The impact of severe acute kidney injury requiring renal replacement therapy on survival and renal function of heart transplant recipients – a UK cohort study

Severe acute kidney injury (AKI), defined as requiring renal replacement therapy (RRT), is associated with higher mortality postheart transplantation, but its long-term renal consequences are not known. Anonymized data of 3365 patients, who underwent heart transplantation between 1995 and 2017, were retrieved from the UK Transplant Registry. Multivariable binary logistic regression was performed to identify risk factors for severe AKI requiring RRT, Kaplan–Meier analysis to compare survival and renal function deterioration of the RRT and non-RRT groups, and multivariable Cox regression model to identify predicting factors of mortality and end-stage renal disease (ESRD). 26.0% of heart recipients received RRT post-transplant. The RRT group has lower survival rates at all time points, especially in the immediate post-transplant period. However, conditional on 3 months survival, older age, diabetes and coronary heart disease, but not post-transplant RRT, were the risk factors for long-term survival. The predicting factors for ESRD were insulin-dependent diabetes, renal function at transplantation, eGFR decline in the first 3 months post-transplant, post-transplant severe AKI and transplantation era. Severe AKI requiring RRT post-transplant is associated with worse short-term survival, but has no impact on long-term mortality. It also accelerates recipients’ renal function deterioration in the long term.     

Fever in liver transplant recipients in the intensive care unit

Whether febrile illnesses in the intensive care unit (ICU) have unique spectrum, etiologies, and outcome has not been determined in liver transplant recipients. We studied 78 consecutive febrile patients over a 4-yr period; 49% (38/78) were in the ICU and 51% (40/78) were in the non-ICU setting. Of febrile patients in the ICU, 87% (33/38) had infection and 13% had non-infectious etiology for fever. Seventy-nine percent (26/33) of the infections associated with fever in the ICU were bacterial, 9% (3/33) were viral, and 9% (3/33) were fungal in etiology. Pneumonia (30%), catheter-related bacteremia (15%), and biliary tree (9%) were the predominant sources of infections associated with fever in the ICU. Bacteremia was documented in 45% of the patients with fever in the ICU. Fifty-three percent (20/38) of the febrile episodes in the ICU occurred during the initial post-transplant stay, and 47% (18/ 38) during a subsequent readmission. Pneumonia accounted for 41% of all febrile infections during the first 7 d of ICU stay, but only 14% of those after 7 d. Febrile patients in the ICU had higher APACHE II scores (p = 0.001), higher APS scores (p = 0.0001), higher bilirubin (p = 0.001), lower cholesterol (p = 0.019), higher prothrombin time (p = 0.001), were more tachycardiac (p = 0.002), and were more likely to have abnormal blood pressure (p = 0.001) than those in the non-ICU setting. Twenty-three percent of all infections in the ICU were unaccompanied by fever and 9% were accompanied by hypothermia. Mortality at 14 d (24 versus 0%, p = 0.001) and at 30 d (34 versus 5%, p = 0.001) was significantly higher in febrile patients in the ICU, as compared to the patients in the non-ICU setting. These data have implications for diagnostic evaluation and management of critically ill febrile liver transplant recipients.     

Long‐term outcomes of transplant recipients referred for angiography for suspected transplant renal artery stenosis

Our aim was to study the long‐term outcomes of all transplant recipients who underwent angiography for suspected TRAS at our institution. The patients were divided into TRAS+ve and TRAS?ve groups based upon angiographically confirmed results. TRAS was confirmed in 58.1% of 74 patients with median time of 8.9 months. Primary angioplasty alone was performed in 56% of patients with TRAS, while the remaining had PTA with stent (PTAS). There was reduction in systolic and diastolic BP (165 ± 19–136 ± 15 mmHg and 82 ± 14 mmHg to 68 ± 12 mmHg; p < 0.05) and number of antihypertensive drugs (3.5 ± 0.9–2.7 ± 1.0; p < 0.05). Overall, graft survival and patient survival from time of transplant were similar in both groups. Graft function was similar for the patients with treated TRAS+ve as compared to TRAS?ve over time. Graft survival and patient survival when compared to an age‐ and year of transplant‐matched cohort control group were also similar. In conclusion, angiography for suspected TRAS is more likely to yield a confirmatory result early in the transplant course as compared to late. Treatment of TRAS in these patients had sustained long‐term graft function. Alternative etiologies of HTN and graft dysfunction should be sought for recipients further out from transplant.     

