Dialysis after kidney transplant failure: do patients start in a worse condition than the general population with chronic kidney disease?

BACKGROUND: Patients with renal graft dysfunction constitute an increasingly prevalent group of end-stage kidney disease (ESKD) patients that require dialysis therapy. These patients have special characteristics that set them apart from the ESKD general population. The aim of this study was to analyse the clinical condition and evolution of patients entering dialysis with a failed kidney graft at the time of restarting dialysis and over a year of therapy according to the K/DOQI guidelines, and to compare them with incidental patients with end-stage kidney disease. We also investigated whether the modality of kidney replacement therapy may determine the clinical improvement of transplant patients. MATERIAL AND METHOD: This is a retrospective observational study of 106 patients with ESKD followed up in the Ramon y Cajal Hospital. They were classified in two groups. Group one was made up of 50 failed native kidney patients who started dialysis between 2000 and 2009. Group two was comprised of 56 transplant patients with graft dysfunction who returned to dialysis between 1997 and 2009. We studied parameters of kidney function, anaemia, calcium-phosphorus metabolism, cardiovascular risk factors and nutritional status at the time both groups started on dialysis and one year later. RESULTS: Both groups had a similar clinical status at the time they started on dialysis in most of the parameters analysed with the exception of anaemia. This was more severe in transplant patients, despite the fact that transplant patients received a higher dose of erythropoietin than non-transplant patients. One year later the main difference between both groups was the residual kidney function rate, higher in non-transplant patients. There were no significant differences in the parameters analysed in patients with a failed graft according to the modality of kidney replacement therapy. CONCLUSION: Failed transplant patients start dialysis with more severe anaemia than patients entering dialysis for the first time. Twelve months later both groups present a similar clinical condition with the exception of residual kidney function, higher in failed native kidney patients. The method of dialysis treatment after kidney transplant failure did not have a bearing on the clinical improvement of our patients.

[Outcome of HIV-infected patients of peritoneal dialysis: experience in a center and literature review]. / Evolución de los pacientes infectados por el VIH en diálisis peritoneal: experiencia de un centro y revisión de la literatura.

Overall survival of HIV-infected has increased over the last ten years. In parallel a higher need for renal replacement therapy (RRT) in this population has been more observed. RRT associated complications and outcomes greatly varied since the introduction of highly active antiretroviral therapy (HAART) and scarce data is available regarding the outcome of peritoneal dialysis (PD) in HIV-infected patients under HAART. We described 8 HIV-infected patients who were admitted at the Peritoneal Dialysis Unit at our institution from November-95 to November-07. Mean age was 40.7 +/- 5.3. Causes of end-stage renal disease were diabetes mellitus type 1 (2), focal and segmental glomerular sclerosis (2), IgA nephropathy (1) and unknown origin (3). High blood pressure was detected in 62,5% of the patients. Mean follow-up was 41.2 +/- 32.1 months (range 12-103). One, two and three year survival was 100, 62.5 and 50% respectively. Overall mortality was 62.5% and cardio-vascular events were the main cause of death (2 patients, 25%). Infective peritonitis rate was 0.36 IP/year, and Staphylococcus epidermidis was the most common pathogen identified. Hospital admission rate was 0.69 admission/year and the main cause of admission was respiratory tract infection. All patients received HAART. Lamivudine, stavudine and nelfinavir were the most frequent treatment prescribed. During the first year in PD undetectable viral load and CD4 % were not modified. A significant weight gain was observed during the first year of the study (60.6 kg. vs 64.9 kg. p > or = 0.016). Our results suggest that PD is a suitable choice for RRT in HIV-infected. Compared to previous studies, an increase in overall survival and a decrease in PD-associated complications were seen. The significance of cardio-vascular risk factors in the outcome of PD in HIV-infected patients is not completely determined. A multidisciplinary approach and a management of patients in individual basis remains mandatory.

[Immune response during laparoscopic and open living donor nephrectomy. An experimental pig model]. / Respuesta inmunohumoral durante la nefrectomía abierta y laparoscópica de donante vivo. Modelo porcino experimental.

