Use of tocilizumab in amyloid a nephropathy associated with Sweet syndrome: a case report and literature review.

Amyloid A nephropathy is a possible complication of chronic inflammatory disease. Proteinuria and kidney failure are the main features of the disease. Tocilizumab (TCZ), an IL6-R antibody approved for rheumatoid arthritis, is a promising choice for histologically demonstrated nephropathy. We describe a case of kidney amyloid associated with Sweet syndrome treated with TCZ. The patient was affected by Sweet syndrome associated with proteinuria. Kidney biopsy showed amyloid deposits. During the follow-up, cutaneous and renal findings were refractory to many immunosuppressive regimen (cyclophosphamide, leflunomide, interferon and steroid). After few years, the patient developed rapidly progressive nephropathy associated with nephrotic syndrome (proteinuria up to 6 g/die). A second kidney biopsy was performed and it showed worsening of amyloid nephropathy. Thus, TCZ was administrated (8 mg/kg once a month) and it stabilized kidney function and induced partial remission of the nephrotic syndrome in the following 2 years.

Blood pressure phenotype reproducibility in CKD outpatients: a clinical practice report.

Out-of-office blood pressure (BP) measurement is encouraged by recent hypertension guidelines for assessing BP phenotypes. These showed acceptable reproducibility in the short term, but few data exist about long-term reproducibility, particularly for chronic kidney disease (CKD) patients. We evaluated changes of the BP phenotypes at 6 and 12 months in 280 consecutive non-dialysis CKD outpatients (186 males, age 71 ± 12 years, eGFR 38 ± 13 ml/min/1.73), without any change in drug therapy. Elevated BP is defined as office BP > 140/90 and home BP > 135/85 mmHg for defining the following BP phenotypes: sustained uncontrolled hypertension (SUCH); white-coat uncontrolled hypertension (WUCH); masked uncontrolled hypertension (MUCH); and controlled hypertension (CH). At baseline, the prevalence of the phenotypes was SUCH 36.6%, CH 30.1%, WUCH 25.4% and MUCH 7.9%, and it was similar at 6 months and 12 months. On the other hand, individual phenotype reproducibility at 12 months was poor both overall (38.0%) and across the different phenotypes (SUCH 53.9%, WUCH 32.4% and CH 32.1%, MUCH 9.1%). Patients who were not maintaining the same phenotype (non-concordant) were not distinguished by age, sex, BMI, eGFR, presence of diabetes or cardiovascular disease, or pharmacological therapy. When reproducibility of BP phenotypes both at 6 months and at 12 months was assessed, it was very low (19.6%), particularly for MUCH (0%), CH (14%) and WUCH (15.5%), while it was 31% for SUCH. In a CKD cohort, the overall prevalence of the different BP phenotypes defined by office and home BP remains constant over time. However, only 38% of patients maintained the same phenotype at 12 months, suggesting a poor reproducibility over time for the BP phenotypes.

[Nutritional and Functional assessment of peritoneal dialysis patients in the clinical practice: Report from MITO-DP Group]. / Valutazione Nutrizionale e Funzionale dei pazienti in dialisi peritoneale nella pratica clinica: l'esperienza del Gruppo Medico-Infermieristico Toscano di Dialisi Peritoneale (M.I.TO.-DP).

