Impaired phosphate handling of renal allografts is aggravated under rapamycin-based immunosuppression.

BACKGROUND: Impaired phosphate handling of the renal allograft is a common problem and of multifactorial origin. The aim of the study was to elucidate whether a rapamycin- or a mycophenolate-based immunosuppressive therapy aggravates the renal phosphate leak in kidney transplant recipients. METHODS: Renal phosphate handling was determined in thirty-eight cadaveric allograft recipients, with good renal function at 8, 12, 20 and 28 weeks after transplantation. Nineteen patients (group 1) received triple immunosuppression with rapamycin, cyclosporine and prednisolone, nineteen other transplant recipients received mycophenolate mofetil, cyclosporine and prednisolone immunosuppression (group 2), and six healthy subjects (group 3) served as controls. After 12 weeks of stable graft function, group 1 patients were divided further into two subgroups. Ten patients were kept on their immunosuppressive regimen (group 1A), whereas the remaining nine randomly chosen subjects had their cyclosporine withdrawn; they were thus maintained on a dual immunosuppression regimen with prednisolone and a higher dosage of rapamycin (group 1B). RESULTS: Renal phosphate reabsorption was significantly lower in group 1 at 8 and 12 weeks after transplantation as compared with groups 2 and 3. At 20 weeks after transplantation, patients with rapamycin-based immunosuppression (groups 1A and 1B) continued to exhibit hypophosphataemia and impaired renal phosphate handling. Group 1B had the lowest TmP/ GFR compared with all groups. At 28 weeks, renal phosphate reabsorption and plasma phosphate levels were no longer different between patient groups and controls. CONCLUSION: These data suggest that rapamycin-based immunosuppression prolongs the phosphate leak of the allografted kidney, leading to low serum phosphate levels during the first weeks after transplantation.     

Studies on the multiple-drug induction immunosuppressive therapies with cyclosporine after renal transplantation

Our induction immunosuppressive therapies were carried out on patients split into three groups. The first group of 25 recipients were treated with regimen I [cyclosporin (CsA); 12 mg/kg/day and prednisolone (Pred)]. The second group of 16 recipients were treated with regimen II [CsA; 6 mg/kg/day, Pred and mizoribine (MIZ) or azathioprine (AZA)]. The third group of 14 recipients were treated with regimen III [CsA; 10 mg/kg/day, Pred and MIZ or AZA]. There was no significant difference among the three groups in renal function three months after renal transplantation. The frequency and grade of rejection were significantly higher in Group II than in the other groups. One of group I had CsA nephrotoxicity and none of group III had liver dysfunction three months after renal transplantation. Group I had a higher incidence of posttransplant hypertension. Hypertension of group I was very severe. We concluded that the triple-drug therapy on group III was the best induction immunosuppressive therapy after renal transplantation of the above three.     

A randomized controlled trial of cyclosporine withdrawal in renal-transplant recipients: 15-year results

BACKGROUND: In renal transplantation, the immunosuppressive efficacy of cyclosporine is counterbalanced by its nephrotoxicity. Although cyclosporine improves short-term graft survival, its long-term effects are unclear. METHODS: Recipients of first cadaver renal transplants were randomized into three groups between 1983 and 1986: azathioprine and prednisolone alone (AP, n = 158), long term cyclosporine alone (Cy, n = 166), and short-term cyclosporine followed by azathioprine and prednisolone (CyAP, n = 165). All groups received methylprednisolone induction. RESULTS: There were no significant differences in patient survival at 15 years (48 vs. 56 vs. 51%, P = 0.14), and 15-year graft survival (censored for death) in those patients in the CyAP group (47 vs. 44 vs. 59%, P = 0.06) was not significantly different statistically. When deaths or graft losses before 12 months were censored, the differences in 15-year graft survival between the groups were significant (58%, 51%, 70%, P = 0.01). The CyAP group also had lower mean serum creatinine at all time points beyond 3 months posttransplant out to 10 years (143 vs. 169 vs. 131 micromoles/L, P = 0.04). Per protocol analysis, after censoring patients at change in therapy, increased the observed differences in 15-year graft survival between the groups (54 vs. 38 vs. 65%, P = 0.01). CONCLUSION: Survival and function of first cadaveric kidney transplants is improved by use of short-term cyclosporine followed by azathioprine and prednisolone. Long-term cyclosporine use reduces long-term graft survival.     

