Incidence and Management of Kaposi Sarcoma in Renal Transplant Recipients: The Greek Experience

ObjectiveOne of the most common malignancies in kidney transplant recipients is Kaposi sarcoma. The incidence of Kaposi sarcoma, which develops after renal transplantation, is 400–500 times higher than that in the general population. The aims of this study were to review the experience with Kaposi sarcoma in the highest-volume transplantation Unit in Greece and to analyze clinical characteristics and response to treatment, with respect to both the patients' survival and the renal graft function.Materials and MethodsThe records of 2008 renal graft recipients between March 1983 and December 2012 were retrospectively reviewed. Kaposi sarcoma was diagnosed based on clinical, laboratory, radiological, endoscopic, and histopathologic examinations. The disease was staged according to the classification of Al-Khader et al.ResultsThe prevalence of Kaposi sarcoma was 1.2% in our renal transplant population. Of these, 1006 recipients underwent living-donor renal transplantation, whereas 1002 received their graft from deceased donors. Post-transplantation malignancy developed in 153 patients, among which, Kaposi sarcoma has been found in 24 cases. Of the 24 cases of Kaposi sarcoma, lesions were mainly cutaneous in 14 cases, visceral and cutaneous in 8, and concomitant visceral and lymph node involvement was observed in 2 patients. With regard to the final outcome, 20 patients (83.3%) showed remission of the disease, whereas 4 patients with visceral involvement (16.6%) did not respond to chemotherapy and discontinuation of immunosuppression and died. Moreover, 8 deaths occurred due to apparently unrelated causes.ConclusionsKaposi sarcoma is an important part (15.7%) of all post-transplantation neoplasias in our series. Furthermore, our findings confirmed the previously described close association between human herpesvirus-8 and post-transplantation Kaposi sarcoma. Reduction of immunosuppression or discontinuation of calcineurin inhibitors results in remission of the disease in most of the cases. Prognosis in patients with Kaposi sarcoma limited to the skin is favorable, whereas visceral involvement is associated with high mortality.     

Factors Predicting Long-term Graft Survival after Kidney Transplantation: Multicenter Study in Japan

A multicenter retrospective study was conducted in 936 living donor kidney transplant recipients treated with cyclosporine (CsA) or tacrolimus (FK) from April 1982. The influences of acute rejection, hyperlipidemia, and hypertension were estimated by Kaplan-Meiers analysis and Wilcoxons analysis. Of 916 recipients, 532 (58.1%) had acute rejections. The 5- and 10-year graft survival rates in the recipients with acute rejection were 75.2% and 55.2%, respectively. The corresponding rates of the recipients without acute rejection were 80.2% and 70.6%, respectively. The graft survival rate was worse in recipients with late-phase rejection and multiple rejection episodes (p < 0.00006). Of 451 recipients, 176 (39.0%) had hypercholesterolemia 3 years after kidney transplantation. The 5- and 10-year graft survival rates in the recipients with hypercholesterolemia were 88.7% and 68.7%, respectively. Those of the recipients without hypercholesterolemia were 95.2% and 83.9%, respectively. The graft survival rate in the recipients with hypercholesterolemia was lower than that in the recipients without hypercholesterolemia (p = 0.003). Of 323 recipients, 123 (38.1%) had hypertriglyceridemia 3 years after kidney transplantation. The 5- and 10-year graft survival rates in the recipients with hypertriglyceridemia were 93.7% and 80.5%, respectively. Those in the recipients without hypertriglyceridemia were 95.1% and 86.5%, respectively. The graft survival rate in the recipients with hypertriglyceridemia was lower than that in the recipients without hypertriglyceridemia (p = 0.371). Of 367 recipients, 151 (41.1%) had systolic hypertension 3 years after kidney transplantation. The 5- and 10-year graft survival rates in the recipients with hypertension were 85.6% and 64.7%, respectively. Those of the recipients without hypertension were 95.6% and 83.8%, respectively. The graft survival rate in the recipients with hypertension was lower than that in the recipients without hypertension (p < 0.001). Acute rejection, hyperlipidemia (hypercholesterolemia and hypertriglyceridemia), and hypertension are predictive factors for long-term graft survival. Especially the onset time, number of rejections, and efficacy of treatment for acute rejection would have a significant influence on long-term graft survival.     

