Impact of hepatitis B and C virus infections on kidney transplantation: a single center experience.

OBJECTIVE: The impacts of hepatitis C virus (HCV) and hepatitis B virus (HBV) infections on patient and renal graft survivals are controversial. This study sought to evaluate the effects of pretransplantation HCV and HBV infections on renal transplant patients and their grafts at our center. PATIENTS AND METHODS: We retrospectively examined 1224 renal transplantations performed between 1992 and 2006, including 28 HBsAg positive; 64, anti-HCV; 9, anti-HCV plus HBsAg positive; and 1123, negative for anti-HCV and HBsAg. The mean posttransplantation follow-up was 5.6 +/- 4.1 years. RESULTS: The prevalences of HBV infection were 6.2% in 1994 and 2.3% in 2006 and those of HCV infection were 6.8% in 1998 and 5.2% in 2006. The rejection rate was higher among HBV+ (46.4%) and HCV+ (40.6%) groups than the negative groups (31.5%), but it was not significant. There were no significant differences in patient and graft survivals among the groups. The major cause of patient death was liver failure among patients with concomitant HBV+ and HCV+ infections and cardiovascular disease among HCV+ and negative patients. CONCLUSIONS: There has been a decrease in the prevalence of recipients with hepatitis virus infections over the last 15 years. Patient and graft survivals were not affected by HCV or HBV infection.

Renal transplantation with expanded criteria donors: the experience of one Portuguese center.

BACKGROUND: The shortage of kidneys available for transplantation has led to enlarged criteria donors (ECD): namely, donors older than 60 years or aged between 50 and 59 years with 2 of the following characteristics-hypertension, predonation serum creatinine level higher than 1.5 mg/dL or cerebrovascular disease as the cause of death. The aim of this study was to analyze renal transplants using ECD compared with standard criteria donors (SCD) concerning the incidences of delayed graft function (DGF), acute rejection episodes (ARE), and patient and graft survivals. MATERIALS AND METHODS: This retrospective study of 409 cadaveric renal transplants over the last 4 years identified ECD in contrast with SCD. RESULTS: Of the transplants, 24.4% used ECD. The baseline characteristics of recipients of ECD versus SCD kidneys were similar, except for age and cold ischemia time. Comparing ECD and SCD, we observed an higher incidence of DGF (35% vs 18%), occurrence of ARE (34.4% vs 16.6%), average serum creatinine levels at 6 (1.87 vs 1.4 mg/dL), and 12 months (1.88 vs 1.43 mg/dL) as well as lower graft survival at 1 (82% vs 91%) and 3 years (75% vs 84%) after transplantation. Recipient survival at 1 year was not different. Multivariate analysis identified recipient age, cold ischemia time, ARE, and DGF as risk factors for graft failure. CONCLUSIONS: Renal transplantation with grafts from ECD shows significantly worse outcomes with higher rates of DGF and ARE, worse graft function, and lower graft survival.

Kidney transplantation with corticosteroid-free maintenance immunosuppression: a single center analysis of graft and patient survivals.

The purpose of this study was to assess the impact of a corticosteroid-free maintenance immunosuppression on graft survival in kidney transplantation. We analyzed 79 patients who were transplanted between June 1, 2006 and May 31, 2007. We excluded hyperimmunized patients, second transplantations, living donors, and black recipients. Patients underwent induction with thymoglobulin or basiliximab, followed by treatment with mycophenolate mofetil (MMF), tacrolimus, and methylprednisolone. On the 5th day, the patients were divided into 2 groups: group A (n = 45) discontinued steroid therapy; group B (n = 34) continued prednisone therapy. We performed a comparative analysis of incidence of delayed graft function (DGF), acute rejection episodes (ARE), renal function at 6 and 12 months, graft and patient survivals, causes of graft loss, and mortality. The 2 groups were similar for donor, recipient, and graft characteristics. The incidences of DGF were 8.9% in group A and 14.7% in group B; those for ARE were 2.3% in group A and 13.8% in group B (P = .077). The mean serum creatinine levels at 6 and 12 months were similar. There were 8 graft losses: 3 in group A (3 deaths with functioning grafts) and 5 in group B (1 death, 3 vascular causes, 1 kidney nonfunction). The 4 deaths were due to infection (n = 3) or neoplasia (n = 1). Graft survivals at 1 year were 98% in group A and 85% in group B, and patient survivals were 98% and 97%, respectively. An immunosuppressive regimen using antibody induction and steroid-free treatment proved to be effective in low-risk patients.

