Study of the renal function in nonrenal organ transplantation.

Kidney disease after transplantation of a nonrenal organ has been described to be the result of the nephrotoxicity from the commonly used calcineurin-inhibitors as well as other factors. The aim of this study was to evaluate renal function and potential risk factors for the development of chronic renal failure among nonrenal organ recipients. We designed a single-center retrospective study including all 165 of our cardiac and liver recipients between February 1998 and October 2003, collecting clinical, analytic, and therapeutic data. We excluded double transplants and patients with survival less than 6 months. Creatinine clearance was calculated according to the Cockcroft-Gault and the Levey Modification of Diet in Renal Disease (MDRD)-5 equations. Although 165 patients received a cardiac or liver transplantation, 17 died in the first 6 months and three were double transplants; therefore we analyzed 145 patients: 107 (74%) cardiac transplantations and 38 (26%) liver transplantations. There were 106 male and 39 female recipients. The mean age (+/-SD) at the time of transplantation was 54 +/- 10 years and the mean follow-up was 2.9 +/- 1.7 years. Urinalysis before transplantation was only performed in 33 patients (22.8%) including three (2.1%) who had proteinuria. Serum creatinine increased until 12 months after transplantation (P < .001), then it recovered its average level. Creatinine clearance calculated using the aforementioned equations showed a similar pattern, with a progressive decline to 12 months (P < .05), with eventual stabilization or even improvement. The factors that we observed to increase the risk of renal damage were age, female sex, obesity, and the presence of proteinuria prior to transplantation. There was a good correlation (r = 0.96) between cyclosporine but not tacrolimus trough levels and serum creatinine at 48 hours after transplantation.

[Parvovirus B9 infection in a renal transplant recipient. Diagnosis by detection of viral genome in peripheral blood]. / Infección por parvovirus B19 en trasplante renal. Diagnóstico por detección del genoma viral en sangre periférica.

Parvovirus B19 can produce a picture known as pure red blood aplasia in recipients of solid organ. Occasionally the viruses cause decrease of the other blood cells, and various extra-hematologic manifestations. Common diagnosis is realised by bone marrow examination. The diagnostic value of the viral genome in the blood stream is not well defined. We reported the case of a male of 17 years of age, whose diagnosis was done by repeated determinations of the viral parvovirus B19 genome in peripheral blood. It was confirmed by a biopsy of the iliac crest. The patient was treated with unspecific IgG immunoglobulins, with complete recovery from the symptoms and signs. It did not have any recurrence of the disease. This case suggests that the realisation of PCR of Parvovirus B19 in renal transplant patients with pure red cell aplasia could be of greater interest in the diagnosis and monitoring of the disease. The detection of the viral genome could avoid the administration of unnecessary blood transfusions, and possibly the realization of bone marrow biopsy.

Infección por parvovirus B19 en trasplante renal. Diagnóstico por detección del genoma viral en sangre periférica / Parvovirus B19 infection in a renal transplant recipient. Diagnosis by detection of viral genome in peripheral blood

El parvovirus B19 puede producir un cuadro de anemia conocido como aplasiapura de células rojas en los receptores de trasplantes de órganos. A veces se asocia adisminución de las otras series sanguíneas y a variada patología extrahematológica. Eldiagnóstico se suele hacer mediante examen de la médula ósea. El valor de la deteccióndel genoma viral en sangre no está bien delimitado. Se describe el caso de unvarón de 17 años que presentó fiebre, anemia recitulocipénica y hepatitis debida ainfección por parvovirus B19, cuyo diagnóstico se realizó mediante determinaciónseriada del genoma viral en sangre periférica y se confirmó por biopsia de cresta iliaca.El paciente respondió al tratamiento con inmunoglobulinas, recuperándose completamentede los síntomas y no presentando recaídas.Se sugiere que ante la presencia de anemia de origen no filiado en un paciente contrasplante renal se debe realizar una PCR de Parvovirus B19 en sangre periférica, sobretodo si se acompaña de reticulocitopenia. La detección del genoma viral en plasma permiterealizar un diagnóstico y tratamiento precoz, evitando la administración de transfusionessanguíneas innecesarias, y posiblemente la realización de una biopsia ósea

