Incidence Of Acute Tubular Necrosis Research Articles

ODP130 Zoledronate-Induced Acute Tubular Necrosis With Baseline Normal Renal Function: A Rare Phenomenon

Abstract Introduction Zoledronate is an intravenous bisphosphonate that is commonly used to decrease bone resorption in patients with osteoporosis. The incidence of acute tubular necrosis (ATN) using zoledronate in patients with normal renal function is rare. Herein, we report the occurrence of severe ATN following treatment with a single zoledronate infusion in a patient with osteoporosis and normal renal function. Case Presentation A 51-year-old female with hypertension, well-controlled type 2 diabetes c/b gastroparesis without nephropathy(HbA1c6.8%), status-post hysterectomy, and bilateral oophorectomy, who was recently diagnosed with osteoporosis. Bone densitometry with Hologic revealed T scores of -2.8 at the spine and a T score of - 0.9 at the left hip. Her medications included lisinopril, metformin, and empagliflozin. Due to a history of gastroparesis, zoledronate was chosen as the preferred treatment. Pre-infusion blood work showed: a creatinine of 0.92 (0.5-1.1 mg/dl), 25-hydroxyvitamin-D 37.8 (30-100 NG/ml), calcium 8.9 (8.5-10.5mg/dl) and urine microalbumin 14 (<30 mg/g). Two days after the infusion, the patient developed emesis, diarrhea, oliguria, and fevers. She was evaluated in the emergency room and found to have acute renal failure (creatinine 10 mg/dL). She was given three liters of intravenous fluids with no improvement in urine output. Microscopic evaluation of spun urine revealed non-dysmorphic RBCs and numerous muddy brown granular casts consistent with ATN. Despite treatment with intravenous fluids, her creatinine did not improve and peaked on hospital days 11 to 11.65mg/dl. A 24-hour urine collection revealed proteinuria of 3 grams/24 hours. The patient was then empirically started on methylprednisolone 500mg for suspected glomerulonephritis. A renal biopsy was subsequently performed, which confirmed ATN. The patient's creatinine improved steadily to 5.49mg/dl by discharge. A subsequent creatinine one-month post-discharge was 1.36mg/dL. Discussion Zoledronate is widely used at low doses in the treatment of osteoporosis. ATN due to zoledronate infusion has been described in patients with pre-existing renal dysfunction and those receiving large and frequent doses for malignancy but rarely reported with the lower doses used to treat patients with osteoporosis and normal renal function. Zoledronate is believed to cause ATN by internalization in the renal tubular cells via the process of fluid-phase endocytosis. The intracellular accumulation of zoledronate may act as an epithelial toxin inducing tubular cytotoxicity. Interestingly, our patient had normal renal function without diabetic nephropathy and did not use nephrotoxic medications prior to the infusion. Conclusion We report a case of severe ATN due to a single dose of zoledronate in a patient with osteoporosis and previously normal renal function. This case highlights the need to be aware of the potential nephrotoxicity of zoledronate even in patients with normal renal function at baseline. Presentation: No date and time listed

Results of anastomosis of accessory lower polar graft artery to internal iliac artery in renal transplantation

Background: Our objective is to perform a renal graft transplant using multiple arteries where the lower polar artery will indeed be anastomosed to the internal iliac artery end to side following declamping the main arterial supply in terms of ischemia time, diuresis, graft perfusion, and postoperative clinical parameters and investigations. Methods: Fifty live donors underwent vascular anastomosis of the graft auxiliary lower polar artery to recipient internal iliac artery end to side anastomosis with various renal arteries bilaterally, including lower polar artery in chosen kidney. The recipients' intraoperative warm and total ischemia periods, as well as their postoperative incidence of acute tubular necrosis, were assessed (ATN). Diuresis, urinary output, and creatinine levels at 1, 3, and 5 days after surgery, as well as at 2 months afterwards. MRI and Doppler ultrasonography, if necessary. Results: In contrast to warm, the mean total ischemia time was 20.86 minutes. Low incidence of ATN (8%) was controlled and postoperative recovery went without a hitch. Regarding postoperative urine output and serum creatinine level monitoring, clinical and laboratory indicators were satisfactory. Depending on the assessment method, colour Doppler ultrasonography reveals well perfused transplanted grafts with a satisfactory peak systolic velocity ratio in the auxiliary graft artery.

