Results of kidney transplantation from deceased donors with acute kidney injury.

BACKGROUND: Different strategies have been initiated to shorten the waiting list time to receive a kidney transplant. Donors with acute kidney injury (AKI) may be a new option. METHODS: Fifty-nine patients received a kidney transplant from an AKI donor defined as having serum creatinine >2 mg/dL at the time of organ procurement. They were compared with a transplant group with normal kidney function defined as creatinine <1.5 mg/dL organ procurement in the same time period, paired by donor and recipient age (control group). Initial evolution, at 1 year, and at the end of the follow-up were evaluated. RESULTS: The AKI donor group had greater delayed graft function (68% versus 36%, P < .01). Graft and recipient survival were similar in both groups at 1 year (92% versus 88%, P = NS; 97% versus 98%, P = NS) and at the end of follow-up (66% versus 66%, P = NS; 90% versus 88%, P = NS). Serum creatinine at 1 year and at the end of the follow-up did not show any differences (1.4 ± 0.5 versus 1.4 ± 0.7 mg/dL, P = NS; 1.4 ± 0.5 versus 1.6 ± 0.9 mg/dL, P = NS). CONCLUSIONS: The transplants from donors with AKI showed greater incidence of delayed graft function, but this did not affect the short- or long-term prognosis of the graft or recipient. This type of donor may be a source of acceptable kidneys.

Everolimus-based immunosuppression therapy for BK virus nephropathy.

BACKGROUND: Mammalian target of rapamycin inhibitors (mTOR-i) have been proposed as possible immunosuppressants of choice in BK virus nephropathy (BKN) because of their antiviral capacity. On this basis, in 2007, our Service proposed a conversion to everolimus (EVE)-based therapy from calcineurin inhibitors with an anti-calcineurin-free therapy protocol in those patients diagnosed of BKN. METHODS: A prospective, single-center case series study was performed. Fifteen cases of BKN were diagnosed from 2007 to the end of 2010. According to our protocol, immunosuppressant treatment was modified in 9 of these patients with suspension of mycophenolate and conversion from tacrolimus to EVE. RESULTS: The renal function achieved by our patients after the transplantation was excellent. Mean serum creatinine (sCr) achieved was 1.16 ± 0.2 mg/dL. Evolution of the renal function after BKN diagnosis and conversion to mTOR-i was positive in all the patients. sCr on diagnosis was 1.85 ± 0.22 mg/dL, sCr at the point in time of conversion to EVE was 2 ± 0.21 mg/dL, and final sCr of the follow-up was 1.6 ± 0.39 mg/dL (P = .05). BK viremia became negative in 5 of our patients and decreased more than 95% in the remaining 4. None of the patients had an acute rejection episode after the change of immunosuppressant. CONCLUSIONS: Conversion to mTOR-i-based therapy could provide an added benefit in BKN and could be an effective strategy for the decrease of the viremia and increase of graft survival in selected patients.

Addition of spironolactone to dual blockade of renin angiotensin system dramatically reduces severe proteinuria in renal transplant patients: an uncontrolled pilot study at 6 months.

Experimental and clinical data strongly suggest that aldosterone may contribute to proteinuria and progressive renal disease. In fact, an aldosterone antagonist seems to be effective for controlling proteinuria in native kidneys. However, there is little information about this approach in renal transplant patients, a population in whom the presence and amount of proteinuria represent risk factors for graft loss, cardiovascular disease, and death. The aim of our study was to evaluate whether addition of an aldosterone antagonist, spironolactone, provided an additional antiproteinuric effect to the angiotensin-converting enzyme inhibitor (ACEI) and angiotensin type I receptor antagonists (ARB). We evaluated the effects on severe proteinuria (4.4±1.4 g/d) at 6 months after prescription of spironolactone (25 mg/d) among 11 renal transplant patients with serum creatinine values less than 3 mg/dL who were under treatment with an ACEI plus an ARB. Patients were examined in the renal transplant outpatient clinic every week for the first month and twice a month thereafter. Nine patients showed a more than 50% (mean=81.5%) reduction in proteinuria not only early, but also sustained at 6 months (4.4±1.4 to 2.3±1.1 g/d) with a mild, nonsignificant deterioration in renal function (serum creatinine 1.6±0.32 to 1.7±0.54 mg/dL). This study showed that spironolactone decreased severe proteinuria among patients treated with an ACEI plus an ARB. This therapy is not recommended for patients with glomerular filtration rates below 40 mL/min. Therefore, it is suggested that using triple blockade of RAS is feasible in selected renal transplant patients to reduce proteinuria, although caution is required to avoid severe hyperkalemia.

