Renal Transplantation

Summary BACKGROUND: Clinical renal transplantation has been performed successfully since 1955. With the introduction of Cyclosporin A to the market, 1982, results markedly improved, and allogeneic renal transplantation became a standard therapy in the treatment of end stage kidney failure. Life expectancy and quality of life is superior in kidney recipients in comparison with patients on dialysis. METHODS: In our center 699, renal transplantations have been performed since 1968. 98.1 % of the transplanted kidneys were from cadaveric donors, 1.9 % from living related donors. Mean age of the recipients was 30.7 ± 13.9 years from 1968 to 1983, and is now 45.9 ± 13.1 (1999 to 2002). The kidneys are normally transplanted to the common iliac vessels in end-to-side fashion. A Politano-Leadbetter antirefluxive implantation of the ureter is obligatory. RESULTS: 5-year graft survival was 19.4 % from 1968 to 1983, 74.3 % from 1984 to 1995, and 81.2 % from 1995 to 1998. Typical surgical complications are hematoma, lymphocele, ureter stenosis and ureter necrosis. The rate of necessary reoperations is 3.9 %. 5-year patient survival is 90 %. Heart disease (50 %), cancer (16 %), and sepsis (15 %) are the most frequent causes of death after renal transplantation. CONCLUSIONS: Renal transplantation continues to be the optimal treatment of terminal kidney failure. New immunosuppressive agents have improved the outcome after kidney transplantation. Enlargement of the donor pool is being attempted by the acceptance of older organs and by the acceptance of pediatric organs for adult recipients, too.     

连续性肾脏替代治疗在慢性肾衰竭并发急性心肌梗死中的应用

目的:总结日间连续性肾脏替代治疗(CRRT)救治慢性肾衰竭并发急性心肌梗死的经验.方法:对9例慢性肾衰竭常规透析时发生急性心肌梗死的患者改行CRRT,观察临床效果,监测血生化、肾功能.结果:所有患者经CRRT治疗,心前区疼痛、胸闷、憋气均有不同程度缓解,7例患者度过急性期,平均治疗时间90～146 h,转为常规血透,目前仍存活;2例患者因并发症死亡.结论:CRRT操作简便,对血流动力学影响小,日间CRRT同样能有效救治病人,使其度过急性期,降低急性心肌梗死的病死率.     

Risk Factors for Development of Acute Renal Failure After Liver Transplantation

Background.?Acute renal failure (ARF) is a common complication after liver transplantation (LTx). Identification of risk factors may prevent the development and attenuate the impact of ARF on patients outcome after LTX. Methods.?Retrospective analysis of variables in the pre, intra, and postoperative periods of 92 patients submitted to LTx was performed in order to identify risk factors for development of ARF after LTx. ARF was defined as serum creatinine ≥2.0 mg/dL in the first 30 days after LTx. Univariate and multivariate analysis by logistic regression were performed. Results.?ARF group comprised 56 patients (61%). Preoperative serum creatinine was higher in ARF group. During the intraoperative period, ARF group required more blood transfusions, developed more episodes of hypotension and presented longer anesthesia time. In the postoperative period, ARF group presented higher serum bilirubin and more episodes of hypotension. Dialysis was required in 10 patients (11%). The identified risk factors for development of ARF were: preoperative serum creatinine >1.0 mg/dL, more than five blood transfusions in the intraoperative period, hypotension during intra and postoperative periods. The identified mortality risk factors were hypotension in the postoperative period and no recovery of renal function after 30 days. Conclusions.?Several factors are involved in the pathogenesis of ARF after LTx and may influence patients outcome and mortality. Pretransplant renal function and hemodynamic conditions in the operative and postoperative periods were identified as risk factors for development of ARF after LTx. Nonrenal function recovery and postoperative hypotension were identified as mortality risk factors after LTx.     

