Are we still making progress in patient survival after kidney transplantation? Results of a regional registry.

Many studies have shown a trend to improved long-term survival of renal transplant recipients. We analyzed the survival of recipients in Andalusia, Spain, from 1984-2007. The study included all the deceased donor, non-multiorgan grafts (n = 5599), grouped over successive 6-year periods, compared for corrected recipient survival. Changes were noted in the recipient characteristics: increased age, diabetes, vascular nephropathy, retransplantation, duration of prior replacement therapy, and reduction in positive hepatitis C virus (HCV+) serology. The univariate analysis showed a significantly worse survival associated with increased age (P < .001), diabetes (P < .001), HCV+ serology (P < .01; 1996-2007), and longer times on replacement therapy, but not with sex or retransplantation. The respective survivals at 1, 5, and 10 years in 1984-1989 were 93%, 86%, and 75%; in 1990-1995, 97%, 92%, and 84%; in 1996-2001, 96%, 91%, and 84%; and in 2002-2007, 96% and 92%, respectively. There was a significant improvement between the first and second periods (P < .001), but no change thereafter. The multivariate analysis (Cox) showed, a significant influence of age >40 years, female gender (relative risk [RR] 0.8; 95% confidence interval [CI] 0.7-0.9), diabetes (RR 2.5; 95% CI 1.8-3.4), and duration of prior replacement therapy (RR 1.08; 95% CI 1.05-1.1). The risk varied significantly depending on the period: using 2002-2007 as the reference period, the RR in 1984-1989 was 3.4 (95% CI 2.6-4.5); in 1990-1995, 1.8 (95% CI 1.3-2.3); and in 1996-2001, 1.4 (95% CI 1.1-1.8; all P < .02). The model remained for 1996-2007, though HCV+ serology was not significant. In conclusion, we showed a significant improvement in recipient survival in Andalusia over time. Correction for worse recipient characteristics suggests continued advances.

Regional survey of patient survival after cadaver renal transplant failure.

Graft failure with return to dialysis is associated with higher mortality, but the determining factors have not been completely studied. We determined predictive factors for survival after renal transplant failure by analyzing demographic and clinical data on kidney recipients in a Spanish regional registry (Andalusia). Among 5547 single-organ cadaveric grafts in Andalusia between 1984 and 2007, 1534 patients returned to dialysis and were followed to death (n = 450), retransplantation (n = 574), or the end of the study period. The most frequent cause of death was cardiovascular disease (36.9%). Actuarial survival rates were 89%, 72%, and 51% at 1, 5, and 10 years, respectively. Upon univariate (Kaplan-Meier) analysis, survival was significantly related only to age at return to dialysis and diabetes. Cox forward step wise multivariate regression analysis showed that predictive factors for lower survival (relative risk -95% confidence interval) were: age (per year), 1.05 (1.05-1.06); male sex, 1.33 (1.1-1.6); and duration of pre-graft renal replacement therapy (per year), 1.02 (1.00-1.05). According to Cox backward stepwise regression analysis, a more saturated model, the predictive factors were: age; male sex; duration of pre-graft renal replacement therapy (per year), 1.03 (1.01-1.06); later study period (1996-2007), 0.81 (0.6-1.0); and primary etiology of chronic kidney disease (CKD). Survival after renal transplant failure was lower among male recipients of advanced age or with a long period of prior renal replacement therapy. Time of transplantation and primary etiology of CKD may also play roles.

Increase in malignancies as cause of death in renal transplant patients.

The Andalusian Kidney Transplant Registry is a Public Health Service Regional Registry of Andalusia, Spain. We have analyzed the causes of death among 5599 kidney transplantations performed between January 1, 1984 and December 31, 2007. The total number of patients who died after renal transplantation was 1106. Of these, 656 patients died with functioning renal grafts, which constituted the group analyzed in this study. No significant differences in the causes of death were observed as a function of age, sex, retransplant status, cause of end-stage renal disease, diabetes, and duration of the previous renal replacement therapy. Infections were the most frequent cause of death in the first year posttransplantation (early deaths). A significant difference was observed when these early deaths were compared with those that occurred after the first year posttransplantation (late deaths); there were fewer deaths due to infections (40.4% vs 15.9%, early vs late) and more deaths from cancer (4.9% vs 23.7%). The causes of death in the period 1984-1995 were compared with those in 1996-2007, excluding the deaths that occurred more than 12 years posttransplantation (not possible in the 1996-2007 periods n = 583). The causes of early death did not change. A significant difference was observed among late deaths with an increase in infections (14% vs 17%) and cancers (20% vs 29.7%). Thus, malignancies became the most frequent cause of late death in the 1996-2007 period. In conclusion, in our region, a long-term change in renal transplant patient mortality is taking place, with a significant increase in deaths due to cancer.