Risk factors for acute rejection in renal transplant recipients experiencing delayed graft function

Acute rejection (AR) superimposed upon delayed graft function (DGF) following renal transplantation worsens graft outcomes. However, risk factors for AR in patients displaying DGF remain unclear. In this study, 71 patients displaying DGF >/= 5 d were investigated. All received cyclosporine, adjunctive azathioprine or mycophenolate mofetil (MMF), and corticosteroids, with 43 receiving anti-CD25 monoclonal antibody induction. AR episodes were seen in 20 of 71 (28%) patients. Higher C2 levels at days 3 and 5 and the use of MMF were associated with a reduced incidence of AR, with increased HLA-DR mismatch associated with an increased risk for AR. C2 levels at days 3 and 5 below 885 and 1096 ng/mL, respectively, showed best discriminatory values for AR. C2 levels showed no correlation with DGF duration. This study suggests that optimizing immunosuppression in patients with DGF (by ensuring adequate calcineurin inhibitor exposure and the use of potent adjunctive immunosuppression) may reduce the incidence of AR without prolonging the duration of dialysis requirement.     

Comparison of survival for haemodialysis patients vs renal transplant recipients treated in Uruguay.

BACKGROUND: Our aim was to compare survival among renal transplant recipients and haemodialysis patients treated in Uruguay. METHODS: All the patients transplanted in Uruguay (n=460) and all the patients who started haemodialysis (HD) in three centres in Uruguay (n=695) from 01 January 1981 to 31 December 1998 were included. Overall survival, adjusted survival and survival of the patients in the low-risk group were compared for HD patients and renal transplant recipients. Diabetic and non-diabetic patients were considered independently. The low-risk group was defined by the absence of any significant risk factor related to mortality on the Cox proportional hazard regression model (age more than 55 years at start of HD, previous history of diabetes, heart disease, cancer, and smoking habit). The significant variables were also used to adjust the survival curve. RESULTS: Overall survival was significantly greater in renal transplant recipients (P<0.0001). One-, five- and ten-year survival rates were 95.2, 88.0 and 78.8% for renal transplant recipients and 90.6, 62.7 and 39.8% for HD patients. In non-diabetic patients, adjusted survival rates (for age, heart disease, cancer, and smoking habit) were similar in renal transplant recipients and HD patients (P=0.8713). In the low-risk group as well, significant differences in survival between renal transplant recipients (n=289) and HD patients (n=134) were not observed (P=0.2312). Ten-year survival rates were 82.6 and 87.9% respectively. In diabetic patients 5-year survival rates adjusted for heart disease, smoking habit, and chronic pulmonary disease were 89.2% for renal transplant recipients and 40.9% for HD patients (P=0. 0168) The relative risk of haemodialysis patients related to renal graft recipients was 2.85 (1.21-6.75). CONCLUSIONS: We conclude that when the outcome is adjusted to co-morbid factors there is no difference between renal transplant recipients and haemodialysis patients survival in non-diabetic patients, while renal transplantation gives better survival rates than haemodialysis in diabetic patients.     

