Systematic microbiological tests in kidney transplantation and their value in predicting posttransplantation infection.

BACKGROUND: Immunosuppressive therapy has many side effects among which is an increased infectious risk for the recipient. Transmission of pathogens from the graft to the recipient has not been well evaluated; there are no guidelines regarding the need for microbiological tests on the graft prior to transplantation. We routinely performed such tests to evaluate the risk and determine whether a patient should receive preemptive antibiotic therapy after transplantation. We herein have reported our preliminary results. MATERIALS AND METHODS: We reviewed 150 consecutive renal transplantations from cadaveric heart-beating donors. Microbiological tests were systematically performed not only on the preservation solution, but also on graft artery, vein, ureter, and perirenal fat. We reviewed the recipient's medical history for clinically significant infectious episodes in the first month after transplantation. RESULTS: Thirty-one percent of all microbiological tests were positive with 23 patients showing multiple positive tests, 74% of which were concordant. We documented 3 cases of direct graft-to-recipient pathogen transmission, all of which presented with 3 positive concordant tests. Graft culture prior to transplantation is often positive, but in more than half of the cases positive tests are either isolated or discordant. We only treated patients with concordant test results; no adverse consequence was observed among the untreated patients. Transmission occurred only in patients with at least 3 concordant tests. CONCLUSIONS: Multiple microbiological tests on the graft prior to transplantation seemed useful to determine which patients would benefit from preemptive antibiotic therapy. Further studies may help to define which microbiological tests are the most important.

Anemia in the period immediately following renal transplantation.

INTRODUCTION: Anemia remains frequent in the first month following renal transplantation and is a risk factor for cardiovascular accidents. The purpose of this study was to analyze the prevalence of anemia during this period notably among different immunosuppressive treatment groups. METHODS: In this study, we entered the patients who had received a renal allograft in our transplant unit from 1993 to 2003, including patients who had received azathioprine (AZA) from 1993 to 1996 and mycophenolate mofetil (MMF) from 1996 to 2003. No patient received rHu-erythropoietin after transplantation during that period. A mathematical model normalized the hemoglobin (Hb) threshold level at which blood transfusion was decided and Hb on admission. RESULTS: One hundred and eighty-eight patients on AZA and 223 on MMF were included in the analysis. The mean age +/- SD was 41 +/- 12 years in the AZA group, and 45 +/- 12 years in the MMF group (P < .006). Before the transplantation, Hb was higher in the MMF group (11.4 +/- 1.9 vs 10.2 +/- 2 g/dL, P < .0001). After normalization at a threshold level of transfusion of 7 g/dL, transfusions were more frequent among the MMF group (72% vs 48%, P < .0001). Double therapy with MMF (1500 mg/d) + steroids or therapy with MMF (750 mg/d) + tacrolimus + steroids increased the risk of transfusion compared to the AZA group. MMF (750 mg/d) + cyclosporine conferred a similar risk of transfusion compared with the AZA group. CONCLUSION: MMF alone or in association with tacrolimus is associated with an increased risk of anemia and transfusion in the immediate posttransplantation period.

Use of the SCOT solution in kidney transplantation: preliminary report.

SUBJECT: This article reports preliminary findings relating to the use of a new preservation solution, the Solution de Conservation des Organes et des Tissus (SCOT), in renal transplantation. This fourth-generation solution combines an extracellular-like composition with 20 kDa polyethylene-glycol, known for its cell-protection capacity and immunocamouflage properties. METHODS: We have reported preliminary data obtained in 29 transplantations (25 cadaveric donors and 4 living related donors) between December 2004 and November 2005. The SCOT solution was used for both in situ flush and static preservation. We compared primary organ nonfunction and delayed graft function rates as well as blood creatinine levels in recipients of grafts processed with SCOT solution, versus University of Wisconsin solution (paired for age with the previous group) and with EuroCollins solution (historic data). RESULTS: We observed delayed graft-function in 10% of the SCOT-processed group, 14% in the University of Wisconsin solution group, and 23% of the EuroCollins group. No case of primary organ nonfunction was reported. Creatinine levels in both SCOT and University of Wisconsin solution groups were similar. We did not observe any humoral or cellular graft rejection in the first 3 months after transplantation. In light of these preliminary results, the use of SCOT is safe for kidney preservation in the human setting. Further experience is warranted to assess the clinical consequences of its immunocamouflage properties as described in animal models.