Vitamin D3 Metabolites in Chronic Renal Failure and After Renal Transplantation

Circulating vitamin D3 metabolites were measured in 31 adultpatients with chronic renal failure and 31 adults between 3and 30 months after renal transplantation. No subject excretedover 1 g urinary protein daily nor received vitamin D or itsmetabolites. There was a positive correlation between 1,25(OH)₂D3and GFR between 15 and 90 ml/min in both chronic renal failure(r=0.60, P<0.001) and transplant subjects (r=0.49, P<0.01)and between 1.25(OH)₂ and 25(OH)D3 after transplant (r=0.69,P<0.001), but not in chronic renal failure (r=0.22, P=ns).There was a weak inverse correlation between 1,25(OH)₂D3 andserum phosphate in chronic renal failure (r=0.36, P<0.05)but not post transplant (r=0.03, P=ns). Compared with 1,25(OH)₂D3concentrations in 16 normal subjects (mean±SEM: 39.5±1.9 pg/ml), chronic renal failure subjects with mild renal impairment(GFR 45–90 ml/min, mean: 61.5±3.3 ml/min, n=17)had reduced 1,25(OH)₂D3 (28.9±2.7 pg/ml, P<0.01).In transplant subjects with mild impairment (GFR 45–90ml/min, mean: 61.4±3.7), 1,25(OH)₂D3 was positively (r=0.79,P<0.001) and iPTH inversely correlated (r=0.51, P<0.05)with 25(OH)D3. In each of nine such subjects studied, seasonalvariations in 1,25(OH)₂ (P<0.001) and PTH (P<0.05, 1-tailedtest), as well as in 25(OH)D3 and 24,25(OH)₂D3 were observed.We conclude that (1) 1,25(OH)₂D3 may be reduced early in thecourse of chronic renal failure and that (2) because of abnormaldependence of 1 ,25(OH)₂D3 on 25(OH)D3, low 25(OH)D3 may resultin reduced 1,25(OH)₂D3 values post transplant. Increased PTHin such cases suggests the functional significance of theseobservations.     

Trends in Cardiac Surgery-Associated Acute Renal Failure in the United States: A Disproportionate Increase after Heart Transplantation

Acute renal failure (ARF) is common after cardiac surgery and more frequent after complex cardiac surgery. While the incidence of ARF is increasing after coronary artery bypass graft (CABG) surgery, trends in other forms of cardiac surgery remain unclear. We investigated the trend of ARF in various cardiac procedures and compared patterns using CABG surgery as a reference group. The study population consisted of discharges from the Nationwide Inpatient Sample from 1988 to 2003, grouped according to surgery as: CABG, CABG with mitral valve, CABG with other valve, valve alone, and heart transplant. Standard diagnostic codes were used to identify ARF among discharges. Multivariable regression was used to determine trends in ARF among various procedures with CABG as a reference group. The incidence of ARF increased in all five groups (p < 0.001) over the 16-year period. The ARF incidence was highest in the heart transplant group (17%). Compared to the CABG population, patients following heart transplantation developed ARF at higher rates during the study period. In contrast, while ARF increased over time in other groups, the rates of rise were slower than in CABG patients. Among heart surgery procedures, ARF incidence is highest in heart transplantation. The incidence of ARF is also increasing at a faster rate in this group of patients in contrast to other procedure groups when compared to CABG surgery. The disproportionate increase in ARF burden after heart transplantation is a concern due to its strong association with chronic kidney disease and mortality.     

Parathyroid Hormone as a Marker for the Differential Diagnosis of Acute and Chronic Renal Failure

It is often difficult to distinguish acute renal failure clinically from chronic renal failure, especially in patients who do not have records of their medical history. We investigated the magnitude of iPTH increase in ARF and the potential role of iPTH as a marker for differential diagnosis of ARF and CRF in new patients referred to our renal unit. We prospectively analyzed 122 (ARF n?=?64, CRF n?=?58) patients referred to our renal unit with serum creatinine higher than 2 mg/dL. ROC curve analysis was performed to investigate role of iPTH for differentiating ARF from CRF. The sensitivity, specificity, and positive predictive value of iPTH in discrimination of ARF and CRF were calculated. There was no statistically significant difference regarding the means of age, sex distribution, and serum chemistry between patients with ARF or CRF. But serum iPTH (p < 0.0001) levels were lower in patients with ARF than in those with CRF. A cutoff, set at 170pg/mL for iPTH to discriminate patients with CRF, yielded a sensitivity of 88% and a specificity of 89%. This study confirms that the iPTH measurement is of clinical value in differentiating acute from chronic renal failure.     

