Months Of Kidney Transplantation Research Articles

Relationship of hemoglobin levels with outcomes in deceased donor kidney transplant: a retrospective cohort study.

Anemia is frequent in patients undergoing replacement therapy for kidney failure. Anemia in the pre- and post-transplantation period might be related to kidney transplant outcomes. The current study therefore sought to assess the relationship between anemia, delayed allograft function (DGF), chronic kidney allograft dysfunction (CAD), and death from any cause following kidney transplantation from a deceased donor. This was a retrospective study with 206 kidney transplant patients of deceased donors. We analyzed deceased donors' and kidney transplant patients' demographic data. Moreover, we compared biochemical parameters, anemia status, and medicines between DGF and non-DGF groups. Afterward, we performed a multivariate analysis. We also evaluated outcomes, such as CAD within one year and death in ten years. We observed a lower frequency of pre-transplant hemoglobin concentration (Hb) but higher frequency of donor-serum creatinine and red blood transfusion within one week after transplantation in the group with DGF. In addition, there was an independent association between Hb concentration before transplantation and DGF [OR 0.252, 95%CI: 0.159-0.401; p < 0.001]. There was also an association between Hb concentration after six months of kidney transplantation and both CAD [OR 0.798, 95% CI: 0.687-0.926; p = 0.003] and death from any cause. An association was found between pre-transplantation anemia and DGF and between anemia six months after transplantation and both CAD and death by any cause. Thus, anemia before or after transplantation affects the outcomes for patients who have undergone kidney transplantation from a deceased donor.

Effectiveness of endourological management of ureteral stenosis in kidney transplant patients: EAU-YAU kidney transplantation working group collaboration

PurposeUreteral stenosis (US) in kidney transplant (KT) recipients is associated with poorer long-term graft survival. Surgical repair is the standard of care, and endoscopic treatment represents an alternative for stenosis < 3 cm. We aimed to determine the effectiveness and safety of endourological management of US in KT patients and predictors of failure.MethodsA retrospective multicenter study was conducted in four European referral centers, including all KT patients with US managed endoscopically between 2009 and 2021. Clinical success was defined as the absence of upper urinary tract catheterization, surgical repair or transplantectomy during follow-up.ResultsA total of 44 patients were included. The median time to US onset was 3.5 months (IQR 1.9–10.8), the median length of stricture was 10 mm (IQR 7–20). Management of US involved balloon dilation and laser incision in 34 (79.1%) and 6 (13.9%) cases, respectively, while 2 (4.7%) received both. Clavien–Dindo complications were infrequent (10%); only one Clavien ≥ III complication was reported. Clinical success was 61% at last follow-up visit (median = 44.6 months). In the bivariate analysis, duckbill-shaped stenosis (vs. flat/concave) was associated with treatment success (RR = 0.39, p = 0.04, 95% CI 0.12–0.76), while late-onset stenosis (> 3 months post KT) with treatment failure (RR = 2.00, p = 0.02, 95% CI 1.01–3.95).ConclusionsConsidering the acceptable long-term results and the safety of these procedures, we believe that the endoscopic treatment should be offered as a first-line therapy for selected KT patients with US. Those with a short and duckbill-shaped stenosis diagnosed within 3 months of KT seem to be the best candidates.

Evaluating several clinical and subclinical characteristics of patients pre- and post-kidney transplant at 103 Military Hospital

Objective: To describe several clinical and subclinical characteristics of patients before and after 6 months of kidney transplant at 103 Military Hospital. Subject and method: From March 2018 to April 2020, a prospective, descriptive study enrolled 75 recipients with 6 months after renal transplant at 103 Military Hospital. Result: Prior to transplantation, 80.3% of patients received dialysis with an artificial kidney, while 9.8% received medical treatment; more than 90% of patients had hypertension, anemia, and dyslipidemia, with 43.8% having residual urine loss. The prevalence of HBV and HCV infection were 24.1%, and 95.5% of patients having HLA compatibility from 1-6/6 AG. There was a significant difference in urea, creatinine, uric acid, cholesterol, triglycerides, LDL-C, HDL-C, and hemoglobin before and after transplantation. However, after transplantation, 17.3% and 41.3% of patients had increased urea and creatinine, respectively. There were a 9.3% decrease in glomerular filtration rate and a 5.3% increase in proteinuria. After 6 months of kidney transplantation, indicators such as hypertension, increased CRP, anemia, and left ventricular hypertrophy significantly improved. Conclusion: Six months after transplantation, patients with end-stage renal disease improved in several clinical and subclinical indicators. Patients may still experience several metabolic disorders after transplantation, such as diabetes, decreased glomerular filtration rate, and increased proteinuria.

