Renal transplantation in old recipients from expanded criteria donors selected by kidney biopsy

Background

In Spain, the number of ideal kidney transplant donors has fallen, with at the same time an increase in the number of older recipients on the waiting list.

Aim

To analyze the results of expanded criteria cadaveric donor kidney transplants into older recipients using grafts selected by kidney biopsy.

Patients and methods

We studied 360 kidney transplant recipients who had been followed to December 2009: 180 in the study group and 180 in a control group composed of younger patients who received grafts from non-expanded criteria donors between 1999 and 2006. A paraffin-embedded kidney biopsy was evaluated by the percentages of sclerosed glomeruli, arteriolar hyalinosis, intimal wall thickening, interstitial fibrosis, and tubular atrophy.

Results

Significant differences were observed in donor age (63.50 ± 5.46 vs 31.90 ± 13.29 years; P < .001) and recipient age (58.40 ± 8.80 vs 40.71 ± 13.23 years; P < .001). Donor renal function was significantly worse among the expanded criteria group (90.80 vs 108.11 mL/min/1.73 m²; P = .006), remaining so over time in the recipient (at 1 year: 42.08 vs 63.71 [P < .001]; at 3 years: 41.25 vs 62.31 [P < .001], and at 7 years: 38.17 vs 64.18 [P < .001]). Censored 7-year graft survivals were 73% versus 87% (P < .001) with similar patient survivals (90.5% vs 95%; P = .39).

Conclusions

Selection of expanded criteria donors by kidney biopsy resulted in good renal function as well as graft and patient survivals at 7 years in older recipients.     

Elevated serum gamma-glutamyltransferase and hypomagnesemia are not related with new-onset diabetes after transplantation

Background

New-onset diabetes mellitus after transplantation (NODAT) contributes to the risk of cardiovascular disease (CVD) and infection, reducing graft and patient survival in kidney transplant recipients. To reduce CVD and improve outcomes of kidney transplant recipients, it is of great interest to more precisely elucidate the risk factors that contribute to the development of NODAT. A previous study reported that hypomagnesemia is an independent predictor of NODAT. Elevated gamma-glutamyltransferase (GGT) activity increases the risk of incident type 2 diabetes in the general population. The objective of this study was to determine whether magnesium (Mg) and GGT were risk factors for NODAT among our population of kidney transplant recipients.

Methods

We retrospectively analyzed 205 non-previously diabetic kidney transplant recipients. GGT was measured before transplantation as well as at months 1, 2, and 12. Mg was measured at months 1, 2, and 12. NODAT was defined at month 12 and at the end of follow-up according to the “2003 international consensus guidelines.”

Results

Although 36 patients (17.5%) developed NODAT at month 12, 55 patients (26.8%) displayed it at the end of follow-up. We did not observe any significant difference, either in mean Mg (month 1, 1.73 ± 0.24 vs 1.75 ± 0.30 [P = .824]; month 2, 1.71 ± 0.22 vs 1.68 ± 0.26 [P = .565]; month 12, 1.77 ± 0.27 vs 1.80 ± 0.24 [P = .596]) or GGT values (pretransplantation, 32 ± 27 vs 33 ± 85 [P = .866]; month 1:39 ± 24 vs 48 ± 70 [P = .452]; month 2, 53 ± 96 vs 48 ± 83 [P = .739]; month 12, 40 ± 37 vs 38 ± 53 [P = .830]) between NODAT and non-NODAT patients at month 12 or at the end of follow-up.

Conclusion

Hypomagnesemia and high GGT activity were not risk factors for NODAT development in kidney transplant recipients.     

A switch from conventional twice-daily tacrolimus to once-daily extended-release tacrolimus in stable kidney transplant recipients

Background

Extended-release tacrolimus (TAC-ER) was developed to provide a more convenient treatment compliance and improve safety by avoiding toxic peak levels. We prospectively evaluated the safety and effectiveness of a 1:1 dose switch from twice-daily tacrolimus to once-daily TAC-ER in stable kidney transplant recipients and assessed their satisfaction with the regimen.

Patients and methods

Tacrolimus was switched to TAC-ER (1:1 dose) in 12 kidney transplant recipients with stable renal function from March 2010 to August 2011. The posttransplantation follow-up period was 7.6 ± 4.3 years (range 1.5-13.2 years). No patient had diabetes mellitus in this group. We evaluated the tacrolimus trough levels, serum creatinine, potassium, glucose, glycohemoglobin (HbA1c), and urine protein concentrations once a month from 6 months prior to 1 year after switching. A satisfaction survey for TAC-ER treatment was performed 3 months after the switch. The questionnaire included administration compliance questions such as “forget to take less often,” “easy to carry,” “easy to store,” and “general satisfaction.”