Mortality in Elderly Patients with Acute Renal Failure

In a retrospective study, we identified 55 elderly patients with acute renal failure (ARF) admitted to our hospital during an 8-year period from 1985 to 1993. Information about the etiology, complications, laboratory data, and treatment course were obtained from the clinical history. Of the 200 patients with ARF admitted to the hospital during this period, 28% were patients more than 60 years old (41 male and 14 female) with an average age of 68.5 ± 7 years. The main causes of ARF were sepsis, volume depletion, low cardiac output, arterial hypotension, nephrotoxicity by antibiotics, and obstructive uropathy. The global mortality of elderly patients with ARF was 53%. The mortality rate of the different types of the ARF were: prerenal 35%, intrinsic 64% (oliguric 76%, nonoliguric 50%), and postrenal 40%. Mortality as a result of sepsis occurred in 18 patients (62%), by cardiovascular disease in 4 patients (13%), by acute respiratory failure in 2 patients (7%), and by other causes in 5 patients (18%). In the cases of sepsis, Pseudomonas was detected in 7 cases (39%), Escherichia coli in 2 cases (11%), Gram-negative nonspecific in 3 cases (17%), Klebsiella in 1 case (5%), and in 5 cases (16%), the hemoculture was negative. The patient survival rate was 47% (26 of 55 patients). Of these patients, 19 recovered their normal renal function (73%), but 7 patients remained with renal failure (27%). In conclusion, the global mortality in the elderly patients without considering the types of ARF was 53%. The oliguric form had the highest mortality rate with 76%. The main causes for mortality were sepsis with 62%, cardiovascular disease with 13%, and other causes 18%.     

Peritoneal Dialysis in Acute Renal Failure

The definition of adequate dialysis in acute renal failure (ARF) is complex and involves the time of referral to dialysis, dose, and dialytic method. Nephrologist experience with a specific procedure and the availability of different dialysis modalities play an important role in these choices. There is no consensus in literature on the best method or ideal dialysis dose in ARF.

Peritoneal dialysis (PD) is used less and less in ARF patients, and is being replaced by continuous venovenous therapies. However, it should not be discarded as a worthless therapeutic option for ARF patients. PD offers several advantages over hemodialysis, such as its technical simplicity, excellent cardiovascular tolerance, absence of an extracorporeal circuit, lack of bleeding risk, and low risk of hydro-electrolyte imbalance. PD also has some limitations, though: it needs an intact peritoneal cavity, carries risks of peritoneal infection and protein losses, and has an overall lower effectiveness. Because daily solute clearance is lower with PD than with daily HD, there have been concerns that PD cannot control uremia in ARF patients. Controversies exist concerning its use in patients with severe hypercatabolism; in these cases, daily hemodialysis or continuous venovenous therapy have been preferred.

There is little literature on PD in ARF patients, and what exists does not address fundamental parameters such as adequate quantification of dialysis and patient catabolism. Given these limitations, there is a pressing need to re-evaluate the adequacy of PD in ARF using accepted standards. Therefore, new studies should be undertaken to resolve these problems.     

Fatal Cardiac Tamponade in Malarial Acute Renal Failure

Uremic hemorrhagic pericarditis occurs much less frequently in acute than in chronic renal failure, but when it does, it is a potentially fatal complication. The possibility of hemorrhagic pericarditis and cardiac tamponade should be considered in patients with acute renal failure and acute hemodynamic instability. This study reports a case of falciparum malaria complicated by acute renal failure that developed fatal cardiac tamponade in the recovery phase of acute renal failure.     

Acute Renal Disease, as Defined by the RIFLE Criteria, Post-Liver Transplantation

Acute renal failure (ARF) can complicate up to 60% of orthotopic liver transplants (OLT). The RIFLE criteria were developed to provide a consensus definition for acute renal disease in critically ill patients. Using the RIFLE criteria, we aimed to determine the incidence and risk factors for ARF and acute renal injury (ARI), and to evaluate the link with the outcomes, patient survival and length of hospital stay. Three hundred patients, who received 359 OLTs, were retrospectively analyzed. ARI and ARF occurred post 11.1 and 25.7% of OLTs, respectively. By multivariate analysis, ARI was associated with pre-OLT hypertension and alcoholic liver disease and ARF with higher pre-OLT creatinine, inotrope and aminoglycoside use. ARF, but not ARI, had an impact on 30-day and 1-year patient survival and longer length of hospital stay. ARI and ARF, as defined by the RIFLE criteria, are common complications of OLT, with distinct risk factors and ARF has serious clinical consequences. The development of a consensus definition is a welcome advance, however these criteria do need to be validated in large studies in a wide variety of patient populations.     

