Delayed graft function in renal transplant recipients: risk factors and impact on 1-year graft function: a single center analysis.

UNLABELLED: Delayed graft function (DGF), a frequent complication after kidney transplantation, occurs among about 60% of recipients of kidneys from deceased donors. DGF has a multifactorial etiology. It is characterized by acute tubular necrosis (ATN) upon biopsy. In this study we sought to identify among a group of recipients of kidneys from deceased donors, the incidence, risk factors, and impacts on patient and graft survivals of DGF. MATERIALS AND METHODS: We retrospectively analyzed medical records from renal transplant recipients aged >18 years who received a deceased donor kidney graft between January 2003 and December 2006. Kidneys lost during the first week posttransplantation were excluded from this series. RESULTS: Among 165 transplants, 111 (67%) displayed DGF, defined as the need for dialysis during the first week posttransplantation. The incidence of DGF was higher among patients with a cold ischemia time (CIT) > 24 hours: 85% vs 60%, DGF vs no DGF (P < .05), as well as for grafts from older donors. After 1-year follow-up, the DGF group showed worse graft function (serum creatinine 1.6 +/- 0.7 vs 1.3 +/- 0.4 mg/dL; P < .05) as well as a greater incidence of graft loss. CONCLUSION: Prolonged cold ischemia and older donor age were associated with a greater incidence of DGF in this series, leading to prolonged hospitalization, increased risk for an acute rejection episode, and reduced graft function and survival after 1 year.

Tuberculosis in renal transplant recipients: a Brazilian center registry.

UNLABELLED: Renal transplant recipients receiving immunosuppression show an increased risk for developing opportunistic infections, such as tuberculosis (TB). TB represents the major cause of morbidity and mortality in the world, mainly in underdeveloped countries. The aim of this study was to analyze the incidence of TB and its presentation among renal transplant recipients over 20 years. PATIENTS AND METHODS: This retrospective analysis included medical records of renal transplant recipients from January 1984 to April 2007. RESULTS: Among 1342 renal transplant recipients, 31 received treatment for TB due to clinical disease (n = 23) or prophylaxis (n = 8). The overall incidence of TB was 1.71%, which was diagnosed at 53 +/- 49 months posttransplantation. The indications for TB prophylaxis were a previous history of TB (n = 6) or direct contact with a TB carrier (n = 1). The most common clinical presentation was extrapulmonary (n = 13). The classical treatment was effective in 16 cases. However, 7 cases of resistant TB required ethambutol added to therapy. Adverse events of treatment included liver toxicity (n = 1) and peripheral neuropathy (n = 1). Three patients died due to TB-related complications. Graft loss was observed in 3 patients after cessation of TB treatment. None of the patients on prophylaxis developed clinical disease. CONCLUSIONS: TB incidence was significantly greater among renal transplant recipients compared with the local population, with a higher incidence of extrapulmonary disease. TB prophylaxis in selected cases was effective, avoiding new infections.

Skin malignancies in renal transplant recipients: a Brazilian center registry.

UNLABELLED: Renal transplant recipients have an increased risk of malignancies, especially nonmelanoma skin cancers, compared with the normal population. The aim of the present study was to analyze the incidence of skin malignancies in a setting of renal transplant recipients over 20 years follow-up. PATIENTS AND METHODS: This retrospective analysis of medical records included posttransplant patients with biopsy-proven skin cancer. Recipients of pancreas kidney transplants or with suspected but not biopsy-proven skin malignancy were excluded from this series. RESULTS: Among 1300 renal transplant recipients from January 1984 to December 2006, 33 (2.5%) were diagnosed with skin malignancies during follow-up. The majority of patients were men (70.2%), of white race (97%), and with a mean posttransplant follow-up of 65 months. The most frequent skin cancer was squamous cell carcinoma (46.2%), in single or multiple lesions (50% each group). Basal cell carcinoma was diagnosed in seven patients; most presented as a single lesion (71.3%). Eight patients presented with more than one histologic type of skin cancer; most frequently squamous and basal cell carcinomas. Kaposi sarcoma was diagnosed in four patients, one of whom also had a basal cell carcinoma. CONCLUSION: The incidence of skin malignancies in this series was 2.5%. The most frequent tumor was squamous cell carcinoma, isolated or in association with basal cell carcinoma. An higher frequency was observed in white male patients, at a mean follow-up of 5 years posttransplantation.

Posttransplant diabetes mellitus: incidence and risk factors.