Hypertension induced by immunosuppressive drugs: a comparative analysis between sirolimus and cyclosporine.

The purpose of this study was to compare the effects of sirolimus (SRL) vs cyclosporine (CsA) concerning the cardiovascular mechanisms hypothetically contributing to hypertension development. Three rat groups were studied: control (vehicle), CsA (5 mg/kg/d), and SRL (1 mg/kg/d). The following parameters were evaluated after 7 weeks of treatment: blood pressured (BP) and heart rate (HR; tail cuff), lipid profile, hematology, plasma and platelet 5-HT and catecholamines (HPLC-ECD), and oxidative equilibrium (serum malondialdehyde [MDA] and total antioxidant status [TAS]). Systolic (SBP) and diastolic blood pressure (DBP) values were higher (P < .001) in both the CsA (146.2 +/- 4.5 and 124.9 +/- 4.5 mm Hg) and SRL (148.9 +/- 4.8 and 126.4 +/- 6.0 mm Hg) groups vs the controls (115.9 +/- 3.3 and 99.1 +/- 2.0 mm Hg). However, HR values were elevated in CsA but not SRL animals. The dyslipidemic pattern of CsA was even more enhanced in the SRL group, with significantly higher low-density lipoprotein cholesterol (LDL-c) and triglyceride (TG) levels vs CsA (P < .05); red blood cells, hematocrit, hemoglobin concentration, mean platelet volume, and platelet distribution width were significantly (P < .05) higher in the SRL vs CsA group. The pro-oxidative profile (increased MDA/TAS) in the CsA group was not reproduced in the SRL cohort. While plasma and platelet 5-HT were elevated in SRL rats, catecholamine content was higher in CsA animals. In conclusion, this study demonstrated that CsA and SRL produce identical hypertensive effects. However, while CsA promotes oxidative stress and sympathetic activation, SRL mainly interferes with lipid profile and hematological parameters. Thus, the hypertensive effects of CsA, a calcineurin inhibitor, and of SRL, an mTOR inhibitor, are associated with impairment of distinct cardiovascular pathways.

Characterization of a rat model of moderate chronic renal failure--focus on hematological, biochemical, and cardio-renal profiles.

The pathophysiological modifications underlying chronic renal failure seems to be dependent on the insufficiency degree, which will determine the moment to start therapy. As there is yet limited information about animal models of moderate chronic renal failure, we intended to perform a complete characterization of the hematological and cardio-renal alterations induced by partial nephrectomy. Blood samples from control and chronic renal failure rats were collected at 0, 3, 9, and 15 weeks in order to evaluate renal function, hematological parameters, iron metabolism, blood lipids, peripheral sympathetic nervous system, and inflammatory and redox status markers. BP, tissues trophy indexes, and kidney histomorphology were also assessed. Our data are consistent with a sustained moderate degree of chronic renal failure with a quickly compensated modest anaemia, though presenting iron metabolism disturbances. Despite the reasonable degree of functionality of the remnant kidney, as suggested by the anaemia correction and by the kidney hypertrophy and moderate lesions, several important cardiovascular modifications were developed. Our model presented hypertension, dyslipidemia, erythropoietic disturbances, sympathetic activation, and oxidative stress. This model might be a good tool to study the cellular/molecular mechanisms underlying moderate stages of chronic renal failure and to evaluate the therapeutic efficacy for prevention and treatment/correction of cardio-renal anaemia syndromes and complications in early stages.

[Diagnosis of congenital syphilis at delivery: maternal serum or cord blood?]. / Pesquisa de sífilis congénita al momento del parto: Suero materno o sangre de cordón?