Effect of basiliximab on renal allograft rejection within 1 year after transplantation

Basiliximab is widely used in clinical practice for initial immunosuppressive treatment of renal transplant recipients, seeking to reduce the incidence of acute rejection episodes without adverse events. This retrospective study included 123 renal allograft recipients transplanted at a single center. All were followed for longer than 1 year after transplantation and treated with calcineurin inhibitor and steroid (methylprednisolone) for prophylactic immunosuppression, but basiliximab and mycophenolate mofetil were optional. We compared the outcomes of renal transplant recipients who were versus treated were not with basiliximab as initial immunosuppressive therapy. Basiliximab was used for initial immunosuppression in 42 patients. Their maintenance immunosuppressive treatment included triple (n = 44) or double (n = 79) regimens, including a calcineurin inhibitor (cyclosporine [n = 87] or tacrolimus [n = 36]), methylprednisolone with or without mycophenolate mofetil. Twenty-six (21.1%) patients had a rejection episode within 1 year after transplantation and 22 (17.9%) had infections. Within the first year after transplantation the patients who were treated with basiliximab showed fewer rejection episodes (n = 6, 14.3%) than the patients without this therapy (n = 20, 24.7%), which was not statistically significant (P = .245). However, basiliximab significantly affected the occurrence of rejection episodes among the double immunosuppressive regimen group (P = .006), but not the triple regimen group (P = .098) without an impact on infection episodes (P value of double, triple = .291, .414) within 1 year after transplantation. We concluded that basiliximab was more useful for the recipients treated with double immunosuppression with a calcineurin inhibitor and steroid than for those on a triple regimen including mycophenolate mofetil.     

扩大标准公民逝世后器官捐献肾移植术后一年内临床效果分析

目的观察并比较扩大标准供者(ECD)和标准供者(SCD)供肾移植受者术后1年内临床效果。 方法回顾性分析2014年3月至2017年3月空军军医大学西京医院接受公民逝世后器官捐献90例肾移植受者临床资料,按供肾来源分为ECD组(31例)和SCD组(59例)。所有受者均应用免疫诱导及三联免疫抑制方案治疗(吗替麦考酚酯或麦考酚钠肠溶片＋他克莫司或环孢素＋甲泼尼龙)。采用t检验或Mann-Whitney U检验比较两组受者肾移植术后1年内血清肌酐(Scr)水平,采用χ²检验和Fisher确切概率法比较两组受者性别比例、受者/移植肾存活率及急性排斥反应(AR)、移植肾功能延迟恢复(DGF)和肺部感染等并发症发生率。P<0.05为差异有统计学意义。 结果ECD组和SCD组肾移植受者术后Scr水平逐步下降。术后1个月内(术后1、3、7、14和21 d)两组受者Scr水平差异均无统计学意义(t＝0.076、0.905、0.670、0.893和0.048,P均>0.05);术后1～12个月,除术后9个月两组受者Scr水平差异无统计学意义(t＝1.727,P>0.05),其余各时间点ECD组受者Scr水平均高于SCD组,差异均有统计学意义(P均<0.05)。两组受者术后1年受者/移植肾存活率分别为93.1%/80.6%和91.5/84.7%,差异均无统计学意义(P＝0.734; χ²＝0.246,P>0.05)。ECD组和SCD组AR发生率分别为12.9%(4/31)和18.6%(11/59),DGF发生率分别为22.6%(7/31)和22.0%(13/59),肺部感染发生率分别为25.8%(8/31)和11.9%(7/59),其他并发症发生率分别为41.9%(13/31)和28.8%(17/59),差异均无统计学意义(P均>0.05)。 结论与SCD相比,ECD供肾移植仍可获得相当的临床效果。在目前供器官来源严重缺乏的情况下,ECD的合理选择可以扩大供肾来源。     

Effects of Immunosuppressive Drugs on Platelet Aggregation and Soluble P-Selectin Levels in Renal Transplant Patients

