Predicting 5-year survival after kidney transplantation in Colombia using the survival benefit estimator tool.

INTRODUCTION: A complex relationship between donor and recipient characteristics influences kidney transplant (KT) success. A tool developed by Bae S. et al. (Survival Benefit Estimator, SBE) helps estimate post-KT survival. We aim to evaluate the predictive performance of the SBE tool in terms of 5-year patient survival after a kidney transplant. METHODS: A retrospective cohort study of all deceased-donor KT recipients between January 2009 to December 2021. A descriptive analysis of clinical and sociodemographic characteristics was performed. The SBE online tool was used to calculate the predicted patient survival (PPS) and the survival benefit at five years post-KT. Comparisons between predictive vs. actual patient survival were made using quintile subgroups. Three Cox regression models were built using PPS, EPTS, and KDPI. RESULTS: A total of 1145 recipients were evaluated. Mortality occurred in 157 patients. Patient survival was 86.2%. Predictive survival for patients if they remained on the waiting list was 70.6%. The PPS was 89.3%, which results in a survival benefit (SB) of 18.7% for our population. Actual survival rates were lower than the predicted ones across all the quintiles. In unadjusted analysis, PPS was a significant protective factor for mortality (HR 0.66), whereas EPTS (HR 8.9) and KDPI (HR 3.25) scores were significant risk factors. The discrimination of KDPI, PPS, and EPTS scores models were 0.59, 0.65, and 0.66, respectively. CONCLUSION: SBE score overestimated actual survival rates in our sample. The discrimination power of the score was moderate, although the utility of this tool may be limited in this specific population.

Comparison of Three Glomerular Filtration Rate Estimating Equations with 24-Hour Urine Creatinine Clearance Measurement in Potential Living Kidney Donors.

Background: The accuracy of the measurement of renal function in potential living kidney donors (PLKD) is essential. The direct measurement of glomerular filtration rate (mGFR) has been considered the "gold standard." The estimated GFR (eGFR) with 24-hour urinary creatinine clearance (CrCl) is frequently used because of its availability. We aim to evaluate the correlation and agreement of eGFR using serum-based creatinine formulas (Cockcroft-Gault, MDRD, and CKD-EPI) and the eGFR based on 24-hour urinary CrCl to evaluate kidney function in PLKD. Methods: We evaluated the kidney function in 799 PLKD using 24-hour urinary CrCl method and compared the correlation and agreement with the eGFR based on creatinine formulas (Cockcroft-Gault, MDRD, and CKD-EPI). We calculated the mean bias (difference), precision (SD of this difference), accuracy, and performed Bland-Altman plots. Results: A total of 799 PLKD were analyzed. The age of the PLKD ranged from 18 to 73 years. Weak to mild correlation was observed between 24-hour urinary CrCl and all formulas (ranged from 0.31 to 0.49). The three equations underestimated the GFR. Using the Bland-Altman graphic, we observed that the CKD-EPI was the least scattered and most precise; however, mean bias and the interval range (limits of agreement) of all formulas were too big to assume equivalence between 24-hour urinary CrCl method and eGFR based on creatinine. Results of mean bias were similar when comparing the three equations in patients with CrCl GFR <60. However, the accuracy of all formulas was better for the female group and the youngest individuals (≤40 years old). Conclusion: In this PLKD cohort, of all the three equations, the CKD-EPI was the least scattered and most precise. However, the correlation and the level of agreement between the three equations and 24-hour urinary CrCl were too low to assume the equivalence.

Resultados en receptores de trasplante renal de donantes cadavéricos con infección por SARS-CoV-2: Una serie de casos en un centro de trasplante en Colombia / Results in kidney transplant recipients from cadaveric donors with SARS-CoV-2 infection: A case series in a transplant center in Colombia

Introducción. La pandemia por COVID-19 ha causado la muerte de 6,5 millones de personas en el mundo y la donación de órganos se ha visto ampliamente afectada, reflejándose en una disminución importante en el número de trasplantes. Colombia no ha sido ajena a dicha problemática. Ante este desafío, el Instituto Nacional de Salud ha permitido tomar donantes cadavéricos con reacción en cadena de la polimerasa con transcripción reversa (RT-PCR) positiva para Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), sin enfermedad activa. El objetivo de este estudio fue describir una serie de pacientes trasplantados de riñón con donantes cadavéricos con RT-PCR SARS-CoV-2 positivo y sus principales desenlaces clínicos. Métodos. Serie de casos de pacientes que fueron llevados a trasplante renal con donante cadavérico con SARS-CoV-2 positivo, sin enfermedad activa, entre mayo y agosto de 2022. Se recolectaron las variables demográficas y clínicas y se evaluó la infección y la mortalidad asociada a SARS-CoV-2 en un mes de seguimiento. Resultados. Un total de 5 receptores de trasplante renal con 5 donantes cadavéricos SARS-CoV-2 positivos fueron evaluados. No se presentó mortalidad ni pérdida del injerto renal. Se registraron dos casos de función retardada del injerto y un caso de rechazo agudo. Ninguno de los pacientes presentó RT-PCR SARS-CoV-2 positiva en el seguimiento posterior al trasplante. Conclusión. Con nuestra serie de casos mostramos que el trasplante de riñón proveniente de donante cadavérico con prueba positiva para RT-PCR SARS-CoV-2, sin evidencia de enfermedad COVID-19 activa, es un procedimiento seguro y una estrategia eficaz para aumentar el número de donantes en pandemia