UNLABELLED: Congenital syphilis (CS) is an important health problem in Chile, with a rate of 0.25/1,000 live newborn (NB) during year 2004. In 2000, the Chilean Ministry of Public Health recommended to perform a screening in cord blood at the moment of delivery. Instead, the Centers for Disease Control and Prevention guidelines recommend the screening in maternal serum since cord blood has up to 5% of false (-) versus 0.5% of maternal serum, both with respect to the NB serum. OBJECTIVE: Maternal serum and NB cord blood were studied during one year to determine the best screening method at delivery. METHODS: RPR was performed and positive results were confirmed by treponemic test (immunochromatographyDetermine, ELISA Captia, Ig and IgM, and MHA-Tp). Serologically confirmed patients were evaluated by the specialist to define CS cases. RESULTS: Between June 1999 and August 2000 2,741 binomies were studied; of these, 37 (1.3%) were RPR reactive and 2.704 were non-reactive. In 11 of the 37 reactive cases, mother and NB were RPR reactive (Group I), in 9 cases the NB was RPR reactive and the mother was non-reactive (Group II), and the other 17 were NB non-reactive and mother reactive (Group III). In group I, 7/11 (64%) were true (+)s and 4/11(36%)) false (+)s of RPR. In group II, 9/9 (100%) corresponded to false (+)s of RPR in cord blood, and in group III, 11/17 (65%) corresponded to false (+)s of RPR in maternal blood but 6/17 (35%) were found to be cases of syphilis during pregnancy. Three of them were not treated opportunely and were designed as CS. In total 9 NB corresponded to CS (6 in group I and 3 in group III). If the screening had been performed only in cord blood, three NB with CS would have not been diagnosed. CONCLUSION: Even when maternal serum has a high rate of false (+)s, it has better sensitivity than cord blood for the diagnosis of CS, thus it is suggested to perform the screening at delivery with maternal serum instead of cord blood samples.

Pediatric Renal Transplantation: Evaluation of Long-Term Outcomes and Comparison to Adult Population.

BACKGROUND: In Europe, pediatric transplantation accounts for only about 4% of all kidney transplantations performed. The aim of our work is to evaluate the evolution of pediatric renal transplantation in our department over time, but also to compare this special population with the adult one. METHODS: We evaluated all pediatric renal transplantations performed in our department between January 1981 and December 2016. We performed the analysis of clinical, analytical, and surgical factors to look for predictive factors of graft loss or decrease of survival. In addition, we performed a comparative study of pediatric and adult populations and an evaluation of the evolution of pediatric renal transplantation in our department over time. RESULTS: We evaluated 101 renal transplantations performed in patients younger than 18 years. Pediatric transplantations corresponded to 3.4% of all renal transplantations performed in our department. The rate of living donors was 12%. Donors of grafts for the pediatric population were significantly younger than in the adult population. The increase in donor age was associated with lower renal graft survival rates. Acute rejections were more frequent in the pediatric population. Eleven pediatric recipients (10.9%) died in the follow-up period. Renal graft survival in the pediatric population was 94.8%, 77.4%, and 66.5% at 1, 5, and 10 years, respectively. There was no significant difference in graft survival in the pediatric and adult population. The pediatric overall survival rate at 1, 5 and 10 years was 97.9%, 96.8%, and 91.9%, respectively. CONCLUSION: Pediatric renal transplantation presents results identical to those identified in adults.

De Novo Urologic Malignancies in Renal Transplant Recipients.

BACKGROUND: Immunosuppressed organ transplant patients have an elevated risk of malignancies. The aim of this study was to determine the incidence of urologic malignancies in renal transplant recipients, as well as to evaluate their monitoring, treatment, and outcomes. METHODS: We conducted a retrospective single-center study of 2897 renal transplants between January 1987 and December 2016. Recipients presenting with de novo urologic malignancies were evaluated. We retrospectively assessed the stage of the disease, treatment performed, and subsequent oncologic outcome. Patients with a history of preexisting cancers were excluded. RESULTS: Sixty-one de novo urologic malignancies were recorded in 58 patients. The overall incidence of urologic malignancies was 2.2%. We identified 29 cases of prostate cancer, 23 of renal cell carcinoma, 6 of transitional cell carcinoma of the bladder, and 1 case of penile carcinoma. No cases of testicular tumors were found. The mean age at tumor diagnosis was 58.7 ± 10.1 years. The median time between renal transplantation and tumor development was 84 months (range, 2-310 months). Fifty-six (96.6%) patients received deceased donor kidneys. The overall survival rate at 5 years after diagnosis of urologic tumor was 82.8%. Tumor-related death was reported in 13.8% of patients. Nineteen (32.8%) patients had graft loss. Of these, 8 patients had no functional graft when the diagnosis of urologic tumor was made. The therapeutic options did not differ from those used in nontransplanted patients. CONCLUSIONS: Due to the increased incidence of tumors and possibly worse prognosis, renal transplant recipients should be screened more regularly.