Everolimus represents an advance in immunosuppression for patients who have developed cancer after renal transplantation.

Renal transplantation provides the best quality of life for the patients with chronic end-stage renal failure. However, the immunosuppression necessary for graft survival may give rise to infectious complications, an increased risk of cardiovascular and neoplastic diseases, all of which can shorten the patient's survival. The objective of this study was to evaluate the efficacy and safety of the proliferation signal inhibitor immunosuppressant drugs everolimus among patients who develop neoplasms after renal transplantation. This retrospective study included 25 patients (mean age -56.5 +/- 14.1 years) who were diagnosed with posttransplant neoplastic disease and immunosuppressed with calcineurin inhibitors (CNIs). Treatment was initiated with everolimus with or without CNIs. During the follow-up, the renal function (initial serum creatinine 1.4 mg/dL vs final serum creatinine 1.3 mg/dL) and proteinuria levels (initial 0.3 g/d vs final 0.4 g/d) remained stable. There was a low percentage of patients with relapse of their tumor. One patient had a relapse of bladder cancer with tumor progression at 3 years; another patient with melanoma developed lymph node invasion. There were neither acute rejection episodes nor cardiovascular complications. The results suggested that tumor relapse was low. The results suggested that immunosuppression with everolimus combined with low doses of CNIs or in single-drug therapy is safe immunosuppression for patients who develop posttransplant malignant diseases.

[Fibrate-induced deterioration of renal function]. / Deterioro de la función renal inducido por fibratos.

INTRODUCTION: Fibrates represent one of the medications used to treat patients with hyperlipemia. Deterioration in renal function is not a very known adverse effect of fibric acid derivates. In the last 26 months we have detected thirteen patients with acute renal failure associated to fibrates in our outpatients' clinic. SUBJECTS AND METHODS: The aim of our study is to analyze our experience in deterioration in renal function associated to fibrates use. This is a retrospective charts review. RESULTS: From the thirteen patients (8 males/5 females) with mean age of 65.5 +/- 12.2 years, ten received Fenofibrate (FN), one Bezafibrate (BZ) and two Gemfibrozil (GF). Six cases had previously normal renal function and the seven remaining had mild chronic renal failure (CRF). The increase of serum Creatinine (Crs) value was higher than 74%. Acute renal failure was reversible in 9 patients (group 1), but the other 4 did not recover their previous renal function (group 2). The average of Crs before fibrate treatment was 1.33 +/- 0.36 mg/dl (Creatinine clearance 63.2 +/- 26.6 ml/min) and the highest average of Crs during the treatment was 2.22 +/- 0.49 mg/d (Creatinine clearance 37.3 +/- 11.9 ml/min). The average time until acute renal failure diagnosis was 6.7 +/- 5.8 months and the recovery of renal function was delayed an average of 3.8 +/- 3.5 months after fibrates withdrawn. Group 2 patients had a higuer Crs and longer time with fibrates than group 1 patients. CPK values were normal in all cases. In two patients renal biopsy was performed and no significant lesions were detected. CONCLUSION: The fibrate treatment can induce an acute renal failure. Four patients (30.8%) did not recover their basal renal function. When fibrate treatment begins a renal function should be monitored specially in patients with CRF.

