Experience with Tandem Pre-Dilution Online Hemodiafiltration and Centrifugal Plasma Exchange in Pretransplant Desensitization for Abo-Incompatible Kidney Transplantation: A Case Report.

BACKGROUND: In the use of therapeutic plasma exchange (TPE) as antibody removal therapy for ABO-incompatible (ABOi) kidney transplantation, it is technically possible to perform online hemodiafiltration (OHDF) and TPE simultaneously for patients who are receiving OHDF. In this study, we report tandem therapy of pre-dilution OHDF and centrifugal plasma exchange (cTPE), instead of membrane plasma exchange, which is the mainstay of TPE in Japan. METHODS: A total of 14 sessions of tandem cTPE and pre-dilution OHDF were performed as preoperative antibody removal therapy for 6 ABOi kidney transplant recipients. cTPE intra-circuit pressure, decreased antibody titer, and adverse events were evaluated. The study was carried out following the ethical standards of the Declaration of Helsinki and Istanbul. Donors were not prisoners or individuals who were coerced or paid. RESULTS: The tandem therapy was completed safely in 12 of the 14 sessions, with no problems such as pressure upper and lower limit alarms or circuit coagulation. In 2 sessions, the tandem therapy had to be interrupted due to coagulation on the dialysis circuit side. Antibody titers were reduced by a median of 3-fold for both IgG and IgM. There was no acute antibody-associated rejection. CONCLUSIONS: In preoperative apheresis therapy for ABOi kidney transplantation, tandem therapy of pre-dilution OHDF and cTPE may be a useful treatment option that can be performed safely and results in sufficient reduction of antibody levels.

Arteriovenous Fistula Closure Using a Simple Ligation Technique After Kidney Transplantation.

BACKGROUNDS: There are advantages and disadvantages with closure of an arteriovenous fistula (AVF) after kidney transplantation, but some cases require closure. The general procedure for closure is angioplasty with exposure of the anastomotic site, but this is often time-consuming and complicated. We have developed a simpler, less invasive, and shorter procedure for AVF closure, in which the anastomotic site itself is not peeled off and the outflow vein close to this site is ligated using 1-0 silk. In this study, we examined the utility of this procedure. METHODS: A retrospective case series study was conducted by review of electronic medical records of patients and surgeries. All patients (n = 52) who underwent AVF closure after kidney transplantation at our hospital between January 2008 and April 2021 were reviewed. Perioperative and long-term postoperative results were examined. This study was carried out following the ethical standards of the Declaration of Helsinki and Istanbul. Donors were not from prisoners, or from those individuals who are coerced of paid. RESULTS: Simple ligation was performed for 46 patients (88.5%). The median time after renal transplantation was 40 (24.5-66.5) months. Median operative time and blood loss were 20 (12.2-30) minutes and 10 (5-15) mL, respectively. Two patients (4.3%) developed the aneurysm after the AVF closure using the simple ligation. CONCLUSION: The simple ligation technique had a relatively shorter operative time and only 2 cases had aneurysm formation. These results suggest that this technique is an option for closure of an AVF after kidney transplantation.

Daprodustat for Post-Transplant Anemia in Renal Transplant Recipients.

BACKGROUND: Daprodustat, a hypoxia-inducible factor prolyl hydroxylase inhibitor, has been reported to be effective in treating conservative renal failure and renal anemia in patients undergoing dialysis. However, its effects on post-transplant anemia have not yet been reported. This study aimed to determine whether daprodustat may be a useful treatment for post-transplant anemia. MATERIALS: Excluding 5 cases in which the drug was discontinued due to side effects, 21 post-transplant patients treated with daprodustat for ≥12 months and available for follow-up were analyzed. Changes in hemoglobin levels, iron metabolism, estimated glomerular filtration rate, and low-density lipoprotein levels were evaluated over 1 year. RESULTS: The average hemoglobin level was 10.1 g/dL before treatment, and after 1, 2, 3, 6, 9, and 12 months, these had increased significantly to 10.9, 11.2, 11.9, 12.3, 12.3, and 12.6, respectively. Ferritin levels were significantly lower throughout the 12-month study period. Transferrin saturation was significantly lower than before treatment during the first 6 months, with no significant differences after that. The participants' estimated glomerular filtration rate and low-density lipoprotein cholesterol levels did not change significantly throughout the treatment. CONCLUSION: Daprodustat significantly increased hemoglobin levels was easily dose-adjusted and was relatively safe for continuous use over 1 year. It was also effective in patients who had responded inadequately to erythropoiesis-stimulating agents. Therefore, we conclude that daprodustat may be a useful treatment for post-transplant anemia.

