Correlation between Neoral 2 hours post-dose levels and histologic findings on surveillance biopsies.

Use of 2-hour postdose (C2) monitoring has been a major step in optimizing immunosuppression following kidney transplantation, and extensive data has confirmed the superiority of C2 monitoring over the conventional trough monitoring (C0) in reducing the occurrence of acute rejection early after transplantation. In this retrospective study, we explored the relationship between Neoral pharmacokinetic parameters and the presence of subclinical rejections (ScRj). In the absence of acute rejection, lower C2 level was associated with more frequent episodes of ScRj. C0 monitoring was not predictive of AR, ScRj or any combinations thereof. Fast elimination in a subgroup of patients is not detected by the C0 and may lead to unnecessary increase of the drug dosage and increased risk of rejection.

Laparoscopic hand-assisted living donor nephrectomy: the Calgary experience.

Laparoscopic techniques, such as hand-assisted live donor nephrectomy (HALDN), have the potential to increase the number of living kidney donors. For these techniques to be acceptable, however, the standards for donor, recipient, and graft survival achieved by the open technique need to be matched. In this study we present the results of the first 20 HALDN procedures at our center. The 20 donors included nine men and 11 women of mean (+/-SD) donor age 41 (+/-10) years and mean donor weight 78 (+/-13) kg. Mean operative time was 174 (+/-32) minutes. Only one patient required an open conversion to procedure because of venous bleeding. All kidneys were successfully implanted; there were no episodes of primary nonfunction or delayed graft function. There were no surgical complications, either in the donor or the recipient. The range of postoperative stay was 3 to 5 days. One recipient died 62 days after transplant from influenza virus pneumonia. There were no other causes of graft loss. Our preliminary results suggest that HALDN is safe and is associated with short-term donor, recipient, and graft outcomes that are at least comparable to the standard open technique.

Early gastric post-transplantation lymphoproliferative disorder and H pylori detection after kidney transplantation: a case report and review of the literature.

The incidence of post-transplantation lymphoproliferative disorder (PTLD) in the adult renal transplant population ranges from 0.7% to 4%. The majority of cases involve a single site and arise, on average, seven months after transplantation. Histopathology usually reveals B-cell proliferative disease and has been standardized into its own classification. Treatment modalities consist of decreased immunosuppression, eradication of Epstein-Barr virus, surgical resection, systemic chemotherapy and monoclonal antibody therapy; however, mortality remains high, typically with a short survival time. In patients who have undergone renal transplantation, approximately 10% of those with PTLDs present with gastrointestinal symptomatology and disease. Reported sites include the stomach, and small and large bowel. Very few cases of Helicobacter pylori or mucosal-associated lymphoid tissue have been described in association with PTLD. In the era of cyclosporine immunosuppression, the incidence of PTLD affecting the gastrointestinal tract may be increasing in comparison with the incidence seen with the use of older immunosuppression regimens. A case of antral PTLD and H pylori infection occurring three months after renal transplantation is presented, and the natural history and management of gastric PTLD are reviewed.

Random protein-creatinine ratio for the quantitation of proteinuria in pregnancy.

OBJECTIVE: To compare random urine protein-creatinine ratios with 24-hour urine protein excretion rates in patients hospitalized with hypertensive disorders in pregnancy. METHODS: All hospitalized, hypertensive patients requiring 24-hour urine protein excretion collections were eligible for the study. During the 24-hour urine collection a separate 2-mL aliquot was taken for a protein and creatinine determination. RESULTS: Seventy-one samples were collected from patients with the following diagnoses: gestational hypertension (n = 56), preexisting hypertension and superimposed gestational hypertension (n = 11), and syndrome of hemolysis, elevated liver enzymes and low platelets (n = 4). The correlation coefficient between the random protein-creatinine ratio and the 24-hour urine protein excretion was 0.94. Calculated excretion rates with at least 300 mg protein in 24 hours had a sensitivity of 0.93, specificity of 0.90, and positive and negative predictive values of 0.87 and 0.95, respectively. For those samples with calculated excretion rates at least 5 g protein in 24 hours, the sensitivity was 1.00, specificity was 0.99, and positive and negative predictive values were 0.75 and 0.99, respectively. CONCLUSION: In nonambulatory hypertensive pregnant patients, there is a strong correlation between random voided protein-creatinine ratios and 24-hour urine protein excretions.

Parvovirus B19-induced constellation of acute renal failure, elevated aminotransferases and congestive heart failure.

This report details a case of acute renal failure and elevated aminotransferases with subsequent development of congestive heart failure in a patient with history of exposure to parvovirus B19 and serological evidence of acute infection with this agent. This constellation of organ involvement has not been previously reported in the literature.

