Components of metabolic syndrome in relation to plasma levels of retinol binding protein 4 (RBP4) in a cohort of people aged 65 years and older.

PURPOSE: Elevated plasma concentration of retinol binding protein 4 (RBP4) has recently emerged as a potential risk factor as a component of developing metabolic syndrome (MS). Therefore, this study aimed to analyse the relationship between components of MS and concentrations of plasma RBP4 in a population of subjects 65 years and older. METHODS: The study sample consisted of 3038 (1591 male) participants of the PolSenior study, aged 65 years and older. Serum lipid profile, concentrations of RBP4, glucose, insulin, C-reactive protein, IL-6, and activity of aminotransferases were measured. Nutritional status (BMI/waist circumference) and treatment with statins and fibrates were evaluated. Glomerular filtration rate (eGFR), de Ritis ratio, and fatty liver index (FLI), as well as HOMA-IR were calculated. RESULTS: Our study revealed a strong relationship between components of MS and RBP4 in both sexes: plasma RBP4 levels were increased in men by at least 3×, and in women by at least 4×. Hypertriglyceridemia was most strongly associated with elevated plasma RBP4 levels. Multivariate, sex-adjusted regression analysis demonstrated that chronic kidney disease [OR 1.86 (95% CI 1.78-1.94)], hypertriglyceridemia [OR 1.52 (1.24-1.87)], hypertension [OR 1.15 (1.12-1.19)], low serum HDL cholesterol [OR 0.94 (0.92-0.97)], and age > 80 years [OR 0.86 (0.81-0.90)] were each independently associated with RBP4 concentration (all p < 0.001). CONCLUSIONS: In Caucasians 65 years and older, RBP4 serum levels are associated with a number of components of MS, independent of sex and kidney function. Hypertriglyceridemia as a component of MS is most significantly related to RBP4 concentration.

Polyomavirus BK replication in de novo kidney transplant patients receiving tacrolimus or cyclosporine: a prospective, randomized, multicenter study.

Polyomavirus BK (BKV)-associated nephropathy causes premature kidney transplant (KT) failure. BKV viruria and viremia are biomarkers of disease progression, but associated risk factors are controversial. A total of 682 KT patients receiving basiliximab, mycophenolic acid (MPA), corticosteroids were randomized 1:1 to cyclosporine (CsA) or tacrolimus (Tac). Risk factors were analyzed in 629 (92.2%) patients having at least 2 BKV measurements until month 12 posttransplant. Univariate analysis associated CsA-MPA with lower rates of viremia than Tac-MPA at month 6 (10.6% vs. 16.3%, p = 0.048) and 12 (4.8% vs. 12.1%, p = 0.004) and lower plasma BKV loads at month 12 (3.9 vs. 5.1 log(10) copies/mL; p = 0.028). In multivariate models, CsA-MPA remained associated with less viremia than Tac-MPA at month 6 (OR 0.60; 95% CI 0.36-0.99) and month 12 (OR 0.33; 95% CI 0.16-0.68). Viremia at month 6 was also independently associated with higher steroid exposure until month 3 (OR 1.19 per 1 g), and with male gender (OR 2.49) and recipient age (OR 1.14 per 10 years) at month 12. The data suggest a dynamic risk factor evolution of BKV viremia consisting of higher corticosteroids until month 3, Tac-MPA compared to CsA-MPA at month 6 and Tac-MPA, older age, male gender at month 12 posttransplant.

A case of acute rejection shortly after initiation of lamivudine therapy in a simultaneous pancreas and kidney recipient with viral hepatitis type B.

We describe a patient with hepatitis B antigenemia, who received a simultaneous pancreas and kidney transplant, developed reactivation of hepatitis B virus infection with aminotransferase elevation, and unexpectedly suffered an acute rejection episode within a few weeks after initiation of lamivudine therapy. At the time of rejection diagnosis, the cyclosporin A (CyA) trough level was 2 times lower than before the start of lamivudine therapy. Only an improvement in liver CyA metabolism in the course of lamivudine therapy can explain such an essential decline. Thus, it is important to emphasize how crucial it is to frequently monitor the CyA level in the early period of lamivudine therapy in transplanted patients with hepatitis to ensure adequate immunosuppression and to avoid acute rejection episodes.