INTRODUCTION: It's been demonstrated laparoscopic access determines a lower surgical stress, by measurement of several markers as different interleuquines (IL) or C-reactive protein (CRP). Endothelin 1 (ET-1) is a powerful vasoconstrictor produced in renal endothelium scarcely studied in laparoscopy. The objective of this study is to analyze immune response during laparoscopic and open donor nephrectomy, in a porcine experimental model by means of measuring IL-2, 10, tumoral necrosis factor alpha (TNFalpha), CRP and ET-1. METHODS: Twenty pigs underwent left nephrectomy, 10 by laparoscopy and 10 by open approach in an experimental model. Both groups were monitorized IL-2, 10, TNF alpha, ET-1 at basal, immediately post surgery, first, third, fifth and seventh days after procedure. RESULTS: The comparative analysis between groups demonstrated a significant increase in levels of CRP (1.44+/-0.88 vs 1.32+/-0.14 mg/dl, p=0.046), TNF alpha (131.14+/-41.37 vs 57.19+/-23.71 pg/ml, p>0.001) and ET-1 (0.91+/-0.49 vs 0.56+/-0.5 fmol/ml, p=0.001) of open nephrectomy group, as a higher levels of IL-2 in laparoscopic group. CONCLUSIONS: Open donor nephrectomy determines a higher immune response than laparoscopic approach. The importance of this fact over the ischemia-reperfusion syndrome or the immediate function of graft is not clearly established.

[Experimental models for research and training in renal transplant]. / Modelos experimentales para la investigación y el entrenamiento en trasplante renal.

An update on aspects and use of different experimental models applied in kidney transplant research is presented . This paper includes qualities, as long as similarities between most frequently used animal models and human clinical standards. Contributions of those models based on microsurgical or laparoscopic techniques are revised. The physiological consequences (hemodynamic, immunologic) of surgical technique (laparoscopy), applied in experimental models as long as non-heart beating organ donor models and organ preservation methods are also reviewed. Finally, an update of those models applied in research in prothocols of either immunosupression or xenotransplant is done.

[Experimental pancreatic islet transplant into the genito-urinary tract simultaneous to kidney transplant]. / Trasplante experimental de islotes de pancreas en el tracto genitourinario asociado al trasplante renal.

INTRODUCTION AND OBJECTIVES: Simultaneous kidney and pancreas transplant is a good treatment for both renal and pancreas insufficiency. Experimental apply of genitourinary tract for pancreas implantation is reported in this work. MATERIAL AND METHOD: Twenty animals aged as average 5.5 monts (SD 1.1) and an average weight of 53 kgr were submitted to this protocol. In the day 1 a left nephrectomy is completed and the graft is perfused with University of Wisconsin solution. A partial pancreatectomy is completed at following, isolation of pancreatic islets by colagenase enzymatic digestion. Islets are dryed with Ditizone and culptured for 24 hours at 37 degrees C and 5% CO2. Day-2 a right nephrectomy is performed and orthotopic renal autotransplant using the left kidney is completed. Pancreatic islets are transplanted in 4 different locations of the genitourinary tract: renal subcapsular space, bladder submucosae, testis parenchyma and vas deferens. Day-7, all the animals were sacrifized to complete pathological study. RESULTS AND CONCLUSIONS: Viable islets were isolated in bladder submucosae and testis after transdeferential injection.

[Comparative analysis of renal graft function after open vs. laparoscopic nephrectomy: experimental model]. / Análisis comparativo de la función del injerto renal de donante vivo tras nefrectomía abierta y laparoscópica: modelo experimental.

