Standard criteria donor pancreas donation status is associated with improved kidney transplant outcomes.

BACKGROUND: Organ donor characteristics can be used to predict outcomes in kidney transplantation. We hypothesized that pancreas donation status could reflect organ quality and be predictive of kidney graft outcomes following Standard Criteria Donor (SCD) kidney transplantation. METHODS: We performed a retrospective analysis of deceased donor kidney alone (DD KA) transplants reported to SRTR from 1992 to 2005. Group 1 = kidney alone recipients from pancreas donors (KA, P+) and Group 2 = kidney alone recipients from non-pancreas donors (KA, P-). We compared patient and graft survival between groups at 10-yr post-transplant. RESULTS: Group 1 (KA, P+) comprised 19 633 (20%) recipients and Group 2 (KA, P-) comprised 78 737 (80%) recipients. Ten-yr graft survival for Group 1 vs. Group 2 was 42.6% and 36.9% (p < 0.0001), respectively. Pancreas donation status (non-pancreas donor) was associated with a hazard ratio for graft loss of 1.23 on univariate analysis (p < 0.0001), and KA, P-remained an independent risk factor for graft failure at 10 yr, HR 1.09 (p < 0.0001). CONCLUSION: Donor pancreas donation status is an independent predictor of improved outcomes of SCD kidney recipients. Further study of the pancreas organ donor pre-procurement is warranted to optimize not only pancreas utilization but also kidney graft outcomes.

A case of nephrogenic fibrosing dermopathy/nephrogenic systemic fibrosis.

BACKGROUND: A 61-year-old female with end-stage renal disease who was undergoing hemodialysis presented with an 8-week history of upper and lower extremity weakness associated with skin tightness and contractures. INVESTIGATIONS: Physical examination, blood analysis, electromyogram and skin biopsy. DIAGNOSIS: Nephrogenic fibrosing dermopathy/nephrogenic systemic fibrosis. MANAGEMENT: Methylprednisolone, thalidomide and physical therapy.

Reversal of end-stage renal disease after aortic dissection using renal artery stent: a case report.

BACKGROUND: Medical management is the conventional treatment for Stanford Type B aortic dissections as surgery is associated with significant morbidity and mortality. The advent of endovascular interventional techniques has revived interest in treating end-organ complications of Type B aortic dissection. We describe a patient who benefited from endovascular repair of renal artery stenosis caused by a dissection flap, which resulted in reversal of his end-stage renal disease (ESRD). CASE PRESENTATION: A 69 y/o male with a Type B aortic dissection diagnosed two months earlier was found to have a serum creatinine of 15.2 mg/dL (1343.7 micromol/L) on routine visit to his primary care physician. An MRA demonstrated a rightward spiraling aortic dissection flap involving the origins of the celiac artery, superior mesenteric artery, and both renal arteries. The right renal artery arose from the false lumen with lack of blood flow to the right kidney. The left renal artery arose from the true lumen, but an intimal dissection flap appeared to be causing an intermittent stenosis of the left renal artery with compromised blood flow to the left kidney. Endovascular reconstruction with of the left renal artery with stent placement was performed. Hemodialysis was successfully discontinued six weeks after stent placement. CONCLUSION: Percutaneous intervention provides a promising alternative for patients with Type B aortic dissections when medical treatment will not improve the likelihood of meaningful recovery and surgery entails too great a risk. Nephrologists should therefore be aggressive in the workup of ischemic renal failure associated with aortic dissection as percutaneous intervention may reverse the effects of renal failure in this population.

Simultaneous pancreas-kidney versus deceased donor kidney transplant: can a fair comparison be made?

BACKGROUND: Simultaneous pancreas-kidney transplantation (SPK) may provide superior patient and kidney graft survival compared with deceased donor kidney transplant alone (DD KA), not because of the addition of a pancreas transplant but because of differences in organ donor, recipient, and transplant characteristics. METHODS: We performed a retrospective analysis from the scientific registry of transplant recipients database comparing patient and kidney graft survival of SPK and DD KA recipients from 1997 to 2005, segregating the DD KA recipients into (a) recipients of KA from pancreas donors (KA, P+) and (b) recipients of KA from non-pancreas donors to control for donor differences. RESULTS: Of 8453 SPK waitlisted patients, 7952 received SPK, 101 received KA, P+, and 401 received KA from non-pancreas donors (KA, P-). Five-year kidney graft survival was not different in the SPK and KA, P+ groups (76.2% vs. 81.9%, P=0.15) and was significantly better than the KA, P- group (64.3%, SPK vs. KA, P-, P=0.002; KA, P+ vs. KA, P-, P=0.01). When controlling for recipient and transplant differences by multivariate analysis, KA, P+ transplant was associated with a 50% reduction in risk for kidney graft loss compared with SPK. CONCLUSIONS: Donor, recipient, and transplant differences exist when comparing SPK to DD KA that bias outcomes in favor of SPK and limit conclusions regarding superior graft and patient survival.