Fluctuations of exercise capacity in patients after kidney transplantation.

INTRODUCTION: The aim of this study was to assess changes in the exercise capacity in subjects with end-stage renal failure undergoing kidney transplantation. MATERIALS AND METHODS: The study group consisted of 16 subjects (9 males and 7 females) of mean age 43.3 +/- 11 years. The control group was composed of 7 healthy subjects (4 males and 3 females) of mean age 43.9 +/- 10 years. The first visit took place at 4-8 weeks after transplantation. Consecutive visits were scheduled for months 4, 10, 16, 24, 36, and 48 thereafter. Heart function was assessed using echocardiography and, an exercise test with analysis of peak oxygen consumption (VO(2)max). Results were correlated with VO(2)max (Pearson). The Mann-Whitney U test was used to compare study and control groups. RESULTS: The results of eligible VO(2)max tests were as follows (medians and ranges): 1 month (n = 15), 19.5 (8.8-27.5) mL/kg/min; 4 months (n = 9), 21.7 (16.0-29.3) mL/kg/min; 10 months (n = 8), 23.3 (13.1-30.0) mL/kg/min; 16 months (n = 9), 26.6 (18.3- 36.0) mL/kg/min; 24 months (n = 9), 22.3 (14.1-35.0) mL/kg/min; 36 months (n = 9) 20.9 (16.4-32.1) mL/kg/min; 48 months (n = 5), 19.7 (17.0-30.9) mL/kg/min; versus 26.8 (26.5-42.5) mL/kg/min in the control group. VO(2)max results achieved by the study group were significantly lower than that in the control group, except for months 16, 24, and 48. VO(2)max was significantly negatively correlated with the following ultrasound parameters: interventricular septum diastolic and systolic diameter, and left ventricle systolic volume. CONCLUSION: The exercise capacity of recipients seemed to be negatively affected by poor blood pressure control, resulting in heart muscle hypertrophy.

Influence of Sociodemographic, Behavioral and Other Health-Related Factors on Healthy Ageing Based on Three Operative Definitions.

OBJECTIVES: Healthy ageing (HA) is a key concept and highly desirable phenomenon in every ageing and already old societies. The aim of our study was to evaluate the influence of socio-economic conditions as well as life-style and other health-related factors on the WHO definition of HA. DESIGN, SETTING, PARTICIPANTS: The study used cross-sectional data of the PolSenior Project - nationwide research evaluating different aspects of ageing in Poland - which included 4'653 respondents aged 65 years and over. MEASUREMENTS: Data were collected by trained interviewers in respondents' homes. Three definitions of HA including or not the participants' chronic conditions were analyzed. RESULTS: The prevalence of HA appeared as high as 17.6% if none or 1 chronic disease was present and 42.8% if no information about chronic diseases was taken into account. The association between known health predictors (age, marital status, education, income) and HA was observed. Moreover, HA appeared in relation with indicators of physical functioning and lifestyle. There was a strong concordance between HA and the fair self-rated health (OR = 1.87; 1.99, and 2.74 for the 1st, 2nd and 3rd definitions, respectively) and opposite relation with self-reported need for help (OR = 0.15; 0.15; and 0.13, respectively). CONCLUSIONS: The HA definition based on no functional activity limitations, no cognitive impairment, no depressive symptoms, no more than one disease and being socially active seems to be a useful approach of HA.

ORAMA: a study to investigate EBPG impact on renal anaemia - design and baseline data.

