Attitudes and knowledge about transplantation in dialyzed patients requesting a cadaveric kidney graft.

AIM: Eighty-two patients answered a multiple choice questionnaire aimed at identifying their presumed and actual knowledge regarding transplantation, given immediately before evaluation by our transplant team for inclusion on our kidney transplant waiting list. SUBJECTS, METHODS AND RESULTS: A total of 78% stated that they had no or incomplete knowledge of transplantation and 22% were very well informed. The mean score for technical knowledge of transplantation (duration, requirement for removal of native kidneys, possibility of obtaining a second transplant, duration of immunosuppressive therapy and duration of the risk of rejection) was 3.1 +/- 0.15 SEM (maximal possible score 5), that for risk knowledge (risks of infections, unpleasant side effects, hypertension, diabetes mellitus, viral infections and cancer) was 1.4 +/- 0.15 (maximal possible score 6). A total of 23% knew that the spouse could donate a kidney, 74% stated that only a blood relative could and 3% that living donation was impossible. CONCLUSIONS: There is scarce knowledge about transplantation, especially with regard to the risks and living donation.

A new biosensor for continuous monitoring of the spent dialysate urea level in standard hemodialysis.

This study gives the results in terms of precision and repeatability of a new on-line urea monitoring system (Ureascan P2 Hospal) capable of measuring the urea concentrations in the spent dialysate. The Ureascan P2 Hospal (UP2H), fitted on single-pass dialysis machines (Integra-Hospal), functions by the presence of a disposable mini-reactor containing urease. The passage through the reactor of a minimum quantity of spent dialysate from the filter diluted with a pH 7 buffer solution (1 ml/min) increases its ionic strength, which is detected by a differential measurement of conductivity in proportion to the urea concentration in the dialysis liquid. We studied 13 dialysis sessions, with bicarbonate buffer, in 8 anuric patients. From 4 to 7 dialysate samples were taken during each treatment to determine the urea and 65 samples were analysed overall. Urea values from the UP2H were compared with those measured on the Dimension Du Pont analyser. Simple linear regression analysis showed an excellent correlation between the 2 measuring methods (r=0.987; p<0.001). The Bland-Altman test gave an average difference between the urea values measured with the UP2H and in the laboratory of 1.3+/-1.2 mg/dl. The agreement limits between 2 SD were -1.2 mg/dl and +3.8 mg/dl respectively. In conclusion, the UP2H we have developed has proved to be a reliable and very useful instrument for adapting, through the urea kinetic mathematical models, the dialysis dose for individual patients.

Continuous tidal peritoneal dialysis (CTPD) prescription and adequacy targets.

NKF-DOQI guidelines suggest a Kt/V value of 2.1 and a creatinine clearance (CRCL) value of 63 L/1.73 m2 of body surface area per week as minimum targets in continuous cycling peritoneal dialysis (CCPD). Those targets are obtained by adapting the CAPD guidelines. The aim of our study was to verify the possibility of reaching the suggested targets with continuous tidal peritoneal dialysis (CTPD) and to check target modification in this automated treatment. Eight anuric patients underwent four consecutive CTPD sessions with increasing total prescribed volumes (17 L, 22 L, 27 L, and 32 L; night 9 h; fill 2.2 L; tidal 75%, day 2 dwells). The Kt/V increase was significant (P = 0.012), unlike that of CRCL, with larger volumes. Two patients did not reach target Kt/V, and four did not reach target CRCL. The volume normalized for 1.73 m2 corresponding to DOQI targets was 19.6 +/- 2.6 L for Kt/V and 20.2 +/- 2.4 for CRCL. The overall Kt/V was 2.29 +/- 0.66 and CRCL was 57.3 +/- 16.5 L/1.73 m2. CRCL/Kt/V overall ratio was 25.6 +/- 4.7 and significantly different from the target ratio (63/2.1 = 30, P < 0.001). The CRCL/Kt/V ratio showed a significant decrease with larger volumes (P = 0.001, linear trend P < 0.001). Adequacy targets can be reached only in some patients on CTPD even with high dialysis volumes. The changes in the CRCL/Kt/V ratio in relation to dialysis volume can be considered for adaptation and evaluation of adequacy targets in automated treatments.

Vesicoureteral reflux after kidney transplantation: clinical significance in the medium to long-term.