Nutritional abnormalities and physical inactivity are risk factors of increased morbidity and mortality in patients with ESRD. Identify and define malnutrition, in particular protein-energy depletion (PEW), is an important task in the management of renal patients. The aim of this multicenter observational study was to implement the assessment of nutritional status and functional capacity in patients on peritoneal dialysis, including tests and validated methods which are relatively easy to apply in daily clinical practice. The study includes all the 133 prevalent patients (80 m, 53 f, age 65 14 years), in peritoneal dialysis treatment (vintage 26 19 months) in 9 centers in Tuscany. We performed anthropometry, bioimpedance (BIA), clinical biochemistry, evaluation of habitual physical activity (RAPA tests) and performance (Sit-To-Stand test), appetite-evaluation questionnaire, and indices including the Malnutrition Inflammation Score (MIS), Geriatric Nutrition Risk Index (GNRI), Charlson comorbidity index, Barthel and Karnowsky index. The latter showed a condition of dependence in 7.2% and 19.7% of cases, respectively. Poor appetite was recorded in 48.2%. The majority of patients fell within the overweight / obesity range (51%) with waist circumference values associated with increased cardiovascular risk in 51% of males and 60% of females. At the BIA analysis, a BCMI <8 kg/m2 was detected in 39% of patients; an estimated protein intake <1.0 g / kg/d was found in 59% of cases; 34% of patients had serum albumin <3.5 g / dl; control of acidosis was good (bicarbonate 25.4 3.8 mM) but hyperphosphatemia was present in 64.6% of patients. A condition of sedentary or light physical activity was reported by 65.1% of patients, vigorous activity only by 11.9%. The 86.5% of patients able to perform the Sit-to-stand test reported a lower than the reference values for age and sex. A diagnosis of PEW was possible in 8% of our series, while a MIS score> 11, indicative of PEW, took place in 12.7% of cases. The values of the MIS correlated directly with age and the degree of comorbidity and inversely with the sit-to-stand test, RAPA tests and appetite level. The data in this study show that single tests indicative of malnutrition disorders are frequent to be found in our series of peritoneal dialysis patients. However, a diagnosis of PEW is quite infrequent. A large percentage of patients are overweight with increased abdominal adiposity, and reduced cell mass and protein intake below recommended levels; the level of habitual physical activity is low, and the level of physical capability is scarce. Therefore it is conceivable a nutritional counseling intervention to increase the intake of proteins, limiting the phosphorus and (when indicated) energy intake and to stimulating spontaneous physical activity or arranging assisted programs for functional rehabilitation. Close monitoring of the nutritional status and implementation of programs of adapted physical activity should have a prominent role in the clinical management of patients on peritoneal dialysis.

Are autoimmune diseases or glomerulonephritis affecting the development of panel-reactive antibodies in candidates for renal transplantation?

Panel-reactive antibodies (PRA) are a major obstacle to kidney transplantation (KTx). It is not completely clear why only some patients develop PRA, whereas others do not. We hypothesized that other factors, such as autoimmune diseases involving the kidney, might be a trigger for PRA development. We reviewed the original diseases that led to renal failure and their possible role in PRA development. Charts of 270 patients on the active waiting list for KTx were reviewed for complete demographics, presence of PRA, peak PRA level, first KTx or retransplantation, original disease, blood transfusions, pregnancy and rejection. Patients were divided into group 1 (PRA >10%) and group 2 (PRA <10%). There was a significantly higher proportion of patients in group 1 with autoimmune diseases than in group 2. The same proportion was found significant for all of the patients as well as for the patients listed for the first KTx (new patients). Previous KTx has significant impact on both class I and II peak PRA levels when compared with new patients who are already sensitized. A subanalysis of retransplantation showed patients with autoimmune disease (54%) have more graft loss due to rejection compared with nonautoimmune disease (43%). There is an association between high PRA level and autoimmune diseases causing renal failure regardless of the previous KTx status. Besides the risk of recurrence, autoimmune disease seems to affect the risk of graft loss due to rejection.

Simultaneous kidney-pancreas transplantation without antilymphocyte induction.

BACKGROUND: The introduction of potent new immunosuppressive agents may allow simultaneous kidney-pancreas transplantation to be performed without antilymphocyte induction. METHODS: We analyzed 30 simultaneous kidney-pancreas transplantations receiving tacrolimus, mycophenolate mofetil, and steroids without without antilymphocyte induction. Eighteen patients underwent pancreas transplantation with portal-enteric (P-E) drainage and the remaining 12 had systemic bladder (S-B) drainage. Target 12 hr trough tacrolimus levels for the first 3 months after simultaneous kidney-pancreas transplantation were 15-20 ng/ml. The oral mycophenolate mofetil dose was 2-3 g/day begun immediately posttransplant in two to four divided doses. Steroids were tapered according to protocol. RESULTS: All patients experienced immediate function of both kidney and pancreas grafts. One-year actuarial patient, kidney, and pancreas graft survival rates are 93, 93, and 90%, respectively. Nine patients (30%) had a total of 13 rejection episodes (12 biopsy proven) including 4 within 2 weeks, 6 between 2 weeks and 3 months, and 3 beyond 3 months after simultaneous kidney-pancreas transplantation. Three rejection episodes were treated with steroids alone and 10 were treated with antilymphocyte therapy (5 OKT3 and 5 ATGAM). A total of seven patients (23%) received antilymphocyte therapy. Three patients (10%) had more than one rejection episode. Two pancreas grafts (7%) and one kidney graft (3%) were lost from rejection. Four patients (13%) developed cytomegalovirus infection, but none had tissue-invasive cytomegalovirus. At present, 22 surviving patients (81%) remain on triple immunosuppression with tacrolimus, mycophenolate mofetil, and prednisone with excellent dual graft function. CONCLUSION: Tacrolimus, mycophenolate mofetil, and prednisone immunosuppression without without antilymphocyte induction is safe and effective after simultaneous kidney-pancreas transplantation.

