Management Of Kidney Transplant Patients Research Articles

Longitudinal non-targeted metabolomic profiling of urine samples for monitoring of kidney transplantation patients

The assessment of kidney function within the first year following transplantation is crucial for predicting long-term graft survival. This study aimed to develop a robust and accurate model using metabolite profiles to predict early long-term outcomes in patient groups at the highest risk of early graft loss. A group of 61 kidney transplant recipients underwent thorough monitoring during a one-year follow-up period, which included a one-week hospital stay and follow-up assessments at three and six months. Based on their 12-month follow-up serum creatinine levels: Group 2 had levels exceeding 1.5 mg/dl, while Group 1 had levels below 1.5 mg/dl. Metabolites were detected by mass spectrometer and first pre-processed. Univariate and multivariate statistical analyses were employed to identify significant differences between the two groups. Nineteen metabolites were found to differ significantly in the 1st week, and seventeen metabolites in the 3rd month (adjusted p-value < 0.05, quality control (QC) < 30, a fold change (FC) > 1.1 or a FC < 0.91, Variable Influence on Projection (VIP) > 1). However, no significant differences were observed in the 6th month. These distinctive metabolites mainly belonged to lipid, fatty acid, and amino acid categories. Ten models were constructed using a backward conditional approach, with the best performance seen in model 5 for Group 2 at the 1st-week mark (AUC 0.900) and model 3 at the 3rd-month mark (AUC 0.924). In conclusion, the models developed in the early stages may offer potential benefits in the management of kidney transplant patients.

Discrepancy Analysis between Histology and Molecular Diagnoses in Kidney Allograft Biopsies: A Single-Center Experience.

Histology diagnosis is essential for the monitoring and management of kidney transplant patients. Nowadays, the accuracy and reproducibility of histology have been criticized when compared with molecular microscopy diagnostic system (MMDx). Our cohort included 95 renal allograft biopsies with both histology and molecular diagnoses. Discrepancies between histology and molecular diagnosis were assessed for each biopsy. Among the 95 kidney allograft biopsies, a total of 6 cases (6%) showed clear (n = 4) or borderline (n = 2) discrepancies between histology and molecular diagnoses. Four out of the six (67%) were cases with pathologically and clinically confirmed active infections that were diagnosed as mild to moderate T-cell-mediated rejection (TCMR) with MMDx. Two cases showed pathological changes that were not sufficient to make a definitive diagnosis of active rejection via histology, while MMDx results showed antibody-mediated rejection (ABMR). In addition, there were six cases with recurrent or de novo glomerular diseases diagnosed only via histology. All other biopsy results were in an agreement. Our results indicate that histology diagnosis of kidney allograft biopsy is superior to molecular diagnosis in the setting of infections and glomerular diseases; however, MMDx can provide helpful information to confirm the diagnosis of active ABMR.