The Impact of Preexisting or Acquired Kaposi Sarcoma Herpesvirus Infection in Kidney Transplant Recipients on Morbidity and Survival

The impact of preexisting or acquired Kaposi sarcoma herpesvirus (KSHV) infection in kidney transplant recipients was evaluated in a prospective study. Serum collected from kidney donors and recipients before transplantation were tested for antibodies against KSHV latent nuclear antigen. Three groups of recipients were defined: group A (KSHV+), group B (KSHV−, KSHV+ donor) and group C (donor and recipient KSHV−). Blood was collected from recipients, every 3 months for 3 years, for KSHV viremia (groups A and B), quantitative (group A) and qualitative serology (group B). Data of group C recipients were extracted from a French database. The prevalence of KSHV antibodies was 1.1% in donors and 3.2% in recipients. There were respectively 161, 64 and 4744 recipients in groups A, B and C.
In group A, 13% developed Kaposi's sarcoma (KS). Age >53.5 years (p = 0.025) and black skin (p = 0.0054) were associated with KS development. In group B, three recipients developed clinical manifestations related to KSHV infection. There was no difference in terms of survival and graft loss between the three groups. In conclusion, although kidney recipients should be aware of the additional risk of KSHV morbidity, KSHV+ recipients should not be systematically excluded from kidney transplantation.     

Characteristics of Liver Transplantation in Argentina: A Multicenter Study

Introduction

There is a lack of information regarding outcomes after liver transplant in Latin America.

Identifying High Risk Groups and Quantifying Absolute Risk of Cancer After Kidney Transplantation: A Cohort Study of 15 183 Recipients

Transplant recipients have increased cancer risk, but data on risk variation across different patient groups are sparse. Rates and standardized rate ratios (SRR) of cancer (all sites, excluding nonmelanocytic skin and lip cancer) compared to the general population were calculated, using Australia and New Zealand Dialysis and Transplant Registry data. Within the transplant population, risk factors were identified (hazard ratios: HR; 95% CI) and absolute risk estimated for recipient groups. A total of 1642 (10.8%) of 15 183 recipients developed cancer. Risk was inversely related to age (SRR 15-30 children, 2 if >65 years). Females aged 25-29 had rates equivalent to women aged 55-59 from the general population. Age trend for lymphoma, colorectal and breast risk was similar; melanoma showed less variability across ages, prostate showed no risk increase. Within the transplanted population, risk was affected by age differently for each sex (p = 0.007), elevated by prior malignancy (HR 1.40; 1.03-1.89), white race (HR 1.36; 1.12-1.89), but reduced by diabetic end-stage kidney disease (ESKD) (HR 0.67; 0.50-0.89). Cancer rates in kidney recipients are similar to nontransplanted people 20-30 years older, but absolute risk differs across patient groups. Men aged 45-54 surviving 10 years have cancer risks varying from 1 in 13 (non-white, no prior cancer, diabetic ESKD) to 1 in 5 (white, prior cancer, other ESKD).     

Acute Femoral Neuropathy Following Renal Transplantation: A Retrospective, Multicenter Study in China

Background

We investigated the relationship between the mode and duration of iliac artery anastomosis and acute femoral neuropathy (AFN).

Methods

A retrospective analysis was performed for 83 AFN cases from 6 transplantation centers in China. The incidence and nature of dysfunction of AFN were classified based upon the duration of iliac arterial anastomosis. No prisoners were used, and no organs from prisoners were used to obtain the data.

