Cadaveric Kidney Transplantation Research Articles

Impact of deceased-donor characteristics on early graft function: outcome of kidney donor pairs accepted for transplantation.

The impact of deceased donor characteristics on kidney transplant outcomes is controversial. Correspondingly, the predictive performance of deceased donor scores remains moderate, and many transplant centers lack validated criteria for graft acceptance decisions. To better dissect donor-related risk from recipient and periprocedural variables, we analyzed outcomes of kidney donor pairs transplanted in different individuals. This study explored (a)symmetry of early outcomes of 328 cadaveric kidney transplant recipients from 164 donor pairs transplanted at three Eurotransplant centers. The primary discriminatory factor was (a)symmetry of partner graft function, defined as early graft loss or impaired graft function [estimated glomerular filtration rate (eGFR) <30 mL/min] 3 months after transplantation. We reasoned that a relevant impact of donor factors would result in a high concordance rate of limited graft function or failure. The observed number of symmetric graft failure after transplantation was less than statistically expected (3 months: 1 versus 2, p = 0.89; and 12 months: 3 versus 5, p = 0.26). However, we found a trend toward an impaired 5-year graft survival of grafts with good function 3 months after transplantation but a failed or impaired partner graft compared to symmetrically well-functioning grafts (p = 0.09). Subsequently, we explored the impact of individual donor and recipient variables on early transplant outcomes. Generalized estimating equations after feature selection with LassoGEE bootstrap selected donor age, donor body mass index, and donor eGFR as the relevant risk factors. Our findings indicate that donor factors impact early outcomes in kidney transplantation but may have a limited role in long-term graft survival, once a graft has been accepted for transplantation. Utilizing donor-based clinical scores has the potential to aid clinicians in acceptance decisions, giving them an estimate of individual posttransplant outcomes. However, the ultimate decision for acceptance should rest with clinicians, who must consider the complex interplay of donor factors, as well as recipient and periprocedural characteristics.

Perioperative Anesthetic Management and Outcome of a Cadaveric Pediatric En-bloc Kidney Transplantation: A Case Report

Kidney transplantation stands as the favored approach to treat end-stage renal disease in children, offering enhanced survival, improved quality of life, and better neuropsychological development compared to dialysis. Transplanting kidneys en bloc remains a complex procedure, diverging from the conventional single kidney transplantation in several aspects, requiring precise skill and expertise to achieve favorable outcomes. In this paper, we report a successful en-bloc kidney transplantation from a 16-month-old pediatric cadaveric donor to a 5-year-old recipient, the youngest individual to undergo an en-bloc kidney transplant in the country, and the contribution of meticulous anesthetic management to this success story.

Laparoscopic ureteroplasty of a transplanted kidney using a healthy native ureter

Introduction. Ureteral strictures are a common urological complication of kidney transplantation. For short narrowings of the ureter, endoscopic operations are used; for extended defects the Boari operation is often performed. An alternative method may be to use a native ureter.Purpose of the study. To study the results of such operations in four patients.Materials &amp; methods. We observed four patients with extended ureteral strictures of a transplanted kidney. Among them were three women and one man. Previously, all patients had undergone a cadaveric kidney transplant; the time from the operation itself to the development of stricture ranged from 3 months to 13 years. Initially, all patients underwent percutaneous drainage of the pyelocaliceal system of the transplanted kidney. After stabilization of creatinine values, the pelvis or pyeloureteral segment of the transplanted kidney was isolated using a transperitoneal approach. Further, the lower third of the ipsilateral native ureter was crossed at the level of the iliac vessels. Its upper end was clipped and anastomosis with the pelvis or ureteropelvic junction of the graft was performed.Results. The procedures were successful in all patients. In three patients the operation was completed using a laparoscopic approach. In one patient in whom extensive ureteral obliteration developed 3 months after transplantation against the background of incompetent ureterocystoneoastomosis and urinary leakage, when the pelvis was isolated, which was covered by the external iliac vein, the latter was injured with bleeding. This required conversion to open access, suturing of the iliac vein defect, further excision of the pelvis and anastomosis with the native ureter. In the post-operative period, the patient developed thrombosis of the iliac and femoral veins below the suturing area, and successful thrombolytic therapy was performed. Nephrostomy drain was removed before discharge and the stent was removed on an outpatient visit 4 to 6 weeks after surgery. Currently the condition of all patients is stable, the graft is functioning, and their diuresis is unchanged, serum creatinine ranges from 106 to 180 μmol/l.Conclusion. The use of a healthy native ureter is an adequate method of replacement of extended ureteral strictures of the transplanted kidney.

