Similar impact of slow and delayed graft function on renal allograft outcome and function.

Kidney transplant patients can be divided into three groups, according to the initial graft function. First-week dialyzed patients form the delayed graft function (DGF) group. Nondialyzed patients are divided into slow graft function (SGF) or immediate graft function (IGF) according to whether the day 5 serum creatinine was higher versus lower than 3 mg/dL, respectively. SGF patients showed worse graft survival, above higher incidence of acute rejection and lower renal function than IGF patients, although few reports have analyzed outcomes in these groups. We analyzed the impact of SGF on graft survival, first-year renal function, and incidence of acute rejection in 291 renal transplant patients. Creatinine was significantly worse at 12 months for SGF and DGF than for IGF patients (1.9 +/- 0.8 mg/dL, 1.8 +/- 0.7 mg/dL, 1.5 +/- 0.5 mg/dL, respectively; P < .05). There was no difference in first-year renal function between SGF and DGF. The acute rejection rate was higher among the SGF than the IGF group (45% vs 21%, P < .05), but not different from DGF patients (42%, P < .05). Graft survival was better among IGF than SGF or DGF patients, with no significant difference between the last two groups (3-year graft survival, 82%, 71%, 70%, respectively; log-rank test, P < .05). Kidney transplant recipients who develop SGF have a worse outcome than patients with IGF, similar to DGF patients. SGF patients show worse graft survival, worse renal function, and higher acute rejection rates than IGF patients, despite not needing dialysis.

[Revascularization of total renal artery occlusion by angioplasty and stent placement]. / Revascularización eficaz de obstrucción total de arterial renal mediante angioplastia y colocación de Stent.

Revascularization of renal artery stenosis for the treatment of hypertension is an established procedure. In selected clinical scenarios, successful revascularization procedures may preserve or restore renal function. We present a 66-year-old man with secundary hypertension and deteriorating renal function caused by bilateral atherosclerotic renal artery disease (complete obstruction of the left renal artery and subocclusive stenosis of the right) in which blood pressure was successfully controlled and renal function improved and maintained steady after bilateral percutaneus transluminal angioplasty and renal artery stenting.

Comparison of the antihypertensive effects of the fixed dose combination enalapril 10 mg/nitrendipine 20 mg vs losartan 50 mg/hydrochlorothiazide 12.5 mg, assessed by 24-h ambulatory blood pressure monitoring, in essential hypertensive patients.

Fixed combinations of calcium channel blockers and angiotensin converting enzyme inhibitors represent an alternative to diuretic-based combination therapy. The aim of the present study was to compare the antihypertensive efficacy of the combination enalapril 10 mg/nitrendipine 20 mg (E/N) vs losartan 50 mg/hydrochlorothiazide 12.5 mg (L/H), assessed by 24-h ambulatory blood pressure monitoring. This multicentre, double-blind, parallel study included 97 hypertensive patients (office diastolic blood pressure (DBP) 90-109 mmHg and daytime DBP > 85 mmHg). After a 2- to 3-week period of single-blind placebo, they were randomized to receive double-blind treatment with E/N (n = 48) or L/H (n = 49) for a 4-week period. The primary outcome measure was the difference in 24-h DBP reduction between treatments from randomization to the end of the double-blind period. Secondary efficacy variables included differences in 24-h systolic (S) BP reduction, daytime, night-time and office SBP and DBP reduction, proportion of responders and controlled patients, trough-to-peak ratio and smoothness indexes. Safety was assessed by the proportion of patients with adverse events and the detection of laboratory abnormalities. No significant differences were observed in the primary outcome measure. The group receiving E/N tended to show greater reductions in most measures (24 h, daytime and office SBP and DBP) and higher BP control rates, but only the difference in the rate of office SBP control (< 140 mmHg) reached statistical significance (42.2 vs 22.4%; P = 0.048). The trough-to-peak ratios and smoothness indexes were similar in both groups. The incidence of adverse events related to the treatment was 27.1% (95% CI 14.5-39.6%) in E/N-treated patients and 14.3% (95% CI 4.5-45.8%) in the L/H group, but differences were not significant. The kind of event more frequently observed were flushing and headache in E/N, and dizziness and asthenia in L/H; all observed adverse events were mild. We conclude that E/N and L/H have a similar antihypertensive efficacy, assessed by office or ambulatory blood pressure monitoring. E/N achieved a significantly higher office SBP control rate, but this was accompanied by an apparently higher proportion of mild adverse events.

Assessment of glomerular filtration rate in transplant recipients with severe renal insufficiency by Nankivell, Modification of Diet in Renal Disease (MDRD), and Cockroft-Gault equations.