BACKGROUND: It is of paramount importance not only to publish anaemia management guidelines for chronic kidney disease (CKD) but also to verify their implementation in clinical practice. The Optimal Renal Anaemia Management Assessment (ORAMA) is the first European study investigating the impact of adherence to the 2004 revised European Best Practice Guidelines (EBPG) and its impact on patient outcomes. METHODS: Participating centres were randomised into 2 groups: group A with, and group B without, access to an EBPG-based computerised clinical decision support (CDS) system after baseline. Patients with stage 2-5 CKD either anaemic (haemoglobin [Hb] <11 g/dL) or treated with erythropoiesis-stimulating agents (ESAs) and/or iron supplementation were enrolled. Primary end points are based on achievement of anaemia-related guideline targets. Here, baseline data are reported descriptively. RESULTS: Fifty-three centres in 8 countries included 739 patients, 81% of whom have received dialysis. Mean baseline Hb was 11.2 g/dL, and 52% of all patients met the EBPG target of >11 g/dL Hb at baseline. However, only 37% of patients had their Hb values >11 g/dL throughout a 3-month prestudy period. Serum ferritin and transferrin saturation were above the guideline target in circa 80% of patients. The vast majority of patients (96%) received ESA therapy at baseline. CONCLUSIONS: In line with findings from previous studies ORAMA baseline data show that achievement of EBPG is suboptimal across European countries. Final results promise an insight into the impact of guideline-based CDS tools on clinical practice and target attainment.

Serum 1-84 and 7-84 parathyroid hormone concentrations and bone in patients with primary hyperparathyroidism.

BACKGROUND AND AIMS: Parathyroid hormone (PTH) acts on bone as both anabolic and catabolic factor. It includes two fractions: 1-84 (cyclase activating PTH, CAP) which increases bone turnover and serum calcium, and 7-84 (cyclase inactivating PTH, CIP) acting the opposite way. The aim of this study was to establish whether bone mineral density (BMD) and turnover in patients' primary hyperparathyroidism (HPT) are dependent on CAP and CIP concentrations. PATIENTS/METHODS: Thirty-one patients with HPT and 29 appropriately matched controls were examined. Parameters of calcium-phosphate homeostasis and BMD were estimated. RESULTS: BMD of radius shaft was lower in patients with HPT as compared with controls, whereas BMD of spine and ultradistal radius were similar. Serum calcium, bone alkaline phosphatase, total PTH, 1-84 PTH, and 7-84 PTH were higher in HPT patients, whereas serum phosphate was lower and beta cross-laps similar. Both total PTH and CAP correlated significantly with BMD of radius shaft and serum calcium concentration, but not with other examined parameters. CONCLUSION: Total and 1-84 PTH are similarly associated with examined parameters in patients with HPT. Thus, determination of serum CAP concentration does not seem to have advantages over total PTH with regard to bone mineral density and bone turnover assessment in those patients.

Relationship Between Individual Components of the Extended-Criteria Donor Definition and the First Post-transplant Kidney Graft Resistance Index, Measured by Doppler Sonography.

BACKGROUND: Despite an increasing utilization of kidneys procured from expanded-criteria donors, little is known about the effects of particular expanded-criteria donors definition components, that is, hypertension, increased creatinine prior to procurement, and cerebrovascular cause of death on the kidney graft Doppler parameters measured shortly after transplantation, whose increased values are associated with unfavorable outcomes. Hence, we analyzed the relationship between expanded-criteria donors components and resistance index values measured within 2 to 3 days post-transplant. MATERIAL AND METHODS: The initial post-transplant resistance index value was measured in 676 consecutive successful first cadaveric kidney graft recipients without delayed graft function or early acute rejection episode. We analyzed resistance index values in 460 patients transplanted with organs from donors <50 years and in 216 recipients with organs from donors >50 years old. RESULTS: In general, expanded-criteria donors status did not influence the initial resistance index values in the whole study group. Unexpectedly, in older donor groups, both the occurrence of donor hypertension and cerebrovascular cause of death resulted in significantly lower resistance index values in kidney graft recipients (0.73 ± 0.10 vs 0.76 ± 0.11 in the non-hypertension group, P = .013 and 0.74 ± 0.11 vs 0.78 ± 0.10 in the non-cerebrovascular cause of death group, P = .015, respectively). In the Cox proportional regression model for graft survival, cerebrovascular cause of death was increasing the risk of graft loss by 55%, while recipient's age had the opposite effect, decreasing the risk of graft loss by 2% per year. CONCLUSIONS: Regardless of the limited influence of expanded-criteria donor status on first post-transplant resistance index value, the long-term observation shows moderate but significantly worse kidney graft survival, mostly as a result of the cerebrovascular cause of donor's death.

