The perception of sleep quality in kidney transplant patients during the first year of transplantation

OBJECTIVE: Poor sleep quality is one of the factors that adversely affects patient quality of life after kidney transplantation, and sleep disorders represent a significant cardiovascular risk factor. The objective of this study was to investigate the prevalence of changes in sleep quality and their outcomes in kidney transplant recipients and analyze the variables affecting sleep quality in the first years after renal transplantation. METHODS: Kidney transplant recipients were evaluated at two time points after a successful transplantation: between three and six months (Phase 1) and between 12 and 15 months (Phase 2). The following tools were used for assessment: the Pittsburgh Sleep Quality Index; the quality of life questionnaire Short-Form-36; the Hospital Anxiety and Depression scale; the Karnofsky scale; and assessments of social and demographic data. The prevalence of poor sleep was 36.7% in Phase 1 and 38.3% in Phase 2 of the study. RESULTS: There were no significant differences between patients with and without changes in sleep quality between the two phases. We found no changes in sleep patterns throughout the study. Both the physical and mental health scores worsened from Phase 1 to Phase 2. CONCLUSION: Sleep quality in kidney transplant recipients did not change during the first year after a successful renal transplantation.

Estudo das alterações ecocardiográficas nos primeiros seis meses após o transplante renal / Study of echocardiographic alterations in the first six months after kidney transplantation

FUNDAMENTO: Alterações cardíacas são muito frequentes nos indivíduos portadores de doença renal crônica terminal e estão associadas com a morbimortalidade. OBJETIVOS: Avaliar as alterações evolutivas cardíacas após o transplante renal. MÉTODOS: Foram avaliados prospectivamente 40 pacientes com doença renal crônica terminal, imediatamente antes e com um mês, três meses e seis meses após o transplante renal, por meio de estudo ecocardiográfico com Doppler tecidual. Os parâmetros de massa ventricular, função sistólica e diastólica foram analisados. RESULTADOS: A média da idade foi 31,6 anos e 40% eram do sexo feminino. Observamos redução do diâmetro diastólico do VE (52,23 para 49,95 mm, p = 0,021) e do índice de massa do VE (131,48 para 113,039 g/m², p = 0,002) após o transplante renal. A razão E/e' média reduziu no terceiro e no sexto meses após o transplante renal em relação ao exame basal (8,13 e 7,85 vs 9,79, p < 0,05). A fração de ejeção aumentou a partir do primeiro mês do transplante renal em relação a exame basal (69,72% vs 65,68%, p < 0,05). A prevalência de disfunção diastólica reduziu 43% no período avaliado. A fração de ejeção e a razão E/e' média basais estiveram associadas com redução do índice de massa do VE após o transplante renal. O índice de massa do VE basal, o sexo feminino e a redução do fósforo sérico apresentaram associação com a redução da razão E/e' média após o transplante renal. CONCLUSÃO: O transplante renal promoveu alterações significativas nos parâmetros ecodopplercardiográficos de massa do VE, função sistólica e função diastólica nos pacientes com doença renal crônica terminal.

BACKGROUND: Cardiac disorders are very common in individuals with chronic kidney disease and are associated with morbimortality. OBJECTIVE: To evaluate cardiac alterations after kidney transplantation. METHODS: We prospectively evaluated 40 patients with chronic kidney disease, immediately before and one month, three months and six months after kidney transplantation, using tissue Doppler echocardiographic study. The left ventricular mass, systolic and diastolic function parameters were analyzed. RESULTS: The mean age was 31.6 years and 40% of patients were female. We observed a reduction in left ventricular diastolic diameter (52.23 to 49.95 mm, p = 0.021) and LV mass index (131.48 to 113.039 g/m2, p = 0.002) after kidney transplantation. The mean E/e' decreased in the third and sixth months after kidney transplantation, when compared to basal values (8.13 and 7.85 vs. 9.79, p <0.05). The ejection fraction increased from the first month after kidney transplantation compared to basal assessment (69.72% vs. 65.68%, p <0.05). The prevalence of diastolic dysfunction decreased 43% during the evaluated period. The basal ejection fraction and mean E/e' were associated with reduced LV mass index after kidney transplantation. The LV mass index at baseline, female sex and decrease in serum phosphorus were associated with a reduction in the mean E/e ' ratio after kidney transplantation. CONCLUSION: Kidney transplantation resulted in significant alterations in Doppler echocardiographic parameters of LV mass, systolic and diastolic function in patients with chronic kidney disease.