New-onset Kidney Biopsy-proven Membranous Nephropathy Induced End-stage Kidney Disease in a Living Donor: A Case Report.

Thirteen years after kidney donation, a 70-year-old man was referred to a nephrologist because of proteinuria. The serum creatinine, albumin, and urinary protein levels were 2.39 mg/dL, 3.0 g/dL, and 6.72 g/gCr, respectively. A kidney biopsy revealed thickening of the glomerular basement membrane with sub-epithelial deposits, suggesting membranous nephropathy. Considering the apparent interstitial fibrosis and diffuse glomerulosclerosis, supportive treatment was chosen. However, 11 months after the kidney biopsy, hemodialysis was required. The present case constitutes an important teaching point, as glomerular disease can occur in living donors and require careful and long-term medical checkup examinations.

Japanese study of the effects of AMG (α1-microglobulin) reduction rates on survival (JAMREDS): protocol of a multicenter prospective observational cohort study.

INTRODUCTION: Recent advances in dialysis therapy have made it possible to remove middle molecules. Removal of small-middle molecules, such as ß2-microglobulin (BMG), can now be achieved with conventional hemodialysis, and removal of large-middle molecules has become a target, particularly for 1-microglobulin (AMG, 33 kD). The AMG reduction rate has emerged as a target for improvement of various clinical symptoms, but the effects on prognosis have yet to be determined. The "Japanese study of the effects of AMG (α1-microglobulin) reduction rates on survival" (JAMREDS) was started in April 2020, with the goal of determining if the AMG reduction rate associates with the risk of mortality and cardiovascular disease (CVD) events. METHODS: JAMREDS is a prospective observational study in patients on hemodialysis (HD) to examine the effects of: 1) AMG reduction rate on survival outcome and CVD events; 2) dialysis treatment modalities (HD, intermittent infusion hemodiafiltration (iHDF), pre/post-dilution online HDF) on survival and CVD events (based on AMG reduction rates with treatment mode); and 3) AMG reduction rates on survival and CVD events in patients undergoing each therapy (iHDF, pre/post-dilution online HDF). The number of planned subjects was 4000 in pre-planning. Data are collected using RED-Cap, which is an EDC system. A total of 9930 patients were enrolled at the beginning of the study at 59 registered facilities. The JAMREDS observation period will continue until the end of 2023, after which the data will be cleaned and confirmed before analysis. CONCLUSION: This study may provide new evidence for the relationship between the amount of removed large-middle molecules (such as AMG) and the mortality and CVD risk. Comparisons with convection volumes will also be of interest. TRIAL REGISTRATION: UMIN000038457. Registered on 1st November, 2019: https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000043823.

A multi-institutional, observational study of outcomes after catheter placement for peritoneal dialysis in Japan.