Introduction. Coronavirus Disease-2019 (COVID-19) pandemic have caused the death of 6.5 million of people worldwide. The organ donation was extremely affected reflecting in the number of transplants. Colombia has not been immune to this problem. Facing this challenge, the National Institute of Health (Instituto Nacional de Salud, INS) allowed to assign cadaveric donors with reverse transcription-polymerase chain reaction (RT-PCR) severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positive without COVID-19. We aim to describe a case series of kidney transplant patients with RT-PCR SARS-CoV-2 positive cadaveric donors, and their main clinical outcomes. Methods. A case series of five patients who underwent kidney transplantation of cadaveric donors with positive RT-PCR SARS-CoV-2 during the study period from May to august of 2022. Demographics and clinical characteristics were collected from the institutional medical records, and we evaluated the mortality and infection associated with SARS-CoV-2. Results. A total of five kidney transplant recipients and five cadaveric donors with positive RT-PCR SARS-CoV-2 were described in the present study. There were not mortality reported and none of the patients had graft loss. Two cases of delayed graft function and one case of acute kidney rejection were documented. None of the patients had positive RT-PCR SARS-CoV-2 in the follow-up. Conclusion. Our series demonstrated that the kidney transplant of cadaveric donors with positive RT-PCR SARS-CoV-2 without clinical evidence of active COVID-19 disease is a safe procedure and an efficient strategy to increase donors during a pandemic

Clinical Outcomes in Living Donor Kidney Transplantation: A Single Center Experience in Latin America.

BACKGROUND: In Latin America, few reports are available about the clinical outcomes of living donor kidney transplants (LDKT). We aim to evaluate the main clinical outcomes for LDKT patients in a single center's experience. METHODS: We retrospectively evaluated 530 LDKT patients who underwent transplantation from August 2008 to December 2020 at Colombiana de Trasplantes. Graft survival censored for death and patient survival were determined up to 5 years post-transplantation by the Kaplan-Meier method. Vascular and urinary complications, readmission, and reintervention rates were documented. RESULTS: A total of 530 LDKT patients were analyzed. Most of the recipients were men (56%). There were 123 patients (23.2%) with a preemptive transplant. Panel reactive antibody type I and II had higher immunologic risk (>20%) in 15.9% of the patients. The donor mean age was 37.8 ± 11.5 years. Most of the donors were women (52.6%) and related to the recipient (69.1%). Multivariate analysis identified panel reactive antibody type II (P = 0.003), female donor (P = 0.001), surgical reintervention at 30 days post-transplantation (P < .01), and delayed graft function (P < .01) as risk factors for graft loss. The graft survival death-censored rates were 93.7% and 89% at 1 and 5 years, respectively. Patient survival rates were 97.0% and 94.1% at 1 and 5 years after transplantation, respectively. CONCLUSIONS: The long-term graft and patient survival rates in our center are comparable to previous reports from other leading centers. The clinical outcomes from a medium-sized center can be noteworthy, although not entirely new.

The use of intraoperative mannitol during the laparoscopic nephrectomy in living kidney donor and the prevention of delayed graft function / Uso de manitol intraoperatorio durante la nefrectomía por laparoscopia en donante vivo de riñón y la prevención de función retardada del injerto

Background and objectives: The administration of mannitol during laparoscopic hand-assisted nephrectomy in the living donor has been controversial with various recommendations about it. This study aims to evaluate the effect of the intraoperative mannitol in the living kidney donor and the incidence of delayed graft function (DGF). Methods: This study was a retrospective observational study with living kidney transplant recipients and donors who underwent laparoscopic hand-assisted nephrectomy at Colombiana de Trasplantes from January 2015 to September 2019. We assessed the impact of mannitol administration in living donors on the main transplant outcomes such as DGF, urinary volume, acute rejection, and mortality at 3 months of follow-up. We performed a descriptive analysis of demographics and clinical variables in our cohort. Results: A total of 367 recipients were evaluated. The incidence of DGF was 5.9% without mannitol versus 6.2% with mannitol (p = 0.99). The acute rejection episodes (12.2% without mannitol versus 4.7% with mannitol) had a trend difference between the comparative groups, but it was still not significant in the bivariate analysis (p = 0.06). The mortality rate in the recipient was not significant (p = 0.69). The mean serum creatinine did not have significant differences at 1 and 3 months of follow-up comparing both groups. Conclusion: The use of mannitol in living donors does not have a significant impact on the incidence of DGF in kidney recipients. A trend of association between mannitol administration and reduced acute rejection episodes was observed, though it was not statistically significant.

