Aortic clamping in pancreas transplantation: is there any harm to the transplanted kidney graft?

INTRODUCTION: Some special situations may require aortic clamping during pancreas transplantation (PT). The most important problem is ischemic injury to a previous transplanted kidney. We sought to demonstrate experience with aortic clamping in PT without special kidney allograft protection measures and its impact on kidney function. METHODS: Retrospective study that analyzed 6 patients who underwent PT (5 pancreas after kidney and 1 simultaneous pancreas-kidney) with aortic clamping. In all cases, the pancreas graft was placed on the right with retrocolic portal-enteric drainage. Serum creatinine was evaluated pre- and posttransplantation. RESULTS: The average clamping time was 19 minutes. The mean serum creatinine was 1.1, 1.15, 0.95, and 1.0, respectively, at pre and postoperative days 1 and 7 and at hospital discharge. Patient, kidney, and pancreatic graft survivals were 100%, 100%, and 83%, respectively. CONCLUSION: The need for aortic clamping in selected cases of PT did not seem to affect the transplanted kidney, even without protective measures, provided that the ischemic time was short.

Use of enteroscopy for treating pancreatitis in a pancreas and kidney transplantation patient with Roux-en-Y portoenteric derivation--a case report.

In pancreas and kidney transplantations, the donor duodenum and pancreas are frequently anastomosed to the jejunum to allow exocrine drainage by creation of a Roux-en-Y jejunal loop. In this situation, those organs are relatively inaccessible using standard endoscopes. We present a case of the use of single-balloon enteroscopy in the treatment of cronic pancreatitis in the donor pancreas.

Endemic and opportunistic infections in Brazilian solid organ transplant recipients.

OBJECTIVE: To evaluate the frequency and clinical features of endemic and other opportunistic infections in liver or kidney transplant recipients in four transplant centres in different geographical areas of Brazil. METHODS: Retrospective analysis of medical and laboratory records of four transplant centres on endemic and other opportunistic infections in liver or kidney transplant recipients. Analyses were performed with spss statistical software. RESULTS: From 2001 to 2006, 1046 kidney and 708 liver transplants were registered in all centres. The average age was 42 years. Among 82 (4.7%) cases with infections, the most frequent was tuberculosis (2.0%), followed by systemic protozoal infections (0.7%), toxoplasmosis (0.4%) and visceral leishmaniasis (0.3%). Systemic fungal infections occurred in 0.6%, of which 0.4% were cryptococcosis and 0.2% were histoplasmosis. Dengue was the only systemic viral infection and was registered in two cases (0.1%), of which one was classified as the classic form and the other as dengue haemorrhagic fever. Nocardiosis was described in one case (0.05%). The infectious agents most frequently associated with diarrhoea were Blastocystis sp., Schistosoma mansoni and Strongyloides stercoralis. CONCLUSIONS: Opportunistic Infections in transplant patients have a wide spectrum and may vary from asymptomatic to severe infections with high mortality. A better understanding of the epidemiology of endemic pathogens and clinical manifestations can contribute to the establishment of an early diagnosis as well as correct treatment aimed at decreasing morbidity and mortality.

Protective effect of N-acetylcysteine on early outcomes of deceased renal transplantation.

We investigated the effects of the antioxidant N-acetylcysteine (NAC) on early outcomes of deceased donor renal transplantation. Between April 2005 and June 2008, adult primary graft recipients of deceased renal donors were assigned to treatment (n = 38) or control (n = 36) groups and evaluated for 90 days and one year after renal transplantation. The treatment group received NAC orally (600 mg twice daily) from day 0 to 7 postoperatively. Renal function was determined by serum creatinine, MDRD and Cockcroft-Gault estimated GFR (eGFR), delayed graft function (DGF) and dialysis free Kaplan-Meier estimate curve. Serum levels of thiobarbituric acid reactive substances (TBARS), were employed as markers of oxidative stress. The NAC group displayed a lower mean serum creatinine during the first 90 days (P = .026) and at 1 year after transplantation (P = .005). Furthermore, the NAC group showed a higher mean eGFR throughout the first 90 days and at 1 year. DGF was lower among the NAC group (P = .017) and these recipients required fewer days of dialysis (P = .012). Oxidative stress was significantly attenuated with NAC (P < .001). Our results suggested that NAC enhanced early outcomes of deceased donor renal transplantation by attenuating oxidative stress.