Frailty status improvement after kidney transplantation.

Frailty is a clinical syndrome characterized by a decrease in strength, resistance and body physiological condition, making the individual more vulnerable, and increasing his/her risk of dependence and death. Kidney transplant (KT) is currently the best end-stage renal disease therapeutic alternative for certain individuals. Frailty status occurs in approximately 20% of KT patients. Thus, it was evaluated if there would be any change in frailty status level in a population of adult patients on chronic HD after receiving KT. A cross-sectional study was conducted on a population of adult hemodialysis patients (n: 57), with the objective of evaluating if there was a significant change in their clinical frailty score (CFS) after 6months of KT. For the statistical analysis, the Student's t-test, and the test of statistical significance between two proportions were applied. Mean CFS before KT was 4 (vulnerable), and after KT was 3 (robust). CFS value was significantly lower after KT (p value < 0.01). A significant improvement was found between pre- and post-transplant clinical frailty scores in hemodialysis adult patients.

Preservation of Antiviral Immunologic Efficacy Without Alloimmunity After Switch to Belatacept in Calcineurin Inhibitor–Intolerant Patients

Belatacept has shown potential for prevention of rejection after kidney transplantation, given its demonstration of reduced nephrotoxicity in combination with absence of significant incidence of rejection. However, concerns have been raised regarding increased risk of viral infection. We set out to explore the impact of the switch to belatacept on alloimmune and antiviral immunity through the study of patients switched from calcineurin inhibitor (CNI) to belatacept within 3months of kidney transplantation compared with a matched cohort of control patients on a CNI-based regimen. After the switch to belatacept, immune phenotyping demonstrated a decrease in naive and an increase in terminally differentiated effector memory (TMRA) T cells, with no significant difference compared with control patients. Donor-specific immune response, measured by intracellular cytokine staining (ICS), did not change significantly either by single or double cytokine secretion, but it was associated with the appearance of donor-specific antibody (DSA) in the control but not the belatacept cohort (P= 0.039 for naive and P= 0.002 for TMRA subtypes). Increased incidence of de novo DSA development was observed in the control group (P= 0.035). Virus-specific immune response, as measured by ICS in response to cytomegalovirus (CMV) or Epstein-Barr virus (EBV), was similar in both groups and stable over time. We found that belatacept use was associated with an absence of alloreactivity without impact on immune phenotype, while preserving the antiviral immune response, for patients switched from a CNI-based regimen. In parallel, the antiviral immune response against CMV and EBV was preserved after the belatacept switch (clinicaltrials.gov: NCT01953120).

P16.27: A Case of Cytomegalovirus (CMV) Esophagitis Without CMV Viremia After SARS-CoV-2 Infection in a Kidney Transplant Recipient While on CMV Prophylaxis

Introduction: CMV prophylaxis significantly reduces CMV infection after solid organ transplants, but patient may still present with CMV primary disease or reactivation during the first six months post-transplant. Although high CMV viral load is usually seen in tissue invasive disease, blood CMV PCR my not be able to diagnose gastrointestinal CMV disease as sensitivity of blood CMV PCR is lower in seropositive patients. CMV and SARS-CoV-2 co-infection has been reported particularly in elderly and immunocompromised patients. We report a unique case of CMV esophagitis without viremia diagnosed after recent SARS-CoV-2 infection in a kidney transplant recipient. Case: Twenty-eight year old Caucasian female with end stage kidney disease due to unknown etiology received negative crossmatch living related renal transplant from her sister. She received Basiliximab for induction and Tacrolimus and mycophenolic acid as maintenance immunosuppression. Patient had intermediate risk for CMV (Donor CMV IgG negative and recipient IgG positive) and was on Valganciclovir for prophylaxis as per the protocol. She had a stable allograft function with serum creatinine around 1-1.2 mg/dl. She developed SARS-CoV-2 infection with mild respiratory symptoms after 2 months of kidney transplant. Mycophenolic acid was held very briefly, and Prednisone 10 mg daily was added to the regimen. She reported chest pain, nausea and vomiting after resuming mycophenolic acid. Blood CMV PCR was undetectable and other laboratory studies were significant for anemia of 9.3 g/dl (baseline 10 g/dl), with stable renal and hepatic functions, without leucopenia or thrombocytopenia. Upper Gastrointestinal endoscopy revealed a large 4-5 cm circumferential ulceration in the mid esophagus with biopsy features suggesting viral cytopathic effect and rare CMV infected cells. Stomach and duodenum were normal. HSV and fungal stains were negative. Patient was started on oral valganciclovir induction dose and showed symptomatic recovery in a few weeks. Conclusion: High index of suspicion is necessary to diagnose CMV co-infection and/or reactivation in the settings of SARS-CoV-2 infection and the tissue biopsy is the key for diagnosis of the tissue invasive gastrointestinal disease.