103 patients who received a cyclosporine-treated primary cadaver kidney transplant (TX) at our center between 1985 and 1989, whose graft survived for more than 1 year and who accepted to undergo voiding cystography after TX were analyzed and grouped according to the highest grade (regardless to whether active or passive) of vesicourteral reflux (VUR): group 0, absent (n = 14); group 1-2, grade I or II (n = 62); group 3, grade III (n = 27). Patient follow-up ranged from 5 to 10 (median 7) years. Patient and graft survivals and prevalence of hypertension (defined as the persistent need of antihypertensive therapy), did not differ significantly between groups (Mantel-Cox test p: n.s. in all cases). GFR (Cockroft and Gault) and proteinuria were evaluated with ANOVA for repeated measures at 1, 2, 3, 4 and 5 years in the 96 patients (group 0: 13, group 1-2: 56, group 3: 27) whose grafts lasted for 5 years or more. Neither GFR values (p: n.s.) nor GFR behaviour over time (p: n.s.) differed between groups, although a progressive decline of GFR was noted in all groups (p < 0.002). Proteinuria neither showed any significant differences between groups in values (p: n.s.) or behaviour over time (p: n.s.), nor any trend in behaviour over time in all groups as a whole (p: n.s.). Finally, in the first 5 years after TX the 3 groups did not differ for number of urinary tract infections (UTIs) (mean value for all patients: 2.5, range 0-22, episodes/pt/5 years) (p: n.s.), or for number of UTIs with leukocyturia (mean 0.6, range 0-6, episodes/pt/5 years) (p: n.s.), or for number of febrile UTIs (mean 0.3, range 0-5, episodes/pt/5 years) (p: n.s.), or for number of UTIs with sepsis (mean 0.1, range 0-2, episodes/pt/5 years) (p: n.s.). The same results were obtained when, instead of episodes/ pt/5 years, percentages of patients without or with 1 or more of such episodes in the same period were considered. In conclusion, VUR does not seem to be hazardous for the transplanted kidney in the medium to long-term.

Influence of length of time on dialysis before grafting on kidney transplant results.

The outcome of kidney transplantation was evaluated in 246 nondiabetic, CsA-treated recipients of primary cadaver transplant, divided into 4 groups according to length of time on dialysis: group < or = 2, 0-24 months; group 2-5, 25-60 months; group 5-15, 61-180 months; group > 15, over 180 months. The 4 groups did not differ in graft survival, proteinuria (g/die), or estimated GFR values at 1, 2, 3, 4, and 5 years after grafting. They did not differ in the frequency of cataract, hip osteonecrosis, tumors, or posttransplant diabetes mellitus at 3 years after grafting. Ocular hypertone (p < 0.02), tendon ruptures (p < 0.001), arterial occlusive disease of lower limbs (p < 0.01), cholelithiasis (p < 0.05), and chronic hepatitis--which occurred only in anti-HCV and/or HBs Ag-positive patients--(p < 0.001), were more frequent in group > 15, and in all these cases but ocular hypertone a linear trend of increasing frequencies with increasing dialytic age was statistically significant. Group 5-15 had the lowest patient survival (p < 0.02). Moreover, a progressive decline of patient survival with increasing dialytic age was noted in groups < or = 2, 2-5, and 5-15. Unexpectedly, group > 15 had remarkably good survival, and this finding denies the hypothesis of a purely linear decline of patient survival after transplantation with increasing dialytic age.

Importance of donor/recipient body weight ratio as a cause of kidney graft loss in the short to medium term.

The importance of the donor/recipient body weight ratio (DRBWR) as a cause of kidney graft loss was evaluated in 112 non-diabetic, ciclosporin-treated, first cadaver kidney transplant recipients. According to the DRBWR, the patients were divided into three groups: 'low' (< or = 0.80), 'medium' (0.81-1.20), and 'high' (> 1.20). The three groups did not differ in patient or graft survival, and the DRBWR was not a predictor of graft failure at multivariate analysis (Cox models), even after only patients with graft survivals > 1 year were considered. The three groups did not differ in glomerular filtration rate (GFR) and proteinuria 6-60 months after renal transplantation. When the 55 patients with a follow-up period > 4 years were considered, no differences between groups were found in GFR or GFR evolution over time. Hypertension was significantly less frequent in group 'high' (Mantel-Cox p = 0.04), but very likely as a consequence of uneven recipient gender (an independent predictor of hypertension at multivariate analysis) distribution between groups, the significance being lost when survival curves were rebuilt by stratifying for recipient gender. DRBWR never resulted as a significant predictor of GFR at multivariate analysis when GFR values 6-60 months after transplantation were analyzed. We conclude that the DRBWR has no major effects on kidney graft function and survival in the short to medium term.

Calcium lactate interference in measuring creatinine in peritoneal dialysis fluids by the Jaffé kinetic method.

Creatinine measurements in peritoneal dialysis fluids using the Jaffé method have poor specificity due to interfering substances. We have checked to see if calcium lactate, in addition to glucose, interferes with the Jaffé kinetic measurement. Eight samples were prepared with increasing concentrations of glucose (960-3890 mg/dL) and eight were prepared with the same glucose content plus 7 mg/dL of calcium lactate, all without creatinine; in addition, 96 samples with increasing concentrations of glucose (1500-4000 mg/dL), calcium lactate (3-7.5 mg/dL), and creatinine (0.75-4.5 mg/dL) were prepared. There was a 0.31 +/- 0.13 mg/dL glucose interference on the Jaffé kinetic measurement in the first series, with an exponential trend. Interference was greater with calcium lactate and glucose: 0.50 +/- 0.16 mg/dL with the same trend. Data from the second series confirm the overestimation: 0.54 +/- 0.05 mg/dL (32.6%) with an exponential trend. The interference of glucose, creatinine, and calcium lactate on the Jaffé kinetic measurement was obtained by multi-variate regression. The single effects of glucose2 and glucose are predominant, but both creatinine and calcium lactate have a significant effect. Our study highlights the nonlinear glucose interference on creatinine measurement with the Jaffé kinetic method and the linear interference of both calcium lactate and creatinine.