Trends in kidney transplantation outcome: the Andalusian Kidney Transplant Registry, 1984-2007.

Herein we have presented the first report from the Andalusian Kidney Transplant Registry, a Public Health Service Regional Registry in Andalusia, Spain (general population, 8 million). The current analysis was limited to 5599 kidney-alone transplants from deceased donors, grouped into 4 time periods: 1984-1989 (n = 846); 1990-1995 (n = 1172); 1996-2001 (n = 1801); and 2002-2007 (n = 2060). The age of the transplant patients rose over time to 21.7% of recipients of ages >or=60 years in 2002-2007. In the later years we observed an increased incidence of vascular and diabetic causes of end-stage renal disease (ESRD). Patients who underwent retransplantation increased from 2.7% in 1984-1989 to 8.1% in 2002-2007. Time on previous renal replacement therapy (RRT) increased from 33.1 +/- 29 to 48 +/- 53 months. Patient survivals at 1, 5, 10, and 20 years were 96%, 91%, 83%, and 63%, respectively. Censoring for death, graft survivals were 90%, 80%, 67%, and 45%, respectively. Compared with the 1984-1989 period, patient survival improved by about 10% (P < .001) since 1990, remaining stable to 2007. Censored 5-year graft survivals progressively improved from 72% to 77%, 82%, and 85% (P < .001). Upon multivariate analysis, gender, age >39 years, diabetes, and RRT duration were independent predictors of patient survival. Age <18 years, retransplantation, and positive hepatitis C virus serology were independent predictors of lower graft survival. Considering 1984-1989 as the reference time period, both patient and graft mortality risks continuously decreased over the following 3 periods (relative risk [RR] = 0.5-0.4-0.3 for patient mortality; RR = 0.8-0.6-0.5 for graft mortality). In summary, despite an increased number of adverse risk factors, both patient and graft survivals have improved from 1984 to date.

Análisis del liderazgo clínico del Director de una Unidad de Gestión Clínica / Analysis of the clinical leadership of the Director of a Clinical Management Unit

Con el objetivo de analizar el Liderazgo Clínico del Director de una Unidad de Gestión Clínica y el de identificar áreas de mejora en su gestión, se utilizó una encuesta de elaboración propia con 21 ítems que evaluó las distintas dimensiones del liderazgo siguiendo los criterios del Modelo Europeo de Excelencia (EFQM). Para ello se incluyeron 16 preguntas que hacían referencia a los distintos subcriterios del liderazgo del modelo. Se añadieron otras cinco para evaluar aspectos no incluidos en el citado modelo como: conocimientos del líder, sentido común, gestión de conflictos y gestión de la inteligencia emocional. La población encuestada fue de los 14 facultativos de la UGC Cuidados Críticos y Urgencia (3 de UCI y 11 de Urgencias) recibiéndose 14 encuestas cumplimentadas de forma anónima. Se describieron medias y desviaciones estándar para cada una de las variables. Los valores globales (media global y DE global) se obtuvieron a partir de la media de los ítems que la componían. Los resultados globales reflejaron una media sobre 10 de 7'55 con una desviación estándar de 1'36 y una mediana de 7'86. Los ítems peor valorados fueron: 6'67 ±1'78 para la gestión de conflictos y 6'88 ±1'95 para la toma de decisiones oportunas. Como conclusión creemos que este tipo de evaluaciones facilita la retroalimentación del líder de la Unidad lo que le permite posicionarse y corregir desviaciones en aspectos clave de su función que pueden tener una importante repercusión en los resultados de la Unidad (AU)

In order to analyse the Clinical Leadership of the Director of a Clinical Management Unit and to identify areas of improvement in his management, this article presents a study using surveys and EFQM criteria, as a tool for providing feedback to the Unit leader, enabling him to position himself and correct deviations in key aspects of his function which may have an important repercussion in the results of the Unit (AU)

Development of a citrus genome-wide EST collection and cDNA microarray as resources for genomic studies.

