Local Variation in Inclusion on Kidney Transplant Waiting Lists: Analysis in the Reference Area of a Kidney Transplant Center.

BACKGROUND: Access for end-stage renal disease (ESRD) patients to the renal transplant (RT) waiting list can vary depending on the criteria used and how they are applied in each dialysis unit. METHODS: This study was performed in the reference area (2.5 million inhabitants) of a transplant center. Data were from a regional registry (Information System of the Autonomous Coordination of Transplants in Andalusia) of total dialysis patients. Patients were grouped according to transplant status as: effective waiting list (WL); never recorded or excluded (E); incomplete immunologic study or discharge data (IIS); temporary contraindication (TC); or active (A). RESULTS: There were 1424 dialysis patients. Of these, 58% were E, 18% were IIS, 14% were TC, and 10% were A. Significant differences were detected for proportion of patients listed as active status (A) in 3 hospital dialysis units (2.9%-13.4%) and 12 hemodialysis centers (4.2%-29.2%); proportion of IIS cases in the hospitals (0%-57%) and dialysis centers (0%-58%); and in proportion of TC cases in the hospitals (19%-50%) and dialysis centers (2.5%-19.3%). The mean age of patients varied significantly between IIS, TC, and A groups (60.3, 54.8, and 52.3 years old, respectively, P < .001). Accentuated differences between the 2 provinces included in the sector were verified. There are notable differences in inclusion of pre-dialysis patients between hospital units. CONCLUSION: We detected considerable variability between hospital units and non-hospital dialysis centers in relation to inclusion on the active transplant waiting list and the proportion of patients with IIS or TC status. It is essential to implement a more homogeneous system for case selection through a specific intervention program from the reference center.

Reasons for Noninclusion on the Kidney Transplant Waiting List: Analysis in a Set of Hemodialysis Centers.

INTRODUCTION: End-stage renal disease patients' access to the renal transplant (RT) waiting list (WL) depends on general criteria and their specific application in the different treatment units. METHODS: Study in nonhospital hemodialysis centers (n = 9), dependent on an adult RT center. Cases included 228 patients considered to have nonactive status on the WL due to incomplete immunologic data (no blood group or HLA typing) or temporary contraindication from an incomplete pretransplant study (nonimmunologic) or comorbidity. Each individual situation was studied by reviewing the center's clinical history with the nephrologist in charge. RESULTS: Three situations were classified three groups. (1) Patients in this group had incomplete basic study (65 patients, 28.5%) pending cardiologic evaluation in 34%; urologic evaluation, 26%; both 18%; others, 9%; study not initiated, 12%. (2) Patients in this group had pre-existing or onset comorbidities (117 patients, 51.3%) pending studies or confirmed resolution: obesity, 30%; cancer, 17%; cardiovascular disease, 14%; digestive pathology, 10%; infection, 9%; neuropsychiatric disorders, 7%; multiple, 13%. (3) Patients in this group had other situations contraindicating RT (46 patients, 20.2%): poor therapeutic adherence, 30%; negative will of the patient, 26%; social issues, 9%; excluded by the center (not reported), 35%. CONCLUSIONS: We detected a high incidence of cases pending basic tests for inclusion on the WL. Obesity can be highlighted as the most frequent cause for noninclusion. Further support and coordination is required with referral hospital centers to increase and refine the RT WL.

Survival and Evolution of Renal Function in Kidney Transplant Recipients From Type II Asystolic Donations: A Single-center Experience.

