Kidney-pancreas Transplant Patients Research Articles

Does obesity really affect renal transplantation outcomes?

IntroductionKidney transplantation is the treatment of choice for patients with stage 5 chronic kidney disease (CKD). About 60% of CKD patients are overweight or obese at the time of kidney transplantation, and post-transplant obesity occurs in 50% of patients, with a weight gain of 10% in the first year and high risk of cardiovascular mortality. Obesity is associated with an increased risk of delayed graft function (DGF), acute rejection, surgical complications, graft loss and mortality. The aim of this study is to assess the clinical evolution of obese and overweight patients that have received a kidney transplant, based on short- and long-term complications associated with a higher BMI. Material and methodsA descriptive, observational, cross-sectional study was conducted with 104 kidney or pancreas-kidney transplant patients between March 2017 and December 2020, with a follow-up until April 2021. For comparative analysis, patients were grouped according to BMI. ResultsMean age was of 56.65 years, 60.6% male and 39.4 % female. Overweight patients experienced prolonged surgeries, more surgical wound dehiscence, delayed graft function, hernias, proteinuria and more indications for renal biopsies. Additionally, obese patients displayed more DGF, indications for renal biopsies, proteinuria, development of diabetes mellitus, atrial fibrillation and needed prolonged hospital stays. ConclusionsDespite a high prevalence of comorbidity in the overweight and/or obese population, we found no reduction in patient and/or graft survival. However, longer follow-up is needed.

Evaluación del impacto de la obesidad en los resultados del trasplante renal

IntroductionKidney transplantation is the treatment of choice for patients with stage 5 chronic kidney disease (CKD). About 60% of CKD patients are overweight or obese at the time of kidney transplantation, and post-transplant obesity occurs in 50% of patients, with a weight gain of 10% in the first year and high risk of cardiovascular mortality. Obesity is associated with an increased risk of delayed graft function (DGF), acute rejection, surgical complications, graft loss and mortality. The aim of this study is to assess the clinical evolution of obese and overweight patients that have received a kidney transplant, based on short- and long-term complications associated with a higher BMI. Material and methodsA descriptive, observational, cross-sectional study was conducted with 104 kidney or pancreas-kidney transplant patients between March 2017 and December 2020, with a follow-up until April 2021. For comparative analysis, patients were grouped according to BMI. ResultsMean age was of 56.65 years, 60.6% male and 39.4% female. Overweight patients experienced prolonged surgeries, more surgical wound dehiscence, delayed graft function, hernias, proteinuria and more indications for renal biopsies. Additionally, obese patients displayed more DGF, indications for renal biopsies, proteinuria, development of diabetes mellitus, atrial fibrillation and needed prolonged hospital stays. ConclusionsDespite a high prevalence of comorbidity in the overweight and/or obese population, we found no reduction in patient and/or graft survival. However, longer follow-up is needed.

Ulcerated, tender nodules of the lower extremities

Ulcerated, tender nodules of the lower extremities

Single center results of simultaneous pancreas-kidney transplantation in patients with type 2 diabetes

Studies have found similar outcomes of Simultaneous Pancreas-Kidney transplantation (SPKT) in patients with Type 2 (T2D) and Type 1 diabetes (T1D). However, there are scarce data evaluating the association of recipient factors such as age, BMI, or pretransplant insulin requirements with outcomes, thus the criteria for the optimal recipient selection remains unclear. In this study, 284 T1D and 39 T2D patients, who underwent SPKT between 2006 and 2017 with 1year of follow-up at minimum, were assessed for potential relationship of pretransplant BMI and insulin requirements with posttransplant diabetes and pancreatic graft failure. Kaplan-Meier analysis showed similar rates of freedom from posttransplant diabetes (94.7% T2D vs. 92.3% T1D at 1yr, and 88.1% T2D vs. 81.1% T1D at 5yrs) and graft survival (89.7% T2D vs. 90.4% T1D at 1yr, and 89.7% T2D vs. 81.2% T1D at 5yrs). There was no significant association between BMI or pretransplant insulin requirements with posttransplant diabetes occurrence in either T1D (p=.10, .43, respectively) or T2D (p=.12, .63) patients in the cohort; or with graft failure (T1D: p=.40, .09; T2D: p=.71, .28). These observations suggest a less restricted approach to selective use of SPKT in patients with T2D.

