[Evaluating renal function and indications for starting dialysis]. / Valoración de la función renal e indicaciones para el inicio de diálisis.

EVALUATION OF THE RENAL FUNCTION: For the follow-up of the graft renal function it must be measured the glomerular filtration rate by means of formulae that use the serum creatinine. The most used equation is the brief formula MDRD. - All patients transplanted must be included in the group of Renal Chronic Disease though the glomerular filtration rate is normal and there is no evidence of renal damage. - The measures of intervention proposed in the classification of the Renal Chronic Disease for its progressive establishment in the stage 1 to 3, must be applied to all the transplanted THE BEGINNING OF DIALYSIS: In spite of receiving attention of Nephrologists along the whole evolution, the patients with chronic dysfunction of the graft that need treatment with dialysis start later and with more uremic complications that the patients who start dialysis for the first time. - To change this trend, it is necessary to consider the treatment with dialysis when the glomerular filtration rate is lower than 15 ml/min/1,73 m2. If there appears any complication related to the uremia that cannot be handled by conservative treatment, the beginning of the dialysis is necessary. THE BEGINNING OF THE DIALYSIS OF PROGRAMMED FORM: The beginning of the dialysis of not programmed form in transplanted patients is difficult to justify if we take into account that such patients, have received nephrological attention along all their evolution. - To get a new vascular access in these patients can be difficult depending on the previous trombosis of arteriovenous fistulas. Therefore, it must be realized a prompt evaluation for de department of vascular surgery to guarantee a suitable vascular access. - As general norm, one must follow the same criterion advised for the not transplanted patient: the vascular access must be considered when the glomerular filtration rate is lower than 20 m/min/1,73 m2. - The patient who is going to be treated by dialysis peritoneal precise a very narrow follow-up to be able to programme the placement of the catheter peritoneal with a minimum of 15 days before beginning the training.

[Choosing the dialysis method for kidney transplant patients with advanced kidney disease]. / Elección de la modalidad de diálisis en la insuficiencia renal avanzada del paciente trasplantado renal.

The choice of the most of dialysis modality after renal graft loss is an unanswered question. Most patients start hemodialysis (HD) in this situation, because of several reasons: 1. In most dialysis programs HD predominates clearly over Peritoneal Dialysis (PD). 2. The star of dialysis in emergency situations makes the physician use HD 3. The fear of infections in case of maintenance of immunosupression to avoid immune response and to keep residual renal function in case of PD. A lot of patients could undergo PD in order to maintain the previous style of life, as an alternative in case of absence of vascular access and to avoid vascular accesses in children. Mortality seems to be greater in patients with graft loss than in those who start dialysis for the first time, although the comparison between both groups is methodologically difficult. However, there is no difference in mortality between patients who start HD and those who start PD. Studies comparing the rate of peritonitis in PD patients in both groups find controversial results. The analysis of the few, retrospective and biased studies which look for differences in patient survival in HD and DP suggests that prognosis of both groups is similar. The choice of dialysis modality must be similar to those patients which begin dialysis for the first time.

Valoración de la función renal e indicaciones para el inicio de diálisis / Evaluating renal function and indications for starting dialysis