Gambaran Histopatologi Ginjal Mencit (Mus musculus Balb/C) yang Diinfeksi dengan Plasmodium berghei

Background: P. berghei is a parasite that causes malaria in small rodents. This parasite is analogous to P. falciparum which causes severe malaria in humans with the highest risk of death compared to 4 other plasmodium species. Complications of falciparum malaria in renal microcirculation is AKI (Acute Kidney Injury). AKI is preceded by the incidence of ATN (Acute Tubular Necrosis) and MPGN (Mesangioproliferative Glomerulonephritis) with ATN being the highest prevalence.
 Objective: This study aims to determine the histopathological appearance of renal tubules of white mice Mus musculus Balb/C which are infected with P. berghei.
 Methods: Descriptive analysis method with quantitative approach is used in this study. The study was conducted at the Anatomical Pathology Laboratory of the Faculty of Medicine, Andalas University. The study was conducted since February to October 2020. The sample size was determined by the Federer formula (2008).
 Results: Percentage of renal tubular cell damage which were 8.42% for the control group, 4.52% for the pellet extract group, and 2.74% for supernatant extract group.
 Conclusion: The study concluded that highest percentage of kidney tubular cell damage was found in the kidney of mice immunization with the control group, and the lowest percentage of kidney tubular cell damage was found in the kidney of mice immunization with supernatant extract.

ASIAN PACIFIC SOCIETY OF NEPHROLOGY CLINICAL PRACTICE GUIDELINE ON DIABETIC KIDNEY DISEASE.

ASIAN PACIFIC SOCIETY OF NEPHROLOGY CLINICAL PRACTICE GUIDELINE ON DIABETIC KIDNEY DISEASE.

Identification of Factors Associated With Acute Tubular Necrosis Following Kidney Transplant in Northern Mexico: Increased Risk With Cold Ischemia After 8 Hours

AimTo identify potential risk factors associated with the incidence of acute tubular necrosis (ATN) following kidney transplant in a sample of patients from northern Mexico. MethodsSecondary analysis of data extracted from clinical files of patients who underwent a kidney transplant between 2000 and 2017 at Christus Muguerza Hospital in the city of Chihuahua. The final sample with complete data included 485 patients. ATN was diagnosed in 13.2% of patients using pathologic, clinical, and laboratory criteria. Adjusted odds ratio (ORs) with 95% CIs from multivariate binary logistic regression were used to identify predictors of ATN. ResultsOnly 4 of 21 variables analyzed remained statistically significant in the final adjusted model. Cold and warm ischemia followed time-trend patterns with higher odds with longer ischemia times. For cold ischemia, compared with 0 to 240 minutes, ORs were 1.32 (95% CI, 0.49-3.51) for 241-480 minutes, 4.87 (95% CI, 2.29-10.3) for 481-960 minutes, and 10.0 (95% CI, 2.86-35.0) for > 960 minutes; for warm ischemia, compared with 40 to 59 minutes, these were 6.27 (95% CI, 1.95-20.8) for 60-70 minutes and 10.32 (95% CI, 1.95-54.4) for 71-110 minutes. Hypotension during surgery was associated with a higher chance of ATN (OR, 15.9; 95% CI, 4.97-50.9). When the recipients’ age was 30 years or older, the probability also increased significantly (OR, 2.88; 95% CI, 1.09-7.57). The final model fitted well and explained 27% of the probability to develop ATN after a kidney transplant. ConclusionShortening the duration of ischemia and avoiding hypotension during surgery is essential to prevent ATN following a kidney transplant.

Which One Is the Best for Living Donation: A Multiple-Artery Left Kidney Nephrectomy or a Right Kidney Nephrectomy?