Clinical and pathological correlations of C4d immunostaining and its infl uence on the outcome of kidney transplant recipients / Correlações clinico-patológicas da marcação de C4d e sua influência na evolução de receptores de transplante renal

INTRODUCTION: C4d is a marker of antibody-mediated rejection (ABMR) in kidney allografts, although cellular rejection also have C4d deposits. OBJECTIVE: To correlate C4d expression with clinico-pathological parameters and graft outcomes at three years. METHODS: One hundred forty six renal transplantation recipients with graft biopsies by indication were included. C4d staining was performed by paraffin-immunohistochemistry. Graft function and survival were measured, and predictive variables of the outcome were determined by multivariate Cox regression. RESULTS: C4d staining was detected in 48 (31 percent) biopsies, of which 23 (14.7 percent) had diffuse and 25 (16 percent) focal distribution. Pre-transplantation panel reactive antibodies ( percentPRA) class I and II were significantly higher in C4d positive patients as compared to those C4d negative. Both glomerulitis and pericapillaritis were associated to C4d (p = 0.002 and p < 0.001, respectively). The presence of C4d in biopsies diagnosed as no rejection (NR), acute cellular rejection (ACR) or interstitial fibrosis/ tubular atrophy (IF/TA) did not impact graft function or survival. Compared to NR, ACR and IF/TA C4d-, patients with ABMR C4d+ had the worst graft survival over 3 years (p = 0.034), but there was no difference between ABMR versus NR, ACR and IF/TA that were C4d positive (p = 0.10). In Cox regression, graft function at biopsy and high percentPRA levels were predictors of graft loss. CONCLUSIONS: This study confirmed that C4d staining in kidney graft biopsies is a clinically useful marker of ABMR, with well defined clinical and pathological correlations. The impact of C4d deposition in other histologic diagnoses deserves further investigation.

INTRODUÇÃO: A fração do complemento C4d é um marcador de rejeição mediada por anticorpos (RMA) em aloenxertos renais, embora na rejeição celular também se observem depósitos de C4d. OBJETIVOS: Correlacionar a expressão de C4d com parâmetros clínicopatológicos e a evolução do enxerto renal em três anos. MÉTODOS: Foram incluídos 146 receptores de transplante renal com biópsias por indicação. A marcação de C4d foi feita por imuno-histoquímica em parafina. Foram medidas a função e a sobrevida do enxerto e determinadas as variáveis preditivas de sua evolução por meio de modelo de regressão de Cox. RESULTADOS: A marcação positiva para C4d foi detectada em 48 (31 por cento) biópsias, das quais 23 (14,7 por cento) tinham marcação difusa e 25 (16 por cento), focal. A reatividade contra painel ( por centoPRA) de classe I e II pré-transplante foi significativamente maior nos pacientes C4d+ quando comparada aos C4d-. Tanto glomerulite quanto pericapilarite foram associadas com C4d (p = 0,002 e p < 0,001, respectivamente). A presença de C4d em biópsias sem rejeição (SR), rejeição celular aguda (RCA) ou fibrose intersticial/atrofia tubular (FI/AT) não teve impacto na função ou na sobrevida do enxerto. Comparados a indivíduos com SR, RCA e FI/AT C4d-, pacientes com RMA C4d+ tiveram pior sobrevida do enxerto em 3 anos (p = 0,034), mas não houve diferença entre RMA versus SR, RCA e FI/AT C4d+ (p = 0,10). Na regressão de Cox, função do enxerto no momento da biópsia e por centoPRA alto foram preditores de perda do enxerto. CONCLUSÕES: A pesquisa de C4d em biópsias do enxerto renal é útil para identificar RMA, com correlações clínicopatológicas bem definidas. O impacto do C4d em outros diagnósticos histológicos necessita de investigação adicional.

Parathyroidectomy after kidney transplantation: short-and long-term impact on renal function

INTRODUCTION: Kidney transplantation corrects endocrine imbalances. Nevertheless, these early favorable events are not always followed by rapid normalization of parathyroid hormone secretion. A possible deleterious effect of parathyroidectomy on kidney transplant function has been reported. This study aimed to compare acute and longterm renal changes after total parathyroidectomy with those occurring after general surgery. MATERIALS AND METHODS: This was a retrospective case-controlled study. Nineteen patients with persistent hyperparathyroidism underwent parathyroidectomy due to hypercalcemia. The control group included 19 patients undergoing various general and urological operations. RESULTS: In the parathyroidectomy group, a significant increase in serum creatinine from 1.58 to 2.29 mg/dl (P < 0.05) was noted within the first 5 days after parathyroidectomy. In the control group, a statistically insignificant increase in serum creatinine from 1.49 to 1.65 mg/dl occurred over the same time period. The long-term mean serum creatinine level was not statistically different from baseline either in the parathyroidectomy group (final follow-up creatinine = 1.91 mg/dL) or in the non-parathyroidectomy group (final follow-up creatinine = 1.72 mg/dL). CONCLUSION: Although renal function deteriorates in the acute period following parathyroidectomy, long-term stabilization occurs, with renal function similar to both preoperative function and to a control group of kidney-transplanted patients who underwent other general surgical operations by the final follow up.