Parvovirus B19 can produce a picture known as pure red blood aplasia in recipientsof solid organ. Occasionally the viruses cause decrease of the other blood cells, and various extra-hematologic manifestations. Common diagnosis is realised by bonemarrow examination. The diagnostic value of the viral genome in the blood stream isnot well defined.We reported the case of a male of 17 years of age, whose diagnosis was done byrepeated determinations of the viral parvovirus B19 genome in peripheral blood. Itwas confirmed by a biopsy of the iliac crest. The patient was treated with unspecificIgG immunoglobulins, with complete recovery from the symptoms and signs. It didnot have any recurrence of the disease.This case suggests that the realisation of PCR of Parvovirus B19 in renal transplantpatients with pure red cell aplasia could be of greater interest in the diagnosis andmonitoring of the disease. The detection of the viral genome could avoid the administrationof unnecessary blood transfusions, and possibly the realization of bonemarrow biopsyParvovirus B19 can produce a picture known as pure red blood aplasia in recipients of solid organ. Occasionally the viruses cause decrease of the other blood cells, and various extra-hematologic manifestations. Common diagnosis is realised by bone marrow examination. The diagnostic value of the viral genome in the blood stream is not well defined. We reported the case of a male of 17 years of age, whose diagnosis was done by repeated determinations of the viral parvovirus B19 genome in peripheral blood. It was confirmed by a biopsy of the iliac crest. The patient was treated with unspecific IgG immunoglobulins, with complete recovery from the symptoms and signs. It did not have any recurrence of the disease. This case suggests that the realisation of PCR of Parvovirus B19 in renal transplant patients with pure red cell aplasia could be of greater interest in the diagnosis and monitoring of the disease. The detection of the viral genome could avoid the administration of unnecessary blood transfusions, and possibly the realization of bone marrow biopsy

Risk factors for cardiovascular disease during the first 2 years after renal transplantation.

The aim of the present study was to assess the role of cardiovascular risk factors in the occurrence of cardiovascular events among 100 consecutive renal transplant recipients during the first 2 years after transplantation. The following parameters were analyzed: (1) demographic data (gender, age, dialysis duration, preexistent diabetes, and pretransplantation events) as well as (2) basal 1-year, and 2-year posttransplantation data for events, body mass index, arterial hypertension, number of drugs for hypertension control, use of ACE or ARA II inhibitors, treatment with lipid- lowering drugs, de novo diabetes, anemia, immunosuppression with cyclosporine versus tacrolimus, and homocysteine, folic acid, serum creatinine, uric acid, PTH-i, and cholesterol total, high-density lipoprotein (HDL)-cholesterol, low-density lipoprotein (LDL)-cholesterol, and triglyceride levels. At the end of the second posttransplantation year, 14 patients versus 86 who did not experience a new cardiovascular event. Patients in the event group had more events pretransplantation and during the first posttransplantation year than those in the non event group (57.1% vs 17.4%; P = .003 and 78.6% vs 2.3%; P = .000, respectively). Furthermore, the former cohort of patients were older, had greater ventricular hypertrophy and had higher triglyceride and serum creatinine concentrations during the 2 years after transplantation. A multiple logistic regression analysis confirmed the relationship between events within 1 year of transplantation and serum creatinine level at the end of 2 years as well as the development of cardiovascular disease within 2 years. In conclusion, our data suggest the need for aggressive intervention during the first year to prevent the development of new cardiovascular events. Renoprotective strategies may also contribute to reduce the cardiovascular risk of renal transplant recipients.

Posttransplantation diabetes mellitus: prevalence and risk factors.