Results

After the switch to TAC-ER, we observed a quick and sustained 25% decrease in TAC trough levels from 4.8 ± 1.0 to 3.6 ± 0.8 (P = .0002). No significant differences in serum creatinine, potassium, glucose, HbA1c, or urine protein concentration were observed during the 14.6 ± 2.6 months' follow-up period. No recipient experienced acute rejection. The satisfaction survey demonstrated that the stable kidney transplant recipients were satisfied with the switch.

Conclusions

A switch from twice-daily tacrolimus to once-daily TAC-ER (1:1 dose) was safe and effective. TAC-ER can improve treatment compliance in stable kidney transplant recipients.     

Klebsiella pneumoniae infection in solid organ transplant recipients: epidemiology and antibiotic resistance

Background

Klebsiella pneumoniae is a well recognized source of nosocomial infection in solid-organ transplant (SOT) recipients. It is also the most common species capable of producing extended-spectrum β-lactamases (ESBL). Its treatment can therefore be a challenge owing to antibiotic resistance.

Methods

Prospective study of all transplant recipients from July 2003 to December 2007 at our center. Klebsiellla pneumoniae infectious events were recorded.

Results

A total of 1,057 patients were enrolled, 509 (48%) renal, 360 (34%) liver, 78 (7%) heart, and 110 (10%) double transplants. We diagnosed 116 episodes of K. pneumoniae infection in 92 patients during the study period, of which 62 were ESBL-producing strains (53%). Thirty-four episodes had bacteremia (29%), 15 of which were caused by ESBL-producing strains. There were no strains of K. pneumoniae producing carbapanemase (KPC). Forty-seven percent of the episodes occurred during the first month after transplantation. The incidence of infection by type of transplant was: renal 11%, liver 7%, cardiac 5%, and double transplant 6% (P = .075). The major sites of infection were urinary tract 72%, surgical wound 5%, intraabdominal 6%, catheter 5%, lung 1%, bloodstream 1%, and others 2%. ESBL-producing K. pneumoniae strains were more common in renal transplant patients (P = .035) and in those who required posttransplant dialysis (P = .022). There were 4 deaths in the first 30 days after the isolation of K. pneumoniae, and 3 of these cases were infections caused by ESBL-producing strains.

Conclusions

There was a high incidence of ESBL-producing K. pneumoniae infections in SOT recipients and renal transplant recipients, and those who required dialysis were more likely to develop infection by this strain. No KPC-producing organisms were found in our series. The existence of such a high level of resistance is a well recognized hospital threat, and appropriate policies and interventions should be addressed in high-risk patients.     

Serum total p-cresol and indoxyl sulfate correlated with stage of chronic kidney disease in renal transplant recipients

Background

Uremic toxins are considered cardiovascular and mortality risk factors in chronic kidney disease (CKD) patients. Both p-cresol and indoxyl sulfate have been shown to induce oxidative stress in vitro and subsequent endothelial dysfunction in uremic patients. Our study evaluated the levels of p-cresol and indoxyl sulfate, and whether they contribute to the progression of CKD in transplant recipients.

Methods

We retrospectively evaluated 95 patients who had received a transplant from February 1987 to June 2010 in our center; the recipients had a mean transplant duration of 5.3 ± 4.9 years and a mean age of 47.8 ± 14.1 years. Among them, 56.8% (54/95) were male. Patients with glomerular filtration rate (GFR) ≥ 60 mL/min/1.73 m² were selected for group 1 (n = 35), and those with GFR < 60 mL/min/1.73 m² were selected for group 2 (n = 60). Demographic and clinical data were compared between groups. Serum and urine levels of p-cresol and indoxyl sulfate were also obtained.

Results

Baseline serum p-cresol and indoxyl sulfate levels were significantly higher in advanced CKD stages (P = .001 and <.0001, respectively). Patients at advanced CKD stages (group 2) had lower serum levels of hemoglobin and albumin (P < .0001), but higher levels of total cholesterol, triglyceride, and uric acid levels (P = .04, .04 and .001, respectively). Body mass index, C-reactive protein, and serum calcium and phosphate levels showed no significant differences between groups. The cut-off value for serum p-cresol between groups was 1.28 umol/L (P = .01), and that for the indoxyl sulfate level was 0.98 umol/L (P = .0001).

