Factors Associated With Delayed Graft Function and Their Influence on Outcomes of Kidney Transplantation.

BACKGROUND: One of the main postoperative complications of kidney transplant is delayed graft function (DGF), which means absence of graft function after transplant or the need for dialysis during the first week post procedure. The occurrence of DGF currently in our hospital is high and has been attributed to a combination of many factors. The aim of this study was to evaluate the factors associated to DGF and their influence in the outcome of kidney transplants. METHODS: Historical cohort of 150 patients transplanted with live or deceased donor kidneys from 2011 to 2013. RESULTS: DGF was associated to time in dialysis and the number of recipient pre-transplant transfusions, donors age, serum creatinine level, use of vasoactive drugs in the donor, distance from place of organ retrieval and transplant center, and duration of cold ischemia time. DGF influenced post-transplantation outcome in regard to length of stay in intensive care, length of hospital stay, acute rejection episodes, and higher creatinine levels at discharge. Patients and graft survival were shorter in the DGF group. CONCLUSIONS: There are multiple factors related to DGF, the most important being those related to donors, and organ storage. The most important factor related to the recipient was the dialysis vintage. We did not find a correlation between DGF and HLA-compatibility. DGF consequences are important, including worse graft function and survival, as well as impact in recipient morbidity and mortality.

Kidney Transplantation at a Southern Brazilian University Hospital: A 35-Year Practice Review.

BACKGROUND: The Nephrology Unit at São Lucas Hospital, a University Hospital in Southern Brazil, has recently reached 35 years since its first kidney transplant. Few centers in the area have made a longitudinal analysis of processes, problems, grafts, and patient survival changes along this time. METHODS: A single-center, retrospective study was performed. Data were separated into different eras, based on the nature of immunosuppression used: pre-cyclosporine (1978-1986), cyclosporine (1987-1997), mycophenolate introduction (1998-2002), new immunosuppressant drugs (2003-2007), and the current period (2008-2013). RESULTS: Between April 27, 1978, and April 30, 2013, 1231 transplants were performed. Significant differences were detected among different eras. The number of transplants has been progressively increasing, to include significantly older recipients (and donors), at a longer waiting list time, receiving organs that underwent longer cold ischemia time (P < .001). Yet, fewer acute rejection episodes and lower incidence of myocardial infarction and post-transplant diabetes mellitus (P < .001) were detected. In the present era, patient survival at 1, 3, and 5 years is 98.3%, 94.6%, and 90.5% respectively, for living donors, and 92.4%, 87.2%, and 80.7% for deceased donors, respectively. Living donor graft survival is 92.2%, 88.7%, and 82.4%, respectively, whereas deceased donor survival is 80.4%, 71.1%, and 63.7%, respectively. CONCLUSIONS: This retrospective analysis has significant historical value. It assembles and depicts a long follow-up period of a transplant series at a single Brazilian center. Throughout the eras, organ and patient survival increased, with fewer rejection episodes or complications, yet with overall decreased graft function.

Does Thymoglobulin Induction Increase Susceptibility to Carbapenem-Resistant Acinetobacter baumannii Sepsis-related Death in Expanded Criteria Donors?

BACKGROUND: Solid organ transplant recipients are susceptible to antibiotic-resistant infections and carbapenem-resistant Acinetobacter baumannii (CRAB) has recently been recognized as a serious complication in solid organ recipients. High mortality rates have been described. METHODS: We retrospectively analyzed 807 transplantations and detected 10 patients who died 24 hours after the diagnosis of septicemia, all with CRAB-positive blood cultures. Recipients were followed up for at least 1 year and were stratified into the following groups: Group 1, patients alive; Group 2, patients that died due to other causes except Acinetobacter infection; and Group 3, patients who died within 24 hours of CRAB diagnosis. RESULTS: CRAB-positive patients died a median of 3.17 (range, 1.81-18.7) months after transplantation. In these patients, expanded criteria donors (ECDs) were more frequent (P < .001), as were the use of anti-thymocyte globulin (ATG) induction (P = .02) and delayed graft function (P = .01). For ECD recipients, death rate from any cause, whether induced with ATG or not, was 25% and 20.6%, respectively (odds ratio [OR], 1.28; confidence interval [CI] 95%, 0.56-2.91; P = .68). The death rate from CRAB-related sepsis was 10.3% and 0% whether receiving ATG or not, respectively (OR, 15.49; CI 95%, 0.87-277.16; P = .014). There was a 25.75-fold increase in the death rate in ECD kidney recipients induced with thymoglobulin and with CRAB-related sepsis. CONCLUSION: Transplants from ECDs and induced with thymoglobulin may be at increased risk of CRAB death in 24 hours when compared with patients with standard donors and induced with thymoglobulin.

