Hepatorenal syndrome.

Acute kidney injury (AKI) secondary to hepatorenal syndrome (HRS) is an ominous complication of end-stage liver disease (ESLD). In HRS, splanchnic and peripheral vasodilatation with reduction in effective arterial volume causes activation of mechanisms leading to intense renal vasoconstriction and functional AKI. HRS is a diagnosis of exclusion and all other causes of AKI (especially prerenal azotemia) have to be considered and excluded. Spontaneous bacterial peritonitis (SBP) frequently precipitates HRS and should be ruled out in all ESLD patients presenting with AKI. Prompt therapy of SBP with intravenous antibiotics and albumin lessens the risk of developing HRS. Combined use of intravenous albumin, splanchnic and/or peripheral vasoconstrictors, and renal replacement therapy (RRT) are only bridges to early liver transplantation (or combined liver-kidney transplantation in selected patients). Transplantation is the only definitive way of improving the long-term prognosis. Close collaboration between hospitalists/internists managing HRS patients and hepatology and nephrology consultants is critically important.

Sequestration of active Cryptococcus neoformans infection in the parathyroid gland despite prolonged therapy in a renal transplant recipient.

Disseminated cryptococcal infection occurs mainly in the immunocompromised host, particularly in those with impaired cellular immunity. The treatment outcome depends not only on the duration and choice of antifungal therapy, but also on the activity of the organism to persist in different parts of the body despite therapy. We present a case of persistence of cryptococcal infection in the parathyroid gland in a kidney transplant recipient. A 38-year-old male renal transplant recipient diagnosed to have disseminated cryptococcosis was treated with discontinuation of immunosuppression, amphotericin B, and flucytosine for 2 weeks, and fluconazole subsequently. Dialysis was initiated when graft function deteriorated after discontinuation of immunosuppression. The patient showed no clinical signs of active cryptococcal infection on fluconazole therapy. One year after the diagnosis of cryptococcosis, and still on fluconazole, he underwent parathyroidectomy, for severe secondary hyperparathyroidism. Surprisingly, active cryptococcal infection with necrotizing granulomatous inflammation was demonstrated in the parathyroid, despite being on therapy. This patient illustrates that persistence of fungal infection despite prolonged therapy can occur in unusual sites such as the parathyroid and may be a source for future recurrence and dissemination.

Renal Complications of Hematopoietic Stem Cell Transplantation: Report of a Case and Review of the Literature.

We report the development of minimal change disease superimposed on preexisting chronic kidney disease secondary to chronic calcineurin inhibitor nephrotoxicity in a hematopoietic stem cell transplantation (HSCT) recipient and review the renal complications of HSCT.

Quality of life and psychosocial factors in renal transplant recipients.

An ideal method for quality of life (QOL) assessment in renal transplant recipients (RTR) has not yet been determined. Present assessments of QOL in RTR are lengthy, cumbersome to administer, and difficult to interpret. We used a previously validated single question QOL scale score (QLS) that directly asks about the patients' overall assessment of their QOL; "Considering all parts of my life-physical, emotional, social, spiritual, and financial--over the past 2 days the quality of my life has been ... ". The QLS ranges from 0 ("very bad") to 10 ("excellent"). Patients were contacted prior to their routine office visit when they were free of acute medical problems. Fifty RTR participated. Psychosocial and medical variables included the Beck Depression Inventory, Illness Effects Questionnaire, Multidimensional Scale of Perceived Social Support, time since transplant, age, creatinine, hemoglobin, and albumin levels. Of the patients, 64% were African-American and 48% were women; 94% of patients had a score>5. Mean QLS was 7.5+/-2.3. Perception of a better QOL correlated with less perception of depression and illness effects and with perception of greater social support and satisfaction with life (all P<.05). Perception of QOL did not correlate with age, time since transplantation, creatinine, hemoglobin or albumin levels. We concluded that QLS is a quick tool to measure subjective QOL in RTR for correlation with psychosocial factors of interest in this group. These studies should be replicated in larger multiethnic populations.

Immunosuppression Minimization and Avoidance Protocols: When Less Is Not More.