Risk factors for intra-abdominal fungal infection after simultaneous pancreas-kidney transplantation: A single-center retrospective experience.

Data on the risk factors and outcome of intra-abdominal fungal infections (IAFI) following simultaneous pancreas-kidney transplantation (PKT) are scarce. A retrospective monocentric study was conducted on all patients who underwent simultaneous PKT from January 2007 to December 2016. Deep sites positive cultures for fungi during the first post-transplantation year were collected. Clinical, radiological, and microbiological data of proven and probable invasive fungal infections were analysed. Among sixteen PKT patients, 15 were included. Seven patients (47%) developed an invasive fungal infection, exclusively IAFI (six proven, one probable). The proven IAFI included four peritonitis, one pancreatic necrosis with infected hematoma, and one patient with positive preservation fluid only (PF). Candida albicans (n=4) was the most prevalent species (associated with Galactomyces candidus in one case), C glabrata, C dubliniensis, and C krusei were found in one case each. Three patients had either a positive direct examination and/or culture for renal or pancreatic PF and the culture of PF was positive for the same species that caused IAFI. IAFIs were significantly associated with pancreatic graft arterial thrombosis (5/7 vs 0/8, P=.007) and fungal contamination of PF (3/7 vs 0/8, P=.008). Among patients with IAFI, all required an early surgical revision post-transplantation [1-18days] and six had early or delayed pancreatic graft removal. One patient died in the first post-transplant year. IAFI is a common complication in PKT, associated with pancreatic graft thrombosis or fungal contamination of the graft PF, and can sometimes lead to pancreatic detransplantation.

First case of Cryptococcus gattii multilobar pneumonia in Switzerland and associated challenges

Cryptococcosis is a frequent complication in immunosuppressed patients, causing mainly central nervous system and lung infection, and leading to increased mortality risk. We present the first documented case in Switzerland of Cryptococcus gattii pneumonia in a kidney-pancreas transplant patient, with a concomitant Pneumocystis jirovecii infection mimicking an immune reconstitution syndrome. Diagnosis of cryptococcal pneumonia was based on a positive serum cryptococcal antigen and confirmed by Grocott’s methenamine silver and periodic acid-Schiff stains on bronchoalveolar lavage fliud. C. gattii was identified with mass spectrometry and antifungal susceptibility testing by microdilution was performed. After an initial successful treatment with liposomal amphotericin-B, flucytosine and tapering of immunosuppression, the patient clinically deteriorated, developing bilateral diffuse ground-glass opacities with consolidations on chest computed tomography. A diagnosis of probable P. jirovecii pneumonia versus an immune reconstitution syndrome was considered. Because of a high titre of Pneumocystis on polymerase chain-reaction testing of bronchoalveloar lavage fluid and high serum b-D-glucan, a diagnosis of probable P. jirovecii pneumonia was made. This case illustrates the potential complications of a cryptococcal infection in immunosuppressed hosts, despite timely diagnosis and appropriate antifungal therapy.