Acute Graft Pyelonephritis Occurring up to 30 Days After Kidney Transplantation: Epidemiology, Risk Factors, and Survival.

Acute graft pyelonephritis is a very common infection in renal transplantation. The impact of acute graft pyelonephritis (AGPN) on graft and patient outcome has not yet been established. Eight hundred seventy kidney and kidney-pancreas transplants were retrospectively studied, over last 13 years, to verify occurrence of AGPN in the first 30 days post-transplantation. We found that 112 patients (15.8%) presented post-transplantatiom AGPN up to 30 days after a kidney transplantation. The occurrence was higher in older patients (P = .005) and in those with ureteral stents (P = .06). Escherichia coli was the most frequent microorganism in urine cultures (32%). Ureteral stent (relative risk = 1.7; confidence interval [CI], 1.1-2.5; P = .018) was a major risk factor for AGPN as well as older ages (RR = 1.02; CI 1.01-1.04; P = .001), length of hospitalization stay (RR = 1.01; CI, 1.01-1.02; P < .001), and anti-thymocyte globulin (ATG) induction (RR = 1.6; CI, 1.022-2.561; P = .04). Long-term graft and patient survival was significantly lower in patients with pyelonephritis in the first 30 days after transplantation (OR 1.43; 95% CI, 0.95-2.16; P = .024 and OR 1.77; 95% CI, 1.12-2.80; P = .006, respectively). Acute pyelonephritis in the first 30 days after transplantation is therefore associated with a lower long-term graft and patient survival.

Placental expression of eNOS, iNOS and the major protein components of caveolae in women with pre-eclampsia.

Caveolae regulate many cardiovascular functions and thus could be of interest in relation to pre-eclampsia, a pregnancy specific disorder characterised by hypertension and proteinuria. We examined placental mRNA and protein expression/localisation of the caveolae components Caveolin 1-3, Cavin 1-4 as well as eNOS/iNOS in normotensive control (n = 24) and pre-eclamptic pregnancies (n = 19). Placental mRNA expression of caveolin-1, cavin 1-3, was lower and eNOS expression was increased in pre-eclampsia (P < 0.05 for all). Additionally Caveolin-1 protein expression was also reduced in pre-eclampsia (P = 0.007); this could be an adaptive response in pre-eclampsia, possibly to attenuate the oxidative stress/inflammation.

PP040. Expression of RANTES (CCL5) in maternal plasma, fetal plasma and placenta in pre-eclampsia and normotensive controls.

INTRODUCTION: Studies have shown pre-eclampsia (PE) as an exacerbation of gestational inflammatory process. RANTES (Regulated upon Activation, Normal T-cell Expressed, and Secreted)/CCL5 is a chemokine, which is involved in chronic inflammation by the recruitment of inflammatory cells. It is secreted by many cell types such as endothelial cells, smooth muscle cells, macrophages, platelets and activated T-cells. Thus we hypothesized that RANTES expression is altered in PE and may be different in gestational tissues (maternal plasma, fetal plasma and placenta). OBJECTIVES: The purpose of the study is to analyze the expression of RANTES (CCL5) in three different tissues: maternal plasma, fetal plasma and placenta, in PE and normotensive controls (NC). METHODS: PE was diagnosed by the National High Blood Pressure Education Program Working Group Report on High Blood Pressure in Pregnancy guidelines. The patients were assisted in the São Lucas Hospital from PUCRS, Porto Alegre, Brazil. Following ethical approval and informed written consent, maternal and umbilical plasma and placental biopsies were taken from 33 PE and 35 NC. Samples were centrifuged immediately after blood collection and plasma was stored at -80°C until assay. Placental Biopsies were taken midway between the cord and periphery, from the central region of cotyledons and were stored as well. RANTES expression was made by the ELISA test, in duplicates. They were also analyzed in each group: maternal age, maternal parity, gestational age on delivery, glucose, body mass index, proteinúria creatinuria ratio, systolic blood pressure (SBP), diastolic blood pressure (DBP), delivery method, birth weight, placental weight and Apgar index in 1st and 5th minute. RESULTS: Maternal age at the time of blood collection was not significantly different between the two groups. The women with preeclampsia delivered earlier and had smaller babies compared with the controls. Significant associations between groups (p<0.001) were seen in SBP, DBP, birth weight and delivery method. RANTES was increased in maternal plasma and placenta in patients with PE and decreased in fetus plasma in the same group (p<0.001). CONCLUSION: In this study, we have shown that RANTES expression in maternal plasma and placenta tissues, in women with established pre-eclampsia, is higher than in gestation-matched women with a healthy pregnancy. It confirms the hypotheses that physiology of PE is associated with an increase of normal gestational inflammatory process. However in fetus tissue, the inflammatory chemokine is decreased in PE women. FUNDING: CAPES Foundation, Ministry of Education of Brazil, Brasília - DF 70040-020, Brazil.