Renal Function in Patients with Orthotopic Liver Transplantation

Due to multiple reasons, acute renal failure (ARF) commonly develops in the early postoperative period of orthotopic liver transplantation (OLT) recipients. The records of OLT recipients between 1999 and 2004 were evaluated. Age, gender, primary disease, history of diabetes, immunosuppressive drugs, pre- and postoperative renal function tests, serum electrolytes, dialysis, liver functions tests, and renal function tests in follow-up period were noted. We followed 16 patients with OLT in our center. ARF developed in 8 patients. Dialysis was performed in only 2 patients, and other patients with ARF were managed with conservative measures. Hypertensive crisis and cerebrovascular stroke developed in 1 diabetic hypertensive patient.     

Heparin Allergy Accompanying Acute Renal Failure

A generalized cutaneous hypersensitivity reaction to a porcine heparin preparation was observed in a patient during the course of acute renal failure. Immunological studies, including gel diffusion and immunoelectrophoresis, suggested that the reaction was to a contaminant of the heparin and involved both IgG and IgE antibodies.     

Immobilization Hypercalcemia-Associated Acute Renal Failure in a Patient with Chronic Tophaceous Gout

We report a case of patient suffering from chronic tophaceous gout of multiple, large joints. The patient was diagnosed with acute renal failure by immobilization hypercalcemia and successfully treated with fluid and diuretics, rehabilitative exercises, and bisphosphonate, without further recurrence during six months follow-up. Acute renal failure can occur in the patient with gout as an acute uric acid nephropathy due to the deposition of uric acid within the renal tubules. Immobilization hypercalcemia is a rare cause of acute renal failure in patients with immobilization due to the limitation of motion. We suggest that immobilization can be a possible cause of hypercalcemia-induced acute renal failure in patients with chronic tophaceous gout involving multiple large joints, and clinical alertness is needed to avoid unnecessary evaluations and life-threatening complications.     

Predictive Factors for Chronic Renal Failure One Year after Orthotopic Liver Transplantation

Chronic renal failure (CRF) is increasingly prevalent in solid-organ-transplant patients. This is in part related to the long-term use of calcineurin inhibitor (CNI) agents. However, in orthotopic liver-transplant (OLT) patients, the effects of superimposed hepatitis C virus (HCV)-related renal lesions could also be a factor. The aim of this cohort study (February 2000 to September, 2003) was to identify the predictive factors at one year post-transplantation for CRF in OLT patients associated with induction therapies. CRF was defined as having a creatinine clearance (CC) lower than 60 mL/min. Of the 97 transplants performed during that period, 72 were still functioning after one year. Of these, 33 patients (45.8%) had CRF. In univariate analysis, the predicting factors for CRF were recipient sex (female), initial liver disease (HCV-related cirrhosis), pre-transplant CC (<80 mL/mn), and post-transplant serum creatinine >130 μmol/L at day 3 and months (M) 1, 3, and 6. In multivariate analysis, the independent predictive factors for CRF included female sex [OR: 11.5 (2.3–58.3); p = 0.003], HCV infection [OR: 5.01 (1.1–22.7); p = 0.03], pre-OLT CC <80 mL/mn [OR: 5.4 (1.2–23.7); p = 0.025], and serum creatinine at M6 greater than 130 μmol/L [OR: 19.6 (3.7–102.5); p = 0.0004]. Among all of the predictive factors for post-OLT CRF, only one is modifiable: post-transplant serum creatinine, which could be, to some extent, related to the long-term use of CNIs.     

