Risk factors and prognosis for proteinuria in renal transplant recipients.

INTRODUCTION: Proteinuria in renal transplant recipients has been recognized as a risk factor of progression of chronic allograft nephropathy and for cardiovascular disease, the main causes of transplant failure. PATIENTS AND METHODS: We analyzed the risk factors for persistent proteinuria (>0.5 g/day) among 337 kidney allograft recipients with a minimum follow-up of 6 months, among a series of 375 transplants performed during a decade, as well as their association with allograft and patient survivals. Patients with proteinuria greater than 0.5 g/d were treated with angiotensin-converting enzyme inhibitors (ACEI) and/or angiotensin-receptor blockers. RESULTS: After a mean follow-up of 53.35 +/- 52.63 months, 68 patients (20.17%) had persistent proteinuria greater than 0.5 g/d. Female patients (P = .012), body mass index (BMI) >25 (P = .008), pretransplant HLA sensitization (P = .039), and delayed graft function (DGF; P = .001) were associated with proteinuria. Induction treatment with antithymocyte globulin (P = .030) and treatment with tacrolimus instead of cyclosporine (P = .046) were associated with an increased risk of proteinuria. Multivariate analysis confirmed the independent value of DGF (RR = 2.23; 95% confidence interval [CI] 1.22 to 4.07; P = .009) and BMI >25 (RR = 1.968; 95% CI 1.05 to 3.68; P = .035) to predict postransplant proteinuria. The mean values of serum creatinine (P = .000) and systolic blood pressure (P < .05) were persistently higher from the early stages after transplantation in the proteinuric group. Graft survival at 5 years was 69% among patients who developed proteinuria and 93% in those without proteinuria (P = .000), with no differences in patient survival (P = .062). CONCLUSION: Proteinuria in renal transplant recipients was related to immunological and nonimmunological factors, some of which, such as hypertension and obesity could be modifiable. Proteinuria in renal transplant recipients predicted a worse allograft survival despite of intensive treatment of hypertension including ACEI/angiotensin-receptor blockers.

Effect of overweight on kidney transplantation outcome.

INTRODUCTION: Obesity is a prevalent problem in renal transplant recipients that is followed by reduced graft and patient survivals. Because the prevalence of overweight (OW) is increasing in the renal transplant population, we studied the influence of OW on graft and recipient evolution. PATIENTS AND METHODS: We analyzed a series of 337 patients with renal allografts having a mean follow-up of 53.4 +/- 30.6 months. We excluded 39 patients obese at transplantation. We compared the evolution of 134 OW patients (45.5%), and 160 patients (54.4%) with a body mass index <25 (NW group). RESULTS: OW patients were older (P = .000) with a higher prevalence of hypertension (P = .028), left ventricular hypertrophy (P = .014), and dyslipidemia (P = .001). They had received kidneys from older donors (P = .019). OW patients showed a higher incidence of acute tubular necrosis (ATN) (P = .006), without a higher incidence of acute rejection episodes (P = .756). Postransplant diabetes mellitus was more frequent (P = .000), and systolic blood pressure (P < .05), total cholesterol (P < .05), and tryglicerides were higher (P < .05) in the OW group. Serum creatinine at 6 months (P = .007) and proteinuria >0.5 g/24 hours, (P = .023) were higher among the OW group. Graft survival was not different between groups, but patient survival was lower in the OW group (P = .002). A logistic regression analysis showed that the recipient age (RR: 5.243) and the presence of OW (RR: 1.100) were independent prognostic factors for patient death. CONCLUSIONS: OW was a common situation among renal transplant candidates. It was associated with worse cardiovascular and metabolic profiles. OW patients showed worse allograft function and lower patient survival. A major effort must be exerted to avoid excessive weight gain, particularly among those OW at transplantation.

[Seasonal perodicity in vascular access thrombosis for haemodialysis]. / Ritmo estacional en la trombosis del acceso vascular para hemodiálisis.

Different studies have shown that some clinical events, particularly cardiovascular and thrombotic events, show a regularity in its appearance. The aim of our study was to analyse the possible existence of seasonal periodicity in the incidence of the vascular access thrombosis in patients on chronic haemodialysis. Prospectively, we collected information of 164 patients with 250 episodes of vascular access thrombosis referred to our hospital from january 1995 to december 1999. An ANOVA test for comparison of the means, and a time series analysis were performed. During the five year study the consecutive number of thrombosis were 43, 57, 55, 59 and 36. When the different seasons were analysed, the cumulative number of events in summer during the study period were 91, a significant increase compared to spring, autumn, and winter (54, 54, and 51, respectively; p<0.001). Time series analysis confirmed that thrombolic events during summer showed an increased incidence over the mean (p<0.001), and it occurred every year. The same results were obtained when the PTFE grafts were analyzed separetely (july RR 2.62, p=0.002; august, RR 2.37, p=0.04), but not with the arteriovenous fistulae. In conclusion, this study showed a seasonal periodicity of vascular access thrombosis, with a PTFE graft. Although the causes were unknown, these data alert us on the convenience of an increased attention to the vascular access during the summer months in order to prevent its thrombosis.

