Mean Serum Creatinine Level Research Articles

Urinary early kidney injury molecules in children with beta-thalassemia major

Background: The aim of this study was to investigate novel urinary biomarkers including N-acetyl-β-d-glucosaminidase (NAG), neutrophil gelatinase-associated lipocalin (NGAL), kidney injury molecule-1 (KIM-1), and liver-type fatty acid binding protein (L-FABP) in children with β-thalassemia major (β-TM). Materials and methods: Totally, 52 patients (29 boys, 23 girls) with β-TM and 29 healthy controls (3–17 years) were included. Various demographic characteristics and blood transfusions/year, disease duration, and chelation therapy were recorded. Serum urea, creatinine, electrolytes, and ferritin and urinary creatinine, protein, calcium, phosphorus, sodium, potassium, and uric acid in first morning urine samples were measured and estimated glomerular filtration rate (eGFR) was calculated. Routine serum and urinary biochemical variables, urinary NAG to Creatinine (UNAG/Cr), UNGAL/Cr, UKIM-1/Cr, and UL-FABP/Cr ratios were determined. Results: Patients had similar mean serum urea, creatinine and eGFR levels compared with controls (p > 0.05 for all). The mean urinary protein to creatinine (UProtein/Cr) ratio was significantly higher in patients compared to the healthy subjects (0.13 ± 0.09 mg/mg and 0.07 ± 0.04 mg/mg, respectively; p < 0.001). Significantly increased UNAG/Cr (0.48 ± 0.58 vs. 0.23 ± 0.16, p = 0.026) and UNGAL/Cr (22.1 ± 18.5 vs. 11.5 ± 6.17, p = 0.01) ratios were found in β-TM patients compared with healthy controls. However, no differences were found in serum and urinary electrolytes or UKIM-1/Cr and UL-FABP/Cr ratios between patients and controls (p > 0.05). Significant correlations were found between urinary biomarkers and urinary electrolytes (p < 0.05). Conclusions: Our results suggest that urinary NAG and NGAL may be considered to be reliable markers to monitor renal injury in β-TM patients.

Application of plasmapheresis in treating the antibody-mediated acute rejection after kidney transplantation

Objective To investigate the efficacy of plasmapheresis therapy for treating the antibody-mediated acute rejection (AMR) after kidney transplantation. Methods The study group consists of 2 male patients and 3 female patients, who suffered with AMR after receiving first-time allograft renal transplantation from January 2011 to September 2013 in our hospital. The age ranged from 41 to 52 years old, average 46 years old. The preoperative diagnosis in all patients was chronic renal insufficiency (uremia stage) and the regular hemodialysis was given to them. The 5 patients received basic immunosuppressive therapy, including cyclosporine A [5 mg/(kg·d)] or FK506 [0.1 mg/(kg·d)], mycophenolate mofetil (MMF) (1.5 g/d) and steroids. All the antibody-mediated acute rejections were diagnosed by renal allograft biopsy and serum DSA determination within 2 weeks after transplantation. Seven cycles of plasmapheresis rescue therapy were given to those patients respectively after the failure therapy of high dose of corticosteroids (1 000 mg/d) and ALG (250 mg/d). 4 cases with primary glomerulonephritis, whose preoperative serum creatinine level was (784±154) μmol/L, were given plasmapheresis therapy within 2 weeks after transplantation. One case with primary anti-glomerular basement membrane disease, whose preoperative serum creatinine level was 935 μmol/L, received plasmapheresis 35 d after transplantation. The serum DSA in all patients was positive before plasmapheresis. Results After 7 cycles of plasmapheresis rescue therapy, the AMR was reversed in four 4 cases, whose plasmapheresis was given within 2 weeks after transplantation. Within three months follow-up, their renal function recovered well, which the mean serum creatinine level was (113±12) μmol/L. In the case, whose plasmapheresis was given 35 days after transplantation, rejection was not reversed. His serum creatinine was 524 μmol/L and the intermittent hemodialysis was given, subsequently. With a follow-up of 12 months, the ultrasound examination showed that the atrophy of transplanted kidney and a high level of serum creatinine (758 μmol/L). Low dose of FK506 (0.5 mg/d) was given based on those results. Conclusions Active application of plasmapheresis can effectively reverse antibody-mediated acute rejection within two weeks after transplantation. Key words: Kidney transplantation; Antibody-mediated acute rejection; Plasmapheresis

Cryptosporidium infection after renal transplantation in an endemic area.