Measurement of glomerular filtration rate (GFR) is time consuming and cumbersome. Several formulas have been developed to predict creatinine clearance (CrCl) or GFR using serum creatinine (Cr) concentrations and demographic characteristics. However, few studies have been performed to discern the best formula to estimate GFR in kidney transplantation. In this study, Cockroft-Gault (CG), Nankivell, and Levey (MDRD) formulas were tested to predict GFR in 125 cadaveric renal transplant patients with severe renal insufficiency (GFR less than 30 mL/min per 1.73 m2). The GFR was estimated as the average Cr and urea clearances. The mean GFR estimated by averaged Cr and urea clearances (22.18+/-5.23 mL/min per 1.73 m2) was significantly different from the mean values yielded by the MDRD formula (20.42+/-6.65 mL/min per 1.73 m2, P=.000), the Nankivell formula (30.14+/-11.98 mL/min per 1.73 m2, P=.000), and the CG formula (29.42+/-8.64 mL/min per 1.73 m2, P=.000). The MDRD formula showed a better correlation (R=0.741, P=.000) than the CG (R=0.698, P=.000) and the Nankivell formulas (R=0.685, P=.000). Analysis of differences using the Bland-Altmann method demonstrated that MDRD gave the lowest bias (MDRD: -1.65+/-4.4 mL/min per 1.73 m2; CG: 7.33+/-6.24 mL/min per 1.73 m2; Nankivell: 8.05+/-9.23 mL/min per 1.73 m2) and narrower limits of agreement (Nankivell: -10.41-26.51 mL/min per 1.73 m2; CG: -5.15-19.81 mL/min per 1.73 m2; MDRD: -10.61-7.31 mL/min per 1.73 m2). In transplant patients with severe renal insufficiency, the MDRD equation seems better than the other formulas to estimate GFR.

Pulse pressure is an independent risk factor of cardiovascular disease in renal transplant patients.

Elevated pulse pressure in the general population has been shown to be associated with cardiovascular disease, which is the main cause of death in renal transplant patients. We investigated the effects that a wide pulse pressure has on cardiovascular disease after renal transplantation in a cohort of 532 transplant patients with functioning grafts for more than one year. Patients were classified into two groups depending on whether the one-year pulse pressure was less than or greater than 65 mm Hg. We analyzed patient survival, posttransplant cardiovascular disease and principle causes of death. Five- and ten-year patient survival were lower among the group with higher pulse pressures. The main cause of death was vascular disease in both groups. The presence of posttransplant cardiovascular disease was higher among the group with higher pulse pressures (RR=1.73). In addition, the incidence of an elevated pulse pressure was directly associated with recipient age and posttransplant diabetes mellitus. In conclusion, pulse pressure represents an independent risk factor for increased cardiovascular morbidity and mortality in renal transplant patients.

[Diagnosis of dominant renal polycystosis in adults by analysis of DNA polymorphism]. / Diagnóstico de la poliquistosis renal dominante del adulto mediante análisis de los polimorfismos del ADN.

BACKGROUND: Adult renal polycystosis (ARP) is a dominant autosomic disease. The gene responsible for this disease in most families has been located on the short arm of chromosome 16 (16 p) by restriction analysis of the DNA polymorphisms (RFLP). METHODS: The existence of several polymorphic markers flanking this gene permits the diagnosis of any member of an affected family. A series of proximal and distal genetic markers have been used to study the segregation of the disease in a group of families with more than one affected member. RESULTS: The clinical and genetic results obtained from a study of 10 Spanish families with ARP have been reported. A high percentage of the members under 30 years of age (40%) did not present renal cysts. CONCLUSIONS: Restriction analysis of DNA are fundamentally for a disease in which a high percentage of carriers remain asymptomatic within the reproductive age.

A study on the efficacy and safety of losartan in elderly patients with mild to moderate essential hypertension.

Despite progress in the detection and treatment of hypertension the percentage of patients with controlled hypertension has failed to increase. The problem of poor blood pressure control is even more serious in elderly hypertensives than in the rest of the population. The antihypertensive drugs of the AIIRA (non-peptide angiotension II receptor antagonist) class are drugs whose use and experience are increasing and whose properties make them particularly useful in the elderly. We tried to assess the efficacy of treatment with losartan, the first AIIRA drug in a cohort of elderly patients with essential hypertension and to assess the percentage of patients achieving optimum BP control and to evaluate its safety, tolerability and metabolic effects. The intervention proved to be highly effective, achieving the anticipated blood pressure levels in the elderly in 77% of subjects after a 16-week follow-up, with very good tolerability. Renal function remained unchanged, as did the subjects' lipid profile.

Risk of cardiovascular disease associated with refractory hypertension in renal transplant recipients.

BACKGROUND: Hypertension is common after renal transplantation, affecting as many as 80% of recipients. It is generally accepted that hypertension is associated with poor graft survival and reduced life expectancy because of increased cardiovascular risk factors. The prevalence of refractory hypertension in renal transplant recipients is unknown, and could be associated with a poor prognosis. OBJECTIVE: To investigate the effects of refractory hypertension on cardiovascular disease (CVD) after renal transplantation in 486 patients with grafts functioning for longer than 1 year. PATIENTS AND METHODS: Patients were classified into 2 groups: (1) 57 with refractory hypertension, that is, systolic blood pressure 130 mm Hg or greater or diastolic blood pressure 80 mm Hg or greater, and receiving treatment with at least 3 drugs, one of which was a diuretic; and (2) the remaining 429 patients. Patient and graft survival, and posttransplantation CVD were analyzed. RESULTS: Refractory hypertension was associated with male sex (82.5% vs 66.5% [P<.01]), poor renal function (mean [SD] serum creatinine concentration 2.2 [1.2] mg/dL vs 1.6 [0.6] mg/dL; Modification of Diet in Renal Disease score 39.2 [20.0] mL/min/1.73 m2 vs 49.2 [18.0] mL/min/1.73 m2 [P=.000]; and steroid therapy (94.7% vs 79.0% [P=.001]). In the group with refractory hypertension, 5-year patient and graft survival rates were lower, and the incidence of posttransplantation CVD was greater (relative risk, 1.7; 95% confidence interval, 1.05-2.18; P=.03). CONCLUSION: Refractory hypertension is an independent risk factor for increased cardiovascular morbidity and mortality in renal transplant recipients.