Full Correction of Posttransplant Anemia Is Associated With Stabilized Cardiac Dimensions Among Kidney Transplant Recipients: A Prospective Randomized Controlled Trial.

OBJECTIVES: Posttransplant anemia might be associated with cardiovascular morbidity and increased mortality. To our knowledge, the debate on anemia correction has neither been revisited nor decided definitively. We aimed to assess the effects of full correction of posttransplant anemia on the cardiovascular system and quality of life among renal transplant recipients with stable graft function who were using erythropoietin-stimulating agents. MATERIALS AND METHODS: We enrolled 247 kidney recipients with stable graft function to be assessed for anemia. Eligible patients were randomized to achieve targeted hemoglobin of 11 to 12 g/dL (group 1, n = 183) or of 13 to 15 g/dL (group 2, n = 64) with the use of erythropoietin-stimulating agents. Patients underwent monthly clinical and laboratory evaluations of kidney graft function. Quality of life and echocardiography were assessed at study start and at 12 months. RESULTS: The 2 groups were comparable regarding pretransplant characteristics. In group 2, we observed comparable posttransplant complications (P > .05) but better graft function at 6 months and better cardiac indexes at 1 year of the study (P < .05). At 12 months, quality of life had improved after full correction of posttransplant anemia in the renal transplant recipients who received erythropoietinstimulating agents. CONCLUSIONS: Full correction of posttransplant anemia in renal transplant recipients was associated with improved quality of life and cardiac indexes without an effect on cardiovascular comorbidity.

End-to-side versus side-to-side anastomosis with distal vein ligation for arteriovenous fistula creation.

INTRODUCTION: There is lack of compelling evidence about the best technique to carry out the anastomosis between the artery and the vein: end to side or side to side. This issue was addressed by very few randomized controlled studies. This topic has recently re-emerged with the advent of the endovascular fistula creation using the side-to-side technique.Objectives: To compare the results of both surgical techniques for the creation of arteriovenous anastomosis. METHODS: This is a randomized controlled prospective study. All renal failure patients, 18 years and older, referred to our institution requiring creation of a new arm arteriovenous fistulas, including distal radio-cephalic, ulno-basilic, proximal brachio-cephalic or brachio-basilic configurations were included. RESULTS: Between February 2018 and October 2018, 378 patients underwent creation of permanent haemodialysis access. A total of 100 patients were randomized equally into the end-to-side and side-to-side groups. Follow-up for the study purpose continued until May 2019 (mean = 9 months, range 1-12). Patients' age ranged from 19 to 68 years. Sevety-seven arteriovenous fistulas were created at the elbow (37 brachio-basilic and 40 brachio-cephalic). Radio-cephalic fistulae were 23, created at wrist and in the forearm. Primary technical success was 97%, and 35 (70%) and 17 (34%) cases achieved functionally maturation in the end-to-side and side-to-side groups, respectively (P = 0.0001). Primary and secondary patency rates at 12 months were 76% end to side versus 78% STS (P = 0.381) and 84% end to side versus 86% STS (P = 0.225), respectively. CONCLUSION: End-to-side technique should be used in all instances of arteriovenous fistulas creation.

Reprocessing practices for gastrointestinal endoscopes: a multicentre study in Egyptian university hospitals.

The aim of this study was to assess the practices of health care workers during gasterointestinal endoscope reprocessing, evaluate their knowledge about reprocessing, and verify their compliance with laboratory and microbiological tests in endoscopy units at Zagazig University and Fayoum University hospitals. All nursing staff on duty from 10 endoscopy units, with 16 flexible endoscopes, were included. Knowledge and practice were assessed by a questionnaire and a checklist. The mean knowledge score was 7.5 (SD 1.9), which was poor. Compliance was 90% for disinfection and 74% for endoscope processing after disinfection. Before reuse after cleaning, no organisms were detected in 5 endoscopes, while 8 colony forming units were found in 2. Pseudomonas aeruginosa was the most common organism isolated. Strict implementation of the reprocessing guidelines are needed, especially the pre-cleaning stage and leak testing. Repeating high level disinfection after storage and before use must be followed.