BACKGROUND: Prevalence of diabetes mellitus (DM) type 2 in Asturias is 10%. The associations between age, family history of diabetes, hypertension, obesity, hypertriglyceridemia, and development of type 2 diabetes are well established. The aim of this study was to evaluate the prevalence of and risk factors for posttransplantation diabetes mellitus (PTDM). METHODS: We retrospectively studied 500 patients who had received a cadaveric renal transplant. Subjects with pretransplantation diabetes (5.6% type 1 and 7% type 2) and nondiabetics (78.2%) were excluded. We only evaluated 46 (9.2%) patients with PTDM. The follow-up period was 6 months to 15 years. We reviewed gender, age, family history of diabetes, body weight, hypertension, cardiovascular events, serum creatinine, hepatitis C virus infection, triglycerides, hyperuricemia, high-density lipoprotein and low-density lipoprotein cholesterol, and immunosuppressive therapies. RESULTS: The median time to diagnosis of PTDM was 3 months (range 1-56 months) after transplantation, a period in which 47% patients developed this complication. Compared with nondiabetics, PTDM patients were significantly older (P = .000), more obese (P = .002), received tacrolimus (P = .027), and had hypertension (P = .014) or cardiovascular events (P = .000). Serum creatinine and hepatitis C virus infection rated were similar in both groups. On multivariate analyses, the risk factors significantly associated with the development of PTDM were greater age (P = .0024), obesity (P = .0032), and hypertension (P = .0516). CONCLUSIONS: Half of the patients with PTDM developed new-onset diabetes within the first 3 months. Age, obesity, and hypertension were among the risk factors for diabetes posttransplantation. After the transplantation, the modifiable risk factors are control of body weight and control of hypertension.

Toxicidad fetal de los fármacos antihipertensivos / Fetal toxicity of antihypertensive drugs

Los estudios realizados con fármacos antihipertensivos en el embarazo y en la lactancia son, en general, de escasa magnitud, de pobre calidad metodológica y limitado seguimiento, por lo que los resultados obtenidos sólo proporcionan la evidencia derivada de la opinión de los expertos consultados. Los riesgos maternofetales de la hipertensión arterial en el embarazo dependen de la gravedad de la hipertensión arterial, de la proteinuria, de la presencia de nefropatía y de las complicaciones derivadas del retardo del crecimiento intrauterino. En el embarazo la decisión de establecer tratamiento antihipertensivo depende de la gravedad de la hipertensión arterial y de la presencia de daño orgánico. Todos los fármacos usados para el tratamiento de la hipertensión arterial en el embarazo atraviesan la placenta, por lo que pueden afectar al feto bien indirectamente disminuyendo el flujo útero-placentario o bien directamente a través de la circulación umbilical. Los fármacos antihipertensivos disminuyen la presión arterial de la madre, pero no mejoran los resultados fetales, siendo el único remedio finalizar la gestación; sin embargo, el parto, siempre adecuado para la madre no lo es tanto para el feto. Los fármacos de primera elección en el embarazo son: metildopa, labetalol y nifedipino. La lactancia materna es la forma más natural y efectiva de satisfacer las necesidades del niño, por tanto debe estimularse su utilización, al menos durante el primer y segundo mes. En la lactancia como en el embarazo la decisión de establecer tratamiento antihipertensivo depende de la gravedad de la hipertensión arterial y de la presencia de daño orgánico. Los betabloqueantes, incluido el labetalol, son los fármacos de primera elección en la lactancia (AU)

Hipertensión arterial: revisión sobre la efectividad y coste-efectividad de su medición mediante la monitorización ambulatoria de 24 horas / Arterial hypertension: efectiveness and cost-efectiveness of its measurement whit 24 hour ambulatory blood pressure monitoring

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Influence of anticalcineurinic therapy in plasma homocysteine levels of renal transplant recipients: a prospective study.