Differential characteristics associated with progression of mitral and aortic regurgitation in patients undergoing kidney transplantation

Abstract Background Heart valve regurgitation is common in patients with end-stage renal disease (ESRD). However, there are no data on the fate of mitral regurgitation (MR) and aortic regurgitation (AR) after kidney transplantation (KT). In this study, we sought to investigate regression or progression rates of MR and AR after KT in patients with ESRD. Moreover, we aimed to explore clinical and echocardiographic factors associated with the progression of MR and AR in patients undergoing KT. Methods Among 1,734 patients who underwent KT from 2005 to 2018 at a single tertiary hospital, 674 patients (407 men; mean 48±12 years) who underwent both pre- and post-KT echocardiography were analyzed comprehensively. Pre-KT echocardiography was performed within three months of KT, and post-KT echocardiography was done between 6 months and 24 months after KT. Severities of MR and AR were graded as no/trivial, mild, moderate, and severe according to the current guidelines. Regression was defined if the severity decreased by one or more grades, while progression was defined if the severity increased by one or more grades. Results Figure 1 shows the regression or progression of MR and AR after KT. 78 (11%) patients showed MR regression, but 41 (6%) experienced MR progression. 13 (2%) revealed AR regression, while 23 (4%) presented AR progression. In patients with MR progression, there were more cases of receiving a second KT, having mitral annular calcification, and showing lesser reduction of left atrial volume after KT. Patients with AR progression showed a longer hemodialysis duration, persistent hypertension after KT, and aortic root dilatation. Factors related to the progression of MR and AR showed statistically meaningful predictive values in a stepwise manner (Figure 2) Conclusions In patients undergoing KT, MR and AR may progress in patients with certain distinct characteristics. Different clinical and echocardiographic characteristics before KT, and reduction of hemodynamic loads after KT determine the progression of MR and AR. Further echocardiographic surveillances after KT are needed in patients with clinical and echocardiographic factors for progression of valve regurgitation. Funding Acknowledgement Type of funding sources: None.

Comparison between Tc-99m DTPA and Tc-99m MAG3 Renal Scintigraphy for Prediction of Early Adverse Outcome After Kidney Transplantation.

Renal scintigraphy (RS) with either technetium-99m diethylene-triamine-pentaacetate (Tc-99m DTPA) or technetium-99m mercaptoacetyltriglycine (Tc-99m MAG3) has both been used to evaluate early allograft function after kidney transplantation (KT). This study was done to compare the predictive performance of RS using these two radiopharmaceuticals for prediction of outcomes during first 3months of KT. This retrospective study included patients who received KT then underwent both Tc-99m DTPA and Tc-99m MAG3 RS, successively. Receiver operating characteristic (ROC) curve analysis was used to determine the predictiveness of RS parameters on early clinical adverse outcomes of either (1) graft-related death, (2) need for graft resection, (3) delayed graft function requiring temporary dialysis, or (4) a serum creatinine level of ≥ 2.0mg/dL at three months post-KT, as well as to predict biopsy-confirmed acute tubular necrosis and acute rejection. Of 187 patients included, 77 (41.2%) had at least one early adverse clinical outcome. Tc-99m MAG3 RS was more predictive than Tc-99m DTPA RS, in terms of AUCROC, in three parameters including time to peak (0.754 vs. 0.516, p-value 0.0001), 20-min to peak ratio (0.762 vs. 0.651, p-value 0.006), and 20-min to 3-min ratio (0.823 vs. 0.699, p-value 0.0005). Acute tubular necrosis was better predicted by Tc-99m MAG3 RS while both were at best only modest in predicting acute rejection. Three parameters which, when obtained from Tc-99m MAG3 RS, had superior predictiveness compared with Tc-99m DTPA RS, including time to peak, 20-min to peak ratio, and 20-min to 3-min ratio.