Kidney transplantation is well established as the best treatment option for end-stage kidney disease. It confers not only a better quality of life but also a significant survival advantage compared to dialysis. However, despite significant improvement in short-term kidney transplant graft survival over the past three decades, long-term graft survival remains suboptimal. Concerns about the possible contribution of chronic calcineurin inhibitor (CNI) nephrotoxicity to late allograft failure and other serious adverse effects of currently used immunosuppressive agents (especially corticosteroids) have led to increasing interest in developing regimens which may better preserve kidney allograft function and minimize other immunosuppression-related problems without increasing the risk of rejection. The availability of newer immunosuppressive agents has provided the opportunity to formulate such regimens. Approaches to this end include minimization, withdrawal, or avoidance of corticosteroids and CNIs. Currently, replacement of a CNI with a mammalian target of rapamycin inhibitor while continuing mycophenolate and discontinuation of corticosteroids within the first post-transplant week is being increasingly utilized. Belatacept-based, CNI-free immunosuppression is an emerging alternative approach to avoiding CNI-mediated nephrotoxicity. We also discuss the evolution, results, and pros and cons of corticosteroid- and CNI minimization protocols. Recent studies suggest that chronic alloimmune damage rather than chronic CNI nephrotoxicity is the major contributor to late kidney allograft failure. The implications of this finding for the use of CNI minimization protocols are also discussed.

Comparison of long-term actual renal allograft survival in mycophenolate mofetil and azathioprine-based triple drug immunosuppression protocols.

INTRODUCTION: The use of mycophenolate mofetil (MMF) in renal transplantation results in a 50% lower incidence of acute rejection compared to azathioprine (AZA). However, the graft survival reports are conflicting: the European trial and US database analysis suggest better survival with MMF, an observation that was not seen in the US and tricontinental studies. METHODS: We retrospectively reviewed our single-center experience (60% African-Americans) comparing the serum creatinine (SCr) values and 3-year actual graft survival with MMF versus AZA-based immunosuppression. Group I included patients transplanted between January 1990 and December 1992 on cyclosporine (CSA), AZA, and steroids; group II subjects, from January 1996 to December 1998 on CSA, MMF, and steroids. We analyzed SCr and all causes of graft losses at 3, 6, 12, 18, 24, and 36 months posttransplantation. RESULTS: The patient demographics were similar in both groups as was the mean SCr values at different times. The time-group interaction for SCr, the Kruskal-Wallis test for SCr for different categories (<1.5, 1.5 to 2.0, 2.0 to 2.5, and >2.5 mg/dL) and the all-cause graft loss between the two groups were not significantly different. CONCLUSION: Our results failed to show better long-term actual graft survival despite the 6-year interval between the two groups. These findings agree with the results of the United States and the tricontinental studies. A lower incidence of acute rejection early after transplantation observed with MMF may not always translate into a long-term benefit, possibly due to the influence of nonimmunological factors, such as hypertension, calcineurin inhibitor toxicity, more frequent cytomegalovirus infections, and increased attempts to withdraw steroids using MMF-based protocols.

Incidence of contrast-induced nephropathy in kidney transplant recipients.

UNLABELLED: Contrast-induced nephropathy (CIN) is responsible for one-third of acute kidney injuries (AKI) in the hospital setting. The incidence of CIN varies from 3% to 30%, depending on the preexisting risk factors, with higher incidence noted with diabetes mellitus, chronic kidney disease, and older age. Though CIN risk factors are common in kidney transplant recipients (KTRs), data about incidence of CIN in this population are sparse. METHODS: We retrospectively analyzed 124 consecutive patients transplanted at our center between January 2002 and December 2013 and received iodinated intravascular contrast with stable kidney function prior to contrast administration. CIN was defined as either an absolute rise in serum creatinine of ≥ 0.5 mg/dL or a ≥ 25% drop in estimated glomerular filtration rate (eGFR) after contrast administration. RESULTS: Seven of 124 (5.64%) patients developed CIN. Kidney function returned to baseline in 5 of the 7 patients within 3 weeks. In 2 patients serum creatinine remained elevated due to recurrent AKI episodes from other causes. Dialysis was not required in any patient. Calcineurin inhibitors (CNIs) were being used in 95% patients at the time of contrast administration. Diabetes mellitus, baseline serum creatinine, age, race, gender, and the use of ACE inhibitor, angiotensin receptor blocker, diuretic, or prophylaxis with intravenous hydration ± N-acetylcysteine did not affect the incidence of CIN. CONCLUSION: Incidence of CIN in KTRs was low in our study (5.6%), much less than previously reported. This low incidence may be related to the high baseline eGFR (>70 mL/min/1.73 m(2)) and use of hypo-osmolar contrast in our patients. In KTRs with baseline eGFR >70 mL/min, the incidence of CIN is low despite the concurrent use of nephrotoxic CNI.

