Changes over time in the causes of death with a functioning graft in kidney transplantation recipients.

INTRODUCTION: Death with a functioning graft (DWFG) is the most frequent cause of loss of kidney transplantation (KT). OBJECTIVE: To analyze the evolution of the causes of DWFG and the frequency of the types of cancer causing DWFG. METHODS: Retrospective study of KT in Andalusia from 1984 to 2018. We analyzed the evolution according to eras (1984-1995; 1996-2007; 2008-2018) and according to post-transplant period (early death: first year post-KT; late death: after first year post-KT). RESULTS: A total of 9905 KT were performed, registering 1861 DWFG. The most frequent causes were cardiovascular disease (25.1%), infections (21.5%) and cancer (19.9%). In early death we did not observe changes, and infections were always the main cause. In late death, cardiovascular death decreased (1984-1995: 35.2%, 1996-2007: 22.6%, 2008-2018: 23.9%), but infections (1984-1995: 12.5%, 1996-2007: 18.3%, 2008-2018: 19.9%) and, above all, cancer-related deaths increased (1984-1995: 21.8%, 1996-2007: 29%, 2008-2018: 26.8%) (P < .001). In the multivariable analysis for late death due to cardiovascular disease, recipient age, retransplantation, diabetes, and the first period were risk factors, while the risk of late death due to cancer and infections was associated with recent eras. In the first year after transplantation, the most frequent neoplasia causing DWFG was post-transplant lymphoproliferative disease, and after the first year, it was lung cancer, without differences when it was analyzed by eras. CONCLUSIONS: Despite the greater comorbidity of the recipients, cardiovascular deaths have decreased. Cancer has been the main cause of late death in recent years. Lung cancer is the most frequent malignancy that causes DWFG in our transplant patients.

Benefits of Routine Screening for Renal Cell Carcinoma of Native Kidney in Renal Transplant Recipients.

BACKGROUND: Renal-cell carcinoma (RCC) is the most common solid organ cancer in kidney transplantation recipients (KTRs). BACKGROUND: Analyze the incidence, prognosis, and evolution of primitive kidney RCC in KTRs at our institution. MATERIAL AND METHODS: Observational descriptive retrospective study in which all KTRs from January 2000 to December 2022 were included. We performed an annual abdominal ultrasound in all KTRs. Demographic and clinical data were collected. The surgical approach, location, size, histologic type, and tumor grade were analyzed. We assessed the coexistence of risk factors. We reported the appearance of tumors in other locations, changes in immunosuppressants (IS) after the diagnosis, and survival and recurrence rates observed during follow-up. RESULTS: Eighteen RCCs of native kidneys were diagnosed with an incidence in our population of 1.08%. The majority were men (77.8%), with a mean age of 59.9 years. The pathologic analysis revealed 11 clear cell carcinomas, 6 papillary carcinomas, and 1 chromophobe cell carcinoma. The median tumor size was 2.7 cm. TNM stage was T1aN0M0 in 15 cases. Laparoscopy was performed to remove the tumor in most cases. All our patients underwent changes in IS therapy, with conversion to mammalian target of rapamycin inhibitors when possible and reduction of IS in all of them. After a mean follow-up of 78.6 months, survival was 100% without tumor recurrence. Seven of the patients were diagnosed with a new tumor in another location. CONCLUSION: In our experience, annual abdominal ultrasound in KTRs may be an option for the early detection of RCC in native kidneys.

High exposure to tacrolimus is associated with spontaneous remission of recurrent membranous nephropathy after kidney transplantation.