Non-human leukocyte antigen antibodies reactive with endothelial cells could be involved in early loss of renal allografts.

Preformed donor-specific human leukocyte antigen (HLA) antibodies have been associated with allograft dysfunction and failure. However, recipients of HLA-identical kidneys can develop acute humoral rejection, implicating putative pathogenic antibodies that are directed against non-HLA antigens. We investigated the presence of endothelial cell-reactive antibodies in 11 patients who experienced early loss of their transplanted kidneys owing to humoral rejection and 1 loss from renal venal thrombosis. We examined the potential efficacy of intravenous immunoglobulin to block the binding of these antibodies, as previously suggested for anti-HLA antibodies.

Hemorrhagic cystitis secondary to adenovirus or herpes simplex virus infection following renal transplantation: four case reports.

Viral infections are common complications following renal transplantation. However, there have been few reported cases of viral cystitis secondary to herpes simplex virus or adenovirus infection. Herein, we have reported four cases of hemorrhagic cystitis secondary to infections with herpes simplex virus and adenovirus following renal transplantation. The etiology was adenovirus in three cases and herpes simplex virus in the remaining case. In all four cases, the primary cause of the renal dysfunction was diabetic nephropathy. All four patients presented with a clinical profile characterized by dysuria, pollakiuria, macroscopic hematuria, and graft dysfunction. Three of the four patients developed these symptoms within the first 3 months after renal transplantation. In all four cases, there was an increase, albeit slight, in creatinine levels, which returned to normal or near-normal values upon resolution of the symptoms. Acute cellular rejection was observed in only one case. Although rare, hemorrhagic cystitis secondary to infection, which typically occurs early in the posttransplant period, causes pronounced symptoms. The infection appears to be self-limiting, resolving completely within 4 weeks.

Influence of single-nucleotide polymorphisms on C-reactive protein levels in chronic kidney disease before and after kidney transplantation.

INTRODUCTION: We sought to evaluate 2 single-nucleotide polymorphisms (SNPs) in the C-reactive protein (CRP) gene promoter region for their effects on CRP levels in chronic kidney disease (CKD) patients before and after a successful kidney transplantation. METHODS: Fifty CKD patients were evaluated before and at the first and second years after the graft. Two SNPs were studied, a bi-allelic (G-->A) at the -409 and a tri-allelic (C-->T-->A) variation at the -390 position in the CRP gene. RESULTS: All patients presented the -409GG genotype. At the -390 position, the "A" allele was not found; there were 15 "CC" patients, 11 "TT" patients, and 24 "CT" patients. CRP levels were different among patients with various genotypes (P < .019). Also the presence of the allele "T" was sufficient to determine differences in CRP levels both in pretransplantation (P = .045) and at 1 year posttransplantation (P = .011), but not at the second year (P = .448). CONCLUSION: SNPs at the -390 position of the CRP gene promoter region influence CRP basal levels in such a way that the "C" allele correlated with the lowest and the "T" with the highest. We did not observe this influence in our patients at the second year posttransplantation.

Disconnecting central hot water and using electric showers to avoid colonization of the water system by Legionella pneumophila: an 11-year study.

Legionella spp. can be difficult to control in hospitals. The objective of this study was to describe an 11-year experience with the use of electric showers in the control of Legionella pneumophila. From June 1989 to March 1990 there was an outbreak of pneumonia caused by L. pneumophila in a 20-bed renal transplant unit in a university-associated tertiary-care hospital. Control measures included hyperchlorination, heating and flushing of the water system with limited results. In November 1993 the central hot water was disconnected and water for bathing was heated using electric showers. From January 1992 to June 1995 water was collected from showers and water faucets and cultured for L. pneumophila every two weeks. Surveillance cultures were then collected every month until May 1999. During this seven-year surveillance period, 1115 samples of water were cultured. Water cultures were positive on 24 of 429 occasions (without cases of legionellosis) during the pre-shower period (22 months). In the post-shower period (67 months) only one of 686 cultures was positive. Subsequently there have been no new cases of nosocomial pneumonia by L. pneumophila although surveillance continues. In conclusion, disconnecting the central hot water was effective in avoiding colonization of the water system by L. pneumophila. Heating was possible by using electric showers, which are effective, easy to maintain and cheap.

Improvement of adynamic bone disease after renal transplantation.