Valoración de la función renal: - Para el seguimiento de la función del injerto renal, debe medirse el filtrado glomerular (FG) mediante fórmulas que utilizan la concentración sérica de creatinina. La ecuación más utilizada es la fórmula abreviada MDRD (Modification of Diet in Renal Disease). - Todos los enfermos trasplantados deben incluirse en el grupo de enfermedad renal crónica (ERC), aunque el FG sea normal y no haya evidencia de daño renal. - Las medidas de intervención propuestas en la clasificación de la enfermedad renal crónica para su instauración progresiva en los estadios 1 a 3 de entrada deben aplicarse a todos los enfermos trasplantados. Comienzo de diálisis: - A pesar de recibir atención nefrológica a lo largo de toda la evolución, los enfermos con disfunción crónica del injerto que reanudan tratamiento con diálisis lo hacen de forma más tardía y con más complicaciones relacionadas con la uremia que los enfermos que se dializan por primera vez. - Para invertir esta tendencia, hay que considerar el tratamiento con diálisis cuando el FG sea inferior a 15 ml/min/1,73 m2. En el momento en que aparezca cualquier complicación relacionada con la uremia que no responda al tratamiento conservador, el inicio de la diálisis es mandatorio. Inicio programado de la diálisis:- La reanudación de diálisis de forma no programada en el enfermo trasplantado es difícil de justificar si tenemos en cuenta que ha recibido atención nefrológica a lo largo de toda su evolución. - La realización de un nuevo acceso vascular en estos enfermos puede ser problemática, dependiendo de los antecedentes de fístulas trombosadas. Es importante una valoración precoz por el Servicio de Cirugía Vascular. - Como norma general, debe seguirse el mismo criterio aconsejado para el enfermo no trasplantado: el acceso vascular debe plantearse cuando el FG sea inferior a 20 ml/min/1,73 m2. - El enfermo que vaya a ser tratado con diálisis peritoneal precisa un seguimiento muy estrecho, para poder programar la colocación del catéter peritoneal con un mínimo de 15 días antes de comenzar el entrenamiento (AU)

Evaluation of the renal function: - For the follow-up of the graft renal function it must be measured the glomerular filtration rate by means of formulae that use the serum creatinine. The most used equation is the brief formula MDRD. - All patients transplanted must be included in the group of Renal Chronic Disease though the glomerular filtration rate is normal and there is no evidence of renal damage. - The measures of intervention proposed in the classification of the Renal Chronic Disease for its progrersive stablishment in the stage 1 to 3, must be applied to all the transplanted patients. The beginning of dialysis: - In spite of receiving attention of Nephrologists along the whole evolution, the patients with chronic dysfunction of the graft that need treatment with dialysis start later and with more uremic complications that the patients who start dialysis for the first time. - To change this trend, it is necessary to consider the treatment with dialysis when the glomerular filtration rate is lower than 15 ml/min/1,73 m2. If there appears any complication related to the uremia that cannot be handled by conservative treatment, the beginning of the dialysis is necessary. The beginning of the dialysis of programmed form: - The beginning of the dialysis of not programmed form in transplanted patients is difficult to justify if we take into account that such patients, have received nephrological attention along all their evolution. - To get a new vascular access in these patients can be difficult depending on the previous trombosis of arteriovenous fistulas. Therefore, it must be realized a prompt evaluation for de department of vascular surgery to guarantee a suitable vascular access. - As general norm, one must follow the same criterion advised for the not transplanted patient: the vascular access must be considered when the glomerular filtration rate is lower than 20 m/min/1,73 m2. - The patient who is going to be treated by dialysis peritoneal precise a very narrow follow-up to be able to programme the placement of the catheter peritoneal with a minimum of 15 days before beginning the training (AU)

Elección de la modalidad de diálisis en la insuficiencia renal avanzada del paciente transplantado renal / Choosing the dialysis method for kidney transplant patints with advanced kidney disease

La elección de la modalidad de diálisis más apropiada para los pacientes que pierden un injerto renal es una pregunta no resuelta. La mayoría de pacientes reinicia tratamiento sustitutivo con hemodiálisis (HD). Hay varias razones para ello: 1. En la mayor parte de los programas, predomina la HD sobre la diálisis peritoneal (DP). 2. La urgencia para el inicio del tratamiento obliga a la HD. 3. El temor a las complicaciones infecciosas por la necesidad de mantener cierto grado de inmunosupresión para evitar fenómenos inmunes y preservar la función residual en el caso de la DP. Muchos pacientes que pierden su injerto se podrían beneficiar de la diálisis peritoneal, manteniendo un estilo de vida más parecido al que tenían en trasplante, preservando el árbol vascular en casos de niños y jóvenes, y como alternativa si no hay acceso vascular. La mortalidad en los pacientes que regresan a diálisis tras el fallo crónico del injerto respecto a la de pacientes que inician diálisis como primer tratamiento sustitutivo parece ser mayor. Sin embargo, no hay diferencias de mortalidad entre los pacientes que inician HD o DP. Los estudios que comparan la tasa de peritonitis en DP tras la pérdida de un injerto y sin injerto renal previo no obtienen resultados homogéneos. La supervivencia de la técnica DP tras perder un injerto es similar a la de la DP inicial. Al comparar la supervivencia de la técnica entre la HD y la DP en estos pacientes, estudios retrospectivos y sesgados encontrados sugieren que ambas técnicas presentan un pronóstico superponible. Con todo ello, debemos concluir que la elección de la modalidad de diálisis tras la pérdida de un injerto debe seguir riterios similares a los que se aplican en pacientes que inician diálisis como primer tratamiento sustitutivo (AU)