No Significant Influence of Reduced Initial Tacrolimus Dose on Risk of Underdosing and Early Graft Function in Older and Overweight Kidney Transplant Recipients.

BACKGROUND: Nowadays, a reduced initial daily dose of tacrolimus (Tac) (0.1-0.15 mg/kg) is recommended for the majority of kidney transplant recipients (KTRs). The aim of the study was to analyze the safety of such a regimen, including the risk of first inadequately low Tac blood level, acute rejection (AR) occurrence, or early graft dysfunction. METHODS: In 2011, we introduced a modified (0.1-0.15 mg/kg/d) initial Tac dosing regimen in older (>55 years) and/or overweight KTRs. To assure the safety of this protocol, we monitored the risk of inadequately low blood Tac level (<6 ng/mL) and incidence of AR or delayed graft function (DGF). The historical cohort with the higher Tac dosing regimen (0.2 mg/kg/d, n = 208) served as a control group. RESULTS: The mean Tac daily dose in 78 KTRs (group with reduced dosing) was 0.133 (95% confidence interval [CI], 0.130-0.136) mg/kg and was significantly lower than the standard, previously prescribed dose of 0.195 (95% CI, 0.194-0.197) mg/kg. Of note, induction therapy was employed twice more often in the reduced Tac dosing group. The dose reduction resulted in a slight, nonsignificant decrease in first Tac trough level. The percentages of patients with first Tac troughs <6 ng/mL (5.1% vs 4.8%), AR (6.4% vs 5.8%), and DGF (25.6% vs 31.2%) were similar in the reduced and standard dosing groups. CONCLUSION: The currently recommended reduction in Tac initial dosing does not increase the risk of inadequate immunosuppression and does not affect the early graft function. Regardless of Tac dose reduction, there is still a substantial risk of Tac overdosing in older or overweight KTRs.

Influence of Polypharmacy on the Quality of Life in Stable Kidney Transplant Recipients.

BACKGROUND: Kidney transplant recipients are frequently treated for other medical conditions and experience polypharmacy. The aim of our study was to evaluate quality of life in relation to medicines' burden in these patients. METHODS: We studied 136 unselected patients with mean post-transplant time of 7.2 ± 4.6 years. Quality of life was evaluated using a validated Polish version of the Kidney Disease Quality of Life-Short Form questionnaire. Data concerning the type (generic name) and number of currently prescribed medications were collected by interview survey. The participants were divided into 3 groups: group 1, patients with a maximum of 4 different medications (n = 37); group 2, patients with 4 to 9 medications (n = 76); and group 3, patients receiving at least 10 different medications (n = 23). RESULTS: The number of medicines taken regularly ranged from 2 to 16. Patients with ≥10 drugs had the highest body mass index and lowest estimated glomerular filtration rate. Patients treated with ≥10 drugs, compared to patients from the 2 other groups, had presented lower subscales results concerning the physical functioning (65.9 vs 84.5 in group 1 and 83.4 in group 2, P < .001 for both comparisons), pain (57.2 vs 82.7 and 76.5, respectively, P < .001 for both), social function (66.8 vs 82.1 and 80.4, respectively, P = .04 for both), and energy/fatigue (54.8 vs 67.7, P = .03 and 65.4, P < .05). Multivariate regression analysis revealed that the number of drugs independently influenced physical functioning, pain, and social function subscales. CONCLUSIONS: Polypharmacy is associated with lower quality of life in patients after successful kidney transplantation. The negative impact of polypharmacy is particularly seen regarding physical functioning and pain severity.

Assessment of the Learning Process After Introducing a New Liver Transplantation Procedure in a Center With Extensive Experience in Kidney Transplantation.

