Early outcomes of kidney transplantation from elderly donors after circulatory death (GEODAS study).

BACKGROUND: Spain has dramatically increased the number of controlled circulatory death donors (cDCD). The initial selection criteria for considering cDCD for kidney transplantation (KT) have been expanded progressively, with practically no limits in donor age during the last years. We aimed to analyze the early clinical outcomes using expanded (> 65 years) cDCD in comparison with standard ones. METHODS: Observational multicenter study including 19 transplant centers in Spain. We performed a systematic inclusion in a central database of every KT from expanded cDCD at each participant unit from January-2012 to January-2017. Surgical procedures and immunosuppressive protocols were based on local practices. Data was analyzed in the central office using logistic and Cox regression or competitive-risk models for multivariate analysis. Median time of follow-up was 18.1 months. RESULTS: 561 KT were performed with kidneys from cDCD, 135 from donors older than 65 years. As expected, recipients from older cDCD were also older (65.8 (SD 8.8) vs 53.7 (SD 11.4) years; p < 0.001) and with higher comorbidity. At 1 year, no differences were found amongst older and younger cDCD KT recipients in terms of serum creatinine (1.6 (SD 0.7) vs 1.5 (SD 0.8) mg/dl; p = 0.29). Non-death censored graft survival was inferior, but death-censored graft survival was not different (95.5 vs 98.2% respectively; p = 0.481). They also presented a trend towards higher delayed graft function (55.4 vs 46.7%; p = 0.09) but a similar rate of primary non-function (3.7 vs 3.1%; p = 0.71), and acute rejection (3.0 vs 6.3%; p = 0.135). In the multivariate analysis, in short follow-up, donor age was not related with worse survival or poor kidney function (eGFR < 30 ml/min). CONCLUSIONS: The use of kidneys from expanded cDCD is increasing for older and comorbid patients. Short-term graft outcomes are similar for expanded and standard cDCD, so they constitute a good-enough source of kidneys to improve the options of KT wait-listed patients.

Kidney transplant from controlled donors following circulatory death: Results from the GEODAS-3 multicentre study. / Trasplante renal con órganos procedentes de donación tras parada circulatoria controlada: resultados del estudio multicéntrico GEODAS-3.

INTRODUCTION: Many European countries have transplant programmes with controlled donors after cardiac death (cDCD). Twenty-two centres are part of GEODAS group. We analysed clinical results from a nephrological perspective. METHODS: Observational, retrospective and multicentre study with systematic inclusion of all kidney transplant recipients from cDCD, following local protocols regarding extraction and immunosuppression. RESULTS: A total of 335 cDCD donors (mean age 57.2 years) whose deaths were mainly due to cardiovascular events were included. Finally, 566 recipients (mean age 56.5 years; 91.9% first kidney transplant) were analysed with a median of follow-up of 1.9 years. Induction therapy was almost universal (thymoglobulin 67.4%; simulect 32.8%) with maintenance with prednisone-MMF-tacrolimus (91.3%) or combinations with mTOR (6.5%). Mean cold ischaemia time (CIT) was 12.3h. Approximately 3.4% (n=19) of recipients experienced primary non-function, essentially associated with CIT (only CIT ≥ 14 h was associated with primary non-function). Delayed graft function (DGF) was 48.8%. DGF risk factors were CIT ≥ 14 h OR 1.6, previous haemodialysis (vs. peritoneal dialysis) OR 2.1 and donor age OR 1.01 (per year). Twenty-one patients (3.7%) died with a functioning graft, with a recipient and death-censored graft survival at 2-years of 95% and 95.1%, respectively. The estimated glomerular filtration rate at one year of follow-up was 60.9 ml/min. CONCLUSIONS: CIT is a modifiable factor for improving the incidence of primary non-function in kidney transplant arising from cDCD. cDCD kidney transplant recipients have higher delayed graft function rate, but the same patient and graft survival compared to brain-dead donation in historical references. These results are convincing enough to continue fostering this type of donation.

Development of a program for kidney transplants using organs donated from donors awaiting cardiac arrest (type III Maastricht).

