Comparison of health status and quality of life of related versus paid unrelated living kidney donors.

The aim of this cross-sectional study was to assess the health status and quality of life (QOL) of paid unrelated versus related living kidney donors postdonation at Shiraz Transplant Center in Iran. We invited all donors (n = 580, 347 paid unrelated, 233 related) who underwent donor nephrectomy at our center from 2004 to 2010 to participate in a health survey and physical examination. Of 580 donors, 144 consented to participate; participation of paid unrelated donors was significantly lower than related (52/347 vs. 92/233; p < 0.001). Participants underwent a complete physical examination, QOL assessment (using a 36-item short form health survey [SF-36] questionnaire) and laboratory work-up. The paid unrelated donors compared with related donors were younger (34.2 ± 7.2 vs. 40.7 ± 9.7 years, p < 0.001), had shorter time since donation (2.9 ± 1.6 vs. 3.8 ± 2 years, p = 0.004), had higher estimated GFR (72.6 ± 22 vs. 63.8 ± 15.3 mL/min/1.73 m(2), p = 0.006) and had a higher percentage of patients with microalbuminuria (35% vs. 0%, p < 0.001). Additionally, general health and social functioning scores among paid unrelated donors were significantly lower (p < 0.001 and p = 0.02, respectively) than related donors. Other SF-36 scores, although lower in paid unrelated donors, did not reach statistical significance. Iranian paid unrelated donors have lower QOL and higher incidence of microalbuminuria compared with related donors.

Portal-endocrine and gastric-exocrine drainage technique in pancreatic transplantation.

BACKGROUND: Pancreas transplant (PTx) is an established treatment for patients with diabetes mellitus. Diagnosis of rejection has continued to be problematic. In 2007, a new technique of PTx with portal-endocrine and gastric exocrine (P-G) drainage was first performed at our institution. This technique facilitates access to pancreas allograft. OBJECTIVE: To report our experience with the first 30 patients who underwent PTx using P-G technique. METHODS: The first 30 patients who underwent PTx between 2007 and 2009 were studied. In these patients, arterial and venous anastomosis was similar to standard portal-enteric (P-E) technique, though contrary to other techniques of enteric drainage, the end of allograft jejunum was anastomosed to the anterior aspect of the stomach. RESULTS: Donor and recipient demographic data, number of antigen matches and immunosuppressant were collected. All patients achieved euglycemia. 3 patients underwent pancreatectomy: 2 due to vessel thrombosis and 1 due to chronic rejection. 3 patients died-2 with functioning pancreatic and renal allografts. 7 patients with CMV and 4 patients with rejection were diagnosed with endoscopy of allograft duodenum and treated. 1-year patient and graft survival was 94% and 85%, respectively. CONCLUSION: This novel technique of PTx has proven to be safe with good patient and allograft survival. Access to donor duodenum and pancreas allograft via endoscopy is unique to this technique and provides the added advantage of life-long easy access to allograft.

Are autoimmune diseases or glomerulonephritis affecting the development of panel-reactive antibodies in candidates for renal transplantation?

Panel-reactive antibodies (PRA) are a major obstacle to kidney transplantation (KTx). It is not completely clear why only some patients develop PRA, whereas others do not. We hypothesized that other factors, such as autoimmune diseases involving the kidney, might be a trigger for PRA development. We reviewed the original diseases that led to renal failure and their possible role in PRA development. Charts of 270 patients on the active waiting list for KTx were reviewed for complete demographics, presence of PRA, peak PRA level, first KTx or retransplantation, original disease, blood transfusions, pregnancy and rejection. Patients were divided into group 1 (PRA >10%) and group 2 (PRA <10%). There was a significantly higher proportion of patients in group 1 with autoimmune diseases than in group 2. The same proportion was found significant for all of the patients as well as for the patients listed for the first KTx (new patients). Previous KTx has significant impact on both class I and II peak PRA levels when compared with new patients who are already sensitized. A subanalysis of retransplantation showed patients with autoimmune disease (54%) have more graft loss due to rejection compared with nonautoimmune disease (43%). There is an association between high PRA level and autoimmune diseases causing renal failure regardless of the previous KTx status. Besides the risk of recurrence, autoimmune disease seems to affect the risk of graft loss due to rejection.

Successful reuse of portal-enteric technique in pancreas retransplantation.

BACKGROUND: The portal venous and enteric drainage (P-E) technique was developed to avoid systemic hyperinsulinemia and bladder related complications. Pancreas retransplantation (Re-Tx) is an important option for patients who have lost their primary grafts. It is unknown whether the P-E technique can be repeated safely in patients who have lost their first pancreas transplant. METHODS: Five patients who lost their pancreas graft after simultaneous kidney-pancreas transplantation with P-E drainage underwent pancreas Re-Tx, again using the P-E technique. RESULTS: P-E Re-Tx was successful in all 5 patients without any technical difficulties or complications. CONCLUSION: The P-E technique can be reused with excellent results in pancreas Re-Tx.

Simultaneous kidney-pancreas transplantation without antilymphocyte induction.