IntroductionThe current approach in living-donor kidney transplant is to preserve the best kidney for the donor and harvest the contralateral one. Due to a shorter renal vein and a greater incidence of venous thrombosis, left kidneys are more frequently elected. Notwithstanding, arterial anatomy may be complex and thus render the transplantation procedure more difficult and prone to complications. ObjectivesTo analyze the outcomes after multiple-artery left kidney nephrectomy (MALKN) and right kidney nephrectomy (RKN). ResultsSeventy-three cases were performed from 1999 to 2017 in our institution: 34 MALKN and 39 RKN. The mean operative time was significantly longer in MALKN. Warm ischemia time, donor and receptor hospital stay, and postoperative complications did not differ between groups.There was a positive correlation between renal arteries' ostia distance in MALKN and the duration of warm ischemia period.There was no significant difference in the incidence of acute tubular necrosis, first-year variations in serum creatinine, and glomerular filtration rate between groups. Long-term graft survival did not significantly differ between groups. Three cases of vein thrombosis after RKN were reported with graft loss. ConclusionThe safety and efficacy of MALKN does not differ from RKN, although there appears to be a higher incidence of vein thrombosis after right kidney transplantation. Despite being technically more demanding, particularly in cases with distant artery ostia, MALKN could be a better option than RKN for living donation, expanding the available donor pool, although more studies are needed to affirm this conclusion.

Effects of pre and post-treatments with dipyridamole in gentamicin-induced acute nephrotoxicity in the rat

This study investigated the pretreatment and post-treatment effects of dipyridamole (20 mg/kg/day, p.o.) in gentamicin-induced acute nephrotoxicity in rats. Rats were administered gentamicin (100 mg/kg/day, i.p.) for 8 days. Gentamicin-administered rats exhibited renal structural and functional changes as assessed in terms of a significant increase in serum creatinine and urea and kidney weight to body weight ratio as compared to normal rats. Renal histopathological studies revealed a marked incidence of acute tubular necrosis in gentamicin-administered rats. These renal structural and functional abnormalities in gentamicin-administered rats were accompanied with elevated serum uric acid level, and renal inflammation as assessed in terms of decrease in interleukin-10 levels. Dipyridamole pretreatment in gentamicin-administered rats afforded a noticeable renoprotection by markedly preventing renal structural and functional abnormalities, renal inflammation and serum uric acid elevation. On the other hand, dipyridamole post-treatment did not significantly prevent uric acid elevation and renal inflammation, and resulted in comparatively less protection on renal function although it markedly reduced the incidence of tubular necrosis. In conclusion, uric acid elevation and renal inflammation could play key roles in gentamicin-nephrotoxicity. Dipyridamole pretreatment markedly prevented gentamicin-induced acute nephrotoxicity, while its post-treatment resulted in comparatively less renal functional protection.

15. Trends of primary diagnoses in renal biopsies

Many renal diseases can be diagnosed relatively safely and defini-tively by renal biopsies. This study investigates diagnoses made from renal biopsies on the Pacific Laboratory Medicine Services (PaLMS) database, the pathology provider for the Northern Sydney Area Health Service, comparing all reports from 2000 and 2010–11. A retrospective analysis of the renal biopsy reports was performed, and a principle diagnosis obtained from each. Diagnoses were then also classified into glomerular, tubulointerstitial, systemic and ‘other' categories. The majority of diagnoses from both time periods were of the glomerular category (41%). Within the glomerular category, IgA nephropathy was the most common principle diagnosis (14.1%). The tubulointerstitial disease category consisted mainly of acute tubular necrosis (12.3%). Chronic hypertension, SLE and diabetic nephropathy were the most common diagnoses in the systemic category (4–7%). The ‘other' category included renal transplant rejection (7.4%) and chronic kidney disease NOS (4.9%). The findings were largely consistent with other renal biopsy studies both from Australia and overseas. Although overall the patterns of diagnoses remained largely unchanged, between 2000 and 2010/11 there was an increase in the relative incidence of acute tubular necrosis possibly due to increased numbers of transplant biopsies, and a relative decrease of IgA nephropathy possibly due to an increase in clinical threshold before biopsy.

Embolization of a Failed Renal Allograft Is Associated with Higher Allosensitization and Worse Graft Outcome in Subsequent Kidney Transplants