Antecedentes y objetivo: La administración de manitol durante la nefrectomía laparoscópica en el donante vivo ha sido discutida con diversas recomendaciones. El objetivo es evaluar la administración de manitol intraoperatorio en el donante vivo de riñón y la incidencia de función retardada del injerto en el receptor. Métodos: Estudio observacional retrospectivo con receptores de riñón y donantes vivos que tuvieron nefrectomía laparoscópica en Colombiana de Trasplantes entre enero de 2015 a septiembre de 2019. Evaluamos el impacto de administrar manitol en los principales desenlaces del trasplante: función retardada del injerto, volumen urinario, rechazo agudo y mortalidad del receptor a los 3 meses post-trasplante. Se realizó un análisis descriptivo de las características demográficas y clínicas. Resultados: Se evaluaron 367 receptores con una incidencia de función retardada del injerto de 5.9% sin manitol versus 6.2% con manitol (p = 0,99), el rechazo agudo (12,2% sin manitol versus 4,7% con manitol) tuvo una tendencia de diferencia entre ambos grupos no significativa (p = 0,06) y la mortalidad del receptor tampoco mostró diferencias significativas (p = 0,69). La media de creatinina sérica al mes y 3 meses no tuvo diferencias significativas en los grupos. Conclusión: El uso de manitol en los donantes vivos de riñón no impactó significativamente la incidencia de función retardada del injerto en los receptores de trasplante. Se encontró una tendencia de asociación en la administración de manitol intraoperatorio y la reducción de los episodios de rechazo agudo al tercer mes post-trasplante en los receptores. No obstante, esta tendencia no tuvo la suficiente relevancia estadística.

Risk Factors for Urologic Complications After Kidney Transplantation and Impact in Graft Survival.

Background and Purpose: Kidney transplantation (KT) is the best therapy for chronic kidney disease (CKD). Major urologic complications (MUCs) are the second etiology associated to morbidity and graft loss following KT, after rejection episodes. The objective of this study was to estimate the incidence, risk factors and impact on graft survival associated to urological complications in KT patients. Patients and Methods: A retrospective cohort based on electronic patient files of kidney transplant recipients from Colombiana de Trasplantes was created for the period August 2008 to September 2019. Initiation of follow-up was defined as the date of transplantation up to 3 years post-transplantation. Incidence of ureteral stenosis, ureteral obstruction, and ureteral leak was measured. A logistic regression multivariate model was adjusted to determine the associated factors to MUCs (yes/no). Patient and graft survival time were analyzed using a Kaplan-Meier method. Results: A total of 1584 KT patients were included in the cohort. MUCs were present in 195 (12.6%) KT patients. We found that dialysis duration (OR: 1.004; p = 0.02) remained significant for the incidence of MUCs in KT patients of deceased donors. Probability of graft and patient survival at 3 years of follow-up was 90.5% and 85.5%, respectively. No significant difference was found on graft and patient survival in KT patients with or without MUCs. Conclusion: MUCs are frequent complications for KT. We did not observe significant differences in graft or patient survival according to the presence of MUCs. The identification of MUCs and risk factors may guide transplant teams for future surgical and clinical decisions.

Nephrogenic Systemic Fibrosis in Patients with Chronic Kidney Disease after the Use of Gadolinium-Based Contrast Agents: A Review for the Cardiovascular Imager.

Gadolinium-enhanced cardiac magnetic resonance has revolutionized cardiac imaging in the last two decades and has emerged as an essential and powerful tool for the characterization and treatment guidance of a wide range of cardiovascular diseases. However, due to the high prevalence of chronic renal dysfunction in patients with cardiovascular conditions, the risk of nephrogenic systemic fibrosis (NSF) after gadolinium exposure has been a permanent concern. Even though the newer macrocyclic agents have proven to be much safer in patients with chronic kidney disease and end-stage renal failure, clinicians must fully understand the clinical characteristics and risk factors of this devastating pathology and maintain a high degree of suspicion to prevent and recognize it. This review aimed to summarize the existing evidence regarding the physiopathology, clinical manifestations, diagnosis, and prevention of NSF related to the use of gadolinium-based contrast agents.

Embolización transcatéter del injerto renal en pacientes con síndrome de intolerancia: reporte de tres casos en un grupo de trasplantes

Introducción el síndrome de intolerancia es un proceso inflamatorio que ocurre hasta en un tercio de los pacientes con pérdida del injerto. Cuando no se obtiene una mejoría de los síntomas con el manejo médico, se indica la realización de nefrectomía del riñón trasplantado, sin embargo, este es un procedimiento invasivo que puede estar asociado a mayor morbilidad y mortalidad. Dada la fragilidad de estos pacientes, se plantea la embolización transcatéter del injerto como una alternativa válida y menos invasiva para el tratamiento de este síndrome. Objetivo describir el uso de la embolización transcatéter como tratamiento al síndrome de intolerancia del injerto. Presentación del caso se reportan tres casos clínicos de pacientes con sintomatología de entre 15 y 20 días de evolución, consistentes en dolor y tumefacción sobre riñón trasplantado y otros signos y síntomas reportados fueron fiebre, hiporexia, pérdida de peso y hematuria macroscópica. Se describe la evolución de los síntomas que en ninguno de los casos expuestos tuvieron mejoría con el ajuste inmunosupresor, descartando en todos los casos etiología infecciosa y estableciéndose así la sospecha síndrome de intolerancia del injerto. Los pacientes fueron manejados con embolización transcatéter de la arteria del riñón trasplantado y el éxito del tratamiento se definió por la resolución de los síntomas. Discusión y conclusión entre las primeras 24-48 horas posprocedimiento, los pacientes presentaron una evolución satisfactoria y, finalmente, egreso. La embolización transcatéter del injerto es una alternativa segura a la nefrectomía del trasplante y que es menos invasiva para el tratamiento del síndrome de intolerancia del injerto.