Cryptosporidium is one of the common causes of infective diarrhea in post-transplant patients in endemic areas. However, data are limited on Cryptosporidium infection in recipients of solid organ transplantation. The aim of this study was to determine the incidence, disease manifestation, management, and outcome of Cryptosporidium infection in living-donor renal transplant recipients (RTR). We performed a detailed retrospective review of the data on all RTR who had diarrheal illness requiring evaluation and hospitalization, and Cryptosporidium infection. During the study period, 119/1235 (8.98%) RTR developed diarrhea, and Cryptosporidium was found in 34/119 (28.5%). Nine of 680 (1.3%) patients were on a cyclosporine (CSA)-based regimen, and 25/643 (3.8%) patients were on a tacrolimus (Tac)-based regimen. The relative risk of developing Cryptosporidium infection was lower on the CSA-based regimen, compared with the Tac-based regimen (odds ratio [OR]: 0.35, 95% confidence interval [CI]: 0.17-0.72, P=0.003). Twelve of the 34 patients had acute graft dysfunction, mainly caused by combined Tac toxicity and dehydration. Mean serum creatinine and trough Tac level were 2.04±0.65mg/dL and 8.24±1.19ng/dL, respectively. Nitazoxanide alone was used in 13 patients, and nitazoxanide in combination with fluoroquinolone in 21 patients, with duration of treatment ranging from 16 to 60days. Tac was changed to CSA in 8/11 patients. The clearance of cysts and response to nitazoxanide alone were significantly lower, compared with combination therapy (61.53% vs. 95.23%, P=0.01, 38.46 vs. 85.71%, P=0.004, respectively). The OR for cyst clearance and response was also significantly lower with nitazoxanide alone, in comparison with combination therapy (OR: 0.65, 95% CI: 0.34-0.92, P=0.01, OR: 0.45, 95% CI: 0.21-0.81, respectively). Four (16%) of 24 patients with response had relapse. Patients with Tac and mycophenolate mofetil combination therapy had a significantly high risk of Cryptosporidium infection. Cryptosporidial infection may require prolonged nitazoxanide therapy, either alone or in combination, with or without reduction in immunosuppression.

Comparison of In-hospital Outcome of Acute Myocardial Infarction in Patients with vs without Diabetes Mellitus in Durres Population

Background: Diabetes mellitus (DM) is a worldwide epidemic and a major public health problem and the mortality of diabetic patients is twice higher than that of with non-diabetic patients. The inhospital outcomes in diabetic patients with acute myocardial infarction (AMI) are less known in Albania. Aim: To compare in-hospital outcomes of AMI in diabetic vs non-diabetic patients in Albania. Methods: A prospective, observational study. Patients with AMI between September 2012 and October 2014 were involved in the current study. Traditional risk factors for CAD, serum creatinine levels, and coronary angiographic results were recorded. In-hospital mortality of patients with and without DM was compared. P value of <0.05 was considered statistically significant. Results: From 420 enrolled patients with AMI, 281 (66.9%) were with DM, and 139 (33.1%) were non-diabetic. Baseline hypertension and cerebral vascular disease were more prevalent in diabetic than in non-diabetic patients. Diabetic patients also demonstrated a higher mean serum creatinine level than non-diabetic individuals (creatinine: 2.3±1.24 vs1.76±0.98 mg/dl P<0.05). Older age, Original Research Article Zera et al.; CA, 3(3): 130-136, 2015; Article no.CA.2015.011 131 multi-vessel diseases, poor renal function and higher killip class were associated with in-hospital mortality in patients with AMI. In-hospital mortality was higher in diabetic than non-diabetic patients (13.7% vs.7.9%, P<0.05). Conclusion: The present study suggests that in Albania, the in-hospital mortality rate in diabetic patients with AMI was higher than that in non-diabetic patients, which may be related to more comorbidies in diabetic patients. Hence, early aggressive treatment in the course of diabetic patients with acute AMI is important.

Parachute Suture Technique with Arteriotomy by using Aortic Punch in Live Related Renal Transplant

Objective: To provide review of our experience in vascular anastomosis technique for kidney transplantation patients. Material and Methods: 100 chronic kidney disease patients 89 males and 11females with mean age 23.5 ± 3 years have been operated for kidney transplantation from January 2011 through April 2015. Vascular part of operation was done using parachute suture technique and arteriotomy by aortic punch. Recipients were prospectively entered into a database and retrospectively reviewed. Data collected included the warm and cold ischemic time, arterial and venous anastomotic time, color Doppler ultrasonography examination of the anastomosis site on 1, 7 postoperative days, mean serum creatinine level on 3, 14 days after the operation and any early or late postoperative complications. Results: Mean kidney warm and cold ischemia time was 7.5 ± 4minutes and 21.5 ± 7minutes respectively. Mean arterial and venous anastomotic time was 7.2 ± 9 minutes and 8 ± 4 minutes respectively. All allografts had single artery. Renal arteries were anastomosed to (53%) common iliac arteries, (40%) external iliac arteries, (6%) internal iliac arteries and just (1%) to lower aorta in recipients; however, allograft renal veins were anastomosed to (95%) common iliac vein and (5%) inferior vena cava recipients. No vascular complications were detected in the early postoperative period by Doppler ultrasonography examination. The mean serum creatinine level on the 3the and 14the days after the operation was 0.9 (range, 0.5-4 mg/dl) and 0.6(range 0.5-1.2 mg/dl) respectively. Slow graft function was diagnosed in 2patients, with a good perfusion of the allografts showed by renal scan. During a mean follow-up of 4 years, we did not encounter any case of renal artery or venous thrombosis or any suspected arterial stenosis. Conclusions: The parachute suture technique is safe and straightforward method for arterial and venous anastomosis in renal transplantation with low complication rates. Using aortic punch for arteriotomy facilitates the arterial anastomosis, which may results in excellent kidney function without stenosis of the renal artery.

