Results of Positive Cross-Match Transplantation in African American Renal Transplant Recipients

Positive cross-match (PXM) renal transplantation has been utilized to address the issue of the increasing demand for transplantation with the shortage of suitable organs. Our primary objective was to analyze the outcomes of African American (AA) PXM renal transplant recipients utilizing AA negative cross-match (NXM) renal transplant recipients as a comparator group. This was a retrospective study consisting of all PXM patients who underwent a desensitization protocol and all AA NXM transplant recipients at the University of Illinois at Chicago from July 2001 to March 2007. We found that AA PXM recipients had significantly lower estimated glomerular filtration rate (eGFR) at 1 year than AA NXM (46.2 vs. 60.6, p = 0.007). AA PXM who experienced acute rejection within the first year were more likely to have an eGFR less than 30 mL/min/1.73 m² at 1 year compared to their NXM counterparts (45.5% vs. 12.5%, p = 0.034). Positive cross-match renal transplantation in AA seems to be associated with a high degree of AR and severe renal compromise at 1 year. Larger studies are needed to determine if protocols that are associated with good short-term outcomes in non-AA need to be modified for the AA population.     

Lung Transplant Recipients Holding Companion Animals: Impact on Physical Health and Quality of Life

Since lung transplant recipients are susceptible to infections and inhaled pollution, many centers warn against pets. However, data supporting this recommendation are lacking. Our program is less restrictive regarding pets. This study, for the first time, investigates the association of pets with physiological and psychological parameters in these patients. A questionnaire concerning pets was sent to 104 lung transplant recipients. Lung function tests, levels of exhaled nitric oxide (FE(NO)), need for antibiotic treatments and hospitalizations, creatinine clearance, body mass index (BMI) and demographic data were assessed. Additionally, the questionnaire of life satisfaction (FLZ), a question on summarized life satisfaction (LS), the life orientation test (LOT), the hospital anxiety depression scale (HADS) and the social support questionnaire (F-SozU) were assessed. Response rate was 86%. Fifty-two percent defined themselves as pet owners, whereas 48% did not. The two groups did not differ in demographic or physiological data. Significant differences in FLZ (79/65, p = 0.04), in LS (4.3/3.9, p = 0.01), LOT (32/29, p = 0.006) and F-SozU (4.5/4.2, p = 0.04) were found in favor of pet owners. In lung transplant recipients keeping pets the frequency of somatic complications is not higher compared to lung transplant recipients without pets. After lung transplantation, pets are associated with a better quality of life.     

Health-Related Quality of Life in Pediatric Liver Transplant Recipients

BackgroundHealth-related quality of life (HRQoL) of liver transplantation (LT) recipients has been widely studied because of increased patient longevity. However, studies in developing countries are scanty. We aimed to evaluate psychometric properties of the Thai version of the PedsQL Transplant Module and used it to determine the HRQoL in LT children.MethodsWe included children aged 2 to 18 years who underwent LT more than 1 year previously. The phase 1 study included a cognitive interview with 20 LT children and their parents using the Thai version of PedsQL Transplant Module and revised the module accordingly. Then, the finalized version was evaluated for psychometric properties in 50 LT children. In phase 2, HRQoL was evaluated in 52 LT children who did not participate in the phase 1 study.ResultsIn the Thai PedsQL Transplant Module, both parent report and child self-report had good internal consistency (α = 0.94 and 0.93, respectively) and substantial reliability (interclass correlation coefficient = 0.82 and 0.77, respectively). Median HRQoL scores from the parent report and child self-report were 80 (interquartile range [IQR], 70, 88) and 77 (IQR, 71, 88), respectively. From the parent report, lower HRQoL was associated with opportunistic viral infection (P = .004) and correlated with a greater number of immunosuppressive agents (ρ = –0.346, P = .014). However, none of these factors were significant according to the child self-report.ConclusionsThe Thai PedsQL Transplant Module has satisfactory psychometric properties. Post-LT children have good HRQoL. To improve their HRQoL, specific attention should be focused on managing viral infection and optimizing immunosuppressive therapy.     

Left Ventricular Hypertrophy in Renal Transplant Recipients in the First Year After Transplantation

Background

Left ventricular hypertrophy (LVH) is a significant risk factor for cardiovascular complications in renal transplant recipients. The study objective here was to assess LVH and related factors in renal transplant recipients in the 1st year after transplantation.

Methods

Echocardiographic examinations were performed in the early post-transplantation period in 43 patients (age, 43.9 ± 12.4 years; male, 53.5%) and at 1 year after transplantation in 40 patients. At the same time, basic blood tests, N-terminal pro–B-type natriuretic peptide (NT-proBNP) level tests, and ambulatory blood pressure measurements were performed. LVH was diagnosed when LV mass index was >95 g/m² in women and >115 g/m² in men. Statistical analyses were performed with the use of the R Package.

