Visceral leishmaniasis in the early post-transplant period after kidney transplantation: clinical features and therapeutic management.

Visceral leishmaniasis (VL) is a rare complication of kidney transplantation, with <100 cases reported in the literature. It is a life-threatening condition and usually occurs as a late complication after transplantation, with a median delay of 18 months between transplantation and onset of disease. We report the clinical features and management of 5 kidney transplant recipients who presented with VL in the early post-transplant period. All patients were successfully treated with liposomal amphotericin B (L-AMB), but 2 patients experienced graft loss. VL should be considered in the differential diagnosis in kidney transplant recipients living in endemic areas, who present with unexplained fever and pancytopenia in the early post-transplant period. Leishmania serology should be included in the screening of all transplant recipients, in order to identify a group of patients who could benefit from preemptive anti-Leishmania therapy. Therapy with L-AMB is highly effective and well tolerated in kidney transplant recipients with VL.

Sirolimus-based immunosuppression in kidney transplantation for type 2 diabetic nephropathy.

INTRODUCTION: Kidney transplantation is the best replacement therapy of type 2 diabetic patients and recently similar graft and patient survival between diabetic and nondiabetic recipients has been reported. However, standard immunosuppressive protocols are lacking. We present our experience with sirolimus-based immunosuppression in a population of 24 type 2 diabetic patients who underwent a kidney transplantation. PATIENTS AND METHODS: From January 2001 to December 2006, 396 kidney transplantations were performed. Twenty-four patients had type 2 diabetes mellitus as a cause of end-stage renal disease. They were randomized in two groups: thirteen patients (group A) received an immunosuppressive treatment with sirolimus, low-dose tacrolimus and steroids, while 11 patients (group B) received sirolimus, mycophenolate mofetil and steroids. RESULTS: Clinical characteristics were similar between the two groups. A slightly better kidney functionality was observed in group B patients. There were neither acute rejection episodes nor severe infectious complications in both groups. One patient in each group underwent a foot amputation. Graft and patient survival was 100% for both groups at a median follow-up of 29 months. CONCLUSIONS: Sirolimus-based immunosuppression is safe and efficacious in type 2 diabetic patients who underwent a kidney transplantation, allowing a better glucose metabolism control.

Acute renal failure due to ureteral obstruction in a kidney transplant recipient with Candida albicans contamination of preservation fluid.

Reported rates of positive preservation fluid cultures range from 5% to 23%, with fungi accounting for 2-10% of all positive cultures. We report the case of a kidney transplant recipient who received a graft with preservation fluid contaminated by Candida albicans, who developed acute renal failure due to ureteral obstruction by fungus balls. The patient was treated with voriconazole with complete restoration of graft function. This rare clinical entity demonstrates the usefulness of pre-transplant cultures of preservation fluid, in order to identify a group of patients who could benefit from antifungal prophylaxis therapy and thereby prevent the need for graft nephrectomy.

Infective complications in renal allograft recipients: epidemiology and outcome.

INTRODUCTION: Successful renal transplantation strictly depends on good control of rejection and better prevention and treatment of infections, which remain serious threats. METHODS: This retrospective, observational study of 245 renal allograft recipients who underwent transplantation between January 2002 and December 2005 included a 21+/-10 months follow-up. RESULTS: A total of 110 (44.9%) patients developed an infective process during the posttransplantation period, namely, 232 infective processes. Eighty patients developed at least 1 episode of urinary tract infection (UTI) 11 patients (4%) had a wound infection, and 30 patients (12%) had pneumonia. We diagnosed 35 cases of bacteremia (35%), whereas cytomegalovirus (CMV) infection was demonstrated in 40 patients (16%). CONCLUSIONS: Immunosuppressive therapy, necessary to avoid acute and chronic rejection, exposes patients to a higher rate of infectious complications. The immunosuppressive protocols led to a relatively low incidence of infectious complications, mainly of little clinical significance. The highest incidence was evident by the sixth month after transplantation, when the immunosuppressive regimen exercised its most depressive effects on patient immune systems.

New-onset diabetes mellitus after kidney transplantation: the role of immunosuppression.