Results

The incidence of AFN was 3.6% (53/1,449) in internal iliac anastomosis (group 1), 3.1% (11/346) in external iliac anastomosis (group 2) (P > .05 vs. group 1), and was 54.2% (19/35) in internal iliac ligation with external iliac anastomosis (group 3 P < .01 vs. groups 1 and 2). In group 1, the duration of the arterial anastomosis was ≤20 minutes in 1 case (1.9%), and >20 minutes in 52 cases (98.1%). In group 2, the duration of arterial anastomosis was ≤20 minutes in 1 case (9.0%) and >20 minutes in 10 cases (91%). In group 3, the duration of the arterial anastomosis was >20 minutes in all cases; 20 cases showed injury to the iliolumbar or deep iliac circumflex artery.

Conclusion

The incidence of AFN was associated with the selection of iliac arteries, the duration of the arterial anastomosis, and an injury to the iliolumbar or deep iliac circumflex artery.     

High Prevalence of Obesity in Thai Renal Transplant Recipients: A Multicenter Study

Background

Obesity is a risk factor for cardiovascular disease and cardiovascular mortality in renal transplant recipients (RTRs). There are limited studies of prevalence and associated factors of obesity in Asian RTRs.

Methods

A cross-sectional study was conducted from July to December 2012 in 4 kidney transplant centers in Bangkok, Thailand. Obesity was diagnosed based on the International Obesity Taskforce-proposed classification. At risk of obesity, obese I, and obese II were defined as having a body mass index (BMI) of 23–24.9 kg/m², 25–29.9 kg/m², and ≥30 kg/m², respectively.

Results

Of 263 recipients studied, 50 (19.0%), 70 (26.6%), and 17 (6.5%) were at risk of obesity, obese I, and obese II, respectively. The prevalence of obesity was 12.6% in the 1st year, was 28.6% in the first 3 years, and rose to 39.7% after 3 years after transplantation. Age (odds ratio [OR], 1.04; 95% CI, 1.01–1.07), systolic blood pressure ≥130/85 mm Hg (OR, 2.82; 95% CI, 1.51–5.26), number of antihypertensive medications (OR, 1.99; 95% CI, 1.42–2.79), fasting plasma glucose (OR, 1.03; 95% CI, 1.01–1.04,) and high-density lipoprotein (HDL) cholesterol (OR, 0.96; 95% CI, 0.94–0.98) were associated with obesity. Compared with 100 RTRs with normal BMI, obese patients tended to have higher prevalence of chronic kidney disease (OR, 1.59; 95% CI, 0.89–2.83).

Conclusions

The study demonstrates the high prevalence of obesity in Thai RTRs especially after 3 years after transplantation. Obesity is more prevalent with advanced age and variable components of metabolic syndrome in the RTR population. Obese RTRs had significantly higher blood pressure and required more antihypertensive medication when compared with RTRs with normal BMI.     

Solid Organ Transplantation After Allogeneic Hematopoietic Stem Cell Transplantation: A Retrospective,Multicenter Study of the EBMT

To analyze the outcome of solid organ transplantation (SOT) in patients who had undergone allogeneic hematopoietic stem cell transplantation (HSCT), a questionnaire survey was carried out within 107 European Group of Blood and Marrow Transplantation centers. This study covered HSCT between 1984 and 2007 in Europe. Forty‐five SOT in 40 patients were reported. Fifteen liver, 15 renal, 13 lung, 1 heart and 1 skin transplantations were performed in 28 centers. Overall survival (OS) of patients after SOT was 78% at 5 years (95% confidence interval [CI], 64% to 92%). OS at 5 years was 100% for renal, 71% (95% CI, 46% to 96%) for liver and 63% (95% CI, 23% to 100%) for lung transplant recipients. The 2‐year‐incidence of SOT failure was 20% (95% CI, 4% to 36%) in patients with graft‐versus‐host disease (GvHD) and 7% (95% CI, 0% to 21%) in patients without GvHD before SOT. The relapse incidence for underlying malignant diseases was 4% at 5 years (95% CI, 0% to 12%). In summary, this study shows that selected patients receiving SOT after HSCT have a remarkably good overall and organ survival. These data indicate that SOT should be considered in selected patients with single organ failure after HSCT.     