BACKGROUND: In recent years, stagnation in the number of kidneys from after brain-dead donors (DBD) has stimulated the use of non-heart beating donors (NHBDs). Herein we present our 5-year experience with type II Maastricht NHBDs in renal transplantation. METHODS: All patients (n = 50) in this study received type II Maastricht NHBD kidneys (March 2012 to February 2017), with a median follow-up of 33 months. RESULTS: Mean donor age was 39 ± 12 years, mean creatinine 1.24 ± 0.2 mg/dL, and the most frequently observed blood group (donors and recipients) was type A (64%). Recipients were slightly younger (51 ± 11 years old), with mean time on dialysis of 30 ± 24 months. Almost all were primary transplants. Pre-transplant panel-reactive antibodies (PRA) were <25%; initial immunosuppression was thymoglobulin, corticosteroids, mycophenolate mofetil, and delayed introduction of tacrolimus. Six percent were nonfunctioning kidneys; 79.6% presented with delayed renal function (mean duration 14 ± 9 days). Acute rejection was seen in 6% of patients. Mean creatinine at month 3 was 1.7 ± 0.8 mg/dL, and 1.5 ± 0.8 mg/dL in the first year. The last available mean creatinine was 1.54 ± 0.7 mg/dL. Proteinuria in the third month, first year, and third year was 0.70, 0.41, and 0.26 g/d, respectively. Recipient survival at the first, third, and fifth year was 100%, 100%, and 86%, and when graft-censored for death was 94%, 91%, and 91%, respectively. The incidence of acute rejection during first year was 6%, and 2% in the second year. Exitus incidence was 4% and cytomegalovirus infection was 21.3%. BK viremia between 1000 and 10,000 copies/mL was seen in 4.3%, and reached >10,000 copies/mL in 2.1%. CONCLUSIONS: Type II NHBD has shown limited frequency of nonfunctioning kidney and high functional delay. The results in survival and renal function are very acceptable, comparable with levels seen in donation after brain death.

Resistant Cytomegalovirus Infection After Renal Transplantation: Literature Review.

BACKGROUND: Resistant cytomegalovirus (R-CMV) is an emerging problem in the renal transplantation population. The most frequent CMVs are high-resistance mutations (UL97 gene). METHODS: We describe our experience in management of R-CMV after renal transplant at our center (2012-2016). RESULTS: We encountered 3 cases of R-CMV infection after renal transplant (all primary infections). All 3 patients received induction therapy with corticosteroids, tacrolimus, and mycophenolate mofetil. The first patient (basiliximab induction, preemptive CMV) developed CMV replication on day +53, which responded poorly both to standard-dose valganciclovir (vGCV) and high-dose ganciclovir (GCV) (creatinine clearance [CrCl] >70 mL/min; vGCV 900 mg twice daily for 50 days and GCV 7.5 mg/kg twice daily for 8 days). Hematologic toxicity occurred. The R-CMV test was positive and foscarnet (FOS) was initiated (90 mg/kg twice daily for 21 days). The second patient presented CMV infection (day +30, thymoglobulin induction, CMV prophylaxis), which was not controlled with the high dose (CrCl 23 mL/min; GCV 3.5 mg/kg twice daily and vGCV 900 mg twice daily), resulting in severe neutropenia. R-CMV was detected and FOS initiated (FOS 50 mg/kg twice daily for 7 days and 50 mg/kg every 2 days for 13 days). The third patient's infection occurred on day +22 (basiliximab induction, preemptive CMV). Standard-dose vGCV was uneffective (CrCl >70 mL/min, vGCV 900 mg twice daily) and it did not respond to the high dose (GCV 7.5 mg/kg twice daily and vGCV 2700 mg/d). Moderate hematologic toxicity occurred. R-CMV was diagnosed and FOS treatment begun (FOS 70 mg/kg per day for 2 weeks). CONCLUSIONS: Resistant CMV infection may be severe due to viral infection and side effects of high-dose antiviral treatment. We presented 3 cases requiring the use of FOS in the absence of response or toxic effects from the usual treatment, with an optimal sustained response (temporary in case 2) and without serious side effects.

Hepatitis C Virus in Kidney Transplant Recipients: A Problem on the Path to Eradication.