Safe immunosuppression. New tool for personalized immunosuppressant treatment in renal transplantation. A case report

Background: The adjustment of immunosuppressive therapy after kidney transplantation (KT) to avoid graft rejection remains an important challenge for clinicians. It is difficult to achieve a good balance between under-immunosuppression (with an increased risk of graft rejection) and over-immunosuppression (with an increased risk of side effects) by only relying on the available information about immunosuppressive drugs (IMS). Immunobiogram® (IMBG) is a novel in vitro diagnostic test that provides clinicians with information about the patient’s sensitivity to individual IMS. Objective: To present a case report of a patient with renal transplant in the maintenance phase who presented several complications probably related to the immunosuppression during the follow-up, where the use of IMBG as complementary information helped clinicians to guide the therapeutical decision. Methods: IMBG is a first-in-class in vitro immunoassay that involves the culture of the patient peripheral blood mononuclear cells (PBMCs) in a semi-solid 3D matrix, then submitted to immune stimulation. It reveals the capacity of an IMS over a gradient to inhibit the activation of immune cells. The read-out allows the building of a dose-response curve per IMS tested, which is mathematically analyzed by a software using the key curve parameters and finally to be translated into a sensitivity map to IMS. Findings: We present a case report of a 72-year-old patient with a cadaveric donor kidney transplant receiving standard immunosuppressive treatment with mycophenolate, tacrolimus, and corticosteroids. The patient presented several episodes of infections during the follow-up (SARS-CoV2, Cytomegalovirus, spondylodisquitis by Staphylococcus aureus, and emphysematous cystitis) which were managed with different treatment adjustments such as de-escalation of mycophenolate and switching to mTOR. The information provided by the IMBG showed a lack of sensitivity to mTOR which allowed to confirm the final adjustment to a treatment with tacrolimus and corticosteroids, remaining the patient stable since then. Discussion: Despite various adjustments to the immunosuppressive therapy during the follow-up, the patient continued experiencing adverse effects that could be related to an over-immunosuppression state. The IMBG provided pharmacodynamic information that complemented the clinical and pharmacokinetic data available, facilitating the individualization of the treatment. Conclusion: The case highlights the potential of the IMBG as a complementary clinical tool for personalized treatment of kidney transplant patient management.

Pregnancy outcomes and complications after renal transplantation

Introduction. Chronic kidney disease (CKD) in pregnancy poses certain risks of both gestational complications and adverse perinatal outcomes, which increase with the decline of renal function.Aim to access pregnancy outcomes in patients who underwent nephrotransplantation.Materials and methods. Retrospective study of pregnant women who gave birth at Academician V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology in the period from 2005 to 2021: 102 pregnancies in 97 patients were analyzed: five recipients had two successful pregnancies.Results. The average age of pregnant women was 31 ± 4.03 years. In equal proportions, patients underwent related or cadaveric kidney transplantation – 52% (n = 53) and 48% (n = 49) of cases, respectively. The average delivery time was 35.5 ± 2.7 weeks. The average weight of newborns was 2545 ± 655 grams. Premature birth (PB) occurred in 47.1%, the average period of birth was 33.4 ± 2.87 weeks, of which early birth (&lt;32 weeks) was 22.5%. The average period of pregnancy after transplantation was 5 ± 3.31 (1–18) years, this period was not associated with obstetric complications or deterioration of graft function. A significant increase in the following parameters was noted during pregnancy: serum creatinine level (p = 0.006), proteinuria (p = 0.003). The glomerular filtration rate also decreased significantly by the end of pregnancy (p = 0.011). Preeclampsia was the leading cause of decreased graft function during pregnancy (32.4%).Conclusions. In general, pregnancy outcomes after nephrotransplantation are favorable, but there is an increased risk of preeclampsia, preterm birth, including operative delivery, urinary tract infection and anemia.

Successful Twin Delivery Through In Vitro Fertilization in a High-Gestation Age Kidney Transplant Recipient: A Case Report

BackgroundNumerous successful pregnancy outcomes have been reported after kidney transplantation, but until now, there have been no reports of healthy twin deliveries through in vitro fertilization treatment in high-gestation aged women with a long post-transplant duration. In our report, we present a case of a high-gestation aged kidney transplant recipient who successfully delivered healthy twins with the aid of in vitro fertilization. Case presentationAt the age of 29, a woman with end-stage kidney disease caused by immunoglobin A nephropathy underwent kidney transplantation. She had a history of premature ovarian failure and had been on continuous ambulatory peritoneal dialysis since the age of 18. Eleven years after starting dialysis, she received a cadaveric kidney transplant. Despite being infertile for 7 years after transplantation, she wished to have children. In vitro fertilization embryo transfer was conducted after failure of ovarian stimulation, considering her age and premature ovarian failure. The patient successfully delivered twins at 29 weeks gestation via cesarean section, as the first fetus presented in breech position. The first newborn weighed 945 g and the second weighed 855 g, with no other congenital abnormalities found. One year after childbirth, neither the recipient nor her babies experienced any fatal complications. ConclusionsA woman who underwent kidney transplantation and has stage 3 CKD may successfully deliver healthy twins through in vitro fertilization embryo transfer, even if she is of advanced maternal age and has a long post-transplant period. However, there is a risk of preterm premature rupture of membrane in such cases.