Protective effects of amifostine on ischemia-reperfusion injury of rat kidneys

Objectives:Amifostine is a drug which can eliminate free oxygen radicals that appear in the body after radiation or chemotherapeutic agent exposure. It is used to decrease the renal toxicity of cisplatin. The aim of this study was to determine the role of amifostine in warm ischemia kidney model for prevention of ischemia/reperfusion injury and also to find out the mechanism for prevention from ischemia/reperfusion injury if such an effect does exist.Materials and Methods:Adult female rats (n = 40) that used in our study were divided into three groups. Group 1: Control (n = 8), group 2: Ischemia-control (n = 16), group 3: Amifostine treated (n = 16). The effect of amifostine on ischemia/reperfusion injury investigated in rat kidneys.Results:At the 7th day, blood urea nitrogen level was statistically significantly higher in ischemia-control group than all groups (P = 0.001) and mean serum creatinine levels were found to be the highest in ischemia-control group (P = 0.091). Mean malondialdehyde levels in left kidneys removed on the 7th day were not significantly different (P = 0.105) at all three groups. Between ischemia-control group and amifostine group, there was a significant difference in reduced glutathione (GSH) levels (P = 0.001). In amifostine group, grade 4 necrosis was not detected neither on 7th day nor day 0.Conclusion:Amifostine could decrease the degree and severity of necrosis after reperfusion. Amifostine could not prevent membrane lipid peroxidation caused by superoxide anion radicals in kidney but they could protect tissues from the harmful effects of ischemia/reperfusion injury by increasing the level of reduced GSH which is a well-known oxygen radical eliminator.

Spectrum of IgA nephropathy in a single center.

Immunoglobulin A (IgA) nephropathy (IgAN) is the most common biopsy-proven primary glomerular disease in the world and a major contributor to the worldwide burden of endstage renal failure, with a wide geographical variation. To determine the incidence, clinical profile and histological pattern of IgAN in our institute, we reviewed all the patients who had native kidney biopsies with the diagnosis of primary IgAN during the period from 1998 to 2009 in the context of the clinical features. A total of 116 patients with IgAN were finally analyzed; 85 (73%) of the patients were male, the mean age of the patients was 29.2 ± 12.2 (range 10-70) years and the mean duration of disease was 10.4 ± 18.7 months (median: 2 months). Hypertension was present in 74 (63.2%) cases. Gross hematuria was rare. The most common clinical presentation was nephrotic syndrome, followed by chronic renal failure. The mean proteinuria level was 2.5 ± 2.3 g/day (median: 1.7 g/day) and the mean serum creatinine level was 3.04 ± 3.3 mg/dL (median:1.7 mg/dL). The morphological sub-classification (Haas): Class I was the most common (44.4%), followed by class V (23%). IgA co-deposition with C3 and lambda was the most common finding in the immunofluorescence study. The glomerular filtration rate decreased with advanced histological damage. The incidence of IgAN was 7.5%, which is lower as compared with studies from elsewhere. IgAN in our population had a more severe clinical presentation.

Analyzing renal involvement in 100 cases of hematological malignancy

Background: Hematological malignancies are the most common nonrenal neoplasms affecting the kidneys. The incidence and type of renal involvement in these malignancies are variable and differ according to malignancy. Objective: To study the prevalence of renal involvement in hematological malignancies and to study the clinical profile of patients in various malignancies. Materials and Methods: A total of 100 consecutive patients of hematological malignancies (leukemia, lymphoma, and multiple myeloma) were prospectively studied for renal involvement and clinical profile. Results: There were 72 men and 28 women with mean age of 46.85 ± 19.23 years. Among them, 43% patients had leukemia, 33% patients had lymphoma, and 24% patients had multiple myeloma. Renal failure was present in 37% of the total patients and one-third patients were having azotemic symptoms at presentation. Mean blood urea and serum creatinine levels were 73.75 ± 77.49 and 2.42 ± 3.22 mg/dl, respectively. Mean glomerular filtration rate (GFR) was 71.29 ± 54.92 ml/min and 17% patients had GFR < 15 ml/min; 62.5% patients of multiple myeloma had renal failure. Four patients had acute urate nephropathy (three patients had acute leukemia and one patient had multiple myeloma). Of the total, 18% patients had hypercalcemia and 41.7% patients had myeloma. Hyperuricemia was observed in 55.5% patients. Tumor lysis syndrome was seen in three patients and all these patients were having multiple myeloma. Male sex, multiple myeloma, and hyperuricemia were significant factors contributing to renal failure (p < 0.05). Conclusion: All patients with hematological malignancies should be evaluated for renal dysfunction and all preventive measures should be used in these patients, especially when initiated on chemotherapy.

