Care Of Renal Transplant Recipients Research Articles

The Health and Economic Impact of Cervical Cancer Screening and Human Papillomavirus Vaccination in Kidney Transplant Recipients

The risk of cervical cancer in women who are kidney transplant recipients is increased, but little is known about the effectiveness of screening and human papillomavirus (HPV) vaccination in this group of women. We sought to determine the cost effectiveness of annual screening for cervical cancers using conventional cytology, liquid-based cytology (LBC), and pretransplant HPV vaccination in kidney transplant recipients. Three deterministic Markov models were developed to compare the costs and health outcomes in a cohort of women (n=1000) with kidney transplants aged 18 to 69 who underwent annual screening using conventional cytology, LBC, and HPV vaccination in HPV naïve women. After a screening period of 50 years, the incremental benefits of screening using conventional cytology compared with no screening were 0.05 life years saved (LYS) (18.2 days of lives saved), the incremental costs were $608, giving an incremental cost-effectiveness ratio of $12,160 per LYS. Compared with conventional cytology alone, the incremental cost-effectiveness ratios of annual screening using LBC and HPV vaccination before transplantation (assuming nonwaning efficacy) were $127,000 and $152,333 per LYS, respectively. The recommended policy of annual screening using conventional cytology is cost effective. The replacement of conventional cytology with LBC is likely to provide minimal survival benefits but considerable costs. Assuming the reported trial-based vaccine efficacy in HPV naïve women, a program of HPV vaccination before kidney transplantation is unlikely to be cost effective. Additional data about the long-term efficacy and safety of HPV vaccination is required before it should be included as standard care of renal transplant recipients.

Association of CCR5-59029 A/G and CCR2-V64I variants with renal allograft survival.

Despite advances in the medical care of renal transplant recipients which have led to an improvement in allograft survival, renal allograft rejection is still a major obstacle to successful organ transplantation. Understanding the mechanisms contributing to allograft rejection will be of great importance for the development of efficient antirejection strategies. The aim of current investigation was to study the impact of polymorphisms of CCR5Delta32, CCR5- 59029 A/G and CCR2-V64I on renal allograft survival. Using PCR and PCR-RFLP methods in 84 renal transplant recipients, the influence of CCR5Delta32, CCR5- 59029 A/G and CCR2-V64I polymorphisms on renal allograft survival in two rejector and non-rejector groups were examined. Rejector group was defined as having rejection before 1 year and non-rejector group had stable graft function at least for 5 years. Significant reductions were found in the risk of renal transplant rejection in recipients possessing the CCR2-64I (A) allele (p=0.03) or 59029-A allele (p=0.03) compared to non-rejector group. There were no significant differences in the frequency of CCR5Delta32 polymorphism in rejector group compared to non-rejector group (p>0.05). It was possible to conclude that the chemokine receptors CCR2-V64I (A) and CCR5- 59029 A alleles may influence renal allograft survival.

Cardiovascular Complications After Renal Transplantation and Their Prevention

By the time of renal transplantation, end-stage renal disease patients have a huge burden of cardiovascular disease (CVD) and are heavily saturated with atherosclerotic risk factors. Worsening of preexisting risk factors or new CVD risk factors may develop in the posttransplant period consequent in part to the diabetogenic and atherogenic potential of immunosuppressive drugs. The annual risk of a fatal or non-fatal CVD event of 3.5 to 5% in kidney transplant recipients is 50-fold higher than the general population. Renal allograft dysfunction, proteinuria, anemia, moderate hyperhomocysteinemia and elevated serum C-reactive protein concentrations, each dependently confer greater risk of CVD morbidity and mortality in the posttransplant period. Long-term care of renal transplant recipients should programmatically incorporate the recommendations of the National Kidney Foundation Working Groups and European Best Practice Guidelines Expert Group on Renal Transplantations into the management of hypertension, dyslipidemia, smoking, and posttransplant diabetes mellitus. Timely utilization of coronary revascularization procedures should be undertaken as these treatments are equally effective in the kidney transplant population.