#5940 CLINICAL UTILITY OF GENETIC TESTING IN A KIDNEY TRANSPLANT CLINIC

Abstract Background and Aims Inherited kidney disease (IKD) is one of the leading causes of end-stage of kidney disease. Genetic diagnosis plays an important role in the counseling and management of kidney transplant patients or those on the waiting list, as it makes it possible to identify the cause of CKD, help in the selection of living donors, carry out genetic counseling and find out the prognosis around the graft survival and the risk of recurrence of the primary disease. The objective of the following study is to analyze the prevalence of IKD in our kidney transplant population and those on the waiting list, the phenotypic characteristics, genetic findings, and the diagnostic reclassification performed after the genetic study. Method This retrospective study has incluyed all genetic test (by next-generation sequencing (NGS) until 529 genes associated with kidney disease) performance between January 2018 and January 2023 in kidney transplant patients or on the waiting list for kidney transplant at Doctor Peset Hospital, using a multidisciplinary team approach. The patients were considered for genomic evaluation if they met one of the inclusion criteria: CKD of unknown etiology, family history of CKD, glomerular disease or chronic tubulo–interstitial disease with no recognized cause, suspicion of aHUS, CKD and other extrarenal syndromic signs or with renal malformations or nephrocalcinosis. Demographic data, family burden and screening, CKD phenotype, urinary anormalities, hypertension, diabetes, results of genetic test, were analyzed. Results We performed genetic testing in 76 patients (43,4% women; 88% Caucasian). Median age at time of kidney failure was 37 years (range: 17–77), 62% of patients had a positive family history of CKD and 29% presented extrarenal manifestations. The majority were male patients (56.6%) and Caucasian patients (88.2%). Most patients presented with an original clinical diagnosis glomerular disease 52,6% (FSGS lesion on biopsy (8/27) and non-diagnostic histology (10/27)), followed by ciliopathy (13%), aHUS (10.5%), and chronic kidney disease of unknown cause (6.6%), tubulointerstitial nephritis (6.6%), and with congenital anomalies (6.6%). In 46 patients had a genetic diagnosis defined as finding a pathogenic or likely pathogenic gene variant that explained the patient's kidney disease. With majority being COL4 variants (26.3%), followed by autosomal dominant polycystic kidney disease (ADPKD) (10.5%), podocytopathy and autosomal dominant tubulointerstitial kidney diseases. There were confirmed within a clinical diagnostic in 28% (above all ADPKD) and resulted in reclassification of the clinical diagnosis in 33% (above all COL4-related nephropathy) and there are more frequently a negative result if clinical diagnosis was unknown etiology, congenital anomalies o aHUS until 60%. With this data, 78% of the patients could have avoided a biopsy and 50% a immunossuppresive treatment with the diagnosis by genetic test. A genetic cause was identified by family screening in 16 families comprising 19 patients. A genetic diagnosis were more likely to have a family history of kidney disease (47,4% versus 14,5%, P &amp;lt; 0.001). There was otherwise no statistically significant difference in any other clinical characteristic (age at onset of kidney disease, age at kidney failure, race, hypertension, diabetes, hematuria, renal cyst or stone). Conclusion Our study demonstrates the clinical utility of genetic study in kidney transplants with unknown etiology or glomerulonephritis or chronic tubule-interstitial disease with no recognized cause or with positive family history of kidney disease, getting a genetic diagnosis until 60%, with a reclassification of the clinical diagnosis in a one-third. A genetic diagnosis is necessary to evaluate to kidney transplant recipients, to identify the etiology of CKD, to perform a genetic counseling and to improve patient management and prognosis.

Robot-assisted ureteral reconstruction for the management of kidney transplant patients with ureteric complications

Robot-assisted ureteral reconstruction for the management of kidney transplant patients with ureteric complications

Effect of allopurinol drug use on GFR and proteinuria in patients with renal transplant recipients (ADOPTR study)

BackgroundHyperuricemia has been associated with the development of hypertension, cardiovascular, and renal disease. However, there is no data about the effect of lowering uric acid level on renal functions and proteinuria in renal transplant recipients. This study aimed to investigate the effect of allopurinol treatment on renal functions in renal transplant recipients (RTR). MethodsA total of 245 patients with renal transplantation were included in this randomized, placebo-controlled study. Patients were randomized to receive either placebo (121 patients) or 300 mg/day allopurinol (124 patients). We have examined uric acid, urinary protein creatinin ratio, MDRD (the modification of diet in renal diseases) and CRP (C-reactive protein) before and 24 weeks after treatment in both group. ResultsIn the allopurinol group, the mean serum uric acid levels, eGFR (estimated glomerular filtration rate), and creatinine urinary albumin creatinin ratio (UACR) significantly improved (p < 0.001). Also uric acid level was positively correlated with the UACR (r = 0,645 p < 0.001) and negatively correlated with MDRD (r = −0,387 p < 0.05) in allopurinol treatment group. A statistically significant increase in CRP level was observed (p < 0,05) in plasebo group. Multivariate regression analysis showed that uric acid was positively correlated with UACR (r = 0,473, β = 0.021, p = 0.002) and negatively correlated with MDRD (r = −0554 β = 0.016, P = 0.001) in allopurinol treatment RTR. ConclusionUrate, a salt of uric acid, is lowered by allopurinol treatment resulting in improved eGFR and decreased proteinuria, when compared to the placebo group. Therefore, we suggest that allopurinol therapy should be part of the management of kidney transplant patients with normal kidney function. Long-term follow-up studies will be useful in revealing the effect of uric acid management on kidney functions and proteinuria.