Timing of mTORI usage and outcomes in kidney transplant recipients.

The introduction of mammalian target of rapamycin inhibitors (mTORi) as immunosuppressive agents has changed the landscape of calcineurin inhibitor-based immunosuppressive regimens. However, the timing of mTORi conversion and its associated outcomes in kidney transplantation have conflicting results. This study investigated the effect of early or late mTORi post-transplant initiation on major transplant outcomes, including post-transplant malignancy, in kidney transplant recipients in our center. We enrolled 201 kidney transplant recipients with surviving function grafts of >3 months between 1983 and 2016. Patients were divided into three groups: early mTORi (initiated within 6 months of kidney transplantation), late mTORi, (mTORi initiation >6 months after kidney transplantation) and no mTORi. The mean creatinine at conversion was 1.46 ± 0.48 mg/dL and 1.30 ± 0.53 mg/dL for the early and late mTORi groups, respectively. During the study period, 10.5% of mTORi users and 19.2% of mTORi nonusers developed malignancy, mainly urothelial carcinoma. After adjustment for confounding factors, mTORi users were found to have a lower incidence of post-transplant malignancy than did nonusers (adjusted OR: 0.28, P = 0.04). No significant difference was observed between early and late mTORi users. Our results verified the potential advantages of mTORi usage in reducing cancer incidence after kidney transplantation. However, no significant result was found related to the timing of mTORi introduction. Future studies should include a longer observation period with a larger cohort.

Deceased vs. living donor kidney transplantation in prediction of acute renal allograft rejection using Tc-99m DTPA renal scan

No data are available regarding different prognostic values of Tc-99m diethylenetriaminepentaacetic acid (DTPA) renal scan in kidney transplantation (KT) recipients according to two distinct donor types: deceased donor KT (DDKT) and living donor KT (LDKT). We evaluated whether the interpretation of Tc-99m DTPA renal scan should be different by the donor type in predicting acute renal allograft rejection (AR). One hundred and seven KT recipients (61 DDKT and 46 LDKT) were included in this study. Tc-99m DTPA renal scan was performed 1week after KT. AR was defined as pathological evidence of renal allograft rejection during the first 6months of KT. Clinical factors and Tc-99m DTPA renal scan findings were compared between patients with and without AR. To further analyze the effect of the donor type, they were again compared within DDKT and LDKT recipients, respectively. AR occurred in 15 patients (7 DDKT and 8 LDKT recipients). Among all patients, time to peak uptake (TTP) of the cortex (TTPCX) measured by Tc-99m DTPA renal scan was independently predictive of AR. Moreover, TTPKD (TTP of the whole transplanted kidney) and TTPCX were the only predictors of AR among DDKT recipients. The most accurate predictors were TTPCX and kidney area on renal scan for DDKT and LDKT, respectively. However, these parameters could not predict AR for the opposite donor type. AR could be effectively predicted by Tc-99m DTPA renal scan obtained at 1week post-KT. Different parameters should be applied according to the donor type in the prediction of AR.