Successful Cost-Effective Prevention of Cytomegalovirus Disease in Kidney Transplant Recipients Using Low-Dose Valganciclovir.

OBJECTIVES: Low-dose valganciclovir prophylaxis is still under investigation in renal transplant procedures. Our aim was to assess the cost effectiveness of 450 mg versus 900 mg valganciclovir prophylaxis in kidney transplant recipients. MATERIALS AND METHODS: In this prospective trial, 201 kidney transplant patients were randomized (1:1) to receive 450 mg/d (group 1, n = 100) or 900 mg/d (group 2, n = 101) valganciclovir prophylaxis for the first 6 months after transplant. Patients were studied for incidence of cytomegalovirus disease, leucopenia episodes, rejection episodes, and graft outcomes along with associated costs over 1 year. Costs (in US dollars) of treatment of rejection were also analyzed. RESULTS: Demographic features of the studied groups were comparable. We found that the cost of cytomegalovirus care in group 1 patients was significantly lower (by 50% at 6 months; P < .001), with less leukopenia episodes (P = .04), lower doses of granulocyte colony-stimulating factor (by 30% at 6 months; P = .03), higher doses of mycophenolate mofetil (P = .04), and less rejection episodes (P = .01) compared with group 2. In group 2, there were more episodes of cytomegalovirus infection (P = .052) and BK virus nephropathy (P = .04). Graft and patient outcomes were satisfactory in both groups. CONCLUSIONS: Low-dose valganciclovir for cytomegalovirus prophylaxis after renal transplant is safer, effective and without breakthrough infection, and less costly than using the usual dose.

Bariatric Surgery in Renal Transplant Patients.

OBJECTIVES: The idea of transplanting organs is not new, nor is the disease of obesity. Obese transplant recipients have greater risk of early death than their cohorts, which is not due to increased rejection but due to obesity-related complications, including arterial hypertension, diabetes, and delayed graft function. Here, our aim was to evaluate the effects of bariatric surgery versus lifestyle changes on outcomes of moderate to severely obese renal transplant recipients. MATERIALS AND METHODS: Twenty-two morbidly obese patients with stable graft function who underwent bariatric surgery were compared with 44 obese patients on lifestyle management (control group). Both groups were evaluated regarding graft and patient outcomes. RESULTS: The studied groups were comparable demographically. In the bariatric study group versus control group, we observed that the mean body mass index was 38.49 ± 9.1 versus 44.24 ± 6 (P = .024) at transplant and 34.34 ± 7.6 versus 44.38 ± 6.7 (P = .002) at 6 months of bariatric surgery. Both groups received a more potent induction immunosuppression, but this was significantly higher in the obese nonbariatric control group (P < .05). There were more patients with slow and delayed graft functions in the same nonbariatric group. The 2 groups were comparable regarding new-onset diabetes after transplant, total patients with diabetes, and graft outcomes (P > .05). CONCLUSIONS: Bariatric surgeries are feasible, safe pro cedures for selected obese renal transplant recipients.

Efficacy and Safety of Low-Dose Versus Standard-Dose Valganciclovir for Prevention of Cytomegalovirus Disease in Intermediate-Risk Kidney Transplant Recipients.

OBJECTIVES: Prophylaxis for cytomegalovirus infection is highly recommended for kidney transplant recipients. The use of daily 900 mg valganciclovir is the usual prophylactic dose, whereas 450 mg daily is under investigation. We evaluated the outcome of using 2 different doses of valganciclovir prophylaxis for cytomegalovirus infection after kidney transplant. MATERIALS AND METHODS: We randomized kidney transplant recipients (1:1) to receive 450 mg daily valganciclovir (group 1) or 900 mg daily valganciclovir (group 2) for the first 6 months after kidney transplant. Serologically, all patients were at moderate risk for cytomegalovirus infection. Patients were studied for incidence of cytomegalovirus disease, leukopenia attacks, rejection episodes, and graft outcomes for 1 year. RESULTS: Demographic features of group 1 (98 patients) and group 2 (98 patients) were comparable. More than 50% of patients received thymoglobulin induction therapy without difference between the groups. There were more leukopenia attacks in group 2 (P = .03) requiring higher doses of granulocyte colony-stimulating factor (P = .03). Group 2 patients received lower doses of mycophenolate mofetil (P= .04) and required reduced doses of valganciclovir (P = .045). Compared with group 1, the high-dose group developed numerically more rejection episodes (P = .057) and more cytomegalovirus infections requiring full treatment (P = .17). Graft and patient outcomes were satisfactory in both groups. CONCLUSION: Six months of low-dose valganciclovir prophylaxis for intermediate-risk kidney transplant recipients was as effective as high-dose valganciclovir with a better safety profile.