INTRODUCTION: The availability of organ donors is a limiting factor for kidney transplants. Donations from non-heart-beating donors (NHBD) can provide as many as one-third of all organs. Controlled patients awaiting cardiac arrest following limitation of life support techniques, or type III Maastricht donors, constitute an alternative that still has yet to be systematically developed. STUDY TYPE: Descriptive series of 10 cases occurring between January and April 2012. METHOD: Over a period of 6 months, we designed a protocol for extracting and managing kidney transplants and providing immunosuppression therapy. Patients are evaluated in accordance with the criteria agreed by a different team responsible for transplant coordination. We established a maximum duration of time between limitation of life-sustaining therapy and death of 120 minutes and 60 minutes warm ischaemia. Two types of graft perfusion were used, one in situ through direct application to the surgical area, and another using ante mortem vascular canalisation. Immunosuppression therapy included induction with thymoglobulin, steroids, and mycophenolate, with introduction of tacrolimus on the seventh day. Data are expressed as median and (range). RESULTS: We included the first 10 cases of kidney transplants with organs from 5 NHBD (type III Maastricht): 4 males, mean age of 57 years (45-66 years), with limitation of life-sustaining therapy due to anoxic encephalopathy (2), intoxication (1), acute stroke (2) and terminal respiratory failure (1). The following mean time intervals were recorded: effective warm ischaemia: 20 minutes (8-23 minutes) and cold ischaemia: 7.5 hours (4-14.1 hours). Recipients had a mean age of 58 years (32-71 years), with various aetiologies (2 cases of glomerulonephritis, 1 polycystic kidney disease, 2 tubulo-interstitial nephropathy, 4 vascular, and 1 unknown), with a mean 31.7 months on haemodialysis (11-84 months); the kidney was a second transplant in two cases. No patients were hyper-immunised. Six patients required a dialysis session at some point, and four had prolonged acute tubular necrosis, over a mean hospitalisation period of 24.5 days (8-44 days). Mean creatinine (Cr) one month after transplantation was 2.1mg/dl (0.7-3.2mg/dl), and mean nadir creatinine was 1.2mg/dl (0.7-3.2mg/dl). One patient did not improve upon Cr values <3.2mg/dl, despite the absence of evidence of toxicity or rejection in a renal biopsy, and the transplant pair reached a Cr of 1.4mg/dl. Throughout the series, similar surgical complications were recorded to those observed in conventional donor situations. CONCLUSIONS: Despite the limitations of this preliminary study, the use of this type of transplant produces favourable short-term evolution. Expanded use of this type of donor could reduce the waiting-list time for a kidney transplant.

Trasplante renal con órganos procedentes de donación tras parada circulatoria controlada: resultados del estudio multicéntrico GEODAS-3 / Kidney transplant from controlled donors following circulatory death: Results from the GEODAS-3 multicentre study

Introducción: Varios países eu:ropeos disponen de programas de donación tras parada cardiaca controlada (cDCD). Veintidós centros participan en el grupo GEODAS, cuyos resultados clínicos presentamos desde una perspectiva nefrológica. Métodos: Estudio multicéntrico retrospectivo observacional con inclusión sistemática de todos los trasplantes renales (TR) procedentes de cDCD, siguiendo protocolos locales de extracción e inmunosupresión. Resultados: Se incluyó a 335 donantes tras cDCD (edad media 57,2 años) fallecidos mayoritariamente por eventos cardiovasculares. Se analizan 566 receptores (edad media de 56,5 años; el 91,9% con primer trasplante renal), con una mediana de seguimiento de 1,9 años. La terapia de inducción fue casi universal (timoglobulina 67,4%; simulect 32,8%) con mantenimiento con prednisona-MMF-tacrolimus (91,3%) o combinaciones con mTOR (6,5%). El tiempo medio de isquemia fría (CIT) fue 12,3 h. Hubo un 3,4% de fallo primario del injerto (n = 19), asociado fundamentalmente al tiempo de isquemia fría (solo el CIT ≥ 14 h se asoció a fallo primario del injerto). La función retrasada del injerto (DGF) fue 48,8%. Los factores de riesgo para la DGF fueron: CIT ≥ 14 h OR 1,6, procedencia de hemodiálisis (vs. diálisis peritoneal) OR 2,1 y edad del donante OR 1,01 (por año). Veintiún pacientes fallecieron con injerto funcionante (3,7%), con una supervivencia de paciente e injerto (censurada para muerte) al segundo año del 95% y del 95,1%, respectivamente. El filtrado glomerular estimado al año de seguimiento fue 60,9ml/min. Conclusiones: El CIT es un factor modificable para mejorar la incidencia del fallo primario del injerto en trasplante renal procedente de cDCD. El trasplante renal con cDCD tiene mayor incidencia en la función retrasada del injerto, pero igual supervivencia de paciente e injerto que la referencia histórica para donación en muerte encefálica. Los resultados son satisfactorios para continuar promoviendo este tipo de donación. Conclusiones: El CIT es un factor modificable para mejorar la incidencia del fallo primario del injerto en trasplante renal procedente de cDCD. El trasplante renal con cDCD tiene mayor incidencia en la función retrasada del injerto, pero igual supervivencia de paciente e injerto que la referencia histórica para donación en muerte encefálica. Los resultados son satisfactorios para continuar promoviendo este tipo de donación