Coronavirus-19 infection in kidney transplant recipients: A comprehensive review.

The COVID-19 pandemic has disrupted health care across the globe. Since the beginning of the pandemic, there have been substantial changes in the approach toward kidney transplantation and management of the virus in transplant recipients. Chronic immunosuppression and comorbidities in renal transplant recipients place them at risk during the pandemic. Data on the risk factors, presentation, and management of kidney transplant patients have become more robust over time. Relevant data on this topic was procured and synthesized with the aid of a comprehensive Medline search on all published studies that investigated COVID-19 infection in kidney transplant recipients. This comprehensive review summarizes the current literature on the epidemiology, clinical features, complications, graft outcomes, and current management of COVID-19 infection in kidney transplant recipients. We further summarize published literature on immunization in kidney transplant recipients.

Antibiotic therapy in case of positive cultures of kidney transplant preservation fluid: a nationwide survey of prescribing practices.

Our survey aimed to describe current prescribing practices for perioperative antibiotic prophylaxis in French kidney transplant centers. We conducted a nationwide cross-sectional clinical vignette-based survey that we sent via email to hospital practitioners involved in perioperative management of kidney transplant patients (KTR). Nearly half of practitioners contacted (182/427, 42.6%) were respondents. A total of 167 getting enough kidney transplant activity were eligible for the survey. The response rate was 50.7% (68/134) among interns and 33.8% (99/293) among seniors. Positive perfusion fluids (PF) cultures for methicillin-susceptible Staphylococcus aureus were associated with antibiotic prescribing in 35% of cases, with no difference in prescribing in patients with diabetes, obesity, or delayed graft function. Antibiotic prescribing was most frequent with Pseudomonas aeruginosa (67%) and Klebsiella pneumoniae strains producing extended spectrum β-lactamases (57%). About 77%, 16%, and 13% of respondents, respectively, reported the existence of local practice guidelines for surgical antibiotic prophylaxis, a standardized approach for antibiotic prescribing in case of positive kidney transplant PF cultures, and local practice guidelines for systematical antibiotic prophylaxis in the early post-transplant period. In France, antibiotic prophylaxis practices in the perioperative kidney transplant period are very heterogeneous. To prevent unnecessary prescribing and bacterial resistance, evidence-based practice guidelines should be developed.

Therapeutic education of the renal transplant patient

The success of kidney transplantation depends on the long-term immune-suppressive treatment; therapeutic education programs for transplant recipients are being implemented world-wide to help patients acquiring the needed skill to manage their treatment and lifestyle in the best possible way. (1)To assess knowledge and observance of transplant patients receiving immunosuppressive treatments, and (2) to develop information, monitoring tools and matrices of therapeutic education program (ETP) adapted to our patients. Our cross-sectional study was conducted in 100 kidney transplant patients followed in our department; age: 34 ± 10.8 years old; sex ratio: 1.76. Observance was assessed by the Girerd's questionnaire and knowledge of their medical status by a questionnaire consisting of 12 items. Eight % of patients did not respect their medical appointment dates. Twenty-five % had a good knowledge of their immunosuppressive treatment. The risk of not taking the immune-suppressant were well-known (more than 80% of correct answers), other notions concerning the mechanisms of action and the possible side effects were much less understood. The knowledge of the risks of treatment, lifestyle and diet was incomplete. The item evaluating what to do if the patient forgets to take a medication received the lowest percentage (5%) of correct answer. This level was significantly correlated with the educational level ( P = 0.02). Forty four percent of our patients were considered as good observers and 51% had minor observance problems. Irregularity in the time of intake appeared to be the main factor in patients’ poor compliance. No relation was evidenced between the level of knowledge of the patients and their level of observance. Our study revealed that our patients’ knowledge was fragmented and insufficient, likely limiting the observance and increasing the risk of kidney rejection. In order to improve this situation, we adapted the ETP methods to our patients’ pathology and established 4 educational tools: an information booklet on kidney transplantation, brochures on drug interactions, explanatory images and interactive maps. We organized information meetings to sensitize patients. This educational program has been appreciated by patients. A future evaluation of its impact on knowledge and observance is required. This ETP implemented in our service represents a considerable step forward in the management of kidney transplant patients. However, a well-structured program, led by a multidisciplinary team, must be implemented for ensuring the effectiveness and safety of treatment.

