Cause of End-Stage Renal Disease Is Not a Risk Factor for Cytomegalovirus Infection After Kidney Transplant

BackgroundCytomegalovirus infection (CMV) after kidney transplantation leads to increased morbidity and mortality. Whether the cause of end-stage renal disease (ESRD) influences the risk of CMV infection post-transplant is not known.MethodsWe analyzed data from 2741 adult kidney transplant recipients from January 1993 through December 2014. The causes of ESRD included diabetes mellitus (n = 947), hypertension (n = 442), polycystic kidney disease (n = 549), and glomerulonephritis (GN) (n = 803). The primary outcome was incidence of CMV infection, defined as the first episode of detectable CMV DNA in the blood following transplant.ResultsThree hundred and thirty patients developed a CMV infection over a median follow-up of 4.5 years. Patients with diabetes mellitus (DM) as the cause of ESRD had a higher incidence of CMV infection post-transplant compared to patients with GN (2.37 vs 1.58/100 person-years, P < .005) whereas hypertension (HTN) and autosomal dominant polycystic kidney disease (PKD) were similar (2.17 and 2.07/100 person-years). DM was associated with a 35% higher risk of CMV infection compared to GN in unadjusted analyses [hazard ratio=1.35 [95% confidence interval 1.02–1.78], P = .04). However, after adjustment for age, the risk of CMV infection was similar in all groups (DM: age-adjusted hazard ratio 1.02 [0.78–1.39]; HTN: 0.96 (0.67–1.36); PKD: 1.08 [0.78–1.48]; compared to GN). The risk of CMV infection increased with age (adjusted hazard ratio=1.32 [1.18–1.47] for every decade of life, P < .001).ConclusionsOur study demonstrates that the cause of ESRD is not a significant risk factor for CMV infection in kidney transplant recipients once adjusted for age. Future studies are needed to identify risk factors for CMV infection to define patient-centered monitoring and prevention.     

Plasma adiponectin concentration before and after successful kidney transplantation

BACKGROUND: Adiponectin, a protein secreted exclusively by adipocytes, is presumed to be involved in the pathogenesis of atherosclerosis and insulin resistance. An elevated plasma adiponectin concentration was found in ESRD patients on hemodialysis (HD). However, the role of kidneys in adiponectin biodegradation/elimination is unknown. Therefore, we assessed plasma adiponectin concentrations in ESRD patients before and after successful kidney transplantation. METHODS: Among 44 hemodialyzed patients (29 men, 15 women; mean age 39 +/- 11 years; mean body mass index [BMI] 23.6 +/- 3.5 kg/m(2); mean duration of HD treatment before kidney transplantation 27 +/- 26 months), plasma adiponectin concentrations and insulin resistance indices (HOMA-R) were measured twice: immediately before kidney transplantation (Tx) and 1-2 days before patient discharge from the hospital with stable kidney transplant function (mean serum creatinine level 191 +/- 105 micromol/L). The control group consisted of 22 normotensive healthy subjects (12 men, 10 women). RESULTS: Among uremic patients, before Tx, plasma adiponectin concentrations were significantly higher than in healthy subjects (20.8 +/- 8.3 vs 8.7 +/- 4.8 microg/mL; P <.001) After successful Tx, plasma adiponectin concentrations decreased significantly (20.8 +/- 8.3 vs 15.7 +/- 7.0 microg/mL before and after Tx, respectively; P <.001). Simultaneously, after successful kidney transplantation, an increase in HOMA-R was observed (1.01 +/- 0.61 vs 1.43 +/- 0.83; P =.002). However, changes in adiponectinemia did not significantly correlate with serum creatinine or HOMA-R. CONCLUSION: The kidneys seem to play an important role in adiponectin biodegradation and/or elimination.     