Background The renal graft intolerance syndrome is an inflammatory process that occurs in one third of the kidney transplant patients with graft loss. If medical treatment for intolerance graft syndrome is not effective, there is an indication of graft nephrectomy. However, graft nephrectomy has higher morbidity and mortality compared to non-invasive techniques. Due to a high fragility in kidney transplant patients, the renal arterial embolization has become a useful minimally invasive therapeutic option for intolerance graft syndrome. Objective We aim to describe the use of renal arterial embolization for renal graft intolerance syndrome. Case presentation We report three clinical cases who were admitted to the emergency department for a history of twenty days of graft pain and swelling. These patients had fever, hyporexia, weight loss and macroscopic hematuria. None of the cases had clinical improvement with immunosuppression adjustment and a diagnosis of renal graft intolerance syndrome was made dismissing infection. Patients were treated with renal arterial embolization and its procedure success were determined as the symptom's resolution. Discussion and conclusion After 24- and 48-hours post-embolization, patients were successfully recovered and discharged in the hospital. Renal graft arterial embolization is a safe and non-invasive alternative to graft nephrectomy to treat renal intolerance syndrome.

Risk factors for graft loss and death among kidney transplant recipients: A competing risk analysis.

INTRODUCTION: Kidney transplantation is the best therapeutical option for CKD patients. Graft loss risk factors are usually estimated with the cox method. Competing risk analysis could be useful to determine the impact of different events affecting graft survival, the occurrence of an outcome of interest can be precluded by another. We aimed to determine the risk factors for graft loss in the presence of mortality as a competing event. METHODS: A retrospective cohort of 1454 kidney transplant recipients who were transplanted between July 1, 2008, to May 31, 2019, in Colombiana de Trasplantes, were analyzed to determine risk factors of graft loss and mortality at 5 years post-transplantation. Kidney and patient survival probabilities were estimated by the competing risk analysis. The Fine and Gray method was used to fit a multivariable model for each outcome. Three variable selection methods were compared, and the bootstrapping technique was used for internal validation as split method for resample. The performance of the final model was assessed calculating the prediction error, brier score, c-index and calibration plot. RESULTS: Graft loss occurred in 169 patients (11.6%) and death in 137 (9.4%). Cumulative incidence for graft loss and death was 15.8% and 13.8% respectively. In a multivariable analysis, we found that BKV nephropathy, serum creatinine and increased number of renal biopsies were significant risk factors for graft loss. On the other hand, recipient age, acute cellular rejection, CMV disease were risk factors for death, and recipients with living donor had better survival compared to deceased-donor transplant and coronary stent. The c-index were 0.6 and 0.72 for graft loss and death model respectively. CONCLUSION: We developed two prediction models for graft loss and death 5 years post-transplantation by a unique transplant program in Colombia. Using a competing risk multivariable analysis, we were able to identify 3 significant risk factors for graft loss and 5 significant risk factors for death. This contributes to have a better understanding of risk factors for graft loss in a Latin-American population. The predictive performance of the models was mild.

Telemedicina para seguimiento de pacientes renales trasplantados durante la pandemia por COVID-19

Contexto: la pandemia por COVID-19 generó la reestructuración de los servicios de salud en el mundo. La teleconsulta ofrece el acceso a la atención en salud a distancia como estrategia de mitigación a la propagación del virus y como una forma flexible de telemedicina. Objetivo: describir los resultados de atención en salud por modalidad de teleconsulta en pacientes trasplantados durante el inicio de la pandemia por COVID-19. Metodología: estudio descriptivo de corte transversal que describe la experiencia del uso de la teleconsulta en el inicio de la pandemia por COVID-19 en un centro de trasplante de órganos en Colombia. La información fue obtenida mediante la recolección directa de la atención en el mes de abril de 2020 y a través del envío de un cuestionario electrónico, estructurado para los pacientes atendidos por teleconsulta. Resultados: un total de 1139 pacientes con trasplante renal fueron valorados en la modalidad de teleconsulta. Alrededor del 50 % de los pacientes atendidos vivían fuera de áreas metropolitanas (n = 564) y un total de 292 (de 800 contactados) respondieron la encuesta enviada con una media de edad de 48 años. Los pacientes presentaron altos porcentajes de satisfacción con el modelo de teleconsulta (n = 278, lo que equivale al 94 %). Se presentaron dos casos sospechosos de COVID-19, los cuales fueron negativos al realizar la prueba de PCR-RT. Conclusiones: la teleconsulta es una herramienta útil en la mitigación de la emergencia sanitaria, con un alto potencial que genera mayor acceso y oportunidad de atención en salud, presentando altos índices de aceptación.