Deterioro de la función renal inducido por fibratos / No disponible

Introducción: Los fibratos representan uno de los grupos de fármacos indicados para el tratamiento de la hiperlipidemia. Uno de sus efectos secundarios, aún poco conocido, es el deterioro agudo de la función renal. En los últimos 26 meses hemos objetivado en nuestra consulta externa de Nefrología un total de13 pacientes con deterioro de la función renal asociado al uso de fibratos. Material y métodos: El objetivo de nuestro estudio es evaluar nuestra experiencia en el incremento de Creatinina sérica (Crs) inducido por fibratos. Se trata de una revisión retrospectiva de una serie de casos. Resultados: De los 13 pacientes (8 hombres/5 mujeres) con edad media de 65,5 ± 12,2 años, diez fueron tratados con fenofibrato, uno con bezafibrato y dos con gemfibrozilo. Seis pacientes partían de una función renal normal y los otros siete presentaban una Insuficiencia Renal Crónica (IRC) leve-moderada previamente al inicio del tratamiento. El incremento de creatinina con respecto a la basal expresado en porcentaje fue superior al 74%. En nueve de los pacientes el deterioro de función renal fue completamente reversible (grupo 1), mientras que en cuatro de ellos la recuperación fue parcial (grupo 2). La media de creatinina antes de recibir tratamiento con fibratos fue de 1,33 ± 0,36 mg/dl (aclaramiento de creatinina 63,2 ± 26,6 ml/min) y la media de la creatinina máxima durante el tratamiento fue de 2,22± 0,49 mg/dl (aclaramiento de creatinina 33,4 ± 8,1 ml/min). El tiempo medio de evolución hasta objetivarse el incremento de creatinina fue de 6,7 ± 5,8 meses y la recuperación de la función renal ocurrió a los 3,8 ± 3,5 meses de la suspensión del tratamiento con fibratos. En los pacientes del grupo 2 se objetivó un mayor incremento de Crs y un tiempo de tratamiento confibratos más prolongado. En los pacientes en los que se obtuvieron niveles de CPK, éstos fueron normales. En dos de nuestros (..) (AU)

Introduction: Fibrates represent one of the medications used to treat patients with hyperlipemia. Deterioration in renal function is not a very known adverse effect of fibric acid derivates . In the last 26 months we have detected thirteen patient s with acute renal failure associated to fibrates in our outpatients’ clinic. Subjects and methods : The aim of our study is to analyze our experience in deterioration in renal function associated to fibrates use. This is a retrospective char t s review. Results: From the thirteen patients (8 males/5 females) with mean age of 65.5 ± 12.2 year s , ten received Fenofibrate (FN) , one Beza fibrate (BZ) and two Gemfibrozil (GF). Six cases had previously normal renal function and the seven remaining had mi ld chronicrenal failure (CRF) . The increase of serum Creatinine (Cr s ) value was higher than 74%. (..) (AU)

[Glomerulopathies associated to HIV infection: a Spanish perspective]. / Glomerulopatías asociadas a la infección por VIH una perspectiva española.

UNLABELLED: HIV nephropathy (HIVAN) is the most frequent cause of chronic renal failure in HIV-infected black patients. However, the prevalence of other glomerulopathies mediated by immunocomplexes has increased in the last years. We report on the glomerular diseases observed in HIV patients in our Hospital. METHODS: A retrospective study of all patients with HIV infection and glomerular diseases diagnosed by renal biopsy. RESULTS: We found 27 patients with the following glomerular diseases: membranoproliferative glomerulonephritis (MPGN) in 8 patients, non-collapsing focal segmental glomerulosclerosis (FSGS) in 7, IgA nephropaty (IgA N) in 6, collapsing glomerulosclerosis in 4 (HIVAN, and membranous nephropaty (MN) in 2. Most of patients were young white men. A high prevalence of coinfection with hepatitis C virus (HCV) (77.8%) and hepatitis B virus (HBV) (37%) was found. At diagnosis, most of patients (90%) had proteinuria, with nephrotic syndrome in 52% of them; 59% presented with acute renal failure. Nine patients (33%) showed malignant hypertension at diagnosis: this complication was particularly common among IgA N patients (4/6, 66%). CONCLUSION: In our Hospital, immunocomplex-mediated glomerulonephritis were more frequent than HIVAN among HIV-infected patients. HCV-associated MPGN was the most frequently detected glomerular disease. A high prevalence of malignant hypertension was observed at diagnosis, particularly among patients with IgAN.

Glomerulopatías asociadas a la infección por VIH una perspectiva española / Glomerulopathies associated to HIV infection: a spanish perspective

