Nucleic Acid Tests for BK Polyomavirus Is Critical in Renal Transplant Recipients.

This study evaluates the incidence of BK polyomavirus (BKV) and prognosis of BKV infection in kidney transplant recipients (KTRs) who received transplantation in our hospital before and after regular BKV nucleic acid test (NAT) was implemented. METHODS: The study included 74 KTRs who received a single kidney either from standard- or expanded-criteria deceased donor between March 2011 and March 2017. BKV NATs were regularly checked in 26 patients (group 1) in the first posttransplant year in accordance with current guidelines since NAT was implemented in our laboratory in 2014. We retrospectively compared 48 KTRs (group 2) who either received NAT when necessary in another laboratory or were not checked before 2014. RESULTS: There was no significant difference in patient characteristics between groups. BKV viruria were confirmed in 8 of 26 (30.8%) group 1 patients, whereas only 2 of 48 (4.2%) BKV infections were confirmed in group 2. None of the BKV(+) KTRs in group 1 developed BK polyomavirus-associated nephropathy (BKVAN), whereas 2 BKV(+) patients (100%) of group 2 developed BKVAN, which indicates renal function deterioration and biopsy-validated nephropathy. There was no significant difference in graft survival and renal function between the 2 groups. CONCLUSIONS: The risk of BKV infection is considerably higher in KTRs using NAT. Because there is no approval treatment, early diagnosis of BKV infection and early reduction of immunosuppression agents is critical for KTRs. Implementation of regular BKV NAT is mandatory before BKVAN and malignant neoplasms develop.

New-onset diabetes mellitus in cyclosporine-treated organ transplant patients in Taiwan: interim analysis (6 months) of postmarketing surveillance.

Posttransplant new-onset diabetes mellitus (NODM) is an important complication among patients receiving immunosuppressants. It has a considerable impact on chronic allograft dysfunction. Calcineurin inhibitors have been implicated in the development of posttransplant NODM. Since high-risk candidates also undergo transplantation, prevention and control of posttransplant NODM is important. A 3-year postmarketing surveillance study is currently underway in Taiwan to evaluate the incidence and risk factors leading to development of NODM among de novo and maintenance solid-organ transplant patients receiving cyclosporine (CsA)-based immunosuppressive therapy. Concomitant therapy consisted of basiliximab, mycophenolate mofetil or enteric-coated mycophenolate sodium, and corticosteroids. Diabetes was diagnosed according to the American Diabetes Association criteria. This 6-month protocol-defined interim analysis included 101 patients (84 de novo, 17 maintenance) who received renal (n = 77), liver (n = 13), or heart (n = 11) transplantation. At the end of 6 months, 8/101 (7.92%) patients experienced NODM. The mean time to NODM was 3.05 months. No significant difference was observed between NODM and non-NODM patients for risk factors: age, body mass index, blood pressure, gender, high-density lipoproteins/triglycerides hdl/tg, and anti-hepatitis C virus. The composite endpoint of biopsy-proven acute rejection, graft loss, or death was reached in four patients, with a mean time to event of 3.81 months. Infections were noted in 34 subjects but, no malignancies. Among 389 adverse events reported in 91 patients (90.1%), the majority were of mild to moderate severity. Two deaths were reported: heart transplant recipients with acute rejection and cytomegalovirus meningitis with respiratory failure. Long-term enrollment with follow-up evaluation of these NODM patients up to 3 years will help evaluate the NODM incidence rates and exact graft survival and overall survival rates of CsA-treated transplant patients in Taiwan.

Hepatocellular carcinoma in renal transplant recipients.

OBJECTIVE: Renal transplant recipients display an increased risk of malignancy due to long-term immunosuppression. The type and incidence of malignancies vary geographically. Hepatocellular carcinoma (HCC) is a leading cause of malignancy in posttransplantation recipients in Taiwan, which is an endemic area for hepatitis B. We performed a retrospective study to investigate the clinical features of HCC among our renal transplant recipients. METHODS: Between 1988 and 2006, 15 patients of the 554 kidney recipients followed up at our transplantation clinic were diagnosed with HCC. The medical records corresponding to these 15 patients were reviewed for age, gender, initial presentation and symptoms, posttransplant duration, immunosuppressive regimens, graft and patient survival, treatment of HCC, and outcomes. RESULTS: Fifteen recipients developed HCC, (2.7%), of whom 11 were men. Four patients were hepatitis B surface antigen (HBsAg)-positive, 4 were anti-hepatitis C antibody (anti-HCV Ab)-positive, and another 7 were negative for HBsAg and/or anti-HCV Ab. The mean age at the time of HCC diagnosis was 52 +/- 12 years, with a mean posttransplantation duration to HCC of 83 +/- 48.4 months. Over a follow-up period of 59.9 +/- 39.1 months, 8 patients remained alive and 7 died. Among these 7 individuals, 6 had no treatment for HCC and died rapidly (<3 months) and, 1 underwent hepatic lobectomy but died 6 months later due to liver failure. All 8 surviving patients received treatment: 4 underwent transarterial embolization (TAE) and the other 4 underwent surgery. As of July 2006, the average survival was 68 months. Three of these 8 patients had graft failure, including 2 whom have returned to maintenance hemodialysis and 1 who had a successful second graft. CONCLUSION: HCC is a major cancer among renal recipients in Taiwan. In our center the outcomes of treatable patients were good. Our study revealed that either TAE or surgery resulted in excellent survival rates. It is necessary to adjust the immunosuppressive regimen in patients with HCC and to detect a malignancy at an early stage to improve the outcomes.

