Sporotrichosis in renal transplant patients

The current report describes two renal transplant recipients who presented with sporotrichosis. In addition, the authors review the general aspects of sporotrichosis in renal transplant recipients reported in the literature. Sporotrichosis is a rare fungal infection in transplant patients and has been reported primarily in renal transplant recipients not treated with antifungal prophylaxis. Extracutaneous forms of sporotrichosis without skin manifestations and no previous history of traumatic injuries have been described in such patients and are difficult to diagnose. Renal transplant recipients with sporotrichosis described in the present report were successfully treated with antifungal therapy including amphotericin B deoxycholate, lipid amphotericin B formulations, fluconazole and itraconazole.     

Hyperlipidaemia in renal transplant patients

Aakhus S, Dahl S, Widerøe TE (Sections of Cardiology and Nephrology, Department of Medicine, University Hospital of Trondheim, Trondheim, Norway). Hyperlipidaemia in renal transplant patients. J Intern Med 1996; 239: 407–15. Objectives. The aim of study was to assess the prevalence and severity of hyperlipidaemia in renal transplant patients in a Nordic country. Design. Multicentre, cross-sectional study. Setting. Outpatients and ward inpatients registered from 23 hospitals covering all regions of the country. Subjects. Renal transplant patients with a functioning graft were registered: 406 patients in all; that is, 43% of the national renal transplant population. All patients used prednisolone, 71% used cyclosporine, either with (51%) or without (20%) azathioprine. Total cholesterol values from general population were obtained from a national survey. Main outcome measures. Blood lipids and their relation to clinical parameters. Results. Total cholesterol was significantly higher in transplant patients than in the general population for both genders and all age groups (P<0.01). Female patients had higher total cholesterol (mean±SD: 7.49±1.61mmolL^-1) than males (7.01±1.55mmolL^-1; P<0.001), and also higher HDL cholesterol (1.55±0.43 vs. males: 1.32±0.46mmolL^-1; P<0.001). Triglycerides were equally elevated in both genders, and 33% had values above 2.2mmolL^-1. Reduced creatinine clearance, a high body-mass index, female gender, hypertension, and coronary artery disease were independently associated with higher total cholesterol. Beta blockers were associated with lower HDL cholesterol and higher triglycerides, and diuretics with higher triglycerides. Blood lipid levels were not associated with cyclosporine immunosuppression. Conclusion. Hyperlipidaemia is prevalent after renal transplantation, and is associated with impaired graft function, hypertension, and with the use of beta blockers and diuretics, but not with the use of cyclosporine.     

Nutritional considerations in renal transplant patients

In renal transplant patients, weight gain generally increases after renal transplantation, which will be influenced by improved appetite and a reversal of the uremic state. However, at least in the early posttransplant period, the increase in body weight is mainly due to an increase in body fat mass. This phenomenon may be partly due to relatively high doses of steroids in the early period after renal transplantation, possibly mediated by their inhibiting effect on lipid peroxidation, but also appears to be related to physical inactivity. The increase in body fat mass may contribute to posttransplant hyperlipidemia, which is improved but not completely normalized by dietary intervention. Current dietary recommendations in stable renal transplant patients do not generally differ from those of the general population, although intense dietary counselling may be indicated in patients with excessive posttransplant weight gain. The effect of supervised exercise training on body composition is currently under investigation.     

Hepatitis B in renal transplant patients

Hepatitis B virus(HBV) poses a significant challenge for both dialysis patients and kidney transplant recipients despite its decreasing rates, especially in developed countries. The best preventive method is vaccination. Patients with chronic renal disease should ideally be vaccinated prior to dialysis, otherwise, reinforced vaccination practices and close antibody titer monitoring should be applied while on dialysis. HBV infected dialysis patients who are renal transplant candidates must be thoroughly examined by HBV-DNA, and liver enzyme testing and by liver biopsy. When needed, one must consider treating patients with tenofovir or entecavir rather than lamivudine. Depending on the cirrhosis stage, dialysis patients are eligible transplant recipients for either a combined kidney-liver procedure in the case of decompensated cirrhosis or a lone kidney transplantation since even compensated cirrhosis after sustained viral responders is no longer considered an absolute contraindication. Nucleoside analogues have led to improved transplantation outcomes with both long-term patient and graft survival rates nearing those of HBs Ag(-) recipients. Moreover, in the cases of immunized HBs Ag(-) potential recipients with concurrent prophylaxis, we are enabled today to safely use renal grafts from both HBs Ag(+) and HBs Ag(-)/antiHBc(+) donors. In so doing, we avoid unnecessary organ discarding. Universal prophylaxis with entecavir is recommended in HBV kidney recipients and should start perioperatively. One of the most important issues in HBV(+) kidney transplantation is the duration of antiviral prophylaxis. In the absence of robust data, it seems that prophylactic treatment may be discontinued in selected stable, low-risk recipients during maintenance immunosuppression and should be reintroduced when the immune status is altered. All immunosuppressive agents in kidney transplantation can be used in HBV(+) recipients. Immunosuppression is intimately associated with increased viral replication; thus it is important to minimize the total immunosuppression burden long term.     

