[Renal transplantation: Procedure and early follow-up]. / Transplantation rénale : réalisation et suivi précoce.

More than fifty years after the success of the two first renal transplantations in Boston and in Necker hospital in Paris, renal transplantation became the treatment of choice of end stage renal failure, because it improves not only the quality of life of the patients but also their long-term survival. In France, more than 3,700 kidney transplantations are performed every year and more than 40,000 patients are living with a functioning kidney allograft. This treatment of end stage renal disease requires a fine-tuned pre-transplant evaluation and a multidisciplinary post-transplant care in order to prevent, to detect and to treat comorbidities and complications of immunosuppression. The ambition of this manuscript is not to describe in an exhaustive way all the aspects of renal transplantation but starting from the experience of a team, recently published data, and national and international guidelines, to try to provide a synthetic and chronological view of the early post-transplant monitoring.

[Current aspects of acute humoral rejection]. / Aspects actuels des rejets aigus humoraux.

Acute clinical antibody-mediated rejection is currently defined by (1), an acute renal failure occurring during the first months following transplantation, (2), at least a microcirculation inflammation (glomerulitis and peritubular capillaritis) on kidney biopsy and (3), the presence in peripheral blood of donor specific antibodies, mostly anti-human leukocyte antigen (HLA) antibodies. The prognosis of this rejection is scored using the severity of vascular lesions and the positivity of C4d on peritubular capillaries. Recently, a subclinical variety of antibody-mediated rejection was recognized as an entity because, as the clinical rejection, it leads to chronic antibody-mediated rejection, currently the most frequent cause of graft loss. The description of these various aspects of antibody-mediated rejection allowed a better understanding of its pathophyiology that may lead in a near future to a more specific treatment.

Clinical and immunological features of very long-term survivors with a single renal transplant.

The aim of this study was to analyze the clinical and immunological features of the 56 still alive patients at our institution harboring a functional first renal transplant since more than 30 years. The mean post-transplant graft survival in all patients was 35.4 ± 3.1 years, the mean serum creatinine concentration was 128.7 ± 7 µmol/l, and the mean urinary protein concentration was 0.6 ± 0.5 g/l. Fifty-one percent of the patients had experienced cancer involving the skin (46.1%) and/or other tissues (28%). Hepatocarcinoma was diagnosed in 11% of the patients with chronic viral hepatitis B and/or C (48%). The 5-year patient survival rate (considered after the 30th transplantation anniversary) was 27% in patients presenting a tumor versus 87% in those tumor-free (P < 0.0001). The thymic output, the proportions of the memory and naïve T cell subsets, and the frequencies of EBV- and CMV-reactive, IFN-γ-producing T cells did not differ from those observed in more recently transplanted patients. These results suggest that the impact of chronic immunosuppression on some immune functions does not worsen over time and that the observed high prevalence of cancer in these patients may be related to the synergistic effects of decreased immunosurveillance and the time required for carcinogenesis.

Impact of norovirus/sapovirus-related diarrhea in renal transplant recipients hospitalized for diarrhea.

BACKGROUND: Diarrhea of unspecified cause frequently occurs after renal transplantation and is usually ascribed to mycophenolic acid toxicity. Norovirus (NoV) and sapovirus (SaV) have been sporadically reported to cause chronic diarrhea in immunocompromised patients. METHODS: We undertook a retrospective study (2008-2009) to examine the clinical and epidemiologic significance of NoV and SaV infections in adult renal transplant recipients hospitalized for acute or chronic diarrhea. RESULTS: Ninety-six renal transplant recipients were hospitalized for diarrhea at our institution during a 16-month period, 87 of whom were included in the study, including 46 patients with chronic diarrhea. Among 41 patients with unexplained diarrhea, 20 patients were screened for NoV/SaV, 16 of whom were positive. Fifteen of them (94%) had chronic diarrhea. When compared with bacterial and parasitic infections, NoV/SaV infections were associated with a greater weight loss at the time of admission, a 8.7-fold longer duration of symptoms and a more frequent need for mycophenolic acid dosage reduction. Eighty-one percent of patients hospitalized for NoV/SaV-associated diarrhea experienced acute renal failure. Five and one patients subsequently had biopsy-diagnosed active graft rejection and oxalate nephropathy, respectively. Ten of the 14 patients who underwent a longitudinal study of NoV/SaV stool's clearance exhibited a prolonged viral shedding period with a median time of 289 days (107-581 days). CONCLUSIONS: Our study indicates that NoV/SaV infection causes posttransplant chronic diarrhea potentially complicated by severe kidney graft impairment.