Introduction: The COVID-19 pandemic led to the restructuring of health services around the world. Teleconsultation offers access to remote health care and a mitigation strategy. Purpose: Describe the results of a teleconsultation program in a transplant center at the beginning of the COVID-19 pandemic. Methodology: Descriptive cross-sectional study describing the experience of the use of teleconsultation during the beginning of the COVID-19 pandemic at an organ transplant center in Colombia. The information was obtained by directly collecting the total number of patients treated during April 2020 and by sending a structured electronic questionnaire to the patients involved in the care. Results: A total of 1139 renal transplant patients were assessed by teleconsultation. The geographical distribution of patients in metropolitan areas and outside the metropolitan area were similar (n=575 and n=564, respectively). Of the total, 292 patients responded to the survey sent with an average age of 48 years. The patients had high satisfaction with the teleconsultation model (n=278, 94%). There were 2 suspected cases of COVID-19, which were negative when performing the PCR-RT test. Conclusions: Teleconsultation is a useful tool in the mitigation of the health emergency, with a high potential, which generates greater access and health care opportunity, presenting high acceptance rates.

Safety and Intraoperative Results in Live Kidney Donors with Vascular Multiplicity After Hand-Assisted Laparoscopy Living Donor Nephrectomy.

BACKGROUND AND PURPOSE: Vascular multiplicity is the most frequent anatomic variation in kidney donors. Despite concerns about risks, these allografts are increasingly used to overcome the shortage of kidney donors. The safety and clinical outcomes in living kidney donors were evaluated with vascular multiplicity after hand-assisted laparoscopic living donor nephrectomy (HALDN). PATIENTS AND METHODS: Data from all living kidney donors who underwent HALDN from 2008 to 2021 was retrospectively reviewed. Patients were divided into two groups as single (SRV) and multiple renal vessels (MRV), and a comparative analysis was done. The primary outcomes include operating room time (ORT), days of hospital stay, estimated blood loss, complications, conversion, and re-operations. RESULTS: MRV were present in 166 out of 612 donors (27.1%). Among those, 10 (1.6%) donors had simultaneous multiple arteries and veins. Additionally, the prevalence of artery and vein multiplicity was 21.8% (n = 134) and 3.5% (n = 22), respectively. Warm ischemia time was significantly different among the two groups but not clinically important. The number of conversions to open technique, the mean ORT, the median blood loss, and days of hospital stay were similar between the SRV and MRV groups, without significant differences. According to the modified Clavien-classification system, no differences were found in the complication rates between the two groups (p = 0.29). Complication rates were 3.3% and 3.6% for the SRV and MRV groups, respectively. CONCLUSION: HALDN is a procedure with safe intraoperative results, even with vascular multiplicity. The presence of multiple renal arteries or veins has no negative impact on the outcome of the donor after living donor nephrectomy.

Desenlaces a largo plazo en pacientes trasplantados renales con donantes de criterios expandidos: experiencia de 10 años / Long-term outcomes in kidney transplant patients with expanded criteria donors: 10-year experience

Introducción. El trasplante renal es el tratamiento de elección para la enfermedad renal crónica. Debido a la brecha con la disponibilidad de donantes, el uso de criterios expandidos es una opción que busca mejorar la tasa de donación mundial. El objetivo de este estudio fue comparar la sobrevida del injerto y del paciente trasplantado con donante de criterios expandidos versus el donante estándar. Métodos. Cohorte retrospectiva de 1002 pacientes con trasplante renal donde se determinó la sobrevida del injerto renal y del receptor a 10 años después del trasplante. La sobrevida del injerto renal y el receptor fueron estimadas por el método de Kaplan-Meier. Una regresión de Cox fue realizada ajustando el modelo multivariado.Resultados. El análisis incluyó 1002 receptores, con un 18,8 % (n=189) que correspondían al uso de donante de criterios expandidos. El grupo de trasplante renal con donante de criterios expandidos tuvo menor sobrevida del paciente (48,1 % versus 63,8 %) y del injerto (63,3 % versus 74,7 %) en comparación con el grupo de trasplante renal con donantes con criterios estándar a los 10 años después del trasplante. La asociación de trasplante renal con donante de criterios expandidos y muerte o pérdida del injerto renal no fueron significativas cuando se ajustaron las variables en el modelo multivariado. Conclusión. El trasplante renal con donante de criterios expandidos tiene menor sobrevida del receptor y del injerto frente al grupo de trasplante renal con donante estándar. No hubo diferencias estadísticamente significativas en cuanto al trasplante renal con donante de criterios expandidos frente a la pérdida del injerto renal o muerte.