Persistent hyperlipidemia in renal transplant patients

The exact nature and significance of posttransplant hyperlipidemia is controversial. In the present study, serum lipids were examined in 201 clinically stable renal transplant recipients before, 1 year after, and at the time of the last follow-up, 5.0 +/- 0.1 yr after transplantation. Hypertriglyceridemia, present in 36% of patients treated with dialysis before transplantation, occurred in 23% 1 year after successful transplantation. At last follow-up, 29% had elevated triglyceride levels. Hypercholesterolemia, present in only 8% of patients before transplantation, was found in 27% 1 year after receiving a renal allograft. At the time of last follow-up, 30% had elevated cholesterol levels. HDL cholesterol levels were normal 1 year after transplantation, and increased significantly during the posttransplant follow-up period. Multivariate stepwise linear regression analysis was used to determine factors independently associated with serum lipid levels. Age, body weight, pretransplant serum lipids, and variables linked to allograft function (urine protein excretion, serum creatinine, and the use of loop diuretics) were independently associated with posttransplant cholesterol and triglycerides. Diabetes, the use of alternate day steroids, beta-adrenergic-blocking antihypertensive medications, and thiazide diuretics were not linked to hyperlipidemia. In addition, changes in variables associated with renal function helped to explain why different factors were associated with lipid levels at 1 year than at the time of last follow-up. Thus, the results of this study suggest that hyperlipidemia is a frequent and persistent complication in clinically stable renal transplant recipients. Multiple factors, including several associated with declining allograft function, appear to be involved in the pathogenesis of posttransplant hyperlipidemia.     

Anal cancer in renal transplant patients

Purpose A comprehensive literature review was performed to examine the prevalence of anal cancer, anal intraepithelial neoplasia (AIN) and anal human papillomavirus (HPV) infection in renal transplant recipients who are at risk of anal cancer due to iatrogenic immunosuppression.Methods Pertinent articles were identified from searches performed on the National Center for Biotechnology Information database using the following keywords: anal cancer, AIN, screening, renal transplant (or kidney transplant), organ transplant recipients and post-transplant malignancies.Results The prevalence of AIN is 20% in renal transplant patients. The prevalence of anal HPV infection in established transplant patients is 47%, and the prevalence of anal HPV infection in new transplant patients is 23%. The relative risk for anal cancer in renal transplant patients is 10.Conclusions As compared to HIV-positive male patients who practise anal intercourse, renal transplant patients showed a modest rise in relative risk for anal cancer. Screening programmes to detect AIN in HIV-positive patients who practise anal intercourse have been introduced on a preliminary basis in sexual health clinics in the US and may become standard practise in this population. The case for screening in renal transplant patients is unclear and would merit further investigation, especially with reference to the prevalence of anal HPV infection in this population. It may transpire that renal transplant patients would benefit more from HPV prophylaxis rather than screening for AIN.     

Infectious arthritis in renal transplant patients

Infectious complications in the renal transplant patient are common, and infecting agents include opportunistic organisms as well as common pathogens. However, we were only able to document 6 patients who had septic arthritis from more than 800 who received a renal transplant at our institution over an 18-year period. Furthermore, only 16 other cases of infectious arthritis have been reported in the literature. All of our patients had an apparent predisposing factor and 3 patients had prior infection with the same organism. The knee was the most commonly infected joint. The initial synovial fluid white blood cell count was usually greater than 30,000 cells/mm3, but 1 patient with viral arthritis initially had noninflammatory fluid. The peripheral blood white blood cell count may not be elevated. All of our cases of initial joint infection occurred by 18 months posttransplant. Blood cultures were positive in 3 of 4 patients with bacterial infection. Followup of these 6 patients averaged 4.3 years. Numerous other rheumatologic syndromes and disorders peculiar to the posttransplant period may mimic a septic joint. Consequently, despite the low frequency of occurrence of septic arthritis, persistent attention to the locomotor system in the transplant patient is warranted.     