A functional genomics project has been initiated to approach the molecular characterization of the main biological and agronomical traits of citrus. As a key part of this project, a citrus EST collection has been generated from 25 cDNA libraries covering different tissues, developmental stages and stress conditions. The collection includes a total of 22,635 high-quality ESTs, grouped in 11,836 putative unigenes, which represent at least one third of the estimated number of genes in the citrus genome. Functional annotation of unigenes which have Arabidopsis orthologues (68% of all unigenes) revealed gene representation in every major functional category, suggesting that a genome-wide EST collection was obtained. A Citrus clementina Hort. ex Tan. cv. Clemenules genomic library, that will contribute to further characterization of relevant genes, has also been constructed. To initiate the analysis of citrus transcriptome, we have developed a cDNA microarray containing 12,672 probes corresponding to 6875 putative unigenes of the collection. Technical characterization of the microarray showed high intra- and inter-array reproducibility, as well as a good range of sensitivity. We have also validated gene expression data achieved with this microarray through an independent technique such as RNA gel blot analysis.

Structural and evolutionary analysis of the copia-like elements in the Arabidopsis thaliana genome.

The analysis of 460 kb of genomic sequence of Arabidopsis thaliana chromosome III allowed us to identify two new transposable elements named AtC1 and AtC2. AtC1 shows identical long terminal repeats (LTRs) and all the structural features characteristic of the copia-like active elements. AtC2 is also a full copia-like element, but a putative stop codon in the open reading frame (ORF) would produce a truncated protein. In order to identify the copia-like fraction of the A. thaliana genome, a careful computer-based analysis of the available sequences (which correspond to 92% of the genome) was performed. Approximately 300 nonredundant copia-like sequences homologous to AtC1 and AtC2 were detected, which showed an extreme heterogeneity in size and degree of conservation. This number of copies would correspond to approximately 1% of the A. thaliana genome. Seventy-one sequences were selected for further analysis, with 23 of them being full complete elements. Five corresponded to previously described ones, and the remaining ones, named AtC3 to AtC18 are new elements described in this work. Most of these elements presented a putative functional ORF, nearly identical LTRs, and the other elements necessary for retrotransposon activity. Phylogenetic trees, supported by high bootstrap values, indicated that these 23 elements could be considered separate families. In turn, these 23 families could be clustered into six major lineages, named copia I-VI. Most of the 71 analyzed sequences clustered into these six main clades. The widespread presence of these copia-like superfamilies throughout plant genomes is discussed.

ZFWD: a novel subfamily of plant proteins containing a C3H zinc finger and seven WD40 repeats.

We describe a new subfamily of WD repeat proteins characterised by the presence of a C3H zinc finger at the N-terminal part of the protein associated with seven WD40 repeats. We have identified four members of this subfamily in Arabidopsis thaliana, one of them with associated expressed sequence tags (ESTs). We have also identified homologous ESTs in rice, cotton, maize, poplar, pine tree and the ice plant. We do not observe animal homologues, suggesting that this subfamily could be specific for plants. Our data suggest an important role for these proteins. Based on the high sequence conservation within the conserved domains, we suggest that these proteins could have a regulatory function.

[Renal artery stenosis in the transplant patient]. / Estenosis de la arteria renal en el trasplantado.

OBJECTIVE: To present our experience in the diagnosis and treatment of renal artery stenosis in kidney transplants. METHODS: A review of 601 renal transplants performed in adults showed 32 cases of renal artery stenosis. The diagnostic techniques utilized were arteriography in 18 patients, DIVAS in 15, echo-Doppler in 11 patients and MAG with captopril test on two occasions. RESULTS: Arterial hypertension was the most common symptom (92.8%), alone (53.1%) or in association with impaired renal function (43.7%). 46.8% of the cases could be managed by drug therapy. Percutaneous transluminal angioplasty was performed in 14 patients. Surgery was required on two occasions. CONCLUSIONS: The incidence of renal artery stenosis in our series of renal transplants in adults up to 1997 was 5.3%. Arterial hypertension with or without impairment of renal function was the most common symptom. Currently, echo-doppler and MAG with captopril test are the most widely utilized diagnostic techniques. Percutaneous transluminal angioplasty is the treatment of choice in renal artery stenosis when arterial hypertension is refractory to drug therapy. Good results are achieved in 57%, although it is not free from complications. In case of failure, revascularization surgery is the alternative approach.