Fungal peritonitis in peritoneal dialysis: critical review of six cases.

Fungal peritonitis (FP) is uncommon in patients on peritoneal dialysis (PD); it is difficult to treat and has a high mortality rate. We report 6 cases of fungal peritonitis observed between 1980 and 1992 in our center. The etiologic agents were: Candida spp., C. guilliermondi, C. parapsilosis, C. albicans, and Verticillium spp. All 6 patients had suffered at least one episode of bacterial peritonitis in the two months before the fungal infection appeared and were all treated by intraperitoneal administration of antibiotics. The catheter was removed early in 3 patients followed by antimycotic therapy, while the remaining 3 patients received antimycotic therapy, with removal of the catheter in a later stage. The result in the first group was that they all switched permanently to hemodialysis, while in the second group there were 2 deaths and 1 transfer to hemodialysis. In the light of these 6 cases, we analyzed 22 published reports to assess risk factors, therapy, and outcome of this pathology. The major predisposing factors were intraperitoneal antibiotics and bacterial peritonitis, and the best results were obtained by continuing PD plus intraperitoneal and systemic antifungal agents.

Comparison of fast peritoneal equilibration tests with 1.36 and 3.86% dialysis solutions.

At present dialysis solutions with different glucose concentrations are used for the peritoneal equilibration test (PET) and Fast-PET in peritoneal dialysis (PD). We compared the results of two Fast-PETs, using 1.36 and 3.86% solutions sequentially in 30 patients on PD treatment, to obtain information on peritoneal transport (D/P-4 h) and ultrafiltration rates. Creatinine, phosphorus and urea D/P-4 h in the two Fast-PETs were not statistically different, unlike those for potassium, beta 2-microglobulin and glucose. The creatinine and phosphorus D/P-4 h values in particular proved to be uninfluenced by the different dialysis solutions. The lack of correlation between the two Fast-PET ultrafiltration values confirmed the difficulty in interpreting this parameter, above all in the case of non-homologous Fast-PETs. We obtained useful indications for comparing different Fast-PET results, but were unable to reach a decisive conclusion regarding the best of the two dialysis solutions for this test.

Clinical significance of vesicoureteral reflux after kidney transplantation.

In this study 103 out of our 125 CsA-treated patients who received between January 1985 and December 1989 a first cadaver kidney transplant that functioned for at least one year were studied with voiding cystography (VC) for vesicoureteral reflux (VUR). All patients had an external uretero-neo-cystostomy. VUR occurred in 89 (86.4%) patients. Patients were grouped according to VUR: absence of VUR (group 0), VUR grade I-II (group 1-2), and VUR grade III (group 3). The 3 groups were comparable for male/female ratio, cause of renal failure, cause of donor death, recipient and dialytic age, immunosuppressive therapy, follow-up, time of VC performance after transplantation. At 6 months and 1, 2, 3, 4, and 5 years after transplantation graft function, number of rejection episodes, and number of urinary tract infections (UTIs) were similar in the 3 groups. In groups 1-2 and 3 hypertension was more frequent than in group 0 and occurred even after the 6th month (whereas this did not happen in group 0), but the differences between the 3 groups were not significant. However, when only the 13 patients who were followed for 5 years were considered, the prevalence of hypertension after 5 years was significantly higher in groups 1-2 and 3 (both 100.0%) than in group 0 (33.3%) (chi-square = 7.88; p < 0.02). Finally, 4.5% of patients with VUR and no patients without VUR had septic episodes linked to UTIs, but the difference was not significant.(ABSTRACT TRUNCATED AT 250 WORDS)

The role of hypertension as a damaging factor for kidney grafts under cyclosporine therapy.

The relative importance of glomerular filtration rate (GFR) and hypertension (permanent need for antihypertensive drugs) for the prognosis of kidney grafts was studied in 135 cyclosporine-treated primary cadaver kidney transplant recipients whose grafts lasted more than 1 year. The start point of 1 year after transplantation was chosen because hypertension developed within the first year in all our hypertensive patients. Graft prognosis in hypertensive patients was not significantly worse than that of normotensive patients; moreover at multivariate analysis, age at transplantation and GFR at 1 year (P = 0.014), but not hypertension, were significant prognostic factors for the graft. At logistic regression, GFR was a significant variable for hypertension (P = 0.009), but hypertension was not a significant variable for renal failure at 1 year (GFR < or = 0.83 mL/sec [50 mL n]; P, NS). Accordingly, hypertension per se resulted much more as a consequence of reduced renal function than as a direct cause of graft damage. However, when hypertensive patients were divided into controlled and uncontrolled, uncontrolled hypertensive patients had the worst prognosis (P = 0.03), and blood pressure control proved a strong prognostic factor for the graft, even after GFR was considered (P = value of the model considering blood pressure control, GFR, and age at transplantation: 0.007). Our data suggest that, apart from being an expression of reduced renal function, hypertension is also a direct kidney graft damaging agent, a role that can be controlled by strict reduction of blood pressure levels.