Conclusion

The serum p-cresol and indoxyl sulfate levels were significantly higher in advanced CKD stages in transplant recipients. To evaluate the use of serum p-cresol and indoxyl sulfate levels as a predictive tool for survival, larger clinical studies are needed.     

Coping styles of patients on the liver transplant waiting list

Introduction

Chronic end-stage liver disease is a difficult situation for the patient.

Objective

The objective of this study was to analyze the disease coping styles of patients on the liver transplant waiting list.

Materials and Methods

The study included 50 patients on the liver transplant waiting list. The instrument used was the Mental Adjustment to Cancer Scale (Ferrero, 94). Coping scales were as follows: fighting spirit, hopelessness, anxious preoccupation, fatalism, and negation.

Results

Only 6% of subjects adapted well, whereas 94% adapted badly: 89% poor fighting spirit, 32% hopelessness, 50% anxious preoccupation, 28% fatalism, and 30% negation. Of those who had a poor fighting spirit, 88% also used another type of maladaptive style. The associated statements were (P < .05) as follows: “I value my life more”; “I don't think about the disease”; “I think about people who are worse off.” Regarding hopelessness, 100% of those who confessed hopelessness also showed maladaptive signs. The associated statements were (P < .05) as follows: “I cannot cheer myself up”; “I cannot help myself”; “I've given up.” Regarding anxious preoccupation, nearly all of these patients (96%) provided dysfunctional answers. The most associated were (P < .05) as follows: “I don't have any plans”; “I feel a lot of anxiety”; “I'm very angry.” Regarding fatalism, all of the patients also had maladaptive behavior. The main types were (P < .05) as follows: “Nothing will change things”; “I cannot control the situation”; “I don't need information.” Regarding negation, Only 14% used this style, and in 86% negation was associated with other inadequate coping styles.

Conclusions

Patients on the liver transplant waiting list were maladaptive to their disease. It is important to establish adequate psychological care for these patients, given the important repercussions in the posttransplantation phase.     

Fundamentals of Laparoscopic Surgery simulator training to proficiency improves laparoscopic performance in the operating room—a randomized controlled trial

Background

The purpose of this study was to assess whether training to proficiency with the Fundamentals of Laparoscopic Surgery (FLS) simulator would result in improved performance in the operating room (OR).

Methods

Nineteen junior residents underwent baseline FLS testing and were assessed in the OR using a validated global rating scale (GOALS) during elective laparoscopic cholecystectomy. Those with GOALS scores ≤15 were randomly assigned to training (n = 9) or control (n = 8) groups. An FLS proficiency-based curriculum was used in the training group. Scoring on FLS and in the OR was repeated after the study period. Evaluators were blinded to randomization status.

Results

Sixteen residents completed the study. There were no differences in baseline simulator (49.1 ± 17 vs 39.5 ± 16, P = .27) or OR scores (11.3 ± 2.0 vs 12.0 ± 1.8; P = .47). After training, simulator scores were higher in the trained group (95.1 ± 4 vs 60.5 ± 23, P = .004). OR performance improved in the control group by 1.8 to 13.8 ± 2.2 (P = .04), whereas the trained group improved by 6.1 to 17.4 ± 1.9 (P = .0005 vs control; P < .0001 vs baseline).

Conclusions

This study clearly demonstrates the educational value of FLS simulator training in surgical residency curricula.     

Obsessive-compulsive psychological symptoms of patients on the liver transplant waiting list

Introduction

Patients on the liver transplant waiting list have increased emotional and clinical symptoms. The presence of psychopathologic symptoms associated with obsession-compulsion as a reflection of alterations due to anxiety disorders is common in these patients.

Objective

To evaluate obsessive-compulsive psychopathological symptoms in patients on the liver transplant waiting list.

Materials and methods

The study included 50 patients on the liver transplant waiting list. The instrument was the SA-45 questionnaire (Derogatis, 75), whose Spanish version was adapted by González Rivera and De las Cuevas (1988). This dimension was evaluated using five statements.

