Optimization of immunosuppression by switching from azathioprine to enteric-coated mycophenolate sodium in stable kidney transplant patients.

The aim of our retrospective, observational, single center study was to analyze renal function changes among stable kidney transplant patients treated with a calcineurin inhibitor (CNI) + azathioprine (AZA), in whom immunosuppression was optimized by a switch from AZA to enteric-coated mycophenolate sodium (EC-MPS) with a view to protecting long-term renal function. Between April 2005 and June 2008, 36 renal transplant patients on previous treatment with a CNI and AZA for a period of 86.94 +/- 66.9 months were switched to EC-MPS. After the change, there were no cases of acute rejection episodes. Six patients (16.6%) developed gastrointestinal secondary effects and 5 had to discontinue EC-MPS treatment: 4 due to severe diarrhea 1 due to thrombocytopenia. Among the remaining patients, it was possible to gradually increase the EC-MPS dose (starting at 376 +/- 122 mg/d vs current at 533.5 +/- 210 mg/d; P < .002), maintaining through levels at 2.1 +/- 1.9 ng/mL. Although 11 patients (30.5%) displayed chronic allograft nephropathy upon the preconversion biopsy, at a follow-up of 29.2 +/- 9.4 months they showed significantly improved renal function (Modification of Diet in Renal Disease [MDRD4] at change 49.5 +/- 19.8 mL/min/1.73 m(2) vs current MDRD4 55.6 +/- 23.4 mL/min/1.73 m(2); P = .02), with no increase in proteinuria (proteinuria at change 0.4 +/- 0.4 g/d vs current proteinuria 0.4 +/- 0.5 g/d; P = NS). This improvement was evident without changes in CNI levels: cyclosporine at change 133.1 +/- 30.2 ng/mL vs current 122 +/- 28 ng/mL (P = NS) and tacrolimus at change 7.7 +/- 2.2 ng/mL vs current 8.2 +/- 2.4 ng/mL (P = NS). In conclusion, conversion from AZA to EC-MPA to optimize immunosuppression seemed to be safe, with no complications in 85% of cases, as well as effective, achieving improved long-term renal function protection. These results suggested a greater protective immunological effect by switching from AZA to EC-MPA.

[Scrotal oedema in a kidney graft recipient]. / Edema escrotal en un paciente portador de trasplante renal reciente.

A 54-year old man received a cadaveric renal allograf for end-stage renal disease due to membranous nephropathy. The patient developed scrotal oedema, 14 days after renal transplantation. The biochemical analysis of scrotal fluid after surgical drainage demostrated urine. Helical computed tomography was performed and it showed contrast leaks in medial, distal ureter and bladder. The urinary fistula was treated with surgical repairment and catheter endoluminal of ureter which was retired in four weeks. The incidence of urinary fistula ranged from 3 to 9%. The scrotal or perineal oedema is unusual clinical presentation of urinary leaks. The diagnosis of urinary fistula may be difficult and depends on a high degree of clinical suspicion. The helical computed tomography is a technique which allows a high resolution three-dimensional reconstruction and it can be used to make the diagnosis of urinary fistula.

Hipertensión vasculorrenal y nefropatía isquémica secundaria a radioterapia / Radiation-induced renovascular hypertension

Se describe el caso de un paciente de 24 años de edad que desarrolló lesiones isquémicas en distintos órganos provocadas por la administración de radioterapia por un orquioblastoma en la infancia. Más de 20 años después de recibir irradiación con cobalto a altas dosis sobre la región abdominogenital presentó una pancreatitis crónica y una colangitis esclerosante, una nefropatía isquémica, con hipertensión arterial vasculorrenal secundaria a estenosis bilateral de arterias renales y un infarto isquémico del cono medular. De todas las lesiones, la que evolucionó más favorablemente fue la renal, ya que aunque la arteria renal derecha tenía una obstrucción prácticamente completa, la izquierda se consiguió dilatar mediante angioplastia transluminal percutánea, con buen resultado final y progresiva mejoría de la función renal. Sin embargo, fue necesario mantener la mayoría de los fármacos antihipertensivos, probablemente debido al efecto presor que seguía ejerciendo la arteria renal derecha ocluida. Tras más de dos años de seguimiento la función renal sigue siendo prácticamente normal y no existen datos de reestenosis de la arteria renal izquierda (AU)