Renal allograft rejection with normal renal function in simultaneous kidney/pancreas recipients: does dissynchronous rejection really exist?

BACKGROUND: Between July 1, 1994 and December 1, 1998, 147 simultaneous kidney/pancreas transplantations were performed at our center. Of 95 patients who experienced at least one acute renal allograft rejection episode after transplantation, 7 (7.4%) developed rejection in the presence of stable and normal or near-normal renal function. METHODS: The indication for renal allograft biopsy was a rising serum lipase, i.e., suspected pancreatic rejection. All seven patients were treated with steroids and augmentation of the tacrolimus dose, with a fall in the serum lipase and no change in the serum creatinine. RESULTS: The serum creatinine levels just before, at the time of, 1 week after the biopsy, and at most recent follow-up were 1.4+/-0.4, 1.3+/-0.3, 1.2+/-0.2, and 1.2+/-0.2 mg/dl. The serum lipase levels just before, at the time of, 1 week after the biopsy, and at most recent follow-up were 1022+/-1157 mg/dl, 874+/-996 mg/dl, 243+/-260 mg/dl, and 94+/-75 mg/dl. The tacrolimus dosages and levels at the time of the biopsy and 1 week later were 14.9+/-5.0 mg/day and 15.0+/-4.0 ng/ml, and 16.4+/-6.3 mg/day and 15.1+/-6.8 ng/ml. CONCLUSIONS: These findings suggest that, in patients undergoing simultaneous kidney/pancreas transplantation, the entity of dissynchronous pancreatic allograft rejection without renal allograft rejection may not really exist. These data also make an additional fundamental point that acute rejection may occur in patients with normal and stable renal function.

Long-term outcomes in simultaneous kidney-pancreas transplant recipients with portal-enteric versus systemic-bladder drainage.

We retrospectively reviewed long-term outcomes in simultaneous kidney-pancreas transplant (SKPT) recipients with portal-enteric (P-E) versus systemic-bladder (S-B) drainage. Forty-five patients were alive with functioning grafts 1 year after SKPT and were followed up for a minimum of 3 years (mean, 5.9 years), including 26 patients with P-E drainage and 19 patients with S-B drainage. Recipient demographic and transplant characteristics were similar between the two groups. In both groups, hospital admissions decreased significantly with increasing time after SKPT, although significantly fewer readmissions occurred in the first year in the P-E than the S-B group. The most common reason for readmission in both groups was infection, followed by miscellaneous, surgical, and immunologic morbidity. The incidence of readmission for dehydration was significantly less in the P-E group (P < 0.01). Mean systolic and diastolic blood pressures were similar between groups, although the number of antihypertensive medications was significantly less in the S-B group. Although fasting C-peptide levels were significantly greater in the S-B group, the two groups were similar with regard to carbohydrate (fasting serum glucose, hemoglobin A(1c)) and lipid (total cholesterol) metabolism. Renal and pancreas allograft functions were similar between the two groups. At 1 year post-SKPT, stabilization in most diabetic complications was reported. Four quality-of-life surveys that provided 29 scores were completed 6 to 24 months (mean, 18.5 months) after SKPT. Improved quality of life was reported in all but one of the scales, with many dimensions showing significant improvements. At 3 years after SKPT, no activity limitation was reported in 76% of patients with P-E drainage versus 53% with S-B drainage (P = 0.11). Five-year actual patient, kidney, and pancreas graft survival rates after P-E versus S-B drainage are 92% and 84%, 81% and 79%, and 88% and 74%, respectively (P = not significant). SKPT with P-E drainage is a safe and effective method to treat advanced diabetic nephropathy and is associated with decreasing morbidity, improving rehabilitation and quality of life, and stablizing metabolic function over time. The long-term prognosis after the first year is excellent and at least similar to the results achieved with S-B drainage.

A prospective comparison of systemic-bladder versus portal-enteric drainage in vascularized pancreas transplantation.