Introduction: Despite the significant improvement achieved in patient and kidney allograft survival nowadays, an important number of patients return to dialysis showing increased allosensitization and worse graft and patient outcome after receiving a second kidney allograft as compared to the first transplant. Whether removal of the failed allograft by selective embolization or transplant nephrectomy directly influences on allosensitization and subsequent graft outcome is still poorly known. Methods: Herein, in a case control study, we evaluated 62 kidney transplant patients from 2000 to 2010; 31 patients undergoing selective embolization for cause of the failed first allograft (group 1) were compared to 31 patients preserving the first failed organ (group 2). We compared the percentages of panel reactive antibody (PRA) between both groups at baseline (before any transplant), after failure of the first transplant as well as after allograft embolization. Moreover, main clinical outcome when receiving a subsequent second kidney allograft between both groups was also analyzed in a 5-year of mean follow-up. Results: Baseline allosensitization was comparable between both groups (PRA>25%: 6.5%± and 4.8%± for groups 1 and 2, respectively). After failure of the first transplant, patients maintaining the failed organ showed significantly higher allosensitization than patients before undergoing selective embolization (PRA>25%: 25.4%± and 8.5%±, respectively; p=0.029). After allograft embolization, patients showed a significant increased in % of PRA levels than before(19.2% to 46.2%, p=0.09). No differences were found between groups regarding incidence of acute tubular necrosis (ATN), acute rejection (AR) or other main clinical variables. Noteworthy, patients maintaining the failed renal allograft displayed a significantly better graft function evolution at 5 years than patients undergoing selective transplant embolization (eGFR=51,91ml/min and 41.5 ml/min, respectively; p=0.09) Conclusion: Preservation of previous renal failed allografts seems to prevent enhance peripheral allosensitization thus, favouring a better allograft outcome in a subsequent renal transplantation. Our data emphasizes the importance of an accurate immunosuppression management after a failed kidney transplant in order to prevent transplant embolization for cause.

Does Kidney Transplantation with Multiple Arteries Affect Graft Survival?

Introduction We compared short- and long-term outcomes of renal transplants with single versus multiple arteries. Patients and methods We retrospectively analyzed data from kidney transplants from 208 living donors performed between 1994 and 2010. Renal grafts were divided into two groups: single renal artery ( n = 164) versus multiple renal arteries ( n = 44). The groups were compared regarding early and late vascular and urological complications. Patient and graft survivals were compared using Kaplan-Meier survivorship curves with comparisons using the log-rank test. Results Both groups were comparable regarding acute rejection episodes, posttransplant hypertension, postsurgery renal artery stenosis, and urologic complications. Only hemorrhagic complications and renal artery thrombosis were significantly higher in the multiple renal arteries group ( P = .027 and .03, respectively). Warm ischemia time was significantly longer in the multiple renal arteries group without any influence on the incidence of acute tubular necrosis ( P = .2). Mean creatinine clearance at 1 year was 65 versus 50 mL/min/1.73 m 2 ( P = .5) and at 5 years, 60 versus 55 mL/min/1.73 m 2 ( P = .1) for the single versus multiple renal arteries groups, respectively. Return to hemodialysis was necessary for 18.8% of the single and 16.1% of the multiple renal arteries group. Conclusion The use of an allograft with multiple renal arteries is a safe, successful surgical procedure, that does not influence patient or graft survivals or increase surgical complication rates provided the surgical team is evolved with technical skill.

Primary Nonfunction of Renal Allograft Secondary to Acute Oxalate Nephropathy

Primary nonfunction (PNF) accounts for 0.6 to 8% of renal allograft failure, and the focus on causes of PNF has changed from rejection to other causes. Calcium oxalate (CaOx) deposition is common in early allograft biopsies, and it contributes in moderate intensity to higher incidence of acute tubular necrosis and poor graft survival. A-49-year old male with ESRD secondary to polycystic kidney disease underwent extended criteria donor kidney transplantation. Posttransplant, patient developed delayed graft function (DGF), and the biopsy showed moderately intense CaOx deposition that persisted on subsequent biopsies for 16 weeks, eventually resulting in PNF. The serum oxalate level was 3 times more than normal at 85 μmol/L (normal <27 μmol/L). Allograft nephrectomy showed massive aggregates of CaOx crystal deposition in renal collecting system. In conclusion, acute oxalate nephropathy should be considered in the differential diagnosis of DGF since optimal management could change the outcome of the allograft.