Respiratory problems in renal transplant recipients admitted to intensive care during long-term follow-up

Cardiovascular disease, malignancies, and infectious complications are major causes of morbidity and mortality of renal transplant recipients. Mortality rates vary between 16% and 40% in an intensive care unit (ICU). The aims of this study were to identify the types incidences of respiratory problems that affected renal transplant recipients admitted to the ICU during long-term follow-up thereby determining the impact of respiratory problems on mortality. We reviewed the data for 34 recipients who had 39 ICU admissions from January 2000 through December 2003. Twenty-four admissions (61.5%) had at least one respiratory problem at admission or developed at least one during the ICU stay. The most frequent problem was pneumonia (n=18, 46.2% of the 39 readmissions), followed by acute respiratory failure (n=10, 25.6%), atelectasis (n=9, 23.1%), pleural effusion (n=8, 20.5%), and pulmonary edema (n=2, 5.1%). The patients who had respiratory problems showed a significantly higher mortality rate than those who did not have respiratory problems (66.6% versus 26.6%, respectively; P<.05). The overall mortality rate was 58.8% (20 patients). Thus, infectious and respiratory problems are the most frequent indications for admission and the most common problems during an ICU stay. The prognosis for patients who either have a respiratory problem upon admission to the ICU or develop one during the ICU stay is poor.     

Endogenous plasma erythropoietin, cardiovascular mortality and all-cause mortality in renal transplant recipients

Cardiovascular disease (CVD) is the main cause of mortality in renal transplant recipients (RTR). Classical factors only partly explain the excess risk. We hypothesized that high EPO--a marker for inflammation, angiogenesis and hypoxia--is associated with CVD in RTR. A total of 568 RTR (51±12 years; 45% female; creatinine clearance (CrCl) 57±20 mL/min/1.73 m(2)) were included at median 6 [IQR 3-11] years after transplantation. Subjects on exogenous EPO and ferritin-depleted subjects were excluded. Median EPO level was 17.3 [IQR 11.9-24.2] IU/L. Gender-stratified tertiles of age-corrected EPO were positively associated with waist circumference (but not BMI), CVD history, time since transplantation, diuretics, azathioprine, CRP, mean corpuscular volume and triglyceride levels, and inversely with CrCl, RAAS-inhibition, cyclosporine, hemoglobin, total- and HDL-cholesterol. During follow-up for 7 [6-7] years, 121 RTR (21%) died, 64 of cardiovascular (CV) causes. Higher EPO (per 10 IU/L) was associated with total (HR1.16 [1.04-1.29], p = 0.01) and CV mortality (HR1.22 [1.06-1.40], p = 0.005), independent of age, gender, hemoglobin, inflammation, renal function and Framingham risk factors. Thus, EPO and mortality are linked in RTR, independent of potential confounders. This suggests that yet other mechanisms are involved. Dissecting determinants of EPO in RTR may improve understanding of mechanisms behind excess CV risk in this population.     

Long-term survival in renal transplant recipients with graft function

Long-term survival in renal transplant recipients with graft function. BACKGROUND: Death with graft function (DWGF) is a common cause of graft loss. The risks and determinants of DWGF have not been studied in a recent cohort of renal transplant recipients. We performed a population-based survival analysis of U.S. patients with end-stage renal disease (ESRD) transplanted between 1988 and 1997. METHODS: Registry data were used to evaluate long-term patient survival and cause-specific risks of DWGF in 86,502 adult (>/=18 years) renal transplant recipients. RESULTS: Out of 18,482 deaths, 38% (N = 7040) were deaths with graft function. This accounts for 42. 5% of all graft loss. Patient survival with graft function was 97, 91, and 86% at 1, 5, and 10 years, respectively. The risk of DWGF decreased by 67% (RR = 0.33, P < 0.001) between 1988 and 1997. The adjusted rate of DWGF was 4.6, 0.8, 2.2, and 1.4 deaths per 1000 person-years for cardiovascular disease, stroke, infections, and malignancy, respectively. The suicide rate was 15.7 versus 9.0 deaths per 100,000 person-years in the general population (P < 0. 001). In multivariate analysis, the following factors were independently and significantly predictive of DWGF: white recipient, age at transplantation, ESRD caused by hypertension or diabetes mellitus, length of pretransplant dialysis, delayed graft function, acute rejection, panel reactive antibody> 30%, African American donor race, age> 45 years, and donor death caused by cerebrovascular disease. CONCLUSIONS: Patients with graft function have a high long-term survival. Although DWGF is a major cause of graft loss, the risk has declined substantially since 1990. Cardiovascular disease was the predominant reported cause of DWGF. Other causes vary by post-transplant time period. Attention to atherosclerotic risk factors may be the most important challenge to further improve the longevity of patients with successful renal transplants.     