Uma estratégia para redução de risco cardiovascular em pacientes transplantados renais / A strategy to improve the cardiovascular risk factor profile in renal transplant patients

FUNDAMENTO: A doença cardiovascular representa a principal causa de morbidade, mortalidade e perda de função do enxerto em receptores de transplante renal (RTR). O tratamento agressivo dos fatores de risco é fortemente recomendado. Entretanto, há um gap entre a terapia baseada em evidência recomendada e o manejo cardiovascular eficaz nesta população. OBJETIVO: Estabelecer uma estratégia de controle de fatores de risco cardiovascular para RTR. MÉTODOS: O risco cardiovascular de 300 RTR de uma Unidade de Transplante Renal foi avaliado através dos critérios de Framingham. Intervenções nos fatores de risco modificáveis foram sugeridas aos médicos assistentes através de cartas anexadas aos prontuários dos pacientes, incluindo modificações no estilo de vida, controle de pressão arterial e uso de tratamento anti-plaquetário e hipolipemiante. Os perfis dos fatores de risco foram re-avaliados depois de 6 e 12 meses. RESULTADOS: A maioria dos pacientes apresentava alto risco cardiovascular (58 por cento). Após 12 meses, a proporção de pacientes recebendo tratamento anti-plaquetário, anti-hipertensivo ou hipolipemiante tinha aumentado de forma significante (29 para 51 por cento, 83 para 92 por cento e 3 para 46 por cento, p < 0,001, respectivamente). Os níveis de colesterol total e triglicérides diminuíram (de 237 para 215 mg/dl, p = 0,001 e 244 para 221 mg/dl, p = 0,03). Embora uma redução não-significante nos níveis de LDL-colesterol tenha sido observada (136 para 116 mg/dl, p = 0,12), os pacientes que iniciaram terapia com estatinas nos primeiros 6 meses do estudo apresentaram uma redução significante de 25 por cento no LDL-colesterol (159 para 119 mg/dl, p < 0,001). A proporção de pacientes com avaliação completa de lipídios no plasma também aumentou (27 por cento para 49 por cento, p < 0,001). CONCLUSÃO: Nossos resultados sugerem que uma estratégia simples e de baixo custo melhora de forma significante o perfil de risco cardiovascular de RTR, ...

BACKGROUND: Cardiovascular disease represents the leading cause of morbidity, mortality and graft function loss in renal transplant recipients (RTR). Aggressive treatment of risk factors is strongly advocated. However, there is a gap between recommended evidence-based therapy and effective cardiovascular management in that population. OBJECTIVE: To establish a cardiovascular risk factor control strategy for RTR. METHODS: The cardiovascular risk of 300 RTR of a renal transplant unit was assessed using the Framingham criteria. Interventions on modifiable risk factors were suggested to attending physicians by letters attached to patients' charts, including lifestyle modifications, blood pressure control and use of antiplatelet and lipid-lowering therapy. Risk factor profiles were re-evaluated after 6 and 12 months. RESULTS: Most patients were at high cardiovascular risk (58 percent). After 12 months, the proportion of patients on antiplatelet, antihypertensive and lipid-lowering therapy was significantly increased (29 to 51 percent, 83 to 92 percent and 3 to 46 percent, p < 0.001, respectively). Total cholesterol and triglyceride levels decreased (237 to 215 mg/dl, p = 0.001 and 244 to 221 mg/dl, p = 0.03). Although a non-significant reduction in LDL levels was observed (136 to 116 mg/dl, p = 0.12), patients starting statins within the first 6 months of the study presented a significant 25 percent reduction in LDL (159 to 119 mg/dl, p < 0.001). The proportion of patients with complete plasma lipid evaluation was also increased (27 percent to 49 percent, p < 0.001). CONCLUSION: Our results suggest that a simple, inexpensive strategy significantly improves the cardiovascular risk profile of RTR, potentially translating into marked benefits for long-term graft function and life expectancy.

Cystatin C and renal function in pediatric kidney transplant recipients

In clinical practice, the glomerular filtration rate (GFR) is often determined with serum creatinine. However, studies have shown cystatin C to be a better parameter for the diagnosis of impaired renal function. We compared GFR estimated by plasma cystatin C with GFR estimated by serum creatinine in a sample of 50 pediatric renal transplant recipients and 24 healthy children. The correlation between GFR estimated by serum creatinine and by cystatin C was significant (r = 0.75; P < 0.001, Person’s correlation); however, in pediatric kidney transplant recipients, the GFR was 6.7 mL/min lower when determined using cystatin C rather than serum creatinine. Moreover, using GFR estimated by cystatin C we found that 42 percent of the pediatric kidney transplant recipients had an estimated GFR <60 mL·min-1·1.73 (m²)-1, whereas when GFR was estimated by the serum creatinine formula only 16 percent of the children had values below this cutoff point indicative of chronic kidney disease (P < 0.001). We conclude that, in pediatric kidney transplant recipients, estimation of GFR yields lower values when cystatin C is used rather than serum creatinine.