BACKGROUND: This multi-institutional, observational study examined whether the outcomes after peritoneal dialysis (PD) catheter placement in Japan meet the audit criteria of the International Society for Peritoneal Dialysis (ISPD) guideline and identified factors affecting technique survival and perioperative complications. METHODS: Adult patients who underwent first PD catheter placement for end-stage kidney disease between April 2019 and March 2021 were followed until PD withdrawal, kidney transplantation, transfer to other facilities, death, 1 year after PD start or March 2022, whichever came first. Primary outcomes were time to catheter patency failure and technique failure, and perioperative infectious complications within 30 days of catheter placement. Secondary outcomes were perioperative complications. Appropriate statistical analyses were performed to identify factors associated with the outcomes of interest. RESULTS: Of the total 409 patients, 8 who underwent the embedded catheter technique did not have externalised catheters. Of the 401 remaining patients, catheter patency failure occurred in 25 (6.2%). Technical failure at 12 months after PD catheter placement calculated from cumulative incidence function was 15.3%. On Cox proportional hazards model analysis, serum albumin (hazard ratio (HR) 0.44; 95% confidence interval (CI) 0.27-0.70) and straight type catheter (HR 2.14; 95% CI 1.24-3.69) were the independent risk factors for technique failure. On logistic regression analysis, diabetes mellitus was the only independent risk factor for perioperative infectious complications (odds ratio 2.70, 95% CI 1.30-5.58). The occurrence rate of perioperative complications generally met the audit criteria of the ISPD guidelines. CONCLUSION: PD catheter placement in Japan was proven to be safe and appropriate.

A Case of Bariatric Surgery for a Japanese Kidney Transplant Recipient With Diabetes Mellitus: A Case Report.

The patient, a 54-year-old woman, underwent a living donor kidney transplant at Osaka City University Hospital 7 years before the bariatric surgery. Her comorbidities were diabetes, sleep apnea, and severe obesity (weight 103 kg, body mass index [BMI] 36 kg/m2), and her diabetes was poorly controlled with an HbA1c of 8.5%. On admission, she weighed 99 kg, BMI was 34 kg/m2, Serum creatinine (S-Cre) was 1.54 mg/dL, and HbA1c was 7.1%. A laparoscopic sleeve gastrectomy was performed, and her weight decreased without complications during the perioperative period. She was discharged on postoperative day 28. Two months after surgery, her weight was 87 kg, BMI 30 kg/m2, S-Cre 1.34 mg/dL, HbA1c 6.7 %, renal function improved, urine protein decreased, and insulin dosage decreased dramatically. We report this valuable case because there are no reports of bariatric surgery in Japanese renal transplant recipients.

Retraction Note: Impact of the third wave of the COVID-19 pandemic and interventions to contain the virus on society and patients with kidney disease in Cambodia.

[This retracts the article DOI: 10.1186/s41100-021-00372-6.].

Experience With the Use of a Novel Agent, Hypoxia-Inducible Factor Prolyl Hydroxylase Inhibitor, for Posttransplant Anemia in Renal Transplant Recipients: A Case Report.

In this study, we report on an experience with the use of a novel agent "roxadustat," a hypoxia-inducible factor prolyl hydroxylase inhibitor (HIF-PHI), for posttransplant anemia (PTA) in renal transplant recipients. Five renal transplant recipients treated as outpatients receiving 150 or 250 µg of "epoetin beta pegol," an erythropoiesis-stimulating agent (ESA), once every 3 months were converted to roxadustat, an HIF-PHI. The dose was 100 mg 3 times a week taken orally on Monday, Wednesday, and Friday. Data check was conducted at 1 month and every 3 months after its introduction, and hemoglobin (Hb), ferritin, and transferrin saturation (TSAT) levels were compared. At 1 month after conversion to roxadustat, Hb levels increased in all cases, the use of roxadustat was suspended/decreased in 2 cases who had Hb overshoot at 1 month, and ferritin and TSAT levels decreased in the initial stage of roxadustat conversion. During a 9-month period, Hb levels tended to increase in cases receiving oral iron administration, graft function was hardly affected, and there were no complications such as thrombosis. In conclusion, conversion from ESA to roxadustat was effective in the treatment of PTA. However, our overshoot case suggested that it might be better to start at a low dose in patients with low body weight, those undergoing iron administration, and those receiving a low dose of ESA. Furthermore, the low levels of ferritin and TSAT we observed at an early stage after roxadustat conversion suggested that there was an increased efficiency in iron utilization.

Impact of the third wave of the COVID-19 pandemic and interventions to contain the virus on society and patients with kidney disease in Cambodia.