Incidence of Primary and Second Cancers in Renal Transplant Recipients: A Multicenter Cohort Study

Limited data exist about cancer prognosis and the development of second cancers in renal transplant recipients. In a retrospective cohort study on 3537 patients incidence rates of the first and, if any, of a second cancer, and standardized incidence ratios [SIR (95% CI)] were computed. Two hundred and sixty‐three (7.5%) patients developed a NMSC, and 253 (7.2%) another type of cancer after a median follow‐up of 6.5 and 9.0 years, respectively. A statistically significant excess risk, if compared to an age‐ and sex‐matched reference general population, was observed for Kaposi sarcoma and NMSC, followed by non‐Hodgkin lymphoma and carcinoma of cervix uteri; a small number of unusual cancers such as tumors of the salivary glands, small intestine and thyroid also were detected at a level worthy of additional scrutiny. Ten‐year survival rate of all noncutaneous cancers was 71.3%, with lower rates for lung carcinoma and non‐Hodgkin lymphoma (0% and 41.7%, respectively). Patients with NMSC had an increased risk of developing a second NMSC [SIR 8.3 (7.0–10.0)], and patients with a primary noncutaneous cancer had increased risk of developing a second noncutaneous cancer [SIR 1.8 (1.2–2.8)], if compared to the whole cohort. Our study underscore that the high risk of primary and second cancer in renal transplant recipients, including unusual cancers.     

Health Locus of Control and Health Behaviors in Organ Transplant Recipients: A Multicenter Study

BackgroundAdherence to health behaviors and to immunosuppressant medications are variables among heart transplant recipients with potential life-threatening outcomes. It is understood that patients with psychosocial barriers are at increased risk of poor outcomes due to various factors. Health locus of control includes any activity that can be done to prevent health problems. Health locus of control is defined as individual beliefs based on past experiences in health issues and having internal and or external control. The literature suggests that patients with a strong internal locus of control have a sense of responsibility for their health behaviors.PurposeTo investigate the effect of the health locus of control on the level of self-reported health behaviors among organ transplant recipients.Materials and Methods. A cross-sectional design was used for this study. The study group comprises 222 individuals after heart, kidney, lung, and liver transplantation. The following standardized tools were used: The Multidimensional Health Locus of Control, The Health Behavior Inventory, Morisky Medication-Taking Adherence Scale 4-item. Data were analyzed using IBM SPSS. The level of significance for the statistical test was set at 0.05.Results. Powerful Others scored the highest among the 3 Health Locus of Control scales in heart, kidney, and liver recipients. Participants paid little attention to Healthy eating habits; however, the total score of the Health Behavior Inventory was high (91.68-94.40). There was a difference between the kind of transplant and center for 4 aspects of health behavior. Higher scores of The Multidimensional Health Locus of Control were associated with higher scores of Health Behaviors and level of adherence. Greater Powerful Others and Internal Health Locus of control predict higher health behaviors explaining 42 % of the variance.ConclusionsThe intensification of declared health behaviors is high. However, in educating posttransplant patients, attention should be paid to strengthening proper healthy eating habits. Associations between health locus of control dimensions and health behavior have been shown among transplant recipients. The health locus of control significantly predicts the intensity of health behaviors. these findings support the need to consider health control beliefs while designing preventive strategies in this group of patients.     