Citocinas e quimiocinas no transplante renal / Cytokines and chemokines in renal transplantation

O transplante renal é a melhor modalidade de terapia renal substitutiva até o momento. Infelizmente a sobrevida do enxerto é interrompida pelos episódios de rejeição aguda ou mesmo de fibrose intersticial atrofia tubular. A dosagem de quimiocinas e citrocinas urinárias como ferramenta alternativa para o diagnóstico dessas complicações tem sido relatada nos últimos anos. Estas substâncias estão sabidamente relacionadas com os mecanismos imunoinflamatórios do transplante renal podendo ser detectadas no tecido renal no plasma e na urina de pacientes transplantados. Drogas anti-inflamatórias inibidores do sistema renina angiotensina e alguns antagonistas de receptores de citocinas ainda utilizados em nível experimental podem interferir com a expressão desses mediadores do sistema imune e por conseguinte alterar a evolução do transplante renal. Neste sentido pretende-se neste artigo fazer uma revisão dos estudos sobre a mensuração de citocinas quimiocinas e dos seus receptores na urina no plasma e no tecido renal de pacientes transplantados no intuito de avaliar uma possível associação entre os níveis desses mediadores e as complicações do transplante renal e sobrevida do enxerto.

Renal transplantation is the best modality of renal replacement therapy so far. Unfortunately, graft survival is interrupted by episodes of acute rejection or tubular atrophy of interstitial fibrosis. The measurement of urinary chemokines and citrocinas as an alternative tool for the diagnosis of these complications have been reported in recent years. These substances are known to be related to immunoinflammatory mechanisms of renal transplantation can be detected in renal tissue in plasma and urine of transplant patients. Anti-inflammatory drugs inhibiting the renin angiotensin receptor antagonists and some cytokines also used on an experimental level can interfere with the expression of these mediators of the immune system and thus alter the course of renal transplantation. In this sense we intend to make this article a review of studies on the measurement of cytokines chemokines and their receptors in the plasma and urine in the renal tissue of patients transplanted in order to evaluate a possible association between the levels of these mediators and the complications of the transplant and renal graft survival.

Biopsia renal en pediatría: análisis de la casuística de 28 años: Hospital de Niños de Valencia-Venezuela: [revisión] / Renal biopsy in pediatrics: casuistica analysis of 28 years: Hospital of Niños of Valencia-Venezuela: [review]

El análisis de los resultados de casuísticas de biopsias renales es importante con fines diagnósticos, terapéuticos y de pronóstico. Evaluar la serie de biopsias renales en el Hospital de Niños de Valencia, Venezuela, durante el período 1978-2007. Fueron analizadas 421 biopsias renales practicadas en 395 pacientes, de 2 meses a 20 años, 57% varones. El material fue procesado por microscopía óptica, inmunofluorescencia y microscopía electrónica en 98% de los casos. Se obtuvo muestra adecuada (más de 10 glomérulos) en 93% de los casos (n=392). Indicaciones clínicas: síndrome nefrótico 199(50%), síndrome nefrítico atípico 53(13%), otro: (hematuria/proteinuria, proteinuria, trasplante, enfermedades sistémicas 143(37%). Resultados Histopatológicos: A.-Glomerulonefrítis primaria (GNP) 302 casos (77%), B.-Nefropatías secundarias (NS) 68 casos (17%), C.-Riñones trasplantados 28 casos (7%).-Diagnósticos en GNP: 1) Lesión de cambios mínimos 140(46%), 2) Glomeruloesclerosis segmentaria y focal 79 (26%), 3) GN proliferativa y/o mesangial 67(22%), 4) GN Membranosa 16 (5%). -Diagnósticos en NS: Nefritis lúpica: 20 casos (32.25%), Nefropatía IgA: 22 casos (35.50%); Otras: 20 casos (32.25%). -Diagnósticos en riñones trasplantados: rechazo agudo 50%, necrosis tubular aguda 25%, rechazo crónico 20%, enfermedad recurrente en trasplante 5%. Complicaciones: Hematuria transitoria: 21 casos (5%), hematoma perirenal: 3(<1%), perforación intestinal: 2 (<0.5%), hemorragia importante: 2 (<0.5%), nefrectomía: 1(0.2%). La presente es una de las primeras casuísticas de biopsias renales reportadas en Latinoamérica y una de las más grandes en el mundo y, de acuerdo a nuestros resultados, es un procedimiento seguro con gran utilidad diagnóstica, pocas complicaciones, sin mortalidad.