Hyperparathyroidism in kidney transplant candidates and postoperative parathyroid gland function in recipients

Objective: to evaluate the effects of secondary hyperparathyroidism (HPT) in kidney transplantation (KT) candidates on recipients’ parathyroid gland function in the first postoperative year.Materials and methods. The retrospective cohort study included 210 patients (103 women, 107 men, age 45 ± 9 years) with stage 5 chronic kidney disease (stage 5 CKD, including dialysis-dependent patients), who had undergone cadaveric KT. Biochemical screening before kidney transplantation and in the postoperative period at 3 and 12 months determined serum levels of parathyroid hormone (PTH), calcium, phosphorus, alkaline phosphatase activity, albumin and creatinine using standard methods. PTH levels of 130–595 pg/mL and ≤130 pg/mL were taken as the target level in the pre- and post-transplant periods, respectively.Results. Fifty-six KT candidates (group 1) had HPT and 154 (group 2) had the target PTH levels. PTH level was 897 (722; 1136) and 301 (229; 411) pg/mL, respectively, p &lt; 0.001. PTH decreased in all recipients at 3 months after KT: by 595 (420; 812) in group 1 and 148 (77; 230) pg/ mL in group 2, p &lt; 0.001, to 254 (180; 455) and 150 (118; 212) pg/mL, respectively, p &lt; 0.001; the target level was detected in 10.7% and 42.2% of recipients, respectively, p &lt; 0.001. At 12 months, blood PTH was 171 (94; 239) pg/mL in group 1 and 112 (90; 135) pg/mL in group 2, p = 0.004; target level was found in 48.2% and 73.4% of recipients, respectively, p &lt; 0.001. Kidney graft function was identical in both recipient groups: acute tubular necrosis in 41.1% and 54.5%; at 3 months, median glomerular filtration rates (GFR) of 60 and 65 mL/min (n.d.); at 12 months, 56 and 54 mL/min (n.d.). Post-transplant PTH levels correlated directly with preoperative levels in both groups and inversely with renal graft function in group 2 recipients.Conclusion. HPT in kidney transplant candidates is a major, graft function-independent predictor of excess PTH secretion in recipients, increasing the risk of persistent HPT 1.9-fold, one year after KT.

First Ever Organ Transplantation from A Brain-Dead Person in Bangladesh: A Successful Outcome of The Human Organ Transplantation Act

On the 19th of January 2023, a historic event took place in the field of medical practice and country’s healthcare system. A 20-year-old girl named Sarah Islam was pronounced clinically dead on Wednesday (18 January, 2023) while being treated at Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh, with her terminal illness as she has been suffering from tuberous sclerosis since her childhood. Her final act was termed 'heroic' by her attending physicians as she became the first patient in the country to donate her organs while being brain-dead. The next day in the early morning (19 January, 2023) doctors conducted the country's first-ever cadaveric kidney transplantation as taken from her. The recipients were two females in their 30s who were reportedly recovering well after the surgery. Those two surgeries were performed separately at Bangabandhu Sheikh Mujib Medical University (BSMMU) Hospital and the National Kidney Foundation Hospital in Dhaka. The Human Organ Transplantation Act (HOTA) officially came into force in Bangladesh on April 13, 1999, allowing organ donations from both living and brain-dead donors; after long discussion, some amendments were ratified by the Parliament in 2018. The Act places some legal requirements around the collection and preservation of human organs as well as ensuring their transplantation into a human body. Few years back, religious leaders came forward to issue a fatwa (religious approval) that recognize both living and brain death criteria and permit both living and brain-dead donors to donate organs for transplantation. Based on that fatwa and a long medical discussion the country’s parliament passed this Act. Enacting the HOTA shows an immense influence in our society on cadaveric organ donation and transplantation especially from brain-dead individuals, and we hope that this historic donation will create more awareness and pave a new path for organ donation campaign in the country in near future. CBMJ 2024 January: vol. 13 no. 01 P: 102-106

A Tubular Vena Cava Conduit Used to Lengthen a Kidney Transplant Renal Artery Injured During Organ Procurement