Results

LVH (mainly concentric) was found in 51.2% of the patients in the early period and in 50% of the patients at 1 year. In 30% of the patients with baseline LVH it regressed at 1 year and in another 30% LVH developed de novo. In the early period, LV mass was influenced by age, sex, body mass index (BMI), estimated glomerular filtration rate (eGFR), and a history of cardiovascular disorders during dialysis therapy, whereas at 1 year after transplantation it was influenced by age, sex, BMI, 24-hour systolic blood pressure, a history of hypertension during dialysis therapy, and abnormal 24-hour blood pressure profile. Weight gain interfered with LVH regression during the 1st year after transplantation, whereas no improvement in blood pressure control contributed to de novo development of LVH. All other patients (those without LVH) had a morphologic abnormality of the left ventricle, the so-called concentric remodeling. Higher NT-proBNP levels were observed in patients with LVH.

Conclusions

LVH is present in one-half of renal transplant recipients in the 1st year after transplantation, and concentric remodeling is present in the remaining patients of this group. An echocardiographic examination is indicated in every renal transplant recipient. Measurements of NT-proBNP levels are helpful in LVH diagnostics.     

Pregnancy in Renal Transplant Recipients

Objective

Renal transplantation with a well-functioning graft leads to a rapid restoration of endocrine and sexual functions. The aim of this study was to examine our experience with pregnancies among renal transplant patients, particularly with regard to their impact on graft function.

Patients and Methods

We analyzed 10 pregnancies in 7 renal transplant recipients for long-term graft outcomes in terms of clinical and biological data.

Results

The mean patient age was 28.5 ± 4 years. They all received a living donor kidney. The time between transplantation and the onset of pregnancy was 33.4 ± 23.2 months. Regarding the immunosuppressive therapy, all patients received steroids and cyclosporine; 4 patients received in addition azathioprine and 2 received mycophenolate mofetil that was changed at 1 month before conception to azathioprine. There was no significant difference between the serum creatinine before and during pregnancy. We did not observe any acute rejection episode. Pregnancy complications were preclampsia in 1 case, hypertension in 1 case, urinary tract infection in 2 cases, and anemia in 80% of patients during the third trimester. Premature rupture of membranes occurred in 1 case and preterm delivery in 2 cases. Two cases of neonatal death were registered. Cesarean section was performed in 50% of cases. The follow-up revealed 2 cases of chronic rejection.

Conclusion

A multidisciplinary approach is necessary for pregnancy which generally occurs at 2 years after kidney transplantation.     

Demodicosis in Renal Transplant Recipients

Solid organ transplant recipients have an increased incidence of skin infections resulting from immunosuppression. Common pathogens include herpes simplex virus, varicella zoster virus, Gram‐positive bacteria and dermatophytes; however, the contribution of multicellular parasitic organisms to dermatologic disease in this population remains less studied. Demodex folliculorum and brevis are commensal mites that reside on human skin. Proliferation of Demodex mites, or demodicosis, is associated with rosacea and rosacea‐like disorders, particularly in immunocompromised populations, although their ability to cause disease is still the subject of debate. We present a case series of four renal transplant recipients with the singular chief complaint of acne rosacea who we diagnosed with demodicosis. Although one of the four patients showed complete resolution following initial antiparasitic therapy, the other three required subsequent antibacterial treatment to fully resolve their lesions. We suggest that demodicosis may be more prevalent than once thought in solid organ transplant recipients and showed that Demodex‐associated acne rosacea can be effectively treated in this population.     

Liver Transplant Recipients With End-Stage Renal Disease Largely Benefit From Kidney Transplantation

Background

The incidence of end-stage renal disease (ESRD) after liver transplant (LT) has increased. The actual benefit of kidney transplantation (KT) is not completely understood in LT recipients with ESRD.

Hyperhomocysteinemia in Renal Transplant Recipients

Renal transplantation is a commonly performed curative procedure for end-stage renal disease. With the increase in renal allograft half-lives, attention is now being focused on cardiovascular morbidity and death in the renal transplant recipient (RTR) population. Among the more novel cardiovascular disease (CVD) risk factors for which this group is at risk is hyperhomocysteinemia. Hyperhomocysteinemia has been associated with an increased risk of CVD, although prospective randomized trials designed to prove causality are still ongoing. Since plasma total homocysteine levels are inversely related to renal function, RTRs have a greatly increased prevalence of hyperhomocysteinemia. Other determinants of homocysteine include B-vitamins, albumin, age, and genetic polymorphisms. Although RTRs are resistant to the typical B-vitamin doses used to correct hyperhomocysteinemia in the general population, they do respond to supraphysiologic dose therapy. In terms of prevalence, etiology, and treatment of hyperhomocysteinemia, RTRs are very similar to the much larger chronic renal insufficiency population. For this reason, RTRs have been chosen as an ideal study population in investigating the effect of reducing hyperhomocysteinemia on CVD outcomes.     