BACKGROUND: Most pancreas transplants are performed with systemic venous delivery of insulin and bladder drainage of the exocrine secretions (systemic-bladder [S-B]). To develop a more physiologic procedure, we performed pancreas transplantations with portal venous delivery of insulin and enteric drainage of the exocrine secretions (portal-enteric [P-E]). METHODS: During an 11-month period, we prospectively alternated 32 consecutive pancreas transplant recipients to either S-B (n = 16) or P-E (n = 16) drainage with standardized immunosuppression. RESULTS: Patient, kidney, and pancreas graft survival rates after simultaneous kidney-pancreas transplantation were 91% S-B versus 92% P-E, 91% S-B versus 92% P-E, and 82% S-B versus 92% P-E, respectively. Pancreas graft survival rates after solitary pancreas transplantation were 80% S-B versus 75% P-E. There were no graft losses either to immunologic or infectious complications in either group, but the incidence of acute rejection was slightly higher in the S-B group (44% S-B vs 31% P-E, P = NS). The cost and length of the initial hospital stay were similar between groups. The incidence of operative complications, major infections, and cytomegalovirus infections were likewise comparable. However, the S-B group was characterized by a slight increase in the number of readmissions, urinary tract infections, and urologic complications. Furthermore, metabolic acidosis and dehydration were more common in the S-B group. CONCLUSIONS: Pancreas transplantation with P-E drainage can be performed with short-term results comparable to those of transplantation with S-B drainage.

Renal allograft outcomes in African American versus Caucasian transplant recipients in the tacrolimus era.

METHODS: Between January 1995 and December 1999, 185 kidney transplants were performed with tacrolimus (TAC)-based immunosuppression including 120 African American (AA, 65%) and 65 Caucasian recipients (C, 35%). Mean follow-up was 34 months. The AA group was characterized by a higher incidence of renal disease due to hypertension (72% AA vs 37% C, P <.001), pretransplant dialysis (95% AA vs 82% C, P =.003), waiting time (1.9 years AA vs 1.1 years C, P =.02), cadaveric donation (88% AA vs 68% C, P =.01), HLA mismatching (mean 3.5 AA vs 2.4 C, P <.001), and delayed graft function (DGF; 50% AA vs 22% C, P =.001). RESULTS: The 5-year actuarial patient and graft survival rates were 96% AA versus 83% C (P = NS) and 83% AA versus 75% C, (P = NS), respectively. The incidence of acute rejection (21% AA vs 12% C, P = NS) and mean time to acute rejection (12 months AA vs 11 months C) were similar. Although the incidence of chronic allograft nephropathy (CAN) was comparable (7% AA vs 5% C), the mean time to CAN was shorter in AA recipients (18 months AA vs 37 months C, P =.03). CONCLUSIONS: These results suggest marked improvement in post-transplant outcomes in the TAC era in patients with multiple immunologic risk factors including AA ethnicity, cadaveric donor source, DGF, and HLA mismatching.

A 9-year experience with 126 pancreas transplants with portal enteric drainage.

HYPOTHESIS: A novel technique of pancreas transplantation (PTX) with portal venous delivery of insulin and enteric exocrine drainage (portal enteric) was developed at our center to improve the PTX procedure. DESIGN: Case series. SETTING: Single-center experience at a university hospital. PATIENTS AND INTERVENTION: From October 1990 through December 1999, we performed 126 PTXs with portal enteric drainage, including 90 simultaneous kidney PTXs (SKPT) and 36 solitary PTXs (18 sequential PTXs after kidney transplantation and 18 PTXs alone). MAIN OUTCOME MEASURES: Patient and graft survival rates; medical and surgical morbidity. Three groups, representing 3 eras of immunosuppression, were compared. Thirty patients underwent SKPT with muromonab-CD3 induction and cyclosporine-based therapy in era 1 (October 1990 through June 1995); 42 SKPTs received tacrolimus and mycophenolate mofetil-based immunosuppression without antibody induction in era 2 (July 1995 through May 1998); and 18 SKPTs were performed in era 3 (June 1998 through December 1999) with either basiliximab or daclizumab induction. RESULTS: One-year patient survival rates after SKPT were 77% in era 1, 93% in era 2, and 100% in era 3 (P =.03). The 1-year kidney graft survival rates were 77% in era 1, 93% in era 2, and 94% in era 3 (P =.08). The 1-year pancreas graft survival rates after SKPT were 60% in era 1, 83% in era 2, and 83% in era 3 (P =.06). The incidences of rejection (63% vs. 33% vs. 39%; P<.001) and thrombosis (20% vs. 7% vs. 6%; P<.001) were decreased in eras 2 and 3. CONCLUSION: Simultaneous kidney PTXs with portal enteric drainage can be performed with improved outcomes.