The choice of the most of dialysis modality after renal graft loss is an unanswered question. Most patients start hemodialysis (HD) in this situation, because of several reasons: 1. In most dialysis programs HD predominates clearly over Peritoneal Dialysis (PD). 2. The star of dialysis in emergency situations makes the physician use HD 3. The fear of infections in case of maintenance of immunosupression to avoid immune response and to keep residual renal function in case of PD. A lot of patients could undergo PD in order to maintain the previous style of life, as an alternative in case of absence of vascular access and to avoid vascular accesses in children. Mortality seems to be greater in patients with graft loss than in those who start dialysis for the first time, although the comparison between both groups is methodologically difficult. However, there is no difference in mortality between patients who start HD and those who start PD. Studies comparing the rate of peritonitis in PD patients in both groups find controversial results. The analysis of the few, retrospective and biased studies which look for differences in patient survival in HD and DP suggests that prognosis of both groups is similar. The choice of dialysis modality must be similar to those patients which begin dialysis for the first time (AU)

Does donor brain death influence acute vascular rejection in the kidney transplant?

BACKGROUND: There is increasing experimental evidence to suggest that donor brain death enhances susceptibility to early inflammatory responses such as acute rejection in the kidney transplant. The aim of the present study was to establish whether the injury induced or aggravated by donor brain death could exert an effect on recipient immunologic tolerance by comparing data from patients receiving a kidney from non-heart-beating donors (NHBD) or from brain-dead donors (BDD). METHODS: We reviewed data corresponding to 372 renal transplants performed from January 1996 to May 2002. The data were stratified according to donor type as 197 (53%) brain-dead and 175 (47%) non-heart-beating donors, and the two groups were compared in terms of acute vascular rejection by Cox's regression analysis. RESULTS: The rate of vascular rejection was 28% in the BDD group and 21.7% in the NHBD (P=0.10). The following predictive variables for acute vascular rejection were established: brain death [RR 1.77 (95% CI 1.06-3.18)], presence of delayed graft function [RR 3.33 (1.99-5.55)], previous transplant [RR 2.35 (1.34-4.13)], recipient age under 60 years [RR 1.86 (0.99-2.28)], female recipient [RR 1.50 (0.99-2.28)], cerebrovascular disease as cause of donor death [RR 1.72 (1.02-2.91)], and triple therapy as immunosuppressive treatment. CONCLUSION: Donor brain death could be a risk factor for the development of vascular rejection in kidney recipients. This process could affect the quality of the graft and host alloresponsiveness. Delayed graft function in transplants from dead brain donors could be a reflection of severe autonomic storm, leading to a higher incidence of vascular rejection in these patients.

Increasing the donor pool using en bloc pediatric kidneys for transplant.

OBJECTIVES: En bloc pediatric kidney transplants (EBPKT) are still a subject of controversy. The aim of this study was to determine whether acceptable long-term graft survival and function can be achieved in EBPKT compared with the transplant of single, cadaveric, adult donor kidneys. METHODS: A retrospective review was conducted of 66 recipients of en bloc kidneys from cadaveric pediatric donors and 434 patients who underwent transplantation with a single kidney from an adult donor between January 1990 and May 2002 at the authors' hospital. The recipients were well-matched demographically. Both transplant groups were analyzed for short- and long-term performance in terms of transplant outcome and quality of graft function. RESULTS: Overall death-censored actuarial graft survival rates at 1 and 5 years were 89.2% and 84.6% in the adult kidney transplants (AKT) and 83.3% and 81.1% in EBPKT, respectively (P=0.56). In the EBPKT group, graft function was improved over that observed in AKT. Vascular thrombosis was the most common cause of graft loss in EBPKT. Acute rejection occurred more frequently in AKT and Cox's regression analysis indicated that undergoing an AKT was a predictive factor for acute vascular rejection (adjusted risk ratio, 3.8; 95% confidence interval, 1.4-10.2; P=0.001). CONCLUSIONS: Overall graft survival was similar in both groups, vascular complications were the main cause of graft loss in EBPKT, and the EBPKT showed excellent long-term graft function and a low incidence of acute rejection.

