Evaluation of renal grafts in patients with lupus nephritis as cause of end-stage renal disease

INTRODUCTION: Kidney transplantation is the best option in end-stage renal disease (ESRD). For many years patients affected with lupus nephritis have had poor graft results. However, this has been changing over recent years with the development of new immunosuppressive drugs and a better comprehension of the natural evolution of the entity. METHODS: We studied 20 patients with lupus nephritis who received 22 kidney grafts: 15 women and five men (n = 11) who were treated with cyclosporine or with tacrolimus (n = 11). Secondary immunosuppression included mycophenolate match (MMF) (n = 13) or azathioprine (n = 9). We analyzed human leukocyte antigen, cold ischemia time, acute tubular necrosis, creatinine, cholesterol, triglycerides, glucose, blood pressure, acute rejection episodes, immunosuppression, infections, disease recurrences, as well as graft and patient survival. RESULTS: After a mean cold ischemia time of 22 +/- 4 hours, nine patients displayed delayed graft function of an average duration 9 +/- 4 days. At 36 +/- 35 months nine grafts were lost: two due to acute rejection; five to chronic allograft nephropathy; and two to venous thrombosis. One patient died of hemorrhagic shock. There were five cytomegalovirus infections. Graft survival was dependent on the type of secondary immunosuppression, incidence of acute rejection episodes and occurrence of delayed graft function. CONCLUSIONS: We found no clinical recurrence of lupus nephritis after transplantation and a low incidence of complications, although there was a trend toward thrombosis. The presence of delayed graft function, episodes of acute rejection, and receiving azathioprine instead of MMF as secondary immunosuppression were associated with poorer graft survival.     

多囊肾致终末期肾病的腹膜透析治疗

我们对本院进行腹膜透析（PD）的多囊肾致终末期肾病患者进行了分析，发现患者进行腹膜透析治疗可取得良好的疗效，不会诱发或加重一些相关并发症，相对安全。     

Survival of lupus nephritis patients after renal transplantation in malaga

Background

Studies have shown that the survival of patients with lupus nephritis (LN) who receive a transplant has results similar to those of nondiabetic control subjects.

Objective

The aim of this study was to evaluate the survival of lupus patients who received a transplant at our center, and to determine risk factors for mortality and graft loss.

Methods

This case-control (1:2) study comprised patients with chronic kidney disease secondary to LN who received a kidney transplant (n = 32) in the Malaga area from 1985 to 2010. The controls subjects (n = 64) were matched by age, sex, and transplant period. We analyzed graft and patient survivals and risk factors compared with long-term transplant patients without LN.

Results

No differences were found in the variables analyzed between groups, except for the most frequent cause of donor death, which was almost significant: stroke in LN and traumatic brain injury in control subjects (P = .05). of the whole study sample, 45% lost the graft, primarily owing to chronic kidney disease (53.5%), followed by vascular thrombosis (16.3%); P = .57. Censored graft losses occurred in 63% of the patients transplanted before 2000, whereas it occurred in 20% of those transplanted after 2000 (P < .001). Censored graft survival was similar between the groups throughout the followup, as was patient survival. Cox regression showed that only acute rejection was associated with a 2-fold increased risk of graft loss.

Conclusions

Our lupus transplant population showed no differences in graft or patient survival compared with control subjects. Those patients who received a transplant from 2000 had better results, which may be related to several factors, such as immunosuppression, correction of cardiovascular conditions, or other factors. Risk factors for death and graft loss were similar to the control population.     

Lower-extremity peripheral arterial disease among patients with end-stage renal disease.

Peripheral arterial occlusive disease (PAOD) accounts for significant morbidity and mortality among end-stage renal disease (ESRD) patients but has not been as extensively studied as other kinds of atherosclerotic disease in this population. The current epidemiology and management of PAOD in ESRD patients is here reviewed and target areas for future research are identified. The prevalence of PAOD appears to be much higher among ESRD patients than in the general population. Risk factors for disease among ESRD patients are not well understood but probably include both conventional and dialysis or uremia-associated risk factors. Standard diagnostic techniques used to identify PAOD in the general population may not be as helpful in ESRD patients because many of these tests are inaccurate in the settings of vascular calcification and small-vessel disease. Despite the fact that this is a common disease in ESRD patients, most of these patients are not screened for PAOD. Interventions that have proven effective in the prevention and treatment of PAOD in the general population, such as smoking cessation, preventive foot care, and exercise, have not been systematically applied to ESRD patients. Furthermore, the optimal management of ischemic ulceration and gangrene in ESRD patients is quite controversial, and better algorithms for the prevention and management of PAOD in ESRD patients are needed. In conclusion, PAOD is common in ESRD patients. Future research should identify risk factors for disease in this population, and efforts should be made to develop strategies for the effective prevention and management of limb ischemia in this population.     