Background/aim. Post-transplant cardiovascular events are associated with increased morbidity and mortality after renal transplantation. Though renal transplantation eliminates cardiovascular disease risk factors by restoring renal function, it introduces new cardiovascular risks derived partly from immunosuppressive medications. In this study, to assess the effects of various immunosuppressive drugs on platelet function of renal transplant patients, we measured soluble P selectin levels (sP-selectin) and performed platelet aggregation studies in patients who have undergone renal transplantation. Methods. sP-selectin levels and platelet aggregation induced by 5 μM adenosine diphosphate (ADP), 5 μM epinephrine, 1.25 mg/mL ristocetin, and 2 μg/mL collagen were studied by whole blood platelet lumi-aggregometer in 40 renal transplant patients. Patients in group 1 (n?=?24) were treated with cyclosporine/mycophenolate mofetil/methylprednisolone, and group 2 (n?=?16) were treated with tacrolimus/mycophenolate mofetil/methylprednisolone. Effects were compared with those in control groups of hypertensive subjects and healthy subjects. Results. Platelet aggregation values induced by ADP, epinephrine, ristocetin, and collagen were lower in cyclosporine-treated patients than tacrolimus-treated patients, hypertensive subjects, and healthy subjects, though the difference was not statistically significant (p?>?0.05). sP-selectin levels were appreciably higher in cyclosporine-treated patients, and statistically significant differences were observed compared with those of tacrolimus-treated patients (p?<?0.05), hypertensive subjects (p?<?0.01), and healthy subjects (p?<?0.05). Conclusion. We conclude that cyclosporine-treated renal transplant patients show enhanced platelet activation in which anti-platelet therapy should be considered, in addition to management of other conventional cardiovascular risk factors, to decrease the cardiovascular morbidity and mortality in this high risk population.     

Glomerulotubular function in long-term renal allograft recipients. A comparison of conventional therapy with cyclosporine

Glomerular and tubular function were assessed, using a lithium clearance technique, in two groups of renal allograft recipients at least one year after transplantation. Group 1 comprised 14 patients receiving low-dose prednisolone and cyclosporine, and group 2, 14 patients receiving low-dose prednisolone and azathioprine. There were no significant differences in creatinine clearances between the two groups, although the clearances of lithium (which is absorbed almost exclusively from the proximal tubule) and sodium were significantly lower in the cyclosporine-treated group. Fractional lithium excretion was also significantly lower in group 1 than in group 2, but there was no significant difference in fractional sodium excretion. The absolute proximal reabsorption of sodium and water did not differ between the groups, although the fractional proximal reabsorption of sodium and water was significantly higher in group 1. In contrast, the distal reabsorption of sodium and of water was significantly lower in the cyclosporine-treated patients than in the azathioprine-treated patients; there were, however, no significant differences in the distal fractional reabsorptions of sodium and water between the two groups. In addition there was no correlation in group 1 between whole-blood cyclosporine levels or time since transplantation and any of the assessed parameters of renal function. These results indicate that tubular concentrating abnormalities in cyclosporine-treated renal allograft recipients are similar to those observed in rodent models of cyclosporine nephrotoxicity. They suggest that the pathogenesis of cyclosporine nephrotoxicity may be similar in renal allograft recipients to that in experimental models.     

Hypertension after renal transplantation. A comparison of cyclosporine and conventional immunosuppression

Hypertension is a common complication after renal transplantation and is associated with increased mortality. Cyclosporine is known to be nephrotoxic and raises blood pressure in recipients of cardiac and bone marrow transplants, but there is conflicting data on the role of cyclosporine after renal transplantation. We have examined this question in patients entered into the second Oxford prospective randomized comparison of short-term cyclosporine treatment alone with conversion to azathioprine and prednisolone at 90 days (CsA group), and conventional therapy with azathioprine and prednisolone throughout (AP group). Blood pressure and antihypertensive medication were similar in the CsA and AP treatment groups during the first 90 days. Following conversion from cyclosporine, mean blood pressure fell from 155/94 to 142/81 within 7 days, and this fall correlated with the change in plasma creatinine over the same period (r = 0.44, P less than 0.05). Blood pressure was subsequently lower in the converted patients than in those treated with AP throughout. Six months after transplantation patients converted from cyclosporine not only had lower blood pressure but also required fewer antihypertensive drugs than AP patients. This study demonstrates that cyclosporine may elevate the blood pressure in recipients of renal transplants. This effect may either be direct or mediated through the effect of cyclosporine on renal function. Administration of corticosteroids during the first three months after transplantation is implicated as a possible cause of persisting high blood pressure.     