Survival Analysis After Kidney-Pancreas and Kidney Transplant in Argentina

Objective To assess survival after kidney-pancreas and kidney transplantation (Tx) using monorgan donors (P- Donor) and with pancreas retrieval (P+ Donor), in patients over the age of 18 in Argentina. Material and Methods The information about both kidney and kidney-pancreas transplant patients was obtained from SINTRA, or the period June 1, 1998 - December 31, 2015. Results 2303 patients were assessed, 58%were males.They received a kidney from a P+ donor, and 606 (26%) received a kidney-pancreas transplant. The median age of the kidney-pancreas recipients was 36.9, and 49.3 for P-, and 42.9 for P+ recipients. KP (kidney pancreas) donors had an average BMI of 23.7 < than kidney donors, whose values were 25.4 for P+ D, and 26.7 for P- D. 92% of the KP recipients had 0% PRA, whereas kidney transplant recipients were 90% for P+ D, and 91% for P-D. Patient survival at one year per group was as follows: 95% P+, 92%P- and 88% KP;and at five years 90% P+,83% P-y 76% KP. Overall survival for kidney grafts was 95% at 30 days; 88% at one year, and 70% at five years. Cox regression analysis for patient survival showed that recipient´s age >35evidenced a HR of 1.84 (CI 95% 1.34-2.52) p=<0.0001. The multivariate analysis showed that KP recipients had a HR of 2.7 (CI 95%1.48-4.93) as compared to kidney recipients, P+ and HR was 2.64 (CI 95%1.79-3.89) as compared to kidney recipients,P-. Recipient´s age >35 and a donor´s BMI >25 were associated with <patient´s survival, which was statistically significant; RP vs renal P+ y RP vs renal P-. When comparing KP transplant patients with kidney recipients, P-, more than 4 years on dialysis at the time of transplant was a risk factor with an HR of 1.43 (CI 95% 1.03-1.98). In the univariate analysis in kidney graft survival, donor´s BMI>25, CI time longer than 24 hours, CVA as the cause of death were unfavorable variables. Conclusions Although the variables related to both donor and recipient in kidney pancreas transplant show a more favorable scenario, patient´s survival in this groupis the lowest compared to other groups. This might be due to the presence of more comorbidity variables at the time of dialysis initiation and diabetes mellitus as the cause of kidney failure.

Long-term results of protocol kidney biopsy directing steroid withdrawal in simultaneous pancreas-kidney transplant patients.

We sought to determine whether protocol biopsies could be used to guide treatment and improve outcomes in simultaneous pancreas-kidney (SPK) patients. Between 2004 and 2013, protocol biopsies were performed on SPK patients at 3-6 months and one year post-transplant. Maintenance immunosuppression consisted of a calcineurin inhibitor, anti-proliferative agent, and corticosteroid. Corticosteroid was withdrawn in negative early biopsies, maintained in subclinical/ borderline biopsies, and increased if Banff IB or greater rejection was identified. Endpoints included presence of interstitial fibrosis and tubular atrophy on biopsy at one year (IF/TA), rejection episodes, and renal and pancreas function at five years' followup. Forty-one SPK transplant patients were reviewed and a total of 75 protocol biopsies were identified. On early biopsy, 51% had negative biopsies, 44% had borderline rejection, and 5% had subclinical rejection. Renal and pancreas function were not significantly different at one, two, and five years post-transplant between negative vs. borderline early biopsy patients. No difference in the degree of IF/TA was found between these two groups. To our knowledge, this is the first study to evaluate protocol biopsies as an investigative tool prior to steroid withdrawal in SPK patients. Our study suggests that there are no detrimental functional or histological effects at five years post-transplant, despite weaning steroids in the negative biopsy group.

Intractable ascites associated with mycophenolate in a simultaneous kidney-pancreas transplant patient: a case report

BackgroundMycophenolic acid (MPA), either given as an ester pro-drug or as an enteric-coated sodium salt, is the most commonly prescribed anti-proliferative immunosuppressive agent used following organ transplantation and widely applied in immune-mediated diseases. Clinicians are well aware of common adverse reactions related to MPA treatment, in particular diarrhea, leukopenia and infections. Here we report a case of severe, persistent ascites associated with MPA treatment. The otherwise unexplained and intractable ascites, requiring repeated paracenteses for more than 8 months, rapidly ceased with stopping the MPA treatment. To our knowledge this is the first case of severe ascites associated with MPA treatment reported in the scientific literature.Case PresentationA 45-year old female with type 1 diabetes mellitus received a simultaneous kidney-pancreas transplant. The surgery was uneventful. However, post-operatively she developed severe transudative ascites requiring in total more than 40 paracenteses treatments draining in the average 2.8 l of ascites fluid. The ascites formation persisted despite exclusion of a surgical complication, fully functioning kidney and pancreas allografts, lack of any significant proteinuria, normalization of circulating albumin levels, intensive use of diuretics and deliberate attempts to increase the intervals between the paracentesis treatments. Various differential diagnoses, including infectious, hepatic, vascular and cardiac causes were ruled out. Nine months after surgery enteric-coated mycophenolate sodium was switched to azathioprine after which ascites completely resolved. When mycophenolate was recommenced abdominal fullness and weight gain reoccurred. The patient had to be switched to long-term azathioprine treatment. More than 1 year post-conversion the patient remains free of ascites.ConclusionMPA is the most widely used antimetabolite immunosuppressive agent. We suggest to consider MPA treatment in the differential diagnosis of severe and unexplained ascites in transplant and non-transplant patients.