La nefropatía asociada al VIH (HIVAN) es la causa más común de insuficiencia renal crónica en los pacientes VIH de raza negra. Sin embargo, en los últimos años la prevalencia de otras glomerulopatías asociadas a inmunocomplejos ha ido en aumento. Nuestro estudio describe la patología glomerular en los pacientes VIH de nuestro centro. Material y métodos: estudio retrospectivo de pacientes VIH con afectación glomerular confirmada mediante biopsia renal. Resultados: Se detectaron 27 pacientes en los que se habían diagnosticado las siguientes glomerulopatías: glomerulonefritis membranoproliferativa (GNMP) en 8, glomeruloesclerosis focal y segmentaria no colapsante (GSF) en 7, nefropatía mesangial IgA (GNIgA) en 6, glomeruloesclerosis colapsante (HIVAN) en 4 y glomerulonefritis membranosa (GNM) en 2. La mayoría de los casos eran varones jóvenes de raza blanca. Destaca una alta coinfección con el virus de la hepatitis C (VHC) (77,8%) y con el virus de la hepatitis B (VHB) (37%). En el momento del diagnóstico la mayoría de los pacientes presentaba proteinuria (96%), con síndrome nefrótico en el 52% de los casos, y un 59% presentaba un deterioro agudo de la función renal. Nueve pacientes (33%) presentaron HTA maligna al diagnóstico, siendo particularmente frecuente esta complicación entre los pacientes con GNIgA (4/6, 66%). Conclusiones: las glomerulopatías más frecuentes en nuestra población VIH son las asociadas a inmunocomplejos, sobre todo la GNMP asociada a la infección por el VHC. La HTA maligna tiene una alta incidencia en los pacientes VIH, más marcada en los pacientes con nefropatía mesangial IgA

HIV nephropathy (HIVAN) is the most frequent cause of chronic renal failure in HIV-infected black patients. However, the prevalence of other glomerulopathies mediated by immunocomplexes has increased in the last years. We report on the glomerular diseases observed in HIV patients in our Hospital. Methods: A retrospective study of all patients with HIV infection and glomerular diseases diagnosed by renal biopsy. Results: We found 27 patients with the following glomerular diseases: membranoproliferative glomerulonephritis (MPGN) in 8 patients, non-collapsing focal segmental glomerulosclerosis (FSGS) in 7, IgA nephropaty (IgA N) in 6, collapsing glomerulosclerosis in 4 (HIVAN, and membranous nephropaty (MN) in 2. Most of patients were young white men. A high prevalence of coinfection with hepatitis C virus (HCV) (77.8%) and hepatitis B virus (HBV) (37%) was found. At diagnosis, most of patients (90%) had proteinuria, with nephrotic syndrome in 52% of them; 59% presented with acute renal failure. Nine patients (33%) showed malignant hypertension at diagnosis: this complication was particularly common among IgA N patients (4/6, 66%).Conclusion: In our Hospital, immunocomplex-mediated glomerulonephritis were more frequent than HIVAN among HIV-infected patients. HCV-associated MPGN was the most frequently detected glomerular disease. A high prevalence of malignant hypertension was observed at diagnosis, particularly among patients with IgAN

[Relapsing nephrotic syndrome in a diabetic patient with minimal change]. / Síndrome nefrótico recidivante por lesiones mínimas en un paciente diabético.

Although nondiabetic nephropathies are common among type 2 diabetic patients, very few cases of minimal change nephrotic syndrome have been reported in diabetic patients. We describe a type 2 diabetic patient that rapidly developed a nephrotic syndrome accompanied by a mild worsening of renal function. Proteinuria was negative one year before and no signs of diabetic retinopathy were found. Renal biopsy established the diagnosis of minimal change disease. Steroid treatment induced a complete remission of nephrotic syndrome and recovery of normal renal function. However, massive proteinuria relapsed two years later. A second cycle of steroids was followed by a disappearance of proteinuria, but a third bout of nephrotic syndrome was observed 6 months later. An 8-weeks cycle of steroids plus chlorambucil induced a complete and persistent remission. Throughout a five-year follow up, no relapse of the nephrotic syndrome was observed and microalbuminuria is negative.

Hipertensión e hipopotasemia / Hypertension and hypopotasemia

Paciente hipertenso joven con mal control de la presión arterial y evidencia de hipopotasemia en el seno de tratamiento farmacológico con tiazidas y carvedilol. Después de suspender el diurético el potasio era de 2,8 mEq/l y en orina de 124 mEq/día. El estudio del sistema renina-aldosterona mostró (basal): renina, 6,9 ng/ml; aldosterona, 148 ng/dl (cociente: 21,4); con ortostatismo de 2 horas: renina, 5,7 ng/ml, y aldosterona, 237 ng/dl (cociente: 41,5).Un escáner abdominal demostró una lesión nodular en la glándula suprarrenal izquierda. El estudio confirmó la existencia de un hiperaldosteronismo primario por adenoma suprarrenal izquierdo y se realizó adrenelectomía izquierda. Un mes más tarde la presión arterial era de 110/70 mmHg y el potasio sérico 4,5 mEq/l. Se revisan las causas de hipertensión e hipopotasemia y el protocolo de estudio escalonado de un paciente con dicha patología (AU)