Long-Term Follow-Up of Active Treatment Versus Minimization of Immunosuppressive Agents in Patients With BK Virus-Associated Nephropathy After Kidney Transplant.

OBJECTIVES: There is no active treatment for postrenal transplant BK virus-associated nephropathy proven to be effective so far. We assessed the effectiveness of actively treating this condition with combined leflunomide, intravenous immunoglobulin, and ciprofloxacin on long-term graft outcome compared with minimization of immunosuppressive drugs. MATERIALS AND METHODS: Kidney transplant recipients were screened for BK virus-associated nephropathy. Group 1 comprised 22 kidney trans plant recipients with twice-positive BK virus polymerase chain reaction results in urine and blood. After diagnosis was confirmed with graft biopsy, antimetabolite (mycophenolate mofetil or azathioprine) was changed to leflunomide and intravenous immunoglobulin and oral ciprofloxacin were given. Group 2 comprised 33 BK virus-associated nephropathy patients treated conventionally with reduced immunosuppressive medications. RESULTS: Fifty-five patients were treated (38 males [69%], 28 patients [50.9%] with type 2 diabetes mellitus). Mean HLA antigen mismatches were 3.65, and 28 patients (50.9%) were HLA-Cw7 negative. All patients received induction therapy, 30 patients (55.6%) received thymoglobulin, and 29 patients (52.7%) received antirejection therapy before BK virus-associated nephropathy diagnosis. Maintenance immunosuppression was prednisolone in 53 patients (96.3%), mycophenolate mofetil (2 g daily) in 52 patients (94.5%), and tacrolimus in 28 patients (50.9%). Subsequent rejection episodes occurred in 38% of patients after diagnosis. Basal mean estimated glomerular filtration rate was 52.5 ± 25.5, which was reduced significantly to 38.1 ± 27.8 mL/min/1.73 m(2) (P < .0001) at end of study but without significant differences between the groups (P = .08 and P = .17). Follow-up was 7.3 ± 4.99 years. Although no significant differences were shown in patient outcome, graft survival was significantly better in group 2 (P = .032). CONCLUSIONS: Administration of 3 different anti-BK virus agents (leflunomide, intravenous immunoglobulin, ciprofloxacin) added no benefit to longterm outcome in patients with BK virus-associated nephropathy. Reduction of immunosuppressive medications appears to be a more effective treatment.

Human leukocyte antigen-DR mismatched pediatric renal transplant: patient and graft outcome with different kidney donor sources.

OBJECTIVES: Kidney transplant is well accepted as the optimal therapy for children with end-stage renal disease, and new trends suggest using human leukocyte antigen-DR mismatched grafts. The aim of work was to assess the effect of human leukocyte antigen-DR mismatch on the outcome of pediatric renal transplant recipients, regardless of the source of kidney graft. MATERIALS AND METHODS: According to human leukocyte antigen-DR matching, 104 pediatric patients were categorized into 3 comparable groups. With optimized immunosuppression protocols, long-term graft and patient outcomes were assessed. RESULTS: We found that posttransplant complications were comparable in the 3 groups, without significant increase in the risk of infections or malignancies, especially in the full human leukocyte antigen-DR-mismatched group. Moreover, we found no significant difference in the 3 groups regarding long-term graft or patient survival. CONCLUSIONS: With optimization of immunosuppression, human leukocyte antigen-DR-mismatched donors can be safely accepted for pediatric kidney transplant with comparable long-term patient and graft survival.