Liberal versus restricted fluid administration in heart failure patients. A systematic review and meta-analysis of randomized trials.

Restrictive fluid intake is recommended, in addition to standard pharmacologic treatment, in the treatment of patients with chronic heart failure (CHF). However, this recommendation lacks firm scientific evidence. We conducted a systematic review and meta-analysis of published randomized controlled trials to estimate the effect of fluid restriction in patients with heart failure.Randomized controlled trials were identified in the MEDLINE, EMBASE, and Cochrane databases using the search-keywords "fluid" and "heart failure". Outcomes were compared in heart failure patients with liberal and restricted fluid intake. Pooled risk ratios (RR) and weighted mean differences (WMD) were calculated using random effects models. Studies focusing on decompensated heart failure were analyzed separately.Six small randomized trials comparing liberal and restricted fluid intake met the inclusion criteria. Significant heterogeneity was noted in the reported studies for several outcomes. There were no differences in readmission rate (5 studies, pooled RR = 1.32; 95% CI: 0.86 to 2.01; P = 0.2), mortality rate (5 studies, pooled RR = 1.50; 95% CI: 0.87 to 2.57; P = 0.14), perceived thirst (4 studies, WMD = -0.7; 95% CI: -2.58 to 1.17; P = 0.46), duration of intravenous diuretics (2 studies, WMD = 0.17; 95% CI: -1.26 to 1.6; P = 0.81) or serum sodium levels (WMD = -1.61; 95% CI: -3.28 to 0.07; P = 0.06) between the liberal fluid intake group and the restrictive fluid intake group. Mean serum creatinine and BNP levels were significantly higher in the liberal fluid group: WMD 0.20 (95% CI: 0.15 to 0.25; P < 0.00001) and 172.59 (95% CI: 67.38 to 277.8; P = 0.001), respectively. There was no difference in any of the outcomes after correcting for heterogeneity.While studies to date are limited by heterogeneity and small sample sizes, the combined data suggest similar clinical outcomes in patients with CHF managed with liberal and restrictive fluid intake. Larger studies are needed to confirm our findings.

Health Risks Among Adults after a Prolonged Flaring Incident at the British Petroleum Plant in Texas City

Objective: Human exposure to benzene is associated with multiple adverse health effects including hematopoietic malignancies, respiratory irritation, and immune system alterations and central nervous system abnormalities. The purpose of this study is to examine health effects of a benzene exposure among adult subjects from a prolonged flaring incident at the British petroleum (BP) refinery in the Texas City, Texas.Methods: The study included adults aged 18 years or older who had been exposed and unexposed to benzene. Using medical charts, clinical data including white blood cells (WBC), platelets, hemoglobin, hematocrit, blood urea nitrogen (BUN), creatinine, alkaline phosphatase (ALP), aspartate amino transferase (AST), and alanine amino transferase (ALT) in adults exposed to benzene were reviewed and analyzed and compared with unexposed adults.Results: A total of 2213 adult subjects (benzene exposed, n=1826 and unexposed, n=387) were included. Benzene exposed subjects had significantly higher levels of WBC (X 103 per µL) counts (7.9±2.3 versus 6.8±1.6, P=0.0000) and platelet (X 103 per µL) counts (270.8±60.9 versus 242.5±53.7, P=0.0.0000) compared with the unexposed subjects. The mean serum creatinine levels (mg/dL) were also significantly increased in the benzene exposed group compared with the unexposed group (1.0 ±0.2 versus 0.8±0.2, P=0.000). Serum levels of ALP (IU/L) was significantly elevated in the benzene exposed subjects compared with the unexposed subjects (82.1±15.6 versus 71.8±8.2, P=0.000). Similarly, benzene exposed subjects had significantly higher levels of AST and ALT compared with those unexposed to benzene.Conclusion: Together, the results of the study reveal that Benzene exposure from the prolonged BP flaring incident caused significant alterations in their hematological and liver markers indicating that adult subjects exposed to benzene may be at a higher risk of developing hepatic or blood related disorders. DisclosuresNo relevant conflicts of interest to declare.