BACKGROUND: Liver transplantation (LTx) is one of the most complex transplant procedures. The aim of the present study was to determine whether the learning process can be observed after the introduction of LTx in a center with extensive previous experience in renal transplantation. METHODS: This retrospective analysis included 264 primary LTx procedures performed with the piggyback technique (2005-2016). The procedures were divided into 4 equal groups. The characteristics of the recipients, data related to the surgery, and the postoperative course and complications were analyzed. RESULTS: We observed a significant reduction in surgical time and in the anhepatic phase duration between Group 1 and the other groups (median surgical time was 455 minutes vs 415 minutes, 410 minutes and 387 minutes, respectively, P < .05; median anhepatic phase duration was 75 min vs 60 min, 62 min, 60 min, respectively, P < .05). There was a decrease in the number of transfused blood units (median in Group 1 of 6 packs vs 3 packs in Group 4, P < .05) and a decrease in blood recovered from the operating field using the Cell Saver system (median in Group 1 of 1570 mL vs 1057 mL, 1123 mL, and 1045 mL, respectively, P < .05). A significant reduction in the number of hemorrhages was found (1.5% in Group 4 vs 13.6%, 10.6%, and 7.6% in the other groups P < .05). The remaining studied parameters were not statistically significant. CONCLUSIONS: Extensive previous transplantation experience affected the lack of typical features of the learning process.

Solid Organ Cancer and Melanoma in Kidney Transplant Recipients: TumorTx Base Preliminary Results.

BACKGROUND: Incidence of malignancy in transplant recipients is higher than in the general population. Malignancy is a major cause of mortality following solid organ transplantation and a major barrier to long-term survival for the kidney. The aim of this study was to estimate the incidence of solid organ malignancy (SOM) and melanoma in renal transplant recipients (RTR) transplanted at 2 representative transplant centers in Poland based on data from the Polish Tumor Registry. MATERIAL AND METHODS: We analyzed the medical data of 3069 patients who underwent kidney transplantation (KTx) between 1995 and 2015. RESULTS: In our study 112 SOM (3.6%) were diagnosed. The majority of patients were male (n = 71; 63.4%; P < .01). The mean age at KTx was 48.0 ± 13.1 years and the mean age at the time of cancer diagnosis was 55.9 ± 12.7 years. The average time of malignancy occurrence was 5.9 ± 5.0 years after KTx. SOM was the cause of death in 60 patients (53%). The most common were malignancies of gastrointestinal tract (25%), urinary tract tumors (23.2%), lung cancer (n = 18; 16%), and lymphoma (13.4%). We found an increase in the percentage of chronic glomerular nephropathy in the group of SOM (n = 56; 50%) compared with renal insufficiency of other etiologies. CONCLUSIONS: RTR in Poland are at a significant risk of malignancy development in a variety of organs, primarily urinary tract tumors and lymphoma. Cancers most frequently occurring in the general population such as lung and colorectal cancer are common in our RTR. On this basis an appropriate tumor screening schedule can be developed in individual countries.

Atrial fibrillation independently linked with depression in community-dwelling older population. Results from the nationwide PolSenior project.

BACKGROUND: Depression is a frequently observed comorbid condition in patients with cardiovascular diseases. In contrast to coronary heart disease and heart failure there is a limited amount of published data concerning the increased prevalence of depression among patients with atrial fibrillation (AF). Therefore, we decided to assess the prevalence of depression in Polish community-dwelling older patients with a history of AF. METHODS: The data were collected as part of the nationwide PolSenior project (2007-2012). Out of 4979 individuals (age range 65-104 years), data on self-reported history of AF were available for 4677 (93.9%). Finally, 4049 participants without suspected moderate or severe dementia in Mini Mental State Examination test were assessed with the 15-item Geriatric Depression Scale (GDS), and a score of 6 points and more was regarded as suspected depression. RESULTS: Mean age (±SD) of the study population was 78.1 (±8.3) years; 52% were males. The history of AF was reported by 788 (19.5%) subjects. In the univariate analysis a self-reported AF history was associated with 42% increase of suspected depression (41% vs 29%; P < 0.001). In multivariate logistic regression AF remained an independent predictor of depression (OR = 1.69; 95%CI: 1.43-2.00), stronger than heart failure, diabetes or coronary heart disease. CONCLUSIONS: In community-dwelling geriatric Polish population AF is associated with higher prevalence of depression. This association is independent from the demographic factors, disabilities and comorbidities (including history of stroke).

Results of Transplantation of Kidneys Procured From Donors After Brain Death Aged 60 Years and Older.