UNLABELLED: Posttransplant diabetes mellitus (PTDM) is common post transplantation and is associated with tacrolimus (TAC) and steroid therapy. The aim of the present study was to analyze the incidences of PTDM and associated risk factors. METHODS: We selected renal transplant recipients treated with TAC, mycophenolate mofetil (MM), and steroids. Exclusion criteria were recipients <18 years old, history of diabetes, recipients of kidney/pancreas, and/or those receiving cyclosporine or sirolimus. PTDM was defined as glucose >126 mg/dL, with or without drug therapy. RESULTS: Among 67 patients who fulfilled the inclusion criteria, 18 (26.8%) developed PTDM within 2 months of transplantation. Compared with normal glucose patients, the PTDM group was older, male, received a kidney from deceased donors, and showed higher pretransplant glucose levels. No differences were noticed in renal function or daily dose of TAC or steroids. However, TAC trough levels in the first month were higher among the PTDM group, despite the lower dose per kilogram. After 1 year of follow-up, weight gain as well as daily TAC per kilogram dose was less among PTDM patients. Analysis of potential risk factors showed a higher incidence of hepatitis C virus infection in the PTDM group, as well as a higher frequency of HLA DR13. CONCLUSION: The incidence of PTDM diagnosed in the early posttransplant period in the present series was 26.8%. Risk factors included older age, male gender, recipients of kidneys from deceased donors, hepatitis C virus infection, higher pretransplant glucose levels, and higher TAC trough levels during the first month posttransplant.

Systemic lupus erythematosus after renal transplantation: is complement a good marker for graft survival?

BACKGROUND: Renal transplantation is considered a safe procedure for patients with systemic lupus erythematosus (SLE). However, the recurrence of disease and its impact on graft survival remains controversial. METHODS: To analyze the presence of lupus serology activity during dialysis and its impact on lupus recurrence after transplantation, we performed a retrospective analysis of 23 lupus patients who received 26 kidney transplantations. RESULTS: Twenty-three patients received 26 renal transplantations from 1984 to 2003. Twelve patients presented pretransplant lupus activity (low complement and ANA > 1/40), without correlation with length of dialysis, but associated with proliferative glomerulonephritis (class IV) pretransplant. Among 26 grafts, 6 were lost in the first 6 months posttransplant. Among the remaining 20 functioning grafts, low complement activity occurred in 8, being associated with recurrence of immune deposits in 3 cases. Analysis of lupus activity showed that only one patient with a normal complement level posttransplant presented SLEDAI > 4, associated with persistent proteinuria and a graft biopsy without immune deposits. Graft survival was reduced in the presence of low complement posttransplantation. CONCLUSION: Low complement levels after renal transplantation, in association with proteinuria may be considered to be a risk factor for recurrence of immune deposits, with a negative impact on graft survival.

Changes in serological markers of hepatitis B virus after renal transplantation.

An estimated 350 million persons worldwide are chronically infected with hepatitis B virus (HBV). Immunosuppression after renal transplantation seems to enhance viral replication and increase the risk of developing cirrhosis and hepatocellular carcinoma. This retrospective study was performed to assess the prevalence among and serological status of HBV infection after renal transplantation at a single university Brazilian center. Thirty six (4.2%) patients among 850 kidney recipients showed positive HBsAg for more than 6 months; 31 were hepatitis B surface antigen (HBsAg) positive at transplantation. Of the 15 hepatitis B e antigen (HbeAg) positive patients, six had spontaneous HBeAg seroconversion and three also had HBsAg clearance. An additional two showed HBeAg clearance with Lamivudine without seroconversion. Among 15 HBeAg-negative patients, three developed HBeAg reversion with no elevation of alanine transferase (ALT) levels and one had HBsAg clearance. Only one patient had acute exacerbation of hepatitis B (ALT > 20 times normal range) but remained HbeAg negative. During follow-up, five patients became HBsAg positive; two reactivations of resolved hepatitis B, two with previous anti-HBS induced by vaccination, and one with no serological marker for HBV. Lamivudine was prescribed for 16 patients, two of whom had HbeAg clearance without seroconversion and five who developed viral resistance to Lamivudine after a mean of 29.2 months. No hepatocellular carcinoma or deaths related to hepatitis B were seen in this group. In summary, prevalence of HBV in kidney transplant patients was 4.2%. Immunosuppression after renal transplantation in HBV infection led to an increased risk of liver complications and changes in HBV serological status.

Effect of panel-reactive antibody in predicting crossmatch selection of cadaveric kidney recipients.