Hematological and hepatic alterations in nonsmoking residents exposed to benzene following a flaring incident at the British petroleum plant in Texas City.

ObjectiveHuman exposure to benzene is associated with multiple adverse health effects with an increased risk of developing carcinogenesis. Benzene exposure is known to affect many critical organs including the hematological, hepatic, renal, lung, and cardiac functions. The purpose of this study is to examine the health effects of benzene exposure among nonsmoking subjects from a prolonged flaring incident that occurred at the British petroleum (BP) refinery in the Texas City, Texas.MethodsThe study included nonsmoking subjects who had been exposed and unexposed to benzene. Using medical charts, clinical data including white blood cell (WBC) counts, platelet counts, hemoglobin, hematocrit, blood urea nitrogen (BUN), creatinine, alkaline phosphatase (ALP), aspartate amino transferase (AST), and alanine amino transferase (ALT) in nonsmoking subjects exposed to benzene were reviewed and analyzed and compared with unexposed adults.ResultsA total of 1422 nonsmoking subjects (benzene exposed, n = 1093 and unexposed, n = 329) were included. Benzene exposed subjects had significantly higher levels of WBC (× 103 per μL) counts (7.7 ± 2.2 versus 6.8 ± 1.7, P = 0.001) and platelet (× 103 per μL) counts (288.8 ± 59.0 versus 245.3 ± 54.4, P = 0.001) compared with the unexposed subjects. The mean serum creatinine (mg/dL) levels were also significantly increased in the benzene exposed group compared with the unexposed group (1.1 ± 0.4 versus 0.8 ± 0.2, P = 0.001). Serum levels of ALP (IU/L) was significantly elevated in the benzene exposed subjects compared with the unexposed subjects (87.3 ± 22.6 versus 69.6 ± 16.5, P = 0.001). Similarly, benzene exposed subjects had significantly higher levels of AST and ALT compared with those unexposed subjects.ConclusionBenzene exposure from the prolonged BP flaring incident caused significant alterations in hematological and liver markers indicating that these nonsmoking residents exposed to refinery chemicals may be at a higher risk of developing hepatic or blood related disorders.

Pretransplant immunologic risk assessment of kidney transplant recipients with donor-specific anti-human leukocyte antigen antibodies.

Patients with pretransplantation strong donor-specific anti-human leukocyte antigen (HLA) antibodies (DSA) are at higher risk for rejection. We aimed to study the safety of kidney transplantation in patients with lower strength DSAs in a prospective cohort study. Three hundred and seventy-three consecutive adult kidney transplant recipients with (DSA+; n=66) and without (DSA-; n=307) DSA were evaluated. Anti-HLA antibodies with mean fluorescence intensity values over 5,000 for HLA-A, HLA-B, and HLA-DR and more than 10,000 for HLA-DQ were reported as unacceptable antigens. Patients received transplant if flow cytometry T-cell and B-cell cross-match channel shift values were less than 150 and 250, respectively, with antithymocyte globulin and intravenous immunoglobulin induction treatment. Patients had a mean number of 1.6 ± 0.8 DSAs with a mean fluorescence intensity value of 2,815 ± 2,550. Twenty-seven percent were flow cytometry cross-match positive with T-cell and B-cell channel shift values of 129 ± 49 and 159 ± 52, respectively. During a median follow-up of 24 months (range, 6-50), there were no statistically significant differences in patient (99% vs. 95%) and graft survival (88% vs. 90%) rates between DSA+ and DSA- groups, respectively. Cumulative acute rejection rates of 11% in the DSA+ group and 12% in the DSA- group were similar. Two DSA+ (3%) and five DSA- (2%) patients developed chronic antibody-mediated rejection (3%). The mean serum creatinine levels were identical between the two groups (1.4 ± 0.6 mg/dL). Similar patient and graft survival, and acute rejection rates can be achieved in DSA+ patients compared to DSA- patients with pretransplantation immunologic risk assessment.

Multidisciplinary Predialysis Education Reduced the Inpatient and Total Medical Costs of the First 6 Months of Dialysis in Incident Hemodialysis Patients