Evaluation and analysis of the results of renal biopsy are important for diagnostic, therapeutic and prognostic matters. To evaluate a series of renal biopsies performed during the period 1978-2007 in the Hospital de Niños de Valencia, Venezuela. All patients had history of either primary or secondary nephropathies. 421 biopsies were done in 377 patients, ages 2 months-20 years; 57% boys. 26 patients were re-biopsed. Percutaneous needle biopsy (PNB) was performed in all the patients, except in one who underwent open biopsy because of a solitary kidney. Renal tissue was processed for optical, inmunofluorescence and electronic microscopy in 98% of cases. The biopsy technique, clinical syndromes at presentation, hystopathological pattern, effectiveness and complications are described. Adequate sample was obtained in 392 cases (93%) (more than 10 glomeruli) and inadequate or failed biopsy in 29(7%). Clinical syndromes at presentation were: nephrotic syndrome: 199 cases (50%), atypical acute nephritic syndrome: 53 (13%), others: hematuria and proteinuria, isolated proteinuria, kidney transplant biopsy or systemic diseases: 143(37%). The hystopathological pattern obtained was as follows. A.-Primary glomerulonephritis (PG): 302 cases, 77%, B.-Secondary nephropathies: 68 cases, 17%, C.- Kidney transplant biopsies: 28 cases, 5 %. Primary Glomerulonephritis diagnosis: minimal change disease: 140 cases, 46%, Focal Segmental Glomerulosclerosis: 79(26%), diffuse proliferative glomerulonephritis/mesangial: 67(22%), membranous glomerulonephritis: 16(5%). Secondary nephropathies: lupus nephritis: 20 cases (32.25%), IgA Nephropathy: 22 cases (35.50%), others: 20 cases (32.25%).Transplant biopsies: rejection 50%, acute tubular necrosis 25%, chronic rejection 20%, and recurrent disease 5%. Complications: transient hematuria: 21(5%), perirenal hematoma: 3(<1%), gut perforation (<0.2%), bleeding which required blood transfusion: 2(<0.5%) and nephrectomy because of incontrollable...

Exploratory calcineurin inhibitor-free regimens in living-related kidney transplant recipients

Chronic allograft nephropathy is among the major causes of graft loss even in low-risk kidney transplant recipients and correlates with acute nephrotoxic events during the first year post-transplant. Therefore, calcineurin inhibitor-free regimens may improve patient and graft survival among recipients of living-related kidney transplants. To confirm this hypothesis, we evaluated the efficacy and safety of two calcineurin inhibitor-free regimens in 92 low-risk recipients of one-haplotype living-related kidney transplants. Immunosuppression consisted of tacrolimus, azathioprine and prednisone (group I, GI, N = 38), 2 doses of daclizumab, mycophenolate mofetil (MMF), and prednisone (GII, N = 33) and 2 doses of daclizumab, MMF, sirolimus and prednisone (GIII, N = 21). At 12 months, treatment failure (biopsy-confirmed acute rejection, graft loss or death) was higher in GII compared to GIII and GI (54.5 vs 24.0 vs 13.1 percent, P < 0.01, respectively). In patients of black ethnicity the incidence of acute rejection was 25 vs 83.3 vs 20 percent (P = 0.055), respectively. Patient and graft survival was comparable. There were no differences in mean creatinine or calculated creatinine clearance at 12 months. Overall incidence of post-transplant diabetes mellitus (3.3 percent) and cytomegalovirus disease (4.3 percent) was similar in all groups. Further development of effective calcineurin inhibitor-free regimens should exclude patients of black ethnicity and may need full-induction therapy, perhaps with depleting agents, and concentration-controlled use of sirolimus and MMF.

Será seguro ampliar la vejiga en relación al trasplante renal? / Is bladder augmentation safe in the setting of renal transplant?

Tradicionalmente se evitaba arriesgar un transplante renal en niños con mal funcionamiento de su vía urinaria. Nuestro centro fue pionero en la región en promover el concepto que la ampliación vesical permitiría un transplante renal exitoso. Para evaluar la veracidad de aquel concepto, revisamos todos aquellos niños tranplantados renales (TX) que tuvieron ampliación vesical (AV). Método: Se realizó revisión retrospectiva de fichas clínicas e imágenes radiológicas de todos los pacientes del programa de transplante renal de nuestro hospital en los últimos 22 años. Los criterios de inclusión fueron haber sido transplantado y haber sido operado de AV previo al 31 de diciembre de 2005. Resultados: Entre 1983- 2005 se realizaron 93 TX. De los 80 casos en que se recuperó todos los datos, 16 (20 por ciento) niños recibieron AV; 7 niñas y 9 niños. Edad y peso promedio al momento del TX fue 12 años (rango 6-17a) y 26 kilos (rango 14-41kg) respectivamente. Los diagnósticos urológicos eran vejiga neurogénica (n =8), uropatía obstructiva (n =5) y RVU (n =3). El segmento utilizado para AV fue ureter (n =7), sigmoide sin desmucosar (n =5), sigmoide desmucosado (n =2) e ileon (n =2). 5 pacientes fueron ampliados post TX. Después de un tiempo promedio de seguimiento de 71 meses (rango 12-144m), las complicaciones más frecuentes fueron ITU (n =13), RVU (n =6), litiasis (n =2) y acidosis metabólica (n =1). Se pudo recuperar información urodinamica previo a la ampliación vesical en 9/16 niños y post ampliación en 16/16. La capacidad vesical pre y post- ampliación presentó una mediana de 108 cc (rango 20-250 cc) y 450cc (rango 130-800cc) respectivamente. La acomodación previo a la AV estaba disminuida en 9/9 (<10 ml/cmH2O) y fue buena en 16/16 (>25 ml/cmH2O). La creatinina post-cirugía en promedio era de 1,28 mg/dl (rango 0,4- 2,39 mg/dl). No hubo pérdida del injerto en esta serie, siendo comparable la sobrevida a 5 años con aquellos niños trasplantados sin ampliación...