PP050. Distribution of ABO and Rhesus blood groups in patients withpre-eclampsia.

INTRODUCTION: The ABO-system of antigens and the Rh-system (D-antigen) is genetically determined and remains the most important blood group systems clinically. Several studies have examined the association between ABO and Rhesus blood group systems and pre-eclampsia. At present there is no consensus to define this association, especially not in a Brazilian population. OBJECTIVES: The purpose of the present study was to evaluate the association between pre-eclampsia versus ABO and Rhesus blood group systems in pregnant women hospitalized in a University Hospital in Porto Alegre, Brazil -Hospital São Lucas (HSL). METHODS: Pre-eclampsia/eclampsia (PE/E) was diagnosed by the National High Blood Pressure Education Program Working Group Report on High Blood Pressure in Pregnancy guidelines. This study consisted of 14,894 pregnant women admitted to the Maternity Department between 2005 and 2010. The patients were reviewed retrospectively for inclusion. Complications in pregnancy not related to pre-eclampsia/eclampsia (PE/E) and those with uncompleted data were excluded. Medical records of 410 women were used to diagnose PE/E. The control group consisted of 8781 women. Each group was subdivided according to their blood groups. RESULTS: In comparison to the PE/E women and controls, no specific relation in blood groups was observed. With respect to ABO and Rh groups, no differences between PE/E and controls were observed (P=0.479 and P=0.169 respectively). When analyzed with both Rh and ABO Pearson Chi-Square also showed no differences (P=0.569). CONCLUSION: This study aimed to demonstrate some association between blood groups and PE/E using a large sample from the south of Brazil, a population not investigated before. In our study, no specific differences were observed between PE/E and controls in the distribution of the blood groups. In conclusion, the results of this study suggest no association between ABO and Rhesus blood group systems and PE/E in our population. FUNDING: CAPES Foundation-Ministry of Education of Brazil.

Increased serum phosphodiesterase activity in women with pre-eclampsia.

OBJECTIVE: To measure the activity of serum phosphodiesterase (PDE) in pre-eclampsia. DESIGN: Case-control study. SETTING: Nephrology Laboratory and Obstetrics Unit at São Lucas Hospital from Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil. SAMPLE: Twenty-nine normal and 28 pregnant women with pre-eclampsia. METHODS: Serum was collected from women with pre-eclampsia, at the time of diagnosis, and from gestation-matched controls. Circulating PDE activity was assessed by measuring consumption of the substrate thymidine 5'-monophosphate p-nitrophenyl ester and expressed as PDE units/l. MAIN OUTCOME MEASURES: Serum PDE Activity. RESULTS: Mean substrate consumption was higher in pre-eclamptic condition (V(max)= 15.8 +/- 1.4 versus 12.7 +/- 0.9 U/L, P= 3.7 x 10(-14)). CONCLUSION: These data suggest that altered PDE activity may play a role in pre-eclampsia endothelial dysfunction.

Quality of life and sexuality in chronic dialysis female patients.

Patients in end-stage renal disease (ESRD) present reduced quality of life (QOL) and impaired sexual function. Previous studies have mostly addressed male sexual dysfunction. This was a cross-sectional controlled study that applied a general and the World Health Organization Quality of Life-bref questionnaires to assess demographic, marital, and sexual conditions, and QOL in 86 healthy women aged 18 or more years (Group 1), and 38 female ESRD patients on dialysis for at least 2 months (Group 2). The effect of several explanatory variables upon QOL components was estimated. Quality of life was lower in Group 2 -- overall, and on physical and environment domains. To undergo dialysis and to be poorly educated negatively affected the QOL. Yet age, a stable marital relationship or being sexually active had no effect. Female patients undergoing chronic dialysis had lower QOL and were significantly more sexually dysfunctional than comparable healthy women. Decline in sexual function had no effect on the QOL.