Prolonged rehospitalizations following renal transplantation: causes, risk factors, and outcomes

BACKGROUND: Although some studies have described rehospitalization after transplantation, few have focused on risk factors and consequences of prolonged hospital stay. Our goal was to determine the causes, risk factors, and outcomes of prolonged rehospitalizations after renal transplantation. PATIENTS AND METHODS: In this retrospective study, 574 randomly selected rehospitalization records of kidney transplant recipients were reviewed from 1994 to 2006. Admissions were divided into group 1, prolonged stay (length of stay >14 days, n=149), and group II, short stay (length of stay 62% of all hospital costs; however, they comprised only 26% of the patients. High-risk kidney transplant recipients for prolonged hospitalizations should be closely observed for infections and graft rejection.     

Seropositivity for cytomegalovirus in patients with end-stage renal disease is strongly associated with atherosclerotic disease.

BACKGROUND: Infection with cytomegalovirus (CMV) is considered a risk factor for progression of atherosclerotic disease. Patients with end-stage renal disease (ESRD) display signs of frequent CMV re-activation, which may be caused by the uraemia-associated defect in cellular immunity. The possible contribution of CMV seropositivity to the hugely increased risk for cardiovascular disease in patients with ESRD is not clear. METHODS: In a retrospective study we analysed the clinical data of patients with ESRD that were evaluated for renal transplantation from January 2002 to March 2006. Classical cardiovascular risk factors and CMV seropositivity were related to the prevalence of atherosclerotic disease. RESULTS: A total of 408 patients were evaluated with a median age of 52 years (range 18-81 years). Multivariate logistic regression identified age (odds ratio; OR 2.7 per decade), smoking (OR 2.2), hypertension (OR 1.9), C-reactive protein (CRP) (OR 2.6) and CMV seropositivity (OR 2.7) as independent variables that were significantly associated with a positive medical history of atherosclerotic disease. The average titre for anti-CMV immunoglobulin G was higher in patients with atherosclerotic disease (100 AU/ml vs 71 AU/ml, P < 0.05). CMV seropositivity was independently associated with an elevated CRP. In addition, patients with the combination of a high CRP and CMV seropositivity showed the highest prevalence of atherosclerotic disease. CONCLUSION: CMV seropositivity is significantly associated with atherosclerotic disease in ESRD patients. Our data suggest that the risk for progressive atherosclerosis is specifically increased in patients with an inflammatory response to CMV.     

Time trends in the epidemiology of renal transplant patients with type 1 diabetes mellitus over the last four decades.

BACKGROUND: Diabetes mellitus (DM) type 1 is an important contributor to end-stage renal disease (ESRD) among younger transplant recipients. However, little is known about the changes in epidemiological characteristics of this population. Especially, time to reach ESRD may have changed in type 1 diabetic patients referred for transplantation, resulting in higher age at time of grafting. Such time trends may allow anticipating future developments regarding the demand for organ replacement in this patient group. METHODS: We retrospectively analysed 173 patients with type 1 DM undergoing renal transplantation at our institution, stratified into four groups according to year of reaching ESRD (A = 1973-1983, B = 1984-1990, C = 1991-1995 and D = 1996-2002). For each group we determined age at diagnosis of DM, age at time of reaching ESRD and age at time of transplantation. From these data, the interval from diagnosis of DM to ESRD and from ESRD to transplantation was calculated. The results were analysed in relation to gender, year of and age at onset of diabetes. RESULTS: Patients reaching ESRD in more recent years (group D) tended to be both younger at diagnosis of DM and older when reaching ESRD, resulting in higher mean age at transplantation (35.0, 37.5, 39.6 and 41.0 years in groups A, B, C and D, respectively). Accordingly, median duration to ESRD has significantly been prolonged over the last five decades in patients with type 1 DM undergoing renal transplantation (group A: 21.0, B: 20.7, C: 22.3 and D: 28.5 years; P < 0.0001), this finding being more pronounced in female patients. CONCLUSIONS: The results of our analysis are compatible with a change in epidemiology in patients undergoing kidney transplantation. Older age at time of reaching ESRD may impact significantly on the demand for renal grafts, as patients are already clearly older nowadays when being transplanted. From our data it cannot be concluded whether this development is due to a change in the progression of diabetic nephropathy or may simply reflect a change in the selection of type 1 diabetic patients referred for transplantation.     