The Outcomes of Living Donor Renal Transplants With Multiple Renal Arteries: A Large Cohort Study With a Mean Follow-Up Period of 10 Years

Background Living donor kidney transplants with multiple arteries are presumed to be associated with an increased risk of complications. Objectives The aim of the study was to compare the outcomes in living donor transplantation with the specific intention of comparing long-term outcomes in which the donor kidney had 1 or more renal arteries. The study was undertaken in 2 large transplant centers. Methods A retrospective analysis of 201 living donor kidney transplants with multiple arteries that were performed between January 1985 and December 2004 was undertaken. We recorded patient and graft survivals, urological and vascular complications. Kaplan-Meier survival estimates were calculated, and 2-tailed Student t-test was used to compare outcomes. P < .05 was considered statistically significant. Results Graft and patient survival at 1 year were 93% and 97% and at 5 years were 87% and 92%. The most common complications were vascular (8.9%), followed by urological (6%), acute tubular necrosis (5.5%), and posttransplant hypertension (4.0%). There was significantly higher incidence of acute tubular necrosis (ATN) in multiple-artery transplants. Conclusion In this large cohort of patients studied, apart from a higher incidence of ATN and vascular complications, it appears that the number of renal arteries did not have any adverse impact on the outcomes. The findings from this study suggest that live donor kidneys with multiple renal arteries can be safely utilized for renal transplantation.

Low-Dose Dopamine in Kidney Transplantation

Background The use of low-dose dopamine (LDD; 0.5–2.5 μg/kg/min) in kidney transplant recipients seeks to increase urine output, prevent arterial vasospasm, and reduce the incidence of acute tubular necrosis. The aim of this study was to evaluate the effect of LDD in the early postoperative period (12 hours) among kidney transplant recipients. Methods We studied all kidney transplant recipients admitted to the Intensive Care Unit (ICU) in the early postoperative period from January 2004 to December 2008. A total of 105 patients were retrospectively assigned to two groups: group A (n = 57) was treated with LDD and group B (n = 48), not treated with LDD. All patients otherwise received the same therapy. Blood sample analysis and kidney function were recorded at 0, 6, and 12 hours after admission. For each patient, we collected the following data: donor and transplant kidney features, recipient demographics, intraoperative events, hemodynamic and kidney function parameters in the ICU, and outcomes. Patients were followed for 6 months after ICU discharge. Results Hourly diuresis and kidney function parameters showed no significant difference between the groups. Significant differences between group A and group B were observed in heart rate (92.63 ± 14.18 vs 82.87 ± 13.5, respectively), hours of ICU length of stay (29.0 ± 17.42 vs 20.43 ± 7.35, respectively), and 6-month mortality rate (8.8% vs 0%, respectively; P < .05). Conclusion LDD prescription in kidney transplantation neither improved kidney function during the postoperative period nor short-term outcomes, but was associated with an increased heart rate, ICU length of stay and 6-month mortality.

Effect of Overweight on Kidney Transplantation Outcome

Introduction Obesity is a prevalent problem in renal transplant recipients that is followed by reduced graft and patient survivals. Because the prevalence of overweight (OW) is increasing in the renal transplant population, we studied the influence of OW on graft and recipient evolution. Patients and methods We analyzed a series of 337 patients with renal allografts having a mean follow-up of 53.4 ± 30.6 months. We excluded 39 patients obese at transplantation. We compared the evolution of 134 OW patients (45.5%), and 160 patients (54.4%) with a body mass index <25 (NW group). Results OW patients were older ( P = .000) with a higher prevalence of hypertension ( P = .028), left ventricular hypertrophy ( P = .014), and dyslipidemia ( P = .001). They had received kidneys from older donors ( P = .019). OW patients showed a higher incidence of acute tubular necrosis (ATN) ( P = .006), without a higher incidence of acute rejection episodes ( P = .756). Postransplant diabetes mellitus was more frequent ( P = .000), and systolic blood pressure ( P < .05), total cholesterol ( P < .05), and tryglicerides were higher ( P < .05) in the OW group. Serum creatinine at 6 months ( P = .007) and proteinuria >0.5 g/24 hours, ( P = .023) were higher among the OW group. Graft survival was not different between groups, but patient survival was lower in the OW group ( P = .002). A logistic regression analysis showed that the recipient age (RR: 5.243) and the presence of OW (RR: 1.100) were independent prognostic factors for patient death. Conclusions OW was a common situation among renal transplant candidates. It was associated with worse cardiovascular and metabolic profiles. OW patients showed worse allograft function and lower patient survival. A major effort must be exerted to avoid excessive weight gain, particularly among those OW at transplantation.

