Risk factors and prognosis of late acute rejection in Chinese kidney transplant recipients.

AIM: Accumulating literature indicates that late acute rejection (LAR) after kidney transplantation portends an unfavourable prognosis. There are no data on the incidence of LAR in Asian subjects, or its risk factors and associated clinical outcomes. METHODS: We conducted a retrospective single-centre case-+control study to investigate the incidence, risk factors and prognosis of LAR in Chinese kidney transplant recipients. Subjects with or without LAR were matched for age, gender, era of transplantation, allograft type, and maintenance immunosuppression regimen. RESULTS: Thirty-two episodes of LAR occurred within an observation period of 12 years giving an incidence rate of 0.46 episodes per 1000 patient-years. Acute rejection within the first year after transplantation was associated with an increased risk of LAR (OR 3.59, P = 0.041). In patients receiving maintenance immunosuppression regimen with steroid, cyclosporin A (CsA) and mycophenolate or an m-TOR inhibitor, patients with LAR showed lower trough CsA levels prior to and at the time of rejection compared to Controls (86.0 ± 26.1 vs. 105.6 ± 13.3 µg/L, P = 0.049; and 75.7 ± 35.7 vs. 106.0 ± 20.5 µg/L, P = 0.032, respectively). Trough CsA level below 80 µg/L was associated with the development of LAR (OR 10.82, P = 0.032). Patients with LAR showed an inferior allograft survival (P < 0.001) while patient survival rates were similar (P = 0.122). CONCLUSIONS: Late acute rejection is uncommon in Chinese kidney transplant recipients but is associated with reduced allograft survival. Risk factors include acute rejection in the first post-transplant year and trough CsA level below 80 µg/L in patients on CsA-based maintenance immunosuppression. Minimization of immunosuppression in apparently stable kidney transplant recipients must be exercised with caution.

Severe liver failure due to influenza A infection in a hemodialysis patient.

Patients with influenza infection most commonly present with upper and occasionally lower respiratory tract symptoms. However, extrapulmonary presentations such as hepatitis are infrequently observed. We report a case of a hemodialysis patient with influenza A infection who presented with severe hepatitis and liver failure, while his respiratory symptoms were mild. It is important to recognize influenza infection as an unexplained cause of hepatitis and liver failure. In our case, liver failure resolved with supportive treatment.

Chronotropic incompetence, echocardiographic abnormalities and exercise intolerance in renal transplant recipients.

BACKGROUND: Chronotropic incompetence (CI) is an independent predictor of cardiovascular events and overall mortality. The prevalence and significance of CI in renal transplant patient has not been examined. METHODS: 38 non-heart failure renal transplant recipients were recruited for a transthoracic echocardiogram and treadmill stress test using the modified Bruce protocol. RESULTS: 15 patients (39.5%) had CI (defined as failure to reach 85% of the maximum age-predicted heart rate, or <8 0% of predicted heart rate reserve). CI patients had higher left ventricular (LV) mass (216.5 ± 56.1 vs. 183.1 ± 40.0 g, p = 0.04), increased septal wall thickness (11.7 ± 1.4 vs. 10.7 ± 1.1 mm, p = 0.03) and posterior wall thickness (10.9 ± 1.9 vs. 9.5 ± 1.7 mm, p = 0.02). At multivariate analysis, CI was associated with elevated serum creatinine [odds ratio (OR) 1.04, p = 0.03] and increased LV mass (OR 1.03, p = 0.03). CI was associated with shorter exercise duration (3.53 ± 2.20 vs. 8.08 ± 2.34 min, p < 0.01) and lower metabolic equivalents (5.40 ± 2.05 vs. 9.82 ± 2.39, p < 0.01). At multivariate analysis, exercise duration was negatively associated with CI (ß = -0.54, p < 0.01). CONCLUSIONS: CI is present in approximately 40% of asymptomatic renal transplant recipients and is associated with reduced exercise tolerance, left ventricular hypertrophy, and worse allograft function .