Influence of Polypharmacy on the Quality of Life in Stable Kidney Transplant Recipients

Background

Kidney transplant recipients are frequently treated for other medical conditions and experience polypharmacy. The aim of our study was to evaluate quality of life in relation to medicines' burden in these patients.

Post Transplant Erythrocytosis in Hypercalcemic Renal Transplant Recipients

In vitro data suggest that calcium plays an important role in normal and disordered erythropoiesis. The purpose of this study is to determine whether there is an association between serum calcium, various hormone levels, and the development of post transplant erythrocytosis (PTE). Data were collected on 283 patients who underwent renal transplantation between 1994 and 1998. The relationship between serum calcium and PTE development was tested using the chi-square test. Univariate and multivariable adjusted models were employed to determine predictors of maximum hematocrit. Selected patients underwent measurement of intact parathyroid hormone (PTH), 1,25-dihydroxy vitamin D, and erythropoietin (EPO). Seventy-three patients (26%) developed PTE. Post transplant erythrocytosis was more common in patients with hypercalcemia compared with patients with normal serum calcium (34% vs. 18%, p = 0.002). In multivariable analyses, serum calcium was a strong independent predictor of maximum hematocrit post transplant, even after adjustment for renal function. A serum calcium of >or=10.2 mg/dL was associated with greater than two-fold increased odds of PTE. There were no differences in hormone levels between subjects with hypercalcemia and PTE, subjects with PTE alone, and subjects with hypercalcemia alone. Hypercalcemia is associated with the development of PTE in renal transplant recipients.     

Outcomes of Recipients With Pancreas Transplant Alone Who Develop End‐Stage Renal Disease

Recipients of pancreas transplant alone (PTA) may be at increased risk for developing end‐stage renal disease (ESRD). The survival experience of PTA recipients developing ESRD has not been described. Furthermore, the relative survival of these patients as compared to diabetics on chronic dialysis is unknown. We studied all adult PTA recipients from January 1, 1990 to September 1, 2008 using the Scientific Registry of Transplant Recipients. Each PTA recipient developing ESRD was matched to 10 diabetics on chronic dialysis from the United States Renal Data System. Cox proportional hazards models were fitted to determine the relation between ESRD and mortality among PTA recipients, and the relation between PTA and mortality among diabetics on chronic dialysis. There were 1597 PTA recipients in the study, of which 207 developed ESRD. Those with ESRD had a threefold increase in mortality versus those without (adjusted hazard ratio 3.28 [95% confidence interval: 2.27, 4.76]). There was no significant difference in the risk of death among PTA recipients with ESRD versus diabetics on dialysis. PTA recipients developing ESRD are three times more likely to die than PTA recipients without ESRD; however, the risk of death in these patients was similar to diabetics on chronic dialysis without PTA.     

尸肾移植受者和亲属活体肾移植受者术后焦虑抑郁的比较

目的 了解尸肾移植受者和亲属活体肾移植受者术后焦虑抑郁状况.方法 采用Zung焦虑自评量表(SAS)和抑郁自评量表(SDS)对71例尸肾移植受者(尸肾组)和74例亲属活体肾移植受者(活体组),于移植术后第3个月进行问卷调查.结果 两组SAS、SDS评分显著高于常模(均P＜0.01);活体组SAS评分显著高于尸肾组(P＜0.01).活体组焦虑、抑郁阳性率显著高于尸肾组(均P＜0.05).结论 肾移植受者术后焦虑抑郁普遍存在.亲属活体肾移植受者术后焦虑抑郁较尸肾移植受者更严重.     

Chickenpox in Adult Renal Transplant Recipients

Five of 610 adults developed chickenpox between 35 days and9.2 years after renal transplantation, and only one patientsurvived. All patients received prednisolone and azathioprineduring the incubation period. Corticosteroid therapy was continued,but azathioprine was stopped after diagnosis. Four patientswere treated with acyclovir, but three were given suboptimaldoses. The patient who survived had been taking the lowest doseof azathioprine and was given the recommended dose of acyclovir.All patients who died developed disseminated intravascular coagulation,and at postmortem examination were found to have had cerebralhaemorrhage. None of the patients treated with acyclovir hadevidence of active varicella-zoster virus infection at postmortem examination, but two had disseminated bacterial and fungalinfections. Chickenpox follows a severe and often fatal course in adultswith renal transplants. Prompt acyclovir therapy can be effective,provided an adequate dose is given. Attention should be directedtowards prevention by the identification and immunisation ofat risk patients prior to transplantation.     