INTRODUCTION: Living donor renal transplant reports a higher patient and graft survival in comparison to cadaver donor and represents a good alternative facing the current lack of organs for transplant. GOALS: To analyze comparatively in an experimental model (pig) the influence of ischemia-reperfusion and functional outcome of renal graft retrieved by open Vs laparoscopic nephrectomy. MATERIAL AND METHODS: 30 lab pigs were nephrectomized (left kidney): 15 by laparoscopy and 15 by open surgery, as living donors, in a model of renal autotransplant. Renal blood flow (RBF) was measured by means of an electromagnetic probe and creatinine levels during the first week after the implant. RESULTS: Comparative analysis of RBF during the immediate 60 min after unclamping showed a significant reduction of average RBF in laparoscopic group in comparison to open group (p < 0.001), with a more evident reduction of RBF in the laparoscopic group during the 5-min period after unclamping (p < 0.001) and a progressive recuperation of RBF during the 1st hour, slowest in laparoscopic group. Creatinine levels in the first week after the transplant decreased progressively from 1.3 to 0.8 mgrs/dl in the open group and from 2 to 1.1 mg/dl in laparoscopic group (p < 0.001). CONCLUSIONS: Renal grafts retrieved by laparoscopy presents a more evident ischemia-reperfusion syndrome shown by a lower average RBF after unclamping and a significant deterioration of renal function during the first week after transplant.

[Modification of the hemodynamic parameters and peripheral vascular flow in a porcine experimental of model of laparoscopic nephrectomy]. / Modificaciones de los parámetros hemodinámicos y de los distintos flujos vasculares periféricos en modelo experimental porcino de nefrectomía laparoscópica.

OBJECTIVES: It has been demonstrated that abdominal high-pressure and the use of CO2 pneumoperitoneum induce changes of the cardiovascular and respiratory systems, attributable to two factors: changes of the cardiac output (CO) and hypercarbia. Other modifications derived from these facts include changes of the systemic vascular resistances (SVR), blood pressure (BP), central venous pressure (CVP), vascular changes like modifications of the renal blood flow (RBF), carotid flow (CF), portal flow, and hepatic artery flow (HAF). Our objective is to analyze the hemodynamic modifications induced by pneumoperitoneum on renal blood flow, carotid flow, portal flow and hepatic artery flow in a porcine experimental model. METHODS: We compared two groups of pigs: CONTROL group (n = 10) and LAPAROSCOPIC group (n = 10), undergoing open or laparoscopic nephrectomy respectively. In every case, catheters were inserted into the right external jugular vein and femoral artery and cardiac output, CVP, blood pressure and systemic vascular resistances (calculated as RVS = (BP/CVP)x 80/CO); these measurements were taken at the following times: baseline, 5, 30, 60 min. and postoperatively. Renal blood flow, carotid flow, portal flow and hepatic artery flow were registered by means of an electromagnetic probe around the vessel 30 minutes after the start of surgery. RESULTS: Comparative analysis shows: an increase of cardiac output in the laparoscopic group, the difference which was maximal at 30 minutes (4.33 + 0.73 vs. 8 .54 + 1.26 l/min., p < 0.,001); a descent of the systemic vascular resistances (1118.81 + 302.52 vs. 663.37 + 81.45 dynes .s.cm5, p < 0.001) and an increase of blood pressure (66.5 + 11.52 vs. 80.25 + 2.49 mm Hg in the laparoscopic group. Flow analysis showed an increase of the carotid artery flow (125.73 + 41.69 vs. 291.7 + 51.52 ml/min., p < 0.001) and a decrease of portal flow (973.67 + 131.70 vs. 546.83 + 217.53 ml/min., p = 0.001) and hepatic artery flow (278.00 + 94.71 vs. 133.33 + 112.32 ml/min., p = 0.03) in the laparoscopic group. There were no significant differences in renal blood flow with the volume expansion used. CONCLUSIONS: Laparoscopic nephrectomy conditions an increase of carotid flow, probably secondary to the increase of cardiac output, and also a diminishment of hepatic perfusion, both arterial and portal. Nevertheless, volume expansion and the limitation of intra-abdominal pressure to 12 mm Hg enable to maintain similar renal blood flow in both groups.

[Comparative analysis about hemodynamic and renal blood flow effects during open versus laparoscopic nephrectomy. An experimental study]. / Análisis comparativo de las modificaciones hemodinámicas y del flujo sanguineo renal (FSR) durante la nefrectomía abierta y laparoscópica. Modelo experimental.