Organ transplantation is limited by the supply of transplantable organs, and the supply of organs cannot meet the needs of patients on the waiting list. Ensuring transplantation of any procured organ is therefore mandatory. Organ injury, mostly to the organ's vasculature, can occur during multi-organ procurement, preventing subsequent transplantation. In such a context, vascular reconstructions of arterial or venous organ injuries can be useful. This report describes the case of an obese 64 year old female with a history of diabetic nephropathy who underwent a cadaveric kidney transplant (right kidney with one main renal artery, one inferior polar artery, one vein, and one ureter). The ex situ preparation of the graft revealed that the main renal artery was injured and cut close to the renal hilum (0.8 cm length, 6 mm diameter), not allowing graft implantation. In order to increase the length of the main renal artery, the donor inferior vena cava was used to create a tubular conduit, allowing subsequent graft implantation. Cold and warm ischaemic times were respectively 12 hours and 36 minutes, with immediate graft function. The patient was discharged on day 8 (serum creatinine level was 95 μmol/L). Twelve month follow up was uneventful (serum creatinine level was 108 μmol/L and duplex ultrasonography showed homogeneous blood flow throughout the graft). This case report highlights the possibility of overcoming an injured kidney graft artery by creating a tubular vena cava conduit in order to allow subsequent transplantation. Vascular reconstructions of organs injured during procurement should be considered.

Metabolic Risk Profile and Graft Function Deterioration 2 Years After Kidney Transplant

Studies exploring the association of body weight and metabolic status with graft function deterioration (GFD) after kidney transplantation have produced inconsistent findings. Few studies have examined whether metabolically healthy overweight or obesity (MHO) may contribute to GFD. To evaluate associations of overweight or obesity and metabolic disorders with GFD in recipients of kidney transplant. This multicenter retrospective cohort study was conducted from January 1, 2020, through June 30, 2021, with a follow-up period of 2 years after kidney transplantation. Participants included adult recipients of cadaveric kidney transplant in 4 transplantation centers in China. Participants were classified as 4 metabolic phenotypes according to their BMI and metabolic status. Data were analyzed from July to August 2023. Overweight and obesity were characterized by body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) of 24 or greater. Metabolic disorder was identified by existence of a minimum of 2 of 4 conditions: hypertension, hyperglycemia, increased triglyceride, and decreased high-density lipoprotein cholesterol. The main outcome was GFD, defined as a decrease in estimated glomerular filtration rate of at least 25% within 6 months to 2 years after transplant. A total of 1260 adult recipients of cadaveric kidney transplant (mean [SD] age, 43.97 [11.51] years; 755 [59.92%] male) were included in the study, and 127 (10.08%) participants experienced the primary outcome of GFD during follow-up. After accounting for confounding factors in multivariable analyses, overweight or obesity (odds ratio [OR], 1.64; 95% CI, 1.10-2.44; P = .02) and metabolic disorder (OR, 1.71; 95% CI, 1.12-2.63; P = .01) were associated with increased risk of GFD. The MHO subgroup exhibited a greater risk for GFD (OR, 2.37; 95% CI, 1.01-5.57; P = .048) compared with participants who did not have overweight or obesity or metabolic disorder. All components of metabolic disorder, with the exception of elevated triglyceride, were associated with GFD. There was a dose-response association of number of metabolic disorder components (OR per 1 additional condition, 1.40; 95% CI, 1.20-1.63; P < .001) and BMI (OR per 1-unit increase, 1.90; 95% CI, 1.03-1.15; P = .002) with increased risk for GFD. A nonlinear association was observed between BMI and risk of GFD. In this cohort study of recipients of cadaveric kidney transplant, individuals with overweight or obesity or metabolic disorder had a significantly higher risk of experiencing GFD. Individuals with MHO had an elevated risk for graft function deterioration. Additional studies with larger sample size and longer follow-up are necessary to validate our findings.

Clinical case of recurrent aHUS after allogeneic cadaveric kidney transplantation

Introduction. Atypical hemolytic uremic syndrome (aHUS) is a systemic orphan disease that reproduces as an uncontrolled activation of the alternative pathway of the complement system and is expressed as systemic thrombotic microangiopathy (TMA). The classical triad of aHUS symptoms are hemolytic anemia, thrombocytopenia, and acute kidney injury (AKI). Currently, diagnosis of aHUS is a diagnosis of exclusion and has no pathognomonic features. It is established based on the clinical presentation of the disease after excluding other forms of TMA, Objective: to increase physicians’ awareness of this rare disease, the diagnosis and treatment of aHUS using a clinical case study.Conclusion. Early diagnosis of aHUS is extremely important, as timely targeted therapy can significantly improve or completely restore the functions of the affected organ.