Low bone remodeling and relatively low serum parathyroid hormone (PTH) levels characterize adynamic bone disease (ABD). The impact of renal transplantation (RT) on the course of ABD is unknown. We studied prospectively 13 patients with biopsy-proven ABD after RT. Bone histomorphometry and bone mineral density (BMD) measurements were performed in the 1st and 12th months after RT. Serum PTH, 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D, and osteocalcin were measured regularly throughout the study. Serum PTH levels were slightly elevated at transplantation, normalized at the end of the third month and remained stable thereafter. Bone biopsies performed in the first month after RT revealed low bone turnover in all patients, with positive bone aluminum staining in 5. In the 12th month, second biopsies were performed on 12 patients. Bone histomorphometric dynamic parameters improved in 9 and were completely normalized in 6, whereas no bone mineralization was detected in 3 of these 12 patients. At 12 months post-RT, no bone aluminum was detected in any patient. We also found a decrease in lumbar BMD and an increase in femoral BMD. Patients suffering from ABD, even those with a reduction in PTH levels, may present partial or complete recovery of bone turnover after successful renal transplantation. However, it is not possible to positively identify the mechanisms responsible for the improvement. Identifying these mechanisms should lead to a better understanding of the physiopathology of ABD and to the development of more effective treatments.

Improvement of adynamic bone disease after renal transplantation

Low bone remodeling and relatively low serum parathyroid hormone (PTH) levels characterize adynamic bone disease (ABD). The impact of renal transplantation (RT) on the course of ABD is unknown. We studied prospectively 13 patients with biopsy-proven ABD after RT. Bone histomorphometry and bone mineral density (BMD) measurements were performed in the 1st and 12th months after RT. Serum PTH, 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D, and osteocalcin were measured regularly throughout the study. Serum PTH levels were slightly elevated at transplantation, normalized at the end of the third month and remained stable thereafter. Bone biopsies performed in the first month after RT revealed low bone turnover in all patients, with positive bone aluminum staining in 5. In the 12th month, second biopsies were performed on 12 patients. Bone histomorphometric dynamic parameters improved in 9 and were completely normalized in 6, whereas no bone mineralization was detected in 3 of these 12 patients. At 12 months post-RT, no bone aluminum was detected in any patient. We also found a decrease in lumbar BMD and an increase in femoral BMD. Patients suffering from ABD, even those with a reduction in PTH levels, may present partial or complete recovery of bone turnover after successful renal transplantation. However, it is not possible to positively identify the mechanisms responsible for the improvement. Identifying these mechanisms should lead to a better understanding of the physiopathology of ABD and to the development of more effective treatments.

Incidence of delayed graft function in cadaveric kidney transplants in Brazil: a multicenter analysis.

To evaluate the frequency of delayed graft function (DGF) in kidney transplant centers in Brazil, we sent a questionnaire requesting information on the number of cadaveric donor kidney transplants performed during the years 2000, 2001, and 2002, the number of early nonfunctioning grafts, and the number of patients on dialysis during the first posttransplant week with subsequent recovery. Among all centers performing more than 50 kidney transplants during the last year of evaluation, 6, performing 612 cadaveric kidney transplants during the study period, replied to the questionnaire. Sixty procedures (9.7%) resulted in nonfunctioning grafts, while 312 (55.6%) patients required dialysis during the first Ptx week: 216 (53.9%) in 2000, 189 (62.3%) in 2001, and 216 (51.6%) in 2002. The frequency of DGF during the study period was higher than that noted by several previous foreign studies. To better evaluate the possible causes of this finding, a more extensive and focused study is warranted.

Identifying cyclosporine blood levels associated with the prevention of renal transplant rejection: a single-center, randomized prospective study.

Multiple-drug therapy may allow reduced individual drug doses with fewer side effects. Blood levels of cyclosporine (CsA) necessary to avoid rejection may vary with different drug combinations. Fifty-eight kidney transplant patients were randomized into two groups: 25 subjects were assigned to the 4-hour area under the curve (AUC(0-4)) Cohort-the "high arm" (4500 to 5500 ng . h/mL)--1 and 33 to the AUC(0-4) "low arm" (2400 to 3400 ng . h/mL). After CsA introduction, AUC(0-4) was drawn on days 4, 7, 14, 21, 28, 42, 56, 70, 84, 90. We compared the proportion of rejection versus rejection-free patients, according to the CsA exposure. Logistic regression analysis showed that an AUC(0-4) of > or =4000 ng . h/mL or a 2-hour cyclosporine level (C(2)) of > or =1450 ng/mL predicted a rejection-free course among patients not receiving induction therapy. When either basiliximab or thymoglobulin was administered, a C(2) and AUC(0-4) of 1043 +/- 151 ng/mL or 3146 +/- 262 ng . h/mL, respectively, were associated with a rejection-free course. Our findings confirm the need for different CsA levels to prevent rejection according to induction therapy. Induction with either basiliximab or thymoglobulin allows reduced CsA levels during the first 3 months after renal transplantation.