The traditional thought was that to relate a kidney transplant (KT) and a bladder augmentation (BA) could be risky. Our centre was one of the first in the region to promote the concept that a bladder augmentation would allow a successful KT. The aim of this study is to evaluate the veracity of that concept. Methods: Case note review of all the patients of the Kidney Transplant Programme from our hospital in the last 22 years. Inclusion criteria were to have received a KT and also a BA before december 31st 2005. Results: There were 93 KT between 1983 and 2005. From the 80 cases where data could be recovered, 16(20 percent) had a BA; 7 girls and 9 boys. Age and weight at the transplant time was 12 years (range 6-17 y) and 26 kg (range 14-41 kg) respectively. Urological diagnoses were neurogenic bladder (n =8), obstructive uropathy (n =5) and VUR (n =3). The segment used for BA was ureter (n =7), sigmoid without demucosalized(n =5), demucosalized sigmoid (n =2) and ileum (n =2). 5 patients were augmented after KT. The mean follow-up was 71 months (range 12-144m) and the most frequent complications were UTI (n =13), VUR (n=6), lithiasis (n=2) and metabolic acidosis (n =1). Pre transplant urodynamic data could be recovered in 9/16 cases and post KD in 16/16. Median bladder capacity pre and post transplantation was 108 cc (range 20-250cc) and 450cc (range 130-800cc) respectively. Bladder compliance pre transplant was reduce in 9/9 (<10 ml/cmH2O) and was good in 16/16 (>25 ml/cmH2O). The mean post KT creatinine was1.28 mg/dl (range 0.4-2.39 mg/dl). There was no graft lost in this series, presenting comparable graft survival at 5 years with those cases of KT without BA. Conclusión: Considering that graft survival is similar between those children with and without bladder augmentation, the authors confirm that BA is not a risky procedure for a KT. On the other hand, if 20 percent of the patient of our Kidney Transplant Programme required...

Oral manifestations and analysis of salivary and blood urea levels of patients under going haemo dialysis and kidney transplant.

AIM AND OBJECTIVES: To evaluate oral manifestations in patients with renal diseases and to correlate blood and salivary urea levels in patients undergoing haemodialysis and kidney transplant. MATERIAL AND METHODS: Study group subjects were selected from patients undergoing hemodialysis and patients who had underwent kidney transplant. Adequate history was recorded. All the groups were examined extra orally and intra orally and findings were recorded. SAMPLE COLLECTION: Venous blood was collected from the antecubital fossa in control group. In patients with renal disease undergoing dialysis, blood was collectedjust prior to the dialysis. Renal transplant patients' blood samples were collected during review visit. Unstimulated saliva was collected and submitted to the laboratory immediately for urea examination by an automated analyzer. RESULTS: Extra oral manifestations like swollen face, pale skin, pedal edema, and bruises on the skin, nausea and vomiting in nearly 50% of the patiens, and oral manifestations like uraemic odour, dry mouth, and altered taste sensation were noted. There was a correlation between blood urea and salivary urea concentration in patients under going hemodialysis and kidney transplant. CONCLUSION: Saliva can be used as a non-invasive diagnostic tool.

Can thymic tissue induce tolerance to kidney allografts?

The aim of this study was to investigate the beneficial effect of donor thymic tissue to induce tolerance in thymokidney allografts, transplanted to thymectomized cross-bred canines. Seven pairs of transplant donors and recipients were selected from 3- to 4-month-old cross-bred canines with major histocompatibility complex [MHC] mismatches. Recipients underwent partial thymectomy 4 weeks before transplantation and received an autologous thymic graft under the renal capsule, which had been engrafted in the donors 3 months before transplantation [thymokidney]. Successful engraftment with evidence of thymocyte development in the donors was determined by gross and histologic examination at the time of transplantation. Biopsy specimens were obtained at the transplant day and 3 months after transplantation and were studied histologically for evidence of hyperacute or acute rejection. At 90 days after the operation, all 7 juvenile thymic grafts had developed with normal thymic structure under the renal capsule. Hyperacute rejection was not observed in allografts, and all of them were functioning until the end of follow-up; however, all of the allografts showed acute cell-mediated rejection 3 months after transplantation. No tolerance was induced by vascularized donor thymokidneys in MHCmismatched canines. The advantages of tolerance over chronic immunosuppression are so great that a potentially tolerogenic approach such as thymic transplantation would seem worthy of further investigations on large animal models. To evaluate the beneficial effects of thymic tissue in tolerance induction, utilizing a short course, lowdose adjuvant immunosuppressant to this regimen and/or application of in-bred MHCmatched canines is suggested