Hyperhomocysteinemia is an independent factor for cardiovascular disease. Renal function and folate level are important determinants of total plasma homocysteine levels. The influence of anticalcineurin drugs on homocysteine levels is controversial. The aims of the study were: (1) to analyze changes in homocysteine levels after the first year of 73 renal transplants and (2) to determine the influence of immunosuppressive anticalcineurin drug therapy on fasting homocysteine concentrations. We examined homocysteine, serum creatinine, folate, and vitamin B12 concentrations immediately after transplant, at 6 months, and after 12 months from renal transplant. Also, MTHFRC677T polymorphism was investigated. Tacrolimus was administered in 28 patients and cyclosporine in 45. Homocysteine levels decreased from 28.41+/-13.71 micromol/L to 18.59+/-8.31 micromol/L after 6 months and to 17.13+/-7.06 micromol/L after 1 year. No relationship was found between homocysteine and folate levels. When anticalcineurin drugs were considered, the homocysteine levels in patients treated with tacrolimus was lower than that in patients treated with cyclosporine at month 6 after transplant (16+/-7.4 micromol/L vs 20.1+/-8.5 micromol/L, P=.03) and after 1 year (15+/-7.6 micromol/L vs 18.4+/-6.4 micromol/L, P=.04). Serum creatinine levels followed the same evolution: they were lower in patients treated with tacrolimus at 6 months (1.35+/-0.36 mg/dL vs 1.57+/-0.45 mg/dL, P=.03) and to a lesser extent at 1 year after renal transplant (1.38+/-0.35 mg/dL vs 1.54+/-0.45 mg/dL, P=.09). The homocysteine value closely related with serum creatinine in both groups. In conclusion, 1 year posttransplant, the homocysteine level was lower among patients treated with tacrolimus, the cohort that also showed the lower serum creatinine concentrations.

Remisión de enfermedad severa por citomegalovirus y enfermedad linfoproliferativa post-trasplante en un receptor de trasplante renal tras terapia con ganciclovir y cambio en la medicación inmunosupresora / Remission of severe disease induced by cmv and lymphoproliferative posttransplant disease after changing the immunosuppression regime

Se describe el caso de un receptor de trasplante renal con sobreinmunosupresión inducida por la interacción de tacrolimus y fluconazol que desarrolló dos enfermedades severas producidas por dos virus diferentes del grupo herpes: enfermedad por citomegalovirus (CMV) y enfermedad linfoproliferativa post-trasplante (ELPT). La detección del genoma del virus de Epstein-Barr (VEB) en sangre periférica precede al diagnóstico de ELPT. Ambas enfermedades remitieron con el cambio del régimen inmunosupresor y tratamiento con ganciclovir. Debido a que la infección por CMV es un factor de riesgo para desarrollar ELPT y a que las manifestaciones clínicas y endoscópicas de ambas enfermedades pueden confundirse, en los pacientes con enfermedad por CMV se debe descartar la presencia de una ELPT concomitante, sobre todo si estos pacientes son seronegativos para el virus de Epstein-Barr. La detección del genoma del VEB en sangre periférica puede ser de gran ayuda en el diagnóstico precoz de ELPT en estos pacientes. (AU)

[Changes in health-related quality of life in the first year of kidney transplantation]. / Cambios en la calidad de vida relacionada con la salud durante el primer año del trasplante renal.