Induction versus noninduction therapy in kidney transplantation: considering different PRA levels and different induction therapies.

To evaluate the rate of acute cellular rejection (ACR) and long-term results in different levels of anti-HLA sensitization, using noninduction or different induction therapies, 763 patients who underwent transplantation from January 1995 to December 2001 were evaluated: 213 patients received induction therapy, 71 received Thymoglobulin (Thymo), 66 Simulect, and 44 OKT3. Follow-up time was at least 1 year for all groups. The Simulect group included older recipients and the OKT3 group had more female patients. Simulect and OKT3 groups had more black patients; Thymo and OKT3 groups had more retransplantations. PRA was low in the noninduction group (mean, 7%) and about the same in the Simulect and Thymo groups (mean, 30%). OKT3 was the most sensitized group (mean = 59%). Dialysis during the first posttransplantation week was more frequent among the induction groups (43% vs 65%; P <.005). Fewer patients experienced rejection episodes in the Thymo group (20% vs 50%; P =.02). Patients were classified according to their level of sensitization, and the Thymo group showed the lower rejection rates in all levels (mean, 20%; P =.001). When analyzing PRA >50%, the Thymo group showed lower rejection rates (12% vs 50%; P =.02). At this level of sensitization, there was no significant difference on graft loss and death with a functioning graft. There was a trend to more cytomegalovirus (CMV) disease in the Thymo group (33% vs 23%; P =.08). Two PTLD were diagnosed, both in the noninduction group. Renal function was better in the Thymo group (1.3 mg/dL). In conclusion, Thymo showed lower ACR rates in all PRA groups. No significant differences in CMV infection, tumors, and patient survival were observed.

Comparison of palpation-guided and ultrasound-guided biopsies in transplanted kidneys.

UNLABELLED: Biopsy is the gold standard for the diagnosis of conditions affecting the function of renal allografts. Obtaining representative tissue in biopsies is critical but these procedures are associated with up to 9% of complications and 20% of inadequate material. Although ultrasound guidance allows perfect control of depth and location of the graft, there is controversy regarding the cost-benefit of its use and reports of unsuitable material in ultrasound-guided biopsies are still high. PURPOSE: To compare ultrasound with the palpation method to guide biopsies in order to see if there is any difference between both methods and which one is better. PATIENTS AND METHODS: The casuistic consisted of 82 renal transplant patients (32 female and 50 male patients, age ranging between 5 and 64 yr; m=31.2 yr) randomized into two groups: GI, palpation-guided; GII, ultrasound-guided. Fifty-six biopsies were performed in GI and 66 in GII. RESULTS: Number of glomeruli, arcuate, and interlobar arteries and arterioles were compared in the two groups and were 503 (m=10) vs. 801 (m=12.9), 24 (m=0.5) vs. 38 (m=0.6), 104 (m=2.1) vs. 154 (m=2.5), and 174 (m=3.5) vs. 264 (4.3), respectively (p<0.05). Inadequate material for analysis in GI and GII was 7.1 and 7.6%, respectively (p=0.72). CONCLUSIONS: Although ultrasound guidance improves the number of glomeruli, arcuate, and interlobar arteries, as well as arterioles, compared with palpation-guided biopsies, there is no difference in the rate of adequate material between the two methods.

Catheter-associated urinary infection in kidney post-transplant patients.