Estimating Glomerular Filtration Rate in Kidney Transplantation

Accurate measurement of GFR is critical for the evaluation of new therapies and the care of renal transplant recipients. Although not accurate in renal transplantation, GFR is often estimated using creatinine-based equations. Cystatin C is a marker of GFR that seems to be more accurate than creatinine. Equations to predict GFR based on the serum cystatin C concentration have been developed, but their accuracy in transplantation is unknown. GFR was estimated using four equations (Filler, Le Bricon, Larsson, and Hoek) that are based on serum cystatin C and seven equations that are based on serum creatinine in 117 adult renal transplant recipients. GFR was measured using radiolabeled diethylenetriaminepentaacetic acid (99mTc-DTPA), and the bias, precision, and accuracy of each equation were determined. The mean (99m)Tc-DTPA GFR was 58 +/- 23 ml/min per 1.73 m(2). The cystatin C-based equations of Filler and Le Bricon had the lowest bias (-1.7 and -3.8 ml/min per 1.73 m2), greatest precision (11.4 and 11.8 ml/min per 1.73 m2), and highest accuracy (87 and 89% within 30% of measured GFR, respectively). The cystatin C equations remained accurate even when the measured GFR was >60 ml/min per 1.73 m2. The creatinine-based equations were not as accurate, with only 53 to 80% of estimates within 30% of measured GFR. Cystatin C-based equations are more accurate at predicting GFR in renal transplant recipients than traditional creatinine-based equations. Further prospective studies with repetitive measurement of cystatin C are needed to determine whether cystatin C-based estimates of GFR will be sufficiently accurate to monitor long-term allograft function.

Renal-Transplant Recipients and Sun Protection

The incidence of skin carcinomas in organ-transplant recipients is high. The main factors implicated in carcinogenesis are immune suppression and ultraviolet radiation. Only the second is avoidable. We have evaluated knowledge of and compliance with sun protection measures among renal-transplant recipients (RTR). A survey by means of a questionnaire including questions about clinical data, knowledge of, and compliance with sun protection was given. The questionnaire was given to 520 consecutive RTR followed up in a single center, and 445 (86%) answered. Of the responders, 91% have been informed of the need for sun protection, in 80% of cases by dermatologists. Sixty-eight percent used more protective measures abroad than at home, 63% avoided going outside during the hottest midday hours, 63% used sunscreen regularly, but 46% used one or less tube of sunscreen a year. A hat was always worn in the sun by 35% and long sleeves by 36%. Women and fair-skinned individuals complied better with protective measures. A minority of patients knew that ultraviolet radiation carries a risk of skin cancer. This survey shows that most RTR are aware of the need for sun protection, but only a minority take adequate protection measures. The better results observed in this study than in previous published investigations may be caused by the great involvement of dermatologists in the care of RTR in our institution. The results of this survey underline the need to inform RTR better about sun-protection measures and the importance of cooperation between transplant physicians and dermatologists.

MYCOPHENOLATE MOFETIL BUT NOT THE TYPE OF CALCINEURIN INHIBITOR (CYCLOSPORINE VS TACROLIMUS) INFLUENCES THE INTRAGRAFT MRNA EXPRESSION OF CYTOKINES IN HUMAN KIDNEY ALLOGRAFT BIOPSIES BY IN SITU RT-PCR ANALYSIS.