Tuberculosis after conversion from azathioprine to mycophenolate mofetil in a long-term renal transplant recipient.

We report the third case in the literature of a patient with a long-lasting renal allograft who experienced tuberculosis just after the switch from azathioprine to mycophenolate mofetil. The switch was likely responsible for the reactivation of dormant tuberculosis; prophylactic antituberculous treatment should be considered in cases of such a therapeutic change.

Fate of a renal tubulopapillary adenoma transmitted by an organ donor.

Organ transplantation from cadaveric donors has a risk of cancer transmission. However, some reports indicate that kidneys bearing small carcinomas can be safely transplanted, as can other organs harvested from the same donor. We report herein the case of two allograft recipients (left kidney and heart with no evidence of tumor) who developed a renal carcinoma soon after transplantation. The initial tumor of the donor was a 17-mm tubulopapillary adenoma found on the right kidney, which was not transplanted. The left kidney recipient rejected all residual tumoral cells after graft removal and immunosuppression discontinuation. The heart recipient died 7 months after transplantation from metastasis of a renal carcinoma. This strongly suggests that circulating carcinoma cells were present at the time of organ retrieval and that they were not cleared by in situ perfusion. In contrast with the literature data, this report indicates that patients with small renal tubulopapillary tumors should not be considered for organ donation.

[Peroperative perfusion of fentanyl or sufentanil: plasma concentrations and postoperative respiratory changes]. / Perfusion peropératoire de fentanyl ou de sufentanil: concentrations plasmatiques et modifications respiratoires postopératoires.

This study was designed to assess postoperatively the time course of respiratory depression due to fentanyl (F) or sufentanil (S), as well as the plasma concentrations. Seventy patients scheduled for orthopaedic surgery lasting more than 3 hours were randomly assigned to two groups, F (n = 8) or S (n = 9). Anaesthesia was induced with etomidate (0.3 mg.kg-1), droperidol (0.15 mg.kg-1), vercuronium (0.1 mg.kg-1), a loading dose of either F (10 micrograms.kg-1) or S (1 microgram.kg-1), and maintained with 60% nitrous oxide in oxygen, and an infusion of F (6 micrograms.kg-1.h-1) or S (0.6 microgram.kg-1.h-1). Mechanical ventilation was maintained postoperatively in the recovery room until the patient could be extubated. PetCO2, SpO2, fR and F and S plasma concentrations were assessed at the end of the opioid infusion, at extubation, every hour for the first 6 hours, and thereafter every 2 h for a further 10 and 18 h. Time to extubation was the same in both groups (301 +/- 141 and 307 +/- 148 min). At the time, plasma concentrations of F and S were 1.35 +/- 0.9 ng.ml-1 and 0.14 +/- 0.07 ng.ml-1 respectively. Secondary peaks in plasma concentration (78% mean increase in comparison to the previous figure) were observed in 6 patients in group F. No similar peaks occurred in group S. Mean elimination half-life was shorter with sufentanil (457 +/- 130 min) than with fentanyl (325 +/- 132 min) (not significant). The results of this study suggest that sufentanil results less frequently in postoperative secondary peaks than fentanyl.

[Combined renal-pancreas transplantation in the treatment for chronic renal insufficiency of diabetic origin . Results from the Pitie Urology Clinic]. / Transplantation combinée rein-pancréas dans le traitement de l'insuffisance rénale chronique d'origine diabétique. Expérience de la Clinique Urologique de la Pitié.