Therapeutic education of the renal transplant patient

The success of kidney transplantation depends on the long-term immune-suppressive treatment; therapeutic education programs for transplant recipients are being implemented world-wide to help patients acquiring the needed skill to manage their treatment and lifestyle in the best possible way. (1) To assess knowledge and observance of transplant patients receiving immunosuppressive treatments, and (2) to develop information, monitoring tools and matrices of therapeutic education program (ETP) adapted to our patients. Our cross-sectional study was conducted in 100 kidney transplant patients followed in our department; age: 34 ± 10.8 years old; sex ratio: 1.76. Observance was assessed by the Girerd's questionnaire and knowledge of their medical status by a questionnaire consisting of 12 items. Eight % of patients did not respect their medical appointment dates. 25% had a good knowledge of their immunosuppressive treatment. The risk of not taking the immune-suppressant were well-known (more than 80% of correct answers), other notions concerning the mechanisms of action and the possible side effects were much less understood. The knowledge of the risks of treatment, lifestyle and diet was incomplete. The item evaluating what to do if the patient forgets to take a medication received the lowest percentage (5%) of correct answer. This level was significantly correlated with the educational level ( P = 0.02). Forty four percent of our patients were considered as good observers and 51% had minor observance problems. Irregularity in the time of intake appeared to be the main factor in patients’ poor compliance. No relation was evidenced between the level of knowledge of the patients and their level of observance. Our study revealed that our patients’ knowledge was fragmented and insufficient, likely limiting the observance and increasing the risk of kidney rejection. In order to improve this situation, we adapted the ETP methods to our patients’ pathology and established 4 educational tools: an information booklet on kidney transplantation, brochures on drug interactions, explanatory images and interactive maps. We organized information meetings to sensitize patients. This educational program has been appreciated by patients. A future evaluation of its impact on knowledge and observance is required. This ETP implemented in our service represents a considerable step forward in the management of kidney transplant patients. However, a well-structured program, led by a multidisciplinary team, must be implemented for ensuring the effectiveness and safety of treatment.

Defining housekeeping genes suitable for RNA-seq analysis of the human allograft kidney biopsy tissue

BackgroundRNA-seq is poised to play a major role in the management of kidney transplant patients. Rigorous definition of housekeeping genes (HKG) is essential for further progress in this field. Using single genes or a limited set HKG is inherently problematic since their expression might be altered by specific diseases in the patients being studied.MethodsTo generate a HKG set specific for kidney transplantation, we performed RNA-sequencing from renal allograft biopsies collected in a variety of clinical settings. Various normalization methods were applied to identify transcripts that had a coefficient of variation of expression that was below the 2nd percentile across all samples, and the corresponding genes were designated as housekeeping genes. Comparison with transcriptomic data from the Gene Expression Omnibus (GEO) database, pathway analysis and molecular biological functions were utilized to validate the housekeeping genes set.ResultsWe have developed a bioinformatics solution to this problem by using nine different normalization methods to derive large HKG gene sets from a RNA-seq data set of 47,611 transcripts derived from 30 biopsies. These biopsies were collected in a variety of clinical settings, including normal function, acute rejection, interstitial nephritis, interstitial fibrosis/tubular atrophy and polyomavirus nephropathy. Transcripts with coefficient of variation below the 2nd percentile were designated as HKG, and validated by showing their virtual absence in diseased allograft derived transcriptomic data sets available in the GEO. Pathway analysis indicated a role for these genes in maintenance of cell morphology, pyrimidine metabolism, and intracellular protein signaling.ConclusionsUtilization of these objectively defined HKG data sets will guard against errors resulting from focusing on individual genes like 18S RNA, actin & tubulin, which do not maintain constant expression across the known spectrum of renal allograft pathology.