Twelve-month pancreas graft function significantly influences survival following simultaneous pancreas-kidney transplantation.

BACKGROUND AND OBJECTIVES: Simultaneous pancreas-kidney transplantation (SPK) is regarded as the treatment of choice for type 1 diabetes (T1DM) and kidney dysfunction, despite the morbidity associated with pancreas transplantation. These morbidities often influence selection of SPK versus living-donor kidney alone (LD KA) transplant. This study quantifies the impact of pancreas graft function on outcomes following SPK. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Using the SRTR database, SPK wait-listed patients transplanted from 1997 to 2005 were evaluated and segregated as: (1) SPK recipients with functioning pancreas graft 12 mo posttransplant (SPK, P+); (2) SPK recipients with loss of pancreas graft function within 12 mo posttransplant (SPK, P-); (3) recipients of deceased donor (DD) KA; (4) recipients of LD KA. The study compared patient and kidney graft survival to 84 mo posttransplant. RESULTS: Patient survival for SPK, P+ was significantly better than the LD KA; SPK, P-; and DD KA cohorts (88.6% versus 80.0%, 73.9% and 64.8%, respectively [P < 0.001]), a finding confirmed by multivariate analysis and not influenced by pancreas-after-kidney transplantation (PAK) rates and outcomes. Unadjusted graft survival was also highest in the SPK, P+ cohort (72.0% versus 63.6%, 59.8%, 49.7%, P = 0.015 versus LD KA). CONCLUSIONS: SPK recipients with functioning pancreas grafts have superior survival compared with LD KA and DD KA, including in the setting of PAK. Early pancreas graft failure results in kidney and patient survival rates similar to KA. These data help further clarify the decision-making of SPK versus KA transplant options for patients and providers.

Reduced dose rabbit anti-thymocyte globulin induction for prevention of acute rejection in high-risk kidney transplant recipients.

BACKGROUND: Despite the prevalent use of rabbit antithymocyte globulin (rATG) as an induction agent in kidney transplantation, the appropriate dose for preventing acute rejection in high-risk patients is not known. Few studies have examined total exposure of rATG less than 6 mg/kg, with fewer studies examining lower dose rATG in patients with increased risk factors for acute rejection. METHODS: We retrospectively analyzed outcomes of 83 kidney transplant recipients at increased risk for acute rejection (repeat transplant, African American race, and panel reactive antibody > or =20%) from July 2004 to July 2007 who were treated with rATG 1.5 mg/kg per day for 3 (n=39) or 4 (n=44) doses for induction to determine the impact of reduced-exposure rATG in the prevention of acute rejection. rATG was initiated intraoperatively and continued on consecutive days. All patients received triple maintenance immunosuppression including prednisone and calcineurin inhibitor. Patients requiring dialysis within 48 hr after transplant were excluded from analysis. RESULTS: One-year acute rejection rates were 10% and 11% in the 3- and 4-dose cohorts, respectively, with 100% patient and graft survival at 1 year in both groups. Patients in the 3-dose cohort were discharged from the hospital sooner than the 4-dose cohort (median length of hospital stay, 3 vs. 4 days; P=0.004). CONCLUSIONS: Our results suggest that a 3- or 4-dose course of rATG (1.5 mg/kg/dose) provides excellent protection against acute rejection even in patients at increased risk, with the potential for cost savings from a reduction in hospital stay and medication administration.

Aggressive immunosuppression minimization reduces graft loss following diagnosis of BK virus-associated nephropathy: a comparison of two reduction strategies.

BACKGROUND AND OBJECTIVES: BK virus-associated nephropathy (BKVAN) has emerged as a leading cause of kidney graft loss, with no known predictors for graft loss and no consensus regarding treatment other than reduction of immunosuppression. DESIGN, SETTING, PARTICIPANTS AND MEASUREMENTS: A single-center retrospective analysis was performed of all cases of BKVAN from 1999 to 2005 for clinical predictors of graft loss, with evaluation of the impact of immunosuppression withdrawal (3-drug to 2-drug immunosuppression) within the first month versus reduction of immunosuppression. RESULTS: Of 910 kidney transplants, 35 (3.8%) cases of BKVAN were diagnosed at a median of 15 months after transplant (range, 5.5 to 90 months after transplant), 16 (46%) of which progressed to graft failure at a median of 11 months (range, 2 to 36 months) after diagnosis. Depleting antibody induction was a significant risk factor for graft loss on univariate analysis, whereas early drug withdrawal (<1 mo following diagnosis) protected against graft loss. On multivariate analysis, these findings were independent predictors of graft outcomes. Additionally, when patients were comanaged by referring nephrologists and the transplant center before the diagnosis of BKVAN, the risk of graft loss was 11-fold higher (P = 0.03) than if patients were managed solely by the transplant center. CONCLUSIONS: Increased awareness and early diagnosis of BKVAN, with aggressive tapering of immunosuppression once established, is critical to preserve kidney graft function. Early drug withdrawal to low-dose two-drug therapy maintenance may be preferable to a general reduction of agents.