CLINICAL COURSE OF SCHIMKE IMMUNO-OSSEOUS DYSPLASIA AFTER KIDNEY TRANSPLANTATION

Schimke immuno-osseous dysplasia (SIOD) is one of the rare causes of steroid-resistant nephrotic syndrome. Extra-renal symptoms of this autosomal recessive disease include spondyloepiphyseal dysplasia, disproportional growth failure and defective cellular immunity. Kidney transplantation (KT) is indicated in these patients when their kidney problems progress to end-stage renal disease (ESRD). Due to the rarity of this condition, clinical course of SIOD after KT is not well known yet. Here we present our experience of SIOD after KT. Since 2014 three children with focal segmental glomerulosclerosis (FSGS) confirmed by biopsy were diagnosed as SIOD through genetic analysis. Onset age of proteinuria was 7, 5, 3 years, respectively. All of them had disproportional growth failure and typical facial feature. They reached ESRD in about two years after diagnosis of proteinuria. At their age of 9, 7, 9 years, these patients had living donor KT from their parents. After KT they suffered from multiple infections. Case 1 had PCP pneumonia requiring ventilator care 2 months after KT, then in 3 months disseminated adenovirus infection occurred along with CMV, EBV, and JC virus infection. The patient succumbed to the infection in 2 months despite aggressive management. Case 2 had CMV infection and PCP pneumonia after 3 months of KT. She suffered from skin infection and otitis. Case 3 suffered from respiratory failure due to CMV infection after 5 months of KT. Recurrent hospitalization was required due to various infections. Allograft has survived for 3.5 years in case 3 despite low-dose tacrolimus single medication (< 5ng/mL), but case 1 lost his graft function along with disseminated adenovirus infection. Case 2 had graft failure after 5 years of KT from acute rejection, probably due to insufficient dosage of tacrolimus and poor compliance. As Extra-renal presentation case 1 had renal vein thrombosis extended to IVC and pulmonary hypertension before KT, lowering his oxygen saturation to 80-90% in room air. Case 2 had severe developmental dysplasia of the hip requiring orthopedic surgery at the age of 5. She had sitting height and leg length ratio of 0.96, vertebral flattening and lordosis on spine x-ray suggesting spondyloepiphyseal dysplasia. After KT she suffered constant headache and Moyamoya syndrome was dignosed. She had an encephaloduroarteriosynangiosis when she was 10yrs 4month old. Case 3 suffered from spontaneous bacterial peritonitis and recurrent rhabdomyolysis along with neutropenia and thrombocytopenia before KT. In three years of KT his neutropenia and thrombocytopenia aggravated and bone marrow study suggested aplastic anemia. Hematopoietic stem cell transplantation is under consideration. In summary, SIOD is a rare systemic disease presenting as FSGS. While KT is indicated for their ESRD, their extra-renal symptoms progress regardless of KT. With its defective cellular immunity multiple infections complicate the clinical course after KT in SIOD.

P1729HEMODYNAMIC AND AUTONOMIC PERFORMANCE IN CHRONIC DIALYSIS AND RENAL TRANSPLANT PATIENTS. IS THERE AN IMPROVEMENT?

Abstract Background and Aims Chronic kidney disease (CKD) is a major public health problem, with high prevalence worldwide. It’s associated with high morbidity and mortality, especially in the advanced stage when substitution therapies are needed. It’s well established that Ps with end-stage kidney disease have increased mortality due to an elevated incidence of cardiovascular diseases (CVD). The best treatment for this population it’s definitely the kidney transplant (KT), mostly because it improves the quality of life and reduces global and CV mortality compared with Ps treated with chronic dialysis (Dx). There is not a convincing explanation about the physiological mechanisms involved in this improvement. Impedance cardiography (IC) it’s a well established, validated method to asses hemodynamics parameters. Study and describe the differences between hemodynamic and autonomic profiles between KT and Dx Ps using IC. Method We studied 331 Ps as part of a cardiovascular evaluation program in Ps with ESKD which is being carried out in our institution (CEMIC, Buenos Aires). Of these, 190 were on Dx and 141 on KT. Non-invasive hemodynamic assessment was performed using IC (Z Logic- Exxer SA) in supine and standing position, taking into account the following variables: heart rate (HR), thoracic fluid content (TFC), stroke volume (SV), systemic vascular resistance index (SVRI), arterial compliance index (ACI), and pre-ejection period (PEP). Ps in the Dx group were studied on the interdialytic day. We evaluated the autonomic profile by studying the variability of HR (Kubios Finland) for three minutes, with measurements of the spectral components, high frequency (HF), low frequency (LF), total power (totpowar) and the ratio LF/HF. We compared absolute supine variables and then the differences between supine and standing positions. Exclusions criteria: less than six months of KT or Dx; incomplete basic hemodynamic study or lack of data; amputation; previous KT. Results We included 107 Ps of Dx and 118 of KT. No significant differences were detected in terms of age, sex, diabetes, and antihypertensive treatment. Ps on Dx had more prevalence of hypertension and CVD. Those in KT group had a median time of 72,5 months of transplantation and 46 months of prior dialysis time, with a media of eGFR (CKD-Epi) of 56 ml/min/1,72 m2. Ps on Dx had a median of 22 months on substitution treatment. The hemodynamic evaluation showed that KT Ps had lower HR (p=o,oo1), higher ACI (p=0,002) and PEP (p=0,05), and a tendency of higher SV (p=0,07). The autonomic evaluation showed no significant differences between the two groups, though the totpowar had a tendency to be higher in the KT group with a median of 367(200-625) compared with 248 (103-465) in the Dx group (p=0,07). The changes in the variables during the standing position evidenced that Ps on Dx had a lower elevation of HR (p=0,04) and SVRI (p&amp;lt;0,001). We assessed the prevalence of orthostatic hypotension defined as a reduction of the SBP in 20 mmHg and/or the DBP in 10 mmHg after standing up. The Dx group had a prevalence of 30% and the KT group of 20%, but the difference was not significant. Conclusion Ps with KT seems to have a better hemodynamic profile than those on Dx, mainly, a better vascular response with a more physiological- compensatory elevation of HR and VSRI when they stand up. Although the autonomic activity showed no significant statistical difference, the total power, an expression of the whole autonomic activity, showed us a clear tendency in favor of KT, which needs to be confirmed with a larger size sample.