BACKGROUND: Complications related to posttransplantation immunosuppressive therapy remain common. New-onset diabetes mellitus after transplantation (PTDM) is a well-recognized complication associated with reduced graft and patient survival. The type of immunosuppression may be responsible for more than two thirds of PTDM. We retrospectively reviewed our experience in a population of 284 kidney transplant recipients, evaluating the incidence of PTDM with regard to the type of immunosuppression. PATIENTS AND METHODS: From January 2001 to December 2005, 284 kidney transplantations were performed using tacrolimus-based (TAC) immunosuppression in 192 patients and a cyclosporine-based (CyA) regimen in 62 patients, whereas 30 patients received sirolimus-based immunosuppression. RESULTS: The overall incidence of PTDM was 4.9%. Among the immunosuppression protocols, 8 patients (4.1%) received TAC and 6 patients (9.6%) received CyA, whereas no patients treated with sirolimus developed PTDM. Graft and patient survival rates were 93% and 100%, respectively. CONCLUSIONS: The overall risk of PTDM with recent immunosuppressive protocols is low, but it is increased among calcineurin inhibitor (CNI)-treated kidney transplant recipients. Sirolimus did not increase the risk of PTDM, allowing potential clinical application in diabetic recipients and in patients affected by PTDM.

BMI and Heath-Carter somatotypes of female students in Ljubljana.

Measurements of 22 anthropometric and two spirometric variables were taken from 86 healthy female students of the University of Ljubljana who were not actively engaged in sports. The BMI and Heath-Carter somatotypes were calculated according to the anthropometric method. The average value of FEVC (Forced Expiratory Vital Capacity) amounted to 4.2 liters, and that of FEV 1 (Forced Expiratory Volume 1) to 3.7 liters and they exceeded the European standards for the corresponding age and height. Central and mesomorph-endomorph somatotypes predominated, and the majority of students were classified into the second group of BMI with a normal body weight. The values of FEVC, FEV 1 and the Tiffeneau index increased in line with the ectomorphic component. No differences in the average FEVC and FEV 1 were found between BMI groups. The Tiffeneau index increased from the third to the first group. It was concluded that the ventilation measures were higher in ectomorphic students, who actually exhaled values that exceeded the requirements of standards the least of all groups. Due to rare statistically significant differences in FEVC and FEV 1 between somatotypes and BMI groups it would be necessary to repeat the analysis on a larger sample. There also appeared to be a need for new Slovenian standards.

Somatopsychic correlates and quality of life of the dialyzed patient: a cross-sectional study.

BACKGROUND: The dialysis delivered after a chronic kidney disease (CDK) or any otherwise severe end-stage renal failure is a complex medical task, leading to major medical and psychopathological distress for the patient. The aim of the present study was to analyze the impact of the dialysis experience on the nephrologic patient's global quality of life. METHODS: In the present cross-sectional study, involving 96 patients with end-stage renal disease receiving hemodialysis, demographic, medical, and psychological differential features across different CDK diagnoses were accounted and were then correlated each other. RESULTS: Among other differential features, the "acknowledgement of dependence" (from the medical device delivering the dialysis) emerged as a factor correlated to "self-sufficiency" in CDK patients receiving hemodialysis. CONCLUSIONS: Although further, larger-sampled studies on the topic are needed, medical and psychological interventions are useful to ensure a better global quality of life and good therapeutic adherence in dialysis patients.

Role of "self-efficacy" in the process of long-term care in kidney transplant recipients.

OBJECTIVE: This study investigated the relationship between self-efficacy, quality of life, and psychic dimensions of patients with kidney transplants. Given the considerable emotional implications and the risk of psychopathology after transplantation, a protective role is assumed of the sense of self-efficacy, both from any psychopathologic disorders and from a precarious quality of life. METHODS: One hundred twenty recipients of kidney transplants from deceased donors were included in the study. The self-efficacy study was performed with the use of the General Self-Efficacy Scale. The quality of life of the subjects was studied with the use of the Short-Form Health Survey; The psychic symptoms of patients were performed using the Revised Symptom Checklist 90 (SCL-90R). RESULTS: Self-efficacy is positively correlated with both physical role limitations and mental health. With increasing self-efficacy there was a decrease of psychic symptoms as investigated with the use of the SCL-90R test. CONCLUSIONS: This study demonstrated the "protective" function of the sense of self-efficacy in the psychic sphere and its positive effect on quality of life, in the sense that an appropriate problem-solving strategy helps the transplant patient to maintain good mental and physical health.