Elevated risk of stroke among patients with end-stage renal disease

BACKGROUND: Although end-stage renal disease (ESRD) has been associated with accelerated vascular disease of the cerebral circulation, there are no prior studies that have estimated the risk of hemorrhagic and ischemic stroke among the United States dialysis population relative to the general population. METHODS: We performed a population-based cohort study to compare rates of hospitalized ischemic and hemorrhagic stroke among incident dialysis patients in the United States Renal System database and non-ESRD subjects from the general population identified in the National Hospital Discharge Survey. RESULTS: After adjustment for age, gender, and race, estimated rates of hospitalized stroke were markedly higher for dialysis patients compared to the general population. The age-adjusted relative risk (RR) of stroke among dialysis patients compared to the general population was 6.1 [95% Confidence Interval (95% CI) 5.1, 7.1] for Caucasian males, 4.4 (95% CI 3.3, 5.5) for African American males, 9.7 (95%CI 8.2, 11.2) for Caucasians females and 6.2 (95%CI 4.8, 7.6) for African American females. When considered as separate outcomes, hospitalization rates for hemorrhagic and ischemic stroke were both markedly elevated for subjects treated with dialysis (ischemic, RR = 4.3 to 10.1; hemorrhagic, RR = 4.1 to 6.7). CONCLUSION: Incident dialysis patients are at markedly higher risk for hospitalized stroke when compared to the general population. Although prior public health initiatives have focused primarily on cardiac disease among patients treated with dialysis, our data suggest that new initiatives are needed to control the high risk of stroke in this population.     

Hydration status of patients with end-stage renal disease after kidney transplantation

Gueutin V, Ficheux M, Châtelet V, Lecouf A, Henri P, Hurault de Ligny B, Ryckelynck J‐P, Lobbedez T. Hydration status of patients with end‐stage renal disease after kidney transplantation.
Clin Transplant 2011: 25: E656–E663. © 2011 John Wiley & Sons A/S. Abstract: Background: This study was carried out to estimate the modification of hydration status within the first three months of renal transplantation. Subjects and methods: Fifty patients who underwent a first kidney allograft were prospectively followed for three months after renal transplantation to assess hydration status by bioimpedance spectroscopy. Results: Two hours before the transplant procedure, 10/42 (23.8%) patients were overhydrated. Two days after surgery, 32/40 (80.0%) patients were overhydrated and at three months, 14/27 (51.9%) patients remained fluid‐overloaded. Peritoneal dialysis (PD) patients had a lower hydration status (?0.60 L) than hemodialysis (HD) patients (0.70 L; p < 0.05) and better residual diuresis (41.7 vs. 8.3 mL/h for HD patients, p < 0.01). Compared with patients who had a delayed graft function (DGF) or a slow graft function (SGF), the immediate graft function (IGF) group had a better hydration status before transplantation (p = 0.031). At three months, 12/14 of the overhydrated patients had a creatinine clearance between 30 and 60 mL/min/1.73 m². Conclusion: Patients receiving a first kidney transplant frequently have a hydration disorder. Transplantation is associated with increased hydration status, which seems to persist if DGF or SGF occurs.     

The evaluation of underlying cardiovascular disease among patients with end-stage renal disease

Although coronary artery disease (CAD) is highly prevalent among patients with chronic kidney disease (CKD), interventions proven to reduce cardiovascular disease (CVD) mortality are underutilized in this population of patients. Given the burden of CVD in this population, knowledge of specific diagnostic tests for detection and evaluation of CAD in patients with end-stage renal disease (ESRD) and their correlation with outcomes is imperative for the practicing nephrologist. Studies that examine the use of exercise electrocardiography testing, pharmacologic stress imaging, single-photon emission computed tomographic myocardial perfusion imaging, electron beam computed tomography, and dobutamine stress echocardiography among patients with ESRD are detailed with recommendations for the noninvasive evaluation of CAD in this population.     