Transplant renal artery stenosis: association with acute vascular rejection.

BACKGROUND: Transplant renal artery stenosis, the prevalence of which varies from 2% to 12%, is an important cause of hypertension and allograft dysfunction. We sought to determine the clinical characteristics of this disorder, assessing, predisposing factors, establishing treatment options, and examining patient outcomes. PATIENTS AND METHODS: Among 321 renal allograft recipients between November 1996 and December 2004, six patients were identified with this finding. We analyzed their clinical data before and after treatment compared with the 315 recipients face of the disorder. RESULTS: The six patients with the disorder were diagnosed within the first year (2 to 8 months; median 5.5 months). All patients displayed renal dysfunction, peripheral edema, and new-onset or uncontrolled hypertension at presentation. Abnormal Doppler findings were observed in 5 (83.3%) patients. The hemodynamically significant stenosis was successfully treated with percutaneous transluminal angioplasty (PTA) in all six. However, 3 (50%) patients displayed recurrent stenosis requiring a second PTA. The mean serum creatinine level decreased from a pre-PTA value of 4.4 +/- 1.8 mg/dL to a 1-month post-PTA value of 2.2 +/- 0.5 mg/dL (P = .027). Patients had no significant improvement in mean systolic and diastolic pressure. Vascular acute rejection episodes were more frequent among the affected than the control group (3/6; 50% vs 18/315; 5.7%; P < .001). No differences were found in age, sex, donor type, etiology of renal disease, immunosuppression, acute tubular necrosis, acute cellular rejection, cold ischemia time, or HLA matching. CONCLUSION: Transplant renal artery stenosis is a common cause of hypertension and renal allograft dysfunction. Acute vascular rejection is associated with this disorder.

Erythropoietin treatment in the sixth posttransplant month as a prognostic factor for renal allograft survival.

The purpose of this work was to assess the prognostic value of the need for erythropoietin (EPO) treatment at 6 months after transplantation. We retrospectively reviewed the outcomes of 143 consecutive cadaveric kidney transplants performed between January 2000 and April 2004, functioning at 6 months postransplantation. Patients were divided into two groups: group EPO6m (n = 24) received EPO treatment in the sixth month, and a control group (n = 119) did not receive EPO. Renal function deterioration (RFD) was considered to be a sustained decrease in creatinine clearance (CrCl) greater than 20% between the sixth month postransplant and the last visit. Mean follow-up was 38 +/- 16 months. The mean ages of the donor (57 +/- 9 vs 49 +/- 12 years; P = .001) and the recipient (59 +/- 12 vs 47 +/- 17 years; P = .000) were greater in the EPO6m group. Delayed graft function (83% vs 48%; P = .001) was more frequent in the EPO6m group. At 6 months after transplantation the EPO6m group showed lower hemoglobin (11.52 +/- 1.71 vs 13.32 +/- 1.69 g/dL; P = .000), higher serum creatinine (2.31 +/- 0.72 vs 1.65 +/- 0.53 mg/dL; P = .000), lower CrCl (33.53 +/- 10.83 vs 53.6 +/- 17.58 mL/min; P = .000), and similar proteinuria. RFD was more common in the EPO6m group (38% vs 10%; P = .026), with a different pattern of evolution of CrCl (-0.098 +/- 0.176 vs +0.093 +/- 0.396 mL/min/mo, P = .000). Multivariate analysis demonstrated that treatment with EPO at 6 months was the only predictor of RFD (RR 4.46; 1.58 to 12.58; P = .005). The need for EPO at 6 months postransplant was a good predictor of later renal allograft deterioration, more sensitive than serum creatinine or proteinuria.

[Chronological aggregation of subcutaneous mycosis in renal transplant recipients]. / Agregación cronológica de cuatro casos de micosis subcutánea invasiva en receptores de trasplante renal.

We present four cases of subcutaneous invasive mycosis in renal transplant recipients that happened in our Unit during a period of eight months. The Microbiology Department did not find any fungi when they studied possible reservoirs and vectors for transmission. We speculate about the reasons of this chronological aggregation. We discuss the treatment that we used for these infections.