Introduction. Kidney transplantation is the treatment of choice for chronic kidney disease. Due to the gap with donor availability, the use of expanded criteria is an option that seeks to improve the global donation rate. The objective of this study was to compare the survival of the graft and the transplanted patient with an expanded criteria donor versus the standard donor. Methods. Retrospective cohort of 1002 kidney transplant patients where survival of the kidney graft and the recipient was determined at 10 years after transplantation. The survival of the kidney graft and the recipient were estimated by the Kaplan-Meier method. A Cox regression was performed by fitting the multivariate model. Results. The analysis included 1002 recipients with 18.8% (n=189) corresponding to the use of an expanded criteria donor. The expanded criteria donor kidney transplant group had lower patient (48.1% versus 63.8%) and graft (63.3% versus 74.7%) survival compared to the donor kidney transplant group with standard criteria at 10 years post-transplant. The association of kidney transplantation with expanded criteria donor and death or loss of the kidney graft were not significant when the variables were adjusted in the multivariate model. Conclusion. Kidney transplantation with an expanded criteria donor has a lower recipient and graft survival compared to the standard kidney transplant group. There were no statistically significant differences in expanded criteria donor kidney transplantation versus kidney graft loss or death.

Sobrevida del paciente adulto mayor y del injerto en trasplante renal / Patient and graft survival in the elderly kidney transplant recipients

Resumen Introducción: el trasplante renal es considerado la terapia más efectiva para el tratamiento de la enfermedad renal crónica (ERC). Recientemente, el trasplante renal ha aumentado en los pacientes mayores de 60 años, dado que presenta ventajas relevantes reportadas en la literatura mundial como un menor riesgo de morir, en comparación con pacientes de la misma edad que continúan en diálisis. Objetivo: evaluar la sobrevida del injerto y del paciente adulto mayor en una cohorte de pacientes con trasplante renal. Materiales y métodos: analizamos retrospectivamente una cohorte de 193 pacientes mayores de 60 años, quienes recibieron trasplante renal en el periodo comprendido entre 2008 a 2019 en nuestros centros de trasplante. Se analizaron variables sociodemográficas y clínicas para determinar la sobrevida del injerto y del paciente a 1, 5 y 10 años postrasplante, mediante el método de Kaplan-Meier. Se realizó un modelo de regresión de Cox para evaluar los potenciales factores de riesgo para pérdida del injerto renal en el primer año postrasplante. Resultados: la media de edad de los pacientes fue de 64,62 ± 3,82 años. La sobrevida del injerto censurada por muerte fue del 90 %, 86 % y 75 % en los años 1, 5 y 10 postrasplante, respectivamente, y la sobrevida del injerto no censurada fue del 82 %, 63 % y 43 %, respectivamente y en el mismo orden, en los mismos periodos documentados. Las principales causas de mortalidad fueron infecciones y enfermedad cardiovascular. La sobrevida del paciente adulto mayor fue del 89 %, 70 % y 55 % en los años 1, 5 y 10 postrasplante, respectivamente. Los factores de riesgo asociados a pérdida del injerto renal en el primer año postrasplante fueron: edad mayor a 70 años (HR 4,2; 95 % CI 1,1-15,3), sexo femenino (HR 2,7; 95 % CI 1,01-7,3) y no adherencia al tratamiento (HR 8,1; 95 % CI 2,1-30,7). Conclusión: los pacientes adultos mayores trasplantados tuvieron desenlaces adecuados en el trasplante renal. Es importante definir herramientas de evaluación del paciente adulto mayor que sean objetivas en el pretrasplante, donde la edad no sea una barrera de acceso al trasplante renal para esta población.

Abstract Background: Kidney transplantation is considered the most effective renal replacement therapy for chronic kidney disease. Recently, kidney transplantation is increasing in elderly recipients. Aged patients who have a kidney transplant have relevant advantages compared to dialysis reported in the literature such as better survival. Objective: We aimed to assess graft and patient survival in a cohort of elderly kidney transplant recipients. Materials and Methods: We retrospectively analyzed a cohort of 193 patients older than 60 years who received a kidney transplant from 2008 to 2019 in our transplant centers. Our study included sociodemographic and clinical variables to determine patient and graft survival at 1, 5 and 10 years after kidney transplantation using the Kaplan-Meier method. Cox regression analysis was used to evaluate the potential risk factors for graft loss during the first year of transplantation. Results: The mean recipient age was 64.62 ± 3.82 years old. The 1, 5 and 10-year death-censored graft survival rates were 90%, 86% and 75% and uncensored graft survival probability was 82%, 63% and 43% at 1, 5 and 10 years, respectively. The main mortality causes were infections and cardiovascular disease. Patient survival was 89%, 70% and 55% at 1, 5 and 10 years, respectively. Independent graft loss risk factors in the first year posttransplant were: age >70 (HR 4.2; 95% CI 1.1-15.3), female sex (HR 2.7; 95% CI 1.01-7.3) and non-compliance (HR 8.1; 95% CI 2.1-30.7). Conclusion: We found that older patients experience good outcomes following renal transplantation. There is a need to determine suitable older recipients based on objective selection criteria where age should not be a barrier to the kidney transplant.

