post‐transplant outcomes of patients with hepatocellular carcinoma (HCC) who took sorafenib prior to orthotopic liver transplantation (OLT) with those patients who were not treated with sorafenib. Thirty‐three patients with HCC who were listed for liver transplantation were studied: 10 patients were treated with sorafenib prior to transplantation in an attempt to prevent progression of HCC while awaiting transplant. The remaining 23 patients were considered controls. The mean duration of sorafenib use was 19.2 (SD 25.2) weeks. Overall death rates were similar between the sorafenib group and control group (20% vs. 8.7%, respectively, P = 0.56). However, the patients in the sorafenib group had a higher incidence of acute cellular rejection following transplantation (67% vs. 22%, OR = 7.2, 95% CI 1.3–39.6, P = 0.04). The sorafenib group also had a higher rate of early biliary complications (67% vs. 17%, OR = 9.5, 1.6–55.0, P = 0.01). The use of sorafenib was found to be an independent predictor of post‐transplant biliary complications (OR 12.6, 1.4–116.2, P = 0.03). Sorafenib administration prior to OLT appears to be associated with an increase in biliary complications and possibly in acute rejection following liver transplantation. Caution should be taken in this setting until larger studies are completed.     

Effect of Cinacalcet in Kidney Transplant Patients With Hyperparathyroidism

ObjectiveIn dialysis patients, cinacalcet could be an effective alternative to parathyroidectomy for treating hyperparathyroidism. In the present study, we aimed to determine the characteristics of subjects with persistent hyperparathyroidism who require parathyroidectomy despite the use of cinacalcet.MethodsNine kidney transplant patients (7 men, 2 women; mean age 53.2 [SD, 8.9] years) who had tertiary hyperparathyroidism were reviewed in a single center. Pre- and postcinacalcet levels of calcium, phosphorous, intact parathyroid hormone (iPTH), and renal function were analyzed to evaluate the effect of cinacalcet treatment in these patients. The baseline parameters before cinacalcet treatment were compared in patients who did and did not undergo parathyroidectomy.ResultsCinacalcet reduced serum calcium levels in all patients (11.48 [SD, 0.73] mg/dL to 10.20 [0.70] mg/dL; P = .008). Serum phosphorous levels significantly increased from 2.28 (SD, 0.77) mg/dL to 3.02 (SD, 0.65) mg/dL (P = .03). The iPTH levels in 7 patients decreased, while the mean level remained unchanged in total subjects. The iPTH levels increased even with cinacalcet treatment in 2 patients. In 3 patients, serum calcium levels abruptly increased after cinacalcet withdrawal. Five patients who showed persistent hypercalcemia due to hyperparathyroidism underwent parathyroidectomy. These 5 patients had significantly different characteristics compared with 4 patients who did not undergo parathyroidectomy: hypercalcemia (11.92 [SD, 0.68] mg/dL vs 10.93 [SD, 0.26] mg/dL; P = .02), hypophosphatemia (1.74 [SD, 0.36] mg/dL vs 2.95 [SD, 0.58] mg/dL; P = .03), and hyperparathyroidism (252.2 [SD, 131.4] pg/dL vs 101.5 [SD, 18.4] pg/dL; P = .02).ConclusionCinacalcet reduced hypercalcemia due to hyperparathyroidism in the transplant patients. However, patients who had pre-existing higher iPTH, hypercalcemia, and hypophosphatemia needed parathyroidectomy. Therefore, cinacalcet could be considered an alternative to parathyroidectomy in selected patients.