Incidence and risk factors of new-onset diabetes mellitus after renal transplantation.

PURPOSE: New-onset diabetes mellitus (PTDM), a major metabolic complication after renal transplantation, examined for incidence and risk factors. METHODS: The records of 358 renal transplant recipients with functioning grafts, from 1986 to 2006, were categorized into two groups according to the usage of tacrolimus (FK): FK-based (n = 120 patients) and non-FK-based (n = 238). Using Kaplan-Meier survival analysis and a Cox regression model, this study analyzed the cumulative incidence of PTDM and risk factors, including gender, age, and presence of hepatitis. RESULTS: Cumulative incidences of PTDM after 1, 3, and 5 years posttransplantation in the FK-based group were 11%, 18%, and 22%, respectively. In the non-FK-based group, the cumulative incidences were 5%, 9%, and 12% (P = .01). Taking into account the risk factors, the cumulative incidence of PTDM was significant among patients 51 years or older (odds ratio, 3.965; P = .005), but not with regard to gender or presence of hepatitis B and/or C. Overall cumulative incidence of PTDM in our series was 15% (54/358), including 44% (24/54) of cases that occurred within 1 year after renal transplantation. CONCLUSION: FK is more diabetogenic than cyclosporine or sirolimus. Older age (> or =51 years) is a significant risk factor, in contrast to hepatitis and gender. About half of these cases of PTDM occurred within 1 year after transplantation. These results suggest that aggressive monitoring of blood sugar is necessary for early detection of PTDM.

Successful outpatient treatment of renal vein thrombosis by low-molecular weight heparins in 3 patients with nephrotic syndrome.

Renal vein thrombosis (RV Thromb) is a serious complication ofnephrotic syndrome. Anticoagulation is usually recommended as the treatment of choice. This study reports 3 nephrotic patients diagnosed to have RVThromb combined with thromboembolic events. Low-molecular weight heparin (LMWHep) was given subcutaneously every 12 hours following the diagnosis of RVTromb, which continued at the outpatient clinic after an average of 11 in-hospital days. The patients visited the nephrology outpatient clinic every other week and underwent magnetic resonance image (MRI) studies at 6-week intervals for follow-up of patency of the involved renal vein. LMWHep was discontinued when MRI showed this patency. The average outpatient treatment period was 74 days. There was no recurrent RVThromb in the follow-up course of 6 months after discontinuation of LMWHep. Kidney function was preserved, as indicated by image studies and serial renal function tests. LMWHep produced a more predictable anti-coagulant effect, a superior bioavailability, a longer half-life and a dose-independent effect than unfractionated heparin and coumadin. These benefits made the outpatient treatment of RVThromb possible. Our report recommends outpatient treatment of RVThromb by LMWHep because it is feasible, effective and safe.

Anticardiolipin antibodies and vascular access thrombosis in Taiwanese haemodialysis patients with chronic hepatitis C: a retrospective study.

Hepatitis C virus causes various extrahepatic immunologic abnormalities. Vascular access thrombosis (VAT) is a major cause of morbidity in chronic haemodialysis (HD) patients. Immunoglobulin-G anticardiolipin antibody (IgG-ACA) is strongly associated with venous and arterial thrombosis in patients with normal renal function. Previous investigations have reported the association of raised IgG-ACA titre recurrent with VAT in HD patient, and also few equivalent studies were reported the same in Taiwan. This study attempted to determine whether raised IgG-ACA titres are associated with increased risk of recurrent VAT in HD patients with chronic hepatitis C. This study enrolled 98 chronic hepatitis C patients undergoing HD. IgG-ACA titre and hepatitis C marker were measured for all subjects. Raised IgG-ACA titres were present in 29.6% (29/98) of patients. In both groups (raised and normal IgG-ACA), the type of shunt did not differ (p = 0.416). There was strong association between raised IgG-ACA titre and recurrent VAT (p = 0.0004). In predicting for more or one episodes of VAT using multiple logistic regression, synthetic graft (p < 0.0001), raised IgG-ACA titre (p = 0.039), presence of hepatitis B (p = 0.004) and haemodialysis duration (p = 0.039) were significant factors. The prevalence of raised IgG-ACA titres was 39.6% among chronic hepatitis C with HD patients. There was strong association between raised IgG-ACA titre and recurrent VAT, and this finding may be the consequence of pathogenetic role of raised IgG-ACA titres on the development of VAT status in HD patients with chronic hepatitis C.

Risk factors for renal allograft survival in patients receiving cyclosporine immunosuppression.