Acute renal failure in bone marrow transplant patients admitted to the intensive care unit

BACKGROUND/AIMS: Review of bone marrow transplant (BMT) cases admitted to our intensive care unit (ICU) and to compare co-morbidity and outcome of BMT patients developing or not developing acute renal failure (ARF). METHODS: A case review of BMT patients admitted to the ICU (a 16-bed medico-surgical ICU in a tertiary care teaching institution) over a 4-year period. RESULTS: Between January 1994 and December 1998, 57 among 441 BMT patients (12.9%) were admitted to the ICU, mainly for respiratory distress (58%) and hypotension (32%). Forty-two patients (73.7%) presented ARF as defined as a doubling of serum creatinine. Compared to the 15 other patients, ARF patients had a higher APACHE II score (30 +/- 8 vs. 25 +/- 7, p < 0.05). For ARF vs. non-ARF patients, there was no difference in age (43.8 +/- 10.8 vs. 44.3 +/- 11.1 years), in requirement for mechanical ventilation (76 vs. 73%) and vasopressors (69 vs. 60%), and in prevalence of graft-versus-host disease (19 vs. 13%) or neutropenia (69 vs. 67%), but the prevalence of sepsis (83 vs. 60%) and liver failure (69 vs. 40%) was higher. Maximum serum bilirubin was markedly increased in ARF compared to non-ARF patients (p < 0.005). For both subgroups, no difference in the administration of potential nephrotoxic agents was identified. Usually, ARF was considered multifactorial by clinicians, with ATN being the most frequent diagnosis (55%). Maximum serum creatinine reached a mean of 330 +/- 130 micromol/l. In 74% of cases, ARF occurred concomitantly or after admission to the ICU. Oligoanuria was present in 38%, whereas polyuria was observed in 17%. Fourteen ARF patients (33%) required dialytic support. Mortality rates were significantly different in ARF vs. non-ARF patients (88 vs. 60%, p < 0.05). Predictive factors for the development of ARF were liver failure (odds ratio (OR) 5.9), low serum albumin (OR 1.2) and APACHE II score (OR 1.1), whereas variables predictive of mortality were mechanical ventilation (OR 14.8), ARF (OR 5.8), liver failure (OR 3.7), and APACHE II score (OR 1.2). CONCLUSIONS: This study confirms that ARF in BMT patients admitted to the ICU is frequent, multifactorial, related to liver failure, and that its development has a negative impact on outcome.     

Switchover to generic cyclosporine in stable renal transplant recipients: a single unit experience

BACKGROUND: The introduction of the immunosuppressant cyclosporine has significantly improved renal transplant survival. It is an expensive drug and generic alternatives may offer cost advantages. However, generic alternatives must be shown to provide equivalent therapeutic efficacy and safety. This study reports our experience of a switch from the microemulsion formulation of cyclosporine, Neoral (Novartis), to the generic equivalent, Cysporin (Mayne Pharma). METHOD: A two-period, single-sequence, cross-over study was done to compare cyclosporine blood levels and the area under the curve (AUC) of Neoral with Cysporin 2 weeks after a 1:1 dose switch. cyclosporine blood levels were measured at time points 0, 2, 4 and 8 h (C0, C2, C4, C8) after the switch. The cyclosporine AUC at 0-4 h and 0-12 h were calculated using the trapezoidal method. The two formulations were considered to result in equivalent blood levels if the 95% confidence interval (CI) of the ratio of the two levels was within 0.8-1.25. RESULTS and CONCLUSION: A total of 38 stable renal transplant patients aged 49.79 +/- 11.38 years (mean +/- SD), who were 7.84 +/- 3.97 years postrenal transplantation, were studied. The Neoral dose at the time of the switch was 2.38 +/- 1.21 mg per kg bodyweight. At all measured time points the 95% CI for the cyclosporine drug level ratio was between 0.9 and 1.15. There were no significant adverse events during the period of study. We conclude that the generic formulation of cylosporin, Cysporin, after a 1:1 switch from Neoral results in equivalent blood levels in stable renal transplant recipients. After switchover cyclosporine levels at C0 or C2 can continue to be monitored as per the institution's current monitoring practice.     