El trasplante renal pediatrico en el Hospital Central Sur de Alta Especialidad (HCSAE) de PEMEX (México) / The renal pediatric transplanttion at the Hospital Central Sur de Alta Especialidad (HCSAE) de PEMEX (Mexico)

Desde Julio de 1984 hasta Julio de 1998, durante 14 años (a), se hicieron 150 trasplantes renales (TR) en el Hospital Central Sur de Alta Especialidad (HCSAE) de Pemex. Entre ellos, 25 (16.7 por ciento) se realizaron en pacientes menores de 18 a: 24 fueron de primera vez, más un segundo TR (tabla 1). Entre los casos pediátricos, 9 fueron del sexo masculino y 15 del femenino , con una edad promedio de 13.7ñ2.7 a (una desviación estándar D.E.) en el momento del TR, con límites de edad entre 8 y 17 a. Todos, excepto uno, estuvieron sujetos a tratamiento dialítico previo al TR. Las causas de la insuficiencia renal crónica terminal (IRCT) en los pacientes pediátricos fueron glomerulopatías en 17 casos, uropatías obstructivas en 6 y nefritis tubulointersticial crónica en 1. Al comparar estas etiologías con las de los 116 casos no pediátricos, se encontraron diferencias estadísticamente significativas en glumerulopatías (p<0.05), en uropatías obstructivas (p<0.01) y en otras causas no pediátricas (p<0.01). No hubo diferencias estadísticamente significativas (NS) entre los casos con nefritis tubulointersticial crónica. El tipo de TR pediátrico realizado fue de donador cadavérico (DC) en 10 pacientes y de donador vivo relacionado (V.R.) en 15. Los pacientes con TRDC no compartieron haplotipos de HL-A entre donador y receptor. Los de VR compartieron un haplotipo. El tratamiento con inmunosupresores (IS) se hizo a base de ciclosporina-A (Cy-A), prednisona (P) y azatioprina (Az) orales (tratamiento triple) según indicaciones del protocolo del TR seguidas en nuestro servicio. Se observaron como complicaciones tempranas 9 rechazos agudos corticosensibles, más uno corticorresistentes que respondió al anticuerpo monoclonal OKT3, con buena evolución posterior. Otras complicaciones tempranas (<1 a de evolución) comprendieron 2 necrosis tubulares agudas, 5 infecciones repetidas de vías urinarias, 3 de ellas operadas por fístulas u obstrucciones, con buen resultado posterior y 3 casos de epilepsia gran mal . Las complicaciones tardías (>1 a) comprendieron 5 rechazos crónicos con nefrectomías, más 2 pacientes con toma irregular de IS, que evolucionaron a IRCT. Todos recibieron tratamiento dialítico posterior. También se observaron 2 casos con neoplasias: un cáncer de ovario y un cáncer cervicouterino in situ. Ambos fueron tratados con buen resultado. Además 2 casos con papilomatosis vaginal y una fractura de fémur por osteodistrofía

Pharmacokinetic studies of cyclosporin in Thai kidney transplantation patients.

Pharmacokinetic studies were performed in 10 Thai patients with kidney transplantation who received microemulsion formulation (Neoral) of cyclosporin A (CsA) twice daily. No agents having pharmacokinetic effect on CsA had been used in these patients. The mean values of 12-h AUC (area under the concentration-blood curve) were 4603.63 +/- 344.61 ng x h/ml. CsA concentrations at 2 hours after dosing had the best value of correlation coefficient with the 12-h AUC. Abbreviated AUC could be calculated by stepwise multiple linear regression analysis and linear trapezoidal rule. The latter is more simple and superior to the former one.

Nuevas combinaciones de inmunosupresores (IS) en el trasplante renal (TR) / New combinatios in immunosuppressor drugs (IS) therapy in renal transplantation (RT)

El siglo XX ha atestiguado un excepcional desarrollo científico del trasplante renal (TR), mediante una verdadera explosión en la obtención de nuevos conocimientos en el tratamiento del rechazo renal, a través de la experimentación animal y la aplicación clínica de inmunosupresores (IS) de acción cada vez más específica, sobre la sensibilización antigénica producida por la introducción en el organismo de un aloinjerto renal.No ha sido posible hasta la fecha elaborar un IS "ideal " que debería .ser atóxico. específico en el bloqueo molecular del mecanismo desencadenante del rechazo agudo o crónico, respetando los mecanismos normales de defensa inmunológica. Debería ser, si fuera posible, estimulante de la expresión de células o moléculas inmunosupresoras específicas y debería ser barato. Ante la ausencia de esta "maravilla" inmunológica, se revisarán brevemente diversas combinaciones de IS que han dado resultados adecuados a la fecha. o que prometen ser exitosas en el futuro próximo.