Hyperleptinaemia of end-stage renal disease is corrected by renal transplantation

Background: Previous studies have reported that patients with end-stage renal disease (ESRD) have elevated plasma leptin concentrations, but the cause and significance of the elevations are unknown. We studied leptin concentrations in 29 adults undergoing renal transplantation, to determine if restoration of renal function reduced leptin concentrations in ESRD. Methods: Leptin concentrations were measured by radioimmunoassay in plasma specimens collected within 1 week before transplant, 6 days post-transplant, and 60 days post-transplant. Results: Plasma letpin concentrations were higher in both male and female ESRD patients compared with a control population of similar age and body mass index (BMI), but most of the disparity was due to a minority of patients with grossly elevated concentrations; the majority of ESRD patients had normal or near-normal leptin concentrations afer accounting for their adiposity with BMI. Six days after successful renal transplantation, average plasma leptin concentrations decreased to control levels. The grossly elevated pretransplant concentrations in a minority of patients were greatly reduced in relation to BMI, and the reduction persisted to 60 days post-transplant. The decrease in creatinine with transplant did not correlate with the decrease in leptin. Conclusions: These results demonstrate that restoration of renal function in ESRD patients reduces hyperleptinaemia, which provides further evidence of a cause/effect relationship between impaired renal function and abnormal leptin metabolism.      

Kidney transplantation improves arterial stiffness in patients with end-stage renal disease

Background

Cardiovascular disease (CVD) is the leading cause of mortality among the patients with end-stage renal disease (ESRD). Arterial stiffness is a well-accepted predictor of cardiovascular mortality in general population and ESRD patients. The aim of this study was to compare the change of arterial stiffness in kidney transplant recipients (KTRs) and ESRD patients, and further investigate the impact of kidney transplantation (KT) on arterial stiffness.

Methods

A total of 138 maintenance hemodialysis patients, 198 KTRs and 75 healthy volunteers were enrolled in this study. The carotid-femoral pulse wave velocity (CF-PWV) and carotid-radial PWV (CR-PWV) were determined, and the correlations of PWV with biochemical parameters were analyzed.

Results

CF-PWV was highest in the maintenance hemodialysis patients, but similar between KTRs and healthy volunteers. Bivariate correlation analysis among KTRs demonstrated that CF-PWV was positively correlated with high level of peripheral diastolic blood pressure, pulse pressure, mean artery pressure, BUN and HDL, but negatively correlated with albumin. Univariate polytomous logistic regression analysis showed that age, BMI, systolic blood pressure, pulse pressure, length of KT and BUN were associated with the increase of CF-PWV value.

Conclusions

Aortic stiffness could be improved after KT. Meanwhile, age, BMI, systolic blood pressure, pulse pressure, length of KT and BUN were independent predictors of the increase of CF-PWV in KTRs.

     

Mortality caused by sepsis in patients with end-stage renal disease compared with the general population

BACKGROUND: In the United States, infection is second to cardiovascular disease as the leading cause of death in patients with end-stage renal disease (ESRD), and septicemia accounts for more than 75% of this category. This increased susceptibility to infections is partly due to uremia, old age, and comorbid conditions. Although it is intuitive to believe that mortality caused by sepsis may be higher in patients with ESRD compared with the general population (GP), no such data are currently available. METHODS: We compared annual mortality rates caused by sepsis in patients with ESRD (U.S. Health Care Financing Administration 2746 death notification form) with those in the GP (death certificate). Data were abstracted from the U.S. Renal Data System (1994 through 1996 Special Data request) and the National Center for Health Statistics. Data were stratified by age, gender, race, and diabetes mellitus (DM). Sensitivity analyses were performed to account for potential limitations of the data sources. RESULTS: Overall, the annual percentage mortality secondary to sepsis was approximately 100- to 300-fold higher in dialysis patients and 20-fold higher in renal transplant recipients (RTRs) compared with the GP. Mortality caused by sepsis was higher among diabetic patients across all populations. After stratification for age, differences between groups decreased but retained their magnitude. These findings remained robust despite a wide range of sensitivity analyses. Indeed, mortality secondary to sepsis remained approximately 50-fold higher in dialysis patients compared with the GP, using multiple cause-of-death analyses; was approximately 50-fold higher in diabetic patients with ESRD compared with diabetic patients in the GP, when accounting for underreporting of DM on death certificates in the GP; and was approximately 30-fold higher in RTRs compared with the GP, when accounting for the incomplete ascertainment of cause of death among RTRs. Furthermore, despite assignment of primary cause-of-death to major organ infections in the GP, annual mortality secondary to sepsis remained 30- to 45-fold higher in the dialysis population. CONCLUSIONS: Patients with ESRD treated by dialysis have higher annual mortality rates caused by sepsis compared with the GP, even after stratification for age, race, and DM. Consequently, this patient population should be considered at high-risk for the development of lethal sepsis.     

