Long-term study of steroid avoidance in renal transplant patients: a single-center experience.

OBJECTIVES: Steroids have played a major role in renal transplantation for more than 4 decades. However, chronic use of steroids is associated with many comorbidities. This study aimed to assess the costs and benefits of a steroid-free immunosuppression regimen in a prospective randomized controlled study of living-donor renal transplantation, which was lacking in the literature. MATERIALS AND METHODS: In our study, 428 patients were enrolled to receive tacrolimus (Tac), mycophenolic acid (MPA), basiliximab (Simulect, Novartis, Basel, Switzerland) induction and steroids only for 3 days (214 patients, study group) and steroid maintenance (214 patients, control group). Median follow-up was 66 ± 41 months. RESULTS: We found that both groups showed comparable graft and patient survival, rejection episodes, and graft function. Posttransplantation hypertension was detected in 40% of the steroid-free group and 80% of the steroid maintenance group (P = .05), whereas posttransplantation diabetes mellitus was detected in 5% and 15% of these 2 groups, respectively (P = .3). CONCLUSIONS: Among low-immunological-risk recipients of living-donor renal transplants, steroid avoidance was feasible, safe, and had less morbidity outcome using Simulect induction, then Tac and MPA as maintenance immunosuppression. Steroid avoidance was associated with a lower total cost despite comparable immunosuppression cost, which was attributed to the lower cost of associated morbidities.

Study of the risk factors and complications of diabetes mellitus after live kidney donation.

OBJECTIVES: Kidney donors, similar to the general population, are at risk for developing type 2 diabetes mellitus (T2DM). The course of donors who develop T2DM has not been well studied. This work estimates the incidence of diabetes after kidney donation, and some risk factors and complications of diabetes mellitus postdonation. MATERIALS AND METHODS: This study examined the records of 2267 donors who donated one of their kidneys between 1976 and 2014 at the Urology and Nephrology Center, Mansoura University, Egypt, and who were regularly followed up at its outpatient clinic. A total of 388 donors were included in the study, and their medical records were revised. RESULTS: Postdonation weight gain and family history of diabetes mellitus were statistically significant for the development of diabetes mellitus, high or very high albuminuria, and/or decreased creatinine clearance. Metformin and insulin use seemed to significantly reduce the protein excretion and creatinine clearance decline in the studied group. CONCLUSIONS: There is a significant impact of a family history of diabetes mellitus on the development of high or very high albuminuria and/or decreased creatinine clearance.

Skin infections in Egyptian renal transplant recipients.

BACKGROUND: The risk of skin infections in renal transplant recipients (RTRs) has been described previously; however, it differs markedly by ethnic groups, skin type, and geographical location. We investigated the prevalence and nature of skin infections in a large series of RTRs in our locality in Egypt. PATIENTS AND METHODS: A total 302 RTRs (216 males and 86 females) were included in this study. They were screened for the presence of bacterial, fungal, and viral skin infections depending on clinical signs, Woods lamp examinations, culture, and biopsy if indicated. The patients were compared with 300 healthy controls matched for age and sex (200 males and 100 females). RESULTS: We found 191 (63.25%) RTRs had some kind of skin infection. Folliculitis (10.3%), tinea versicolor (30.1%), dermatophytosis (19.5%), and onychomycosis (7.6%) were statistically significantly more common in RTRs compared with control subjects. CONCLUSION: Our RTRs have higher prevalence rates of folliculitis and superficial fungal infections than the healthy population and they should be searched for in every patient with renal transplantation to ensure early treatment and avoid complications. Low-dose ketoconazole should be considered in renal transplant populations with high rates of superficial fungal infections, as it may reduce risk of such infections.

Pregnancy outcome after renal allograft transplantation: 15 years experience.

OBJECTIVE: To present our 15 years' experience in the management of 67 pregnancies in renal allograft recipients in Egypt. METHODS: A retrospective study of 67 pregnancies that occurred in 41 renal allograft recipients over the last 15 years. The study was performed in Department of Obstetrics & Gynecology, and Nephrology & Urology Center at Mansoura University, Egypt. RESULTS: Gestational diabetes occurred in 5.7%, infection in 13.4% and proteinuric hypertension in 19.2% of pregnancies. Graft dysfunction and obstructive uropathy occurred in 30.7% and 9.6% of pregnancies, respectively, but no episodes of graft rejection were reported. Pre-term labour was found in 40.9% and fetal growth retardation occurred in 19.2% of pregnancies. Perinatal mortality was in the order of 9.6%. Pregnancy outcome was better in non-cyclosporine group, in non-proteinuric hypertensive groups and in repeated pregnancies compared to the counter groups. CONCLUSION: Although pregnancy in renal transplant recipients is high-risk, successful outcome is expected for singleton pregnancy and is even better with repeated pregnancies in those cases with stable and good graft function. This satisfactory outcome is generally achieved if the graft is stable and the post-transplant interval is more than 2 years.

The new rHuEPO alpha (epotin) in the management of anemia of end-stage renal disease in patients on maintenance hemodialysis.

Recombinant human erythropoietin has proved to be effective to treat anemia of end-stage renal disease (ESRD). The aim of this study was to assess the efficacy and safety profile of Epotin, a rHuEPO produced in the Middle East. One hundred thirty patients with Hct

Coadministration of ketoconazole and cyclosporine for kidney transplant recipients: long-term follow-up and study of metabolic consequences.