Risk factors for delayed renal graft function and their impact on renal transplantation outcome.

OBJECTIVE: The objective of this study was to evaluate the risk factors for delayed graft function (DGF) and their influence on renal graft outcome. PATIENTS AND METHODS: We reviewed 1462 consecutive renal transplantation and identified 245 patients (17.1%) with delayed graft function and 1120 patients with immediate graft function. Forty-one cases were excluded because of a nonfunctioning graft as well as 26 other cases because of insufficient data. We compared the incidence, donor and recipient risk factors, and impact on graft outcomes, as well as patient and graft survival of delayed graft function. RESULTS: Donor weight and age, recipient weight, age, length of dialysis, and cold ischemia time were significantly higher in the delayed graft function group. Higher rates of acute rejection and chronic graft dysfunction were observed in this group of patients; we also observed worse graft function and survival. CONCLUSIONS: Multiple risk factors are associated with delayed graft function, which contribute decisively to a worse outcome.

Efficacy of renal preservation: comparative study of Celsior and University of Wisconsin solutions.

OBJECTIVE: We sought to compare the efficacy of Celsior and University of Wisconsin (UW) solutions on the perfusion and cold storage of renal grafts for human transplantation. PATIENTS AND METHODS: Retrospective analyses of 313 kidney transplants were performed between 2002 and 2005; group A (n = 160), UW solution and group B (n = 153), Celsior solution were used in the preservation of the organs. The mean donor age was lower in group B (group A = 42.67 years vs group B = 38.96 years; P < .05), living donors were more frequent in the UW group (group A = 10% vs group B = 0.9%; P < .001). Multiorgan procurement procedures were more common in the Celsior group (group A = 75% vs group B = 81.7%; P < .001). Recipients with no associated comorbidities were more frequent in the UW group (group A = 50% vs group B = 36%; P < .001). Recipient mean age, cold ischemia time, and HLA matches were comparable. RESULTS: Delayed graft function (group A = 22.7% vs group B = 20.6%), acute rejections (group A = 21.4% vs group B = 18.4%), and serum creatinine at 6 months (group A = 1.75 vs group B = 1.67 mg/dL), 1 year (group A = 1.47 vs group B = 1.74 mg/dL), and 2 years (group A = 1.43 vs group B = 1.58 mg/dL) showed no differences (P = NS). Graft (group A = 82.23% vs group B = 84.11%) and patient (group A = 93% vs group B = 93.69%) survivals at 3 years were similar (P = NS). There were no differences in the causes of graft loss. CONCLUSION: The efficacy of UW and Celsior solutions is equivalent in the cold storage and renal preservation for transplantation.

Comparative study between two techniques of ureteroneocystostomy: Taguchi and Lich-Gregoir.

OBJECTIVE: The aim of this study was to evaluate the results of renal transplantation comparing 2 techniques of ureteroneocystostomy (Taguchi vs Lich-Gregoir). PATIENTS AND METHODS: Between October 2002 and December 2005, we performed 277 renal transplant procedures in which we used 1 of these 2 techniques of ureteral implantation (Taguchi or Lich-Gregoir). We evaluated the results as well the rate of urinary complications, dividing the patients into 2 groups. The Taguchi group had 60 patients (21.7%) and the Lich-Gregoir group had 217 (78.3%). The 2 groups were compared according to donor and recipient age and weight. RESULTS: Small differences were observed regarding immediate diuresis, acute rejection, graft survival, patient survival, renal function, or rate of urinary complications. The differences did not achieve statistical significance. CONCLUSIONS: Both techniques showed similar results; however, the Taguchi technique is simpler and more rapid. Greater experience is needed to evaluate the long-term results.