Evaluación del conocimiento en donación de órganos y tejidos de los profesionales de salud asociados con servicios de cuidado crítico y urgencias / Assessment of Organ and Tissue Procurement Knowledge in Health Care Workers Associated to Critical and Emergency Care Units

RESUMEN Objetivo: Evaluar el nivel de conocimiento de profesionales en salud frente a la donación de órganos y tejidos en Barranquilla. Metodología: Estudio de corte transversal con encuesta semiestructurada sobre el conocimiento de la donación de órganos y tejidos en el personal de salud entre junio hasta diciembre de 2019. Se incluyen 232 profesionales de la salud en los servicios de Unidad de Cuidado Intensivo (UCI) adultos o pediátrica y Urgencias en seis Instituciones Prestadoras de Salud (IPS) de Barranquilla. Resultados: El 75 % de nuestros encuestados fueron mujeres. Se incluyó auxiliares de enfermería (43,5 %), profesionales en enfermería (25,4 %), médicos (22,8 %) y fisioterapeutas (8,2 %). El 84,5 % de los evaluados definió correctamente la muerte encefálica (ME); 50,4 % tiene conocimiento adecuado sobre la presunción en donación; el 52,4 % identifica apropiadamente la legislación, y el 78,9% conoce la activación de alerta en donación. No se encontraron resultados estadísticamente significativos en nivel de conocimiento comparado entre IPS (p=0.42), aunque se encontró una diferencia entre el concepto de presunción legal de la donación entre los servicios UCI adulto, pediátrica y Urgencias (p=0.000) y la definición de ME entre los profesionales asociados (p=0.001). Conclusión: Este diagnóstico del nivel de conocimiento en donación y trasplantes identificó una contundente necesidad de educación y entrenamiento continuo que podría ser gestionada con esfuerzos regionales en pro del mejoramiento del proceso y la tasa de donación de órganos y tejidos.

ABSTRACT Objective: To assess the knowledge level of organ donation and transplantation in health care workers at Barranquilla city in Colombia. Methodology: We performed a cross-sectional study from June to December 2019. Data were collected with the use of a semi-structured questionnaire regarding organ and tissue donation for transplant. This questionnaire was applied to 232 health care professionals associated with six health institutions located at Barranquilla. The main medical areas were adult and pediatric critical care units and emergency departments. Results: 75% of the participants were female. The study included nursing assistants (43,5%), nurses (25,4%), physicians (22,8%) and physiotherapists (8,2%). 84,5% of the participants had a correct definition of Brain Death (BD) and 50,4% had adequate knowledge about presumption consent in organ donation, 52,4% knew organ donation laws correctly, and 78,9% knew how to activate an organ donation alert. here was no significant difference in organ and tissue donation knowledge comparing the six health institutions (p=0.42). However, we found a significant difference in presumption consent in organ donation regarding medical areas (p=0.000), and ME definition distinguish between health care staff (p=0.001). Conclusion: We identified a need for education and training regarding organ and tissue donation in health care staff. Regional efforts should focus on improving the level of knowledge in these areas to increase the organ donor pool and strengthen transplant programs.

Herpes simplex virus-1 encephalitis in a kidney transplant patient / Encefalitis por herpes simple tipo 1 en paciente con trasplante renal

Abstract The incidence of herpes simplex virus-1 (HSV-1) infection in kidney transplant patients is 3% in those who have received antiviral prophylaxis versus 9.8% without prophylaxis. Herpes viruses usually cause mucocutaneous lesions and only occasionally cause visceral disease or central nervous system infection in immunosuppressed and immunocompetent patients. The gold standard for diagnosis is DNA detection using polymerase chain reaction (PCR) in the affected organ. According to the literature, it is treated with acyclovir, with which remission is expected in most cases without sequelae. Here we present the clinical case of a kidney transplant patient who had HSV-1 encephalitis (with the virus detected in the cerebrospinal fluid (CSF) through PCR), and received the standard treatment with complete recovery of his neurological state. (Acta Med Colomb 2020; 45. DOI:https://doi.org/10.36104/amc.2020.1387).

Resumen La infección por herpes simple tipo 1 (HSV tipo 1) en los pacientes con trasplante renal tiene una incidencia de 3% en quienes han recibido profilaxis antiviral versus 9.8% sin profilaxis. Los virus herpes habitualmente producen lesiones mucocutáneas y sólo en ocasiones causan patología visceral o infección del sistema nervioso central en pacientes inmunosuprimidos e inmunocompetentes. La prueba de oro estándar para su diagnóstico es la detección del ADN mediante la reacción de cadena polimerasa (PCR) en el órgano afectado. El tratamiento de acuerdo con la literatura es con aciclovir, con el cual se espera una remisión de la enfermedad en la mayoría de los casos sin secuelas. A continuación, presentamos el caso clínico de un paciente con trasplante renal quien cursó con encefalitis por HSV tipo 1 detectado en líquido cefalorraquídeo (LCR) mediante PCR, quien recibió tratamiento estándar con recuperación completa de su estado neurológico.(Acta Med Colomb 2020; 45. DOI:https://doi.org/10.36104/amc.2020.1387).