Pneumocystis carinii pneumonia in renal transplant recipients

In 1991 and 1992 Pneumocystis carinii pneu monia (PCP) was diagnosedin 28 renal transplant recipients. The incidence of PCP in ourrenal transplant centre was remarkably increased from 1.1% before1991 to 11.5% in 1991–1992. We compared 28 PCP patientswith a control group of 27 renal transplant recipients, matchedfor transplantation day and with out an episode of PCP. Themean age was significantly higher in the PCP group (50±13 versus 38±13 years). We observed no differences inbasic immunosuppres sive and rejection treatment nor in antibioticconsump tion, number of hospitalization days, and incidenceof CMV infection. In March 1993 we introduced PCP prophylaxis.More than 140 renal transplant recipients received co-trimoxazole,starting 1 day after trans plantation and continued for a periodof 4 months. To the time of writing no one in this group haddeveloped PCP.     

Long-term functional and morphological effects of transcatheter arterial embolization of traumatic renal vascular injury

OBJECTIVE

To assess the long‐term morphological and functional outcome of superselective transarterial embolization (TAE) for treating traumatic renal vascular injury.

PATIENTS AND METHODS

The surgical records of 124 patients with traumatic renal vascular injury managed by TAE between 1990 and 2004 were reviewed, of whom 81 completed a long‐ term follow‐up and were included in the final analysis. Patients were followed using serum creatinine levels, grey‐scale ultrasonography, intravenous urography (IVU) and radioisotopic renography using ^99mTc‐mercapto‐acetyl triglycine (MAG3) and ^99mTc‐dimercaptosuccinic acid (DMSA).

RESULTS

Embolization resulted in the cessation of haematuria in all patients but two (97.5%). At 3 months, serum creatinine levels increased in four of nine patients with a solitary kidney, but only one of them required haemodialysis. After a mean follow‐up of 4.6 years, IVU showed a normal calyceal configuration in 70% of renal units, pyelonephritic changes in 26% and no dye excretion in 4%. DMSA scans showed no evidence of photopenic areas in 17 renal units (21%). The mean (sd ) percentage of DMSA uptake by the corresponding kidney improved from 24 (9)% at the 3‐month scans to 32 (10)% at the last follow‐up scan (P < 0.001). Using MAG3, the mean (sd ) glomerular filtration rate improved significantly from 26 (11) mL/min at the 3‐month scan to 32 (9) mL/min at the last follow‐up (P < 0.05).

CONCLUSIONS

Superselective TAE is safe and effective for traumatic renal vascular injury. The short‐term deleterious effects were more pronounced in patients with a solitary kidney. The long‐term follow‐up showed functional and morphological improvements in the embolized renal units.     