Surgical complications after pancreas transplantation with portal-enteric drainage.

BACKGROUND: Despite recent advances, surgical complications remain an important source of morbidity after pancreas transplantation (PTX). Several previous studies have delineated the surgical complications after PTX with systemic-bladder (S-B) drainage, but data are limited regarding the incidence and outcomes of surgical complications after PTX with portal-enteric (P-E) drainage. STUDY DESIGN: We retrospectively studied surgical complications after 83 vascularized PTXs with P-E drainage in 79 patients (65 simultaneous kidney-PTXs [SKPT] and 18 solitary PTXs [SPT], 8 pancreas alone and 10 pancreas after kidney transplantation). Twelve (15%) were retransplants. A surgical complication was defined as the need for repeat laparotomy within the first 3 months after PTX. RESULTS: A total of 53 surgical complications requiring repeat laparotomy occurred in 31 patients (37%). The incidence of surgical complications in SKPT and SPT was 38% and 33%, respectively. The most common indications for repeat laparotomy were: vascular thrombosis in 13% (SKPT 14% and SPT 11%), intraabdominal infection in 10% (SKPT 12% and SPT 0%), intraabdominal bleeding in 8% (SKPT 8% and SPT 11%), and duodenal allograft leak in 4% (SKPT 3% and SPT 6%). Patient survival rates at 1 and 3 years with versus without surgical complications were 84% and 80% versus 94% and 86%, respectively (p = NS). Pancreas graft survival rates at 1 and 3 years with versus without surgical complications were 48% and 44% versus 89% and 76%, respectively (p < 0.0001). The incidence of surgical complications was 45% in the first 42 P-E transplantations performed between 1990 and 1995, compared with 29% in the next 41 transplantations performed during 1996 and 1997 (p = NS). The mean number of repeat laparotomies per patient decreased from 1.2 in the former group to 0.5 in the latter group (p = NS). The incidence rates of vascular thrombosis, intraabdominal infection, and duodenal leak in the former and latter groups were 17% versus 10%, 12% versus 7%, and 2% versus 5%, respectively. CONCLUSIONS: Surgical complications after PTX are common, and their incidence and outcomes with P-E drainage are similar to those with S-B drainage. The complication rate does not vary according to the type of transplant (SKPT versus SPT). Increasing experience with P-E drainage results in a decreased incidence of surgical complications.

Observations on the use of sirolimus and tacrolimus in high-risk renal transplant recipients.

Sirolimus is the first of a group of mammalian target of rapamycin inhibitors to be introduced for clinical use in the United States. At the University of Tennessee in Memphis, we have evolved strategies for the use of sirolimus in kidney transplant recipients; which utilize the drug as a primary immunosuppressant and exploit its potential for preserving renal function. Conversions from the calcineurins to sirolimusbased immunosuppression established the efficacy of calcineurin-free immunosuppressants in selected high-risk patients. The conversion experience stimulated the design of protocols for primary use of sirolimus. Posttransplant use of sirolimus was associated with low incidence of rejection whether sirolimus was used with low-dose Prograf or in calcineurin-free protocols. Primary use with full-dose Prograf was associated with a high incidence of calcineurin-related nephrotoxicity and was abandoned in our program. Hematologic and lipid side effects were manageable, as was an observed increase in wound-healing problems and lymphocele formation. Continuous modifications of the sirolimus protocols to increase our benefit-to-risk ratio are ongoing and indicate a continued role for the drug in posttransplant immune suppression.

Conversion to sirolimus in solid organ transplantation: a single-center experience.