OBJECTIVE: To study the changes in the health related quality of life (HRQOL) during the first year following renal transplant (RT), comparing azathioprine vs mycophenolate mofetil (MMF) in triple immunosuppressant therapy with prednisone and cyclosporine. METHODS: Prospective, open and random study with 26 patients who received a primary cadaveric renal transplant consecutively. Analysis of clinical variables: delayed graft function (DGF), acute rejection (AR), infections and comorbidity; analytical: haemogram, albumin and serum creatinine, hepatic function, cyclosporin levels; instruments for assessing the HRQOL: Psychological General Well-being Index (PGWBI) and Euroqol-5d (EQ-5d) health questionnaire, which includes a self-assessment scale of the state of health, Visual Analogical Scale (VAS). Controlled collection of data upon discharge following renal transplant, and subsequently 1, 3, 6, and 12 months following the first questionnaire. RESULTS: There were no differences between patients on azathioprine or MMF, except that AR occurred less frequently with MMF (7% vs 42%, p = 0.065). Global AR: 23%, cytomegalovirus infection/illness: 81%/8%, readmissions: 42%. There was an improvement in HRQOL measured by the progressive increase in the scores on the PGWBI, EQ-5d and VAS during the first three months following RT. By the sixth month, in comparison to the third, a decrease in the score was observed (PGWBI, p = 0.011). Later the HRQOL improved, but without reaching the maximum scores achieved. CONCLUSIONS: Patients on MMF showed less frequent incidence of AR. The HRQOL decreases during the third and the sixth month, but with less intensity in patients on MMF, probably related to the lower rate of AR, and excluding the over 60s.

Cambios en la calidad de vida relacionada con la salud durante el primer año del trasplante renal / Changes in the health related quality of life during the first year following renal transplant

Objetivo: Estudiar los cambios en la calidad de vida relacionada con la salud (CVRS) en el primer año del trasplante renal (TR), comparando azatioprina vs Mofetil micofenolato en triple terapia inmunosupresora con prednisona y CsA. Métodos: Estudio prospectivo, abierto y aleatorizado con 26 pacientes que recibieron consecutivamente un primer trasplante renal de cadáver. Análisis de variables clínicas: disfunción inicial del injerto, rechazo agudo (RA), infecciones y comorbilidad; analíticas: hemograma, albúmina y creatinina séricas, función hepática, niveles de CsA; instrumentos de evaluación de la CVRS: Índice de bienestar psicológico (IBP) y Cuestionario de salud Euroqol-5D (EQ-5d) que incluye un termómetro de autovaloración del estado de salud (EVA). Recogida controlada de datos al alta del trasplante renal y al 1, 3, 6 y 12 meses del primer cuestionario. Resultados: No hubo diferencias entre los pacientes con azatioprina o MMF, salvo que el RA fue menos frecuente con MMF (7 por ciento vs 42 por ciento, p = 0,065). RA global: 23 por ciento. Hubo una mejoría de la CVRS medida por el aumento progresivo en las puntuaciones del IBP, EQ-5d y EVA en los 3 primeros meses del TR. Al sexto mes se observó una disminución de la puntuación en comparación con el tercero (IBP, p = 0,011) y posteriormente mejoró la CVRS pero sin llegar a las máximas puntuaciones conseguidas. Conclusiones: Los pacientes con MMF presentaron menos episodios de RA. La CVRS disminuye entre el tercer y sexto mes, con menos intensidad en los pacientes con MMF, en probable relación con la menor tasa de RA (AU)

[Remission of severe disease induced by CMV and lymphoproliferative post-transplant disease after changing the immunosuppressive regime]. / Remisión de enfermedad severa por citomegalovirus y enfermedad linfoproliferativa post-trasplante en un receptor de trasplante renal tras terapia con ganciclovir y cambio en la medicación inmunosupresora.

We describe a renal transplant recipient, with overimmunosuppression induced by the interaction of tacrolimus and fluconazole, who developed two severe diseases produced by two different viruses of the herpes group (cytomegalovirus [CMV] disease and posttransplant lymphoproliferative [PTLD] disease EBV-related). Detection of Epstein-Barr virus (EBV) DNA in the blood preceded the histological diagnosis of PTLD. Both diseases improved after changes in the immunosuppressive regime and treatment with ganciclovir. Because CMV infection is a risk factor in developing PTLD, and the clinical and endoscopic manifestations of both diseases could be become confused, PTLD should be excluded in EBV seronegative patients that develop CMV disease. The detection of the EBV genome in blood could help in the early diagnosis of PTLD in these patients.

Is the loss of health-related quality of life during renal replacement therapy lower in elderly patients than in younger patients?