CONTEXT: There is still controversy as to the use and dosage of antimicrobial prophylaxis of the urinary infection associated with urethral catheterization in the post renal transplant period. OBJECTIVE: To determine whether patients develop urinary infection during short-term urethral catheterization after renal transplant without routine antimicrobial prophylaxis. DESIGN: Prospective study. SETTING: Kidney Transplantation Unit. SAMPLE: 20 patients submitted to non-complicated kidney transplant, with a normal urinary tract and no risk factors present regarding urinary infection. Aged 15 to 65 years. MAIN MEASUREMENTS: Before the transplant, material from the urethral meatus and urine were collected for culture. After the transplant, in the period during which the patient was with short-term urethral catheterization (4 to 5 days), material from the urethral meatus and urine from the bladder and the collecting bag were taken daily from all recipients for culture. RESULTS: There was a predominance of coagulase-negative Staphylococcus and S. viridans in the normal urethral meatus flora and in the first two days of urethral catheterization. After the second day, there was a predominance of E. coli and E. faecalis. Urinary infection did not occur during the period of urethral catheterization. In the follow up only one female patient (7%) had asymptomatic bacteriuria caused by E.coli after the withdrawal of the urethral catheter. CONCLUSIONS: Infection urinary does not occur during the period of urethral catheterization in kidney post-transplant patients. Thus, antimicrobial prophylaxis is not recommended for these patients to prevent urinary infection.

Incisional hernia and its repair with polypropylene mesh in renal transplant recipients.

PURPOSE: We evaluate the incidence of incisional hernia after kidney transplantation, predisposing factors and the results of surgical repair with polypropylene mesh. MATERIALS AND METHODS: We reviewed the records of 371 consecutive kidney transplants performed between April 1995 and February 2000. Patients with clinical signs of hernia at the transplant incision site were included in the study. Predisposing factors for incisional hernia were also reviewed. A prospective protocol of surgical correction was established using polypropylene mesh and patient outcome was studied. RESULTS: We identified 14 patients (3.8%) with an incisional hernia at the transplant incision site. Hernias developed 3 to 840 days after transplant surgery and were significantly more common in white (p = 0.019) and cadaveric graft (p = 0.02) recipients. Predisposing factors in 11 cases included complications of transplant surgery in 7, bladder obstruction in 2, large polycystic kidneys in 1 and chronic pulmonary disease in 1. Surgical repair was performed by primary fascial approximation and polypropylene mesh reinforcement in 13 cases and by pre-peritoneal mesh placement in 1. Minor subcutaneous wound infection developed in 1 patient. No relapses were noted at a mean followup of 17.8 months. CONCLUSIONS: In the majority of cases incisional hernia develops in the first 3 months after transplant surgery. The incidence is significantly higher in white patients and after cadaveric donor transplantation. Surgical complications of transplant surgery are important predisposing factors for incisional hernia after kidney transplantation. Surgical repair using polypropylene mesh is safe and effective in this group of patients.

Introduction of mycophenolate mofetil and cyclosporin reduction in children with chronic transplant nephropathy.

Chronic transplant nephropathy (CTN) is the most important cause of kidney graft dysfunction. Studies in adult populations have reported a beneficial effect of non-nephrotoxic mycophenolate mofetil (MMF) on graft function in this setting. However, few studies were reported in children in this setting. We therefore reviewed the charts/medical records of renal transplanted patients < 18 yr of age at a single center who had switched from azathioprine to MMF as a result of progressive loss in graft function, for which vascular, infectious, and urological causes were excluded. Serum creatinine (SCr) and calculated creatinine clearance were compared prior to and after MMF introduction. Thirteen patients (nine male/four female), followed-up for 59.3 +/- 35.4 months after transplantation, were analyzed. Age at MMF introduction was 14.2 +/- 3.6 yr. In 11 patients a previous biopsy had shown features of CTN and four patients also presented signs of chronic cyclosporin A (CsA) nephrotoxicity. MMF was started at a dose of 1211 +/- 351 mg/day, and the CsA dose was decreased from 6.69 +/- 3.15 mg/kg/day 6 months before MMF to 4.8 +/- 2.3 mg/kg/day at the time of MMF introduction. CsA was withdrawn in four patients. The median (25-75%) SCr value increased from 1.60 mg/dL (range 1.3 to 1.87 mg/dL) 6 months before MMF to 2.2 mg/dL (range 1.87-2.32 mg/dL) when MMF was introduced. Six months after introduction of MMF, the SCr level had decreased to 1.5 mg/dL (range 1.2-1.8 mg/dL) and remained stable until the last follow-up (17.5 +/- 9.2 months after MMF was started). A similar pattern occured with calculated SCr clearance. There were no acute rejections after changes in immunosuppression. The safety of MMF was also analyzed and in only one patient was the drug stopped as a result of intractable diarrhea. These findings suggest that MMF is sufficiently powerful to allow a decrease/withdrawal of CsA without the burden of acute rejection in a pediatric population with CTN.