Dense deposit disease in association with monoclonal gammopathy of unknown significance.

Several renal pathologic entities have been reported in patients with lymphoplasmacytic disorders with their typical excess immunoglobulin production. We report dense deposit disease in a patient who was discovered to have an IgG kappa monoclonal protein without clinical evidence of underlying lymphoplasmacytic malignancy during investigation for chronic renal failure with associated nephrotic range proteinuria. This case is unusual since dense deposit disease occurs only rarely in older patients and has not been reported in association with monoclonal gammopathy of unknown significance. Because of the diversity of renal lesions associated with lymphoplasmacytic disorders, renal biopsy is necessary to assess the type of renal lesion in this patient population.

Metabolic acidosis in hemodialysis patients: a study of prevalence and factors affecting intradialytic bicarbonate gain.

The correction of uremic acidosis is one of the goals of hemodialysis; however, despite acceptable hemodialysis protocols, metabolic acidosis remains a common problem. The prevalence of acidosis and significance of factors affecting bicarbonate flux during hemodialysis were studied. A cohort of 70 stable patients receiving high-efficiency hemodialysis for at least 4 months was studied prospectively over a 1-year period. Twenty patients (28%) had a mean predialysis serum bicarbonate of less than 21 mEq/L. The patients with or without metabolic acidosis had similar mean net ultrafiltration and percent ultrafiltration, but acidotic patients had a higher percent increase in bicarbonate during hemodialysis (35 +/- 12 versus 27 +/- 10 [p = 0.008]). The latter suggests an increased net daily acid gain in patients with metabolic acidosis (1.19 +/- 0.32 mEq/kg versus 1.05 +/- 0.35 mEq/kg [p = 0.04]). A review of factors affecting intradialytic bicarbonate gain showed that predialysis serum bicarbonate (diffusive gradient) was the most significant with a demonstrated linear relationship between these two variables (R2 0.51). The role of dialysance and blood flow, assessed together using percent urea reduction, was minor as was the effect of ultrafiltration. At our level of dialysis delivery, prevalence of metabolic acidosis is low, and dialysis-related factors do not contribute to the persistence of metabolic acidosis. Net daily acid gain was higher in acidotic patients and accounts for the long-term maintenance of metabolic acidosis. For individual dialysis treatments, the diffusive gradient is the most important determinant of bicarbonate gain, with only a minor role being demonstrated for percent urea reduction and ultrafiltration rate.

Economic appraisal of maintenance parenteral iron administration in treatment of anaemia in chronic haemodialysis patients.

BACKGROUND: Iron deficiency is common in haemodialysis patients and adequate supplementation by the oral or parenteral route has been limited by drug side-effects, absorption, and cost. Intermittent doses of intravenous iron dextran complex are recommended in patients with inadequate iron stores despite maximal tolerated oral dose. We conducted a prospective study with economic analysis of a regular maintenance intravenous iron regimen in this group of patients. METHODS: Fifty patients comprising one-half of our haemodialysis population required intravenous iron treatment, i.e. they failed to achieve an arbitrary goal serum ferritin 100 microg/l despite maximal tolerated oral iron dose. After a loading dose of intravenous iron dextran complex (IV-FeD) based on Van Wyck's nomogram (400+/-300 mg) they received a maintenance dose of 100mg IV-FeD once every 2 weeks. Initial goal serum ferritin was set at 100-200 microg/l. If no increase in haemoglobin was achieved at this level, transferrin saturation was measured to assess bioavailable iron, and when less than 20%, goal serum ferritin was increased to 200-300 microg/l. Recombinant human erythropoietin (rHuEpo) was used where needed to maintain haemoglobin in the 9.5-10.5 g/l range only if ferritin requirements were met. Results. Mean haemoglobin rose from 87.7+/-12.1 to 100.3+/-13.1 g/l (P<0.001, Cl 7.7-17.9) at mean follow-up of 6 months (range 3-15 months). In patients on rHuEpo, dose per patient was reduced from 96+/-59 u/kg per week to 63+/-41 u/kg per week, representing a 35% dose reduction (P<0.05, Cl 1-65). An annual cost reduction of $3166 CDN was projected; however, in the first year this is offset by the cost of the loading dose of IV-FeD required at the beginning of treatment. No adverse reactions were encountered. CONCLUSION: Iron deficiency is very common in our haemodialysis population, especially in those patients receiving rHuEpo. A carefully monitored regimen of maintenance parenteral iron is a safe, effective, and economically favourable means of iron supplementation in patients with insufficient iron stores on maximum tolerated oral supplements.