Non-meningeal, non-pulmonary cryptococcosis with limited posterior uveitis in a kidney organ transplant recipient with antibody-mediated rejection: a case report

BackgroundCryptococcosis is one of the most frequent fungal eye infections in patients with immunosuppression. Currently, treatment approaches for non-meningeal, non-pulmonary cryptococcosis are based on those used for cryptococcal meningitis or pneumonia.Case presentationWe present a rare case of non-meningeal, non-pulmonary cryptococcosis with clinical manifestations limited to one eye of a cadaveric kidney transplant recipient with chronic-active antibody-mediated rejection. Typical manifestations, diagnosis, and treatments, including antifungal therapies, adjunctive therapies, and immunosuppression reduction, are discussed. After timely diagnosis and treatment, her visual acuity recovered to baseline without recurrence or sequelae of cryptococcosis.ConclusionsClinicians should be aware of rare presentations of fungal infections, especially when a kidney transplant recipient with rejection has been treated with intensive immunosuppressants. Early diagnosis with individualized therapies may have a favorable prognosis.

Effects of recipient education disparity on living donor kidney transplant outcomes across different ethnic groups: a retrospective study in the United States.

Previous studies have shown that education level is associated with the prognosis of cadaveric kidney transplant recipients. However, it is unclear whether education affects the prognosis of living kidney transplant (LDKT) recipients. In addition, it remains to be determined whether the uneven distribution of educational levels consistently affects the prognosis of LDKT recipients across ethnic groups (White, Black, Hispanic and Asian). After establishing inclusion and exclusion criteria, we conducted a retrospective study of LDKT recipients who received their first single LDKT between 2005 and 2020. The LDKT recipients were divided into lower- and higher-education groups according to categorize the educational level of recipients, and transplant outcomes, including graft survival, patient survival, and death-censored graft survival (DCGS), were analyzed and compared. Graft survival, DCGS and patient mortality were significantly better in the higher-education group compared with those in the lower-education group (P<0.001), with the risk of graft failure, death censored graft failure (DCGF) and patient mortality increasing by 11%, 15% and 7% in the lower-education group, respectively. Furthermore, compared with the higher-education group, the risk of graft failure in Black recipients increased by 18% [adjusted hazard ratio (aHR), 1.18; 95% confidence interval (CI): 1.07 to 1.30], and the risk of patient mortality among White recipients decreased by 7% (aHR, 0.93; 95% CI: 0.87 to 0.99). However, there were no significant differences in graft failure and patient mortality among Hispanic and Asian recipients, respectively. This study revealed that LDKT recipients with a higher education level had better transplant outcomes. However, these transplant outcome differences were mainly found in White and Black recipients. These data confirm the significant effect of different levels of education on the prognosis of LDKT recipients.

Kidney Transplantation in the New Hospital Model in Turkey: 3 Years of Experience in Ankara City Hospital

ABSTRACT&#x0D; &#x0D; Objective: City hospitals, as a new model hospital, started to serve in approximately 20 different cities in Turkey. In this study, we aimed to present the 3 years experience of Ankara City Hospital kidney transplant unit, which has exceeded 100 cases, as a new hospital model.&#x0D; &#x0D; Materials and Methods: We retrospectively collected the data of 101 end-stage renal disease patients who underwent live or cadaveric kidney transplantation in the Department of Urology at Ankara City Hospital. The demographic data of the recipient and donor, postoperative complications, patient survival and graft functions were recorded.&#x0D; &#x0D; Results: Patient and graft survival rates of the recipients were 96% and 98% at 36 months follow-up, respectively. The median serum creatinine level at post-op first day, 1 months, 6 months, 12 months, 18 months, 24 months and 36 months posttransplantion was 1,3 (range, 0,7-5,7) mg/dl, 1,3 (range, 0,8-1,7) mg/dl, 1,3 (range, 0,8-2,5) mg/dl, 1,3 (range, 0,7-2) mg/dl, 1,2 (range, 0,8-1,9) mg/dl, 1,4 (range, 0,8-2,4) mg/dl and 1,4 (range, 1-2,4) mg/dl, respectively. 6 (5,9%) patients with urinoma were treated conservatively with urinary catheterization and percutaneous drainage. Renal artery stenosis was observed in 2 (2%) patients.&#x0D; &#x0D; Conclusion: Kidney transplantation is still the most important treatment option for ESRD patients in Turkey as in the world. In our center, we observed that graft function results were acceptably good at 36 months follow-up. &#x0D; &#x0D; Keywords: city hospital, graft function, kidney transplantation