Pulmonary Infections in Renal Transplant Recipients

Forty-six episodes of pulmonary infection occurred in 41 patients during a seven year period in which 187 renal transplants were performed in 168 patients. Thirty-seven episodes followed 152 cadaveric transplants (24.39%), and four episodes followed 35 living related donor transplants (11.4%). Five patients had two episodes of pulmonary infection. Twenty-four patients recovered, and 17 died (41.5%). Pulmonary infections appeared from two days to three years after transplantation, but predominated in the first four months (32/46). They were caused primarily by bacterial agents (74%) with protozoa, fungi, and viruses appearing less frequently. In 35 episodes, a single etiologic agent was found, but 11 were caused by two or more agents. When compared with noninfected recipients, there was no significant difference with regard to number of rejection crises, maintenance prednisone dosage, or blood glucose. However, subnormal renal function was significantly associated with the development of infection. Azathioprine dosages were actually higher for the noninfected patients, reflecting a tendency to lower the dose of azathioprine in the presence of decreased renal function. Fever was the most common presenting symptom. Transtracheal aspiration with Gram stain and direct sensitivity plating routinely provided early and accurate identification of the organism and a guide for therapy in bacterial infections. Pulmonary infection in renal transplant recipients is associated with a high mortality rate. Early diagnosis and specific treatment are essential to successful management.     

Paradoxical Depression in Renal Transplant Recipients

Paradoxical depression occurs despite a completely successful transplantation without tissue rejection or other medical complications. In this study, the occurrence of paradoxical depression was retrospectively investigated among 1139 Japanese successful renal transplant recipients January 1997 through September 2006. Among the 1139 recipients, 103 visited the Department of Psychiatry after renal transplantation, including 40 with depressive symptoms and 15 with a physical problem considered to have nonparadoxical depression. The other 25 recipients were considered to have paradoxical depression; that is, more than half of the 40 recipients with depressive symptoms had paradoxical depression. There were no significant differences in the clinical characteristics, including average age at the time of renal transplantation, rate of living-donor transplantation, rate of ABO incompatibility, method of dialysis (hemodialysis or peritoneal dialysis), duration of dialysis, and time interval between the renal transplantation and the initial visit to the Department of Psychiatry among the 2 groups. These results suggested that there was another risk factor or interactions between factors. Of the 25 recipients, 6 had relationship problems, 6 had social-rehabilitation problems, and 13 had mentioned no clear psychological problems. These psychological factors might in fact be related to the loss of an imagined past. Additional consecutive prospective studies are needed—a challenging prospect for consultation liaison psychiatrists in the field of transplantation.     

Evolution of Quality of Life in Renal Transplant Recipients and Patients With Multiple Sclerosis: A Follow-up Study

ObjectiveWe aimed to compare the evolution of quality of life in 2 medical conditions under immunotherapy (cadaveric renal transplantation [G₁] and multiple sclerosis [G₂]), and to assess the clinical significance of the results compared with a representative age-adjusted sample of the general Spanish population (G₃).MethodsUsing a mixed design (2 × 2), the SF-36 Health Survey was administered to 60 patients with one of these clinical conditions (30 in each group; the patient group factor), matched for gender, and homogenized regarding age and working status. All renal patients had undergone transplantation 6 months before the first assessment, and all neurological patients presented a relapsing-remitting course and a mild-moderate disability level. Both patient groups were assessed a second time 6 months later (the phase factor). A mixed analysis of covariance was computed controlling for age as a covariate. Cohen's d was reported as an effect size index and to analyze the clinical significance regarding a representative age-adjusted sample of the general Spanish population (n = 5821).ResultsStatistically significant differences were found between patient groups in vitality, bodily pain, social functioning, and mental health (P < .01), in which worse levels were displayed by patients with multiple sclerosis in both phases (Cohen's ds_1-2 from 0.61 to 1.40). Likewise, an interactive effect was observed in physical functioning [F(1,57) = 12.93; P = .001], such that the performance of daily physical activities improved in renal recipients after 6 months, but it decreased in neurological patients. Patients with multiple sclerosis showed higher, clinically significant impairment in all SF-36 dimensions in both phases compared with renal recipients (Cohen's ds_2-3 from ?0.50 to ?1.61), who presented clinically significant impairment in general health, role-physical, and role-emotional (Cohen's ds_1-3 from ?0.73 to ?1.28).ConclusionsRenal transplant recipients need specialized health care 1 year after transplantation because they still display relevant impairment in daily functioning compared with the general population.