Non-Heart-Beating Donor Kidney Transplantation Survival Is Similar to Donation After Brain Death: Comparative Study With Controls in a Regional Program.

Non-heart-beating donors (NHBD) are an increasing source of organs for kidney transplantation (KT) compared with donation after brain death (DBD), but the results in each regional transplantation program require local analysis. We compared 164 KT from NHBD (83 Maastrich type II A-B [T2] and 81 type III [T3]) with 328 DBD controls. NHBD kidneys were implanted with less cold ischemia, mean time on renal replacement therapy for NHBD recipients before transplantation was less too, and a higher proportion of thymoglobulin was also used. Besides NHBD-T2 more frequently showing the A group and patients being younger (48.9 ± 11 vs DBD 55.2 ± 15 years old; P < .001), there was a lower proportion of retransplant recipients and HLA sensitization; HLA-DR compatibility was slightly worse. Proportion of nonfunctioning allograft and necessity of dialysis after transplantation for NHBD were 4.9 and 68.3% versus DBD 4.3 and 26.9% (P < .001); renal function after a year was significantly less in NHBD (serum creatinine 1.79 ± 0.9 mg/dL vs 1.46 ± 0.5 in DBD; P < .001). NHBD recipient survival rates were 96% and 96% for the 1st and 3rd years, respectively, versus 96% and 94% for DBD, respectively (not significant [NS]). Graft survival rates censored by death were 91% and 89% (1st and 3rd years, respectively) versus 95% and 94% for DBD, respectively (NS). We did not find significant differences about survival between NHBD-T2 and T3. In the multivariable survival study (Cox, covariables with statistical significance demonstrated previously in our region), NHBD is not a prognosis factor for recipient or graft survival. Regarding current criteria for choosing donors and the graft allocation applied in Andalusia, short-term survival for NHBD transplantation is similar to DBD. Renal function in the short term is slightly worse, which is why it is important to monitor results over a long term, especially those from NHBD-T2.

A new program of kidney transplantation from donors after cardiac death in Spain.

Despite the high rate of kidney transplantation in Spain, a disparity still exists between the numbers of donors and waiting-list patients. Donors after circulatory death (DCD) have been propagated as a promising approach to reduce the donor kidney shortage. In Europe most of the countries use controlled DCD, but in Spain, mainly uncontrolled DCD are harvested and until 2010 at only four institutions. In January 2010, we began a program of donation after uncontrolled DCD (Maastricht type II; unsuccessful resuscitation). The aim of this observational study was to describe our preliminary results. The numbers of recovered and transplanted organs per DCD were 27. There were no cases of primary nonfunction, but delayed graft function was present in 85% of recipients. Despite this impairment, about 75% of patients reached a serum creatinine below 2 mg/dL in the second month, with 1-year graft and patient survivals of 85% and 100%. Although, our preliminary results with a not very long follow-up and small number of patients suggested that utilization of DCD should be expanded because this type of donor increases the number of cases and opportunities of end-stage renal disease patients to reduce the waiting times for transplantation.

Evolution of left ventricular mass in renal transplant recipients: the influence of glucose homeostasis and oxidative stress.