Long‐term graft function with tacrolimus and cyclosporine in renal transplantation: Paired kidney analysis

Aim: The first prospective, randomized trial with paired kidney analysis was conducted to compare the efficacy and safety of tacrolimus with cyclosporine‐based immunosuppressive therapy in renal transplant recipients. This paper reports the long‐term follow‐up results of the authors' previously published study, with the main focus on graft survival and renal function. Methods: Chinese patients transplanted in our centre between June 1998 and June 2005 with their first deceased renal transplant were included. Patients were included if both kidneys were received by the authors' centre, thus allowing a paired analysis. Patients were randomized to receive triple immunosuppressive therapy with either tacrolimus or Neoral cyclosporine, concomitantly with prednisolone and azathioprine therapy. Results: Seventy‐six patients received cadaveric kidneys from 38 donors. Each pair of kidneys was randomly assigned to a separate group (38 subjects/group). The mean follow‐up duration was 6.1 ± 1.8 years. The mean calculated creatinine clearance was significantly higher in patients receiving tacrolimus‐based therapy. The rate of biopsy‐proven acute rejection was lower in the tacrolimus group (18.4% vs 42.1%, P = 0.03). The patient and graft survival were comparable in both treatment arms. Significantly fewer patients on tacrolimus‐based therapy developed hypercholesterolaemia (P = 0.05). However, there was no significant difference in the development of post‐transplant diabetes mellitus, hypertension, opportunistic infection and malignancy between both groups. Conclusion: Using the immunosuppressive regimen, tacrolimus‐based therapy provided adequate immunosuppression with better renal function and less acute rejection, as compared with cyclosporine‐based therapy.     

A controlled trial of steroids in cyclosporine-treated renal transplant recipients

In a randomized controlled clinical trial, 117 recipients of a kidney transplant were treated with cyclosporine (15-17 mg/kg/day) either alone or with prednisolone 0.3 mg/kg/day in addition. There were no exclusions and all patients have been followed-up from 14 to 39 months. No differences in the survival of the patients or their transplants were seen between the two groups. Actual survival of first cadaver grafts was 73% at one year in the group receiving cyclosporine alone and 76% in the group with added steroids. Survival of second or third grafts in the steroid group was somewhat worse but not significantly so. All 6 recipients of living-donor grafts are currently alive with good function. Infective complications were significantly less common in the group not receiving routine steroids, and these patients were also at less risk of developing a changed facial appearance. However, half the patients in this group have subsequently required steroids because of previous rejections, and cyclosporine nephrotoxicity has been significantly more common. Nonetheless, we have found no overall advantage in combining cyclosporine with low-dose maintenance prednisolone, and we advise that patients undergoing renal transplantation receive cyclosporine alone in the first instance.     

Clinical experience in renal transplantation

In Shiga Prefecture, 378 chronic renal failure patients were registered at the end of 1981. In 1982, the Kidney Transplantation Group, composed of the department of Urology and the 1st division of Surgery, was organized in our hospital and 10 living related renal transplantations and 8 cadaver renal transplantations were performed between July 1982 and October 1984. As immunosuppressants, azathioprine, mizoribine, cyclosporine, prednisolone, methylprednisolone and ALG were used. Azathioprine was used mainly for living transplantation and cyclosporine mainly for cadaver transplantation. ALG was used only for the initial 3 living transplantations. Mizoribine was sometimes used in combination with azathioprine to reduce the dose of azathioprine and reduce its severe side effects. Seven episodes of acute rejection were experienced and all episodes were remitted by methylprednisolone pulse therapy. There were 20 major post-transplant complications in 13 recipients and among them 2 pulmonary infections were fetal (1 from aspergillus infection and 1 from cytomegalovirus infection). The 10 living related kidney transplantation recipients are all well and none have undergone hemodialysis. Three of the 8 cadaver renal transplantation are well without hemodialysis. One patient could not obtain diuresis. In addition to our experience of renal transplantation, the preoperative scheduled blood transfusion with combination of azathioprine administration, was briefly discussed.     