BACKGROUND: The increase of intraabdominal pressure to 10 mmHg provokes a decrease of renal blood flow (RBF). Pneumoperitoneum during laparoscopic techniques with intra-abdominal pressure (IAP) to 15 mmHg, results in a decrease in RBF, urine output and glomerular filtration rate (GFR). PURPOSE: Analyze the changes in RBF, urine output an GFR in a porcine experimental model during open vs laparoscopic nephrectomy. MATERIALS AND METHODS: 30 pigs (medium weigh= 22.6+3.2 Kg) were divided into two groups: Laparoscopic nephrectomy was performed using 15 pigs and open nephrectomy in 15 pigs, following a living donor nephrectomy autotransplantation model. Study parameters were urine volume and GFR baseline values, 30 and 60 minutes during nephrectomy. RBF was measured using an electromagnetic flow catheter around the main renal artery during the initial 60 minutes of nephrectomy. RESULTS: The laparoscopic technique was associated with a significant reduction of RBF (80+2.7 vs 262+3 ml/min) (p<0.005), diuresis (42%) and GFR (38%), vs the open group. CONCLUSIONS: Laparoscopic nephrectomy involves a significant reduction of RBF, GFR and diuresis, which is potentially transcendent in living donor nephrectomy and kidney transplantation.

[Extra-anatomic urinary diversion by subcutaneous catheter]. / Derivación urinaria extra-anatómica mediante catéter subcutáneo.

Percutaneous nephrostomy has been one of most used palliative method of urinary diversion to treat cronic renal failure in neoplasic patients. Psychological and social factors meke this measure to be rejected by some patients even sin situations where this is the only action that would make their survival longer. The utilization of ureteral stents provides benefits to a certain percentage of patients, not being possible its usage in all the occassions. Urinary subcutaneous diversion can be a simple and well tolerated alternative for the patient. The following clinic case describes and approach implementing a subcutaneous stent in a 60-y-old male with a severe ureteric obstruction after failed management by endoscopy or open surgery.

[Celsior's kidney preservation in renal transplantation. Our experience]. / Preservación con Celsior en trasplante renal. Nuestra experiencia.

BACKGROUND: The goal of this research is to make a comparative analysis of acute tubular necrosis (NTA) incidence in function of preservation solution used: Wisconsin vs Celsior. METHODS: From January 1994 to December 2002, 229 kidney transplantation procedures were executed; 190 of them were perfused with Wisconsin (82.9%) and 39 with Celsior (17.1%). After checking the statistical homogeneity of both groups, we analysis comparatively the incidence of NTA and the evolution of serum creatinine in function of preservation solution utilized. RESULTS: There was not statistical significant difference in NTA incidence between Celsior (23%) and Wisconsin group (36%). We assessed that each group were comparable with regard to NTA incidence of subgroups with cold ischemia times longer 12 hours. Creatinine serum in Celsior group tended to be lower than Wisconsin group at 1, 3, 6 and 12 months posttransplantation (statistically significant difference, p<0.05) CONCLUSIONS: Kidney preservation in Celsior solution provides similar results to the ones obtained in Wisconsin solution in relation with NTA incidence and kidney function with the added advantage of a lower cost.

[Ureteral stenosis after kidney transplantation: treatment with a self-expanding metal prosthesis]. / Estenosis ureteral post-transplante renal: tratamiento con prótesis metálica autoexpandible.

OBJECTIVE: To determinate the efficacy in the treatment of ureteral estenoses after renal transplantation with metallic self-expandable stent. MATERIALS AND METHODS: From october of 1995 to april of 2002, 8 ureteral obstruction post renal transplantation have treated by means of implants of a metallic self-expandable stent (6 men and 2 women). The average time of pursuit was of 30 months (rank 2-53 months). In this work the severity and location of the estenosis are analysed, the method of implant of the stent, the permeability of the same one, the levels of creatinine pre and postimplant and the complications derived from the same one. RESULTS: The treatment was effective in the 100% of the patients (8/8), with an average reduction of the creatinine of 36% (rank 13.6%-59.6%). The complications were minimum and the hospital stay was short. CONCLUSIONS: In the patients with: chronic deterioration of the graft with short functional expectation, patient with high surgical risk and reestenosis after ureteral reimplantation by previous ureteral estenosis, the use of a metallic self-expandable stent, constitutes technique of election given its efficacy and low associate morbidity.