BACKGROUND: Left ventricular hypertrophy, considered an independent factor for cardiovascular mortality, is frequent among renal transplant recipients (RTR), in whom we investigated changes in left ventricular mass (LVM) after grafting and associations with possible causal factors, especially glucose metabolism and oxidative stress. METHODS: We performed a prospective study of 37 RTR without prior diabetes mellitus who were evaluated at three times after transplantation (medians of 0.6, 16 and 28 months) by means of the LVM index (LVMI, echocardiographic measure of LVM related to body surface area, g/m(2)), oral glucose tolerance test and determinations of malondialdehyde and total glutathione (GSH), as well as glomerular filtration rate (GFR) estimate by the Modification of Diet in Renal Disease formula. We calculated the overall increment (DeltaLVMI) and percent change of LVMI. Patients were diagnosed to be prediabetic (PD) or new-onset diabetes after transplant (NODAT) according to ADA criteria. RESULTS: The mean LVMI decreased significantly over time among whole group baseline = 108.34 ± 27.71 g/m(2) versus middle: 100.03 ± 27.53 g/m(2) versus final: 90.62 ± 24.06 g/m(2) (P = .000). However, 13.5% of subjects showed an increased LVMI and 59.5%, a decrease less than 20%. Patients with NODAT at the end of the study showed a positive DeltaLVMI, which was negative in nondiabetics (0.24 ± 16.14 versus -19.86 ± 12.61 g/m(2), P = .018). Compared with DeltaLVMI(-) recipients, patients with DeltaLVMI(+) showed a greater proportion of PD and NODAT at baseline (60% and 40% versus 18.8% and 12.5%, P = .017), and significantly higher all-time fasting glycemia, lower estimated GFR, and greater increments of malondialdehyde and GSH over time. Those with a <20% LVMI decrease experienced progressive GFR impairment over time, as opposed to those with an LVMI decrease > 20%, who showed greater and improving GFR over the whole study. CONCLUSIONS: LVMI does not always improve in RTR; the evolution of ventricular mass after renal transplantation is influenced by glucose metabolism disorders, oxidative stress, and graft function.

[Importance of ultrapure dialysis liquid in response to the treatment of renal anaemia with darbepoetin in patients receiving haemodialysis]. / Importancia del líquido de diálisis ultrapuro en la respuesta al tratamiento de la anemia renal con darbepoetina en el paciente en hemodiálisis.

Chronic inflammatory diseases and infections are a major cause of hyporesponse to erythropoiesis-stimulating factors. We conducted this prospective study in 107 patients in haemodialysis with dialysis liquid that was potentially contaminated from a bacteriological perspective in order to test the hypothesis that ultrapure dialysis liquid can improve the response to treatment with darbepoetin and reduce inflammatory markers. These patients had to have been stable in the last 8 weeks in relation to haemoglobin level and the administered dose of darbepoetin. Two filters (one of hydrophilic nylon and another of polysulfone) were added to the water treatment process, the first one prior to distribution ring output and the second before the dialyser. The patients were evaluated for 12 months. The dosage of darbepoetin was varied to maintain haemoglobin levels ranging from 11 to 14 g/dl. We measured resistance to the erythropoiesis-stimulating factor, defined as the quotient between weekly dose of darbepoetin and haemoglobin levels, baseline and every two months, the baseline and monthly endotoxin count and reactive protein C at baseline and every 6 months. 94 patients completed the study. The resistance index fell significantly during follow-up (p<0.001) and was measurable from the second month on. Haemoglobin levels remained within the established margins with a 34% reduction in the weekly dose of darbepoetin at the end of the follow-up period. Both reactive protein C and the endotoxin count were significantly reduced (p<0.001) compared to baseline after 6 and 12 months. To conclude, the bacteriological purity of the dialysis liquid reduces inflammatory markers in patients receiving haemodialysis, improving the response to treatment with darbepoetin in renal anaemia.

[Effect of irbesartan in proteinuric non-diabetic renal disease]. / Efecto de irbesartin en patología renal proteinúrica no diabética.

This randomized, prospective, two-arm clinical study evaluated the antiproteinuric and nephroprotective effects and the safety of treatment with an angiotensin II receptor antagonist (irbesartan) in patients with chronic glomerulonephritis (CGN) as compared to angiotensin-converting enzyme inhibitors (ACEIls). A total of 50 patients with CGN diagnosed by renal biopsy and protein levels in 24-hour urine higher than 1 g were enrolled. All patients received treatment for at least 24 months, 27 in group 1 (irbesartan) and 23 in group 2 (ACEs). A significant decrease in proteinuria (p < 0.001) was seen in both groups (49.2% in group, 1, and 44.8% in group 2) since the third month, and confirmed at 12 and 24 months of follow-up (58.1% and 62.7% in group 1, and 56.8% and 55.4% in group 2, respectively), with no significant differences being seen between the two groups. No differences were found in blood pressure control. No significant decrease was found in any of the groups in the glomerular filtration rate, but this showed higher values in the group treated with ACEIs (2.98 +/- 7.77 vs 1.64 +/- 6.84 ml/min/year), though the difference with irbersartan was not statistically significant. No side effects occurred among patients treated with irbesartan, whereas three patients initially treated with ACEIs showed intolerance (cough). In conclusion, irbesartan showed in our study an antiproteinuric and nephroprotective effect similar to ACEIs in patients with chronic glomerulonephritis, and its administration was also shown to be safe.