Ten years' experience in the research of abdominal compartment syndrome (2004-2014)

Intra-abdominal hypertension and abdominal compartment syndrome are frequent findings among severe surgical ill patients. In spite of the fast diagnostic methods and effective therapeutic procedures the mortality is high. The causing factors lead to increased intra-abdominal pressure and abdominal compartment syndrome. It can be defined as adverse physiologic consequences that occur as a result of an acute increase in the intra-abdominal pressure. The most common causes are retroperitoneal haemorrhage, pancreatitis, bowel obstruction, tense ascites, peritonitis and serious visceral edema due to massive fluid resuscitation. The affected systems are cardiovascular, respiratory, renal, central nervous systems, splanchnic organs, and finally the whole body. The diagnostic method is the intra-abdominal pressure monitoring. The bases of the treatment are adequate fluid resuscitation, non-surgical management and decompression. The authors review the topic including the international and Hungarian references based on their ten years experience.

Effect of CYP3A5*3 on kidney transplant recipients treated with tacrolimus: a systematic review and meta-analysis of observational studies.

The highly variable pharmacokinetics of tacrolimus can hamper the optimal management of kidney transplant patients. This variability has been attributed to the genetic polymorphism of CYP3A5 6986A>G, but the evidence is not clear. We conducted a meta-analysis of studies evaluating the effect of CYP3A5 polymorphism on kidney transplant recipients with tacrolimus plasma concentration divided by daily dose per body weight (C/D) and clinical outcomes. We searched in MEDLINE and EMBASE. We found evidence suggesting a significantly lower C/D among CYP3A5*1 allele carriers compared with carriers of the CYP3A5*3/*3 genotype at weeks 1 and 2, and months 1, 3, 6 and 12. We demonstrated that the expresser genotype might have higher risk of acute rejection and chronic nephrotoxicity. In conclusion, CYP3A5 6986A>G polymorphism can affect tacrolimus pharmacokinetics and the incidence of acute rejection and chronic nephrotoxicity on kidney transplant recipients. Patients at high risk of developing tacrolimus-related complications could be detected even before their kidney transplant.

Serum and Renal Tissue Markers of Nephropathy in Rats Under Immunosuppressive Therapy: Cyclosporine Versus Sirolimus

Cyclosporin (CsA) has been progressively replaced by other drugs with putatively fever side effects, including nephrotoxicity and hypertension. Sirolimus (SRL) is one of the main options for management of kidney transplant patients in the post-CsA era. It shows identical efficacy with apparently less cardiorenal side effects than CsA. However, doubts remain concerning the mechanisms of putative renoprotection by SRL as well as the best serum and/or tissue markers for nephropathy, as assessed in this study employing CsA- and SRL-treated rats. Three groups (n = 6) were treated orally during a 6-week protocol: control (vehicle); CsA (5 mg/kg body weight per day Sandimmun Neoral); SRL (1 mg/kg body weight per day Rapamune). Blood pressure and heart rate were assessed with a “tail cuff”. Renal dysfunction and morphology were characterized using serum creatinine and blood urea nitrogen (BUN) levels as well as hematoxylin and eosin and periodic acid Schiff staining, respectively. We examined serum concentrations of interleukin (IL)-2, IL-1β, high-sensitivity C-reactive protein, tumor necrosis factor TNF-α, and vascular endothelial growth factor and kidney mRNA expression of interleukin-1β (IL-1β), tumor protein 53 (TP53), mammalian target of rapamycin (mTOR) and proliferating cell nuclear antigen (PCNA), as well as markers of lipid peroxidation in the kidney and serum. Both CsA and SRL induced significant increases in systolic and diastolic blood pressure, but only CsA caused tachycardia. CsA-treated rats also displayed increased serum creatinine and BUN levels, accompanied by mild renal lesions, which were almost absent among SRL-treated rats, which presented hyperlipidemic and hyperglycemic profiles. CsA-induced nephrotoxicity was accompanied by kidney overexpression of inflammatory and proliferative mRNA markers (IL-1β, mTOR and PCNA), which were absent among SRL group. In conclusion, the antiproliferative and antifibrotic character of SRL may explain its less nephrotoxic profile. Renal over expression of mTOR in the CsA-treated group, associated with renal dysfunction and structural damage, reinforces the potential beneft of SRL as a strategy to reduce CsA-evoked nephrotoxicity.

