Total cholesterol correlates with cyclosporine C2 levels in kidney transplant recipients under maintenance immunosuppression.

The aim of this study was to assess the relationship between cyclosporine (CyA) trough level (C0) and 2-hour postdose (C2) and total cholesterol (TC) in kidney transplant (KT) recipients on Neoral maintenance immunosuppression. In KT recipients who had more than 5 years of follow-up, stable graft function, and stable Neoral dose, we measured C2 and C0 blood levels, serum creatinine, mean total cholesterol (TC) over the last 5 years, prednisone dose, use of beta-blockers and thiazides. Correlations between C0 and C2 levels and TC were performed with the Pearson coefficient. Receiver operating characteristics (ROCs) were used to define the threshold with greater accuracy for significant variables at the correlation test. Statistical tests were performed with SPSS 9.5 The C2 correlated with TC (0.31; P=.008) whereas C0 did not. The C2 level was an independent predictor for TC after adjusting for recipient age, gender, dose of prednisone, creatinine clearance, and use of beta-blockers and thiazides (B coefficient=1.124(E-3); P=.009). A threshold C2 value of 700 microg/L yielded to a TC level of 5.2 mmol/L. This is the first study to report a correlation between C2 levels and TC. Although C2 explained a small fraction of TC variability, it is an independent predictor of TC in KT recipients on Neoral maintenance immunosuppression. A long-term C2 value under 700 microg correlates with better control of hypercholesterolemia.

Evaluating the impact of an aggressive strategy to create wrist arterio-venous fistula in patients on hemodialysis.

OBJECTIVES: To compare two approaches to hemodialysis arterio-venous fistula (AVF) creation, and to evaluate the benefit of expanding wrist-AVF selection criteria. BACKGROUND: The recommendation summarized under the Dialysis Outcome and Quality Initiative (DOQI) suggests the placement of a wrist-AVF as a first choice for patients starting hemodialysis. However, its benign complications contrast with its high early failure rates. In the absence of predictors of a successful access, decision on whether or not to attempt such an access depends on the subjective clinical judgment. METHODS: This is a retrospective study of patients with ESRD disease in Southern Alberta who underwent a vascular access creation during the year 2000. The surgery was performed by 2 surgeons each having his own approach to access selection (approach A and B). Approach A had broader criteria (vessels < 3 mm) for wrist-AVF creation, whereas approach B was more conservative, thus limiting the selection to patients with wrist vessels superior to 3 mm. The type of simultaneous access created in the same limb was dependant of this first choice. A Markov decision tree analysis was used to model yearly transition between patent and failed access. The absence of further possibility of access creation in the same arm was taken as a time horizon. Sensitivity analysis was used to test the effect of maximizing a wrist-AVF on overall arm failure. RESULTS: In approach A there was 69% of wrist AVF creation as the first type of access compared to 31% in approach B. A two-year wrist-AVF patency was 80% in approach B versus 61% in approach A. The expected mean time to complete limb failure was longer in patients treated with approach A (3.62 versus 3.50 years). Sensitivity analysis showed an ultimate benefit for approach A. CONCLUSIONS: Wrist vessel size less than 3 mm should not be a limiting factor for the creation of a wrist-AVF. Maximizing the creation of such an access, despite increasing the rate of early failure, prolongs the option of hemodialysis access in the same arm.