Introduction: We aimed to characterize the incidence and clinical presentation of membranous nephropathy (MN) after kidney transplantation (KT), and to assess allograft outcomes according to proteinuria rates and immunosuppression management. Methods: Multicenter retrospective cohort study including patients from six Spanish centers who received a KT between 1991-2019. Demographic, clinical, and histological data were collected from recipients with biopsy-proven MN as primary kidney disease (n = 71) or MN diagnosed de novo after KT (n = 4). Results: Up to 25.4% of patients with biopsy-proven MN as primary kidney disease recurred after a median time of 18.1 months posttransplant, without a clear impact on graft survival. Proteinuria at 3-months post-KT was a predictor for MN recurrence (rMN, HR 4.28; P = 0.008). Patients who lost their grafts had higher proteinuria during follow-up [1.0 (0.5-2.5) vs 0.3 (0.1-0.5) g/24 h], but only eGFR after recurrence treatment predicted poorer graft survival (eGFR < 30 ml/min: RR = 6.8). We did not observe an association between maintenance immunosuppression and recurrence diagnosis. Spontaneous remission after rMN was associated with a higher exposure to tacrolimus before recurrence (trough concentration/dose ratio: 2.86 vs 1.18; P = 0.028). Up to 94.4% of KT recipients received one or several treatments after recurrence onset: 22.2% rituximab, 38.9% increased corticosteroid dose, and 66.7% ACEi/ARBs. Only 21 patients had proper antiPLA2R immunological monitoring. Conclusions: One-fourth of patients with biopsy-proven MN as primary kidney disease recurred after KT, without a clear impact on graft survival. Spontaneous remission after rMN was associated with a higher exposure to tacrolimus before recurrence.

Impact of physical exercise in patients with chronic kidney disease: Sistematic review and meta-analysis. / Impacto del ejercicio físico en pacientes con enfermedad renal crónica: revisión sistemática y metaanálisis.

Physical exercise may offer multiple benefits to patients with chronic kidney disease (CKD). However, it was not traditionally recommended because of the possibility of impairing renal function and increasing proteinuria. The objective of this study is to review the clinical trials on physical exercise in patients with CKD and describe its effect on the progression of kidney disease and other factors associated. Randomized clinical trials (RCT) comparing an intervention that included an exercise component with a control group without physical exercise in non-dialysis patients with CKD from 2007 to 2018 in English and Spanish were included. PubMed, Scopus, Embase, Ovid (Medline) and PEDro databases were used for the search. Effects of physical exercise were summarized by the standardized mean difference (SMD). No differences were found in glomerular filtration rate or proteinuria between the intervention group and the control group: SMD -0.3 (P=.81); SMD 26.6 (P=.82). Positive effects were obtained on peak oxygen consumption: SMD 2.5 (P<.001), functional capacity: SMD 56.6 (P<.001), upper limb strength: SMD 6.8 (P<.001) and hemoglobin: SMD 0.3 (P=.003). An improvement on the quality of life was also evident using the KDQOL-36 survey: SMD 3.56 (P=.02) and the SF-36 survey: SMD 6.66 (P=.02). In conclusion, the practice of low-intensity physical exercise routinely has no negative impact on renal function. On the contrary, it improves aerobic and functional capacity, impacting positively on the quality of life.

Direct-Acting Antiretroviral Therapy in Renal Transplant Recipients With Human Immunodeficiency Virus-Hepatitis C Virus Coinfection: Report of Our Experience and Literature Review.

A minor graft and patient survival are described in renal transplant recipients with hepatitis C virus (HCV) and human immunodeficiency virus (HIV) coinfection than in recipients infected with only HIV. The high efficacy of direct-acting antivirals could improve the results. The experience reported in renal transplant recipients with coinfection is very limited. MATERIAL AND METHODS: We analyzed the evolution of renal recipients with HIV-HCV coinfection treated with direct-acting antivirals in our center. Clinical, analytical, and microbiological variables were collected before and after treatment. RESULTS: From 2001 to 2018 we performed 11 renal transplants in patients with HIV infection, and 6 (54.5%) had HIV-HCV coinfection. One patient lost the graft before the development of direct-acting antivirals. Another patient with functioning graft has refused to receive any treatment. Four patients have been treated with direct-acting antivirals. One was treated 18 months before the transplant; 3 received treatment after transplant. All received sofosbuvir-based therapies. All had a sustained virologic response after 12 weeks and an improvement of liver function. In the patients treated after renal transplant, time post transplant at the beginning of treatment was 99.6 (SD, 22.8) months, and follow-up after treatment in all patients was 40.2 (SD, 8.16) months. To modify immunosuppressive regimen was not necessary, although 2 patients required an increase of tacrolimus doses. We do not observe deterioration of renal function. All have maintained a good immunologic and microbiological control without requiring changes in antiretrovirals. We do not observe complications associated with treatment. CONCLUSIONS: Direct-acting antivirals therapy is safe and effective and may offer new possibilities to patients with HIV-HCV coinfection.

Characteristics and Evolution of Renal Transplant Recipients Infected by Carbapenemase-Producing Klebsiella pneumoniae.