Simultaneous renal transplantation and native nephrectomy in patients with autosomal-dominant polycystic kidney disease.

UNLABELLED: Our objective was to study the influence on transplant outcome of unilateral native nephrectomy of massively enlarged kidneys at the time of renal transplantation among patients with end-stage renal disease owing to autosomal-dominant polycystic kidney disease (ADPKD). PATIENTS AND METHODS: We studied 159 renal transplants in patients with ADPKD divided into two groups according to the need to perform a unilateral native nephrectomy owing to enlarged kidneys (N+; n = 143) versus those not (N0; n = 16) needing this procedure. Parameters related to the donors, grafts, recipients, and operative data were correlated with short- and long-term outcomes. The groups were homogeneous in terms of recipient and donor ages, genders, HLA compatibilities, and length of pretransplant dialysis. RESULTS: When no nephrectomy was needed surgery length was shorter (N0, 3.01 vs. N+, 4.23 hours; P < .001), less intraoperative crystalloids were infused (N0, 1.84 vs. N+, 2.76 L; P < .001), and less plasma (N0, 2.07 vs. N+, 2.93 U; P < .05), or blood (N0, 1.05 vs. N+, 1.81 U; P < .05) transfusions were required. Hospital stay was similar (N0, 12.70 vs N+, 16.50 days; P not significant [NS]). There was only one urologic complication in the nephrectomy group. There were no differences (P = NS) in rates of delayed graft function (N0, 19.9%; N+, 12.5%), acute rejections (N0, 25.5%; N0, 33.3%), chronic allograft dysfunction (N0, 15.8%; N+, 28.6%). Graft function at 1 month as well as 1 and 5 years were comparable. Patient and graft survivals were similar at 1 and 5 years. There were no differences in the causes of graft loss or patient death. CONCLUSION: In patients with ADPKD native nephrectomy of massively enlarged kidneys may be safely performed during the transplant procedure with no repercussions on the length of hospital stay, graft short- and long-term function and patient survival. However the procedure eads to a longer operative time and greater need for fluids and blood products.

Oxidative stress in cyclosporine-induced hypertension: evidence of beneficial effects or tolerance development with nitrate therapy.

The aim of this study was to evaluate the effect of cyclosporine (CsA) on oxidative stress as well as the use of a nitric oxide (NO) donor, the organic nitrate isosorbide-5-mononitrate (Is-5-Mn), to prevent or reverse CsA-induced toxicity, namely on the vascular NO-cGMP pathway or on oxidative equilibrium. The following rat groups (n = 8) were tested: (1) a control group; (2) the CsA group (5 mg/kg/d for 7 weeks); (3) the Is-5-Mn group (150 mg/kg/d, twice a day for 7 weeks); (4) the preventive group (Is-5-Mn + CsA) treated for 2 weeks with Is-5-Mn only, and thereafter with both drugs for 7 weeks; (5) the curative group (CsA + Is-5-Mn) beginning 7 weeks after CsA, and following thereafter with both drugs for 5 weeks. The following parameters were evaluated: aortic cNOS activity and cGMP content; plasma levels of lipid peroxidation (malondialdehyde [MDA] levels); antioxidant capacity (glutathione peroxidase [GPx] and superoxide dismutase [SOD] activities, total antioxidant status, and vitamins A, C, and E); and peroxynitrite formation (3-nitrotyrosine [3-NT] content). Is-5-Mn + CsA therapy showed, when compared with the CsA group, total prevention of CsA-induced NO and cGMP attenuation, and no relevant influence on antioxidant indices, as well as on MDA and 3-NT levels. However, when compared with this CsA group, the curative group (CsA + Is-5-Mn) showed NO-cGMP values only partially reversed, and an enhancement in lipid peroxidation (5.6 +/- 1.4 vs 12.78 +/- 3.63 mumol/L; P < .05) and in peroxynitrite formation (16.7% incidence of positives vs 83.3% incidence of positives). Our data suggested that nitrate therapy may provide a valid choice to prevent CsA-induced NO-cGMP decrease, without a negative influence on the oxidative equilibrium. However, when the local environment is adverse, as occurs after CsA therapy, Is-5-Mn seemed to enhance the CsA-induced oxidative stress, promoting even worse deleterious effects, probably through the generation of the cytotoxic ROS peroxynitrite.