Increased risk of hip fracture among patients with end-stage renal disease

BACKGROUND: Although patients with end-stage renal disease (ESRD) are at increased risk for bone loss, the risk of hip fracture in this population is not known. We compared the risk of hip fracture among dialysis patients with the general population. METHODS: We used data from the United States Renal Data System (USRDS) to identify all new Caucasian dialysis patients who began dialysis between January 1, 1989, and December 31, 1996. All hip fractures occurring during this time period were ascertained. The observed number of hip fractures was compared with the expected number based on the experience of residents of Olmstead County (MN, USA). Standardized incidence ratios were calculated as the ratio between observed and expected. The risk attributable to ESRD was calculated as the difference between the observed and expected rate of hip fracture per 1000 person-years. RESULTS: The number of dialysis patients was 326,464 (55.9% male and 44.1% female). There were 6542 hip fractures observed during the follow-up period of 643, 831 patient years. The overall incidence of hip fracture was 7.45 per 1000 person years for males and 13.63 per 1000 person years for females. The overall relative risk for hip fracture was 4.44 (95% CI, 4.16 to 4.75) for male dialysis patients and 4.40 (95% CI, 4.17 to 4.64) for female dialysis patients compared with people of the same sex in the general population. While the age-specific relative risk of hip fracture was highest in the youngest age groups, the added risks of fracture associated with dialysis rose steadily with increasing age. The relative risk of hip fracture increased as time since first dialysis increased. CONCLUSIONS: The overall risk of hip fracture among Caucasian patients with ESRD is considerably higher than in the general population, independent of age and gender.     

Risk factors for hip fracture among patients with end-stage renal disease

BACKGROUND: Although bone disease is well described among end-stage renal disease (ESRD) patients, little attention has been paid to the occurrence of fracture. We sought to identify factors that are associated with hip fracture among ESRD patients. METHODS: Data from patients who participated in the United States Renal Data System Dialysis Morbidity and Mortality Study Wave 1 were used for this study. Hip fractures occurring among these patients between 1993 and 1996 were identified from Medicare claims data available from the United States Renal Data System. Cox proportional hazards models were used to estimate the risk of hip fracture associated with demographic and medical variables. RESULTS: Of the 4952 patients included in this analysis, 103 sustained a hip fracture. In the multivariate analysis, age (per increasing decade, RR = 1.40, 95% CI 1.20, 1.64), female gender (RR = 2.26, 95% CI 1.48, 3.44), race (blacks compared with whites, RR = 0.58, 95% CI 0.37, 0.91), body mass index (per 1 unit increase, RR 0.89, 95% CI 0.86, 0.93), and the presence of peripheral vascular disease (RR 1.94, 95% CI 1.29, 2.92) were independently associated with hip fracture. Serum intact parathyroid hormone (iPTH), aluminum, diabetes, and bicarbonate levels did not appreciably influence the risk of hip fracture. CONCLUSIONS: Demographic and other characteristics that predict risk of hip fracture in the population at large also do so in ESRD patients. However, we could identify no characteristics of ESRD or its treatment that were independently related to hip fracture incidence.     

Vitamin D receptor genetic variants among patients with end-stage renal disease

Back ground and objectives: Vitamin D receptor (VDR) gene polymorphism is reported to be associated with end-stage renal disease (ESRD). We have investigated the potential role of VDR gene polymorphisms among ESRD. Design and methods: The influence of VDR gene polymorphism in 258 ESRD patients comprising of 226 (87.5%) male and 32 (12.5%) females was investigated in this study. We compared ESRD patients with 569 healthy controls. The distribution of male and female among controls was 485 (85.3%) males and 84 (14.7%) females. This polymorphism was studied by using polymerase chain reaction (PCR). The product was digested by using restriction enzymes Apa1, Taq1, Fok1, and Bsm1. Results: We observed a significant difference in the genotype frequencies of the Apa1-aa (p = 0.0001, OR = 2.1, 95% CI = 1.45–3.08), Fok1-ff (p = 0.001, OR = 3.44, 95% CI = 1.76–6.76), and Bsm1-BB (p = 0.0004, OR = 6.8, 95% CI = 2.2–21.58). At allelic level B allele of Bsm1 was significantly different among ESRD patients as compared to controls (p = 0.0001). The combined analysis revealed that ESRD patients with Fok1 and Bsm1 polymorphism were at increased risk of 4.33-fold. The haplotype analysis revealed individuals with a/t/F/b haplotype were at greater risk of 11.0-fold (95% CI = 1.38–87.69). The serum calcium levels were significantly higher (p = 0.001) in Bsm1 “BB” genotype. Interpretations and conclusions: Bsm1 and Fok1 gene polymorphism of VDR gene were associated with ESRD among north Indians.     