Results

Among of the patients on the liver transplant waiting list, 46% had no relevant obsessive-compulsive symptoms. Of these, 28% had no symptoms and 18% had some symptoms, but the overall evaluation in these patients was no greater than the cutoff point. The remaining 54% had relevant obsessive-compulsive clinical symptoms, most commonly (1) “Having difficulty making decisions” (P < 3.45 · 10⁻⁹); (2) “Having difficulty concentrating” (P < 1.70 · 10⁻⁸); (3) “One's mind goes blank” (P < 3.04 · 10⁻⁴); (4) “Having to repeatedly check everything being done” (P < 1.37 · 10⁻¹); and (5) “Having to do things slowly to make sure they are done properly” (P < 5.02 · 10⁻¹).

Conclusions

Many patients on the liver transplant waiting list have obsessive-compulsive psychopathologic symptoms. Their detection and application of adequate psychological treatment are important to minimize the effects of emotional changes onward from the pretransplant phase.     

Ambulatory blood pressure monitoring in renal transplant patients: should it be routinely performed?

Introduction

Arterial hypertension is common among kidney transplant patients. It increases cardiovascular risk and is a factor for progression of renal failure. Our objective was to perform ambulatory blood pressure monitoring (ABPM) in renal transplant patients with office hypertension.

Methods

Patients were divided into 2 groups according to their mean ABPM blood pressures with treatment: well-controlled hypertension (blood pressure [BP] <130/85 mmHg), and poorly controlled hypertension (BP > 130/85 mmHg). A “nondipper pattern” was defined as a decrease of <10% or an increase, and a “raiser pattern,” in which mean blood pressure was greater during the nocturnal than the diurnal period. “White coat effect” was considered when the mean of 3 BP measurements in the clinic was >140/90 mmHg among well-controlled hypertensive patients as documented by ABPM.

Results

ABPM was performed in 53 patients: 25 (47%) “well-controlled hypertensives” and 28 (53%) “poorly controlled hypertensives.” Of the latter, 24 (85%) showed a nondipper or raiser pattern with only 4 revealing dipper patterns. We compared well-controlled with poorly controlled hypertensives. The latter cohort were older (54.4 ± 9.3 vs 45.5 ± 13.8 years; P = .009), received grafts from older donors (56.7 ± 15.0 vs 45.8 ± 17 years; P = .02); had worse renal function measured by serum creatinine (1.7 ± 0.5 vs 1.4 ± 0.4 mg/dL, P = .03) or the Modification of Diet in Renal Disease (MDRD) = 4 formula (41.8 ± 14.0 vs 55.4 ± 20.5 mL/min/1.73 m²; P = .009), and displayed more proteinuria (0.30 ± 0.33 vs 0.18 ± 0.10 g/d, P = .08). Nondipper or raiser patients showed a higher mean body mass index (27.1 vs 21.7 kg/m²; P = .04). Among 25 well-controlled patients, 11 presented “white coat phenomenon.”

Conclusion

We observed an important “white coat” effect, a large prevalence of uncontrolled nocturnal hypertension, and a small but important incident of “masked hypertension.” Factors related to hypertension control were patient age, donor age, renal function, induction use, and proteinuria.     

Influence of relatives' anxious symptomatology on the quality of life of pretransplant hepatic patients

Objectives

We sought to analyze the influence of anxiety symptoms of relatives of patients undergoing a pretransplant study on the quality of life of the hepatic patients body pain, physical role, mental health, general health, vitality, social functioning, emotional role, and physical functioning.

Materials and Methods

We assessed 2 groups: 51 patients with hepatic cirrhosis and 51 of their closest relatives who were studied while the patients were hospitalized to undergo the pretransplant study. We used a “Psychosocial Survey” (in both groups), the “Hospital Anxiety and Depression Scale” (HADS) in the relatives, and the “SF-36 Health Survey” (in the patients).

Results

The results showed that the patients whose relatives presented clinical levels of anxiety showed the worst quality of life, specifically for the dimensions “mental health” (P = .016) and “emotional role” (P = .041).     

Influence of Single-Nucleotide Polymorphisms on C-Reactive Protein Levels in Chronic Kidney Disease Before and After Kidney Transplantation

Introduction

We sought to evaluate 2 single-nucleotide polymorphisms (SNPs) in the C-reactive protein (CRP) gene promoter region for their effects on CRP levels in chronic kidney disease (CKD) patients before and after a successful kidney transplantation.

Methods

Fifty CKD patients were evaluated before and at the first and second years after the graft. Two SNPs were studied, a bi-allelic (G→A) at the −409 and a tri-allelic (C→T→A) variation at the −390 position in the CRP gene.