Dual effect of nitrate therapy for cyclosporine-induced hypertension on vascular and platelet morphofunctional markers; an animal model.

The present study sought to evaluate the prevention and reversion effects of isosorbide-5-mononitrate (Is-5-Mn) on the development of hypertension (HT) and on the underlying vascular and platelet morphofunctional disturbances, using an animal model of cyclosporine (CsA)-induced HT. The following rat groups (n = 8) were tested: (1) a control group (orange juice, for 7 weeks); (2) the CsA group (5 mg/kg/d for 7 weeks); (3) the Is-5-Mn group (150 mg/kg/d, twice a day for 7 weeks); (4) the prevention group (Is-5-Mn + CsA) treated for 2 weeks with Is-5-Mn only and thereafter with both drugs for 7 weeks; (5) the curative group (CsA + Is-5-Mn) beginning 7 weeks after CsA and following thereafter with both drugs for 5 weeks. Blood pressure, lipid profile, vascular lesion, platelet aggregation and morphology, and platelet thromboxane A(2)/vascular prostacyclin equilibrium were evaluated. Is-5-Mn + CsA therapy prevented (systolic blood pressure [SBP]: 114.3 +/- 1.9 mm Hg, P < .001; diastolic blood pressure [DBP]: 97.0 +/- 3.3 mm Hg, P < .001) the CsA-induced HT (SBP: 146.2 +/- 4.5 mm Hg, P < .001; DBP: 124.9 +/- 4.5 mm Hg, P < .001 vs control: SBP: 111.6 +/- 0.7 mm Hg; DBP: 94.6 +/- 1.0 mm Hg), as well as the vascular lesion and the platelet morphofunctional disturbances. The curative group did not show attenuated CsA-induced BP increase; it showed further enhancement of the HT effect (SBP: 159.7 +/- 5.5 mm Hg, P < .05; DBP: 132.8 +/- 2.8 mm Hg), as well as worsened vascular lesions and platelet function, namely a disruption in the TXA(2)/PGI(2) equilibrium. Our data suggested that Is-5-Mn therapy may be a valid choice to prevent the morphofunctional changes associated with CsA-induced HT, when used as a preventive therapy. A careful evaluation of the impact of nitrate therapy should be considered, particularly the negative effect on cardiovascular hemodynamics, when considering its use after previous CsA disturbances have been established.

Prostate Cancer in Renal Transplant Recipients: Diagnosis and Treatment.

BACKGROUND: We currently know that prostate cancer (Pca) risk is reduced in patients undergoing kidney transplantation. However, its impact and treatment are not widely studied. METHODS: This was a retrospective study of male patients submitted to kidney transplantation in our center from 1980 to 2016 evaluating incidence, treatment, and follow-up of Pca in our population. RESULTS: In 1805 patients undergoing kidney transplantation, 20 men were diagnosed with Pca, leading to an incidence of 1.1%. Median age at renal transplantation was 53.4 years with a median age at diagnosis of Pca of 61.2 years. Initial median prostate-specific antigen (PSA) was 6 ng/mL and Gleason score was 7 (3 + 4) in about 50% of cases. Bone metastasis developed in 10% and no visceral metastases were diagnosed. The majority of patients were submitted to radical prostatectomy and bilateral pelvic lymph node dissection. Some other cancers occurred in these patients such as skin and pulmonary cancers. In 35% of the cases, the graft was lost. The main cause of patient death was cardiovascular. The mean graft survival was about 14 years. The majority of patients are alive with functioning grafts (65%). CONCLUSION: In our center the clinical incidence of Pca in patients undergoing kidney transplantation is 1.1% and surgical treatment seems to be a good initial option.

Cadaveric donor factor variations during a 12-year period: influence on kidney transplant outcomes.