Allograft biopsy in kidney transplant recipients in the medical city of Baghdad

To determine the safety and efficacy of the practice of renal allograft biopsy and verify its impact on the management of kidney transplant patients presenting with graft dysfunction, we studied 50 renal allograft biopsies of 47 adult patients (38% males, mean age 32.4 ± 11 years) performed in the medical city complex from November 2008 to April 2011. All the biopsies were performed with a guidance of ultrasound. The procedure, complications, histological diagnoses and impact of the biopsy data on patients' management were recorded. Thirty percent of the biopsies were performed in the first 12 months post-transplantation and 24% were performed after the 60 th month. Adequate biopsy was achieved in 76% of the patients, with a 96% safety rate. Acute rejection was diagnosed in 38% of the biopsies and chronic allograft nephropathy in 38%, and they were the most common histological patterns in the study. The results of allograft biopsies positively impacted the management strategy in all study groups. Renal allograft biopsy was a useful and a relatively safe tool for the diagnosis of acute and chronic graft dysfunction in our experience.

Challenges and considerations in diagnosing the kidney disease in deteriorating graft function

SummaryDespite significant reductions in acute-rejection rates with the introduction of calcineurin inhibitor (CNI)-based immunosuppressive therapy, improvements in long-term graft survival in renal transplantation have been mixed. Improving long-term graft survival continues to present a major challenge in the management of kidney-transplant patients. CNIs are a key component of immunosuppressive therapy, and chronic CNI toxicity has been widely thought to be a major factor in late graft failure. However, recent studies examining the causes of late graft failure in detail have challenged this view, highlighting the importance of antibody-mediated rejection and other factors. In addition, the diagnosis of CNI nephrotoxicity represents a challenge to clinicians, with the potential for over-diagnosis and an inappropriate reduction in immunosuppressive therapy. When graft function is deteriorating, accurately determining the cause of the kidney disease is essential for effective long-term management of the patient. Diagnosis requires a thorough clinical investigation, and in the majority of cases a specific cause can be identified.

New Immunosuppressive Therapies and Surgical Complications After Renal Transplantation

BackgroundTo analyze the association between the principal immunosuppressive drugs (mycophenolate mofetil, calcineurin inhibitors and mammalian target of rapamycin [mTOR] inhibitors) used in the routine management of kidney transplant patients and the development of postoperative surgical complications. Materials and MethodsWe analyzed 415 kidney transplants, studying the influence of various immunosuppressive regimens on the main postoperative surgical complications. ResultsThe mean follow-up for the entire group was 72.8 months (± 54.2 SD). Patients treated with myeophonolate mofetil (MMF) and cyclosporine (n = 121) experienced a higher frequency of wound eventration odds ratio [OR], 5.2; 95% confidence interval [CI], 1.2–23.5; P = .03) compared with azathioprine and cyclosporine (n = 71). Compared with transplant recipients treated with tacrolimus and MMF (n = 181), transplant recipients treated with cyclosporine and MMF (n = 121) had a significantly greater frequency of wound eventration (OR, 3.7; 95% CI, 1.5–9.5; P = .005), urologic (OR, 2; 95% CI; 1.02–3.9; P = .04), wound (OR; 2.2; 95% CI; 1.07–4.6; P = .03), late (OR, 1.7; 95% CI; 1.01–3.03; P = .04), and Clavien grade 3 surgical complications (OR; 1.9; 95% CI, 1.1–3.37; P = .01). Patients treated with mTOR inhibitors (n = 26) had higher rates of lymphocele (OR, 3.6; 95% CI, (1.1–11.4; P = .002) compared with those who received tacrolimus (n = 197). ConclusionsNew immunosuppressive drugs have improved short-term functional results; however, in some cases they seem to increase surgical complications rates.

Hypertension in the kidney transplant recipient

Elevated arterial blood pressure is common after kidney transplantation and contributes to shortened patient and allograft survivals and increased fatal and nonfatal cardiovascular events. Unfortunately, current evidence indicates that arterial blood pressure remains poorly controlled in kidney transplant recipients. One concern is how best to evaluate treated levels of arterial pressure in transplant recipients as office and clinic measurements often differ from blood pressure readings obtained using ambulatory blood pressure monitoring. Some antihypertensive drugs interact with immunosuppressive medications and adversely affect electrolyte balance and kidney function, which complicates the management of kidney transplant patients. Target blood pressure readings have been suggested by different guidelines, but patient-specific management plan is still lacking. Understanding the basic mechanisms responsible for the persistent hypertension after kidney transplantation is helpful in drafting patient-directed management plan that includes both pharmacologic and nonpharmacologic interventions to achieve target blood pressure control. In this review, we propose a multilayered treatment plan that addresses hypertension in both the early and late posttransplant periods, bearing in mind complications of antihypertensive medications, interactions with immunosuppressive drugs, patient comorbidities, and patient-specific cardiovascular risk factors in the posttransplant period.