Management and Outcome of Living Kidney Grafts with Multiple Arteries

Kidney allografts with multiple renal arteries (MRAs) have been used with increasing frequency since the advent of laparoscopic live donor nephrectomy. To determine if MRA grafts affect the short- and long-term outcomes of grafts and patients, we analyzed 340 grafts procured by open nephrectomy. We divided the graft recipients into five groups according to the methods used for vascular reconstruction. We compared patient and graft survival, serum creatinine levels, total (rewarm) ischemic times (TIT), incidence of acute tubular necrosis (ATN), need for antihypertensive drugs, incidence of acute rejection episodes, and vascular and urologic complications, between the MRA group and a control group of patients with single-artery renal grafts. In patients who underwent multiple anastomoses in situ, prolonged TIT resulted in an increased incidence of ATN, but there was no significant difference between the MRA groups and the control group (P = 0.45). The incidence of vascular complications was higher in the MRA groups (P < 0.01), but there were no significant differences in the other variables among the groups. Multiple renal artery grafts procured by open nephrectomy can be transplanted as successfully as those with single arteries, by using meticulous suturing techniques.

Use of different immunosuppressive strategies in recipients of kidneys from nonheart-beating donors

In nonheart-beating donor (NHBD) kidney transplants, immunosuppressive management is difficult mainly because of the high incidence of acute tubular necrosis. This has meant that since the start of our NHBD transplant program, several immunosuppression regimes have been used. The aim of this retrospective study was to evaluate the results obtained over 7 years using different treatment protocols. A total of 172 consecutive NHBD transplants performed between April 1996 and December 2002 were treated as follows: G-I (n = 21), cyclosporine (8 mg/kg/day) plus azathioprine plus steroids; G-II (n = 65), low-dose cyclosporine (5 mg/kg/day) plus mycophenolate plus steroids; G-III (n =17), low-dose tacrolimus (0.1 mg/kg/day) plus mycophenolate plus steroids; and G-IV (n = 69), daclizumab plus low-dose tacrolimus plus mycophenolate plus steroids. Delayed graft function rates were 76.2%, 72.3%, 76.5%, and 42%, respectively, for the four groups (P = 0.000). Rejection-free patient rates were 76.2%, 46.2%, 35.3%, and 71% (P < 0.001). Vascular rejection rates were 19%, 30.8%, 52.9%, and 18.8%, (P = 0.025). Two-year graft survival was 71.4% in group I, 95.4% in group II, 94.1 in group III, and 93.8% in group IV (P =0.004). Patient survival was worse in group I (75.2% in group I, 100% in group II, 100% in group III, and 96.7% in group IV at 2 years; P < 0.001). The use of daclizumab and low-dose tacrolimus could be effective at lowering the incidence of delayed graft function in NHBDT, with no negative repercussions on acute rejection.

Fluid Management in Kidney Transplantation: Central Venous Pressure Guided vs Esophageal Doppler Monitoring

Background: Maximizing renal blood flow during reperfusion of the transplanted kidney could be the key factor to prevent acute tubular necrosis (ATN). To achieve such a goal, augmentation of circulating blood volume is necessary. We evaluated stroke volume monitored or CVP guided volume expansion method and, which method would be better for the outcome. Methods: Forty three patients (Group I) of 79 patients received maximum hydration guided by CVP maintaining 12-15 mmHg, other 36 patients (Group II) received fluid to achieve maximum SV using esophageal doppler monitor. All patients received albumin (maximal dose 1,145 ml in Group I and 2,981 936.4 ml in Group II. Incidence of ATN (Group I; 9.3% and Group II; 8.3%), tests for renal function were not statistically significant in both Group, but two patients in Group I was administered in intensive care unit (ICU). Conclusions: Lesser fluid was administered in the Group used with SV augmentation than conventional CVP guided group and there was no difference in the incidence of ATN between two group. In kidney transplantation, esophageal doppler monitoring may be better in fluid management than CVP monitoring.