Chronic renal failure and end-stage renal disease are associated with a high rate of mortality after heart transplantation

The aim of the study was to analyze the etiology, the factors for progression of chronic renal failure to end-stage-renal disease (ESRD), and the influence of ESRD on the survival rate among a cohort of 59 heart transplant patients (HTP) referred for the management of chronic renal failure (CRF). At the time of the first nephrology consultation (6 +/- 4.25 years after cardiac transplantation) the mean creatininemia was 261.5 +/- 99 micromol/L and mean creatinine clearance (Cockcroft formula) was 32 +/- 15 mL/min. The cause of CRF were calcineurin inhibitor toxicity in 38.9% of patients, vascular events in 15.2%, hemolytic uremic syndrome in 5%, membranous glomerulopathy in 3.3%, diabetes in two patients, focal/segmental glomerulosclerosis in 3.3%, renal hypoplasia in 1.7%, and unknown in 27%. Evolution to ESRD occurred in 38.9% of patients: 17 patients started hemodialysis, three peritoneal dialysis, and two received a preemptive kidney transplantation. Creatininemia (micromol/L) at the time of nephrology referral was 229.2 +/- 72.6 versus 315.8 +/- 113.4 (P < .001) and creatinine clearance (mL/min) was 34.9 +/- 15.1 versus 27.3 +/- 13.7 (P = .049) for patients with CRF versus ESRD, respectively. Both proteinuria (g/24 hours) of 1 +/- 2.2 versus 2.3 +/- 1.8 (P = .02) and tobacco use in 35.1% versus 54.4% (P = .045) were significantly associated with progression of CRF, while age at the time of heart transplantation, cause of cardiac failure and renal failure, high blood pressure, type 2 diabetes, dyslipidemia, alcoholism, cirrhosis, and cerebral vascular accident were not. Death occurred in 18 HTP: 50% of patients with ESRD and 18.5% of patients with CRF-a 2.6 relative risk of of death in HTP patients with ESRD compared with HTP with CRF only (P < .01).     

Plasma tissue-type plasminogen activator, fibrinogen, and time on dialysis prior to transplantation are related to carotid intima media thickness in renal transplant recipients

The majority of deaths among patients after renal transplantation is attributed to cardiovascular disease (CVD). Intima media thickness (IMT) of the common carotid artery is related to coronary and cerebrovascular arterial disease. One of the major causes of death due to CVD is acute coronary syndrome, which is precipitated by coronary plaque rupture and subsequent thrombosis. The aim of the study was to evaluate associations between some fibrinolytic factors: antigens of tissue-type plasminogen activator (t-PA), plasminogen activator inhibitor (PAI-1), and thrombin-activatable fibrinolysis inhibitor (TAFI), and IMT in a population of renal transplant recipients. The study was performed on 33 Caucasian, clinically stable kidney transplant recipients (11 women, mean age 43 years, range 26 to 62 years). All the patients were on triple immunosuppressive regimen (cyclosporine, prednisone, and azathioprine) and had stable graft function (serum creatinine 1.7 +/- 0.7 mg/dL). The mean time since transplantation was 49.9 months (range 4.1 to 131.8 months). In univariate analysis IMT correlated significantly with age (r =.5; P =.001), pulse pressure (PP) (r =.4; P =.05), time on dialysis prior to transplantation (r =.6; P =.001), fibrinogen (r =.4; P =.02), and t-PA (r =.6; P =.001). Multiple regression analysis showed that t-PA antigen concentration (P =.001), fibrinogen (P <.05), and time on dialysis prior to transplantation (P <.05) were positive independent predictors of IMT. These data support the concept of the coincidence of disturbances in fibrinolysis and arterial remodelling in patients after kidney transplantation. On the other hand the study shows that the duration of dialysis therapy before transplantation is detrimental to the arterial vasculature.     

Causes of rehospitalization after renal transplantation; does age of recipient matter?