Adverse influence of recipient lymphoid resistance to in vitro immunosuppression on the outcome of kidney transplants

The study investigated whether preoperative in vitro sensitivity of lymphocytes from potential renal transplant recipients could identify patients at increased risk of acute rejection following transplantation and immunosuppression with cyclosporine, azathioprine, and prednisolone. Mixed lymphocyte culture responses were measured preoperatively in the presence of methylprednisolone, CsA, and antithymocyte globulin, and without immunosuppressive agents in 50 transfused recipients of primary cadaver renal transplants. Patients were classified as sensitive if all three immunosuppressive agents produced more than 50% inhibition of their MLC responses, and as resistant if one or more agents failed to produce 50% inhibition. All patients received postoperatively a standardized triple immunosuppressive regimen. Acute rejection was confirmed histologically and treated with Pred with or without ATG or monoclonal antibody OKT3. A total of 29 patients (58%) were sensitive and 21 (42%) were resistant; 4 patients were resistant to 3 agents, 5 were resistant to MP and ATG, 6 were resistant to MP and CsA, and 6 were resistant to MP alone. Sensitive and resistant groups did not differ in age, sex, transfusion history, HLA A, B and DR mismatches or duration of follow-up. The resistant group had a higher rate of graft loss from acute rejection (chi 2 = 6.0, d.f. = 1, P less than 0.02), more episodes of acute rejection (chi 2 = 8.7, d.f. = 3, P less than 0.05), and a higher proportion of patients in whom reflux nephropathy was the cause of renal failure (chi 2 = 18.3, d.f. = 1, P less than 0.001). The resistant group also had a higher proportion of highly sensitized patients and higher serum creatinine concentrations than the sensitive group, although the differences did not reach statistical significance. The study indicates that patients at high risk of acute rejection of renal allografts can be identified by a pretransplant in vitro assay, a finding that could influence recipient selection and immunosuppression.     

Factors Associated with Hyperhomocysteinemia After Renal Transplantation

Recent studies show that clinically stable renal transplant recipients have an increased prevalence of hyperhomocysteinemia (hyperHcy), but the mechanism of this disorder has not yet been elucidated. The aim of the present study was to evaluate the factors associated with hyperHcy after a successful renal transplantation. In 106 stable renal transplant recipients, total serum Hcy level (tHcy), folate, total protein, serum creatinine concentration, creatinine clearance, lipid status, body weight (BW), body mass index (BMI), and body fat (BF) were determined. The mean doses of cyclosporine, prednisolone, and azathioprine (mg/kg/day) were recorded. The mean serum tHcy level was significantly higher in renal transplant patients than in healthy controls (22.02 ± 8.02 versus 13.0 ± 3.3 μmol/L; p < 0.001), and the incidence of patients with hyperHcy was 82%. Comparison of the group of 20 patients with tHcy level <15 μmol/L and the group of 86 patients with tHcy level >15 μmol/L revealed that the latter was significantly older, heavier, had been longer on dialysis before renal transplantation, and had older donors and poorer renal graft function. Significant correlation was found between tHcy level and recipient age, dialysis duration, BW, creatinine clearance, serum creatinine, and folate concentration. However, multivariate analysis indicated that creatinine clearance (p = 0.025) and BW (p = 0.03) were the only determinants of elevated total Hcy level in renal transplant recipients. HyperHcy persists after successful kidney transplantation in the majority of renal transplant recipients, and its appearance is primarily associated with creatinine clearance and body weight.     

Kidney Transplantation Achievements in Mongolia

Between August 2006 and August 2009, 33 patients with end-stage renal disease were the recipients of kidney transplantations. The donors were living related 29 operations with 4 recipients of 2 deceased donors following accidents with cardiac arrest controlled after permission by the next of kin. We used standard techniques for the donor and recipient operations.All recipients were prescribed 1 dose of alemtuzumab (Campath 1 H 20-30 mg), peroperatively preceded by 500 mg methylprednisolone. In 2 recipients, a second infusion of Campath 1 was administered on postoperative day 2.On postoperative day 3, we prescribed monotherapy with either cyclosporine (n = 29) at a starting dose of 7 mg/kg body weight or tacrolimus (n = 6) at a starting dose of 0.7 mg/kg body weight. With the exception of patients treated for an acute rejection episode, no patient received steroid therapy.There were 7 acute rejection episodes, which were treated with 3 consecutive daily doses of methylprednisolone (250 mg).The 1-year patient survival was 94% and 2-year graft survival, 84.8%. We concluded that the use of Campath 1 together with a non-steroid maintenance immunosuppressive regimen provided acceptable graft and patient survival in our developing country.     