The Arabidopsis CBF gene family is composed of three genes encoding AP2 domain-containing proteins whose expression Is regulated by low temperature but not by abscisic acid or dehydration.

We have identified two genes from Arabidopsis that show high similarity with CBF1, a gene encoding an AP2 domain-containing transcriptional activator that binds to the low-temperature-responsive element CCGAC and induces the expression of some cold-regulated genes, increasing plant freezing tolerance. These two genes, which we have named CBF2 and CBF3, also encode proteins containing AP2 DNA-binding motifs. Furthermore, like CBF1, CBF2 and CBF3 proteins also include putative nuclear-localization signals and potential acidic activation domains. The CBF2 and CBF3 genes are linked to CBF1, constituting a cluster on the bottom arm of chromosome IV. The high level of similarity among the three CBF genes, their tandem organization, and the fact that they have the same transcriptional orientation all suggest a common origin. CBF1, CBF2, and CBF3 show identical expression patterns, being induced very rapidly by low-temperature treatment. However, in contrast to most of the cold-induced plant genes characterized, they are not responsive to abscisic acid or dehydration. Taken together, all of these data suggest that CBF2 and CBF3 may function as transcriptional activators, controlling the level of low-temperature gene expression and promoting freezing tolerance through an abscisic acid-independent pathway.

Molecular characterization of the zerknüllt region of the Antennapedia complex of D. subobscura.

We have characterized at the molecular level the zerknüllt (zen) region of the Drosophila subobscura Antennapedia complex. The sequence comparison between D. subobscura and D. melanogaster shows an irregular distribution of the conserved and diverged regions, with the homeobox and a putative activating domain completely conserved. Comparisons of the promoter sequence and pattern of expression of the gene during development suggest that the regulation of zen has been conserved during evolution. The conservation of zen expression in a subpopulation of the polar cells indicates the existence of an important role in such cells. We describe a transitory segmented pattern of expression of zen in both species, suggesting the existence of interactions with a pair rule gene. Some indirect clues indicate that the z2 gene might be absent from the D. subobscura genome. A chromosome walk initiated to reach the proboscipedia gene of D. subobscura reveals that the distance between pb and zen is at least four times the one described for D. melanogaster and for D. pseudoobscura. Finally, we present cytological evidence showing that the ANT-C is inverted in D. subobscura as compared to D. melanogaster.

In situ localization of the Antennapedia gene on the chromosomes of nine Drosophila species of the obscura group.

The homeotic Antennapedia gene, cloned from the genomic DNA of D. subobscura, was localized on the polytene chromosomes of nine species of the Drosophila obscura group. In all of them, the probe used hybridized on chromosomes equivalent to the E element of Müller's terminology. These results are consistent with the idea that single copy genes do not move around the genome and that chromosomal elements have conserved their genetic identity during evolution.

[Maternal-fetal transmission of HIV in Catalonia and the Balearic Islands]. / Transmisión materno-infantil de la infección por el virus de la inmunodeficiencia humana (VIH) en Cataluña y Baleares.

Two hundred and ninety three cases of children born of HIV positive mothers have been observed between January 1984 and June 1988 in Catalonia and Balearic Islands, with a ration of 9.5/10,000 newborns. Sex was not significant in the infected group. Most of the cases (68%) have been detected since 1987 and represent a significant increase in HIV positive children and thus of those who will present with clinical manifestations of this infection.

Optic pathway gliomas in neurofibromatosis.

Two patients, a 5-year-old girl and a 3-year-old boy, with documented neurofibromatosis (NF-1) and visual pathway gliomas are reported. In the first patient, the tumor was a typical pilocytic astrocytoma confined to the proximal half of the right optic nerve just near the globe. The tumor was excised; after a follow-up of 7 years recurrence has not occurred. The second patient had a glioma of the left optic nerve, with involvement of the chiasm, optic tracts, probably lateral geniculate body, optic radiations and basal ganglia. Biventricular hydrocephalus, possibly due to the occlusion of Monro's foramina, was also noted. In this case, magnetic resonance imaging (MRI) was superior to computed tomography for visualizing the posterior extension of the lesions. The patient received X-ray therapy and after a follow-up of 3 years the clinical symptomatology remains stationary. It is suggested that the optic pathway involvement detected by MRI may represent a dysplastic element NF-1 rather than a truly neoplastic change.