BACKGROUND: This study assessed the causes and related factors of rehospitalization following renal transplantation among elderly compared with younger patients. METHODS: We reviewed the charts of 567 patients rehospitalized after kidney transplantation from 2000 to 2006. According to age at the time of transplantation, hospitalizations were divided into two groups: group 1 (age >or=50 years) and group II (age 20 to 50 years). Demographics, clinical findings, causes for rehospitalization, patient outcomes (recovery, graft loss, death), intensive care unit (ICU) admission, length of hospital stay, time interval from transplantation to rehospitalization, as well as hospital costs were compared between the two groups. RESULTS: One hundred eighty-five (32.6%) rehospitalizations were charted for group I, who showed a higher proportion of admissions due to infection (42.2% vs 29.8%, P=.004) and macrovascular disease (3.8% vs 1.0%, P=.027) compared with group II. ICU admission (8.8% vs 2.4%, P=.001), mortality (10.2% vs 3.6%, P=.008), and hospital charges (1610 +/- 933 vs 931 +/- 850 purchase power parity dollars, P=.001) were also seen more frequently in group I but displayed a lower frequency of admissions due to graft rejection (20% vs 34.3%, P=.001). CONCLUSION: Recipient age at the time of transplantation was a main factor affecting rehospitalization among our patients.     

Transplantation in Diabetic Kidney Failure Patients: Modalities,Outcomes, and Clinical Management

Diabetes mellitus (DM) is a common and devastating disease, affecting up to 19.3 million Americans. It is the leading cause of chronic kidney disease (CKD) and end‐stage renal disease (ESRD) in the United States. Diabetic patients with ESRD have a high incidence of cardiovascular disease and death. For those kidney transplant patients with no history of DM prior to transplantation, the development of new onset diabetes after transplantation (NODAT) also poses a serious threat to both graft and patient survival. Kidney transplantation is the best renal replacement option for diabetic ESRD and has the potential to halt the progression of cardiovascular diseases. Early referral for transplant evaluation is essential for pre‐emptive or early kidney transplantation in this cohort of patients. In type 1 DM patients with ESRD, simultaneous pancreas and kidney transplantation (SPK) should be encouraged; and in patients facing prolonged waiting time for SPK transplantation but with an available living donor, living donor kidney transplantation followed by pancreas after kidney transplantation (PAK) is a suitable alternative. Islet transplantation in type 1 diabetics is deemed experimental by Medicare, and easy access to this modality remains restricted to qualified patients enrolled in clinical trials or with private insurance. The optimal management of kidney transplant patients with pre‐existent DM or NODAT involves a multi‐pronged approach consisting of pharmacological and nonpharmacological intervention to address all potential cardiovascular risk factors such as glycemic and lipid control, blood pressure control, weight loss, and smoking cessation. Finally, re‐transplantation should be recommended in suitable kidney transplant patients when the kidney allograft demonstrates continuous and progressive decline in function.     

Noninvasive assessment of left ventricular function prior to and 6 months after renal transplantation

BACKGROUND: The purpose of this study was to evaluate the effect of a successful kidney transplantation on left ventricular functional parameters that can be measured with gated-single photon emission computed tomography (gated-SPECT) myocardial perfusion scintigraphy in patients with end-stage renal disease. MATERIALS AND METHODS: Thirty-two consecutive patients (22 male) who had undergone a successful kidney transplantation in whom gated-SPECT myocardial perfusion scintigraphy was performed prior to and 6 months after surgery were included. Functional parameters, such as left ventricular ejection fraction (LVEF), wall motion, and wall thickening, were calculated with quantitative gated-SPECT. RESULTS: The mean LVEF improved significantly (P<.001) from 52% (SD+/-11) before to 63% (SD+/-10) after renal transplantation. This was attributable to a significant improvement in the end-systolic volume (P=.028). Wall motion and wall thickening improved in almost all myocardial segments. We found a significant correlation between the levels of urea and creatinine and the LVEF. However, correlations between an increase in the LVEF and the improvement in urea (P=.30) and creatinine (P=.26) levels were not significant, which is probably related to the number of patients studied. CONCLUSION: The systolic left ventricular dysfunction in terms of LVEF, wall motion, and wall thickening improves significantly 6 months after kidney transplantation in patients with end-stage kidney disease. Long-term follow-up is required to establish the prognostic value of these findings.     