BACKGROUND: Hepatitis C virus (HCV) still has significant prevalence in kidney transplant (KT) recipients and is related to poor recipient and graft survival. New direct-acting antivirals (DAA) are leading to a radical change in the problem. METHODS: We studied HCV prevalence at the time of transplantation and in follow-up patients, the way cases are handled, and the results of DAA. RESULTS: A total of 2,001 KT had been performed in our center since 1978. Pre- or post-transplantation HCV serology was present in 1,880 cases and was positive in 13.4%. A total of 1,195 transplant recipients were still being monitored by us, with only 60 (5%) HCV+ and 45 (3.6%) RNA+ cases. Of these 45 HCV+/RNA+, 25 had been or were being treated, 7 were about to begin treatment, 1 was awaiting new DAA treatment owing to low glomerular filtration rate (GFR), 3 were being evaluated, 2 had been excluded owing to high comorbidity, 2 refused to be treated, 2 needed to return to hemodialysis, and 1 was lost to follow-up. Except 1 case where Viekira Pak was used because of low GFR, all cases included sofosbuvir as the main drug associated with either ledipasvir (70%) or daclatasvir (25%). Ribavirin was added as coadjuvant in 35% of cases. Twenty-one patients had completed treatment (84%). Two patients had to interrupt DAA therapy (8%), one because of hepatotoxicity and the other as a result of a liver transplantation. In every case, the graft maintained function and negativization of viral replication occurred. CONCLUSIONS: Side effects have been low, anemia related to ribavirin being the main one. Just one case needed to be interrupted at the 7th week of DAA therapy due to hepatotoxicity. It has frequently been necessary to adjust immunosuppression treatment with the use of higher doses of tacrolimus.

New Antivirals for Hepatitis C Infection Among Infected Kidney Transplant Recipients: A Case Report.

The most common hepatopathy in end-stage renal disease is chronic hepatitis C virus (HCV) infection, which decreases allograft and patient survival in kidney transplants. Until last year we did not have treatments free of interferon, which was contraindicated after renal transplantation owing to the risk of allograft rejection. Recently, new drugs have been discovered for interferon-free regimens. These drugs present a cure rate of up to 90% and can be used in transplant recipients. Here we present our 1st 3 cases. In our experience, new antivirals have proven to be effective and safe for the treatment of HCV hepatopathy in kidney transplant recipients and liver-kidney transplantation, thus helping us to prevent complications related to HCV infection in transplant recipients.

Enfermedad por depósito de cadenas ligeras. Experiencia en nuestro medio / No disponible

La enfermedad por depósito de cadenas ligeras (EDCL) es una entidad rara, caracterizada por el depósito de un solo tipo de cadena ligera en la membrana basal del riñón. Puede asociarse a una discrasia de células plasmáticas, aunque en ocasiones no se detecta patología hematológica y se denomina idiopática. Suele manifestarse como una insuficiencia renal severa con proteinuria nefrótica, no tiene tratamiento claramente establecido y el pronóstico es malo. El objetivo de este trabajo es analizar las características de los casos de EDCL diagnosticados en nuestro medio. Se identifican 6 casos, todos entre 1999 y 2005 de un total de 640 biopsias realizadas en ese periodo, 4 mujeres y 2 varones, media de 57 años. Se detectó un mieloma en 3 pacientes(50%). La insuficiencia renal aguda o de rápida evolución fue la presentación clínica más frecuente (66%) junto con proteinuria nefrótica (66%). Todas las biopsias mostraban engrosamiento de la membrana basal tubular y depósito lineal de cadenas kappa en la misma. La lesión glomerular más frecuente fue la glomérulo esclerosis nodular (83%).En un caso la afectación fue exclusivamente túbulo intersticial con cilindros tubulares asociados. Se trataron 3 pacientes,2 con mieloma. Requirieron diálisis 5 pacientes: 3 con EDCL idiopática con un tiempo medio desde el diagnóstico hasta recibir la misma de 7 días, y 2 con mieloma que tardaron una media de 46 días en requerir diálisis. Fallecieron 4 pacientes, 2 con mieloma. El tiempo de seguimiento hasta el exitus fue de 13 semanas para los pacientes con mieloma y de 110 semanas para el resto. Conclusión, la EDCL parece mas frecuente de lo publicado y se asocia a mieloma en la mitad de los casos. Se presenta con daño renal severo y la evolución renal y del paciente es mala (AU)