BackgroundThe multidisciplinary pre-dialysis education (MPE) retards renal progression, reduce incidence of dialysis and mortality of CKD patients. However, the financial benefit of this intervention on patients starting hemodialysis has not yet been evaluated in prospective and randomized trial.MethodsWe studied the medical expenditure and utilization incurred in the first 6 months of dialysis initiation in 425 incident hemodialysis patients who were randomized into MPE and non-MPE groups before reaching end-stage renal disease. The content of the MPE was standardized in accordance with the National Kidney Foundation Dialysis Outcomes Quality Initiative guidelines.ResultsThe mean age of study patients was 63.8±13.2 years, and 221 (49.7%) of them were men. The mean serum creatinine level and estimated glomerular filtration rate was 6.1±4.0 mg/dL and 7.6±2.9 mL⋅min−1⋅1.73 m−2, respectively, at dialysis initiation. MPE patients tended to have lower total medical cost in the first 6 months after hemodialysis initiation (9147.6±0.1 USD/patient vs. 11190.6±0.1 USD/patient, p = 0.003), fewer in numbers [0 (1) vs. 1 (2), p<0.001] and length of hospitalization [0 (15) vs. 8 (27) days, p<0.001], and also lower inpatient cost [0 (2617.4) vs. 1559,4 (5019.6) USD/patient, p<0.001] than non-MPE patients, principally owing to reduced cardiovascular hospitalization and vascular access–related surgeries. The decreased inpatient and total medical cost associated with MPE were independent of patients' demographic characteristics, concomitant disease, baseline biochemistry and use of double-lumen catheter at initiation of hemodialysis.ConclusionsParticipation of multidisciplinary education in pre-dialysis period was independently associated with reduction in the inpatient and total medical expenditures of the first 6 months post-dialysis owing to decreased inpatient service utilization secondary to cardiovascular causes and vascular access–related surgeries.Trial RegistrationClinicalTrials.gov NCT00644046

Belatacept-based, ATG-Fresenius-induction regimen for kidney transplant recipients: A proof-of-concept study

Belatacept provides effective immunosuppression while avoiding the nephrotoxicities associated with calcineurin inhibitors (CNIs). However, existing belatacept-based regimens still have high rates of acute rejection. We hypothesized that therapy with belatacept, mycophenolic acid (MMA), steroids and induction therapy with rabbit anti-thymocyte globulin Fresenius (ATGF), rejection rate could be reduced. Prospective, single center, proof-of-concept study including males and females aged ≥18years, Epstein–Barr virus (EBV)-seropositive recipients of a first, HLA non-identical, live or deceased donor kidney allograft. Only patients with a calculated panel reactive antibody score of 0% were included. Three donors were positive for Chagas disease. Six of twelve patients had at least one infection and five were readmitted to the hospital for treatment. One patient had a Trypanosoma cruzi infection via the graft treated successfully. Median cold ischemia time for the transplant patients with a deceased donor was 21.5h. Mean serum creatinine levels at 1, 3 and 6months were 1.76±0.59, 1.55±0.60 and 1.49±0.60mg/dl, respectively. Two of twelve patients experienced clinical, biopsy-proven rejection, successfully treated with methylprednisolone. No patient developed post-transplant lymphoproliferative disorder (PTLD) or any other malignancy and no patient lost their graft or died during follow-up. The potential of this approach makes it worthy of further investigation.

Laparoscopic nephrectomy for massive polycystic kidney disease: Updated technique and outcomes.

We present our technique of laparoscopic nephrectomy for massive polycystic kidneys in patients with autosomal dominant polycystic kidney disease (ADPKD) and review the outcome analysis of our experience. We retrospectively reviewed all transperitoneal laparoscopic nephrectomies done for polycystic kidneys at a university hospital. Our technique included three 12-mm ports with additional one or two 5-mm ports, with usage of retraction devices, such as the Jarit PEER retractor (J. Jamner Surgical Instruments, Inc, Hawthorne, NY). In total, 39 (left 14, right 25) laparoscopic nephrectomies were performed in 32 patients (male 21, female 11). Surgical indications were varied: to create space for future renal transplant in 21 (54%), to alleviate pain in 16 (41%), to prevent recurrent urosepsis in 2 (5%), to prevent recurrent bleeding which would require transfusions in 2 (5%) and to remove a renal tumour in 1 kidney (2.5%). Four patients had surgery for more than one reason. The mean age and body mass index were 52.2 years (range: 29-72) and 26.9 kg/m(2) (range: 21.6-34.0), respectively. The mean preoperative hemoglobin and serum creatinine levels were 131.6 g/L (range: 107-171) and 514 µmol/L (range: 84-923), respectively; 26 (81%) patients were on dialysis. The mean operative time and estimated blood loss were 185 minutes (range: 113-287) and 94 mL (range: 10-350), respectively. No patient required open conversion. The mean specimen size was 24.2 cm (range: 15-38); weight 1515 g (range: 412-4590) and the length of extraction incision was 9.2 cm (range: 6-13). There were 1 Grade 2 2 (2.5%), 2 Grade 3b (5%) and 1 Grade 4a-d (2.5%) complications. The mean length of stay was 4.5 days (range: 3-8). Our technique of laparoscopic nephrectomy for massively enlarged polycystic kidneys in ADPKD is safe and offers all the advantages of minimal access surgery, such as smaller incision, decreased estimated blood loss, excellent cosmesis and faster recovery.