Complete replacement of methylprednisolone by azathioprine in cyclosporine-treated primary cadaveric renal transplant recipients.

In cyclosporine (CsA)-treated renal transplant recipients complete corticosteroid withdrawal followed by CsA monotherapy has been associated with severe rejection episodes in a significant proportion of patients. We report the results of replacement of steroids by azathioprine (AZA) in 25 primary cadaveric renal transplant recipients initially treated with CsA and methylprednisolone (MP). MP taper was started 8.8 +/- 5.6 months posttransplant when the MP dose was either 10 mg/day or 20 mg every other day. MP was tapered off over a 5-month period. At the initiation of MP taper, AZA was added at 1 mg/kg/day and increased to 1.5 mg/kg/day after two months. The CsA dose was adjusted to maintain trough serum levels as measured by radioimmunoassay (RIA) of 50-75 ng/ml, during and after MP withdrawal. Seventeen patients have remained continuously off MP for 14.6 +/- 5.0 months with stable renal function. Reinstitution of MP at 10 mg/day was required in 8 patients, 6 for rejection (1.8 +/- 0.7 months after MP withdrawal), 1 for AZA-induced leukopenia, and 1 for de novo glomerulopathy. Renal function returned to baseline in all 6 patients with rejection after reinstitution of MP. Two of these patients have again been successfully retapered off MP. In the patients withdrawn from MP, body weight and mean arterial blood pressure had decreased by 2.1 +/- 1.3 kg (P less than .05) and 11 +/- 7 mmHg (P less than .05), respectively, at the time of the most recent follow-up compared with values at the initiation of steroid withdrawal. The number of blood pressure medications per patient decreased by 38% (P less than .05) and 6 patients were able to discontinue all antihypertensive drugs after cessation of steroids. Discontinuation of MP also resulted in a decrease in serum cholesterol concentration from 248 +/- 50 to 217 +/- 55 mg/dl (P less than .05). We conclude that steroids can be replaced by AZA in the majority of CsA-treated primary cadaveric renal transplant recipients by the end of the first posttransplant year without an adverse effect on graft survival. This protocol resulted in significant reductions in serum cholesterol, mean arterial blood pressure, and body weight, and may avoid the long-term side effects of steroid therapy.

Influence of the pretransplant hematocrit level on early graft function in primary cadaveric renal transplantation.

Although use of human recombinant erythropoietin has alleviated symptoms of anemia in renal failure, effects of increased hematocrit (HCT) on early post-transplant renal function are unknown. Of 244 consecutive primary cadaveric kidney recipients transplanted over 74 months, 43% had HCT > or = 30% and 57% had HCT < 30% at transplantation. The incidence of delayed graft function (DGF) was greater in recipients with HCT > or = 30% (61%) than in recipients with HCT < 30% (33%; P = 0.0001). Ten percent of recipients with HCT > or = 30% experienced primary nonfunction (PNF) of the allograft (P = 0.0001). No recipient with HCT < 30% had PNF. Absolute rises in HCT over the 3 months preceding transplantation were greatest in those with PNF (2.5 +/- 2.4) followed by those with DGF (2.0 +/- 3.1) and immediate graft function (IGF) (0.2 +/- 5.2; P = 0.0328). Logistic regression analysis identified HCT > or = 30% (P = 0.0014), cold storage > or = 24 hr (P = 0.0006) and rising HCT (P = 0.0090) as independent predictors of DGF with relative risks of 3.1-, 3.3-, and 2.7-fold, respectively. Recipients with rising pretransplant HCTs who underwent dialytic fluid removal within 24 hr before transplantation had DGF with greater frequency (67%) than nondialyzed recipients with rising HCTs (45%). Primary cadaveric kidney recipients with HCT > or = 30% at transplantation have significantly greater risk for DGF and PNF. Rising pretransplant HCT levels may predispose recipients to DGF; this risk may be heightened in those undergoing hemodialysis shortly before transplantation.

Histologic and immunophenotypic evaluation of pretreatment renal biopsies in OKT3-treated allograft rejections.