BACKGROUND: Renal transplant (RT) recipients are especially susceptible to carbapenem-resistant Klebsiella pneumoniae carbapenemase (KPC) infections. However, published experience is limited. OBJECTIVE: To analyze the characteristics and evolution of RT recipients with KPC infection in our hospital. METHODS: We performed a retrospective cohort study of all RT recipients with KPC infection in our hospital from December 1, 2017 (first case), to July 31, 2019. For each RT recipient infected with KPC, 3 controls were selected. RESULTS: During the study period, 8 RT recipients presented KPC infection. Seven were detected in the first year post-RT. The most common site of infection was urine. In 2 cases the germ was isolated in blood. The number of patients with diabetes was significantly higher in the group with KPC infection (P = .023), and urologic interventions were more frequent in those patients (P = .039). No differences were found in the immunosuppressive treatment. A total of 62.5 % of patients required readmission after the KPC infection. One patient died of septicemia by KPC. In all these cases, the clone of KPC isolated was KPC ST512. CONCLUSION: KPC infection is more frequent in the first months after the RT and causes an important number of hospital admissions. It can be cause of death in RT recipients, especially in those with isolation of the germ in blood. Diabetes and urologic interventions were more frequent in this population. The analysis by molecular typing suggests exposure to a common source, highlighting the importance of preventive isolation measures and surveillance for limiting the transmission of this bacteria.

Cambios en el tiempo de las causas de muerte con injerto funcionante en los receptores de trasplante renal / Changes over time in the causes of death with a functioning graft in kidney transplantation recipients

Introducción: La muerte con injerto funcionante (MCIF) es la causa más frecuente de pérdida del trasplante renal (TR). Objetivo: Analizar la evolución de las etiologías de MCIF y la frecuencia de los tipos de neoplasia causantes. Métodos: Estudio retrospectivo de los TR en Andalucía desde 1984 hasta 2018. Analizamos la evolución de las MCIF según etapas (1984-1995; 1996-2007; 2008-2018) y según período post-TR (muerte precoz: primer año post-TR; muerte tardía: tras el primer año post-TR). Resultados: Se realizaron 9.905 TR; se produjeron 1.861 MCIF. Las causas más frecuentes fueron enfermedad cardiovascular (25,1%), infecciones (21,5%) y neoplasias (19,9%). En las muertes precoces no observamos cambios en el tiempo; las infecciones siempre fueron la causa principal. En las tardías, desciende la muerte cardiovascular (1984-1995: 35,2%; 1996-2007: 22,6%; 2008-2018: 23,9%) y aumentan las muertes por infecciones (1984-1995: 12,5%; 1996-2007: 18,3%; 2008-2018: 19,9%) y, sobre todo, por cáncer (1984-1995: 21,8%; 1996-2007: 29%; 2008-2018: 26,8%) (p<0,001). En el análisis multivariante para muerte tardía cardiovascular, edad del receptor, retrasplante, diabetes y primera etapa fueron factores de riesgo, mientras que el riesgo de muerte tardía por cáncer e infecciones se asoció con las etapas recientes. La neoplasia más frecuente en el primer año post-TR fue la enfermedad linfoproliferativa post-TR y tras el primer año el cáncer de pulmón, sin diferencias entre etapas. Conclusiones: A pesar de la mayor comorbilidad del receptor, las muertes cardiovasculares han descendido. Las neoplasias son la principal causa de muerte tardía en los últimos años. El cáncer de pulmón es la neoplasia más frecuente causante de MCIF en TR. (AU)

Introduction: Death with a functioning graft (DWFG) is the most frequent cause of loss of kidney transplantation (KT). Objective: To analyze the evolution of the causes of DWFG and the frequency of the types of cancer causing DWFG. Methods: Retrospective study of KT in Andalusia from 1984 to 2018. We analyzed the evolution according to eras (1984-1995; 1996-2007; 2008-2018) and according to post-transplant period (early death: first year post-KT; late death: after first year post-KT). Results: A total of 9,905 KT were performed, registering 1,861 DWFG. The most frequent causes were cardiovascular disease (25.1%), infections (21.5%) and cancer (19.9%). In early death we did not observe changes, and infections were always the main cause. In late death, cardiovascular death decreased (1984-1995: 35.2%, 1996-2007: 22.6%, 2008-2018: 23.9%), but infections (1984-1995: 12.5%, 1996-2007: 18.3%, 2008-2018: 19.9%) and, above all, cancer-related deaths increased (1984-1995: 21.8%, 11996-2007: 29%, 2008-2018: 26.8%) (P<0.001). In the multivariable analysis for late death due to cardiovascular disease, recipient age, retransplantation, diabetes, and the first period were risk factors, while the risk of late death due to cancer and infections was associated with recent eras. In the first year after transplantation, the most frequent neoplasia causing DWFG was post-transplant lymphoproliferative disease, and after the first year, it was lung cancer, without differences when it was analyzed by eras. Conclusions: Despite the greater comorbidity of the recipients, cardiovascular deaths have decreased. Cancer has been the main cause of late death in recent years. Lung cancer is the most frequent malignancy that causes DWFG in our transplant patients. (AU)