BACKGROUND: The introduction of potent new immunosuppressive agents may allow simultaneous kidney-pancreas transplantation to be performed without antilymphocyte induction. METHODS: We analyzed 30 simultaneous kidney-pancreas transplantations receiving tacrolimus, mycophenolate mofetil, and steroids without without antilymphocyte induction. Eighteen patients underwent pancreas transplantation with portal-enteric (P-E) drainage and the remaining 12 had systemic bladder (S-B) drainage. Target 12 hr trough tacrolimus levels for the first 3 months after simultaneous kidney-pancreas transplantation were 15-20 ng/ml. The oral mycophenolate mofetil dose was 2-3 g/day begun immediately posttransplant in two to four divided doses. Steroids were tapered according to protocol. RESULTS: All patients experienced immediate function of both kidney and pancreas grafts. One-year actuarial patient, kidney, and pancreas graft survival rates are 93, 93, and 90%, respectively. Nine patients (30%) had a total of 13 rejection episodes (12 biopsy proven) including 4 within 2 weeks, 6 between 2 weeks and 3 months, and 3 beyond 3 months after simultaneous kidney-pancreas transplantation. Three rejection episodes were treated with steroids alone and 10 were treated with antilymphocyte therapy (5 OKT3 and 5 ATGAM). A total of seven patients (23%) received antilymphocyte therapy. Three patients (10%) had more than one rejection episode. Two pancreas grafts (7%) and one kidney graft (3%) were lost from rejection. Four patients (13%) developed cytomegalovirus infection, but none had tissue-invasive cytomegalovirus. At present, 22 surviving patients (81%) remain on triple immunosuppression with tacrolimus, mycophenolate mofetil, and prednisone with excellent dual graft function. CONCLUSION: Tacrolimus, mycophenolate mofetil, and prednisone immunosuppression without without antilymphocyte induction is safe and effective after simultaneous kidney-pancreas transplantation.

Use of glucose disappearance rates (kG) to monitor endocrine function of pancreas allografts.

We have reported that a decline in glucose disappearance rate (kG) in pancreas transplant recipients is associated with pancreatic rejection. The purpose of this study was to determine test-retest reliability of kG monitoring and to establish the kG criteria for diagnosing abnormal graft function. Six healthy non-diabetic volunteers and 14 stable pancreas recipients underwent 2 intravenous glucose tolerance tests 7 d apart. All kG values in non-diabetic volunteers had < 15% variation between the two determinations (r = 0.96, P < or = 0.0006). Similarly, 13/14 recipients experienced < 20% variation in kG with one patients experiencing a 23% variation (r = 0.90, P < or = 0.0001). Using a 20% change from baseline as the reference value, we monitored 28 pancreas recipients for 2-36 months post-transplant. Of 253 kG values, 160 (64%) did not exceed the 20% change from baseline, 65 (26%) declined > 20% and 28 (11%) increased > 20%. Of 160 stable kG values, 154 (96%) were associated with normal graft function while 6 (4%) occurred in the context of rejection. Of 65 kG values declining by > or = 20%, 47 (72%) accurately identified acute rejections diagnosed by biopsy (70%) or response to treatment (30%), 12 (19%) were associated with identifiable causes of increased insulin resistance and only in 6 (9%) cases a cause for the decline was unidentifiable. The kG values with > 20% rise from baseline were, in 15%, associated with identifiable causes of decreased insulin resistance. The sensitivity of the kG as a marker for rejection was 88.7%, specificity 91%, positive predictive value 72.3%, negative predictive value 96.8%, and accuracy 90.5%. These data confirm that a > 20% deterioration of glucose disappearance rate is associated with pancreas allograft rejection, and confirms the utility of kG monitoring in clinical follow-up of pancreas transplant recipients.

Intragraft angiotropic large-cell lymphoma of T cell-type in a long-term renal allograft recipient.

Chronic immune suppression is a risk for the development of post-transplantation lymphoproliferative disorders, which are frequently caused by a B-cell dyscrasia. We report a unique primary presentation of the rare angiotropic lymphoma in a kidney allograft, 18 years after transplantation. The diagnosis was made by a percutaneous allograft biopsy specimen when the recipient presented with renal dysfunction and intermittent hematuria. Immunostaining of the biopsy specimen revealed a T-cell lineage of the neoplastic cells rather than the more common B-cell source. At the time of biopsy, there was no evidence of systemic dissemination of lymphoma. The intragraft lymphoma resolved completely after chemotherapy, but the patient died 6 months later as a result of an intracerebral hemorrhage. At autopsy, intravascular lymphoma was only found in the cerebral vessels. To the authors' knowledge, this is the first report of angiotropic T-cell lymphoma in a kidney allograft. A description of the clinical, pathologic, and immunohistochemical features of this case is provided, as well as reviews of previous reports of renal angiotropic lymphoma and post-transplantation T-cell lymphomas.

A technique for portal pancreatic transplantation with enteric drainage.

Twelve patients were operated upon using this technique. Early results show that hyperinsulinemia has abated in these patients and that the need for postoperative bicarbonate replacement, admissions for dehydration or hematuria resulting from pancreatic exocrine drainage into the bladder are also eliminated (9). This new technique of portal pancreatic transplantation is suitable for patients undergoing combined pancreatic and renal transplantation in whom rejection of the pancreas can be monitored through the function of the renal allograft. The procedure is technically feasible and safe. However, large trials are needed to document the full benefits and continued safety of this new procedure.