Erythropoietin requirements: a comparative multicenter study between peritoneal dialysis and hemodialysis.

BACKGROUND: The management of anemia with erythropoietin (EPO) is important in the global treatment of dialysis patients. There is a general impression that anemia control with EPO is obtained more easily in peritoneal dialysis (PD) patients than in hemodialysis (HD) patients. The EPO administration route has to be the same to compare the two techniques adequately. METHODS: To compare EPO action by subcutaneous (SC) route in HD and PD, 132 stable patients were recruited (HD: 69, PD: 63) from six centers, with adequate dialysis criteria (Kt/V in HD >1.3; weekly Kt/V in PD >1.8). In a cross-sectional study, the EPO dose/week, the number of EPO doses/week, hemoglobin (Hb), ferritin, transferrin saturation index (TS), albumin and intact parathyroid hormone (iPTH) were analyzed. Iron treatment, comorbidity and ACE inhibitors (ACEI) and angiotensin II antagonist (AIIA) treatment were recorded. A multivariate regression model was used in the statistical analysis. RESULTS: The mean Hb level was the same in both groups, HD 11.6 (1.3) g/dL, PD 11.4 (1.4) g/dL, p=0.3. The SC, EPO doses required to obtain the Hb levels were higher in HD than in PD patients, with a difference of 64.3 u/Kg/week, statistically significant in the multivariate regression model (p=0.001, 95% CI 42.6-86.0). The number of EPO doses/week was also higher in HD patients (65% of HD patients with > or = 3 doses, 19% of PD patients with three or more doses, p<0.001). TS was similar in both groups, while ferritin was higher in HD patients, with a higher percentage of HD patients using intravenous (i.v.) iron (HD 77% vs. PD 49%, p=0.001). Serum albumin and iPTH were lower in PD patients (p<0.001 and p=0.04, respectively), but the percentage of patients with intact parathyroid hormone (iPTH) >500 pg/mL was similar in both groups (HD 17%, PD 14%). CONCLUSIONS: With the same administration route, PD patients showed a reduced EPO requirement, and less frequent EPO administration than HD patients, to obtain the same Hb level. No other factors, except those involved in better depuration of erythropoiesis inhibitors in PD, seemed responsible for the different EPO requirements.

Renal transplantation from non-heart beating donors: a promising alternative to enlarge the donor pool.

The aim of this study was to compare the survival and midterm function of kidneys from non-heart beating donors (NHBD) with those of kidneys from heart beating donors (HBD). From 1989 to 1998, 144 kidneys were procured from NHBD at the Hospital Clínico San Carlos in Madrid, of which 95 were transplanted. The kidney grafts were maintained from the moment of the diagnosis of cardiac arrest until the time of procurement by cardiopulmonary bypass. There was no significant difference in renal function and the number of rejection episodes between the NHBD and HBD transplants. The NHBD kidneys showed a 5.73-fold increase in the incidence of delayed graft function (adjusted relative risk 95% confidence interval, 2.82 to 11.62). One- and five-year survival rates for NHBD grafts were 84.6 and 82.7%, respectively, compared with 87.5 and 83.9% for HBD (P = 0.5767). Cox analysis showed that the predictive factors for worse NHBD graft survival were type of NHBD donor and the occurrence of corticoresistant rejection. Ninety of the NHBD organs were procured from subjects suffering irreversible cardiac arrest on the street who were transferred to our center for the sole purpose of donation. Fifty-four of these kidneys were transplanted and all showed primary function. When a strict protocol is adhered to, the outcome of renal transplant from NHBD compares well with that from HBD. It is believed that the high number of organs obtained from subjects undergoing irreversible cardiac arrest on the street might encourage the adoption of new criteria for the management of this type of pathology with the ultimate goal of kidney donation.