Linfohistiocitosis hemofagocítica por Histoplasma capsulatum en paciente con trasplante renal / Hemophagocytic Lymphohistiocytosis induced by Histoplasma capsulatum in a kidney transplant patient

La linfohistiocitosis hemofagocítica (LHH) por Histoplasma capsulatum, presentación rara de la histoplasmosis diseminada, es causada por la fagocitosis de las células hematopoyéticas por macrófagos tisulares. Presentamos el caso de un paciente masculino de 44 años con trasplante renal que asiste por fiebre sin otra sintomatología. Inicialmente se obtiene una gota gruesa positiva para P. vivax, iniciando manejo antimalárico. A los 2 días de tratamiento, el paciente presenta disfunción multiórganica, se rectifica diagnóstico en centro de referencia reportando en extendido de sangre periférica la presencia de levaduras de H. capsulatum en polimorfonucleares, resultado confirmado con prueba de inmunodifusión. Se ajusta manejo, pero el paciente fallece. El diagnóstico de infecciones por gérmenes inusuales con presentaciones inespecíficas es un reto en pacientes con inmunosupresión.

Hemophagocytic Lymphohistiocytosis (HLH) induced by Histoplasma capsulatum is a rare entity who is characterized by phagocytosis of hematopoietic cells by tissue macrophages. A 44-year-old male patient with kidney transplantation was admitted to our ambulatory service with fever. Initially, we performed a thick drop test who was positive for P. vivax, so antimalarial therapy was initiated. Patient then progressed to multiple organ dysfunction after 2 days of treatment. Thus, a reference center went back over the blood smear which revealed the presence of yeast cells H. capsulatum within polymorphonuclear cells. This result was confirmed by an immunodifussion assay. Despite of antifungal treatment, patient passed away. The diagnosis for unusual microorganism with unspecific clinical presentation could be a challenge in immunosupressive patients.

Acute Kidney Injury in Hospitalized Kidney Transplant Recipients.

BACKGROUND: Acute kidney injury (AKI) is a main cause of morbidity, hospitalization, and hospital readmission in kidney transplant recipients. We aimed to determine AKI incidence and risk factors following kidney transplant to assess outcomes such as renal function and graft loss after AKI. METHODS: We conducted a retrospective cohort study with hospitalized kidney transplant recipients during 2016 to 2017. Clinical data of 179 patients were reviewed. The primary outcome was AKI incidence and risk factors. To determine AKI occurrence, we based it on creatinine criteria from Acute Kidney Injury Network classification. RESULTS: We documented a total of 179 hospital admissions; AKI was diagnosed in 104 patients (58.1%). Recipients with higher baseline serum creatinine (odds ratio, 2.6; confidence interval [CI], 1.5-4.5; P < .001) and hospital admission because of infections (odds ratio, 2.4; CI, 1.1-5.2; P = .020) were more likely to experience AKI. A total of 19 recipients (10.6%) had graft loss with a significant AKI association (P = .003) at 12 months after admission. Intensive care unit length of stay (P = .63) and hospital stay (P = .55) were not different in patients with AKI compared with the control group. CONCLUSIONS: As a main clinical finding, we concluded that infections and higher serum creatinine baseline level were associated with the development of AKI.

Syndecan-2 Attenuates Radiation-induced Pulmonary Fibrosis and Inhibits Fibroblast Activation by Regulating PI3K/Akt/ROCK Pathway via CD148.

Radiation-induced pulmonary fibrosis is a severe complication of patients treated with thoracic irradiation. We have previously shown that syndecan-2 reduces fibrosis by exerting alveolar epithelial cytoprotective effects. Here, we investigate whether syndecan-2 attenuates radiation-induced pulmonary fibrosis by inhibiting fibroblast activation. C57BL/6 wild-type mice and transgenic mice that overexpress human syndecan-2 in alveolar macrophages were exposed to 14 Gy whole-thoracic radiation. At 24 weeks after irradiation, lungs were collected for histological, protein, and mRNA evaluation of pulmonary fibrosis, profibrotic gene expression, and α-smooth muscle actin (α-SMA) expression. Mouse lung fibroblasts were activated with transforming growth factor (TGF)-ß1 in the presence or absence of syndecan-2. Cell proliferation, migration, and gel contraction were assessed at different time points. Irradiation resulted in significantly increased mortality and pulmonary fibrosis in wild-type mice that was associated with elevated lung expression of TGF-ß1 downstream target genes and cell death compared with irradiated syndecan-2 transgenic mice. In mouse lung fibroblasts, syndecan-2 inhibited α-SMA expression, cell contraction, proliferation, and migration induced by TGF-ß1. Syndecan-2 attenuated phosphoinositide 3-kinase/serine/threonine kinase/Rho-associated coiled-coil kinase signaling and serum response factor binding to the α-SMA promoter. Syndecan-2 attenuates pulmonary fibrosis in mice exposed to radiation and inhibits TGF-ß1-induced fibroblast-myofibroblast differentiation, migration, and proliferation by down-regulating phosphoinositide 3-kinase/serine/threonine kinase/Rho-associated coiled-coil kinase signaling and blocking serum response factor binding to the α-SMA promoter via CD148. These findings suggest that syndecan-2 has potential as an antifibrotic therapy in radiation-induced lung fibrosis.