End-to-side versus end-to-end uretero-ureteral anastomosis in preemptive kidney transplantation from living donors: A monocentric experience.

PURPOSE: End-to-end (ETE) pyeloureterostomy is an alternative to ureteroneocystostomy for urinary anastomosis during kidney transplantation (KT). In preemptive KT from living donors (PKT-LD), end-to-side (ETS) uretero-ureteral anastomosis could have the benefits of pyeloureterostomy without ligation of the native kidney ureter. This study aimed to compare ETS to ETE uretero-ureteral anastomosis in PKT-LD. METHODS: A monocentric retrospective 8-year study included all consecutive cases of PKT-LD, excluding ureteroneocystomy anastomosis and homolateral nephrectomy. Two groups were compared: ETS and ETE. Perioperative data on graft function and urological complications were collected. RESULTS: One hundred and six patients were included: 48 patients in the ETS group and 58 patients in the ETE group. Median follow-up was 37.5 months [17.3; 57.5]. The estimated glomerular filtration rate at postoperative day ten and 3 months was similar in both groups. The overall complication rate was 16%, with no significant difference between the 2 groups. There was one ureteral stenosis in each group. None of the patients in the ETS group presented urinary fistula, whereas it occurred in one (1.7%) in the ETE group. Back pain due to native kidney obstruction occurred in 5 patients in the ETE group (8.6%), but not in the ETS group. CONCLUSION: In preemptive kidney transplantation from living donors, urinary anastomosis can safely be performed as an end-to-side uretero-ureteral anastomosis, with low urological complications. It could prevent symptoms and complications due to native kidney obstruction. LEVEL OF EVIDENCE: IV.

Urinary mRNA for the Diagnosis of Renal Allograft Rejection: The Issue of Normalization.

Urinary messenger RNA (mRNA) quantification is a promising method for noninvasive diagnosis of renal allograft rejection (AR), but the quantification of mRNAs in urine remains challenging due to degradation. RNA normalization may be warranted to overcome these issues, but the strategies of gene normalization have been poorly evaluated. Herein, we address this issue in a case-control study of 108 urine samples collected at time of allograft biopsy in kidney recipients with (n = 52) or without (n = 56) AR by comparing the diagnostic value of IP-10 and CD3ε mRNAs-two biomarkers of AR-after normalization by the total amount of RNA, normalization by one of the three widely used reference RNAs-18S, glyceraldehyde-3-phosphate dehydrogenase (GAPDH) and Hypoxanthine-guanine phosphoribosyltransferase (HPRT)-or normalization using uroplakin 1A (UPK) mRNA as a possible urine-specific reference mRNA. Our results show that normalization based on the total quantity of RNA is not substantially improved by additional normalization and may even be worsened with some classical reference genes that are overexpressed during rejection. However, considering that normalization by a reference gene is necessary to ensure polymerase chain reaction (PCR) quality and reproducibility and to suppress the effect of RNA degradation, we suggest that GAPDH and UPK1A are preferable to 18S or HPRT RNA.

Early Low Urinary CXCL9 and CXCL10 Might Predict Immunological Quiescence in Clinically and Histologically Stable Kidney Recipients.

We monitored the urinary C-X-C motif chemokine (CXCL)9 and CXCL10 levels in 1722 urine samples from 300 consecutive kidney recipients collected during the first posttransplantation year and assessed their predictive value for subsequent acute rejection (AR). The trajectories of urinary CXCL10 showed an early increase at 1 month (p = 0.0005) and 3 months (p = 0.0009) in patients who subsequently developed AR. At 1 year, the AR-free allograft survival rates were 90% and 54% in patients with CXCL10:creatinine (CXCL10:Cr) levels <2.79 ng/mmoL and >2.79 ng/mmoL at 1 month, respectively (p < 0.0001), and 88% and 56% in patients with CXCL10:Cr levels <5.32 ng/mmoL and >5.32 ng/mmoL at 3 months (p < 0.0001), respectively. CXCL9:Cr levels also associate, albeit less robustly, with AR-free allograft survival. Early CXCL10:Cr levels predicted clinical and subclinical rejection and both T cell- and antibody-mediated rejection. In 222 stable patients, CXCL10:Cr at 3 months predicted AR independent of concomitant protocol biopsy results (p = 0.009). Although its positive predictive value was low, a high negative predictive value suggests that early CXCL10:Cr might predict immunological quiescence on a triple-drug calcineurin inhibitor-based immunosuppressive regimen in the first posttransplantation year, even in clinically and histologically stable patients. The clinical utility of this test will need to be addressed by dedicated prospective clinical trials.