Increased sensitivities of peripheral blood mononuclear cells to immunosuppressive drugs in cirrhosis patients awaiting liver transplantation

Successful immunosuppressive therapy is critical for liver transplantation. However, a considerable number of patients show clinical resistance to the therapy and experience rejection episodes, or alternatively exhibits serious adverse effects of drugs. We examined the in vitro response of peripheral blood mononuclear cells (PBMCs) to immunosuppressive drugs in cirrhosis patients awaiting liver transplantation. We evaluated the suppressive efficacy of prednisolone, methylprednisolone, cyclosporine, and tacrolimus on the in vitro blastogenesis of PBMCs obtained from 22 cirrhosis patients and 31 healthy subjects. In vitro drug concentrations giving 50% inhibition of PBMC blastogenesis (IC50s) were calculated. Two out of these 22 patients received liver transplantation from living donors, and their clinical courses were surveyed until 5 weeks after operation. The median IC50 values for prednisolone, cyclosporine, and tacrolimus against blastogenesis of PBMCs from cirrhosis patients were significantly lower than those of PBMCs from healthy subjects (p < 0.01). However, large individual differences were observed in the IC50 values of the immunosuppressive drugs examined, especially in the cirrhosis patients. One recipient exhibiting high PBMC sensitivity to tacrolimus (IC50 = 0.001 ng/ml) showed good clinical course without rejection until 5 weeks after liver transplantation. The other recipient exhibiting relatively low PBMC sensitivity to taclolimus (IC50 = 0.30) showed allograft rejection at 1 week after operation. We concluded from these observations that PBMCs of cirrhosis patients are vulnerable to the immunosuppressive effects of prednisolone and calcineurin inhibitors. However, large individual variations in the IC50 values suggest that patients exhibiting relatively lower sensitivity to these drugs may have risks of rejection, whereas highly sensitive patients are possibly able to reduce the dose of immunosuppressive drugs to avoid serious drug-adverse effects, after liver transplantation.     

Renal Transplantation and Idiopathic Thrombocytopenic Purpura: Two Case Reports

Kidney transplantation has rarely been performed in patients with immune thrombocytopenic purpura (ITP). We present two cases of kidney recipients from unrelated donors in women who had prior chronic refractory ITP. Their immunosuppression included induction therapy with antithymocyte globulin (ATG) and maintenance treatment with cyclosporine and prednisone. Kidney transplantations were safely performed without any complication. The platelet count of our patients increased gradually after the surgery, and maintenance with cyclosporine, mycophenolate mofetil, and prednisolone allowed graft function and satisfactory hemostasis. During the 3- and 8-year follow-up periods in our recipients, graft function was well maintained. We speculated that immunosuppressive agents, especially cyclosporine, may result in safe platelet counts and resolve thrombocytopenia in cases with refractory ITP prior to transplantation.     

Electrolyte Free Water Clearance Could Be an Early Sign of Renal Dysfunction in Renal Transplant Patients

Data on free water excretion capacity of renal transplant recipients are scant. The aim of this study was to evaluate the ability of electrolyte free water clearance (E-CH₂O) by the allograft in renal transplant patients and the effects of various immunosuppressive drugs. Renal transplant recipients with good graft function (creatinine < 1.5 mg/dL) as well as controls were divided into five groups according to their immunosuppressive regimen: group I, azathioprine (n = 15); group II, cyclosporine (n = 28); group III, tacrolimus (n = 28); group IV healthy controls (n = 20); and group V renal transplant donors (n = 16). Following a 12-hour fast, we administered oral water loading (20 mL/kg) with urine collection for 3 hours. We calculated creatinine clearance for 3 hours and E-CH₂O. No matter which immunosuppressive drug, the E-CH₂O of recipients (groups I, II, and III) was lower than that of donors or healthy controls. The creatinine clearance of the cyclosporine arm was significantly lower than all of the other groups. Decreased E-CH₂O in renal transplant patients might be due to diminished water input to the loop of Henle related to subclinical allograft insufficiency as a result of posttransplantation pathology and/or immunosuppressive drug therapy or the transport of water into the extrarenal interstitium as a result of vascular endothelial dysfunction due to the pretransplant uremic milleu.     

