Prediabetes is a risk factor for cardiovascular disease following renal transplantation.

Prediabetes and post-transplant diabetes mellitus affect about 20-30% of renal transplant patients. The latter is a risk factor for cardiovascular disease. However, no clear evidence linking prediabetes and cardiovascular disease is available. To study this we analyzed the impact of prediabetes on cardiovascular disease in 603 renal transplant patients followed with repeated oral glucose tests for up to five years and a long term survival evaluation. Prediabetes and post-transplant diabetes mellitus were defined at 12 months after transplantation to avoid their high reversibility rate before this period. 73 cardiovascular events were observed. The incidence of events was significantly higher in patients with either prediabetes, (17%; 0.023 person/year) or post-transplant diabetes mellitus (20%; 0.028 person/year) than in normal individuals, (7%; 0.0095 person/year). The incidence of events was comparable between prediabetes and post-transplant diabetes mellitus. Prediabetes at 12 months was a risk factor for cardiovascular events in univariate and multivariate Cox survival analyses (hazard ratio 2.24, 95% confidence interval 1.11-4.52). Prediabetes at three months and hemoglobin A1c at 12 months were not significantly associated with cardiovascular disease. Thus, prediabetes is a risk factor for cardiovascular disease in renal transplantation, a population at high risk for cardiovascular events. Since prediabetes is potentially a reversible condition, there is an opportunity to prevent cardiovascular disease in this population.

Role of prostacyclin (epoprostenol) as anticoagulant in continuous renal replacement therapies: efficacy, security and cost analysis.

BACKGROUND: Heparin remains the drug most commonly used for anticoagulation in continuous renal replacement therapies (CRRTs). However, in patients with hypercoagulability, heparin is insufficient or, in cases with an increased risk of bleeding or thrombocytopenia, it may be contraindicated. Epoprostenol, a potent vasodilator, antithrombotic and antiplatelet agent, could be an alternative. PATIENTS AND METHODS: We studied the records of patients treated under continuous venovenous hemodiafiltration in an academic tertiary hospital of 900 beds, between January 2000 and June 2003. Epoprostenol was prescribed to patients with (i) filter hypercoagulability, defined as consumption of 2 or more filters in the last 24 hours; (ii) low platelet count; or (iii) recent severe hemorrhage. RESULTS: Thirty-eight out of 248 (15%) patients who were under CRRT received epoprostenol for more than 72 hours. Epoprostenol was indicated due to filter hypercoagulability in 48%, thrombocytopenia in 68% (7 patients both) and hemorrhage in 3% of cases. The overall time for epoprostenol therapy was 9,749 hours. The mean filter duration previous to epoprostenol was 23 +/- 12 hours and after administering this drug 38.2 +/- 11.9 hours (p = 0.0001). In 6 patients, heparin and epoprostenol were simultaneously administered. The adverse effects were hemorrhage, which presented in 7 patients (18%) and a fall in blood pressure in another 7 (18%), which recovered in the next 24 hour after starting treatment. Cost analysis demonstrates some advantage with epoprostenol in patients with increased tendency to clotting. CONCLUSIONS: Epoprostenol may be safely used to prevent clotting of the extracorporeal circuits, either alone in patients with thrombocytopenia and/or increased risk of bleeding, or in combination with heparin in states of hypercoagulability.

Prognostic utility of preimplantation kidney biopsy from deceased older donors in first year post-transplant renal function.

BACKGROUND: Preimplantation renal biopsy provides potentially valuable information about post-transplant renal function. OBJECTIVE: To assess the prognostic value of preimplantation kidney biopsy from older donors in determining 1-year post-transplant estimated glomerular filtration rate MDRD-4 (eGFR). METHODS: We evaluated a cohort of 124 renal transplant recipients from deceased donors ≥60 years old, performed at our center between March 2008 and May 2012. Biopsies were assessed by applying the score proposed by O'Valle et al. The overall score was stratified into 3 levels: 0-3, 4-5 and 6-8 points. Kidneys scoring > 8 points were discarded. A total of 77% of the donors were ≥70 years. RESULTS: One year post-transplant, mean eGFR (SD) was lower in transplant recipients with 6-8 points (38.5 [14.1] mL/min/1.73m(2)) than in the group scoring 4-5 points (46.3 [15.7] [p=0.03]) and the group scoring 0-3 (49.6 [12.5] [P=.04]). Seven patients (19%) had eGFR <30mL/min/1.73m(2) 1 year post-transplant in group 6-8 vs. 8 (14%) in group 4-5 and none in group 0-3. In the logistic regression, OR (95% IC), to determine patients with 1-year post-transplant eGFR (<30mL/min/1.73m(2)), delayed graft function (6.3 [1.9-21.3]) and acute rejection (5.8 [1.1-31]), were significant. The adjusted OR of biopsy score group 6-8 vs. 0-5, was 2.2 (0.7-7.3). CONCLUSIONS: Allografts with higher pathologic score in preimplantation renal biopsy were associated with a worse 1-year post-transplant eGFR. Delayed graft function and acute rejection were significant risk factors for 1-year post-transplant low eGFR.