BACKGROUND: Previous studies have reported that elderly (aged 65 years or over) end-stage renal disease (ESRD) patients have poorer health-related quality of life (HRQOL) than both younger patients and healthy subjects of the same age. The aim of present study was to evaluate the effect of ESRD and its treatment on the HRQOL, and to determine the effects of age and gender. METHODS: A cross-sectional multicentric study was carried out with 485 haemodialysis and renal-transplant patients, using the SF-36 Health Survey to evaluate their HRQOL. SF-36 scores were standardized by age and gender using Spanish normative data. Karnofsky scale score (KS), socio-demographic, and clinical data were also collected. RESULTS: In renal-replacement therapy (RRT), chronic haemodialysis, and renal-transplant patients, SF-36 standardized scores of elderly patients were higher than in younger patients. Therefore the reduction in HRQOL of elderly patients, in relationship with that of the general population of the same age and gender, was lower than in younger patients. In the case of renal-transplant patients, standardized scores in elderly patients were higher than in the general population for all parameters. CONCLUSIONS: Using standardized scores, elderly patients on renal replacement therapy (haemodialysis and kidney transplant) had relatively better HRQOL than younger patients, and in the case of transplant patients, they had even better HRQOL than in the general population of the same age and gender.

[Preeclampsia and peripartum cardiomyopathy: infrequent association]. / Pre-eclampsia y miocardiopatía periparto: una asociación infrecuente.

Peripartum cardiomyopathy (PPCM) is a rare form of congestive heart failure that affects women late in pregnancy or in the early puerperium. PPCM is a disorder of unknown etiology that can have potentially devastating consequences. Although the etiology of PPCM remains unclear, a number of risk factors for this disorder have been proposed. However, the disease can occurred in women without these risk factors. Preeclampsia is associated with PPCM. However, cardiomyopathy is an infrequent complication of preeclampsia. Treatment of PPCM is similar to that other types of congestive heart failure. The pregnancy outcome is uncertain. Probably it depends on whether ther heart size returns to normal. We present the case of a 38 years old woman, who developed in an 33rd week of gestation a PPCM. She had some risk factors (include preeclampsia) but had a favorable evolution with conventional treatment. The rarity of the syndrome, its potential consequences, and the probable association with preeclampsia, stimulated us to present this case.

Pre-eclampsia y miocardiopatía periparto: una asociación infrecuente / Preeclampsia and peripartum cardiomyopathy: an uncommon association

La miocardiopatía periparto es una rara forma de insuficiencia cardíaca que afecta a mujeres en la última fase del embarazo y durante los primeros meses del postparto. No se conoce la etiología de este proceso, aunque sí se han descrito diversos factores que lo favorecen, entre ellos la pre-eclampsia.El proceso sigue representando una complicación grave de la gestación, pues en buena parte de los casos la función ventricular puede quedar gravemente comprometida. La regresión completa de la miocardiopatía varía mucho según las series. El pronóstico de cara a futuros embarazos no es bueno y salvo que se asista a una completa recuperación funcional, deben desaconsejarse nuevas gestaciones.Presentamos aquí un caso de una secundigesta de 38 años, que en la semana 33 del embarazo, desarrolló una miocardiopatía en el seno de una pre-eclampsia leve.Con tratamiento convencional se observó una rápida recuperación. La rareza del cuadro, su excelente evolución, y su asociación con la pre-eclampsia nos han llevado a presentar este caso. (AU)

Health related quality of life (HRQOL) of kidney transplanted patients: variables that influence it.