[Comparative study of ureteral anastomosis with or without double-J catheterization in renal transplantation]. / Estudio comparativo entre anastomosis ureteral con o sin cateterización con doble j en trasplante renal.

OBJECTIVE: To analyze the impact of the use of the routine double-J stent in the incidence of urological complications, like fistula, stenosis, ureteral obstruction and urinary tract infection. METHODS: A retrospective study was conducted on two groups of patients: 28 without double-J stent and 28 with it. We reviewed urological complications: stenosis, fistula and obstruction. We paid special attention to urinary tract infection and other inherents complications to the use of double-J stents. RESULTS: A patient from the double-J stended group (3.6%) developed a urinary fistula and there were no obstructions. 13 patients (46.6%) had a positive urinary culture in the first month post RT. Two urinary fistulas and 4 obstructions were developed in the non-stended group. Six major complications of the urinary tract. 14 patients (50%) had a positive urinary culture in the first month post RT. CONCLUSIONS: The use of double-J stent across uterovesical anastomosis decreases the post-RT ureteral complications. Stent placement does not increase the risk of urinary tract infection in the early post-RT.

[Renal transplantation and urinary infection. Review]. / Trasplante renal e infección urinaria. Revisión.

Urinary infection (UTI) is the most frequent infection after renal transplantation (RT). The literature shows and incidence between 10-98%. The risk of associated bacteraemia is close to 12%. Gram- bacteria are the most frequent causal agents (70%), although gram+, mainly enterococcus and staphylococcus, candida and some other exotic germs such as Corynebacterium are also potential etiological agents. Certain factors present in the receptor during pre-RT, RT itself and post-RT condition the development and evolution of UTIs. Clinical signs and symptoms are multiple ranging from asymptomatic bacteriuria to graft's abscess or septic shock. Incidence in females (54%) is higher than in males (29%). Immunosuppressive regimes based on Cyclosporin (35%) show lower incidence of UTI than those based in Azathioprine (50%). Antibiotic prophylaxis with Co-trimoxazol reduces incidence of UTIs at post-RT and delays the time of appearance of the first UTI episode.

[Neoplasm prevalence in renal transplantation]. / Prevalencia de neoplasias en el trasplante renal.

OBJECTIVE: To analyze the prevalence of neoplasms in renal transplant patients and the relative risk for each tumor type according to the immunosuppression regimen. METHODS: 609 renal transplants were reviewed. The risk index was determined by the ratio of the cases observed and predicted. RESULTS: Tumor prevalence was 4.9% (30/609); 6.3% (25/393) were males and 2.3% (5/216) were females. The most common tumors were cutaneous tumors other than melanoma, accounting for 2.4% (15/609), followed by Kaposi's sarcoma, pulmonary epidermoid carcinoma and genitourinary tumors (0.5%) and non-Hodgkin lymphoma (0.3%). Tumor prevalence was 6.8% for the group treated with azathioprine-prednisone and 3.9% for the cyclosporine A-prednisone-treated group. The estimated relative risk of having a neoplasm was 10-fold higher for the males and 4.2-fold higher for the females vs the general population. The mortality rate was 36.6%; specifically tumor-related in 82%. The mortality rate for those with solid tumors was 77.7%. The long-term survival rate for the group that developed a tumor was significantly lower than that of the general population, 75% vs 53%, respectively (p < 0.05). CONCLUSION: In this series no significant differences were observed relative to tumor prevalence or type according to the immunosuppression regimen. A recipient of a renal graft has a higher risk of developing a tumor. Cutaneous tumors were the most frequent. The long-term survival is lower for recipients of renal grafts who develop a tumor.

[Assessment of arterial hypertension associated with renal transplantation using Doppler ultrasonography]. / Evaluación mediante eco-Doppler de la hipertensión arterial asociada al trasplante renal.