Valor pronóstico de la biopsia renal preimplante en donantes fallecidos de edad avanzada en la función renal al año del trasplante / Prognostic utility of preimplantation kidney biopsy from deceased older donors in first year post-transplant renal function

Antecedentes: La biopsia renal preimplante puede aportar información útil evolutiva postrasplante. Objetivo: Analizar el valor pronóstico de la biopsia renal de donantes de edad avanzada respecto al filtrado glomerular estimado MDRD-4 (FGe) al año del trasplante. Métodos: Estudiamos a 124 receptores de trasplante renal de donantes fallecidos de ≥60 años, con biopsia renal preimplante. Los trasplantes fueron realizados en nuestro centro, entre marzo del 2008 y mayo del 2012. Las biopsias se valoraron según el baremo propuesto por O’Valle et al. y se categorizaron en 3 grupos: 0-3, 4-5, 6-8 puntos. Se descartaron los riñones con una puntuación >8. El 77% de los donantes tenía ≥70 años. Resultados: El FGe medio (DE) del grupo 6-8 al año del trasplante: 38,5 (14,1) mL/min/1,73m2 fue menor que el del grupo 4-5: 46,3 (15,7) (p=0,03) y del grupo 0-3: 49,6 (12,5) (p=0,04). Se registraron 7 (19%) pacientes con FGe<30mL/min/1,73m2 en el grupo 6-8 vs. 8 (14%) en el grupo 4-5 y ninguno en el grupo 0-3 (p=0,17). En el análisis de regresión logística, OR (IC 95%), que valoró los pacientes con FGe<30mL/min/1,73m2 al año del trasplante, la función retrasada del injerto (6,3 [1,9-21,3]) y el rechazo agudo (5,8 [1,1-31]) fueron significativos. La puntuación del daño histológico de las biopsias, grupo 6-8 vs. 0-5, presentó un OR ajustado no significativo de 2,2 (0,7-7,3). Conclusiones: Los riñones con mayor afectación histológica presentaron un menor FGe al año del trasplante. La función renal retrasada del injerto y el rechazo fueron factores de riesgo significativos de un bajo FGe al año del trasplante (AU)

Background: Preimplantation renal biopsy provides potentially valuable information about post-transplant renal function. Objective: To assess the prognostic value of preimplantation kidney biopsy from older donors in determining 1-year post-transplant estimated glomerular filtration rate MDRD-4 (eGFR). Methods: We evaluated a cohort of 124 renal transplant recipients from deceased donors ≥60 years old, performed at our center between March 2008 and May 2012. Biopsies were assessed by applying the score proposed by O’Valle et al. The overall score was stratified into 3 levels: 0-3, 4-5 and 6-8 points. Kidneys scoring > 8 points were discarded. A total of 77% of the donors were ≥70 years. Results: One year post-transplant, mean eGFR (SD) was lower in transplant recipients with 6-8 points (38.5 [14.1] mL/min/1.73m2) than in the group scoring 4-5 points (46.3 [15.7] [p=0.03]) and the group scoring 0-3 (49.6 [12.5] [P=.04]). Seven patients (19%) had eGFR <30mL/min/1.73m2 1 year post-transplant in group 6-8 vs. 8 (14%) in group 4-5 and none in group 0-3. In the logistic regression, OR (95% IC), to determine patients with 1-year post-transplant eGFR (<30mL/min/1.73m2), delayed graft function (6.3 [1.9-21.3]) and acute rejection (5.8 [1.1-31]), were significant. The adjusted OR of biopsy score group 6-8 vs. 0-5, was 2.2 (0.7-7.3). Conclusions: Allografts with higher pathologic score in preimplantation renal biopsy were associated with a worse 1-year post-transplant eGFR. Delayed graft function and acute rejection were significant risk factors for 1-year post-transplant low eGFR (AU)