Acute Renal Failure and Hypercalcemia

Hypercalcemia can result from excessive bone resorption, renal calcium retention, excessive intestinal calcium absorption, or a combination of these conditions. Hypercalcemia may also provoke acute renal failure (ARF) or hypertension, or aggravate the tubular necrosis that is frequently found in cases of ARF. The association of ARF and hypercalcemia was studied retrospectively in eight patients based in the data in their charts. Data are expressed as median and percentile (25th; 75th). Our results show that ARF associated with hypercalcemia was related with comorbidity in all cases (cancer, multiple myeloma, hyperparathyroidism, sarcoidosis, vitamin D intoxication, and leprosy). Maximum median serum creatinine levels were 3.3 mg/dL (2.7, 3.8 mg/dL) before treatment and 1.1 mg/dL (0.9, 1.3 mg/dL) after treatment. Maximum total median serum calcium was 15.9 mg/dL (13.5, 19.8 mg/dL) before treatment and 9.1 mg/dL (8.4, 9.7 mg/dL) after treatment. Maximum median ionized serum calcium was 2.1 mmol/L (1.8, 2.2 mmol/L) before treatment and 1.1 mmol/L (1.0, 1.2 mmol/L) after treatment. Different kinds of treatment induced a rapid fall in serum calcium concentration. All patients were treated with hydration and diuretics, and three patients also received calcitonin. Serum creatinine concentration always fell simultaneously with the decrease in serum calcium in all cases. All patients progressed with nonoliguric renal failure. In conclusion, in ARF, patients are frequently hypocalcemic. Usually, the presence of hypercalcemia associated with ARF is indicative of the presence of comorbidity, as observed in all eight patients studied here. There was an improvement of renal function in all cases as serum calcium levels decreased.     

Acute Ischemia/Reperfusion Injury After Isogeneic Kidney Transplantation Is Mitigated in a Rat Model of Chronic Renal Failure

The influence of chronic renal failure on renal susceptibility to an acute ischemic insult was evaluated. Recipient Lewis rats were randomly assigned to undergo 5/6 nephrectomy (chronic renal failure, CRF) or sham operation (normal renal function, NRF). After 11 weeks, normal kidneys of Lewis donor rats were transplanted in the recipients. The outcome of the isografts was assessed. Filtration capacity of the isografts in the CRF rats was preserved to approximately one-quarter of its normal capacity on the 1st day post-transplantation, whereas it fell to 0 in the NRF rats. This was reflected by a significantly higher increase in serum creatinine in the latter group. The isografts in the CRF rats had a significantly lower degree of acute tubular necrosis and no increase in the number of macrophages and T lymphocytes in the first 24 h in contrast to the NRF rats. Epithelial regeneration and repair started earlier in the CRF group. In conclusion, the present study indicated that CRF blunted ischemia/reperfusion injury of a transplanted kidney, and that its regeneration capacity was certainly not hampered by the presence of chronic uremia. These results will be the basis for studies on modulation of early leukocyte-endothelial interactions resulting from immunological disturbances inherent to the uremic environment.     

Acute Renal Failure Secondary to Fenofibrate Monotherapy-Induced Rhabdomyolysis

Fenofibrate, a fibric acid derivative, is used to treat diabetic dyslipidemia, hypertriglyceridemia, and combined hyperlipidemia alone or in combination with statins. Rhabdomyolysis is defined as a pathological condition of skeletal muscle cell damage leading to the release of toxic intracellular material into the circulation. Its major causes include trauma, ischemia, toxins, metabolic disorders, infections, and drugs. Rhabdomyolysis associated with fenofibrate is extremely rare. In nearly all of the presented cases, there was a predisposing factor for rhabdomyolysis such as diabetes, older age, renal insufficiency, and hypothyroidism. Here, we report a nondiabetic, nonhypothyroidic young female patient without any known prior renal disease presenting with acute renal failure developing after fenofibrate treatment.     

Successful Transplantation of Kidneys from a Donor with Myoglobinuric Acute Renal Failure

The shortage of donor organs is reflected in the growing number of patients on the waiting list for kidney transplantation worldwide. It seems to be sensible to expand the scarce donor pool by the cautious use of extended donor criteria. Kidneys from a 21-year-old deceased donor road traffic accident victim who suffered acute renal failure (ARF) due to myolysis were transplanted. Both transplantations were successful after an initial period of delayed graft function. Therefore, kidneys from deceased donors with ARF should not be excluded for transplantation in general.     

Management and Prevention of Acute Renal Failure in Solid Organ Transplantation

The anion gap in myeloma patients had been well studied. IgG myeloma usually has decreased anion gap, whereas IgA myeloma always presents with normal anion gap. We report an unusual presentation of IgA myeloma with decreased anion gap and renal failure due to superimposing of acetazolamide-related bicarbonate loss.