The Effect of Corticosteroid Withdrawal on Glucose Metabolism and Anti-GAD Antibodies in Simultaneous Pancreas-Kidney Transplant Patients.

Corticosteroid withdrawal may reduce insulin resistance; however, it could also influence pancreatic autoantibody profile in simultaneous pancreas-kidney (SPK) transplant patients. To evaluate the effect of corticosteroid withdrawal on glucose metabolism and anti-glutamic acid decarboxylase (GAD) antibody titers in SPK patients with type 1 diabetes after 12 months of follow-up. In this retrospective study, fasting glucose and glycated hemoglobin (A1c) were compared before and after 3, 6, and 12 months of corticosteroid withdrawal in 80 SPK patients. In addition, weight, anti-GAD, and C-peptide levels were compared before and after withdrawal. Finally, fasting and postglucose, insulin, and C-peptide levels were compared before and after withdrawal in 25 patients undergoing oral glucose tolerance test (OGTT). Fasting glucose levels did not change during corticosteroid discontinuation. After 12 months, A1c slightly increased from 4.6% (0.4%) to 4.8% (0.6%) (P < .01) and C-peptide decreased from 2.8 (1.1) ng/mL to 2.4 (1.3) ng/mL (P <. 01). In patients submitted to OGTT, glucose, insulin, and C-peptide levels did not change. There was no alteration in the proportion of anti-GAD positive tests (41% vs 45%). Anti-GAD titers remained stable or decreased in 70% of positive patients. Corticosteroid withdrawal has no significant effect on glucose metabolism and on anti-GAD profile among SPK patients.

Dosing of Enteric-Coated Mycophenolate Sodium Under Routine Conditions: An Observational, Multicenter Study in Kidney Transplantation.

BACKGROUND Dosing of enteric-coated mycophenolate sodium (EC-MPS) should be adjusted to reflect concomitant immunosuppression, but it is largely undocumented whether such modifications are carried out during routine clinical practice. MATERIAL AND METHODS MyLIFE was an observational study of adult kidney-only or kidney-pancreas transplant patients starting -EC-MPS at 33 French transplant centers. Data were collected at first EC-MPS dose and 6 months later. The primary objective was to describe initial EC-MPS dosing according to concomitant immunosuppression. RESULTS There were 461 patients analyzed (174 started EC-MPS by month 1 post-transplant ['de novo'] and 287 started EC-MPS >1 month post-transplant ['maintenance']), receiving cyclosporine (CsA) (n=76), tacrolimus (n=363), or a mammalian target of rapamycin (mTOR) inhibitor (n=22). Mean (SD) starting dose was 1130 (511) mg/day, 1006 (441) mg/day, and 769 (300) mg/day in the CsA, tacrolimus, and mTOR inhibitor groups, respectively (p=0.003). In the de novo subpopulation, the starting dose was 1440 mg/day in 66.7% (14/21) of CsA-treated patients and 71.9% (110/153) of tacrolimus-treated patients, with an intensified dose of 2160 mg/day in 28.6% (6/21) and 8.5% (13/153), respectively. There was a non-significant trend to a higher rate of biopsy-proven acute rejection in patients receiving CsA versus tacrolimus or an mTOR inhibitor (p=0.082). Adverse events with a suspected relation to EC-MPS occurred in 21.0%, 23.1%, and 9.1% of the CsA, tacrolimus, and mTOR inhibitor subpopulations, respectively. CONCLUSIONS EC-MPS is usually initiated at the dose recommended for de novo CsA-treated kidney transplant patients, then titrated downwards as required. An early intensified regimen is not used frequently. The EC-MPS dose is modified in <20% of de novo patients to account for concomitant tacrolimus therapy instead of CsA administration.