GRAFT FUNCTION AFTER KIDNEY TRANSPLANTATION FROM NON-HEARTBEATING DONORS ACCORDING TO MAASTRICHT CATEGORY

Donor shortages have led to some groups using alternative sources such as non-heartbeating donors (NHBDs). Kidneys from NHBDs suffer from warm ischemia at cardiac arrest which is reflected by acute tubular necrosis of the allograft, resulting in a period of delayed graft function. NHBDs are categorized by the circumstances surrounding the agonal events of death which reflect differences in the likelihood of ischemic injury to the kidney. In this study we determined the impact of ischemic injury on the renal function of kidneys procured from different categories of NHBDs. From 1998 to 2003, 144 kidneys were procured from 72 NHBDs resulting in 93 transplants characterized into Maastricht categories II, III and IV NHBD renal transplants. Renal function after transplant was evaluated from the last dialysis until discharge from hospital, and then at 3 monthly intervals thereafter. Primary warm ischemic time is more prolonged in the uncontrolled donor (category II) than controlled donor (category III greater than IV). Delayed graft function occurs more frequently (Maastricht category II 83.8%, III 67.4% and IV 0%, ANOVA p <0.05) and the return to normal function is more prolonged in uncontrolled donors. This is illustrated by the greater incidence of acute tubular necrosis (Maastricht category II 81.1%, III 65.2% and IV 50.0%, ANOVA p = nonsignificant) in the kidney allograft. There was no difference in year 1 allograft survival (Maastricht category II 83.9%, III 92.5% and IV 100%, ANOVA p = nonsignificant). Early graft function is poorest in kidneys derived from Maastricht category II donors and best in category IV with III in-between. However, after 3 months the function of kidneys from all donors is the same.

Outcomes after renal transplantation for FSGS in children.

Focal segmental glomerulosclerosis (FSGS) is the primary diagnosis resulting in end-stage renal disease in approximately 12% of children receiving renal transplantation. Recurrent FSGS after transplantation is unpredictable and clear risk factors have not been identified. Post-transplantation, the incidence of acute tubular necrosis requiring dialysis is higher in children with FSGS compared with other diagnoses and may represent immediate severe recurrence. Graft survival is decreased in children with FSGS compared with other primary diagnoses, and the impact is greatest in recipients of living donor transplants. Graft loss caused by recurrent FSGS is significantly higher in living donor transplants compared with cadaveric donor transplants in children. Compared with adults, the impact of FSGS on graft survival appears to be greatest in children. White recipient race is associated with a higher risk of graft loss from recurrent FSGS. Efforts to elucidate the mechanisms of recurrent FSGS and to understand risk factors based on genetics, potential circulating cytokines and permeability factors, age and race must move forward before we can significantly impact outcomes in renal transplantation for FSGS.

PLASMAPHERESIS IMPROVES OUTCOMES OF HIGHLY SENSITIZED RENAL ALLOGRAFT RECIPIENTS

P337 Aims: The presence of preformed anti-HLA antibodies as demonstrated by high panel reactive antibody (PRA) screen is a well recognized risk factor for increased acute humoral and cellular rejection after transplant. We previously reported the effect of perioperative removal of preformed antibodies by plasmapheresis on the outcome of highly sensitized recipients of kidney transplants. We now present longer follow up in a greater number of patients treated with this protocol. Methods: Since Jan 2000, 20 patients with a high PRA underwent renal transplantation after a minimum of 1 preoperative plasmapheresis. Plasmapheresis was done with a 1.0 volume plasma exchange using 5% human albumin. Post-transplant, an additional 3 plasma exchanges were done (range 1-4) all concluding by POD #7. Nadir, 6 month, current creatinine, incidence of acute tubular necrosis (ATN), incidence of acute cellular rejection (AR) and acute humoral rejection (AHR), graft survival, and patient survival were analyzed. Patients were treated with a high-risk immunosuppression protocol that included tacrolimus, steroids, and thymoglobulin. All rejection episodes were biopsy proven. Results: The study group consisted of 7 African American patients, 10 Hispanic, and 3 Caucasians. Average peak PRA was 82% (range 5-100) and average PRA at time of transplant was 60% (0-100). At current follow-up (mean of 22 months, range 4-41 months) the patient survival is 100%. Graft survival at 1 year was 100%. One graft was lost to non-compliance at 24 months, and another one to CR at 27 months. The incidence of AR at one year was 10% (2/20). We did not document any instance of acute humoral rejection. The average creatinine in patients with a functioning graft (n=18) is 1.31 mg/dL. Conclusion: Perioperative plasmapheresis decreases the risk of acute cellular and humoral rejection in highly sensitized renal transplant recipients. The routine application of this strategy has allowed us to obtain in this high risk group graft survival and rejection rates comparable to un-sensitized patients.