Transplantation in Diabetic Kidney Failure Patients: Modalities, Outcomes, and Clinical Management

Diabetes mellitus (DM) is a common and devastating disease, affecting up to 19.3 million Americans. It is the leading cause of chronic kidney disease (CKD) and end-stage renal disease (ESRD) in the United States. Diabetic patients with ESRD have a high incidence of cardiovascular disease and death. For those kidney transplant patients with no history of DM prior to transplantation, the development of new onset diabetes after transplantation (NODAT) also poses a serious threat to both graft and patient survival. Kidney transplantation is the best renal replacement option for diabetic ESRD and has the potential to halt the progression of cardiovascular diseases. Early referral for transplant evaluation is essential for pre-emptive or early kidney transplantation in this cohort of patients. In type 1 DM patients with ESRD, simultaneous pancreas and kidney transplantation (SPK) should be encouraged; and in patients facing prolonged waiting time for SPK transplantation but with an available living donor, living donor kidney transplantation followed by pancreas after kidney transplantation (PAK) is a suitable alternative. Islet transplantation in type 1 diabetics is deemed experimental by Medicare, and easy access to this modality remains restricted to qualified patients enrolled in clinical trials or with private insurance. The optimal management of kidney transplant patients with pre-existent DM or NODAT involves a multi-pronged approach consisting of pharmacological and nonpharmacological intervention to address all potential cardiovascular risk factors such as glycemic and lipid control, blood pressure control, weight loss, and smoking cessation. Finally, re-transplantation should be recommended in suitable kidney transplant patients when the kidney allograft demonstrates continuous and progressive decline in function.

Compliance of kidney transplant patients to the recommended lifestyle behaviours: Single centre experience

Successful management of kidney transplant patients requires lifelong therapeutic regimen. Lifestyle changes of the patients after transplantation is the key link between the process of transplantation and its outcome, which is why those patients are in great need for complying with their recommended lifestyle behaviours. The aim of the study was to identify compliance of kidney transplant patients to the recommended lifestyle behaviours. One hundred adult kidney transplant patients of 6 months duration and more participated in this study regardless of age or sex. A structured questionnaire was developed which included socio-demographic characteristics, the recommended lifestyle behaviours of the kidney transplant patients and the kidney transplant patient's health condition and his results from the laboratory tests. The time spent with each patient ranged between 45 and 60 min. About three or four patients were interviewed on each visit. The results found that patients have good compliance with immunosuppressive agents with partial degree to other lifestyle behaviours. The conclusion is that intensive assessment of patients before and after transplantation should be done to identify their needs which help to improve their compliance. The nurse must provide the kidney transplant patients with the necessary knowledge of the recommended lifestyle behaviours.

Utility of Biopsy in Kidney Transplants With Delayed Graft Function and Acute Dysfunction

Renal biopsy is currently the gold standard to assess the causes of renal allograft dysfunction. In the present study, we prospectively assessed the role of the renal allograft biopsy in the diagnosis and treatment of renal allograft dysfunction. Seven hundred and fifteen biopsies were performed in 399 patients. The anatomopathological results in group 1 (delayed graft function) were: 60.4% acute tubular necrosis, 17.6% acute rejection, 4.3% calcineurin inhibitor toxicity, and 17.7% other diagnoses; in group 2 (acute graft dysfunction): 42.3% acute rejection, 22% acute tubular necrosis, 8.4% calcineurin inhibitor toxicity, and 27.3% other diagnoses. Among patients with delayed graft function, 42.2% of biopsies led to a change in the treatment. In 60.5%, the biopsy of patients with acute dysfunction led to a change in the patient management. In our series, the result of the biopsy disagreed with the clinical diagnosis in 39.6% and 57.7% of cases, respectively. These results demonstrated that renal graft biopsy remains an indispensable tool for the accurate management of kidney transplant patients.