UNLABELLED: Our purpose was to evaluate changes in cadaveric donor factors between 1993 and 2004 and their impact on the short- and long-term outcomes of renal transplants in a single center. PATIENTS AND METHODS: Cadaveric renal transplants performed in our unit between 1993 and 2004 were divided in two groups of identical length: A (n = 455; 1993-1998) and B (n = 465; 1999-2004). Major differences related to donor, graft, and recipient factors were analyzed between groups and correlated with main outcome parameters. Recipient age, gender, weight, etiology of end-stage renal disease, average length of dialysis, and cold ischemia were not different in the two periods. RESULTS: Grafts harvested in our hospital were more frequent in group A (92.3 vs 78.2%; P < .005). Traumatic causes of death were more frequent before 1999: 90.9 vs 70.9% (P < .001). Mean donor age was higher after 1999: 31.37 vs 35.94 years (P < .005). Female donors were more frequent in the second period: 20.5 vs 26.6% (P < .05). Mean donor weight was also higher: 52.36 vs 67.86 kg (P < .05). All of these differences were unfavourable characteristics regarding graft outcomes. Delayed graft function (A = 13%, B = 24.2%), acute rejection episodes (A = 41.2%, B = 28%), and chronic allograft dysfunction (A = 23.5%, B = 14.4%) were also significantly different between the two cohorts (P < .005). Graft function (serum creatinine at 1 and 2 years), patient and graft survivals, causes of graft loss, and of patient death were similar across time. CONCLUSION: The unfavorable tendency in the quality of cadaveric donors during the last 12 years had no negative impact on graft function and patient outcome.

Do elderly patients deserve a kidney graft?

PURPOSE: Compare renal transplant long-term outcomes among recipients aged 60 years or older with those in younger patients. PATIENTS AND METHODS: We analyzed 103 transplants in recipients above 60 years of age for the influence of key factors related to the graft and patient. The results were compared with 1060 transplant recipients aged 18 to 59 years. RESULTS: The mean ages were 62.93 and 40.35 years for the older and younger group. The older group showed a higher prevalence of obesity and unknown etiologies for the end-stage renal disease. Important comorbidity was significantly more frequent among recipients aged more than 60 years, mainly of a cardiovascular nature (56% vs 18.5%). Donor age (39.75 vs 31.59 years), cold ischemia time (22.43 vs 20.49 hours) and human leukocyte antigen compatibilities (2.59 vs 2.36) were significantly greater in the older subset. After a mean follow-up of 4.72 and 6.07 years for the older versus younger group, we found no differences in initial graft function, acute rejection rate, and serum creatinine/clearance. Patient and graft survivals at 1, 5, and 10 years were lower among the 60+ group. There were no differences in graft survival censored for death with a functioning graft, namely, 95.1%, 89.4%, and 81.2% for the 60+ cohort. The main cause of graft loss in the older group was death with a functioning graft. CONCLUSION: Renal transplantation should be considered for selected patients older than 60 years. Despite a shorter life expectancy, they benefit from it similar to younger recipients.

Calcineurin inhibitor-free immunosuppression in renal transplantation.

PURPOSE: To describe our initial results using a calcineurin inhibitor-free immunosuppression protocol in renal transplants. PATIENTS AND METHODS: Between October 2001 and June 2003, 56 recipients of a renal allografts were started on an immunosuppression protocol without calcineurin inhibitors, consisting of basiliximab, sirolimus, mycophenolate mofetil, and steroids. We analyzed patient and graft survival, acute rejection episodes, and renal function. RESULTS: The mean follow-up was 19.6 months. Actuarial patient survival at 1 and 2 years was 98.1% and 95.3%, respectively. Actuarial graft survival at 1 and 2 years was 92.9% and 87.6%, respectively. Acute rejection occurred in 27.8% of the patients, usually Banff 1 (73.3%). There was stable renal function with mean serum creatinine of 1.3, 1.4, 1.3, and 1.3 mg/dL at 1, 6, 12, and 24 months after transplant. CONCLUSIONS: The use of immunosuppression free of calcineurin inhibitors is effective and safe. Further follow-up is needed to evaluate the impact on long-term results.

Pediatric renal transplantation: comparative study with renal transplantation in the adult population.