[Treatment of renal anemia with darbepoetin alfa administered once every other week in predialysis patients with chronic kidney disease and previously treated with epoetin alfa]. / Tratamiento de la anemia renal con administración una vez cada dos semanas de darbepoetina alfa en pacientes con insuficiencia renal crónica prediálisis previamente tratados con epoetina alfa.

Darbepoetin alfa is an erythropoiesis-stimulating glycoprotein with up to 3 times longer half-life than recombinant human erythropoietin (rHuEPO) in humans. The aim of this study was to assess the efficacy and safety of darbepoetin alfa given once every other week as treatment of anemia in predialysis patients with chronic renal failure (CRF) previously treated with once-weekly epoetin alfa. A total of 42 CRF patients were included, all of whom had previously been treated with epoetin alfa and showed stable hemoglobin (Hb) levels without dose changes during the last 8 weeks prior to enrolment in this study. All patients received s.c. darbepoetin alfa once every other week at doses calculated from the protein mass equivalence between rHuEPO and darbepoetin alfa. Follow-up lasted for 24 weeks. Dose adjustments were conducted to preserve target Hb levels between 11 and 13 g/dl. Thirty-nine patients completed the 24 weeks of study. Hb levels increased during follow-up [mean values of 0.39 (p < 0.002), 0.58) (p < 0.001), and 0.83 g/dl (p < 0.001) at 8, 16 and 24 weeks, respectively] despite reducing the darbepoetin alfa dose up to 15% at 24 weeks [from 0.192 microg/kg body weight to 0.185, 0.178 and 0.163 at 8, 16, and 24 weeks, respectively (p < 0.001)]. No adverse events related to darbepoetin alfa were reported. In conclusion, these results show s.c. administration of darbepoetin alfa once every other week was superior to weekly epoetin alfa as a maintenance treatment for anemia in predialysis CRF patients, since the former provided higher Hb levels. Moreover, darbepoetin alfa administration was safe in these patients.

[Change of EPO treatment from subcutaneous epoetin to intravenous epoetin or darbepoetin alpha]. / Estudio comparativo sobre el tratamiento de la anemia renal en el paciente en hemodiálisis: cambio de vía de administración de epoetina alfa frente a conversión a darbepoetina.

This prospective, two-arm, clinical trial assesses the effectiveness in maintaining the levels of haemoglobin (Hb) between 11 and 13 g/d1 and the safety of changing the administration route (from subcutaneous to intravenous) of epoetin (rHuEPO) alpha at equidose versus a changeover to darbepoetin alpha, taking the exact equivalence in peptide mass between the two as referent in patients with chronic renal insufficiency (CRI) in haemodialysis. A total of 112 patients previously treated with epoetin and no dose modification during the 8 weeks prior to the study and stable levels of Hb were included. Of these, 92.1% finished the follow-up period (24 weeks). After changing the administration route of rHuEPO, a significant increase in the resistance index (REI, weekly dose per kilogram of weight/levels of hemoglobin) was observed with mean values of 2.73 (p < 0.018) and 4.37 (p < 0.001) after 16 and 24 weeks respectively, requiring an increase of the dose greater than 15% over the baseline in 6 1.1% of the patients. The changeover to, darbepoetin alpha, independently of the administration route, was accompanied by a decrease in REI starting in the 8th week (mean levels of 0.012, 0.018 and 0.023 after 8, 16 and 24 weeks respectively), significant (p < 0.001) at the 3 cutoff points of the study. The conversion factor increased significantly up to 1:260 in week 24. Both erythropoietic stimulating factors (EST) were well tolerated and no unexpected side effects were observed. In conclusion, treatment of anaemia with darbepoetin alpha in patients with CRI in haemodialysis previously treated with rHuEPO proved to be more effective than the use of epoetin intravenously, significantly improving the resistance index. In addition, the treatment with darbepoetin alpha was well tolerated in these patients.