Results

All patients presented the −409GG genotype. At the −390 position, the “A” allele was not found; there were 15 “CC” patients, 11 “TT” patients, and 24 “CT” patients. CRP levels were different among patients with various genotypes (P < .019). Also the presence of the allele “T” was sufficient to determine differences in CRP levels both in pretransplantation (P = .045) and at 1 year posttransplantation (P = .011), but not at the second year (P = .448).

Conclusion

SNPs at the −390 position of the CRP gene promoter region influence CRP basal levels in such a way that the “C” allele correlated with the lowest and the “T” with the highest. We did not observe this influence in our patients at the second year posttransplantation.     

Improvement in Gastrointestinal and Health-related Quality of Life Outcomes After Conversion From Mycophenolate Mofetil to Enteric-coated Mycophenolate Sodium in Liver Transplant Recipients

Objective

To evaluate improvement in gastrointestinal (GI) symptoms and health-related quality of life (HRQoL) in liver transplant recipients switched from mycophenolate mofetil (MMF) to enteric-coated mycophenolate sodium (EC-MPS).

Methods

A multicenter, open-label, single-arm study was undertaken in maintenance liver transplant recipients who reported GI complications with MMF therapy. The patients were switched to equimolar doses of EC-MPS at baseline. The primary end point was the change in the Gastrointestinal Symptom Rating Scale (GSRS) total score after 6 to 8 weeks of treatment with EC-MPS. Other key assessments for GI symptoms and HRQoL included the GSRS subscores, the Gastrointestinal Quality of Life Index (GIQLI), the Psychological General Well-Being Index, and the Overall Treatment Effect (OTE). Paired t-test was used to assess the difference in the mean score changes over time.

Results

A total of 34 patients were enrolled and switched to equimolar doses of EC-MPS. After 6 to 8 weeks of EC-MPS treatment, mean GSRS total score improved significantly from 2.88 ± 0.66 to 2.10 ± 0.78. Mean improvement in GSRS total score (−0.77 score points; P = .001) exceeded the minimal clinically important difference. Significant improvements were observed in all GSRS subscales (P < .05), GIQLI total scores (P = .001), and GIQLI subscales “GI symptoms” (P < .001) and “physical function” (0.013). Patients who continued EC-MPS reported sustained benefits compared with patients who switched back to MMF after 6 to 8 weeks of treatment with EC-MPS. On the OTE scale, improvement in symptoms was reported in 76.5% and 61.8% of the patients as perceived by the physicians and the patients. Improvement in HRQoL was reported by 41.2% of the patients. No deaths, biopsy proven acute rejections, or graft losses were reported during the study.

Conclusion

Conversion from MMF to EC-MPS was associated with a significant improvement in GI symptoms and HRQoL in liver transplant recipients.     

Effects of the new immunosuppressive agents on the occurrence of malignancies after renal transplantation

Introduction

The risk of malignancies in renal transplant recipients is considerably greater than in the general population. The purpose of the present study was to investigate the effects on the appearance of malignancies of 3 immunosuppressive periods: azathioprine (AZA), cyclosporine (CsA), and tacrolimus (TAC).

Patients and Methods

This study included 1029 first renal transplant recipients of mean age at transplantation of 44.6 ± 14.9 years with a mean follow-up of 95.6 ± 84.2 months. Initial immunosuppression was AZA-based (n = 198), CsA-based (n = 524), and TAC (n = 307). A total of 280 recipients were also treated with mycophenolate mofetil or mycophenolic acid.

Results

There were 157 patients (15.3%) who displayed ≥1 malignancy; there were 95 skin (9.2%) and 74 (7.8%) non-skin malignancies with presentations at 74 ± 62 and 107 ± 77 months, respectively (P = .003). The skin malignancies included squamous cell carcinomas (n = 41), basal cell carcinomas (n = 41), Kaposi sarcomas (n = 7), and melanomas (n = 4). Among the solid tumors, lymphoproliferative disorders (n = 15), digestive tract (n = 14), kidney and urinary tract (n = 11), lung (n = 10), and breast (n = 3) carcinomas. The cumulative incidences at 5, 10, and 15 years were 6%, 10%, and 18% for skin and 3%, 7%, and 14% for non-skin malignancies, respectively. Multivariate analysis showed that age at transplant in years (P = .000) and male gender (P = .000) were the only variables associated with skin malignancies; age at transplant in years (P = .004) and treatment with OKT3 (P = .000) were associated with non-skin malignancies. Malignancies were the cause of death in 18% of recipients who died with functioning grafts.