Kaposi Sarcoma of the Medial Foot in an MSM,HIV-Negative Man: A Fifth Clinical Variant

Kaposi sarcoma (KS) is a low-grade vascular neoplasm with four well-documented clinical types: classic, African (endemic), acquired immunodeficiency syndrome (AIDS)-associated (epidemic), and iatrogenic, as well as a fifth recently described variant, men having sex with men (MSM) without human immunodeficiency virus (HIV) infection. Often distinguishable on clinical exam, KS lesions are typically found on the skin and mucosa of immunocompromised individuals, though numerous published reports have demonstrated the ability of KS to present in immunocompetent individuals. Here, we present the case of a 66-year-old, HIV-negative MSM with violaceous, non-blanching macules and patches of the medial foot referred to dermatology by his primary care physician. Histopathologic analysis revealed Kaposi sarcoma. Although this patient engaged in same-sex sexual behaviors, his HIV-negative status and otherwise lack of immunocompromise would deter many clinicians from suspecting a diagnosis of KS. Despite therapy, disease prognosis is often dependent upon stage at diagnosis. Therefore, it is important that every clinician understand the cutaneous findings associated with KS and be aware of the higher rates of KS even in HIV-seronegative MSM to facilitate prompt diagnosis and immediate treatment of this high-risk population.     

Pneumonia After Lung Transplantation in the Resitra Cohort: A Multicenter Prospective Study

The aim of the present study is to evaluate the epidemiology, etiology and prognosis of pneumonia in lung transplant (LT) recipients. This is a prospective, multicenter study of a consecutive cohort of LT recipients in Spain. From September 2003 to November 2005, 85 episodes of pneumonia in 236 LT recipients were included (incidence 72 episodes per 100 LT/year). Bacterial pneumonia (82.7%) was more frequent than fungal (14%) and viral pneumonia (10.4%). The most frequent microorganisms in each etiological group were Pseudomonas aeruginosa (n = 14, 24.6%), CMV (n = 6, 10.4%) and Aspergillus spp. (n = 5, 8.8%). Incidence of Aspergillus spp. and CMV pneumonia is lower than previously reported, probably due to the spread of universal prophylaxis. Pneumonia caused by viruses appeared significantly later than pneumonia due to gram-negative bacilli, fungi and those without known etiology (p < 0.01, p = 0.03 and p = 0.02, respectively). The routine use of ganciclovir has changed the natural history of CMV infection, so that pneumonia appears later, once prophylaxis is suspended. The probability of survival during the first year of follow-up was significantly higher in the multivariate analysis in LT recipients who did not have a pneumonia episode compared with those that had at least one episode (p < 0.01).     

Impact of Early or Delayed Cyclosporine on Delayed Graft Function in Renal Transplant Recipients: A Randomized, Multicenter Study

The benefit of delayed cyclosporine in reducing risk of delayed graft function (DGF) is not clearly established. This study compared early vs. delayed cyclosporine microemulsion (CsA-ME) in de novo renal transplant patients. Patients were randomized to early (day 0, n = 97) or delayed (day 6, n = 100) CsA-ME at an initial dose of 8 mg/kg/day with dose adjusted according to C₂ level. All patients received enteric-coated mycophenolate sodium (EC-MPS), steroids and an anti-interleukin-2 receptor antibody. In both groups, 33% of patients were at high risk of DGF; 26 patients (26.8%) in the early CsA-ME group and 23 patients (23.0%) in the delayed CsA-ME group experienced DGF (n.s.). Renal function at 3 months was comparable (creatinine clearance 51.1mL/min with early CsA-ME and 53.8 mL/min with delayed CsA-ME), and remained similar to 12 months. Treatment failure, defined as biopsy-proven acute rejection, graft loss or death, did not differ significantly at 12 months (23.7% with early CsA-ME vs. 29.0% with delayed CsA-ME). Biopsy-proven acute rejection occurred in 15.5% of early CsA-ME and 26.5% of delayed CsA-ME patients (n.s.). Both regimens were well tolerated. These data suggest that early or delayed introduction of CsA-ME results in similar renal function in renal transplant patients regardless of DGF risk level.