UNLABELLED: The incidence and prevalence of patients on renal replacement therapy (RRT) who receive a renal transplant are continuously increasing in Spain. At the moment, they are the main group of end-stage renal disease (ESRD) patients in our region (60% of total RRT patients). The aim of the present study was to assess the health related quality of life (HRQOL) of kidney transplanted patients of our region, and to identify socio-demographic and clinical variables that influence it. The intention was also to compare the HRQOL of these patients with that of chronic haemodialysis (HD) patients and of the general population. METHODS: Two hundred and ten kidney transplanted patients and 170 HD patients were evaluated using the Karnofsky performance scale (KPS), sickness impact profile (SIP), and SF-36 Health Survey (SF-36). Socio-demographic and clinical data, including a comorbidity index (CI), were also collected. To compare our patients with the general population we used SF-36 mean scores from an aleatory sample taken from our region. RESULTS: Transplant patients had lower mean scores on SIP dimensions and higher scores on SF-36 dimensions than chronic HD patients. In transplant patients, we found significant differences on SIP and SF-36 scores in gender, educational level, haematocrite and haemoglobin, CI, time since transplantation, and KPS. CONCLUSIONS: The HRQOL of transplant patients is clearly better than that of chronic HD patients and similar to that of the general population. Differences in the HRQOL within transplant patients did not appear to be as a result of patient's age, but rather it would appear to be a consequence of gender, analytic figures, CI, KPS score, time with transplant, and educational level.

Control of cytomegalovirus disease in renal transplant patients treated with prednisone, azathioprine and cyclosporine using intensive monitoring and decreased immunosuppression.

BACKGROUND: The aim of this trial was to study the effectiveness of intensive monitoring, together with an early decrease in immunosuppression, in reducing the prevalence of CMV disease in renal transplant recipients treated with prednisone, azathioprine and cyclosporine. METHODS: From 1/95 to 11/97 a prospective, longitudinal study was conducted among 146 consecutive, unselected, renal transplant patients in our unit. Only 96 patients whose immunosuppressive regimens consisted of prednisone, azathioprine and cyclosporine and whose follow-up period was greater than 4 months were included in the study. Preemptive therapy was administered to 27 high-risk patients. CMV antigenemia (CMV-AG) and other virological tests were performed weekly for the first 4 posttransplant months. The immunosuppression was decreased when the first positive CMV-AG was detected. Azathioprine was completely withdrawn when the CMV-AG count was greater than 10 cells per 10(5) PBLs. The cyclosporine dose was gradually decreased in the next 4 weeks, but it was not withdrawn in any patient. The prednisone dose was modified according to the immunosuppressive protocol. RESULTS: 53% (51/96) of the patients had positive CMV-AG on at least one occasion. The dose of azathioprine was decreased after CMV-AG detection in 41/51 (80.4%) patients and it was completely withdrawn in 23 of these (45%). The mean decrease in the dose of azathioprine was 73 +/- 31 (25-175) mg, a mean percentage decrease of 76 +/- 27% (25-100%). The dose of cyclosporine was progressively decreased during the 4 weeks after detection of the first CMV-AG (mean cyclosporine levels: 210 +/- 66, 196 +/- 54 and 164 +/- 36 ng/ml at the time of first CMV-AG detection, 2 and 4 weeks respectively, p < 0.0001, repeated measures analysis of variance). None of the 45 patients without CMV-AG and only 2 of 51 (3.9%) patients with CMV-AG developed symptomatic CMV disease (2% of the total). CMV disease was of moderate intensity in both patients. Only 3/51 (5.8%) patients developed acute rejection after the first CMV-AG detection in the 4 posttransplant months. CONCLUSION: The results of this study suggest that intensive monitoring and an early reduction of immunosuppression, together with preemptive therapy in high-risk patients, is effective in diminishing the prevalence and severity of CMV disease.

Disseminated herpes simplex virus infection in a renal transplant patient as possible cause of repeated urinary extravasations.

Disseminated herpes simplex virus type 2 (HSV-2) infections are infrequent in patients receiving organ transplants, but usually have a poor outcome. We describe the case of a renal transplant patient who developed a disseminated HSV-2 infection with repeated urinary extravasations. The diagnosis was carried out using a multiplex polymerase chain reaction nested assay and it suggested HSV-2 as a possible cause of repeated urinary fistulas.