AIM: The influence of panel-reactive antibody level (%PRA) on crossmatch results was evaluated among 866 patients on the waiting list for cadaveric renal allografting from January 2001 to August 2005. We evaluated the results for 124 potential donors for a kidney, including 2008 crossmatches. Four hundred eighteen patients were tested against only 1 donor. METHODS: Serum samples were screened for anti-HLA antibodies using immunoglobulin (Ig)G enzyme-linked immunosorbent assay (ELISA) PRA kit and the %PRA of the most reactive sample (peak) was used for patient stratification, according to sensitization level. Crossmatches were performed on fresh donor T lymphocytes from peripheral lymph nodes, using classical and anti-human-globulin enhanced complement-dependent cytotoxicity (CDC-T) methods. The tests were performed using peak and current patient sera before and after dithiothreitol treatment. The crossmatch was assumed to be negative when no reactivity was observed in all tests. RESULTS: The incidences of positive crossmatch were as follows: 72.3%, 14.6%, and 7.2%, among patients with PRA >50%, PRA

Urine cytology as a screening method for polyoma virus active infection.

Polyoma virus nephropathy (PVN) occurs in 3% to 4% of renal transplants, causing graft loss in about 50% of cases. The presence of viral cytopathic changes in graft epithelial cells is the only diagnostic tool for PVN. However, identification of cells with viral inclusions (decoy cells) in urine can be used as a screening tool for viral replication of or for active infection with PV. The aim of the present study was to identify the occurrence of PV active infection in renal transplant recipients. Two hundred forty urine cytology samples, collected from 80 transplant patients with stable renal function, were collected on a monthly basis and stained with the Pap smear for decoy cells. Active infection with polyoma virus was confirmed by urine immunostaining. All samples were analyzed blindly and classified as negative or positive (>1 decoy cell/sample). Among 240 urine cytologies collected from 48 men and 32 women, decoy cells were identified in 37.5%. No differences were observed in serum creatinine or immunosuppressive regimen between patients with positive versus negative cytology. No graft losses occurred secondary to PVN in the present study setting. The incidence of decoy cells in this series (37.5%) was consistent with previous reports (20% to 40%), suggesting that active infection may be confirmed by PV immunohistochemistry. The absence of PVN in this group may be attributed to the low doses of immunosuppressive drugs in the late posttransplant transplant period, but also to the unknown incidence of polyoma virus infection in Brazil.

Percutaneous renal graft biopsy: a clinical, laboratory and pathological analysis.

CONTEXT: Renal allograft biopsies have been used as a good method for monitoring the evolution of kidney transplants for at least 20 years. Histological analysis permits differential diagnosis of the causes of allograft dysfunction to be made. OBJECTIVES: To correlate the data of urinalysis and serum creatinine with histological diagnosis of renal graft in a group of renal transplant patients. DESIGN: Accuracy study, retrospective analysis. SETTING: A university terciary referral center. SAMPLE: 339 percutaneous allograft biopsies obtained from 153 patients. Blood and urine samples were obtained before the graft biopsy. MAIN MEASUREMENTS: Laboratory evaluation and hystological analysis (light microscopy, immunofluorescent electronic microscopy). RESULTS: Most of the biopsies (58.9%) were performed during the first month post-transplant. An increase in serum creatinine was associated with acute tubular and/or cortical necrosis. Proteinuria and normal serum creatinine were associated with glomerular lesions. Non-nephrotic range proteinuria and an increase in serum creatinine were associated with chronic rejection. CONCLUSION: Evaluation of serum creatinine and urinalysis can be useful in suggesting the histological graft diagnosis.

Nutritional status and body composition in patients early after renal transplantation.