Early Kidney Dysfunction After Liver Transplantation Is Associated With Reduced Graft and Patient Survival

Introduction: In this study, we aimed at investigating the frequencies of acute renal dysfunction (ARD) and chronic kidney disease (CKD) post-liver transplant (LT), the risk factors associated with renal dysfunction post-LT, and to determine the clinical impact of renal dysfunction with regards to both graft and patient survival after LT. Methods: We analyzed 535 patients with cirrhosis who received a liver transplant over the period of 1989 to 2010. Estimated glomerular filtration rate (eGFR) was determined using the 4 variable MDRD formula, ARD was defined as eGFR >90 ml/min prior to transplant, followed by eGFR <60 ml/min at 3 months post-LT, and CKD was defined as eGFR <60 ml/min after LT, evidence of intrinsic renal disease, or need for renal replacement therapy. Results: Three hundred fifty-nine were males (67%), and the mean age at LT was 52±10 years. Cirrhosis etiology was HCV cirrhosis (35%), alcohol cirrhosis (33%), autoimmune liver disease (25%), NASH (2%), and HBV (6%). Diabetes was present in 180 (34%), and hypertension in 244 patients (46%) prior to LT. Mean serum creatinine level was 111±80 μmol/L, and 186 patients (35%) had a diagnosis of CKD prior to LT. ARD was documented in 34 patients (6%) after LT, and a new diagnosis of CKD post-LT was made in 88 patients (16%). Risk factors associated with development of ARD were age >60 years (14 vs. 6%; p=0.01) and male gender (12 vs. 5%; p=0.01). Risk factors for development of CKD post-LT were diabetes (23 vs. 13%; p=0.003) and hypertension (22 vs. 12%; p=0.001). Graft survival (133±13 vs. 168 ±11 months; p=0.03) and patient survival were significantly reduced when eGFR was <60 ml/min at 3 months (133±13 vs. 185±12 months; p=0.006; Figure 1). Hazard ratio for mortality was 1.6 (95% confidence interval [CI] 1.2-2.3; p=0.006) for those patients with eGFR <60 ml/min at 3 months.Figure 1Conclusion: ARD and CKD are frequent complications after LT. Older age and male gender are associated with a higher risk for ARD, whereas diabetes, hypertension, and early reduction in the eGFR are associated with higher risk of CKD after. Recognition of early kidney dysfunction after LT is important in an effort to establish strategies to improve graft and patient survival after LT.

Non-HLA Antibodies: Angiotensin II Type 1 Receptor (Anti-AT1R) and Endothelin-1 Type A Receptor (Anti-ETAR) Are Associated With Renal Allograft Injury and Graft Loss

IntroductionNon-HLA antibodies specific for angiotensin II type 1 receptor (anti-AT1R) and endothelin-1 type A receptor (anti-ETAR) of vascular cells activate signaling pathways leading to cell proliferation and vascular injury. The aim of this study was to evaluate the impact of non-HLA antibodies on kidney allograft morphology and function in patients who underwent a kidney biopsy due to renal function impairment. Patients and MethodsThe study included 65 consecutive renal transplant patients who were evaluated for the presence of non-HLA and anti-HLA antibodies at the time of transplant biopsy. Results of pre-transplant CDC cross-match were negative. A kidney allograft biopsy was performed between 6 days and 13 years (42 ± 49 months) after transplantation, and the diagnosis was made on the basis of the Banff criteria. The level >9 U/L of anti-AT1R and anti-ETAR antibodies was considered high. ResultsA high level of non-HLA antibodies (anti-AT1R and/or anti-ETAR) was found in 7 (10.7%) of 65 patients at the time of biopsy. Graft loss in the non–HLA-positive patients was significantly higher (71% in non–HLA-positive cases after 7.8 ± 2.6 months vs 11% after 6 months in non-HLA–negative cases [P = .00099]). In these non–HLA-positive patients, the mean anti-AT1R level was 15.3 ± 9.4 U/L and the mean anti-ETAR level was 13.8 ± 8.6 U/L. In only 2 of these patients were anti-HLA antibodies additionally detected: anti-class I in 1 and anti-class II in both patients. The mean serum creatinine level was 2.34 ± 0.6 mg/dL at the time of biopsy. Results of an early biopsy revealed acute vascular rejection (Banff grade IIB). Chronic allograft injury was found (grading cg1-3, cv1-2, ci1-2, ct1-2) in the remaining 6 patients. C4d was present in 3 of 7 patients. ConclusionsHigh levels of anti-AT1R and/or anti-ETAR antibodies were associated with morphological and functional allograft injury and graft loss in these study patients. Non-HLA antibodies can be helpful in assessing the risk of graft failure.