P992 Aims: The aim of the study was to assess the molecular background of anti-allograft response by the detection of low-abundance mRNA of cytokines. Methods: Our analysis included 56 renal needle core biopsies from kidney transplant recipients who received their grafts from cadaveric donors. Biopsies were performed in case of graft dysfunction and were assessed on the basis of histopathological evaluation using Banff classification. Recipients were immunosuppressed with one of calcineurin inhibitors (CNI): cyclosporine (CsA) or tacrolimus (TAC) + prednisone + azathioprine or mycopnenolate mofetil (MMF). Tubular and glomerular expression of IL-2, IL-6, IL-10, IFN-γ, TGF-β1 and PDGF-B mRNA were assessed using semiquantitative evaluation of the RT-PCR in situ. The principle was to perform RT-PCR amplification of target mRNA in situ on paraffine tissue sections. Following the amplification DNA copies were hybridized with digoxigenin-labelled nucleotides. This procedure resulted in a light microscopy visualization of granular precipitates at the sites of investigated mRNA chains. Cytokine mRNA expression was quantified by calculating the mean number of positive points per area unit in all glomeruli and 30 randomly chosen tubules by two independent investigators, blinded to the status of the biopsy. Constitutive gene expression was examined in renal specimens obtained from living donor kidney biopsies taken during harvesting of the organ, before procurement. Results: We found that biopsies from patients treated with CNI + MMF were different from those treated with CNI + azathioprine. The tubular expressions of mRNA for IL-6 and TGF- β1 in biopsies with acute rejection (n=34) obtained from patients treated with MMF (n=12) were significantly lower than in biopsies obtained from patients treated with azathioprine (n=22) (p<0.02). Moreover 80% of the recipients in the MMF-treated group had serum creatinine levels less than 2 mg/dL one year after biopsy whereas in the azathioprine-treated group only 25% of the recipients had preserved renal function in the same time (p<0.05). There was no significant difference between the groups treated or not with corticosteroids. Conclusions: Our study did not confirmed previous thesis, that CsA and TAC differ in their ability to stimulate overproduction of TGF-β. The pattern of examined cytokines gene expression did not differ between patients under different CNI treatment. These results indicate strong inhibition of humoral response and downregulation of fibrosis in these recipients that may protect from the development of chronic rejection. Our results support the usefulness of MMF in the long-lasting care of renal transplant recipients.

The postanesthesia care of an adult renal transplant recipient

Renal transplantation is the most common type of solid organ transplant performed in this country. For the PACU nurse, the immediate postoperative care of a renal transplant recipient can present a very unique and interesting challenge. Like all patients arriving to the PACU, the initial assessment of an immediate postoperative renal transplant recipient should first address the routine postsurgical concerns of airway, respiration, and hemodynamics. Most renal transplant programs have set protocols for the care required during the immediate posttransplant stay in the PACU. The postanesthesia nurse caring for these patients must become knowledgeable of these protocols. The following is a review of the immediate postanesthesia care for both the “fresh” renal transplant and the care of the long-term renal transplant recipient who has had surgery. © 2003 by American Society of PeriAnesthesia Nurses.

Recommendations for the Outpatient Surveillance of Renal Transplant Recipients

Abstract. Many complications after renal transplantation can be prevented if they are detected early. Guidelines have been developed for the prevention of diseases in the general population, but there are no comprehensive guidelines for the prevention of diseases and complications after renal transplantation. Therefore, the Clinical Practice Guidelines Committee of the American Society of Transplantation developed these guidelines to help physicians and other health care workers provide optimal care for renal transplant recipients. The guidelines are also intended to indirectly help patients receive the access to care that they need to ensure long-term allograft survival, by attempting to systematically define what that care encompasses. The guidelines are applicable to all adult and pediatric renal transplant recipients, and they cover the outpatient screening for and prevention of diseases and complications that commonly occur after renal transplantation. They do not cover the diagnosis and treatment of diseases and complications after they become manifest, and they do not cover the pretransplant evaluation of renal transplant candidates. The guidelines are comprehensive, but they do not pretend to cover every aspect of care. As much as possible, the guidelines are evidence-based, and each recommendation has been given a subjective grade to indicate the strength of evidence that supports the recommendation. It is hoped that these guidelines will provide a framework for additional discussion and research that will improve the care of renal transplant recipients.

Assignment1 of the human PHLDA1 gene to chromosome 12q15 by radiation hybrid mapping

Many complications after renal transplantation can be prevented if they are detected early. Guidelines have been developed for the prevention of diseases in the general population, but there are no comprehensive guidelines for the prevention of diseases and complications after renal transplantation. Therefore, the Clinical Practice Guidelines Committee of the American Society of Transplantation developed these guidelines to help physicians and other health care workers provide optimal care for renal transplant recipients. The guidelines are also intended to indirectly help patients receive the access to care that they need to ensure long-term allograft survival, by attempting to systematically define what that care encompasses. The guidelines are applicable to all adult and pediatric renal transplant recipients, and they cover the outpatient screening for and prevention of diseases and complications that commonly occur after renal transplantation. They do not cover the diagnosis and treatment of diseases and complications after they become manifest, and they do not cover the pretransplant evaluation of renal transplant candidates. The guidelines are comprehensive, but they do not pretend to cover every aspect of care. As much as possible, the guidelines are evidence-based, and each recommendation has been given a subjective grade to indicate the strength of evidence that supports the recommendation. It is hoped that these guidelines will provide a framework for additional discussion and research that will improve the care of renal transplant recipients.