OBJECTIVE: To analyze results of transplantation of kidneys procured from donors after brain death aged 60 years and older (hereafter denoted by "≥60") compared to kidneys procured from donors after brain death aged 40-59 years (hereafter denoted by "40-59") in medium-term follow-up period, and to assess factors that affect recipient and kidney graft survival. MATERIAL AND METHODS: 92 transplant recipients of kidneys procured from donors after brain death ≥60 were enrolled into the study. The control group were 363 recipients of kidneys procured from donors after brain death 40-59. RESULTS: Mean values of serum creatinine were higher in recipients of kidneys procured from donors after brain death ≥60 compared to control after 3 years: 168.2 ± 57.5 (n = 59) vs 147.9 ± 65.7 (n = 294), P < .05; and after 5 years: 196.2 ± 95.3 (n = 38) vs 157.3 ± 80.0 µmol/L (n = 211), P < .01. Restricted mean recipient survival time was 56.4 (95% confidence interval: 55.0-57.8) and 52.0 (48.0-56.1) months, P < .05; and kidney graft survival time was 51.6 (49.6-53.5) and 43.9 (39.0-48.9) months, P < .01 in recipients who received kidneys from donors after brain death 40-59 and from donors after brain death ≥60 respectively. In Cox regression, donor death due to cardiovascular disease proved to be the factor increasing risk of kidney graft loss (hazard ratio 1.553, P < .001). CONCLUSIONS: The survival and function of kidneys procured from donors after brain death ≥60 at medium-term follow-up remain worse compared to kidneys procured from donors after brain death 40-59, and the donor dependent risk factor of kidney graft loss is cardiovascular disease, which caused donor death.

Plasma adiponectin concentration in patients after successful kidney transplantation--a single-center, observational study.

BACKGROUND AND AIM: Adiponectin is an anti-inflammatory protein secreted almost exclusively by adipocytes which improves insulin sensitivity and presents antiatherogenic properties. Plasma adiponectin concentration is almost 3 times higher in hemodialysis patients and markedly decreased after successful kidney transplantation. However, until now, there are no studies analyzing plasma adiponectin concentration in kidney transplant patients (KTx) during the long-term period after transplantation. Therefore, the aim of present study was to examine plasma adiponectin concentration in KTx patients during the wide range of time after transplantation. MATERIAL AND METHOD: Single center, cross-sectional study including 228 KTx adult recipients (143 M and 85 F) with estimated glomerular filtration rate (eGFR) > or = 15 ml/min, 80 hemodialysis patients (34 M and 46 F) and 52 healthy subjects (33 M and 19 F). Plasma adiponectin concentration was estimated together with HOMA-IR (homeostasis model assessment insulin resistance index) and plasma lipid profile. RESULTS: In KTx patients plasma adiponectin concentration 14.0 (13.1-15.0) microg/ml was significantly (p < 0.001), lower than in hemodialysis ones 29.0 (24.7-33.3) microg/ml, however, significantly (p < 0.001) higher than in healthy subjects 10.1 (8.8-11.5) microg/ml. Among KTx patients the highest plasma adiponectin concentration was observed in the subgroup of patients surviving with the functioning graft more than 8 years after transplantation. In KTx patients, significant, negative correlations were found between plasma adiponectin concentration and BMI (p = 0.017), HOMA-IR (p = 0.02) and estimated GFR (p < 0.009), respectively. Multiple regression analysis performed in the group of KTx patients, with plasma adiponectin concentration as the dependent variable and BMI, age, gender, estimated GFR as independent variables showed that in this model (R2 = 0.09) plasma adiponectin concentration significantly depends on BMI (p = 0.035), gender (p = 0.004) and eGFR (p = 0.023). CONCLUSIONS: Patients with long-term renal graft survival are characterized by a higher plasma adiponectin concentration. Kidney graft function (assessed as estimated GFR) is an important factor influencing plasma adiponectin concentration.

Results of a 6-month, multicenter, open-label, prospective study concerning efficacy and safety of mycophenolate sodium in de novo kidney transplant recipients.