Beta-Cell Replacement: Pancreas and Islet Cell Transplantation.

Pancreas and islet transplantation are 2 types of beta-cell replacement therapies for type 1 diabetes mellitus. Since 1966, when pancreas transplantation was first performed, it has evolved to become a highly efficient procedure with high success rates, thanks to advances in surgical technique and immunosuppression. Pancreas transplantation is mostly performed as simultaneous pancreas-kidney transplantation in patients with end-stage nephropathy secondary to diabetes. In spite of its efficiency, pancreas transplantation is still a major surgical procedure burdened by high morbidity, which called for the development of less invasive and hazardous ways of replacing beta-cell function in the past. Islet transplantation was developed in the 1970s as a minimally invasive procedure with initially poor outcomes. However, since the report of the 'Edmonton protocol' in 2000, the functional results of islet transplantation have substantially and constantly improved and are about to match those of whole pancreas transplantation. Islet transplantation is primarily performed alone in nonuremic patients with severe hypoglycemia. Both pancreas transplantation and islet transplantation are able to abolish hypoglycemia and to prevent or slow down the development of secondary complications of diabetes. Pancreas transplantation and islet transplantation should be seen as two complementary, rather than competing, therapeutic approaches for beta-cell replacement that are able to optimize organ donor use and patient care.

Health‐related quality of life may improve after transplantation in pancreas–kidney recipients

Pancreas-kidney transplantation (PKT) may significantly improve quality of life (HRQOL) in patients with type 1 diabetes. We have assessed the changes felt by PKT patients, using the Gastrointestinal Quality of Life Index (GIQLI) and EuroQol-5D questionnaires. Patients were asked to compare how their HRQOL had changed from pre-transplantation to the last visit. The 60 men and 66 women enrolled had a mean follow-up of five yr; 84.1% with both grafts, 15.9% with one graft functioning. In all domains of EuroQol-5D scores improved after PKT, as well as the visual analogue scale health state (from 38% to 84%, p < 0.001; effect size 3.34). In GIQLI, physical function was felt better after PKT than before (14.83 ± 3.86 vs. 7.86 ± 4.43, p < 0.001; effect size 1.68); the same was observed for psychological status, social function, and GI complaints. Concerning the burden of medical treatment, the score significantly improved (from 1.31 to 3.63, p < 0.001, effect size 2.02). The rate of unemployed patients decreased after PKT (from 50.8% to 36.5%, p < 0.001). Multivariate analysis showed that having only one functioning graft was associated with worse HRQOL scores (B = -5.157, p = 0.015). In conclusion, for all assessed domains, patients reported a significant improvement in HRQOL after PKT. Maintenance of the two grafts functioning predicted higher improvement of HRQOL scores.

A randomized, open label, crossover study examining impact of Prograf and Advagraf on mycophenolic acid pharmacokinetics in kidney pancreas transplant patients

A randomized, open label, crossover study examining impact of Prograf and Advagraf on mycophenolic acid pharmacokinetics in kidney pancreas transplant patients

Ischemia Reperfusion Injury in Human Kidney-Pancreas Transplantation: Protection By α-Lipoc Acid Require the Treatment of Both The Donor and The Recipient.