Infección por SARS-CoV-2 en lista de espera de trasplante renal: ¿Se puede trasplantar un paciente con antecedente de COVID-19? / Sars-CoV-2 infection on the kidney transplant waiting list: can a patient be transplanted after covid-19?

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Impacto del ejercicio físico en pacientes con enfermedad renal crónica: revisión sistemática y metaanálisis / Impact of physical exercise in patients with chronic kidney disease: Sistematic review and meta-analysis

El ejercicio físico podría ofrecer múltiples beneficios al paciente con enfermedad renal crónica (ERC). No obstante, tradicionalmente no se recomendaba por la posibilidad de deteriorar la función renal y aumentar la proteinuria. El objetivo del estudio es revisar los ensayos sobre ejercicio en pacientes con ERC y describir su impacto sobre la progresión de la enfermedad renal y otros factores asociados. Se seleccionaron ensayos clínicos aleatorizados desde 2007 a 2018, en inglés y en español, que compararan un grupo intervención con un componente de ejercicio con un grupo control sin ejercicio físico en pacientes con ERC en prediálisis. Para la búsqueda se emplearon las bases de datos PubMed, Scopus, Embase, Ovid (Medline) y PEDro. Los efectos del ejercicio sobre las variables analizadas se resumieron calculando la diferencia de medias estandarizada (DME). No se encontraron diferencias en el filtrado glomerular ni en la proteinuria entre el grupo intervención y el grupo control (DME: −0,3; p = 0,81; DME: 26,6; p = 0,82). Se obtuvieron efectos positivos sobre el consumo pico de oxígeno (DME: 2,5; p < 0,001), la capacidad funcional (DME: 56,6; p < 0,001), la fuerza en miembros superiores (DME: 6,8; p < 0,001) y la hemoglobina (DME: 0,3; p = 0,003). También se evidenció mejoría sobre la calidad de vida usando los cuestionarios KDQOL-36 (DME: 3,56; p = 0,02) y SF-36 (DME: 6,66; p = 0,02). En conclusión, la práctica de ejercicio de forma rutinaria y a baja intensidad no tiene impacto negativo sobre la función renal. Por el contrario, mejora la capacidad aeróbica y funcional, repercutiendo positivamente en la calidad de vida

Physical exercise may offer multiple benefits to patients with chronic kidney disease (CKD). However, it was not traditionally recommended because of the possibility of impairing renal function and increasing proteinuria. The objective of this study is to review the clinical trials on physical exercise in patients with CKD and describe its effect on the progression of kidney disease and other factors associated. Randomized clinical trials (RCT) comparing an intervention that included an exercise component with a control group without physical exercise in non-dialysis patients with CKD from 2007 to 2018 in English and Spanish were included. PubMed, Scopus, Embase, Ovid (Medline) and PEDro databases were used for the search. Effects of physical exercise were summarized by the standardized mean difference (SMD). No differences were found in glomerular filtration rate or proteinuria between the intervention group and the control group: SMD -0.3 ( P= .81); SMD 26.6 (P = .82). Positive effects were obtained on peak oxygen consumption: SMD 2.5 (P < .001), functional capacity: SMD 56.6 (P<.001), upper limb strength: SMD 6.8 (P < .001) and hemoglobin: SMD 0.3 (P = .003). An improvement on the quality of life was also evident using the KDQOL-36 survey: SMD 3.56 (P = .02) and the SF-36 survey: SMD 6.66 (P = .02). In conclusion, the practice of low-intensity physical exercise routinely has no negative impact on renal function. On the contrary, it improves aerobic and functional capacity, impacting positively on the quality of life