BACKGROUND: Calcineurin inhibitors are associated with adverse events, including nephrotoxicity and diabetes that might reduce the benefits of long-term graft survival. We report our experience in converting kidney (K), kidney-pancreas (KP), pancreas (P), and (L) recipients from a calcineurin inhibitor/mycophenolate mofetil (MMF)/prednisone dose-induced nephrotoxicity (K = 9, KP = 5, P = 1, L = 5), hemolytic uremic syndrome (HUS) (K = 7, KP = 5), chronic allograft nephropathy (K = 12, L = 1), and glucose intolerance (K = 9, KP = 6, P = 2, L = 2). METHODS: The conversion protocol consisted of an abrupt discontinuation of the calcineurin inhibitor with sirolimus (8-12 mg, PO loading dose) initiated 24-72 hours after stopping the calcineurin inhibitor. Sirolimus was titrated to target trough levels of 12-16 ng/mL. Daclizumab 2 mg/kg IV was given to all KP and P recipients on days 0 and 14 postconversion. RESULTS: Resolution of HUS occurred in 12 of 12 patients (100%) with a drop in serum creatinine from 3.3 +/- 1.5 to 1.8 +/- 0.9 mg/dL (P =.04). Sirolimus conversion due to nephrotoxicity, HUS, and chronic allograft nephropathy improved serum creatinine from 2.9 +/- 1.4 to 2.2 +/- 0.9 mg/dL (P =.01). Eleven of 19 patients (58%) resolved glucose intolerance. Two patients suffered rejection due to noncompliance. Increases in cholesterol (208 +/- 70 to 243 +/- 77 mg/dL, P <.05) and triglycerides (232 +/- 145 to 265 +/- 148 mg/dL, P = NS), and minimal reduction in platelet values (243 +/- 85 to 237 +/- 85, P = NS) occurred. CONCLUSIONS: These data suggest that a calcineurin inhibitor-free immunosuppressive regimen with sirolimus, mycophenolate mofetil, and steroids preserves graft function in patients with clinical indications warranting calcineurin inhibitor discontinuation.

Renal pathology and clinical presentations of polyomavirus nephropathy in simultaneous kidney pancreas transplant recipients compared with kidney transplant recipients.

INTRODUCTION: The purpose of this study was to describe and compare the renal histopathology and clinical course of simultaneous kidney-pancreas transplant (SKP) recipients with kidney transplant (KT) recipients with polyomavirus nephropathy (PVN). METHODS: Between 1997 and 2002, 20 patients (7 SKP, 13 KT) were diagnosed with PVN. Clinical characteristics and outcomes of PV-N were correlated with histopathologic examinations of renal allograft biopsy and compared between SKP and KT recipients. RESULTS: There were no differences in demographics between SKP and KT recipients with PV-N. The mean time to PVN was 611 (172 to 1174) days posttransplant in SKP and 343 (83 to 720) days posttransplant in KT (P =.05). The serum creatinine at the time of diagnosis was similar between SKP and KT recipients. All patients were treated with reduction in immunosuppression. After a median follow-up of 2 years, the patient survival was 71% in SKP and 100% in KT. Four grafts (57%) were lost owing to PVN in SKP group and three grafts (23%) were lost owing to PVN in the KT group. More patients (43%) in SKP had a history of acute rejection prior to diagnosis of PVN compared to KT (8%) and biopsy-proven tacrolimus nephrotoxicity prior to PVN was more common in SKPT (86%) than in KT (8%) patients (P <.05). SKP patients with evidence of diffuse fibrosis and high total sum scores at time of presentation all subsequently lost their grafts. CONCLUSIONS: SKP recipients with PVN had a worse clinical course than KT recipients.

Tacrolimus without antilymphocyte induction therapy prevents pancreas loss from rejection in 123 consecutive patients.

In this series, antilymphoid induction therapy did not appear to be necessary to prevent early graft loss from rejection. In addition, we have followed cytomegalovirus (CMV) antigenemia (pp65) for CMV infection. Although some patients developed a positive antigenemia in the seropositive to negative donor-recipient combinations, only one patient had a prolonged febrile course for 1 week.

Fine-needle aspiration biopsy in renal transplantation: a review of cytologic features.

Fine-needle aspiration biopsy has been found to be a sensitive and reproducible method for kidney transplant monitoring. Cytological evaluation of the aspirates and blood samples taken concurrently were done from May-Grünwald-Giemsa-stained cytocentrifuge preparations. There were no complications related to this procedure. From the specimens it was possible to detect the immunoactivation cells and to evaluate the condition of the graft parenchymal cells, permitting diagnosis of rejection, acute tubular necrosis, and cyclosporine toxicity. Our findings corroborate other studies in the literature documenting the useful role of cytologic examination of fine-needle aspiration biopsy in renal transplantation.