Influence of immunosuppression on the prevalence of cancer after kidney transplantation

The prevalence of cancer in renal transplant patients is greater than in the general population. It is influenced by demographic and ethnic characteristics. We performed a retrospective study of 793 patients who received 872 kidney transplants at our center during 23 years. The age at transplantation was 41.4+/-14.0 years, the follow up 75.4+/-69.4 months. The cohorts include 203 patients treated with azathioprine-prednisone; 510, cyclosporine-based therapy; and 159, tacrolimus-based therapy. There were 95 patients (10.9%) who developed at least one neoplasm with 9 having more than one type of tumor. The incidence was of 17.3 cases per 1000 patients-years. Forty-four (46.3%) had skin cancer, 8 (8.4%) Kaposi sarcoma and 43 (45.3%) a non-skin cancer. Seven of eight patients with Kaposi sarcoma were on CsA therapy. The risk of developing a neoplasm at 5, 10, and 15 years was 8%, 17%, and 30% respectively. In a multivariate analysis, the risk factors associated with neoplastic diseases were older age (OR=1.061; 95% CI 1.039-1.084; P=.000), male sex (OR=2.658; 95% CI 1.536-4.599; P=.000), length of follow-up (OR=1.121; 95% CI 1.073-1.172; P =.000), and immunosuppression with CsA (OR=4.448; 95% CI 1.334-14.764; P=.015). Cancer was the cause of death in 26 patients, the fourth most common cause after cardiovascular disease, infection, and liver failure. We conclude that malignancies are an important cause of morbidity and mortality among transplant patients. Special attention must be devoted to older male patients with a long-term follow up to develop preventive and surveillance strategies.     

Pain affects health-related quality of life in kidney transplant recipients

BACKGROUND: Chronic pain is prevalent in end-stage renal disease patients undergoing chronic hemodialysis. We do not fully know the intensity of chronic pain experienced by kidney recipients in comparison to those on chronic hemodialysis and healthy controls. Moreover, the effect of chronic pain on kidney recipients' health-related quality of life (HRQoL) is yet to be comprehensively addressed. We designed this study to find an answer to these questions. METHODS: In this case control study, we studied 205 kidney recipients, 69 hemodialysis patients, and 100 healthy controls, who were matched for age, sex, monthly family income, and educational level. The patients were evaluated for the intensity of chronic pain by Visual Analogue Scale (VAS). HRQoL was measured with Short Form 36 (SF-36) in the kidney recipients. Chronic pain intensity was compared in the study groups, and in the kidney recipients the correlation between SF-36 subscores and severity of pain was assessed. RESULTS: Severity of pain in the kidney recipients was lower than the hemodialysis patients, but more than the healthy controls (P=.001). The VAS pain score negatively correlated with the scores of SF- 36 total (r=-.329, P=01), mental health (r=-.190, P=07), physical health (r=-.275, P=.001), physical function (r=-.339, P=.001), role limitation due to physical problems (r=-.478, P=.001), role limitation due to emotional problems (r=-.326, P=.001), and bodily pain (r=-.894, P=.001). DISCUSSION: The intensity of chronic pain experienced by the kidney recipients is less than that experienced by patients under chronic hemodialysis, but higher than healthy subjects. Focusing on chronic pain as a cause of post-renal transplantation morbidity is expected to improve post-renal transplantation quality of life.     