Between 1989 and 1995, 32 patients underwent combined kidney-pancreas transplantation for diabetic chronic renal failure. Only one of these patients received an isolated pancreas following cessation of function of a previously implanted segmental pancreas. The surgical technique always consisted of pure retroperitoneal transplantation into the right iliac fossa of a total pancreas transplant with duodenovesical anastomosis. The postoperative complications included one death on D10 from pulmonary vein thrombosis in a patient with sickle cell anaemia and early loss of the transplanted pancreas due to venous thrombosis. Nine patients underwent at least one surgical revision, due to a leaking duodenovesical anastomosis in 8 cases. With a mean follow-up of 33 +/- 20 months, the results demonstrate, apart from the early death indicated above, another death at 50 months of a patient who had lost his pancreas due to early venous thrombosis and who died with a functioning kidney. 23 of the 30 surviving patients have a functioning kidney and pancreas (79%), i.e. 74% of the total population of 32 patients. Loss of pancreatic function was surgical in two cases (one case of infection of the transplant site, one case of thrombosis), vascular in one case due to rupture of a mycotic aneurysm into the duodenum and immunological in three cases: two of these pancreases retained partial function allowing perfect blood glucose control with less than 10 units of ordinary insulin per day. Lastly, a perfectly functioning pancreas was removed 13 months after transplantation because of renal rejection not controlled by reinforced immunosuppression. Compared to the data of the international registry, these results demonstrate the value of the retroperitoneal approach used in this series and the improvement of the results obtained with increasing experience of the transplant team.

[Kidney transplantation from living related donors: experiences from one center]. / Transplantation rénale à partir de donneurs vivants apparentés (DVA): expérience d'un centre.

Living related donor (LRD) renal transplantation has remained underdeveloped in France up until now. The reduction of the number of available grafts and especially the superiority of the results of LRD transplants recently led us to develop this type of transplantation. We present the retrospective analysis of our experience of 63 cases from March 1973 to June 1995. The actuarial graft survival rate was 91% at 1 year and 87% at 3, 5 and 10 years. The 5- and 10-year survival rates of HLS-identical transplants (n = 17) was 100%. The donor morbidity was minimal (2 cases of parietal suppuration, 1 pulmonary atelectasis). These results emphasize the superiority of LRD transplantation, which also has the advantage of allowing transplantation of hyperimmunized patients in whom the waiting time for a brain-dead donor kidney is long and unpredictable.

[Use of mycophenolate mofetil (MMF) in kidney transplantation: results of a single center trial]. / Utilisation du mycophénolate mofétil (MMF) en transplantation rénale: résultats d'une expérience monocentrique.

Mycophenolate Mofetil (MMF) is a new immunosuppressant demonstrated to be effective at the dose of 2 to 3 g/day. The objective of this study was to determine whether MMF could be used at a lower dose with the same efficacy. Two patient groups were studied: 334 patients treated with azathioprine (AZA) and 60 patients treated MMF (at the dose of 750 mg/day, for patients receiving triple combination therapy or 1.5 g/day for those receiving two-agent combination therapy). The rest of the treatment was identical for the 2 groups. The main endpoint was the incidence of acute rejection at 3 months, which was 16% in the MMF group and 35% in the AZA group (p = 0.003). Multivariate analysis confirmed the impact of the type of purine synthesis inhibitor used (AZA or MMF, p = 0.007) on the acute rejection rate at 3 months. This study confirms the value of MMF, even at doses lower than those recommended in the international literature, with improved safety. MMF has now replaced azathioprine in our immunosuppressant protocols.

Organ procurement from donors deceased from cardiac death: a single-center efficiency assessment.

Organ donation after cardiac death has been used for kidney and liver procurement in France since 2006. Until recently, most teams relied on in situ cold perfusion to prepare the donor before organ retrieval. Our team has used since 2007 normothermic abdominal recirculation. While this technique is presumed to be more difficult to implement, it also ensures a lower rate of primary nonfunction when compared to in situ cold perfusion. We present the efficiency results of our organ donation after cardiac death program. After 3 years, we have been able to establish a program in which we use normothermic abdominal recirculation in 97% of donors after cardiac death. The yearly efficiency of this program is comparable to the national efficiency of organ procurement from conventional deceased donors in France.