Cambodia detected its first case of COVID-19 just 3 days before WHO declared that the outbreak constituted as PHEIC. As of February 15, 2021, and after two major outbreaks, only 479 cases had been reported, 396 (83%) of which were imported. This small number of cases was largely thanks to stringent measures and policies put in place by the government to curb the spread. Despite these efforts, a third cluster outbreak was declared on February 20, 2021. It has disrupted all aspects of life in Cambodia. As in many other countries affected by the virus, economic hardship, lockdowns in cities, and food insecurity ensued. Against the backdrop of this widespread impact on the citizens of Cambodia, we conducted this review article to better understand the situation of healthcare workers in nephrology and dialysis patients and the challenge they face in providing and receiving essential medical care. Healthcare providers have continued working to serve their patients despite facing a high risk of catching SARS-CoV-2 and other challenges including difficulties in traveling to work, increased physical and mental burden, and higher stress due to measures taken to minimize the risk of transmission during patients' care. Some healthcare workers have been discriminated against by neighbors. The most difficult mission is when having to deal with families whose loved one is denied access to a hemodialysis session due to suspected COVID-19 while waiting for PCR test results. Hemodialysis patients reported facing economic hardship and increasingly difficult circumstances. When access to food is limited, patients have eaten canned or dried salted food rather than an appropriate hemodialysis diet. Because hemodialysis centers are concentrated in a few cities, access has become even harder during the travel ban. In-center hemodialysis rules are stricter and does not allow family members or escorts to enter the unit. Only a few hemodialysis patients have been vaccinated. Before COVID-19, hemodialysis patients already faced major burdens. The pandemic appears to be decreasing their quality of life and survival even further. Through this study, we have revealed current hardships and the need to improve the situations for both healthcare workers in nephrology and hemodialysis patients in Cambodia.

Impact of stroke history on the presence of cerebral microbleeds in hemodialysis patients.

INTRODUCTION: Cerebral microbleeds (CMBs) are detected on gradient-echo T2*-weighted magnetic resonance imaging (MRI). Clinically, CMBs are often detected after stroke, including in cases of intracerebral hemorrhage and ischemic cerebrovascular disease. Hemodialysis (HD) patients are widely known to have a high incidence of stroke, and HD patients without stroke history have been reported to have a high prevalence of CMBs. In this study, we investigated whether history of stroke affects the prevalence of CMBs in HD patients. METHODS: A cross-sectional study was performed in 241 HD patients who underwent brain T2*-weighted MRI. We compared the prevalence of CMBs between the patients with and without a history of stroke. Moreover, the relationship between history of stroke and presence of CMBs was examined by multivariate logistic regression analysis. RESULTS: Among these patients, 22 (9.1%) had a history of stroke. CMBs were detected in 70 patients (29.0%). The prevalence of CMBs was significantly higher in patients with a history of stroke compared to those without this history (54.5 vs. 26.5%, p = 0.012). In the multivariable analysis adjusted for background characteristics, history of stroke was a significant and independent factor related to CMBs (OR: 3.24, 95%CI: 1.18-8.89, p = 0.02). DISCUSSION/CONCLUSIONS: As has been reported for non-dialysis patients, our results showed a high prevalence of CMBs in HD patients with a history of stroke, and indicated that a history of stroke is significantly and independently associated with CMBs in HD patients.

Antiplatelet therapy and future intracerebral hemorrhage in hemodialysis patients with cerebral microbleeds.