Conclusion

Malignancies are an important cause of morbidity and mortality among renal transplant recipients. The new immunosuppressive agents do not increase the risk of malignancies. Special surveillance is needed for older, male recipients.     

Early postoperative spectral Doppler parameters of renal transplants: the effect of donor and recipient factors

Background

The objective of this study was to explore the donor and recipient factors related to the spectral Doppler parameters of the transplant kidney in the early posttransplantation period.

Methods

This retrospective study included 76 patients who underwent renal transplantation assessed using Doppler ultrasonography (US) on the first postoperative day. We compared spectral Doppler parameters (peak systolic velocity [PSV] and resistive index [RI]) of the segmental artery of the transplant kidney according to the type of renal transplant, level of serum creatinine (SCr) of donor prior to organ donation, and donor/recipient age.

Results

RI was significantly higher in deceased-donor kidney transplantation (DDKT) as compared with living-donor kidney transplantation (LDKT; 0.73 ± 0.10 vs 0.66 ± 0.11; P = .007). In the DDKT recipients, multivariate analysis showed donor SCr was the only factor affecting PSV (P = .023), whereas recipient age was the only factor affecting RI (P = .035). In the LDKT recipients, multivariate analysis showed recipient age was the only factor affecting both PSV (P = .009) and RI (P = .018).

Conclusion

Spectral Doppler parameters in the early posttransplantation period are related to the type of renal transplant, donor renal function, and recipient age. These factors should be taken into consideration when interpreting the results of spectral Doppler US.     

Quality of life and physical activity in liver transplantation patients: results of a case-control study in Italy

The aim of the study was to assess the quality of life (QOL) and the physical activity of liver transplant recipients compared with the general population. The case-controlled pilot study was accomplished through the administration of 2 questionnaires: 36-item Medical Outcomes Study, Short-Form General Health Survey (SF-36) for quality of life (10 scores) and International Physical Activity Questionnaire (IPAQ) to estimate the physical activity (metabolic equivalent score). Fifty-four patients who underwent liver transplantation using the piggyback technique and 108 controls from the general population at the orthopedic ambulatories were enrolled between 2002 and 2009. Participants had a mean age of 55 years (range, 41-73). The multivariate analysis showed significant differences for some scales of the SF-36: liver transplant recipients displayed lower values for “Mental Composite Score” (P = .043), “physical activity” (P = .001), “role limitations due to physical health” (P = .006), “role limitations due to the emotional state” (P = .006), and “mental health” (P = .010). The metabolic equivalent positively associated with all examined SF-36 scales. The present study focused on the QOL and physical activity of liver transplant recipients, demonstrating that transplant recipients scored lower than the general population. Liver transplantation may allow full recovery of health status, but the physical and social problems persist in some patients. Interventions aimed at improving rehabilitation programs, regular psychosocial support, and follow-up in all phases of treatment may give patients a more satisfying lifestyle after transplantation.     

Body Image in Kidney Transplantation

Introduction

Psychologic disturbances are becoming more common in kidney transplantation, owing to effects of immunosuppressive therapy. In this study, we explored the incidence and specifity of psychopathology among kidney transplant patients. Twenty kidney transplant recipients underwent the Machover Draw-A-person test to detect significant variables (V1=V6) hypothetically related to chronologic age, education, years from transplantation, and gender differences. Emotional coarctation (V1) in the sense of “mental rigidity,” “egocentrism,” and “hypercontrol” were present in all transplant recipients (100%), followed by difficulty in interpersonal relationships (V3; 70%) and anxiety (V5; 70%). This research confirmed the hypothesis that transplantation can display a potential risk to the psychologic balance of the patient. Psychologic evaluation may be a fundamental step together with surgical aspects and management of immunosuppression to achieve well-being of kidney transplant recipients.     

Hyperhomocysteinemia after kidney transplantation

Objective

To determine the prevalence of hyperhomocysteinemia (plasma homocysteine[Hcy] concentration ≥15 μmol/L) and evaluate its correlation with allograft function.

Materials and Methods

The study included 159 stable renal transplant recipients (104men and 55 women). The prevalence and severity of hyperhomocysteinemia werecompared in the transplant recipients vs 72 patients (48 men and 24 women) receivinghemodialysis therapy.