Acute cardiac tamponade: an unusual cause of acute renal failure in a renal transplant recipient.

We report a case of slow graft function in a renal transplant recipient caused by uremic acute pericardial effusion with tamponade. Urgent pericardiocentesis was done with an improvement in blood pressure, immediate diuresis, and quick recovery of renal function back to baseline. Pericardial tamponade should be included in consideration of causes of type 1 cardiorenal syndrome in renal transplant recipients.

Active management versus minimization of immunosuppressives of BK virus-associated nephropathy after a kidney transplant.

OBJECTIVES: Thus far, there is no active treatment for BK virus-associated nephropathy after a kidney transplant that has proven to be effective. We sought to assess the effectiveness of treatment with leflunomide, intravenous immunoglobulin, and ciprofloxacin on graft outcome after 1 year compared with a historical group treated with reduced immunosuppressive medications strategy. MATERIALS AND METHODS: Group 1 (n = 19) was composed of kidney transplant recipients with twice positive BK virus-polymerase chain reaction in urine and blood who underwent graft biopsy to confirm BK virus-associated nephropathy. Once BK virus-associated nephropathy was diagnosed, antimetabolite (mycophenolate mofetil or azathioprine) was changed to leflunomide, and intravenous immunoglobulin and oral ciprofloxacin were given. Group 2 (n = 14) was composed of BK virus-associated nephropathy patients treated conventionally with reduced immunosuppressive medications. RESULTS: Thirty-three patients were treated, 23 were males (70%), there were 15 were deceased donors (45.5%), 15 were diabetics (45.5%), mean human leukocyte antigen mismatches were 3.76, seven had a zero DR mismatch (21.2%), and 8 were CW7 negative (24.2%). All patients received induction therapy (thymoglobulin in 22 [66.6%]), 7 had delayed graft function (21.2%) and 18 received antirejection therapy before receiving BK virusassociated nephropathy diagnosis (52.9%). Maintenance immunosuppression was prednisolone and mycophenolate mofetil (2 g/d) in 31 patients (94%), and tacrolimus in 13 (39.4%). Tacrolimus was given to 12 patients in group 1 (63.1%), while sirolimus was given to 7 patients in group 2 (50%). One graft was lost in each group by the end of the study, and 1 patient died with functioning graft in group 2. CONCLUSIONS: No significant difference existed in 1-year graft outcomes between treatment of BK virus-associated nephropathy by reduction of immunosuppressive medications or actively by leflunomide, intravenous immunoglobulin, and ciprofloxacin.

Evaluation of growth in low-body-weight kidney transplant Egyptian children: 25-year experience.

BACKGROUND: Identification of problems associated with kidney transplantation in low-body-weight children is an essential step toward improving graft function and patient survival as well as quality of life. PATIENTS AND METHODS: This study comprised 63 renal transplant children weighing 25 kg or less at time of renal transplantation. All children received a living donor renal allotransplant between December 1984 and March 2009. These children were retrospectively evaluated regarding their survival, graft survival as well as physical growth. RESULTS: Our patient and graft survival rates at 1, 5 and 10 years were 98.4%, 96.8% and 96.8%, and 94.9%, 82.6% and 58.4%, respectively. Significant risk factors for growth retardation post renal transplant were identified and included older age at time of transplant (p=0.019), female sex (p=0.010), retarded growth at time of transplant (p=0.011, by univariate analysis, and p=0.028, by multivariate analysis), incidence of chronic rejection (p=0.012), higher steroid cumulative dose (p=0.013) and graft dysfunction (p=0.009, by multivariate analysis). CONCLUSION: The current final height of low-body-weight transplant Egyptian children has remained suboptimal. The management of growth retardation posttransplant is multifactorial and should start early before transplantation, with optimal care of growth in children with chronic kidney disease. Moreover, expedited transplantation, whenever indicated, and optimization of posttransplant graft function with minimal steroid exposure are essential factors which were shown to be possible using immunosuppression based on tacrolimus plus mycophenolate mofetil, after basiliximab induction.