Nocardiosis in renal transplant recipients in Kuwait

BACKGROUND.: Nocardiosis has emerged as an important bacterial disease amongrenal transplant recipients, leading to considerable morbidityand mortality. Apart from the increasing problem of resistancein pathogenic nocardiae, the spectrum of species causing diseasehas enlarged in recent years. There are no published reportson nocardiosis from Middle-East countries. METHODS.: A retrospective review of case records of 513 renal transplantrecipients between January 1989 and January 1995 was done inthe transplant unit of our hospital. Information was collectedon clinical details, type of donor, immunosuppressive therapy,prophylaxis, and outcome. Isolation of Nocardia species fromappropriate clinical specimens was the sole criterion for diagnosis. RESULTS.: Nocardiosis was diagnosed in six recipients with a disease incidenceof 1.2%. Four patients had received unrelated kidneys. Co-morbidconditions were diabetes mellitus (3), viral hepatitis (2) andneutropenia (1). Clinical manifestations included deep-seatedskin abscesses and pulmonary disease in three each. Cerebralabscess and meningitis were found in two patients with pulmonarydisease. Pathogens were Nocardia asteroides in four and N. otitidiscaviarum and N. farcinica in one each. In contrast to invitro susceptibility results, clinical response was differentin that five patients who received trimethoprim-sulphamethoxazole(TMP-SMX) alone (2) or in combination with cefuroxime (3) respondedwell. CONCLUSION.: The study stresses a high index of suspicion for nocardiosisin susceptible hosts who present with cutaneous abscess, pulmonaryinfiltrative lesions, and cerebral manifestations. TMP-SMX incombination with cefuroxime seems to be a highly effective therapy.It does not appear mandatory to reduce or discontinue immunosuppressivetherapy during treatment of nocardiosis.     

The influence of body mass index on the long-term survival of patients with renal cell carcinoma after tumour nephrectomy

OBJECTIVE

To assess whether under‐ or overweight at the time of surgery has any effect on the survival of the patients with renal cell carcinoma (RCC), as obesity increases the risk of developing RCC.

PATIENTS AND METHODS

We prospectively evaluated 780 patients who had nephrectomy for RCC between 1990 and 2005. We used uni‐ and multivariate Cox proportional hazards models to assess the effect of body mass index (BMI), tumour stage, Fuhrman grade, age, sex, histological type and performance status on cancer‐specific survival (CSS). Patients were grouped according to BMI (in kg/m²), as underweight (<18.5), normal (18.5–<25), overweight (25–<30) and obese (≥30).

RESULTS

The median (range) follow‐up was 5.3 (0.5–15.4) years, the patients being followed until June 2006; 254 patients died during the follow‐up. Multivariate analyses of all patients showed that tumour stage, Fuhrman grade, Karnofsky performance status, age, sex and BMI were independent prognostic factors for CSS. While underweight patients had a significantly worse prognosis than those of normal weight, overweight or obese patients had a similar outcome to that of patients of normal weight. In a subgroup analyses including patients with localized RCC only, there was a strong tendency to less aggressive disease in the overweight group (P = 0.081).

CONCLUSIONS

Being underweight is an unfavourable and new risk factor for CSS in patients with RCC treated by nephrectomy. Although not significant, there seems to be a limited favourable prognostic effect of overweight on CSS in patients with localized RCC.     

移植肾功能延迟恢复的临床诊治体会

目的．探讨肾移植术后移植肾功能延迟恢复（DGF）的病因及治疗方法。方法分析本组发生的43例肾移植术后DGF患者的临床资料，主要原因：急性排斥（AR）17例（39．5％），急性肾小管坏死（ATN）16例（37．2％），输尿管梗阻4例（9．3％），免疫抑制剂肾毒性4例（9．3％），动脉吻合口狭窄2例（4．6％）。经血液透析治疗16例，ATG／ALG或OKT3治疗12例，外科手术6例。结果36例肾移植术后8—113d（平均23．8d）肾功能恢复正常，2例肌酐在176—300μmol／L之间，4例恢复血透，1例死于肺部感染。结论AR和ATN是引起肾移植术后DGF的主要因素，术前严格配型、合理筛选受者及保证供肾质量等是成功的关键。     

Fluid balance of pediatric hematopoietic stem cell transplant recipients and intensive care unit admission