The concept of self and emotional involvement in living kidney donation: a psychometric investigation.

OBJECTIVE: The aim of our study was to analyze, from a psychological point of view, living kidney donor personality, examining a sample of 18 living kidney donors. PATIENTS AND METHODS: The personality study was performed using The Millon Clinical Multiaxial Inventory-III in 18 potential kidney donors, 6 of whom were genetically and 12 emotionally related individuals. RESULTS: Our study showed the presence of narcissistic, histrionic, and obsessive-compulsive personality traits in living kidney donors. CONCLUSIONS: It is necessary to explore the development of motivation for living donation in order to achieve and maintain a harmonious relationship with the recipient while respecting their individuality.

The study of personality in renal transplant patients: possible predictor of an adequate social adaptation?

BACKGROUND: This study explored the personality characteristic traits within a sample of renal transplant patients, seeking to obtain predictive index for likely clinical impacts. PATIENTS AND METHODS: The personality study was performed using the Structured Clinical Interview Axis II Personality Disorders for Diagnostic and Statistical Manual of Mental Disorders fourth edition, text revision in 60 recipients of kidney transplantations from deceased donors. RESULTS: The personality trait that prevailed in the female gender was borderline, while in the male gender it appeared to be predominantly obsessive-compulsive personality trait. CONCLUSIONS: The personality study proved to be a good index to predict effects on the level of social adjustment. In this way, patients who have shown pathologic personality traits can be identified early to provide adequate psychologic-psychiatric support and follow-up.

Predictive value of the Charlson comorbidity index in kidney transplantation.

BACKGROUND: Nonimmunologic factors have been recently implicated in worse outcomes after kidney transplantation, producing a need to predict the operative risk among kidney recipients. We assessed the predictive value of the Charlson comorbidity index (CCI) among kidney transplant recipients. METHODS: A retrospective study of 223 first deceased-donor kidney transplantations performed from 2000 to 2007 evaluated the role of comorbidities. RESULTS: About 50% of recipients displayed >1 comorbid condition before transplantation; the most frequently reported was diabetes mellitus. Increasing CCI scores significantly affected graft and patient survivals. Crude analysis showed a significant association between CCI >1 and risk of death (hazard ratio [HR], 3.87; 95% confidence interval [CI], 1.06-14.06; P = .04). After adjustment for several covariates, high CCI values remained significantly predictive of posttransplantation outcomes with a HR for death of (12.53; 95% CI, 1.9-82.68; P = .009). CONCLUSIONS: Our predictive model showed a strong association of CCI and patient survival even after adjustment for several clinical covariates. CCI may be used to evaluate patients referred for kidney transplantation who display a significant burden of comorbid conditions that increase the risk of premature death or graft loss.

The role of obesity in kidney transplantation outcome.

BACKGROUND: The number of obese kidney transplant candidates has been growing. However, there are conflicting results regarding to the effect of obesity on kidney transplantation outcome. The aim of this study was to investigate the association between the body mass index (BMI) and graft survival by using continuous versus categoric BMI values as an independent risk factor in renal transplantation. METHODS: We retrospectively reviewed 376 kidney transplant recipients to evaluate graft and patient survivals between normal-weight, overweight, and obese patients at the time of transplantation, considering BMI as a categoric variable. RESULTS: Obese patients were more likely to be male and older than normal-weight recipients (P = .021; P = .002; respectively). Graft loss was significantly higher among obese compared with nonobese recipients. Obese patients displayed significantly lower survival compared with nonobese subjects at 1 year (76.9% vs 35.3%; P = .024) and 3 years (46.2% vs 11.8%; P = .035). CONCLUSIONS: Obesity may represent an independent risk factor for graft loss and patient death. Careful patient selection with pretransplantation weight reduction is mandatory to reduce the rate of early posttransplantation complications and to improve long-term outcomes.

Delayed graft function and long-term outcome in kidney transplantation.