Cytomegalovirus prophylaxis using oral ganciclovir or valganciclovir in kidney and pancreas-kidney transplantation under antibody preconditioning

We investigated retrospectively the risk factors for cytomegalovirus (CMV) infection under ganciclovir or valganciclovir prophylaxis (oral ganciclovir 1 g tid, valganciclovir 450 mg/d) in our kidney and simultaneous pancreas-kidney (SPK) transplant patients undergoing transplantation between July 1, 2001 and February 28, 2003. Two hundred eleven patients receiving prophylactic oral ganciclovir or valganciclovir were included in the study. All patients were given antibody preconditioning (thymoglobulin 178, alemtuzumab 33). Duration of prophylactic treatment was between 3 and 8 months. Fifteen (7.1%) patients developed a positive CMV antigenemia in the first 6 months after transplantation, and 18 of 176 (10.2%) patients developed a positive CMV antigenemia during the first year. No patient developed tissue invasive CMV disease. At 6 months after transplantation, valganciclovir was slightly more effective than ganciclovir prophylaxis (P=.052). Positive donor CMV serology significantly increased the risk of CMV infection compared to CMV-negative donors (P=.014 and P=.003 at 6 and 12 months, respectively). Duration of CMV prophylaxis for more than 3 months decreased the risk of CMV infection (P=.04 and P=.009 at 6 and 12 months, respectively). Either valganciclovir prophylaxis (450 mg/d) or high-dose oral ganciclovir (1 g tid) is effective in preventing tissue-invasive CMV disease, and results in a low incidence of CMV antigenemia in patients undergoing kidney and SPK transplantation.     

Among therapy modalities of end-stage renal disease, renal transplantation improves survival in patients with amyloidosis

The aim of this study was to investigate the results of renal transplantation in amyloidosis patients compared with those on hemodialysis. We compared a group of 25 patients with systemic amyloidosis and end-stage renal disease (ESRD) treated with renal transplantation with a control group of 30 patients with systemic amyloidosis and ESRD treated with hemodialysis. Overall 1-, 2-, and 5-year survival rates were 86.9%, 82.6%, and 78.2%, respectively, for patients, who had renal transplantations versus 60.7%, 50%, and 46.4%, respectively, for patients on hemodialysis treatments (P < .001). Among the control group 15 patients died at 9.4 +/- 7.5 months after starting hemodialysis. Among transplantation group five patients died during follow-up (mean 12.3 +/- 13.6 months); the major cause of death was infection. Only 18 patients experienced recurrences after renal transplantation; their 5-year survival rate was 84.2% versus 50% for patients who had no recurrence (P < .001). Patients with amyloid recurrence also had better long-term survival rates than patients in hemodialysis group (P < .001). In conclusion amyloidotic patients maintained on chronic dialysis have a high mortality rate. Better survival was noted for patients who had renal transplantations despite recurrences. These results encourage transplantation in amyloid renal end-stage disease.     

Does etiology of end-stage renal disease affect sleep quality in kidney transplant recipients?

BACKGROUND: That hypertension (HTN) as a leading cause of end-stage renal disease (ESRD) is linked to sleep disorders in the general population can be the basis of a hypothesis that HTN may be a contributing factor to the poor quality of sleep in some kidney transplant recipients. This study was designed to investigate the correlation between ESRD secondary to HTN and sleep quality among kidney transplant recipients. METHODS: In this case control study, 201 kidney transplant recipients were divided into group I (ESRD) secondary to HTN, (n=82) and group II (ESRD secondary to other causes, n=119). The groups were matched for medical comorbidities, demographic and clinical data, and symptoms of anxiety and depression. Sleep quality assessed by means of the Pittsburgh Sleep Quality Index (PSQI) was compared between the study groups. RESULTS: The mean (SD) of the total PSQI score was significantly high in group I compared with group II (7.42 +/- 2.36 vs 6.60 +/- 3.07, P=.042). Similar results were observed for the sleep duration scores in the groups (1.22 +/- 1.12 vs 0.86 +/- 1.12, P=.026). In group I, all the other PSQI components were higher than those in group II, difference that were statistically significant. CONCLUSION: Sleep quality and duration was poorer among our kidney transplant recipients with ESRD secondary to HTN compared with the controls. Further studies, however, are required to investigate whether HTN is responsible for the reported poor quality of sleep in some kidney transplant recipients.     

The outcome of renal transplantation among systemic lupus erythematosus patients.