Outcome of kidney transplantations performed with preformed donor-specific antibodies of unknown etiology.

The detection of preformed donor-specific alloantibodies (DSA) with multiplex-bead arrays has led to the common observation that individuals without a history of pregnancy, transfusion or transplantation can have circulating anti-HLA antibodies of unknown etiology. We retrospectively analyzed the risk of antibody-mediated rejection (AMR) and graft outcome in 41 kidney transplant recipients with DSA of unknown etiology (DSA cause-unk) at the time of transplantation. Twenty-one patients received a posttransplantation desensitization protocol, and 20 received standard immunosuppressive therapy. The mean number of DSA was 1.4 ± 0.8, ranging from 1 to 5. Complement-dependent cytotoxicity crossmatches were negative for all the patients. Flow cytometry crossmatches were positive in 47.6% of cases. The incidence of acute AMR was 14.6% at 1 year, regardless of the immunosuppressive regimen. No patients experienced graft loss following AMR. At month 12, across the entire population of patients with DSA cause-unk, the outcomes were favorable: the measured glomerular filtration rate was 63.8 ± 16.4 mL/min/1.73 m(2), the screening biopsies showed low frequencies of microvascular inflammation and no transplant glomerulopathy, and graft and patient survival were 100%. In conclusion, patients with DSA cause-unk are able to mount AMR but have favorable 1-year outcomes.

[From retroperitoneal fibrosis to gastric linitis]. / De la fibrose rétropéritonéale à la linite gastrique.

Retroperitoneal fibrosis may reveal many diseases, including neoplasias. An 83-year-old man presented with an acute renal failure due to compressive retroperitoneal fibrosis. Clinically the only abnormal feature was a cutaneous subclavicular infiltrated lesion and laboratory features included hypereosinophilia, anemia and elevated acute phase reactants. A thoracic CT-scan showed pleuritis and para-esophageal lymph node and the 18FDG-PET-scan an hypermetabolism lesion of the oesophagus. Gastroscopy and colonoscopy found a gastric linitis, already multi-metastatic at diagnosis. The gastric linitis can present with many decepting clinical forms, increasing the risk of delayed diagnosis.

Characteristics and regional variations of group D streptococcal endocarditis in France.

The proportion of infective endocarditis (IE) caused by group D streptococci (GDS; formerly Streptococcus bovis) increased markedly in France, to account for 25% of all cases of IE by 1999. In an attempt to explain this phenomenon, a comparative analysis of GDS and oral streptococci (OS) causing IE was performed. This study was based on data collected from a large cross-sectional population-based survey that was conducted in 1999. In total, 559 cases of definite IE were recorded, of which 142 involved GDS and 79 involved OS. Patients with GDS IE were older (62.7 vs. 56.6 years, p 0.01) and had a history of valve disease less frequently than did patients with OS IE (33.8% vs. 67.1%, p <0.0001). At-risk procedures for IE were performed less frequently in patients with GDS than in patients with OS (14.8% vs. 24.1%, p 0.08), but co-morbidities were more frequent in the GDS group (59.9% vs. 32.9%, p 0.0001). Diabetes, colon diseases and cirrhosis were also more frequent in the GDS group (p 0.006, p <0.0001 and p 0.08, respectively). Rural residents accounted for 31.0% of the GDS group, but for only 15.2% of the OS group (p 0.001). Likewise, the proportion of GDS IE was higher in regions with mixed (urban and rural) populations (Franche-Comté 81.8%, Marne 68.7%, Lorraine 70.3% and Rhône-Alpes 65.3%) than in exclusively urban regions (Paris and Ile de France 58.0%). Further investigations are required to elucidate the link in France between the incidence of GDS IE, rural residency and nutritional factors.