α-lipoic acid (ALA) is a potent antioxidant and is approved for treatment of diabetic sensorimotor polyneuropathy in some countries. Patients that received kidney-pancreas transplantation in order to ameliorate polyneuropathy, may be treated with ALA. We have previously observed that the administration of ALA to donors and recipients protects from IRI, by decreasing serum IL-8 and postoperative amylase and lipase values in blood. The aim of the present work was to determine if the administration of ALA only to the recipient would protect from IRI. The study included 24 kidney-pancreas transplant patients. They were divided in three groups: G1: without ALA treatment; G2: ALA (600 mg) was administered to the deceased donor at the time of ablation and, to the recipients during the surgical procedure; G3: ALA (600 mg) was administered only to the recipients immediately previous to the surgical procedure. Blood samples were obtained at the beginning of the surgery; at the end of surgery and after the unclamping procedure; 12 h after surgery; and every one or two day after the transplant. Human inflammatory cytokines (TNF-α, IL-1β, IL-10, IL-8, IL-6 and IL-12p79) and SLPI were measured by Cytometric Bead Array and sandwich ELISA, respectively. The measurements of serum amylase, lipase, glycemia and creatinine levels were performed as markers of organ rejection for at least 10 days post-surgery. An increased in IL-8 (p<0.01) and a decreased in SLPI was observed immediately after the surgery in group 1 (p=0.006) and group 3 (p=0.024). However, in group 2 we observed an increased in SLPI (p=0.009), while there was a mild but not statistically significant increased in IL-8. The analysis of measurement of serum lipase and amylase showed that the mean values of the group 2 were lower than group 1 and 3 (P < 0.001). Overall, these results demonstrate that lipoic acid is capable of reducing ischemia reperfusion injury in simultaneous kidney pancreas transplantation, as long as donor and recipient are treated with the drug. DISCLOSURES:Incardona, C.: Employee, GADOR.

Examination of Carbohydrate Metabolism Parameters After Simultaneous Pancreas-Kidney Transplantation

End-stage renal failure, a frequent complication of type 1 diabetes mellitus, requires renal replacement therapy. Our team examined the laboratory parameters of carbohydrate metabolism in 18 patients with type 1 diabetes at 10 to 89 months after simultaneous pancreas-kidney transplantation. We compared these results with those of 17 patients with type 1 diabetes who had formerly received kidney-alone transplantations, and were undergoing insulin treatment, as well as with those of 16 metabolically healthy controls. The hemoglobin A1c (HbA1c) and blood glucose levels of the pancreas-kidney transplant recipients were within the normal ranges, not differing significantly from those of the healthy controls. In contrast, the HbA1c and glucose levels were significantly elevated among kidney transplanted diabetic subjects. However, fasting and 2-hour insulin levels of pancreas-kidney transplant patients were significantly higher than those of the controls, indicating insulin resistance. According to these results, the insulin secretion by the pancreas graft sufficiently compensated for insulin resistance. Thus 10 to 89 months after successful pancreas-kidney transplantation, carbohydrate metabolism by type 1 diabetic patients was well controlled without antidiabetic therapy.

Excellent Outcomes of Simultaneous Pancreas Kidney Transplantation in Patients From Rural and Urban Australia

Simultaneous pancreas and kidney (SPK) transplantation is performed to restore normoglycemia and renal function in patients with type 1 diabetes mellitus and end-stage renal failure. The National Pancreas Transplant Unit (NPTU) in Sydney provides a service to a population spread across 7.4 million km. We aimed to see if SPK transplantation outcomes differed between recipients from metropolitan (M) centers and those from nonmetropolitan (NM) regions. Using a prospectively collected database, patient and graft survival were analyzed. Patients were categorized according to region of residence and by distance from the NPTU. Between January 2001 and May 2010, 165 patients underwent first-time SPK transplantation at the NPTU. There were 126 M and 39 NM recipients. Median distance from the NPTU was 732 km for donors (range, 0-3930 km) and 887 km for recipients (range, 1-4114 km). Median follow-up was 5.2 years (range, 1.1-10.3 years). Actuarial 5-year patient survival was 94% in M and 95% in NM groups. At 5 years, non-death-censored pancreas graft survival was 75% and 82% among M and NM patients, respectively, while kidney allograft survival was 88% in M and 92% in NM groups. There was no significant difference in patient and graft survival between groups. Distance of donor and recipient from the NPTU did not influence graft or patient survival. SPK transplantation can be performed with excellent outcomes at a national center with a vast catchment area, irrespective of donor or recipient location.