OBJECTIVES: The incidence of arterial hypertension post-renal transplantation has been reported to be 48.6%. The present study investigated the usefulness of echo Doppler in detecting renal artery stenosis and the effects of arterial pressure control and hypotensive agents on the vascular resistance of the renal graft. METHODS: A total of 234 echo Doppler studies were done in 110 patients. The pulsatility index (PI), resistance index (RI), acceleration and mean velocity (MV), maximum systolic (SVMX) and minimum diastolic (DVMN) velocities of the external iliac, renal, segmental, interlobar and arcuate arteries were determined. RESULTS: In the stenotic segment, an elevation of SVMX was observed, followed by turbulent flow in the post-stenotic segment in 73% of the cases with arterial stenosis. The hypertensive patients had a higher external iliac artery RI than the normotensives. The beta-blockers reduced the RI in large vessels (external iliac), the vasodilators in medium-sized extraparenchymal vessels (segmental) and the calcium antagonists changed the PI in the smaller caliber intraparenchymal vessels (interlobar and arcuate). CONCLUSIONS: Evaluation by echo Doppler is the first diagnostic approach in patients suspected as having arterial stenosis of the renal graft. It permits evaluating blood flow changes from hypertension and hypotensive agents.

[Nephrectomy of the transplanted kidney]. / Trasplantectomía del injerto renal.

A total of 118 allograft nephrectomies (TX) were performed after 474 renal transplants (TR) (24.9%). 49.1% of the patients were immunosuppressed with azathioprine-prednisone (AZA-PRED) and 50.9% with cyclosporine-prednisone (CSA-PRED). Mean time to TX after returning to hemodialysis was 36.2 +/- 6.4 days (0-372). Acute rejection (33.1%) was the first cause of TX, followed by chronic rejection (26.3%), vascular complications (25.5%), recurrent renal disease (5.9%), non-functioning allograft (4.2%) and not clearly established cause (1.7%). The surgical technique was extracapsular in 70.3% of the cases and subcapsular in 29.7%. The mean post-TR time to TX was significantly greater (p < 0.01) for the subcapsular technique. The mean surgical time was 106 +/- 4.4 min (45-300). Post-TX morbidity was 34%. Hemorrhage (11.2%) was the most frequent complication. The rest of the complications were infection (10.4%), neurologic (5.4%), gastrointestinal (4.5%), pulmonary (3.6%), cardiovascular (2.7%), nerve lesions (2.7%), lymphocele (0.9%) and urinary fistula (0.9%). The post-TX mortality was 6.5% (7/118), although it was significantly lower in the patients immunosuppressed with CSA-PRED (1.6%) than in those treated with AZA-PRED (10.3%).

[Diagnostic yield of the urodynamic study of the upper urinary tract in the orthotopic and transplanted kidney]. / Rentabilidad diagnóstica del estudio urodinámico del tracto urinario superior, en el riñón ortotópico y trasplantado.

Urodynamic pressure-flow studies (Whitaker test) of 28 kidneys (21 orthotopic and 7 transplanted) with equivocal obstruction of the upper urinary tract (UUT) yielded a sensitivity rate of 77.7% and a specificity rate of 75% in the orthotopic kidney, and sensitivity and specificity rates of 75% in the transplanted kidney. Trauma to the transplanted kidney (denervation, ischemia and surgery) does not modify the urodynamic of the pyelocaliceal system, thus conferring on the test the same diagnostic reliability as in the orthotopic kidney.

[Rupture of the graft in kidney transplant. Our caseload]. / Rotura del injerto en el trasplante renal. Nuestra casuística.

316 kidney transplants were carried out in the Ramón y Cajal Hospital between November 1979 and December 1988. The number of breakages was 7. In this paper we analyse the incidence of this complication as well as the etiopathogeny of the process, highlighting the relationship between the appearance of acute rejection, alterations in coagulation, and instrumental manoeuvres carried out on the graft, especially in the first days after transplant. The clinical pattern usually displayed was pain with swelling and pasting in the area of the implant, along with hypotension, oliguria and deterioration of kidney function. We underline the importance of echography as the follow-up method in the early detection of hematomas, perirenal collections, etc., which, together with the preceding clinical data, will orientate us towards an early diagnosis. We study the possible relationship of this complication with different factors, singling out the reduced frequency of appearance after the advent of cyclosporin and its use as an immunosuppressive drug. We advocate the conservation of the implant with three dimensional corsseting, provided this is feasible and the general conditions of the patient so permit.