The use of antiplatelet drugs is thought to increase the risk for intracerebral hemorrhage (ICH) in patients with cerebral microbleeds (CMBs). However, hemodialysis (HD) patients have a high prevalence of CMBs and diverse pathologies that require antiplatelet therapy. In this study, we investigated whether the use of antiplatelet drugs increases the risk for ICH in HD patients with CMBs. Brain magnetic resonance imaging (MRI), including T2*-weighted MRI, was performed in 179 HD patients with no history of cerebrovascular events. CMBs were detected and patients were followed prospectively with a median follow-up period of 5.2 [1.4-6.2] years. To investigate whether the influence of antiplatelet therapy on the development of ICH differs in cases with and without CMBs, the inverse probability of treatment weighting method was used, including an interaction term between the presence or absence of CMBs and use of antiplatelet drugs. As a result, CMBs were detected in 45 patients (25.1%), and antiplatelet drugs were used in 66 patients (36.9%). When the effect of antiplatelet therapy on the incidence of ICH was modified by the presence of CMBs at baseline (P for interaction <0.001), the use of antiplatelet drugs was a significant risk factor for ICH in HD patients without CMBs, but not in HD patients with CMBs. Furthermore, the burden of CMBs significantly increased the risk for ICH, but the increase in this risk was slower in antiplatelet drug users as compared to non-antiplatelet drug users (P for interaction = 0.02). The influence of antiplatelet drugs on the development of ICH differed depending on the presence or absence of CMBs. In fact, the use of antiplatelet drugs did not increase the risk for ICH in HD patients with CMBs.

Safety and Efficacy of Tandem Hemodialysis and Selective Plasma Exchange in Pretransplant Desensitization of ABO-Incompatible Kidney Transplantation.

INTRODUCTION: In patients requiring both hemodialysis (HD) and apheresis, the 2 treatments can be performed simultaneously. At our hospital, selective plasma exchange (SePE) is often performed along with HD for removal of isoagglutinins before ABO-incompatible (ABOi) kidney transplantation. The 2 treatments can be completed within the HD schedule, which allows the treatment time to be shortened. This approach is also less stressful for patients because fewer punctures are required. In this study, we investigated the safety and efficacy of tandem HD and SePE. METHODS: A total of 58 SePE sessions in 30 ABOi kidney transplant recipients were investigated. The SePE circuit was connected in parallel with the HD circuit, and tandem HD and SePE therapy was performed using filtration methods. The SePE sessions were divided into 2 groups: those with SePE monotherapy (group S, n = 20) and those with tandem therapy (group T, n = 38). Changes in transmembrane pressure (TMP), arterial pressure (AP), venous pressure (VP), and decrease in isoagglutinin titers over time were compared between the groups with adjustment for background data. RESULTS: The internal pressures (AP and VP) were higher in group T, and there were significant differences in changes of TMP and AP over time between groups T and S. Membrane exchange was required in 1 case in group T due to coagulation. There was a more significant decrease of immunoglobulin G isoagglutinin titers in group T compared to group S. No case had antibody-mediated rejection after transplantation. DISCUSSION/CONCLUSION: In HD/SePE tandem therapy, internal pressures were higher and TMP and AP tended to increase more compared to SePE monotherapy, but we were able to perform the 2 treatments without any functional problems. Tandem therapy was also effective in decreasing isoagglutinin titers, which suggests that this may be a beneficial treatment modality as apheresis before ABOi kidney transplantation.

A case of anti-aquaporin-4 antibody-positive optic neuritis treated by selective immunoadsorption.

Anti-aquaporin-4 (AQP4) antibody-positive optic neuritis is a condition in which a patient testing positive for anti-AQP4 antibody presents with optic neuritis only. The disease is classified as a neuromyelitis optica spectrum disorder (NMOSD) and is a steroid-resistant refractory optic neuritis. Patients are treated by oral administration of steroids, steroid pulse therapy, and apheresis therapy. The patient in our case was a 48-year-old female who was diagnosed with anti-AQP4 antibody-positive optic neuritis by her ophthalmologist, and was referred to our hospital. Selective plasma exchange (SePE) was initially started, but she strongly preferred treatment as an outpatient due to family circumstances. Therefore, selective immunoadsorption (SeIA) was used from the second session to minimize loss of coagulation factors. The RRs were 16.5-33.3% for anti-AQP4 antibody, 7.48-18.57% for fibrinogen, and 0.8-4.57% for factor XIII. After the 7th SeIA session, the patient was followed up with a maintenance dose of 10 mg/day oral prednisolone as an outpatient at our Department of Ophthalmology. This is the first report to investigate the removal rate (RR) of anti-AQ4 antibody using SeIA. In our case, the anti-AQP4 antibody level before the last SeIA session was still not completely negative, but there was clinical improvement in vision. SeIA was highly effective in maintaining coagulation factor levels. Therefore, our results suggest that SeIA is a safe treatment that can be performed in an outpatient setting.