BACKGROUND: Clinical outcome of renal transplantation among systemic lupus erythematosus (SLE) patients remains a topic of controversy. Most of the previous reports were based upon small single-centre studies that were not always well-designed. METHODS: We conducted the retrospective analysis using data from USRDS and UNOS databases. Patients were divided into five groups based on the cause of end-stage renal disease (ESRD): diabetes mellitus (DM), SLE, glomerulonephritis, hypertension and other causes. Between 1990 and 1999, 2886 renal transplantation recipients with ESRD due to SLE were identified from a total of 92 844 patients. RESULTS: The mean follow-up period of this study was 4.7 +/- 2.4 years. While unadjusted analysis using Kaplan-Meier curves demonstrated an association between SLE and improved allograft survival compared with DM, in multivariate analysis the SLE group had worse allograft [hazard ratio (HR) 1.09, P < 0.05] and recipient (HR 1.19, P < 0.05) survival compared with the DM group. Subgroup analysis based on the type of donor showed that SLE patients who received deceased donor allograft had worse allograft and recipient survival (HR 1.14, P = 0.002 and HR 1.30, P = 0.001, respectively) compared with non-SLE deceased donor allograft recipients. Among living allograft recipients, there were no significant differences in either allograft or recipient survival compared with non-SLE recipients. CONCLUSIONS: SLE as a cause of ESRD in renal transplant recipients is associated with worse allograft and recipient survival compared with DM; this association is true for the entire population and for the recipients of deceased donor (but not living donor) transplant. Deceased donor allograft recipients have worse outcomes compared with living allograft recipients.     

Predictive value of urinary retinol binding protein for graft dysfunction after kidney transplantation

High concentrations of retinol binding protein (RBP) are found in the urine of patients with tubulointerstitial injury. We evaluated the predictive value of urinary RBP (RBPu) for development graft dysfunction after kidney transplantation. METHODS: Serum creatinine and RBPu were prospectively measured at months 3, 6, and 12 in 221 kidney transplant patients. Baseline graft function was defined as the lowest serum creatinine value during the first 3 months after transplantation. Graft dysfunction was assessed at 1 year as a >-20% or >-30% change in the inverse creatinine ((Delta)1/Cr) compared to baseline value at month 3. RESULTS: Among 183 patients with normal graft function (Cr 0.6 mg/L (95% CI = -13% to -1.3%, P =.018). The percentage of patients with >-20% or >-30% (Delta)1/Cr was higher among patients with RBPu > 0.6 mg/L (34% vs 47%, P =.042; 21% vs 34%, P =.035). RBPu > 0.6 mg/L was the only variable independently associated with >-30% (Delta)1/Cr at 1 year, with an odds ratio (OR) of 1.95 (95% CI 0.99 to 3.80, P =.05). CONCLUSIONS: RBPu may serve as a surrogate marker for graft dysfunction early after transplantation for patients with normal graft function, allowing early institution of intervention therapies to prolong allograft survival.     

Pre-transplant predictors of cerebrovascular events after kidney transplantation.

BACKGROUND: We evaluated cerebrovascular events (CVE) after kidney transplantation (KTx) and sought to identify pre-transplant predictors of transient ischaemic attacks (TIA) and strokes post-transplantation. METHODS: A total of 1617 consecutive kidney and 16 kidney-pancreas recipients transplanted between 1995 and 2005 were analysed in this retrospective single-centre study. Risk factors for CVE, e.g. recipient and donor age and gender, diagnosis of chronic kidney disease, end-stage renal disease (ESRD) duration, histories of hypertension, hyperlipidaemia, smoking, atrial fibrillation (AF), diabetes mellitus (DM), ischaemic heart, peripheral- and cerebro-vascular disease, as well as pre-transplant myocardial infarction or CVE (i.e. TIA/strokes) were analysed. Furthermore, the predictive value of pre-transplant screening tests, i.e. echocardiography (n = 1184) and carotid ultrasound (n = 922), was investigated. RESULTS: During a median follow-up of 4 years, 64 CVE (54 strokes and 10 TIA) were observed. Nineteen (5.1%) of 373 deceased patients died from fatal stroke. Recipient age, history of AF and hyperlipidaemia (P = 0.00, respectively), reduced left ventricular function (LVF) (P = 0.01) and the degree of stenosis by carotid ultrasound (P = 0.002), duration of ESRD (P = 0.03) and interstitial nephritis as renal disease cause (P = 0.04) evolved as predictors of TIA/stroke post-transplant in univariate analysis. In multivariable analysis, AF (P = 0.001) and DM (P = 0.037) were significant predictors for post-transplant CVE. CONCLUSIONS: AF and DM are independent predictors of CVE after KTx. Beyond their general ability to detect sev- erely comorbid patients, pre-transplant screening tests (e.g. carotid ultrasound or echocardiography) were not able to identify renal transplant candidates at risk for CVE after transplantation.     