Bag exchange in continuous ambulatory peritoneal dialysis without use of a face mask: experience of five years.

This article describes our five-year experience of continuous ambulatory peritoneal dialysis (CAPD) with bag exchanges performed without use of a face mask. The study took place in the renal unit at a university hospital. All patients admitted to the CAPD program from February 1995 to March 2000 were trained to perform bag exchanges without use of a face mask. Occurrence of peritonitis episodes was the outcome of interest. We evaluated 94 patients (52 women, 42 men) with a mean age of 48 +/- 21 years and a total follow-up of 50,502 patient-days. During that time, 79 episodes of peritonitis occurred in 46 patients, for a peritonitis rate of 0.57 episodes/year. The most frequently isolated micro-organisms were Staphylococcus epidermidis in 20 patients (25.3%) and S. aureus in 11 patients (13.9%). Renal transplantation was the major cause of drop-out [23 patients (43.4%)], followed by peritonitis [14 patients (26.4%)], death due to cardiovascular complications [9 patients (17.0%)], loss of ultrafiltration [2 patients (3.8%)], and other causes [5 patients (9.4%)]. The probability of being free of peritonitis at 12 months was 0.60, and at 60 months, 0.37. Peritonitis rates during the study period were not different from those reported by other centers, supporting the hypothesis that routine use of a face mask during CAPD bag exchange may be unnecessary.

Depression, anxiety and adjustment in renal replacement therapy: a quality of life assessment.

OBJECTIVES: To measure the quality of life (QOL) of patients on RRT with regard to depression, anxiety, and adjustment to illness. MATERIAL: The study was conducted between 1996 and 1998 at a teaching hospital in Porto Alegre, Brazil. The study population included 125 patients (transplant n = 64, hemodialysis n = 42 and continuous ambulatory peritoneal dialysis [CAPD] n = 19). METHODS: The Beck Depression Inventory (BDI), the State-Trait Anxiety Inventory (STAI), and the Psychosocial Adjustment to Illness Scale (PAIS) were used for patient assessment. Results were analyzed using the Kruskall-Wallis, Mann-Whitney and ANOVA tests. RESULTS: Depression scores were higher for hemodialysis patients compared with transplant patients (H = 15.22; p < 0.005). CAPD patients had intermediate scores (no statistical difference). As far as anxiety was concerned, no statistical difference was observed when the groups were compared. In terms of adjustment to illness, hemodialysis patients were significantly less well adjusted than transplant patients (H = 23.34; p < 0.001). Patients on CAPD had intermediate scores, with no significant difference compared with the other two groups. CONCLUSION: The overall quality of life of transplant patients is higher than that of hemodialysis patients.

Peritonitis prevention in CAPD: to mask or not?

OBJECTIVE: To assess the efficacy of wearing a face mask to prevent peritonitis during continuous ambulatory peritoneal dialysis (CAPD) bag exchange. SETTING: Renal unit at a university hospital. PATIENTS: Two groups of patients on CAPD were compared: those performing bag exchange with (n = 24) and those without a face mask (n = 40). OUTCOMES: Occurrence of first episode of peritonitis and total number of episodes. RESULTS: No difference was found between groups with respect to probability of developing the first episode of peritonitis (p = 0.757). Patients holding university degrees had evidence of protection, with borderline significance [relative risk (RR) 0.52; confidence interval (CI) 95%, 0.23 -1.18; p= 0.109]. Cox's proportional hazard regression analysis also demonstrated a significant protective factor for patients with university level education (RR 0.42; Cl 95%, 0.18 - 0.98; p = 0.04). Incidence of peritonitis was not significantly different between groups: with-mask group had 1.0 episode/year, and without-mask group had 0.94 episodes/year. Staphylococcus epidermidis was the most commonly identified agent. Staphylococcus aureus was found more frequently in the with-mask group (p = 0.003). Peritonitis due to Streptococcus viridans and Enterococci were detected only in the without-mask group. CONCLUSION: The current study suggests that routine use of face masks during CAPD bag exchanges may be unnecessary and could be discontinued.