#6797 EFFICACY OF DESENSITIZATION TREATMENT IN HYPERIMMUNIZED PATIENTS AWAITING A CADAVERIC KIDNEY TRANSPLANTATION

Abstract Background and Aims On all kidney waiting lists, patients who have antibodies against more than 80% of a panel reactive antibody (PRA) are difficult to transplant, even with national or regional programs. Desensitization treatment with high-dose intravenous immunoglobulin and rituximab could be offered to patients with a long waiting time for a cadaveric donor to improve their odds of finding a kidney. Method Retrospective, single-center study including all hyperimmunized patients on the waiting list for a cadaveric kidney donor who received a desensitization treatment between 2010-2020. To be considered to the desensitization protocol, all the patients must have a PRA above 75% and have been on the waiting list more than 3 years, without any offer. Our treatment was based on the modified Cedars-Sinai Medical Center protocol. Eight hyperimmunized patients on the waiting list for a cadaveric donor kidney transplant (50% male with a mean age of 41.5±16.4 years) received desensitization treatment with intravenous immunoglobulin and Rituximab. Six of the 8 patients (75%) were on renal replacement therapy with hemodialysis and two on peritoneal dialysis (mean time on dialysis 48±14 months). 75% had received a previous transplant. The median PRA calculated was 98%. The time between desensitization and kidney transplantation, the percentage of reactivity against panel cells (PRA) before and after therapy, graft and donor survival, as well as episodes of acute rejection and viral infections were analyzed. The mean follow-up time after transplantation was 67 months. Results No patient presented significant side effects to desensitization treatment. Seven of the 8 patients (87.5%) could be transplanted from a cadaveric donor (negative crossmatch test), in a median 8 months after desensitization. No significant changes were observed in the PRA levels. In the immediate post-transplant period, there were 2 graft losses (28.6%) due to non-immunological causes (1 venous thrombosis in a patient with a coagulation disorder and 1 primary graft failure). Creatinine at discharge was 1.6±0.4 mg/dl and 1.4±0.2 a year after the transplant. Five-year censored death graft survival was 100%. Three patients presented viral replication (1 due to cytomegalovirus (CMV), 1 due to polyomavirus (BK) and another CMV+BK), which became negative after switching to m-Tor therapy. There were no episodes of acute rejection. No patient developed cancer during the follow-up. Conclusion Desensitization treatment with immunoglobulin and rituximab on hyperimmunized patients on the cadaveric waiting list is a safe and effective treatment that increases the chances of achieving a kidney transplant in highly sensitized patients.

#4909 THE HEALTHCARE ACTIVITY BURDEN OF A HOME-BASED TREATMENT: A SUMMARY OF THE FIRST 365 DAYS OF PERITONEAL DIALYSIS

Abstract Background and Aims Peritoneal dialysis (PD) is the incident kidney replacement therapy (KRT) for 16% of patients in Scotland. Conveying the healthcare-related burden associated with KRT is essential for informed patient choice but has not been characterised as comprehensively in PD as in haemodialysis (HD) or kidney transplantation. Knowledge of the patient journey and the cumulative impact of renal service interactions is key to practising patient-centred realistic medicine, and considering service configuration, resource deployment, and the targeting of carbon emission reductions necessary for addressing the climate emergency. This study therefore aimed to capture the nature and extent of kidney-related healthcare activity in the first year of PD therapy. Method This retrospective observational study included all incident adult patients on PD between 1st January 2015–31st December 2019 from two Scottish health boards servicing a population of 1.6 million people. Analysis was undertaken of prospectively recorded healthcare-related activity from the electronic patient record. Data pertaining to hospital admissions, scheduled and unscheduled outpatient clinic, and home visit activity was captured up to the first 365 days post commencement of PD, and censored by death or switch in KRT modality. Data concerning dialysis access activity, radiological activity and relevant infection episodes was also analysed. Carbon mapping of healthcare activity was estimated using patient postcode data and previously published carbon footprint estimations. Results PD was initiated in 122 patients over the study period. Four patients died and 63 patients (52%) transitioned to another KRT within 365 days of commencing PD (10 live donor kidney transplantation, 19 cadaveric kidney transplantation, 34 HD) and one patient recovered native function. The median duration from insertion of PD catheter to utilisation was 26 days (IQR 34). Mean distance travelled to renal unit was 23.7 miles. Over the first year, patients had a mean 36.4 days (SD 22.7) of face-to-face contact days with renal services. This included a mean of 1.5 (SD 1.6) hospital admissions, with a median 5 (IQR 10.8) in-patient days. Additionally, a mean of 2.5 (SD 2.5) unscheduled ambulatory assessments per patient; 4.7 (SD 6.2) telephone consultations; 14.9 (SD 8.96) face-to-face clinics with a PD nurse and 7 (SD 3.9) with a nephrologist, and 2.5 (SD 3.4) home visits occurred. Within these contact episodes there were on average 4.4 (SD 4.1) radiological investigations per patient (3.1 x-rays, 0.4 CTs, 0.4 ultrasounds, 0.1 MRIs); and 1.4 (SD 0.3) infection events (0.02 bloodstream infections, 0.2 urinary tract infections, 0.7 PD catheter site infections, and 0.5 PD peritonitis episodes). The estimated carbon footprint from patient contact with renal services was 803.6kg CO2e/patient; this included 402.6kg CO2e/patient for inpatient days, 54.6kg CO2e/patient for unscheduled ambulatory assessment, 0.24kg CO2e/patient for telephone consultations, 293.8kg CO2e/patient for outpatient clinic activity and 17.6kg CO2e/patient for home visits, and 34.8kg CO2e/patient for radiological investigation and treatment of infection episodes. Conclusion Although PD is a home-based therapy patients should be aware of the frequency of attendance and admission days in the first year. KRT transition appeared common in this cohort, with similar proportions of transplantation and conversion to HD which prompts consideration of early vein mapping for arteriovenous haemodialysis in patients without prospect of early transplantation. Sixty-eight percent of the cohort experienced at least one infection episode necessitating anti-microbials, with implications for patient experience and anti-microbial stewardship. The length of time PD catheters remained in situ but not used was heterogeneous and merits further examination given the frequency of infection episodes and KRT transition. Estimates of carbon footprint relating to routine and unscheduled care indicate that carbon hotspots include patient travel and hospital admissions, and episodes of peritonitis; a full life cycle analysis is merited.