P1032CMV INFECTION &amp; RISK OF NEW ONSET DAIBETES AFTER TRANSPLANTATION

Abstract Background and Aims NODAT is a frequent complication among kidney transplant recipients and is considerably associated with risk of allograft rejection and allograft loss. The present research study was aimed to identify whether CMV infection acts as risk factor for NODAT development in kidney transplant recipients. Method This retrospective study recruited 59 kidney transplant recipients (43 males and 16 females). The diagnosis of NODAT was established if two fasting plasma glucose readings were ≥126 mg/dL after the 3rd month of post-transplantation. We carefully monitored recipients for CMV viremia (CMV DNA copies/mL) in the plasma through quantitative Polymerase Chain Reaction (qPCR). The 1 year post-transplantation allograft outcomes due to CMV viremia were also measured; eGFR (CKD-EPI method), allograft and transplant patient survival. Results In this study, 14 (23.7%) patients were diagnosed with NODAT. The CMV load and CMV viremia was elevated in NODAT cohort in comparison with their counterparts (4000 versus 3600 and 51.1 versus 47.6, respectively); however, no statistical relationship was observed (P = 0.79 and P = 0.84, respectively). We witnessed significantly high CMV DNA replication in first (1-6 months) half of the post-transplant period in both controls and NODAT patients; however, statistically significant CMV DNA replication was only observed for NODAT cohort (P&amp;lt;0.001). Majority of the NODAT diagnoses; 9 out of 14 (64.3%), in our cohort was made during the first six months of kidney transplantation (P&amp;lt;0.001). Overall, 7 (11.9%) of the kidney transplant recipients recruited in our study progressed to symptomatic CMV infection. We also witnessed that a greater CMV viremia load was worsening the kidney allograft function at 12 months post-transplantation. The allograft and patient survival (censored for death) was poor in the NODAT cohort; however, without any statistical significance. Conclusion The present study demonstrated that CMV infection is not a risk factor for NODAT development among kidney transplant recipinets.

Biochemical Characteristics of Bone Mineral Metabolism before and throughout the First Year after Kidney Transplantation, Persistent Hyperparathyroidism, and Risk Factors in a Latin Population.

Bone mineral metabolism disease, which included persistent hyperparathyroidism, is common after successful kidney transplantation (KT) and is related with negative outcomes in kidney transplant recipients. There is a lack of information about bone mineral metabolism, persistent hyperparathyroidism, and its risk factors in Latin kidney transplant recipients (KTRs). Material and Methods: A retrospective study was conducted in 74 patients aged 18–50 years with evolution of 12 months after KT and estimated glomerular filtration rate (eGFR) >60 ml/min; biochemical data of bone mineral metabolism before and at 1, 3, 6, and 12 months of KT were registered. Results. Age was 33 (IQR 27–37) years; 54% (n = 40) were men. Before KT, all patients had hyperparathyroidism, 40% (n = 30) hypocalcemia, 86% (n = 64) hyperphosphatemia, and 42% (n = 31) hyperphosphatasemia. After KT, an increase of calcium and a diminution of PTH, phosphorus, and alkaline phosphatase were corroborated (p=0.001). All patients had hypovitaminosis D (deficiency: 91% (n = 67); insufficiency: 9% (n = 7)); 40% (n = 30) had persistent hyperparathyroidism at 12 months. Hyperphosphatasemia before KT (OR = 4.17 (95% CI: 1.21–14.44); p=0.04), hyperparathyroidism at 6 months (OR = 1.84 (95% CI; 1.67–2.06); p=0.02), hypovitaminosis D at 6 months (OR = 3.94 (95% CI: 1.86–17.9); p=0.01), and hyperphosphatasemia at 6 months (OR = 1.47 (95% CI: 1.07–2.86); p=0.03) were risk factors for persistent hyperparathyroidism at 12 months after KT. Conclusion. Persistent hyperparathyroidism at 6 months, hypovitaminosis D, and hyperphosphatasemia are risk factors for persistent hyperparathyroidism at 1 year of KT in Latin population.