Occult hepatitis B in renal transplant patients

BACKGROUND: Occult hepatitis B (HB) is characterized by the presence of HBV-DNA in patients who do not have HB surface antigen (HBsAg) detectable in sera, and is frequently described in patients with hepatitis C virus (HCV) infection. These viral liver diseases are common and may have a negative impact on the survival of renal transplant patients, especially if they are both present. In this study we aimed to evaluate the prevalence of occult HB in renal transplant patients either with or without HCV infection. PATIENTS AND METHODS: In a cross-sectional survey 101 HbsAg-negative renal transplant patients were evaluated; 51 were anti-HCV positive. Sera were analyzed for the presence of the S and core genes of the HBV-DNA by a nested polymerase chain reaction technique. Markers of HBV infection and liver function tests were also analyzed. RESULTS: The core gene was identified in 1 HCV-infected patient and 1 anti-HCV-negative patient who also presented the S gene (prevalence: 2% and 1% for each gene, respectively). HCV-infected patients had longer pre-transplant dialysis time (50.8 +/- 34.6 vs. 32.0 +/- 20.9; P < 0.001). Liver function tests were also increased in the HCV-infected group: alanine aminotransferase (P < 0.001), aspartate aminotransferase (P < 0.05), gamma-glutamyl transpeptidase (P<0.02), and alkaline phosphatase (P < 0.04). Multivariate analysis revealed that HCV infection was the only determinant of the altered results of the liver function tests. CONCLUSION: We found that occult HB is a condition present in our population of renal transplant patients and that HCV infection does not seem to be associated with occult HB infection in this setting.     

巴利昔单抗联合小剂量抗人T细胞兔免疫球蛋白诱导在肾移植中的应用效果分析

目的分析在肾移植免疫诱导治疗中联合使用巴利昔单抗和小剂量抗人T细胞兔免疫球蛋白(ATG-F)的安全性和有效性。方法回顾分析2014-01-01～2014-12-31在该院首次行同种异体肾移植术受者的临床资料以联合使用巴利昔单抗和ATG-F免疫诱导治疗的受者作为观察组,其对侧供肾受者且接受ATG-F单诱导者作为对照组,两组均采用他克莫司(FK-506)+霉酚酸酯+美卓乐三联维持治疗,共14对患者入组观察。对比两组患者术后1年内移植肾功能延迟恢复(DGF)、急性排斥反应(AR)、肺部感染和继发性糖尿病的发生率,以及肾功能、血FK-506谷浓度的差异。结果两组术后1年内均无移植肾失功及死亡患者。观察组和对照组的AR的发生率分别为14.29%(2/14)、7.14%(1/14),DGF的发生率分别为14.29%(2/14)、14.29%(2/14),观察组未出现继发性糖尿病,对照组出现1例,差异均无统计学意义(P0.05)。观察组术后1年内肺部感染的发生率为14.29%(2/14),对照组为21.43%(3/14),差异无统计学意义(P0.05)。观察组FK-506谷浓度在术后第3个月、6个月、9个月显著低于对照组(P0.05)。结论巴利昔单抗联合ATG-F的免疫诱导方案能有效预防肾移植术后排斥反应,不增加感染性并发症的发生率,同时可减少早期肾移植患者体内钙调神经蛋白抑制剂(CNIs)类药物的暴露量。     

Urinary tract infection in renal transplant patients

Summary The incidence of urinary tract infections (UTI) in 299 renal graft transplantations (281 patients) was analyzed. UTI episodes were demonstrated in 185 grafts (62%), most frequently in the first month after transplantation. The infectious episodes were mostly recurrent. Persistent infection, detected in 11% of grafts, was associated with urologic complications in almost all cases. No significant correlation between the primary renal disease and the UTI rate was found, and there was no significant correlation between UTI and sex. In grafts with recurrent infectious episodes, vesicoureteral reflux was more common. No significant difference was observed in the residual bladder volume, irrespective of whether infection was present or not. The urine was infected by a number of hospital strains, particularlyKlebsiella, Enterobacter and indole-positiveProteus strains. An overwhelming majority of UTI episodes (96%) were asymptomatic. Antibody-coated bacteria in urinary sediment were present in only 19% of infectious episodes. Clinically severe courses were observed in infections associated with urologic complications (especially urinary fistulae); these were difficult to treat and were often a source of sepsis and a risk factor in graft loss.