[First reported cases of Streptococcus pyogenes meningitis in Central African Republic]. / Premiers cas de méningites à streptocoque du groupe à rapportés en République Centrafricaine.

Streptococcus pyogenes or group A streptococcus is an uncommon cause of bacterial meningitis. The purpose of this report is to describe two cases of Streptococcus pyogenes meningitis observed in Bangui, Central African Republic. The first case occurred in a 44-year-old woman who also presented pyodermitis. The second case involved a 34-year-old woman who also presented chronic middle ear infection and AIDS. Both strains of Streptococcus pyogenes were classified as biotype group 5 and showed resistance to tetracycline. They were also T-nontypable and of the emm 117 genotype and 117.1 subtype. Pulsed-field gel electrophoresis confirmed that both strains originated from the same clone.

[Evaluation of Prolex for the rapid identification of streptococci isolated in medical microbiology]. / Evaluation de Prolex pour l'identification rapide des streptocoques isolés en microbiologie médicale.

The need to rapidly identify streptococci responsible for acute infectious diseases has led to the development of agglutination techniques that are able to identify streptococcal group antigens (A, B, C, D, F, and G) directly from primoculture colonies on blood agar. The Prolex agglutination tests (Pro-Lab Diagnostics, Richmond Hill, Ontario, Canada), distributed in France by i2a, have been used for the determination of group antigens of 166 isolates of streptococci and enterococci previously identified in the National Reference Center for Streptococci. The results obtained with the Prolex reagents have permitted to correctly identify all pyogenic beta-hemolytic streptococci (23 Streptococcus pyogenes, 21 Streptococcus agalactiae, 33 Streptococcus dysgalactiae subsp. equisimilis including 6 group C and 27 group G, and 5 Streptococcus porcinus including 4 group B). Four differences between unexpected agglutinations (A or F) and species identifications have been obtained. These differences were observed for four non-hemolytic isolates of Streptococcus mutans, Streptococcus gordonii, Streptococcus infantarius, and Streptococcus suis. The anti-D reagent has been of value as a marker for isolates of enterococci. Thus, these results confirm the abilities of these agglutination tests for the grouping of beta-hemolytic streptococci. Moreover, the use of Prolex has the advantage to be rapid because of the non-enzymatic but chemical extraction of streptococcal antigens.

Induction of a mucosal immune response to the streptococcal M protein by intramuscular administration of a PADRE-ASREAK peptide.

In a previous study, it was shown that an intramuscular administration of amino acid PADRE-ELDKWA sequence induced a mucosal immune response to a conserved epitope of human immunodeficiency virus in mice. In the same model, here it is shown that this method can be used with a selected peptide from the M protein of group A streptococci. The PADRE-ASREAK sequence was injected in mice by the intramuscular route. Antibodies against M protein were detected in extracts of mucosal tissues and in serum. The repertoire isotypes of serum immunoglobulin G (IgG) and mucosal IgA and IgG antibodies varied, according to the dose of injected peptide. The highest mucosal IgA antibody response was obtained with 0.01 micro g of antigen per injection, whereas the systemic IgG antibody response increased with 10 micro g of antigen. Mucosal antibody production against streptococci was confirmed by immunofluorescence analysis. These results provide evidence that this novel approach of mucosal vaccination may be of advantage for bacterial systems and suggest a new field of investigation based on synthetic peptide analogues.