BACKGROUND: There are still many controversies about the impact of delayed graft function (DGF) on kidney transplantation outcome. The aims of this study were to define factors associated with DGF and to ascertain the relative impact of DGF on kidney transplantation outcome, both in the early postoperative period and in long-term follow-up. PATIENTS AND METHODS: Four hundred kidney transplant recipients were reviewed to assess the clinical impact of DGF on long-term outcome. RESULTS: The overall prevalence of DGF was 24.3%. DGF was significantly associated with increasing recipient and donor age, duration of dialysis, and cold ischemia time. Patients with DGF displayed a significantly worse graft (P = .005) and patient (P < .001) survival compared with recipients with immediate function. CONCLUSION: DGF is a frequent complication of renal transplantation and may be associated with a reduced graft and even patient survival. Strategies to prevent graft injury and, more specifically, DGF may be an important clue to provide a better long-term outcome in kidney transplantation.

Magnetic resonance with diffusion-weighted imaging in the evaluation of transplanted kidneys: updating results in 35 patients.

BACKGROUND: We compared values of apparent diffusion coefficient (ADC) with renal function indices among a population of kidney transplant recipients who underwent magnetic resonance with diffusion-weighted imaging (DWI) of their grafts. MATERIALS AND METHODS: Thirty-five patients with right iliac transplanted kidneys were studied using 1.5-T magnetic resonance. Diffusion echo-planar sequences with several b-values were acquired to investigate transplanted grafts. Patients were divided into 3 groups according to their creatinine clearances; Group A, clearance >60 mL/min; Group B, clearance >30 and ≤60 mL/min; and Group C, clearance ≤30 mL/min. ADC values between groups were compared using Mann-Whitney U test. Receiver operating characteristic (ROC) curves were used to predict the normal function (Group A) versus renal failure cohorts (Group C). RESULTS: Comparing mean values of ADC between Group A and Group C patients, we observed a significant difference (P = .0003) with higher ADC values among patients with a normal creatinine clearance (>60 mL/min). Comparing Groups B and C did not show a significant difference (P = .05); nor did Group A and Group B reveal a significant difference (P = .38). To predict normal clearance values, the Group A ROC curve showed an area under curve (AUC) of 0.780 with a sensitivity of 92.3% and a specificity of 68.2% at a threshold ADC value of ≥2.08 × 10(-3) mm(2)/sec. In the prediction of low clearance values, the Group C ROC curve showed an AUC of 0.846 with a sensitivity of 83.3% and a specificity of 82.6% using a threshold ADC value of ≤2.07 × 10(-3) mm(2)/sec. CONCLUSIONS: Updating our experience among 35 patients, DWI was confirmed to be a promising noninvasive tool to assess renal function; an ADC ≥2.08 × 10(-3) mm(2)/sec may be used as a threshold to predict a normal clearance. However, an overlap of ADC values between groups is a limit.

Correlational study between psychic symptoms and quality of life among hemodialysis patients older than 55 years of age.

BACKGROUND: The loss of renal function and urination with dialysis can produce a strong emotional crisis in a patient. This study explored the correlation between psychic symptoms and quality of life among hemodialysis patients who were older than 55 years of age in relation to demographic characteristics of age, time on dialysis, and education. PATIENTS AND METHODS: Twenty patients undergoing hemodialysis were included in the study. The psychic symptoms were studied using the Symptom Checklist-90. Revised (SCL-90 R) and the quality of life was studied using the Complete Form Health Survey (SF 36). RESULTS: The high correlation between psychological sizes investigated through the SCL-90 R test and those for the SF-36 test confirmed the close relationship between physical disorders and mental suffering, and reduced vitality, and lack of socialization. CONCLUSION: The psychiatrist and psychologist may help hemodialysis patients to improve their quality of life by providing new coping strategies for each of the family, occupational, and social network.

Magnetic resonance with diffusion-weighted imaging in the evaluation of transplanted kidneys: preliminary findings.