PURPOSE: To retrospectively review our experience with pediatric renal transplantation and to compare the results with the adult population. PATIENTS AND METHODS: Between January 1981 and August 2003, 74 renal transplants were performed in patients < or =18 years at the time of the transplant--the pediatric group versus 1153 patients in the adult group. We analyzed various risk factors for actuarial kidney graft and patient survivals using the Kaplan-Meier method. RESULTS: Median ages were 13.8 +/- 3.5 and 42.6 +/- 2.4 years, respectively. There was no statistically significant difference in the human leukocyte antigen matching or immunosuppression. There was, however, a younger donor age and shorter ischemia time in the pediatric group. Overall, kidney transplant survival rates for patients < or =18 years at 1, 2, 5, and 10 years were 94.4%, 91.3%, 70.6%, and 58.2%, respectively, with no significant difference for patients older than 18 (91.2%, 89.3%, 78.8%, 60.5%, P = .4325). There was a significantly decreased graft survival in the adult group at 10 years when the donor age was over 60 years and when the ischemia time was > or =20 hours. The incidence of delayed graft function and the creatinine levels of functioning grafts did not differ between the two groups. During the follow-up, acute rejections were more frequent in the younger group. Patient survival in the pediatric group at 1, 2, 5, and 10 years was 98.6%, 98.8%, 98.6%, and 90.3%, respectively, significantly lower in the adult group (95.3%, 94.0%, 87.9%, 76.8%, P < .02). CONCLUSIONS: Renal transplantation may be successfully performed in the pediatric patients with end-stage renal disease. Overall graft survival at 10 years did not differ significantly between the two groups. There is a higher incidence of acute rejections but longer patient survival in the pediatric population.

Small kidneys for large recipients: does size matter in renal transplantation?

BACKGROUND: Imbalance between transplanted renal mass and the metabolic demands of the recipient has been identified as a predictor of renal graft function. Multiple factors have been used to test this influence, but none of them is consensually accepted. The aim of this study is to evaluate the influence of the imbalance between transplanted renal mass and the metabolic needs of the recipient by analyzing the relationship between the ratio of the weight of the renal graft and the body weight of the recipient (Kw/Rw) on transplantation outcomes. METHODS: Prospective observational study of 236 first and single cadaveric renal transplants in non-hyperimmunized recipients was conducted. Grafts were orthogonally measured and weighed immediately before implantation, and these measures were correlated with donor and recipient data. According to the Kw/Rw ratio, patients were divided into three groups: Kw/Rw < 2.8 (P25), Kw/Rw = 2.8-4.2, and Kw/Rw > 4.2 (P75). After a mean follow-up of 5.2 years, transplant outcomes (delayed graft function; acute rejections; and estimated 1-, 6-, 12-, 36-, and 60-month renal function, graft, and patient survivals) were evaluated and correlated in uni- and multivariate analyses with the Kw/Rw ratio. RESULTS: Mean values for graft dimensions were 109.47 × 61.77 × 40.07 mm and the mean weight was 234.63 g. Mean calculated volume was 145.64 mL. The mean Kw/Rw ratio was 3.65 g/kg. These values were significantly lower for female grafts (3.91 vs 3.24, P < .001). According to the Kw/Rw ratio groups, there were no differences on delayed graft function, acute rejection episodes, and estimated graft function at the defined times. The increase in estimated glomerular filtration rate by a mean of 3.6 mL/min between 1 and 6 months for patients with Kw/Rw < 2.8 was not statistically relevant when compared to the higher ratio group with a mean variation of -0.91 mL/min (P = .222). Graft survival rate at 5 years after transplantation was 79% in the Kw/Rw < 2.8 group and 82% in the Kw/Rw > 4.2 group (P = .538). Patient survival rate at 5 years after transplantation was 85% in the Kw/Rw < 2.8 group and 92% in the high ratio group (P = .381). Kw/Rw ratio was not an independent risk factor for transplant failure at 5.2 years in a multivariate logistic regression analysis. Irrespective of recipient weight, graft survival was significantly higher for grafts with volume or weight above the 50 percentile (vol > 134 mL, P = .011 or weight > 226 g, P = .016). CONCLUSION: The imbalance between implanted renal mass and recipient metabolic demands does not seem to influence the functional outcomes and graft survival up to 60 months post-transplantation. Nevertheless, irrespective of recipient weight, graft survival is significantly higher for grafts with volume or weight above the 50 percentile.