Role of Early Systemic Inflammatory Response in Simultaneous Pancreas-Kidney Transplantation

Pancreas grafts are susceptible to surgical complications mostly related to exocrine secretions and the low microcirculatory blood flow through the gland. During simultaneous kidney-pancreas transplantation, the systemic response depends on reperfusion of two organs acute graft pancreatitis, immunotherapy, coagulopathy, bleeding, and other factors. We performed a retrospective review of 10 adult simultaneous pancreas-kidney transplant patients to evaluate progression of early postoperative inflammation in the absence of infection. All patients were treated with four-drug therapy. We performed analyses of procalcitonin (PCT), C-reactive protein, serum creatinine, amylase, and lipase levels over the first 5 postoperative days.Relatively high peak PCT levels (maximum 130 ng/mL) were reached within 24 to 48 hours postoperatively followed by a moderate decrease. Consistent with this observation, the serum creatinine, amylase, and lipase levels decreased continuously to normal concentrations within the first week. The increased PCT levels seemed depend upon the surgical procedure and intraoperative events. PCT was superior to C-reactive protein to discriminate infection from inflammation in this setting. The dynamics of PCT levels, rather than absolute values, seemed to be important. Lack of a decrease in PCT levels after the peak, suggested an infectious complication or the development of sepsis. Monitoring and assessment of PCT levels may help in early recognition of infection and institution of therapy.

Kidney–pancreas transplantation

For patients with diabetes, insulin therapy can be an effective treatment for years. However, many diabetics eventually develop complications from the disease, including neuropathy, amputations, atherosclerosis, and kidney failure. While kidney failure can be managed with dialysis, difficulties with monitoring fluid intake and diet, bone loss, anemia, and venous access can be problematic for the patient. Due to the decreased life expectancy and difficulties of medical management of patients with diabetes and renal failure, combined renal-pancreas transplantation is an increasingly used option available to type 1 diabetics with concurrent renal failure due to refinements of surgical technique and immunosuppressive therapy. Due to the increasing number of kidney-pancreas transplant patients, longer post-transplant survival, and increasing number of hospitals performing the procedure, more transplant patients are having their care increasingly shifted away from the major transplant centers to general community hospitals. In many kidney-pancreas transplants patients who present to the emergency department for suspected transplant dysfunction, imaging plays a critical initial role in their diagnosis and management. Therefore, it has become increasingly important that community and emergency department radiologists be able to recognize the normal imaging appearance of renal-pancreas transplants and to identify acute findings.

Hepatitis E Virus and the Kidney in Solid-Organ Transplant Patients

Hepatitis E virus (HEV) infection is an emerging disease in industrialized countries. Few data regarding genotype 3 HEV extrahepatic manifestations exist. We assessed kidney function and histology in solid-organ transplant patients during HEV infection. In all, 51 cases of genotype 3 HEV infections were diagnosed (34 kidney, 14 liver, and 3 kidney-pancreas transplant patients). Of these, 43.2% were cleared of the virus spontaneously within 6 months of infection, whereas 56.8% evolved to chronic hepatitis. Twelve of these patients completed a 3-month antiviral therapy and were followed up for 6 months posttreatment. Kidney function (estimated glomerular filtration rate [eGFR] obtained by the Modification of Diet in Renal Disease equation) and proteinuria were assessed before infection, during HEV infection and during follow-up. Kidney biopsies were obtained from patients with high proteinuria and decreased eGFR levels. During HEV infection, there was a significant decrease in eGFR in both kidney- and liver-transplant patients. Glomerular diseases were observed in kidney biopsies obtained during the acute and chronic phases. This included membranoproliferative glomerulonephritis and relapses in IgA nephropathy. The majority of patients had cryoglobulinemia that became negative after HEV clearance. Kidney function improved and proteinuria decreased after HEV clearance. HEV-associated glomerulonephritis seems to be an HEV-related extrahepatic manifestation. Further studies are required to confirm these observations.