BACKGROUND AND PURPOSE: Although cyclosporine (CsA) has been widely used in renal transplantation for more than 10 years, no large series of renal transplant patients has been studied in southern Taiwan. The purpose of this retrospective cohort study was to investigate the risk factors for graft survival in renal transplant recipients. METHODS: From August 1987 to January 1998, 101 primary cadaveric renal transplantations were performed. The minimum follow-up period was 1 year. CsA and prednisolone were initially used as immunosuppressive agents in all patients. Use of lower doses of CsA to reduce CsA trough level (50-99 ng/mL) in hepatitis B surface antigen (HBsAg)-positive recipients was attempted at 6 months after transplantation. RESULTS: Graft actuarial survival rates at 1, 5, and 10 years posttransplantation were 89%, 75%, and 57%, respectively. Acute rejection and increased recipient age were found to be significant risk factors (p < 0.05) affecting graft survival, with hazard ratios of 5.20 and 1.74, respectively, by multivariate analysis using a Cox proportional hazards model. Hepatitis B and/or hepatitis C infection had no influence on graft survival. CONCLUSIONS: In this series of cadaveric renal allograft patients, the risk factors affecting allograft survival were acute rejection and recipient age.

Ischemic bowel disease in chronic dialysis patients.

BACKGROUND: Ischemic bowel disease, especially acute mesenteric ischemia, carries high morbidity and mortality rates. Any delay in diagnosis or treatment aggravates the patient's outcome. Owing to the scarcity of reports concerning ischemic bowel disease in chronic dialysis patients, we investigated the ischemic bowel disease in chronic dialysis patients. METHODS: From January 1986 through April 1997, medical records of 2416 chronic dialysis patients at our hospital were reviewed. Among them, 5 patients with surgically documented ischemic bowel disease were enrolled. The clinical manifestations, laboratory findings, operative findings, pathologic test results and prognoses of these patients are reported. RESULTS: Abdominal pain, abdominal distension and bloody stool were major initial presentations. The mean age of the patients was 62.4 years at the time of diagnosis of ischemia. All patients had hypertension, 3 patients had hyperlipidemia, three patients had diabetes mellitus and three patients had history of shunt occlusion. Four patients had leukocytosis. Image studies revealed dilatation of bowel loops in four patients. Peritonitis made exploratory laparotomy necessary. The findings during operation showed turbid ascites and variable degrees of bowel ischemia or gangrene. The methods of surgical intervention depended on the severity of the disease. Only one patient died due to extensive ischemic bowel involvement and subsequent sepsis. CONCLUSION: It is mandatory to have an index suggestive of ischemic bowel disease in chronic dialysis patients with unexplained abdominal pain or discomfort. Early diagnosis and aggressive surgical intervention is the cure modality for patients with acute ischemic bowel disease.

Assessment of dialysis adequacy using the dialysate urea monitor: preliminary experience of the dialysate urea monitor.

Numerous studies have identified a strong linkage between the delivered dialysis dose (Kt/V) and the survival of hemodialysis (HD) patients. However, the current method used to calculate Kt/V requires multiple blood samples and the process is complex and time consuming. We evaluate the performance of a recently developed on-line monitor (Biostat 1000 dialysate urea monitor, Baxter) that measures the urea concentration in the effluent dialysate and displays Kt/V and nPCR immediately after hemodialysis. To verify the performance of the urea monitor, we selected 21 hemodialysis patients, calculated their Kt/V and nPCR values from blood samples obtained during each hemodialysis, and compared the results with data obtained using the urea monitor. The Kt/V and nPCR values calculated by the urea monitor were both significantly correlated with those obtained using blood samples (R = 0.804, p < 0.001 in Kt/V and R = 0.749, p < 0.001 in nPCR). Our results suggest that the urea monitor may be used for on-line assessment of dialysis adequacy and obviates the need for blood sampling.

[Clinical experience of automated double filtration plasmapheresis].

Double filtration plasmapheresis, one kind of fractionation plasmapheresis, was developed from membrane type plasmapheresis to remove only the pathogen and return the normal protein back to the patient. We started our automated double filtration plasmapheresis since December 1993. There were 13 patients who received one hundred treatments totally during one year period. And they are myasthenia gravis (8 patients); acute inflammatory demyelinating polyneuropathy (1 patient), multiple myeloma (1 patient); acquired factor VIII inhibitor (1 patient); autoimmune hemolytic anemia (1 patient); systemic lupus erythematous (1 patient). Technically double filtration plasmapheresis is easy to perform and time-saving. It also makes necessity of replacement fluid less frequent. Incidence of complication is rare, and this includes hypotension 2%, palpitation 1%, headache 1%, hemolysis 4%, air emboli 1%, high secondary pressure 2%, and no motality during our treatment. Clinical response is documented in cases of myasthenia gravis; acute inflammatory demyelinating polyneuropathy and acquired factor VIII inhibitor in our study. In conclusion, double filtration plasmapheresis is a time-saving, convenient, and safe therapeutic modality with rare complication. Because its effectiveness on limited kinds of diseases and costs relatively high price, thus plasmapheresis should be used in selected cases and treat aggressively if indicated.