Results

The mean (SD; range) fasting total Hcy concentration was higher in thehemodialysis group compared with the renal transplantation group: 27.4 (18.3; 10-95)μmol/L vs 16.6 (9.5; 4.5-45.0) μmol/L (P = .00). Hyperhomocysteinemia occurred morefrequently in patients receiving hemodialysis therapy (74% vs 49%). No significantcorrelation was observed between Hcy concentration and recipient sex, cyclosporinetrough concentration and concentration at 2 days after dosing, dyslipidemia,cytomegalovirus infection, diabetes mellitus, or aspartate or alanine aminotransferaseconcentration. Multivariate regression analysis revealed that serum creatinineconcentration (P = .02) was the major determinant of increased total Hcy concentration inrenal transplant recipients.

Conclusion

A high prevalence of moderate hyperhomocysteinemia was observed in renaltransplant recipients. There was no correlation between graft function and Hcyconcentration.     

Should a lower quality organ go to the least sick patient? Model for end-stage liver disease score and donor risk index as predictors of early allograft dysfunction

Background

There is a global tendency to justify transplanting extended criteria organs (ECD; Donor Risk Index [DRI] ≥1.7) into recipients with a lower Model for End-Stage Liver Disease (MELD) score and to transplant standard criteria organs (DRI < 1.7) into recipients with a higher MELD scores. There is a lack of evidence in the current literature to justify this assumption.

Methods

A review of our prospectively entered database for donation after brain death (DBD) liver transplantation (n = 310) between January 1, 2006, and September 30, 2010, was performed. DRI was dichotomized as <1.7 and ≥1.7. Recipients were divided into 3 strata, those with high (≥27), moderate (15-26), and low MELD (<15) scores. The recently validated definition of early allograft dysfunction (EAD) was used. We analyzed EAD and its relation with donor DRI and recipient MELD scores.

Results

The overall incidence of EAD was 24.5%. Mortality in the first 6 months in recipients with EAD was 20% compared with 3.4% for those without EAD (relative risk [RR], 5.56, 95% confidence interval [CI], 1.96-15.73; P < .001). Graft failure rate in the first 6 months in those with EAD was 27% compared with 5.8% for those without EAD (RR, 4.63; 95% CI, 2.02-10.6; P < .001). In patients with low MELD scores, a significantly increased rate of EAD (25%) was seen in patients transplanted with a high DRI liver compared with those transplanted with a low DRI liver (6.25%; P = .012). In moderate and high MELD recipients, there was no significant difference in the rate of EAD in patients transplanted with a high DRI liver (62%) compared with those transplanted with a low DRI liver (59%).

Conclusion

These results suggest that contrary to common belief it is not justified to preferentially allocate organs with higher DRI to recipients with lower MELD scores.     

Survival Benefit in Heart Transplant Recipients Who Have Coronary Artery Disease Confirmed Using Angiography and Are Receiving Sirolimus

Introduction

The aim of this study was to assess efficacy and safety of sirolimus (SIR) in heart transplant recipients to prevent further development of coronary artery disease (TxCAD) already confirmed by using coronary angiography.

Material and Methods

We performed a retrospective case-control study involving all 60 heart transplant recipients receiving SIR in a number of combinations with other immunosuppressive drugs, and 60 matched individuals after heart transplantation treated without SIR. TxCAD was diagnosed using elective coronary angiography in 9 subjects in the study group (8 males and 1 female) of mean age 44 ± 11 years, including ischemic cardiomyopathy in 4 members. The control group of 15 individuals 15 males of mean age 47 ± 7 years, including ischemic cardiomyopathy in 8. We compared time to develop significant TxCAD and death caused by TxCAD, and all-cause deaths. Significance was assessed using log-rank and chi-square tests, when applicable.

Results

Significant TxCAD (critical coronary lesions, myocardial infarction or death) was observed in 5 (56%) patients receiving SIR and 11 (73%) without SIR (P = not significant [NS]). Time to develop significant TxCAD was comparable. There were 2 (22%) deaths in the SIR group and 8 (53%) in the control group (P = NS). Survival time was significantly longer among subjects receiving SIR (P = .02). None of deaths in the study group was caused by TxCAD compared with 6 (40%) deaths among controls (P = .09). Time of freedom from death caused by TxCAD was significantly longer in the study group (P = .023).

Conclusion

SIR prolonged survival in heart transplant recipients with TxCAD confirmed using coronary angiography.