PP-095 A RARE PRESENTATION OF HELLP SYNDROME AT 16TH WEEK OF GESTATION

Background: The prospects for children born with thalassemia currently include increased life expectancy and minimal or no organ damage. With the advances in the care of patients with β-thalassemia major (β-TM), there is a remarkable increasing prevalence of disrupted kidney functions due to various supposed factors. Therefore, early recognition of those likely to progress has become increasingly substantial. Serum creatinine and GFR, the current main diagnostic biomarkers, however, have several shortcomings for the evaluation of renal dysfunction. The aim of this study was to investigate novel urinary biomarkers including N-acetyl-b-Dglucosaminidase (NAG), neutrophil gelatinase-associated lipocalin (NGAL) urinary kidney injury molecule-1 (KIM-1), and liver-type fatty acid binding protein (L-FABP), to determine renal involvement in children with β-thalassemia major (β-TM). Methods: This prospective study involves measurements of the serum and urinary biochemical parameters, complete blood count, novel urinary biomarkers including urinary NAG to Creatinine (UNAG/Cr), UNGAL/Cr, UKIM-1/Cr and UL-FABP/Cr ratios and various demographic factors in 52 β-TM children and 29 healthy controls with comparable age and sex. Results: Patients had similar mean serum urea, creatinine and eGFR levels compared with controls (p>0.05 for all). The mean urinary protein to creatinine (UProtein/Cr) ratio was significantly higher in patients compared to the healthy subjects (0.13±0.09 mg/mg and 0.07±0.04 mg/mg, respectively; p=0.05). Significant correlations were found between urinary biomarkers and urinary electrolytes. Conclusion: Our results suggest that urinary NAG and NGAL may be

The impact of Ramadan fast on patients with gout.

Ramadan fast is a religious custom in Islam. Increased serum uric acid level during this month had been reported in past studies of nongout patients. The objective of this study was to assess the impact of Ramadan fast on patients with gout. All Moslem patients with gout from the registry of Nazareth Hospital, who intended to fast during Ramadan, were asked to participate in our study (group 1). Data regarding age, gender, income, education, duration of gout, meds, adherence to low-purine diet, and gouty attacks were documented. Age- and gender matched Moslem patients from the same registry, but who did not intend to fast during Ramadan, were asked to participate as a control group (group 2). Just prior to and at the end of Ramadan, blood for uric acid, creatinine, and urea levels were obtained as well as body mass index, from all the patients. During Ramadan, patients were monitored for gouty arthritis or renal calculi attacks, as well as low-purine diet and medicine adherence. Twenty-one and 22 patients from groups 1 and 2, respectively, completed the study. Mean serum uric acid, urea, creatinine, and body mass index levels at the end of Ramadan fasts in group 1 patients were 8.11 mg/dL, 26.38 mmol/L, 0.87 mg/dL, and 31.0 kg/m, respectively, as compared with 7.92 mg/dL (P = 0.707), 24.54 mmol/L (P = 0.769), 0.84 mg/dL (P = 0.180), and 30.5 kg/m (P = 0.907) respectively, obtained just prior to the fast. No significant change in any parameter was seen also in group 2 patients. There also was no significant change between the 2 groups in arthritis or renal calculi attacks and also in medication and low-purine diet adherence, during Ramadan. There was no risk for a significant increase in gouty arthritic/renal calculi attacks or serum uric acid in patients with gout during Ramadan fast.

Utilization of vascular conduits to facilitate renal transplantation in patients with significant aortoiliac calcification.

To describe the use of vascular conduits (donor iliac artery or saphenous vein) in renal transplantation recipients with extensive aortoiliac calcification. Vascular conduits were used in 10 renal transplants with severe vascular calcification at Cleveland Clinic from 2009 to 2013. Both iliac artery (N = 8) and saphenous vein (N = 2) grafts were used. Surgical technique is reviewed in detail. Surgical complications, patency on renal transplant ultrasonography, and serum creatinine level at multiple time points were reviewed. Mean follow-up time was 26 months (7-44 months). Mean serum creatinine level was 1.42 mg/dL (1.04-1.74 mg/dL) at 6 months, 1.35 mg/dL (0.83-1.86 mg/dL) at 12 months, and 1.43 mg/dL (0.79-1.81 mg/dL) at last follow-up. All patients were demonstrated postoperatively to have patent vasculature on renal ultrasonography. No patients experienced lower extremity vascular complications. Death-censored graft survival was 100%. One patient died from complications after mitral valve replacement, and one patient died from metastatic squamous cell carcinoma of the tongue. Both patients had functioning grafts at the time of death. Vascular conduits can be used to facilitate renal transplantation in the setting of severe recipient aortoiliac calcification, thus allowing for successful transplantation of these complex recipients.