Splenectomy for ABO-Incompatible Kidney Transplantation and Very Late-Onset Cytomegalovirus Disease.

INTRODUCTION: Splenectomy had been previously performed in ABO-incompatible kidney transplantation to reduce the B cell pool. However, studies have shown that patients undergoing splenectomy may have a lifelong susceptibility to infection and mortality. Splenectomy may affect the incidence of cytomegalovirus (CMV) disease even at a very late stage after transplantation in ABO-incompatible recipients. PATIENTS AND METHODS: Seven patients received their graft from an ABO-incompatible living donor at our institution and underwent splenectomy for B cell reduction. Among them, 3 recipients experienced very late-onset CMV disease approximately 10 years after their transplant and were enrolled in this study. RESULTS: Very late-onset CMV disease occurred at 9 years and 9 months, 15 years, and 13 years and 5 months after transplantation, respectively. Two recipients suffered from CMV retinitis, while one experienced colitis. The age of the patients at onset of CMV disease was 69 years, 42 years, and 71 years, respectively. CONCLUSION: This may be the first report on very late-onset CMV disease after splenectomy in ABO-incompatible kidney transplantation. We should be aware that these recipients can experience very late-onset CMV disease even approximately 10 years after their transplant.

Selective plasma exchange in ABO-incompatible kidney transplantation: comparison of substitution with albumin and partial substitution with fresh frozen plasma.

We have performed selective plasma exchange (SePE) as apheresis before ABO-incompatible kidney transplantation since 2015. In this study, we divided the SePE sessions into two groups, those using albumin alone (Group A) and those partially using fresh frozen plasma (FFP) (Group F), and compared their clinical efficacies. A total of 58 sessions of SePE (Group A: n = 41, Group F: n = 17) were performed in 30 recipients of ABOi kidney transplantation during the study period and the decrease in isoagglutinin titers, changes in the levels of serum IgG and IgM as well as coagulation factors (fibrinogen, factor XIII), and incidence of side effects were retrospectively compared. There was a more significant decrease of isoagglutinin titers in Group F compared to Group A. Immunoglobulins and coagulants were replenished in Group F. Meanwhile, the incidence of side effects was significantly higher in Group F. SePE using FFP, which can effectively decrease isoagglutinins titers and replenish immunoglobulin and coagulation factors, may be a beneficial treatment modality as apheresis before ABO-incompatible kidney transplantation, in spite of a disadvantage that there are many side effects.

Association of sarcopenia with phase angle and body mass index in kidney transplant recipients.

Malnutrition is an important risk factor for the development of sarcopenia. Recently, phase angle (PhA) obtained from the bioelectrical impedance analysis is increasingly becoming known as a nutritional status marker and may be considered a good indicator to identify elderly patients at risk of sarcopenia. In this study, we investigated the prevalence of sarcopenia and the relationship between sarcopenia and PhA or body mass index (BMI) as nutritional factors, and evaluated the discrimination performance of these nutritional factors for sarcopenia in 210 kidney transplant recipients. The median age was 55 years and 11.1% had sarcopenia. This prevalence of sarcopenia was lower than previous reports in kidney transplant recipients, maybe because of the differences in sarcopenia definitions and population demographics such as age, sex, race, and comorbidities. Both PhA and BMI were negatively correlated with sarcopenia after adjusting for age, sex, dialysis vintage, time after transplant, presence of diabetes mellitus, hemoglobin, estimated glomerular filtration rate, and the other nutritional factor. The discrimination performance for PhA and BMI had enough power to detect sarcopenia. These results suggest that PhA and BMI can be used in clinical practice to predict sarcopenia in kidney transplant patients.

Latest insights on ABO-incompatible living-donor renal transplantation.