In a prospective randomized study including 100 kidney transplant recipients, we previously reported on the safety and financial benefits of the coadministration of ketoconazole (keto) to cyclosporine (CsA)-treated kidney transplant recipients. In this study, we report on the long-term follow-up of these patients and their control group, as well as possible metabolic consequences of this drug combination. Evaluation of 51 keto-treated patients and their control group (49 patients) included graft function, lipogram, fasting blood glucose, liver function tests, serum calcium, phosphorus, and radiological and histopathologic assessments. Follow-up of these patients for 54 months showed that the CsA dose reduction was 72.9% at 12 months, decreased to 69.3% at the last follow-up. We also found that the mean keto dose required for CsA dose reduction decreased to 82.8 +/- 24.1 mg/d compared with the starting dose (100 mg/d). Diagnosis of acute rejection episodes was similar in both groups. However, in the control group, rejection episodes were more recurrent, with poorer response to treatment. Acute CsA nephrotoxicity was more common in the keto group, but this was encountered more at keto induction and was rapidly reversed on further reduction of CsA doses. Chronic graft dysfunction was statistically significantly less in the keto group during the first year. However, by the end of the study, the difference was not statistically significant. In this study, hepatotoxicity was similar in the two groups. On studying the metabolic consequences, we found that serum cholesterol, low-density lipoprotein, and triglyceride levels were lower in the keto group. Bone mineral contents in both groups were less than the mean values for age- and sex-matched healthy controls. From this study, we conclude that long-term use of low-dose keto in CsA-treated kidney transplant recipients is safe and cost-saving and may induce better graft function. Bone mineral contents, vitamin D blood levels, and lipid profiles are not affected by long-term keto coadministration in CsA-treated kidney transplant recipients.

Live-donor renal transplantation at the Urology & Nephrology Center of Mansoura: 1976-1998.

Based on more than 1,200 living donor transplants performed at the Urology & Nephrology Center at Mansoura University between 1976-1998, we report: 1. The overall graft survival rate was 75.8% and 51.9% at 5 and 10 years, respectively, with a projected half-life of 10.7 years. 2. Three factors acted as independent variables that significantly influenced graft survival: the number of HLA mismatches, the number of acute rejection episodes and the presence of posttransplant hypertension. a. Grafts with 2 or fewer HLA-A, -B and -DR mismatches had a significantly better survival rate. b. The incidence and the number of early acute rejection episodes had a significant negative impact on graft survival. c. A significant reduction in graft survival was associated with hypertension uncontrolled by or newly developed after transplantation. 3. Bilharziasis had no impact on the outcome. 4. Despite improvements in tissue matching and immunosuppression, an important proportion of grafts is still lost following living-donor kidney transplantation. 5. Efforts must be directed to identify better regimens, which can provide adequate immunosuppression and minimal nephrotoxicity.

Clinical significance and long-term evolution of minimal change histopathologic variants and of IGM nephropathy among Egyptians.

In children, the most frequent idiopathic nephrotic syndrome is minimal change nephrotic syndrome (MCNS). Typically, MCNS shows no abnormalities by light microscopy: "nil disease". Beside this classic picture, there are other minor light microscopic abnormalities which are considered as MCNS variants. Our 172 MCNS patients were divided into a nil disease group, two groups of MCNS variants (mild mesangial hypercellularity and mild mesangial thickening) and a fourth group with normal light microscopy and diffuse IgM deposition (IgM nephropathy group). The relation of this fourth group to MCNS is controversial in the literature. Age and serum creatinine were significantly different in the four histologic groups (P=0.03 for age and 0.047 for serum creatinine). Comparing the groups in pairs, it appeared that these significant differences were due to significantly higher age and serum creatinine in the mild mesangial hypercellularity group than in the IgM nephropathy group (P = 0.02 for age and 0.01 for serum creatinine). The groups were similar as regards follow-up creatinine clearance and early and late steroid response. We concluded that mild mesangial hypercellularity may differ from other MCNS forms as regards age at presentation and renal function. We also suggest that IgM nephropathy with normal light microscopy is similar to MCNS.

Chromatographic assay and pharmacokinetic studies of propofol in human serum.

A high-performance liquid chromatographic system with automated precolumn extraction was developed for the determination of propofol in human serum. Propofol of directly injected serum sample was enriched on a protein-coated mu Bondapak phenyl precolumn while serum constituents such as proteins and salts were eluted to waste. Thereafter, using an on-line column-switching system, the drug was quantitatively transferred and separated on a second analytical column followed by spectrophotometric determination at 270 nm. Good precision, accuracy and linearity were obtained over a range of 30-3000 ng/mL propofol in human serum. The developed method proved to be fast, simple, reproducible, reliable and therefore convenient for propofol monitoring from serum. The recovery of propofol in serum samples from the lowest to the highest concentration ranged from 96.84 to 100.16% (n = 5). The assay was applied to study the pharmacokinetic of the drug in six women undergoing elective caesarean section under general anaesthesia induced with a single intravenous bolus dose of propofol (2.5 mg/kg).

Living-related-donor kidney transplantation outcome in recipients with primary focal-segmental glomerulosclerosis.

We studied the outcome of renal transplantation in 30 patients with primary focal-segmental glomerulosclerosis (FSGS) and in 30 controls in whom renal failure was secondary to nonglomerular renal diseases. All patients received living-related-donor kidneys, and the majority had one-haplotype HLA matching. Within the follow-up period, the mean serum creatinine values were significantly higher in FSGS recipients as compared with the control group (p = 0.02). However, the frequency of acute rejection episodes and the mean blood pressure values were not significantly different between the two groups. There was a tendency of a higher incidence of proteinuria among FSGS recipients in comparison with the controls. Moreover, nephrotic-range proteinuria occurred only in 3 recipients of the FSGS group. Recurrence of FSGS was morphologically documented in 2 recipients 7 and 18 months, respectively, after transplantation. It is concluded that FSGS as the primary disease has a negligible impact on the living-related-donor kidney transplantation in the Egyptian population. Therefore, this disease should not discourage transplantation for this group of patients.