Early Posttransplant Care of Renal Transplant Recipients

Seminars in DialysisVolume 12, Issue 5 p. 320-328 Early Posttransplant Care of Renal Transplant Recipients V. ram Peddi, V. ram Peddi Division of Nephrology and Hypertension, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OhioSearch for more papers by this authorM. roy First, M. roy First Division of Nephrology and Hypertension, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OhioSearch for more papers by this author V. ram Peddi, V. ram Peddi Division of Nephrology and Hypertension, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OhioSearch for more papers by this authorM. roy First, M. roy First Division of Nephrology and Hypertension, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OhioSearch for more papers by this author First published: 05 January 2002 https://doi.org/10.1046/j.1525-139X.1999.99049.x Address correspondence to: V. Ram Peddi, MD, Assistant Professor of Medicine, Division of Nephrology and Hypertension, Department of Internal Medicine, PO Box 670585, University of Cincinnati College of Medicine, Cincinnati, OH 45267–0585. E-mail: ram.peddi@uc.edu. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Volume12, Issue5October/November 1999Pages 320-328 RelatedInformation

Incidence and long-term cost of steroid-related side effects after renal transplantation.

Corticosteroids are an essential component of most immunosuppressive regimens currently used in renal transplantation because of their efficacy in reducing acute rejection and improving graft survival. Steroids, however, are associated with numerous side effects that lead to increased patient morbidity and mortality. The incidence and economic cost of steroid-related side effects have not been quantitatively assessed. Thus, based on a systematic review of the published literature, we estimated the incidence of steroid-related hypertension (15%), posttransplantation diabetes mellitus (10%), peripheral fractures (2% per year), avascular necrosis of the hip (8%), and cataracts (22%). In addition, we estimated that approximately 5% of patients who have cataracts or avascular necrosis of the hip require surgery. We used these literature-based estimates in a model to project the costs of treating side effects over a 10-year posttransplantation time frame for a 50-patient cohort that represented an average-sized renal transplant center. Steroid-induced hypertension and its complications were the most expensive side effect ($93,900), followed closely by posttransplantation diabetes ($89,700) and avascular necrosis of the hip ($61,700). Cataracts and peripheral bone fractures were less costly ($16,300 and $4,300, respectively). The cumulative projected 10-year cost of all side effects for the 50-patient cohort was $265, 900, or $5,300 per transplant patient. Steroid-related side effects add to the long-term cost of medical care of renal transplant recipients. These costs provide a rationale for further investigation of steroid-sparing immunosuppression protocols.

International standardization of criteria for the histologic diagnosis of renal allograft rejection: The Banff working classification of kidney transplant pathology

A group of renal pathologists, nephrologists, and transplant surgeons met in Banff, Canada on August 2-4, 1991 to develop a schema for international standardization of nomenclature and criteria for the histologic diagnosis of renal allograft rejection. Development continued after the meeting and the schema was validated by the circulation of sets of slides for scoring by participant pathologists. In this schema intimal arteritis and tubulitis are the principal lesions indicative of acute rejection. Glomerular, interstitial, tubular, and vascular lesions of acute rejection and "chronic rejection" are defined and scored 0 to 3+, to produce an acute and/or chronic numerical coding for each biopsy. Arteriolar hyalinosis (an indication of cyclosporine toxicity) is also scored. Principal diagnostic categories, which can be used with or without the quantitative coding, are: (1) normal, (2) hyperacute rejection, (3) borderline changes, (4) acute rejection (grade I to III), (5) chronic allograft nephropathy ("chronic rejection") (grade I to III), and (6) other. The goal is to devise a schema in which a given biopsy grading would imply a prognosis for a therapeutic response or long-term function. While the clinical implications must be proven through further studies, the development of a standardized schema is a critical first step. This standardized classification should promote international uniformity in reporting of renal allograft pathology, facilitate the performance of multicenter trials of new therapies in renal transplantation, and ultimately lead to improvement in the management and care of renal transplant recipients.