Acute antibody-mediated rejection of the kidney transplant - experience of a single center in Croatia.

AIM: To describe the experience of the Department of Nephrology and Dialysis, University Hospital Rijeka, Croatia, in the treatment of patients with acute humoral rejection (AHR) of kidney transplant by using high dose of intravenous immunoglobulin (IVIG) alone and as a first line treatment. METHODS: Eight kidney transplant recipients in whom the AHR appeared at different time after the transplantation were reported. At the time of transplantation cross-match in all patients was negative for both T and B cells. At the time of presentation, all patients had signs of renal allograft dysfunction and the rejection was proven by biopsy of the kidney transplant with positive C4d-staining and histopathological evidence of antibody-mediated injury. Early rejection was considered within 180 days after the transplantation and the late one 180 days after the transplantation. In two cases plasmapheresis (PAF) with albumin as replacement fluid was performed. Plasma exchange was done with a 35 mL/kg/body weight volume exchange with albumin for six times. RESULTS: Acute humoral rejection was classified as early in three patients and in five as late one. In two patients PAF had been performed as the first line treatment. After the completion of PAF, recuperation of severe graft dysfunction was incomplete and in addition IVIG (as a single dose of 2.0 g/kg) was administered to these patients. In six patients IVIG as a single dose of 2.0 g/kg was applied as the first line treatment. CONCLUSION: Usage of high dose IVIG in the treatment of the acute humoral rejection is efficient, safe and relatively well tolerated.

Use of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in the early period after kidney transplantation.

The role of renin-angiotensin system inhibitors (ACE-inhibitors) or angiotensin receptor blockers (ARB) in the renal transplant recipients (RTRs) is incompletely defined and according to the current guidelines they should be initiated after six months post-transplantation. The aim of the present paper is to evaluate the efficiency and safety of early (within six months post-transplantation) versus late (after six months post-transplantation) initiation of ACE-inhibitors or ARB in RTRs. The study group compromised of 108 RTRs (50 male and 58 female) who received a kidney transplant. Beside other prescribed antihypertensive drugs all of them took and ACE inhibitors or ARB in order to achieve blood pressure control. For this analysis purpose, recipients were stratified into two groups according to the time of ACE inhibitors/ARB initiation into early (within six months post-transplantation) and late (after six months after transplantation) group. For each patient haemoglobin, serum creatinine and potassium levels were analyzed at the beginning of ACE inhibitors/ARB introduction and at the end of the first, third, sixth and twelfth month. In the 54 (50%) of the 108 patients ACE inhibitors/ARB were initiated within six months post-transplantation and in 49 (90.7%) of them within three months (in 29 patients within one month; in 13 within two months; in 7 within 3 months) post-transplantation. In additional 54 (50%) patients ACE inhibitors/ARB were initiated, but after six months post-transplantation. There was no statistically significant difference between the two groups related to age or gender and due to the duration of dialysis treatment before the transplantation. Analyzing the haemoglobin, creatinine and potassium serum levels after initiation of therapy with ACE inhibitors/ARB trough observed period we did not found any statistically significant difference in all measured parameters between the two groups of patients and also within the same group of patients. Therefore, according to experience from our Institution early initiation of ACE inhibitors or ARB appears to be safe in carefully selected recipients with relatively good early graft function.

Survival of patients treated with online hemodiafiltration compared to conventional hemodialysis.

Accumulating data from observational studies showed that online hemodiafiltration (OLHDF) might improve survival in chronic hemodialysis (HD) patients. According to this data, the aim of our study was to investigate whether there was a difference in survival of patients treated with OLHDF compared to standard, conventional HD. We included 85 prevalent patients with end-stage renal disease (ESRD) treated with HD as a method of renal replacement therapy (RRT) for more than three months. Patients were previously treated with HD and divided into two groups: in 42 patients new treatment with OLHDF was introduced, and 43 patients were treated with HD. Both groups were followed over a period of 36 months. The study showed significantly better survival of patients treated with OLHDF, compared to the survival of patients treated with HD in the whole study population, as well as in the subgroups of diabetics, of patients who were on RRT with HD for more than five years and of the patients who were older than 65 years. In the nondiabetics, patients who were on RRT for less than five years and in the patients who were younger than 65 years, survival results in the OLHDF group were not significantly better compared to those in the HD group. As in our study, there are accumulating data from observational studies that HDF may improve survival in chronic HD patients, but new, prospective randomized trials are needed to support evidence about this hypothesis.

[Long term survival patient on hemodialysis--case report]. / Dugogodisnje prezivljavanje bolesnikana lijecenju hemodijalizom--prikaz slucaja.

BACKGROUND AND AIM: The mortality of chronic kidney disease patients is very high. Patients on chronic renal replacement therapy are also et very high mortality risk. Nevertheless, by the advance in renal replacement therapy the surveillance of these patients could be long with reasonable quality of life. The present a patient on renal replacement therapy for more than 38 years. CASE HISTORY: Our patient was born in 1946. Twenty years later acute glomerulonephritis was diagnosed and he was treated with corticosteroid therapy for four years. Despite treatment his renal function deteriorated and haemodialysis was started in 1974. At that time, the haemodialysis regime was 12 hours two time per week and Kill dialyzer were used. Bicarbonate dialysis was introduced in 1984. Last 15 years our patient is on the hemodiafiltration. The treatment by erythropoietin was started in 1993. During this 38 years, he received two cadaveric kidney transplants. The first transplantation was in December 1974 in our hospital. Few days after transplantation he get rejection and transplant kidney never functioned. After one month he get thrombosis of the graft and transplantectomy was performed. The second cadaveric transplantation was performed abroad in 1985. Transplant kidney functioned only four days and fifth days urgent transplantectomy was performed. After these experience our patient decline any new kidney transplantation. First arteriovenous fistula was created at the time of start haemodialysis and was functional for 30 years. First arteriovenous graft was created after 30 years on the left forearm few years later on the left upper arm. Last graft has been in good function for six years. The last two years he has a central venous catheter. A subtotal parathyroidectomy was performed in 1983. After parathyroidectomy parathyroid hormone values were between 30 to 55 pmol/L, and the values of serum calcium and serum phosphate were in reference values. Last 15 years he had bone pain and before 10 years he had patlogical hip fracture. Due to vascular disease he often had skin ulcers and infections, particularly on the both hands. Very often he was treated by analgetics, sedatives, including opiates. Last severe complications was a bowel perforation, successfully treated by surgical intervention. SOCIAL HISTORY: Our patient graduated on the university. He is married and had one child. He has worked in the profession for several years. He was founder of association for dialysis and kidney transplant patients. Last twenty years he and colleagues conducted a private centre for haemodialysis. It was the first private centre in the country. CONCLUSION: Dialysis treatment sometimes can significantly prolong life, i.e. far more than expected in this group of patients and can offer appreciable quality of life.