BACKGROUND: The aim of this study was to compare values of apparent diffusion coefficient (ADC) and diffusion (D) with renal function indexes, in a population of kidney transplant recipients who underwent magnetic resonance with diffusion-weighted imaging (DWI) of the transplanted graft. MATERIALS AND METHODS: We studied 21 patients using a 1.5-Tesla magnetic resonance; DWI sequences were acquired with several b-values. Patients were divided into 3 groups by their creatinine clearance values: group A, clearance >60 mL/min; group B, clearance >30 and ≤60 mL/min; and group C, clearance ≤30 mL/min. ADCs values between groups were compared using the Mann-Whitney U test. Receiver operating characteristic (ROC) curves were created for prediction of normal renal function (group A) and renal failure (group C). RESULTS: Comparing mean values of ADC between groups A and C, we observed a difference (P=0.0012), with higher values in group A. Regarding mean values of D, we observed a difference between groups A and C (P=0.022). In the comparison between contiguous groups, we observed no difference for ADC and D values. In the prediction of normal clearance values (group A), ROC curve showed an area under curve (AUC) of 0.861, with a sensitivity of 88.89% and specificity of 75% using a threshold ADC value ≥2.1 × 10(-3) mm(2)/sec. For prediction of normal clearance values (group A), ROC curve showed an AUC of 0.787, with a sensitivity of 77.8% and specificity of 83.3% using a threshold D value ≥2.3 × 10(-3) mm(2)/sec. CONCLUSION: Although studies with a larger number of patients are needed, DWI represents a promising tool for noninvasive assessment of renal function. An ADC ≥ 2.1 × 10(-3) mm(2)/sec and a D ≥ 2.3 × 10(-3) mm(2)/sec may be used as a threshold for predicting normal clearance.

Quality of life in kidney transplantation from marginal donors.

OBJECTIVE: Enhancement of the subjective components, recognition of overall needs, and careful consideration of subjectively perceived quality of life among dialysis and/or transplanted patients appear to be key objectives to promote optimized adherence to treatment and active cooperation of the patient. This study explores the relationship between self-rated health among recipients of kidney transplantations from deceased marginal donors (age older than 55 years) in relation to gender, age, time on dialysis, years after transplantation, and donor age. PATIENTS AND METHODS: Posttransplant quality of life was assessed with the Complete Form Health Survey (SF-36) in 70 recipients of kidney transplantations from marginal deceased donors. RESULTS: Donor age did not negatively influence health status perceived by the subjects. The vitality and mental health seemed to increase with greater donor ages, but the status of perceived health, vitality, social activities, and mental health were negatively influenced by the age of the transplant. CONCLUSIONS: Our study shows that good general health and social well-functioning can be achieved also among recipients of organs from older donors. Thus, age alone should not be a barrier to organ donation, providing that the organ function is normal and that specific disease is absent in the organ.

Body image in kidney transplantation.

INTRODUCTION: Psychologic disturbances are becoming more common in kidney transplantation, owing to effects of immunosuppressive therapy. In this study, we explored the incidence and specifity of psychopathology among kidney transplant patients. Twenty kidney transplant recipients underwent the Machover Draw-A-person test to detect significant variables (V1=V6) hypothetically related to chronologic age, education, years from transplantation, and gender differences. Emotional coarctation (V1) in the sense of "mental rigidity," "egocentrism," and "hypercontrol" were present in all transplant recipients (100%), followed by difficulty in interpersonal relationships (V3; 70%) and anxiety (V5; 70%). This research confirmed the hypothesis that transplantation can display a potential risk to the psychologic balance of the patient. Psychologic evaluation may be a fundamental step together with surgical aspects and management of immunosuppression to achieve well-being of kidney transplant recipients.

Contamination of preservation fluid in kidney transplantation: single-center analysis.

INTRODUCTION: Contamination of preservation fluid is common, with a reported incidence of 2.2% to 28.0%, and may be a major cause of early morbidity after transplantation. Herein, we report our experience with routine examination of preservation fluid collected just before implantation, focusing on the rate of contamination and the clinical consequences to recipients. MATERIALS AND METHODS: We analyzed 62 samples of preservation fluid for microbial and fungal contamination. RESULTS: Twenty-four samples (38.7%) were contaminated with at least 1 organism. Bacterial contamination alone was observed in 18 samples; all patients received prophylactic treatment with intravenous piperacillin/tazobactam, 4.5 g/d for 10 days, without clinical sequelae. Six samples were contaminated with Candida species; all patients received prophylactic treatment with fluconazole, 100 mg/d for 3 months. One patient developed reversible acute renal failure due to ureteral obstruction by fungus balls at 30 days after transplantation. CONCLUSION: Contamination of preservation fluid occurs frequently after kidney transplantation. Bacterial contamination evolved without symptoms in most patients treated with prophylactic antibiotic therapy. Fungal contamination may be potentially life-threatening. However, graft nephrectomy is not mandatory if the involved Candida species is identified correctly and appropriate antifungal therapy is rapidly prescribed.