Evaluation of kidney functions and cyclosporine levels in renal transplant patients on Panimum Bioral in post transplant period.

A retrospective analysis of the patients being given Panimun Bioral (microemulsion cyclosporine) after renal transplantation was done at IKRDC, (Institute of Kidney Diseases & Research Centre), Ahmedabad. A total of 21 patients were included for analysis. Patients were evaluated for various parameters e.g. weight, cyclosporine levels, S. Creatinine and BUN at three time schedules as 0 to > or = 30 days, > 30 to > or = 60 days and > 60 to 120 days after renal transplantation. The analysis of data obtained indicates the kidney function tests improved in these patients and therapeutically safe blood cyclosporine levels were achieved in all the three timeschedules.

Optimal cyclosporine therapy--an Indian experience.

Thirty consecutive adult patients who underwent renal transplantation were prospectively studied. The immunosuppression consisted of cyclosporine, azathioprine and prednisolone. Oral Cyclosporine CyA was initiated at a dose of 7 mg/kg/Day and reduced by 1 mg/kg/month. Blood level of CyA was monitored by monoclonal RIA (Cyclo-Trac-NS) method on 3rd, 10th, 30th, 60th, 90th and 180th days. The dose was titrated according to the blood level and the renal function. In spite of progressive reduction in the dose of CyA, the blood level did not show any significant change, probably because of increased absorption or decreased metabolism. Though the percentage change in CyA dose was significant, the CyA level and serum creatinine remained relatively stable during the follow up period. Our patients required relatively lesser dose to achieve optimum blood level. Though the blood level of CyA ranged between 387 and 2120 ng/dL. There was no evidence of rejection or irreversible nephrotoxicity.

Estudio comparativo de los niveles séricos de B2 microglobulina entre pacientes hemodializados crónicos y transplantados renales asociados al tiempo de hemodiálisis y diuresis residual de pacientes de la unidad de Hemodiálisis del Hospital Nacional de Sur-IPSS, Arequipa 1995

Recientemente se ha identificado una nueva entidad patológica, la Amiloidosis relacionada a la hemodiálisis donde la B2m es la principal componente de la sustancia amiloidea. TIPO DE ESTUDIO: Analítico, prospectivo, transversal, aleatorio y controlado. METODO: Los pacientes hemodializados crónicos que se consideraron para el estudio fueron 50, seleccionados en forma aleatoria simple, los mismos que se dializan usando menbranas de Cuprophane. Los pacientes transplantados renales seleccionados fueron 15 sin problemas de rechazo agudo. Los controles fueron 15. A los que se les determinó los niveles séricos de B2m mediante radio-inmunoensayo, RIA-125I. A través de la aplicación del Kit: B2-microglobulina IRMA 125Ix100. "Diagnostic Products Corp" USA. Se determinó las características poblacionales y el tiempo de hemodiálisis mediante la revisión de la historia clínica y la aplicación de una ficha de datos. Finalmente se midió la diuresis residual mediante la recolección y cuantificación volumétrica de las orinas. RESULTADOS: Los niveles séricos promedio y desviación standar de B2m en 50 pacientes hemodializados crónicos fueron: 45.23 ñ 15.92 mg/L. El tiempo de hemodiálisis promedio y desviación standar en 50 pacientes hemodializados crónicos son: 40.76 ñ 36.21 meses. La diuresis residual promedio y desviación standar en 50 pacientes hemodializados crónicos son: 260.92 ñ 437.86 ml. El coeficiente de correlación de Pearson al asociar B2m y el tiempo de hemodiálisis es (r=0.343,p<0.05) hasta los 84 meses. La linea de regresión de: y=0.27x + 36.79. El coeficiente de correlación de Pearson al asociar B2m y la diuresis residual es (r=-0.293,p<0.05) hasta los 84 meses. La linea de regresión de: y=-0.0106x + 48.76. Posterior a los 84 meses, ambas correlaciones se pierden. Según el concepto de exposición acumulada de B2m el 42 por ciento de la población tiene niveles mayores a 1500. El promedio y desviación standar de los niveles séricos de B2m en los pacientes controles sanos, y transplantados renales fueron: 1.17 ñ 0.084 mg/L; 4.52 ñ 1.34 mg/L respectivamente. Al comparar los niveles séricos de B2m entre los grupos de estudio incluyendo el grupo de hemodializados crónicos, se halló una diferencia altamente significativa(p<0.001 t student). CONCLUSIONES: Se concluye que existe correlación positiva entre los niveles séricos de B2m y el tiempo de hemodiálisis hasta las 84 meses(7 años). Existe correlación inversa entre los niveles séricos de B2m y la diuresis residual hasta los 84 meses(7 años). Los niveles séricos de B2m entre los pacientes hemodializados crónicos, controles sanos y transplantados renales son diferentes