The histologic features immunophenotype of intragraft mononuclear populations, and HLA-Dr expression in pretreatment formalin-fixed renal allograft biopsies were correlated with outcome of OKT3 therapy in 35 steroid resistant renal transplant rejections. Therapeutic response (63% overall) was better in pure acute cellular rejections (ACR) (13/15, 87%) than ACR with interstitial fibrosis (4/12, 33%) or with vascular injury (5/8, 62%). Intragraft T lymphocytes were more numerous in vascular rejection (mean 566/mm2) compared with pure ACR (mean 265/mm2, P = .049), and macrophages were greater in pure ACR (203/mm2) compared with ACR with interstitial fibrosis (83/mm2, P = .051). Distribution of T cells, B cells, plasma cells, and macrophages among various histologic categories was otherwise statistically similar. There was no correlation between therapeutic response to OKT3 and intragraft concentrations of individual mononuclear cell subsets. Vascular and/or epithelial HLA-Dr expression was present in 17/25 (68%) cases and was not associated with histologic features or treatment response. Follow-up graft function (median 7 months) correlated significantly with therapeutic response to OKT3 (P = .0004) and histologic presence of interstitial fibrosis (P = .031), but was not related to concentration of individual mononuclear subsets or HLA-Dr expression. We conclude that intragraft concentrations of major mononuclear cell types may relate to histology, but that these do not predict treatment response or graft outcome, and thus poorly reflect intensity or possible heterogeneity of host immunologic rejection mechanisms.

Removal of lymphocytotoxic antibodies by pretransplant immunoadsorption therapy in highly sensitized renal transplant recipients.

A high level of panel-reactive antibodies (PRA) in potential renal transplant recipients is associated with a long waiting time until transplantation and correlates inversely with graft outcome. We report our experience with the employment of immunoadsorption (IA) using a column composed to sepharose-bound staphylococcal protein A (which has a relatively selective affinity for binding IgG compared with other immunoglobulins) to decrease the PRA levels and expedite transplantation in 6 highly sensitized potential renal transplant recipients (1 primary and 5 awaiting second transplants). All patients had PRA levels of greater than or equal to 70% for a duration of 1 year prior to IA. Only patients with antibody specificity localized to 1 or 2 HLA A or B antigens were accepted for the study. IA procedures were performed on alternate days until a twofold decrease in antibody titer had occurred (maximum: 6 procedures). Repeat procedures were initiated if the HLA antibody titer returned to its baseline value. Intravenous cyclophosphamide (CY) (10 mg/kg/day every 3 weeks) and methylprednisolone (MP) (0.5 mg/kg/day) were provided as adjunctive immunosuppression until transplantation. A total of 44 immunoadsorption procedures were performed (27 primary and 17 repeat) with treatment of 2.49 +/- 0.02 plasma volumes per session. Serum IgG concentration decreased 95 +/- 3% and PRA activity decreased 75 +/- 16% after the primary treatment course. Four patients received cadaveric grafts within 3.7 +/- 1.2 months following the last IA procedure. Three grafts are functioning at 1 year, 8 months, and 8 weeks posttransplant. The remaining graft demonstrated primary nonfunction. All four patients had a past positive crossmatch using pre-IA sera with their respective donors. Patients not transplanted exhibited rapid resynthesis of IgG and a return of the PRA towards baseline levels within a few weeks after IA. We conclude that IA can effectively remove HLA antibodies and expedite graft availability in highly sensitized patients.

Effective long-term immunosuppression maintained by low cyclosporine levels in primary cadaveric renal transplant recipients.