Marital quality in kidney transplant recipients: easy to predict, hard to neglect

BACKGROUND: Given the significant role of post-renal transplant familial support in the patient's adherence to treatment, a study into the contributors to marital quality in this population seems necessary. This study sought to identify the predictors of poor post-renal transplant marital quality. METHODS: This cross-sectional study was conducted in 2006 on 125 married kidney transplant recipients. Marital quality was evaluated using the Revised Marital Adjustment Scale (RMAS). A score below the fourth-quartile MAS score of a group of age- and sex- matched healthy controls was interpreted as poor marital relationship. Multiple logistic regression analysis was utilized to evaluate the predictors of poor marital relationship. RESULTS: The mean time interval between transplantation and assessment of marital quality was 43 +/- 15 months. Poor post-renal transplant marital quality can be predicted by the kidney transplant recipient's sex (M/F) (odds ratio [OR]; 0.31; 95% confidence interval [CI], 0.11 to 0.90; P=.031), age at transplantation (OR, 0.93; 95% CI, 0.89 to 0.98; P=.005), educational level (OR, 0.67; 95% CI, 0.44 to 1.03; P=.067), and monthly family income (OR, 2.20; 95% CI, 1.09 to 4.44; P=.028). CONCLUSION: Presenting a simple prediction model for poor post-renal transplant marital relationship, this study will make it possible to detect patients at a higher risk of poor marital quality and thus avoid treatment noncompliance. At the time of transplantation, using simple demographic variables and providing couple-based health education programs as a part of a familial approach to renal transplantation may improve the outcome of such high-risk patients.     

Vascular complication and Doppler ultrasonographic finding after renal transplantation

OBJECTIVES: Vascular complications are common after renal transplantation. In this study we correlated Doppler sonographic indices and transplant kidney function. METHODS: We reviewed data on 244 renal transplant patients. Doppler ultrasonographic evaluation was performed during the first 2 weeks after renal transplantation. We determined resistive index (RI) and pulsatility index (PI) in the interlobar arteries and thrombosis of renal and lower limb veins. Serum creatinine (Cr) and cyclosporine levels were evaluated prior to sonographic assessment. RESULTS: The mean age of the 142 male and 102 female patients was 36.31 +/- 3.30 years. Prevalence of real artery stenosis was 9.5%. In these patients the mean serum Cr level (2.21 +/- 1.83 mg/dL) was significantly higher than among patients with patent renovascular tributary (1.49 +/- 1.00 mg/dL; P=.03). RI and PI were also significantly correlated with serum Cr(P=.05 and .001, respectively). There was no relationship between cyclosporine level or panel-reactive antibody with RI and PI. Retransplant patients showed higher RI than first renal allograft recipients (0.72 +/- 0.16 vs 0.63 +/- 0.11; P=.006). Serum Cr level was higher among renal allograft recipients with Doppler evidence of thrombosis of the lower limb veins (3.1 +/- 0.98 mg/dL versus 1.56 +/- 1.13 mg/dL; P=.04). CONCLUSIONS: RI and PI are two valuable Doppler ultrasonographic markers to determine renal allograft function and related vascular complications.