Helicobacter pylori antibodies in hemodialysis patients and renal transplant recipients

In this cross-sectional, controlled study, Helicobacter pylori ( H . pylori ) infection, a probable factor in the development of gastrointestinal problems, was investigated in dialysis patients and renal transplant recipients. Forty-seven dialysis patients (22 male, 25 female, mean age of 36.6±15 yr (range 18–83 yr)), 57 renal transplant recipients (39 male, 18 female, mean age of 36.8±10 yr (range 19–60 yr)) and 55 healthy individuals (34 male, 21 female, mean age of 33.4±9.6 yr (range 21–58 yr)) were included and no significant difference was found in the study groups. The mean time spent on dialysis in the hemodialysis group was 32.5±27.7 months (range 1–100 months). H . pylori antibodies were detected in 22 of 57 (38.6%) patients in the transplantation group, 31 of 47 (65.9%) patients in the dialysis group and 39 of 55 (72.5%) in the control group. No correlation was found between H . pylori infection and age, sex, primary disease, frequency of dialysis, duration and type of transplantation and the immunosuppressive therapy. However, patients with H . pylori antibodies spent a shorter time on dialysis compared to patients without the antibodies (26.6±23.5 vs 44.1±32.1 months, p=0.038). The frequency of H . pylori infection in the transplantation group was significantly lower than the control and dialysis groups (p<0.01). This finding may be explained on the basis of decreased humoral antibody response to H . pylori infection, secondary to immunosuppressive therapy rather than decreased incidence of infection in the transplantation group. Finally, we concluded that the value of the serological test for diagnosis of H . pylori infection should be interpreted cautiously in these patient groups.     

Laparoscopic v open donor nephrectomy for pediatric kidney recipients: preliminary report of a randomized controlled trial

BACKGROUND AND PURPOSE: Laparoscopic surgery is widely accepted for nephrectomy in adult renal transplantation. The success of this technique has not been compared with open donor nephrectomy (ODN) in children. PATIENTS AND METHODS: In this randomized clinical trial, 40 adult kidney donors were randomly divided into two groups: 20 cases of laparoscopic donor nephrectomy (LDN) and 20 of ODN. Recipients had an age of <15 years. Our exclusion criteria were previous renal transplantation, hemolytic uremic syndrome, focal segmental glomerulosclerosis, oxalosis in the recipients, and multiple renal arteries bilaterally in donors. RESULTS: All donor nephrectomies were completed as scheduled, and no patients undergoing LDN required conversion to open nephrectomy. No patients in either the ODN or the LDN group required reoperation. Acute rejection was diagnosed in six patients receiving kidneys procured by ODN (30%) and 4 patients (20%) receiving kidneys obtained by LDN (P = 0.3). No recipients or donors died. At 1 year, the graft survival times in the ODN and LDN groups were 310.8 +/- 28.8 and 302.7 +/- 28.2 days, respectively (P = 0.8). CONCLUSION: At our medical center, pediatric LDN recipients had graft outcomes similar to those of ODN recipients. We recommend LDN for harvest of kidneys for pediatric recipients at experienced centers.     

Avascular necrosis of bone after renal transplantation

Summary: Avascular necrosis (AVN) of bone is the most debilitating musculoskeletal complication that can follow renal transplantation, and has been reported in 3-41% of patients. In this unit 351 renal transplants have been done on 285 recipients. Five (1.8%) of these patients (mean age 41.6 years; range 22-57 years; four female; all cadaveric kidneys) developed AVN which affected both hip joints. the mean duration of renal failure before dialysis was 18.2 months (range 5-36). All five were on dialysis for a mean of 16.2 months (range 4-29) pre-transplant. No patient had radiological evidence of renal osteodystrophy prior to transplantation. the first 116 patients were immunosuppressed with prednisone/azathioprine and four (3.5%) developed AVN. the subsequent 169 patients were treated with prednisone/azathioprine/ cyclosporine and one (0.6%) developed AVN. Only two of the five patients needed treatment for acute rejection (methylprednisolone 3 g and 6 g). the mean time from transplantation to onset of joint pain was 45.4 months (range 6-108). Total hip replacement (THR) was undertaken on all 10 joints with the first side being operated on after a mean of 73.2 months (range 23-124) from transplantation and the contralateral side after 88.4 months (range 24–144). Total hip replacement resulted in relief of pain in all joints: three surgical revisions were required, two for dislocation and one for a fractured prosthesis. This study has shown a low prevalence of AVN after renal transplantation. Possible explanations include careful control of renal osteodystrophy while on dialysis and the use of low dose prednisone in the immunosuppressive regimen.