INTRODUCTION: After renal transplantation recovery in nutritional status occurs during the first year. We assessed the changes in nutritional status after transplantation in 145 transplant recipients (94 males, 51 females). METHODS: Patients were evaluated immediately after renal transplant (baseline data) and at 6 months' follow-up. Analysis included body mass index (BMI), body composition (skin fold and arm circumference), and estimated body composition (calculated percent of fat, arm circumference, arm muscle circumference, and arm muscle area). Other data obtained from medical records included renal function (MDRD) serum albumin and lipid profile. RESULTS: At baseline evaluation (21 ± 15 days posttransplant), mean BMI was 23.9 ± 3.9 kg/m(2), serum albumin was 3.7 ± 0.7 g/dL, and lipid profile showed (cholesterol 158.5 ± 52.7 mg% and triglycerides 135.9 ± 91.8 mg%. Body composition analysis showed better adaptation of muscle mass in females [AC (91 ± 10.2 × 98 ± 14.6; male × female, P < .05) arm muscle circumference (92.6 ± 1.4 × 102.3% ± 2.9%, male × female, P < .05) and arm muscle area (87.1 ± 22.3 × 105.5% ± 25.9%, male × female, P < .05)]. Body fat was above the recommended levels in 80% of patients, especially females. After 6 months we divided the groups according to BMI, observing better renal function in the normal weight group compared with obese subjects (60 ± 17.2 × 39.5 ± 19.8 mL/min MDRD, P < .05), despite comparable estimated glomerular filtration rate at baseline. CONCLUSION: The nutritional assessment of patients with end-stage renal disease early after renal transplantation, showed inadequate body composition, with increased fat and reduced lean body mass. The lower glomerular filtration rate after 6 months may be attributed to relatively inadequate renal mass or to obesity-induced hyperfiltration.

[Nephrotic syndrome caused by membranous glomerulonephritis associated with chronic myeloid leukemia]. / Síndrome nefrótica por glomerulonefrite membranosa associada a leucemia mielóide crônica.

A patient developed nephrotic syndrome four years after diagnosed chronic myelogenous leukemia. Renal histology showed characteristic changes of membranous glomerulopathy. To our knowledge, this is the first reported case of membranous glomerulopathy associated with chronic myelogenous leukemia.

Acute tubulointerstitial nephritis and uveitis with antineutrophil cytoplasmic antibody.

We report a case of acute tubulointerstitial nephritis and uveitis (TINU syndrome) in a 47-year-old woman who also was found to have antineutrophil cytoplasmic antibody. The patient developed severe acute renal failure that improved after a high dose (1 mg/kg/d) of corticosteroid therapy. The diagnosis of the disorder is discussed, as well as the finding of antineutrophil cytoplasmic antibody.

Efeitos imediatos e a médio prazo da administração de verapamil em ratos com hipertensão renal experimental / Immediate and midterm effects of the administration of verapamil in rats with experimental renal hypertension

Os efeitos imediatos e a medio prazo do verapamil sobre a pressao arterial de ratos foram estudados em dois modelos distintos de hipertensao arterial experimental por estenose de arteria renal: l Clip2 rins (modelo GII) e 1 clip 1 rim (modelo GI). Houve reducao significante da pressao arterial em ambos os grupos: maior grau de reducao foi observado no modelo GII (27%) comparado ao modelo GI (l7%). Entretanto, ao final do tratamento a medio prazo, nao mais se observaram diferencas entre os dois grupos. Tambem, o efeito imediato nao foi diferente entre os dois grupos, quer quanto a resposta maxima (GI = 22,6% vs GII = 26,2%), quer quanto a duracao do efeito avaliada pelo T l/2 (GI = 120 min vs GII = 150 min). Estes dados sugerem que o verapamil e igualmente eficaz em reduzir os niveis hipertensivos nestes dois modelos. Portanto, o mecanismo de acao parece ser inespecifico, atraves do antagonismo de calcio, podendo estar envolvidas reducoes do debito cardiaco e/ou vasodilatacao periferica. Por isto, estudos hemodinamicos detalhados dos mecanismos de resposta pressorica a esta droga sao necessarios antes da aplicacao indiscriminada em hipertensao humana

Tratamento da hipertensão arterial leve e moderada com baixas doses de captopril / Treatment of mild and moderate arterial hypertension with low doses of captopril

Quinze pacientes portadores da hipertensao arterial sem complicacoes, apos um periodo de 2 semanas de placebo, foram tratados com captopril (25-75 mg), isolado ou associado a diuretico tiazidico, por 8 semanas A pressao arterial media do periodo placebo era de 125,1 mmHg, caindo para 109,9 mmHg, apos as 8 semanas de captropril e diuretico. Esta diferenca foi estatisticamente significante p < 0,01. Doze destes pacientes usaram diuretico isoladamente durante 4 semanas, notando-se elevacao da pressao arterial media para 116,8 mmHg.Esta diferenca foi estatisticamente significante (p < 0,05). O estudo permitiu concluir que o captopril, isolado ou associado a diuretico, mostrou-se eficaz no tratamento da hipertensao arterial, pois normalizou a pressao arterial em 10 dos 15 pacientes estudados. Como uso isolado de diuretico, notou-se elevacao da pressao arterial em 9 dos 12 pacientes estudados