Nephrotoxicity and cost are the major problems in the use of cyclosporine (CsA) in renal transplantation. Thus, maintenance of CsA levels at the lower limits of the therapeutic range is desirable. The lowest CsA level effective in preventing rejection while avoiding nephrotoxicity has not been defined. We report on 44 primary cadaveric renal transplant recipients treated with a protocol that involved a progressive reduction in the trough CsA levels. CsA was initiated at an oral dose of 15 mg/kg, and this dose was adjusted to achieve serum trough levels, as measured by radioimmunoassay, of 150-200 ng/ml during the first month, 100-150 ng/ml during the second month, 75-100 ng/ml during the third month, and 50-75 ng/ml thereafter. Patient and graft survival at 18 months were 94% and 83.6%, respectively. The mean daily CsA doses were 6.7 +/- 3.1 mg/kg at 6 months, 5.5 +/- 3.2 mg/kg at 12 months, and 4.7 +/- 2.4 mg/kg at 18 months. Corresponding trough serum CsA levels were 94 +/- 59 ng/ml, 64 +/- 22 ng/ml, and 44 +/- 21 ng/ml at 6, 12, and 18 months, respectively. Mean serum creatinine concentrations were 1.8 +/- 0.6 mg/dl at 6 months, 1.7 +/- 0.5 mg/dl at 12 months, and 1.6 +/- 0.5 mg/dl at 18 months. The mean serum creatinine concentration at 18 months was not significantly different from that of 18 conventionally treated primary cadaveric renal transplant recipients (1.6 +/- 0.5 vs. 1.4 +/- 0.4 mg/dl, P = .31). A total of 67% of patients did not have any rejection episodes under this protocol, while 71% of patients never developed CsA nephrotoxicity. No patient was taken off CsA for progressive nephrotoxicity. We conclude that trough serum CsA levels of 50-75 ng/ml, as measured by radioimmunoassay, are sufficient to maintain effective immunosuppression in the long-term management of primary cadaveric renal transplant recipients. These values are much lower than previously recommended, and this approach ameliorates chronic CsA nephrotoxicity.

Outcome of low-dose ganciclovir for cytomegalovirus disease prophylaxis in renal-transplant recipients.

To assess the outcome of low-dose-ganciclovir prophylaxis (500 mg twice a day for 3 months) in renal-transplant recipients, a retrospective analysis of 185 patients transplanted between 1998 and 2001 was performed. There were 29 (15.6%) patients who belonged to the highest risk group, donor cytomegalovirus (CMV) positive, recipient negative (D + R-), and 37 (20%) patients in the lowest risk group, D-R-. Induction immunosuppression consisted of polyclonal antibody or OKT3 (n = 62, 33.5%), interleukin-2 receptor antibody (n = 61, 33%), and no induction (n = 62, 33.5%). CMV disease occurred in 13 (7%) patients. Highest incidence was in D + R- group (17.2%), with no cases in D-R- group (P = 0.03). Tissue-invasive CMV occurred in 4 of these 13 patients. In patients developing CMV disease, there was no evidence of ganciclovir resistance and no mortality over a mean follow-up of 42 months. Low-dose ganciclovir was found to be as effective in decreasing the incidence of clinical CMV disease as high-dose ganciclovir (1 gm three times a day for 3-6 months) in previous studies.

Care of the renal transplant recipient in the emergency department.

End-stage renal disease is becoming more common in the United States because of the aging of the population and the increased prevalence of predisposing conditions such as diabetes and hypertension. Renal transplantation is the preferred treatment for patients with end-stage renal disease. This article reviews the medical problems that might bring renal transplant recipients to the emergency department, the information emergency physicians should be aware of in evaluating and treating these patients, and the critical importance of close communication between emergency and transplant physicians in treating them.

The evolving approach to ethical issues in living donor kidney transplantation: a review based on illustrative case vignettes.

Living donor kidney transplantation which involves performing a major surgical procedure on a healthy person solely to benefit another person has always involved dealing with difficult ethical issues. Beneficence, non-maleficence, donor autonomy, altruistic donor motivation, coercion-free donation, fully informed consent and avoidance of medical paternalism have been the dominant ethical principles governing this field ever since the first successful living donor kidney transplant in 1954. The increasing reliance on living donors due to the rapidly growing disparity between the number of patients awaiting transplantation and the availability of deceased donor kidneys has brought with it a variety of new ethical issues of even greater complexity. Issues such as confidentiality of donor and recipient medical information, the appropriateness of the invented medical excuse to avoid donation and the approach to misattributed paternity discovered during work-up for living donor transplantation have made the information to be disclosed prior to obtaining donor's consent much more extensive. In this article, we review the current thinking and guidelines (which have evolved considerably over the past several decades) regarding these ethical issues using five illustrative case vignettes based on donors personally evaluated by us over the past 35 years.

The Utility of Serial Allograft Biopsies during Delayed Graft Function in Renal Transplantation under Current Immunosuppressive Regimens.