Atypical haemolytic uremic syndrome with refractory multiorgan involvement and heterozygous CFHR1/CFHR3 gene deletion

BackgroundWe present this challenging case report of Atypical Haemolytic Uremic Syndrome (aHUS) presenting with multi-organ involvement in a patient and heterozygous CFHR1/CFHR3 gene variant, which was refractory to initial eculizumab therapy.Case presentationA forty-three year old female presented with aHUS and had heterozygous disease-associated deletions in the complement genes CFHR1/CFHR3. She had progressive kidney failure and severe extra-renal manifestations including cardiomyopathy and haemorrhagic cystitis; as well as pulmonary, gastrointestinal and neurological involvement. The initial kidney biopsy revealed thrombotic microangiopathy (TMA) changes involving all glomeruli. Clinical improvement was initially seen during eculizumab initiation with suppressed CH50 level, but a new rhinovirus/enterovirus upper respiratory tract infection triggered further severe multi-organ disease activity. The extra-renal manifestations stabilised, then ultimately improved after a period of eculizumab dose intensification. However, the impact on dose intensification on this improvement is unclear. Despite the extra-renal clinical improvement, she ultimately progressed to end-stage kidney disease (ESKD), commencing peritoneal dialysis for three years before undergoing a successful uncomplicated cadaveric kidney transplant without prophylactic eculizumab. Two years after transplant, she has excellent transplant graft function without any further disease recurrence.ConclusionsThis case highlights the concept of extra-renal manifestations in aHUS initially resistant to eculizumab, which potentially responded to dose intensification. Whilst organ injuries are potentially reversible with timely targeted treatment, it appears that the kidneys are most vulnerable to injury.

Donör yaşının alıcı greft fonksiyonu üzerine etkisi

Purpose: End-stage renal disease (ESRD) is a highly morbid and mortal condition. Renal transplantation is the most favorable and preferred solution of this disease. Age is an important factor that can effects the success of transplantation. In this study, we investigated the effect of donor age on the outcomes of kidney transplantation.&#x0D; Materials And Methods: 101 ESRD patients who underwent live or cadaveric kidney transplantation were included and analyzed retrospectively in this study. We reviewed age, sex and body mass index (BMI) of the donors and age, sex, BMI, length of stay, estimated glomerular filtration rate (eGFR) and serum creatinine measurements of the recipients were recorded. Recipient serum creatinine levels were recorded at intervals up to 18 months after transplantation. &#x0D; Results: Donors were divided into 3 groups according to age (50 years (n:34). There was no statistically significant difference between the groups in terms of donor's gender, BMI, living/cadaveric ratio, and recipient's gender, age, and BMI (p&gt;0,05). Length of hospital stay of recipients whose donor

Beneficial outcomes of glucagon like peptide-1 agonist therapy in a patient with Bardet Biedl syndrome and kidney transplant