Introduction: Many European countries have transplant programmes with controlled donors after cardiac death (cDCD). Twenty-two centres are part of GEODAS group. We analysed clinical results from a nephrological perspective. Methods: Observational, retrospective and multicentre study with systematic inclusion of all kidney transplant recipients from cDCD, following local protocols regarding extraction and immunosuppression. Results: A total of 335 cDCD donors (mean age 57.2 years) whose deaths were mainly due to cardiovascular events were included. Finally, 566 recipients (mean age 56.5 years; 91.9% first kidney transplant) were analysed with a median of follow-up of 1.9 years. Induction therapy was almost universal (thymoglobulin 67.4%; simulect 32.8%) with maintenance with prednisone-MMF-tacrolimus (91.3%) or combinations with mTOR (6.5%). Mean cold ischaemia time (CIT) was 12.3 h. Approximately 3.4% (n = 19) of recipients experienced primary non-function, essentially associated with CIT (only CIT ≥ 14 h was associated with primary non-function). Delayed graft function (DGF) was 48.8%. DGF risk factors were CIT ≥ 14 h OR 1.6, previous haemodialysis (vs. peritoneal dialysis) OR 2.1 and donor age OR 1.01 (per year). Twenty-one patients (3.7%) died with a functioning graft, with a recipient and death-censored graft survival at 2-years of 95% and 95.1%, respectively. The estimated glomerular filtration rate at one year of follow-up was 60.9 ml/min. Conclusions: CIT is a modifiable factor for improving the incidence of primary non-function in kidney transplant arising from cDCD. cDCD kidney transplant recipients have higher delayed graft function rate, but the same patient and graft survival compared to brain-dead donation in historical references. These results are convincing enough to continue fostering this type of donation

Inmunoterapia con bcg en carcinoma papilar de vejiga / Immunotherapy with bcg in papillary bladder carcinoma

Se presenta el caso de un paciente de sexo masculino de 58 anos de edad, con el diagnóstico de Carcinoma papilar superficial de vejiga en quien se realizo inmunoterapia con BCG como tratamiento. El paciente presentó una cistitis granulomatosa como complicación de la inmunoterapia; recibiendo tratamiento específico y suspendiendo la inmunoterapia durante cinco meses. Posteriormente se retoma el tratamiento logrando la erradicación tumoral.

This is a case of a 58 years old male patient with the diagnostic of papilar carcinoma in bladder. It was done an immunotherapy with BCG as treatment. A short term complication of inmunotherapy was a granulomatous cystitis, that the patient presented , He received specific treatment and the inmunotherapy was suspended for five months; furthermore. we continue with the treatment achieving the tumoral erradication.

Diagnóstico de leishmaniasis utilizando medio d cultivo tstb en pacientes de trópico de Cochabamba / Diagnóstico de leishmaniasis utilizando medio d cultivo tstb en pacientes de trópico de Cochabamba

Se realizó un estudio prospectivo, analítico y experimental para determinar el porcentaje de sensibilidad de un nuevo medio de cultivo para el diagnóstico de Leishmania, denominado TSTB (Torrico-Solano-Torrico-Bermúdez). Se obtuvieron las muestras por aspirado de úlceras con sospecha clínica de Leishmaniasis de pacientes provenientes del trópico de Cochabamba. Los objetivos planteados fueron determinar el porcentaje de sensibilidad del cultivo ya mencionado y analizar el crecimiento de parásitos de Leishmania. Como resultados se obtuvo un 90% de sensibilidad mediante este método diagnóstico y una mínima contaminación por hongos (mohos y levaduras); además, un cambio de coloración en el medio de cultivo debido al crecimiento y multiplicación de los parásitos por consumo de los nutrientes.

A prospective, analytic and experimental study was realized, in which we tried to determine the percentage of sensitive of a new culture medium for the diagnosis of Leishmania, denominated Torrico-Solano-Torrico-Bermudez (TSTB). Samples were obtained by a piration of ulcers with clinical suspicion of Leishmaniasis from patients proceeding from the tropical area of Cochabamba. The objectives planted were to determine the percentage of sensitive of the mentioned culture and to analyze the growth of the parasites of Leishmania. As a result, a 90 % of positivity was obtained with this diagnostic method, with a minimum contamination by fungus (moss and yeast); further more, a change in the colour of culture medium was observed, because of the growth and multiplication of the parasites by consumption of the nutrients.