Delayed graft function (DGF) of kidney transplants increases risk of rejection. We aimed to assess the utility of weekly biopsies during DGF in the setting of currently used immunosuppression and identify variables associated with rejection during DGF. We reviewed all kidney transplants at our institution between January 2008 and December 2011. All patients received rabbit antithymocyte globulin/Thymoglobulin (ATG) or Basiliximab/Simulect induction with maintenance tacrolimus + mycophenolate + corticosteroid therapy. Patients undergoing at least one weekly biopsy during DGF comprised the study group. Eighty-three/420 (19.8%) recipients during this period experienced DGF lasting ≥1 week and underwent weekly biopsies until DGF resolved. Biopsy revealed significant rejection only in 4/83 patients (4.8%) (one Banff 1-A and two Banff 2-A cellular rejections, and one acute humoral rejection). Six other/83 patients (7.2%) had Banff-borderline rejection of uncertain clinical significance. Four variables (ATG versus Basiliximab induction, patient age, panel reactive anti-HLA antibody level at transplantation, and living versus deceased donor transplants) were statistically significantly different between patients with and without rejection, though the clinical significance of these differences is questionable given the low incidence of rejection. Conclusions. Under current immunosuppression regimens, rejection during DGF is uncommon and the utility of serial biopsies during DGF is limited.

Renal allograft outcome in recipients of positive-crossmatch combined liver-kidney transplantation.

BACKGROUND: Successful kidney transplantation despite positive crossmatch (+CXM) before transplantation is well recognized in combined liver-kidney transplant (CLKT) recipients. This is probably due to immunologic protection of the renal allograft (RA) conferred by the liver allograft. However, occurrences of antibody-mediated rejection and poor long-term RA outcome is also documented with +CXM CLKT recipients, suggesting that such immunologic protection may not be universal. METHODS: A total of 1,401 CLKT recipients with known status of pre-transplantation CXM were identified from the United Network for Organ Sharing registry from January 1, 1986, to December 31, 2006. Univariate analysis for significant differences in clinical variables and Kaplan-Meier estimate for patient and graft survivals were performed. The results were compared between positive and negative CXM groups. RESULTS: Pre-transplantation +CXM was seen in 17.3% (242/1401) of CLKT recipients studied. The demographic and clinical characteristics were similar between the groups, except for higher panel reactive antibody level and CXM positivity in female recipients. Outcome analysis showed higher RA rejection (19.3% vs 10.8%; P = .026) and increased hospital length of stay (37.3 ± 46.0 vs 28.8 ± 33.2 days; P = .028) in the +CXM group. RA survivals at 1, 3, and 5 years were 8%, 7%, and 6% lower in the +CXM group. The patient and liver allograft survivals were not different between the groups. CONCLUSIONS: In CLKT recipients with pre-transplantation +CXM, the immunologic protection of RA conferred by the liver allograft is less robust than previously perceived and may lead to higher rejection rate and poor RA outcome. This can be mitigated with routine pre-transplantation CXM.

Increasing trend in infection-related death-censored graft failure in renal transplantation.

BACKGROUND: Advances in kidney transplantation have significantly improved early outcomes but failed to improve long-term graft survival. Despite many causes, the contribution of infection to death-censored graft failure (DCGF) is unknown. The aim of our study is to assess the impact of infections on DCGF using United Network for Organ Sharing data. METHODS: We analyzed 38,286 DCGFs among 189,110 first kidney transplants performed between January 1, 1990 and December 31, 2006. Information on infection contributing to DCGF was available in 31,326 DCGF recipients. Student's two-sample t test for normally distributed variables, Wilcoxon rank sum test for nonnormally distributed, and Chi-square test for categorical variables were used in univariable comparisons. Multivariable logistic regression analysis was performed to assess the independent contribution of variables to infection-related DCGF. RESULTS: Overall, infection accounted for 7.7% (2397/31,326) of all DCGF. The rate of infection-related DCGF increased from 6.4% in 1990 to 10.1% in 2006 and was significantly higher during 1997 to 2006 when compared with 1990 to 1996 period (9.1% vs. 6.3%, P<0.001). Over these 17 years, the trends in infection-related DCGF and rejection rates showed an inverse relationship with the former exceeding the latter starting in 2005. The risk of infection-related DCGF was higher (14.1%) in recipients older than 65 years and exceeded the rejection rate in those older than 60 years. Urological complications and polyoma infection were the most significant risk factors with odds ratios of 8.77 (confidence interval: 5.15-14.93) and 2.55 (confidence interval: 1.41-4.61), respectively. CONCLUSION: Infection is increasingly contributing to DCGF in recent years and warrant reevaluation of current immunosuppression protocols, especially in older recipients.