BACKGROUND: Mycophenolate sodium (MPS) was designed to reduce the gastrointestinal side effects of mycophenolic acid. The aim of our study was to determine the safety and efficacy of MPS in de novo renal transplant recipients. PATIENTS AND METHODS: This 6-month, multicenter, open-label, single-arm, prospective study was carried out in three centers in Poland. Thirty patients were recruited. Immunosuppressive regimen contained of MPS and cyclosporine (CsA) with or without steroids. RESULTS: The 6-month graft and patient survival was 100%. The incidence of suspected acute rejection episodes (ARE) was 5/30 (16.7%), including biopsy-proven ARE in 2 (6.7%) cases. ARE reversed after therapy. At month 6, the mean serum creatinine level was 1.4 mg/dL, and the mean creatinine clearance (according to the Cockroft-Gault formula) was >70 mL/min. The most frequent adverse effects included diarrhea, delayed graft function, anemia, and lymphocele. Among infections, most common were infections of urinary tract, cytomegalovirus infections, and infections of respiratory tract. Only three patients (10.0%) terminated the study prematurely, including two who discontinuated because of an adverse event, and one because of noncompliance. CONCLUSIONS: An immunosuppressive regimen, including MPS and CsA, with or without steroids, provided effective antirejecton prophylaxis and was well tolerated.

Did volume of lymphocele after kidney transplantation determine the choice of treatment modality?

INTRODUCTION: Lymphocele is a lymph collection that forms after surgery following injury to lymph nodes and vessels. The aim of the study was to perform a retrospective analysis of different treatment modalities of lymphocele in patients after kidney transplantation. MATERIAL AND METHODS: A lymphocele located in renal graft area was observed in 25 of 386 transplanted patients (6.5%). Mean patient age was 45 (95% confidence interval [CI], 40 to 50) years. Mean observation time was 35 (95% CI, 27 to 43) months. RESULTS: Mean time from transplantation to diagnosis of lymphocele was 29 days (range, 4 to 127). In 13 patients (54.2%), the lymphocele was symptomatic, requiring initial treatment by repeated needle aspirations or percutaneous drainage. Among 7 patients with persistence of the lesion treatment by sclerotherapy with doxycycline, povidone-iodine, and/or ethanol was successful in 4 cases who showed maximal lymphocele volume of 500 mL. Three other patients, namely, volumes of 120, 874, and 2298 mL were referred for surgery; in two cases, internal marsupialization was performed and in one case external drainage was necessary due to abscess formation. Mean time from the diagnosis to recovery in patients requiring surgical treatment was 15 (range, 8 to 24) weeks. Eleven patients with asymptomatic lymphoceles (mean volume 45 mL; range, 8 to 140) were monitored to resolution after a mean of 4 (range, 1 to 11) weeks. CONCLUSION: All lymphoceles with the maximal volume exceeding 140 mL were clinically symptomatic. Initial percutaneous drainage with or without sclerotherapy was an effective method of treatment. Punctures, drainage, and sclerotherapy were not effective in patients with lymphoceles (>500 mL).

The intrarenal vascular resistance parameters measured by duplex Doppler ultrasound shortly after kidney transplantation in patients with immediate, slow, and delayed graft function.

BACKGROUND: Evaluation of pulsatility (PI) and resistive (RI) indexes by duplex Doppler ultrasound shortly after kidney transplantation reflects the exacerbation of interstitial edema. The aim of study was to characterize factors that influence PI and RI in patients with immediate (IGF), slow (SGF), or delayed (DGF) kidney graft function. PATIENTS AND METHODS: PI and RI were measured in 200 transplanted patients at 2 to 4 days postoperatively. We excluded patients with acute rejection episodes within the first month. IGF, which was defined as serum creatinine <264 micromol/L at 3 days, SGF, which was defined as creatinine >264 micromol/L by day 3 with a maximum of one dialysis, and DGF, which was defined as more than 1 dialysis were observed in 33.3%, 41.5%, and 25.2% of patients, respectively. The examined donor parameters were age, hypotensive episodes, catecholamine infusion, central venous pressure, and glomerular filtration rate. The recipient factors were age, history of hypertension, diabetes mellitus, ischemic heart disease, and stroke. Additionally cold ischemia time (CIT), HLA mismatch, and PRA were analyzed. RESULTS: The lowest PI and RI values were observed among patients with IGF (PI 1.37 [1.28 to 1.46]; RI 0.72 [0.69 to 0.74]); moderate values in SGF (PI 1.65 [1.52 to 1.78]; RI 0.78 [0.76 to 0.80]) and the highest values in DGF (PI 2.09 [1.83 to 2.35]; RI 0.83 [0.80 to 0.86]) differences that were highly significant. Hypotensive episodes and catecholamine infusion in the preharvest period had essential impacts on PI or RI values in the early posttransplant period. There was no significant correlation between PI or RI values and CIT. A slower ATN resolution was observed in DGF patients with higher PI values. CONCLUSION: Ischemic injury, which occurred mainly prior to organ harvesting, played a dominant role determining intrarenal resistance in the early posttransplant period.