Abstract Introduction Bardet Biedl syndrome (BBS) is a rare hereditary disorder characterized by early-onset obesity, metabolic syndrome, type 2 diabetes, hypogonadism, polydactyly and renal failure. There is lack of data on the use of glucagon-like peptide-1 receptor agonist (GLP-1RA) for management of patients with BBS and kidney transplant. Herein, we report our findings on body weight, graft kidney function and metabolic parameters in a patient with BBS and kidney transplant. Clinical Case A 35-year-old man with BBS was referred to our clinic for morbid obesity, diabetes and dyslipidemia. He also had retinitis pigmentosa, acanthosis nigricans, hypertension and hypogonadotropic hypogonadism, but no polydactyly. Due to polycystic kidney disease, the patient underwent cadaveric kidney transplantation ten years ago. He quickly gained weight after starting glucocorticoids following the kidney transplant. Current medical treatment consisted of metformin 1000 mg BID, testosterone 250 mg injection every three weeks, amlodipine 5 mg daily, mycophenolate mofetil 500 mg BID, and cyclosporin 25 mg BID. His body mass index (BMI) was 45 kg/m2, body fat percentage was 41%, waist and hip circumferences were 120 and 125 cm, respectively. On laboratory examination, his fasting plasma glucose and glycated hemoglobin (HbA1c) levels were 140 mg/dL and 7.8%, respectively. A low-density lipoprotein level of 178 mg/dL, a high-density lipoprotein level of 45 mg/dL, and a triglyceride level of 200 mg/dL were found in the lipid profile. His serum creatinine and estimated glomerular filtration rate (eGFR) were 1.9 mg/dL and 66.3 mL/min/1.73 m2, respectively. The initial treatment strategy was lifestyle changes and dietary management which did not result in significant weight loss after 6 months. Following a thorough discussion on medical treatment options with the patient, exenatide was started considering obesity, diabetes and patient preference for affordability. Initial dose of 5 mcg BID was gradually titrated up to 10 mcg BID, with frequent monitoring of his kidney function tests. Over a 6-month period, exenatide treatment resulted in significant weight loss, with a reduction in BMI to 40 kg/m2, body fat percentage to 35%, waist and hip circumferences to 114 and 120 cm, respectively. HbA1c decreased from 7.8% to 6.2%, and eGFR increased from 66.3% to 84.2%. His hypertension, dyslipidemia, and urinary protein: creatinine ratio also significantly improved. He has maintained his weight and glycemic control during further follow up of 10 months. Conclusion Weight management in BBS could be challenging, and kidney transplantation may make it even more difficult. Here we show that GLP-1RA use results in significant weight loss along with improvements in glycemic control, metabolic parameters, and renal function in a patient with BBS and kidney transplant. More data are needed to confirm long term efficacy and safety of GLP-1RA in these patients.

PS-R05-7: MALIGNANT PHASE OF HYPERTENSION IN A PATIENT ON PERITONEAL DIALYSIS

Background: Posterior reversible encephalopathy syndrome (PRES) describes a disorder of abrupt onset neurological symptoms due to potentially reversible lesions on brain imaging. Case reports of PRES in PD patients are scarce. Case presentation: A 42-year-old male presented to the emergency department (ED) with two weeks of worsening occipital headaches, nausea, vomiting and dizziness. The patient had a background of end-stage renal disease due to primary focal segmental glomerulosclerosis, and resistant hypertension. He had been receiving peritoneal dialysis (PD) for one month; hypertension was treated with torasemide 100 mg/day, perindopril 10 mg/day, amlodipine 10 mg/day, moxonidine 0.6 mg/day, doxazosin 8–16 mg/day. One week earlier, he was brought into ED due to hypertensive crisis (blood pressure (BP) was 190/120 mmHg); intravenous labetolol 20 mg, oral moxonidine 0.4 mg, doxazosin 8 mg were administered; afterwards he was released for outpatient treatment. On admission, BP was 187/114 mmHg, heart rate - 75 beats/minute, oxygen saturation - 98% on room air, and body temperature - 36.5°C. Laboratory tests revealed severe renal dysfunction (serum creatinine: 1478 mcmol/l, serum urea: 29.1 mmol/l) and normal inflammatory indicators (WBC: 4.51 x 109/l, CRP: 0.65 mg/l) (Table). Head CT showed no obvious intracranial hemorrhage, ischemia, or mass lesion; PRES was suspected. Due to hypervolemia, he was temporarily transferred to hemodialysis. On day 12, fundoscopy revealed flame-shaped hemorrhages, microaneurysms, cotton wool patches in the posterior pole surrounding the optic nerve. On day 14, he was transferred to the intensive care unit (ICU) due to uncontrollable hypertension (BP was 202/129 mmHg) and epileptic seizure; MRI showed bilateral subcortical occipital and frontoparietal hyperintensity with vasogenic edema typical of PRES. BP was decreased to approximately 155/90 mmHg using a combination of anti-hypertensive medication and ultrafiltration. Subsequently he was discharged on day 28. Two months later he underwent cadaveric kidney transplantation. After the transplantation, his BP control improved and he was left with bisoprolol 5 mg/day, amlodipine 10 mg/day, and doxazosine 4 mg/day (office BP one month after the transplantation: 124/90 mmHg, after two months: 135/95 mmHg, after three months: 135/95 mmHg). Conclusions: This is to the best of our knowledge the fifth report of PRES in an adult patient undergoing PD, and the first presenting a PD patient with history of PRES whose hypertension control improved after kidney transplantation. It is likely that the cause of described PRES episode was multifactorial, originating from the complications of ESRD, hypertension and poor compliance with PD.