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Harnwegsinfektionen nach Nierentransplantation

Zusammenfassung Die Häufigkeit von Harnwegsinfektionen (HWI) bei 299 Nierentransplantaten (281 Kranken) wurde analysiert. HWI-Episoden wurden bei 185 Transplantaten festgestellt (62%), vorwiegend im ersten Monat nach der Transplantation. Die Infektions-Episoden waren meistens Rezidive. Eine persistierende Infektion (in 11% der Transplantate) trat fast immer im Zusammenhang mit einer urologischen Komplikation, insbesondere als Folge einer Harnfistel auf. Es wurde keine signifikante Korrelation zwischen der primären Nierenerkrankung und HWI nachgewiesen, zwischen der Rate an HWI und Geschlecht bestand ebenfalls keine signifikante Korrelation. In Transplantaten mit rezidivierenden Infektionen fand sich sehr oft ein vesikoureteraler Reflux. Es wurden keine signifikanten Unterschiede in der Größe der Restharnmenge bei Patienten mit oder ohne Infektion beobachtet. Der Urin war häufig mit Erregern wieKlebsiella, Enterobacter und Indol-positivenProteus-Stämmen infiziert. Der größte Teil der HWI-Episoden (96%) verlief asymptomatisch. Antikörper-beladene Bakterien im Harnsediment fanden sich nur bei 19% der Infektions-Episoden. Ein klinisch schwerer Verlauf von HWI war vor allem mit urologischen Komplikationen, vor allem Harnfisteln, verbunden; diese Infektionen waren schwer therapierbar und häufig die Ursache einer Sepsis bzw. von Transplantat-Verlust.

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This paper is dedicated to Prof. Dr. med.H. Losse, Münster, on the occasion of his 65th birthday.     

Abdominal aortic aneurysmectomy in renal transplant patients

Because renal transplantation is allowing an increased number of patients to survive for prolonged periods, abdominal aortic aneurysms can be expected to occur with growing frequency in these patients. Surgical management of such cases involves the provision of allograft protection. To date, the literature contains 15 reports of abdominal aortic aneurysms in renal allograft recipients. We describe a 16th case and discuss the management of these patients.     

Increased platelet activation in renal transplant patients

BACKGROUND: Patients with functioning renal transplants are at risk of graft thrombosis in the postoperative period, and of fistula thrombosis and other thrombotic events thereafter. Investigation and therapeutic manipulation of haemostasis in these patients offers a means to counter this thrombotic tendency. METHODS: Platelet aggregation in whole blood, plasma von Willebrand factor and plasma fibrinogen levels were measured in 32 stable renal transplant patients (creatinine <200 micromol/litre, age of graft >4 months) and in 32 age, sex and smoking-habit matched normal controls. RESULTS: In both patient and control groups, seven patients were smokers and the remaining 25 were non-smokers. There was no significant difference in age between patients and controls [patients, median: 39 (20-64) years; controls: 38 (24-60) years]. Spontaneous platelet aggregation was significantly higher in the patients at all time points studied [30s-6 min; at 4 min: patients median (interquartile range) 19.4 (11.3-27.3)%; controls, 8.0 (5.1-15.0)%, P < 0.0005]. ADP-induced aggregation was also increased at a concentration range of 0.1-3 microM (at 1 microM, 1 min, patients median (interquartile range) was 52.4 (30.5-70.0)%; controls was 16.5 (1.4-31.4)%, P < 0.0001). Transplant patients had significantly higher von Willebrand factor and fibrinogen levels compared with the controls (von Willebrand factor, patients median (range): 158 (13-269)%; controls: 85 (43-223)%, P < 0.00001; fibrinogen, patients: 3.29 (2.12-7.39) g/litre; controls: 2.81 (1.84-4.65) g/litre, P < 0.0002). CONCLUSION: Patients with stable renal transplants have in vitro evidence of enhanced platelet activation, and increased plasma von Willebrand factor and fibrinogen levels.     

Azathioprine and hepatic venocclusive disease in renal transplant patients

We report 3 cases of hepatic venocclusive disease occurring in renal transplant patients receiving azathioprine and combine our experience with 4 other previously reported cases. The data suggest a clinical syndrome characterized by (a) delayed clinical onset, (b) striking male predominance, (c) presentation with jaundice followed by evidence of portal hypertension, and (d) poor prognosis. One of our patients, who is still alive 40 mo after the first onset of symptoms of liver disease, showed striking clinical improvement with discontinuation of azathioprine and subsequent deterioration on reinstitution. We suggest that azathioprine may be closely linked with the development of venocclusive disease in renal transplant patients and that the frequency of this disorder may be more common than previously reported. To attempt to prevent a fatal outcome, this group of patients should be closely monitored for the earliest signs of hepatic venocclusive disease through periodic serum bilirubin and alkaline phosphatase determinations. Patients with abnormal tests should undergo liver biopsy. If hepatic venocclusive disease is found, prompt withdrawal of azathioprine is indicated.