Simultaneous transabdominal bilateral nephrectomy in potential kidney transplant recipients.

BACKGROUND: Bilateral nephrectomy of potential kidney graft recipients is indicated for patients with recurrent infections in the polycystic kidneys or chronic pyelonephritis resulting from vesicoureteric reflux. The aim of this study was to analyze the frequency of complications after simultaneous bilateral transperitoneal nephrectomy. PATIENTS AND METHODS: Twenty hemodialysis patients (age 28 to 55 years) were referred for simultaneous bilateral nephrectomy between 1996 and 2004. Among the 18 patients with autosomal-dominant polycystic kidney disease, 11 experienced recurrent cysts or urinary tract infections and two, episodes of disabling flank pain. Five patients with extremely enlarged kidneys were asymptomatic. Two patients presented vesicoureteric reflux with chronic pyelonephritis. In all cases the kidneys were removed transperitoneally via a transverse or midline incision. RESULTS: Although no fatal outcome was recorded, three patients required brief hospitalizations in the intensive care unit. The only intraoperative complication was spleen injury in five patients. Surgical postoperative complications developed in nine patients (45%) including: extended drainage and delayed wound healing (n = 4), postoperative hernia (n = 3), prolonged abdominal pain (n = 3), perihepatic hematoma (n = 2), stress duodenal ulceration (n = 1), and subileus (n = 1). Five patients displayed thrombosis of their dialysis access, probably as a consequence of low blood pressure. After surgery 15 patients were placed on the waiting list and 10, successfully transplanted. CONCLUSION: Simultaneous transabdominal bilateral nephrectomy was associated with a high risk of postoperative complications, but may save the suffering associated with a repeated operation in potential kidney graft recipients who have an indication for bilateral nephrectomy.

Early donor lymph node procurement and local HLA typing reduce cold ischemia time and risk of acute tubular necrosis in cadaveric kidney transplantation.

Prolonged cold ischemia time (CIT) is one of the most common causes of acute tubular necrosis (ATN) with consequent delayed graft function after kidney transplantation. The aim of the study was to analyze the impact of early donor lymph nodes (LN) procurement in combination with local or central HLA typing on CIT, on donor-recipient HLA mismatches, and on the early results of grafts. Two hundred six cadaveric procedures were performed from 2001 to 2004 including 86 cases out of 119 recipients who were matched locally and 60 cases out of 87 recipients who were matched centrally, wherein LN were obtained before kidney harvest. CIT was significantly shorter when LN were obtained before kidney harvesting both in local (13.6 vs 20.6 hours) and central (20.1 vs 27.7 hours) matching (both P < .001). ATN frequency was significantly lower in patients with LN obtained earlier (27.9%) when matched locally versus (35.0%) when matched centrally. Kidney graft function estimated at 12 months was similar in both groups. CIT longer than 19.5 hours predicted ATN occurrence with 57.7% sensitivity and 66.4% specificity. Local matching resulted in shortening CIT compared to central matching (15.5 vs 22.4 hours); however, the mismatch in HLA class I and HLA class II were significantly worse (HLA A + B 2.76 vs 2.45, HLA DR 1.21 vs 0.82). These discrepancies did not significantly influence the frequency of ATN (36.1% vs 40.0%) or the kidney graft function at 12 months.