Fluid administration is essential in patients undergoing hematopoietic stem cell transplant (HSCT). Admission to pediatric intensive care unit (PICU) is required for 11–29% of pediatric HSCT recipients and is associated with high mortality. The objective of this study was to determine if a positive fluid balance acquired during the HSCT procedure is a risk factor for PICU admission. The medical records of 87 consecutive children who underwent a first HSCT were reviewed retrospectively for the following periods: from admission for HSCT to PICU admission for the first group (PICU group), and from admission for HSCT to hospital discharge for the second group (non-PICU group). Fluid balance was determined on the basis of weight gain (WG) and fluid overload (FO). PICU group consisted of 19 patients (21.8%). Among these, 13 (68.4%) developed ≥10% WG prior to PICU admission compared with 15 (22.1%) in the non-PICU group (p < 0.001). Thirteen patients (68.4%) developed ≥10% FO prior to PICU admission compared with 31 (45.6%) in the non-PICU group (p = 0.075). Following multivariate analysis, ≥10% WG (p = 0.018) and cardiac dysfunction on admission for HSCT (p = 0.036) remained independent risk factors for PICU admission. Smaller children (p = 0.033) and patients with a twofold increase in serum creatinine (p = 0.026) were at risk of developing ≥10% WG. This study shows that WG is a risk factor for PICU admission in pediatric HSCT recipients. Further research is needed to better understand the pathophysiology of WG in these patients and to determine the impact of WG prevention on PICU admission.     

Optimal body mass index that can predict long‐term graft outcome in Asian renal transplant recipients

Aim: There is limited data concerning the impact of recipient body mass index (BMI) on graft outcome in Asian renal transplant recipients. The aim of this study is to identify whether obesity (BMI ≥25 kg/m²) and overweight (BMI ≥23 kg/m²) can predict graft outcome. Methods: This is a single‐centre retrospective study. All patients who received kidney transplantation between 1997 and 2005 were recruited. Patients were categorized according to two different designated BMI cut‐off values. Results: One hundred and thirty‐one patients were recruited with a median follow‐up duration of 73 months. If a BMI cut‐off value of 25 kg/m² was used, 86.3% patients were classified as non‐obese and 13.7% as obese. Obesity was significantly associated with poor renal graft function and decreased patient and graft survival. On the other hand, 34.3% patients were classified as overweight and 65.7% patients as normal if a BMI cut‐off value of 23 kg/m² was used. Overweight was significantly associated with a lower glomerular filtration rate only. Cox regression analysis showed that obesity (odds ratio (OR) = 3.09), acute rejection (OR = 5.68), pre‐transplant diabetes mellitus (OR = 3.21) and age of recipient (OR = 1.06) were all significant independent risk factors associated with graft failure. Conclusion: Recipient BMI ≥25 kg/m² is a significant predictive factor for long‐term renal graft outcome in the Asian population.     

Early post‐transplant conversion from tacrolimus to belatacept for prolonged delayed graft function improves renal function in kidney transplant recipients

Prolonged delayed graft function (DGF) in kidney transplant recipients imparts a risk of poor allograft function; tacrolimus may be detrimental in this setting. We conducted a retrospective single center analysis of the first 20 patients converted to belatacept for prolonged DGF as part of a clinical protocol as a novel treatment strategy to treat prolonged DGF. Prior to conversion, patients underwent an allograft biopsy to rule out rejection and confirm tubular injury. The primary outcome was the estimated glomerular filtration rate (eGFR) at 12 months post‐transplant; secondary outcome was the change in eGFR 30 days post‐belatacept conversion. At 1 year post‐transplant, the mean eGFR was 54.2 (SD 19.2) mL/min/1.73 m². The mean eGFR on the day of belatacept conversion was 16 (SD 12.7) mL/min/1.73 m² and rose to 43.1 (SD 15.8) mL/min/1.73 m² 30 days post‐conversion (P<.0001). The acute rejection rate was 20% with 100% patient survival at 12 months post‐transplant. There was one graft loss in the setting of an invasive Aspergillus infection that resulted in withdrawal of immunosuppression and transplant nephrectomy. Belatacept conversion for prolonged DGF is a novel treatment strategy that resulted in an improvement in eGFR. Additional follow‐up is warranted to confirm the long‐term benefits of this strategy.