Biliopancreatic diversion in a renal transplant patient.

Surgery is usually the only solution to modify the evolution of morbid obesity and resolve the associated co-morbidities. There is very little written regarding malabsorptive surgery and transplantation. A 48-year-old male with hypertension, hyperuricemia and obesity underwent renal transplantation in 1994 for renal amyloidosis. He was maintained on oral immunosuppressive cyclosporine. The patient developed uncontrollable hypertension, hyperlipemia, hyperglycemia and increasing weight to a BMI of 44. Thus, in December 2004, he underwent biliopancreatic diversion (BPD). After 18 months follow-up, he has lost 85% of his excess weight, and his hypertension, hyperglycemia and hyperlipemia are markedly improved. Renal function was not modified, nor were the levels of cyclosporine. He has had no complications derived from the BPD, and has a better quality of life.

The macrophage infiltration index and matrix metalloproteinase-II expression as a predictor of chronic allograft rejection.

The presence of macrophages on renal biopsy specimens is considered an important cofactor in the development of chronic allograft nephropathy (CAN). Macrophages can activate the expression of matrix metalloproteinases (MMP), which induce glomerulosclerosis, arteriosclerosis, and interstitial fibrosis. The aim of our study was to demonstrate if they were related to the development of CAN. We analyzed matrix metalloproteinase (MMP) expression with specific monoclonal antibodies on 53 kidney biopsies performed due to the suspicion of a first acute rejection (AR) episode: 24 of the grafts have been lost due to CAN and the rest are still functioning. The group with CAN showed worse graft function and greater proteinuria from the beginning. The macrophage infiltration index (MI) expression was significantly higher in that group also (18.8 +/- 12 vs 12.5 +/- 9.15; P < .05), with a more important presence of macrophages in the interstitium and tubules. We observed a positive correlation between MI and tubular infiltration (r(2) = 0.52; P < .001) and between MMP-II and MI in the interstitium (r(2) = 0.3; P < .05) and with the global MI (r(2) = 0.3; P < 0.05). The last correlation was more powerful in the group with CAN (r(2) = 0.4; P < .05). According to our experience, global MI and tubular infiltration during an AR episode are good markers of long-term graft survival. The correlation between MI and MMP-II supports the role of macrophages in the development of CAN, although further studies are needed to clarify the nature of this relationship.

Hypertension and long-term renal allograft survival: effect of early glomerular filtration rate.

BACKGROUND: For many years, hypertension has been related to long-term survival of patients and kidney grafts, although the nature of this relationship has not been completely defined. The aim of this study was to analyse the influence of early glomerular filtration rate on post-transplant hypertension and on graft survival. METHODS: A total of 432 kidney transplanted patients on cyclosporin therapy, with a functioning graft for at least 1 year, were studied. They were divided into two groups depending on their early creatinine clearance: group A [<60 ml/min (n=270)] and group B [>60 ml/min (n=162)]. RESULTS: There were no differences in sex, aetiology of renal failure, number of retransplants, PRA, HLA mismatches and pre-transplant blood pressure. One year after transplantation, blood pressure was higher in group A (systolic BP 148/diastolic BP 86/mean BP 117) than in group B (systolic BP 140/diastolic BP 82/mean BP 111) (P<0.003). We observed a negative correlation between early creatinine clearance and 1-year blood pressure (P<0.01). Five and 10 year graft survival was 60 and 37% in group A and 87 and 69% in group B, respectively (P<0.000). A multivariate Cox analysis showed that 1-year blood pressure (P<0.0029, RR=1.76) and early creatinine clearance (P<0.000, RR=3.27) had a significant influence on graft survival. CONCLUSIONS: The 1-year post-transplant blood pressure is a non-immunological risk factor in long-term graft survival. Patients with a lower initial glomerular filtration rate are more susceptible to the development of secondary hypertension and worse graft survival.

Circulating adhesion molecules during kidney allograft rejection.

Adhesion molecules appear on leukocytes and endothelial cells mediating the localization and migration of leukocytes to sites of inflammation. Rejecting kidney grafts have shown an increased expression of these molecules. Recent reports have detected in serum soluble forms of adhesion molecules that could play a role in regulating inflammation. We have measured by ELISA the circulating serum levels of ICAM-1, VCAM-1 and E-selectin in: 23 controls, 33 chronic renal failure patients (CRF), 20 hemodialysis patients (HD), 17 samples from 6 patients with stable kidney graft function (STx), 25 samples from 8 patients with steroid-responsive rejection proven by biopsy, and 28 samples from 9 patients with steroid-resistant rejection and good response to OKT3. There was not a rise in cICAM-1 or cE-selectin levels during rejection compared with the steady phase before and after rejection. In the case of cVCAM-1, only the OKT3 group showed increased rejection levels (P < 0.05) that were maintained after rejection. For ICAM-1, CRF and HD groups had higher levels than the remaining groups. cVCAM-1 levels were elevated in all groups when compared with control, furthermore, OKT3 and HD groups had higher levels than the STx, CRF, or steroid-responsive groups. For cE-selectin, we only found differences between the CRF and both rejection groups. Serum creatinine correlated significantly with c-ICAM-1 and cVCAM-1 R = 0.30 and R = 0.22), but not with cE-selectin. We conclude that soluble adhesion molecules levels are not valuable markers for rejection. Patients with chronic renal failure have increased levels of adhesion molecules, which could reflect an impaired elimination.