Risk factors for incident stroke among patients with end-stage renal disease

Although patients with ESRD experience markedly higher rates of stroke, no studies in the US have identified risk factors associated with stroke in this population. It was hypothesized that black race, malnutrition, and elevated BP would be associated with the risk of stroke among patients with ESRD. Data from the United States Renal Data Systems were used. Adult Medicare-insured hemodialysis and peritoneal dialysis patients without a history of stroke or transient ischemic attack (TIA) were considered for analysis. The primary outcome was hospitalized or fatal stroke. Cox proportional hazards models were used to determine the associations between the primary predictor variables and stroke. The rate of incident stroke was 33/1,000 person-years in the study sample. After adjustment for age and other patient characteristics, three markers of malnutrition were associated with the risk of stroke-serum albumin (per 1 g/dl decrease, hazard ratio [HR] = 1.43), height-adjusted body weight (per 25% decrease, HR = 1.09), and a subjective assessment of undernourishment (HR = 1.27)-as was higher mean BP (per 10 mmHg, HR = 1.11). The association between black race varied by cardiac disease status, with blacks estimated to be at lower risk than whites among individuals with cardiac disease (HR = 0.74), but at higher risk among individuals without cardiac disease (HR = 1.24). This study confirms the extraordinarily high rates of stroke in ESRD patients on dialysis and identifies high mean BP and malnutrition as potentially modifiable risk factors. The association between black race and stroke differs by cardiac disease status; the reasons for this differing effect of race deserve further investigation.     

A case of recurrent lupus nephritis after renal transplantation

A case of recurrent lupus nephritis in an 18-year-old girl with a renal transplant is described. Serological titer of ANA and Anti-DNA were low prior to renal transplantation following pulse therapy with methylpredonisolone and high dose oral predonisolone. A living related transplantation was performed after 6 months of hemodialysis. Maintenance immunosuppressive therapy consisted of predonisolone, mizoribine and cyclophosphamide. Graft function remained stable for one and half years after transplantation. Clinical recurrence was heralded by the development of proteinuria. If the serologic activities had been analyzed, the increase in ANA and Anti-DNA titers a few months before the onset of proteinuria might have predicted a possible histopathological recurrence. Fortunately, however, despite the histological and clinical recurrence of systemic lupus erythematosus, her renal allograft has continued to function fairly well.     

Outcomes of renal transplantation after end-stage renal disease due to diabetic nephropathy: a single-center experience

Background

Diabetic nephropathy is the most common cause of end-stage renal disease (ESRD) worldwide. However, data on renal transplantation outcomes in diabetic nephropathy among Japanese remain inadequate. This retrospective study was conducted to summarize our renal transplantation experience in diabetic ESRD patients.

Methods

We retrospectively studied 462 patients who underwent kidney transplantation between 1989 and 2011, including 23 with diabetic ESRD (DM group) and 439 with nondiabetic ESRD (NDM group). We compared demographic and clinical variables between these 2 groups.

Results

Mean age was higher in the DM group (48.0 vs 38.2 years; P < .001), and there was no significant difference in gender or donor source. The 1-, 3-, and 5-year graft survival rates in the DM and NDM groups were 100% vs 98.3% (ns), 82.4% vs 94.9% (P < .05), and 66.7% vs 90.3% (P < .01), respectively. The 1-, 3-, and 5-year patient survival rates were 95.0% vs 96.5% (ns), 88.2% vs 95.2% (ns), and 84.6% vs 92.9% (ns), respectively. One patient (4.3%) in the DM group and 6 (1.4%) in the NDM group died from cardiovascular disease during the follow-up period (ns). The incidence of rejection did not differ between the DM and NDM groups. There were no significant differences in the total infection rate or the urinary tract infection rate.

Conclusions

Renal transplantation in diabetic ESRD patients yields good results in terms of patient survival and complications, suggesting that renal transplantation can be performed in these patients and should become a more established treatment option.