The Light chain deposition disease (LCDD) is a strange entity characterized by the deposition of only one type of light chain in the renal tubular basement membranes. It can be associated to a plasmacell dyscrasia, however, it can occur in the absence of any detectable hematological disorder and it is called idiopathic LCDD. The clinical manifestation is renal insufficiency and nephrotic proteinuria, it does not have a clearly fixed treatment and has a severe prognosis. The aim of this work is to analyse the characteristics of the LCDD cases diagnosed within our environment. Six cases were identified, all of them between 1999 and 2005,from a total amount of 640 renal biopsies performed during this period, 4 women and 2 men, average age of 57. Multiple myelomain 3 patients was detected (50%). The acute renal failure or rapidly progressive renal insufficiency was the most frequent clinical presentation (66%) together with nephrotic proteinuria (66%). All the biopsies showed tubular basement membranes thickening and kappa chains with a linear distribution within the same. The most frequent glomerular pathological finding was the nodular sclerosing glomerulopathy (83%). In one of the cases the affectation was exclusively tubular interstitial with tubular casts. 3 patients were treated, 2 with multiple myeloma. 5 patients needed dialysis: 3 with idiopathic LCDD within an average time of 7 days from the diagnosis to its reception, and 2 with myeloma, who started needing dialysis in an average of 46 days. 4 patients died, 2 of them with myeloma. The monitoring time until the death was 13 weeks for the patients with myeloma and 110 weeks for the rest. Conclusion: The LCDD seems to be more frequent than what has been published and it is associated to the myeloma in half of the cases. It appears together with severe renal insufficiency and the patient's and renal prognosis is poor (AU)

[Light chain deposition disease. Experience in our environment]. / Enfermedad por depósito de cadenas ligeras. Experiencia en nuestro medio.

UNLABELLED: The Light chain deposition disease (LCDD) is a strange entity characterised by the deposition of only one type of light chain in the renal tubular basement membranes. It can be associated to a plasma cell dyscrasia, however, it can occur in the absence of any detectable hematological disorder and it is called idiopathic LCDD. The clinical manifestation is renal insufficiency and nephrotic proteinuria, it does not have a clearly fixed treatment and has a severe prognosis. The aim of this work is to analyse the characteristics of the LCDD cases diagnosed within our environment. Six cases were identified, all of them between 1999 and 2005, from a total amount of 640 renal biopsies performed during this period, 4 women and 2 men, average age of 57. Multiple myeloma in 3 patients were detected (50%). The acute renal failure or rapidly progressive renal insufficiency was the most frequent clinical presentation (66%) together with nephrotic proteinuria (66%). All the biopsies showed tubular basement membranes thickening and kappa chains with a linear distribution within the same. The most frequent glomerular pathological finding was the nodular sclerosing glomerulopathy (83%). In one of the cases the affectation was exclusively tubular interstitial with tubular casts. 3 patients were treated, 2 with multiple myeloma. 5 patients needed dialysis: 3 with idiopathic LCDD within an average time of 7 days from the diagnosis to its reception and 2 with myeloma, who started needing dialysis in an average of 46 days. 4 patients died, 2 of them with myeloma. The monitoring time until the death was 13 weeks for the patients with myeloma and 110 weeks for the rest. CONCLUSION: The LCDD seems to be more frequent than what has been published and it is associated to the myeloma in half of the cases. It appears together with severe renal insufficiency and the patient's and renal prognosis is poor.