This review summarizes the latest insights on ABO-incompatible living-donor renal transplantation. Desensitization protocols and clinical outcomes were investigated, and a comparison was made with kidney-paired donation, which is not permitted in Japan for ethical reasons. Although renal transplantation is greatly beneficial for most patients with end-stage kidney disease, many of these patients must remain on dialysis therapy for extended periods due to the scarcity of organs from deceased donors. ABO blood type incompatibility was once believed to be a contraindication to renal transplantation due to the increased risk for antibody-mediated rejection and early graft loss attributable to isoagglutinins. Recently, pretransplant desensitization strategies, such as removal of isoagglutinins and antibody-producing cells, have achieved successful outcomes, although it remains unclear whether graft survival and patient morbidity are equivalent to those for ABO-compatible renal transplantation. The present review suggested that ABO-incompatible living-donor renal transplantation might be a favorable radical renal replacement therapy for patients with end-stage kidney disease.

Conversion From Cyclosporine to Once-Daily Tacrolimus on 50:1 mg Basis: A Short-Term Pilot Study.

OBJECTIVES: In addition to graft dysfunction, renal transplant recipients on cyclosporine may be switched to tacrolimus to reduce its drug-related secondary clinical effects and undesirable cosmetic side effects. However, the dose level of once-daily tacrolimus for these patients has yet to be established. The objective of this prospective study was to confirm the safety of converting stable renal transplant recipients on cyclosporine to once-daily tacrolimus at a 50:1 mg ratio. MATERIALS AND METHODS: Our study enrolled 17 patients receiving cyclosporine who were observed for 3 months. Graft biopsies did not reveal any acute rejection, and the conversion ratio to once-daily tacrolimus was 50:1 mg. Dose adjustments were made to achieve a target tacrolimus trough concentration of 3 to 5 ng/mL at 2 weeks, and graft biopsies were taken after the 3-month observation period. RESULTS: Dose adjustment was required in 7 recipients (41.2%) within 3 months of conversion. None of the recipients had acute cellular rejection or C4d deposition, and the mean estimated glomerular filtration rate of 38.7 ± 11.0 mL/min/1.73 m2 at baseline was significantly improved to 42.0 ± 10.0 mL/min/1.73 m2 at month 3. CONCLUSIONS: Although recipients of renal transplant can be forced to discontinue cyclosporine administration due to undesirable adverse effects, our study showed that a once-daily dose of tacrolimus may be safe when administered at a conversion ratio of 50:1.

Hypercalcemia Is a Risk Factor for the Progression of Aortic Calcification in Kidney Transplant Recipients.

BACKGROUND/AIMS: Vascular calcification is common and progressive in chronic kidney disease, including kidney transplant recipients (KTRs). However, the risk factors associated with the progression of aortic calcification (AoC) in KTRs have not been fully elucidated. In the present study, we evaluated AoC and examined the factors associated with its advancement in KTRs. MATERIALS: This was a prospective longitudinal study that included 98 KTRs. We quantitatively investigated infrarenal abdominal AoC using the Agatston score, as measured by multi-slice computed tomography. After the baseline investigation, a follow-up scan was performed after 3 years, and the Agatston scores were obtained again. The changes in laboratory data affecting the 2nd Agatston scores were examined by multivariable analysis using non-linear regression after adjustment for several confounders. RESULTS: The 2nd Agatston scores were significantly greater than the baseline Agatston scores (p < 0.001). After adjustment for the confounders, the change in corrected serum calcium exhibited a significant non-linear correlation with the 2nd Agatston scores (p = 0.022 for non-linearity/p = 0.031 for the effect of corrected serum calcium). Moreover, an interaction was present from the baseline AoC in the effect of corrected serum calcium on the progression of AoC, and the effect of hypercalcemia was greater in patients with higher baseline Agatston scores (p = 0.049). CONCLUSION: The present study revealed that hypercalcemia is a risk factor for the development of infrarenal abdominal AoC in KTRs. Furthermore, the effect of hypercalcemia was greater in patients with more severe vascular calcification.