Increased soluble fms-like tyrosine kinase 1 after ischemia reperfusion contributes to adverse clinical outcomes following kidney transplantation

Renal ischemia reperfusion injury (IRI) adversely affects clinical outcomes following kidney transplantation. Understanding the cellular mechanisms and the changes in gene/protein expression following IRI may help to improve these outcomes. Serum soluble fms-like tyrosine kinase 1 (sFlt-1), a circulating antiangiogenic protein, is increased in the first week following kidney transplantation. We evaluated the casual relationship of elevated sFlt-1 levels with renal microvascular dysfunction following IRI in a longitudinal study of 93 kidney transplant recipients and in several animal models. Transplant recipients with higher sFlt-1 levels had higher odds of delayed graft function, graft rejection, impaired graft function, and death. In a subgroup of 25 participants who underwent kidney biopsy within 4 months of kidney transplantation, peritubular capillary area was lower in those with elevated serum sFtl-1 levels. The administration of recombinant sFlt-1 into rodents resulted in significant structural and functional changes of the renal microvasculature, including reduced peritubular capillary density and intracapillary blood volume, and lead to increased expression of inflammatory genes and increased fibrosis. In a murine model of IRI, the kidney was a site of sFlt-1 production, and systemic neutralization of sFlt-1 preserved peritubular capillary density and alleviated renal fibrosis. Our data indicate that high sFlt-1 levels after IRI play an important role in the pathogenesis of microvascular dysfunction, thereby contributing to adverse clinical outcomes following kidney transplantation.

Comparison of Sleep Quality in Hemodialysis Vs Kidney Transplant Recipients Using Pittsburgh Sleep Quality Index (PSQI)

Background Disturbed sleep causes depression and poor health related quality of life (HRQoL). Studies have shown that poor sleep quality is an independent predictor of mortality in patients with end stage renal disease (ESRD). To compare the effect of kidney transplantation (KT) on sleep quality, we did a prospective study comparing patients on haemodialysis (HD) with kidney transplant recipients. Material and Methods Pittsburgh sleep quality index (PSQI) was used to assess 40 patients each following KT and those undergoing HD. A PSQI score of 5 or more was considered indicative of poor sleep quality. All patients were requested to fill the questionnaire (self-assessment) while attending for HD sessions or follow up clinics. All transplant recipients were within 6 months of kidney transplantation and were not dependent on HD at the time of filling the questionnaire. Results There were 40 respondents in each group. Mean age in KT group was 50.7 years (21-75 years, 62% Males, 38% Females). In HD group mean age was 62.3 years (26-90 years,64% Male and 36% Females). Those with previous psychiatric history were excluded. In KT group, 15 out of 40 (37.5%) had PSQI score of more than 5 (poor sleep). In HD group, 32 out of 40 (80%) had PSQI score of > 5 and thus poor sleep (p< 0.5). The highest PSQI score was 17 in KT and 16 in HD group. Pain was one of the biggest reasons in both groups for sleep disturbance. Most of the respondents reported better sleep quality prior to the development of kidney disease. Reasons for poor sleep are multifactorial and include medications, increasing age, chronic ill health and presence of co morbidities however both of these groups were relatively age matched and had same subsets of co morbidities. Conclusion Incidence of poor sleep was much higher in patients on HD when compared with KT recipients. Hence, we can conclude KT improved sleep quality. Even after transplantation, the proportion of respondents reporting sleep disturbances was higher than general population. Poor sleep quality continues to adversely affect HRQoL. Further research and clinical attention for sleep disturbances in these patients is warranted.

Use of Electron Microscopy (EM)to Detect Transplant Glomerulopathy (TG) in Patients with Late-Indication Allograft Biopsy

Introduction The main causes of late graft loss are: death of patients with functioning graft and chronic allograft nephropathy, in which it stands out, to chronic rejection mediated by antibodies (cABMR). cABMR was defined during the Banff meeting in 2005 due to: Transplant Glomerulopathy (TG), Multilamination of the basal membrane of the tubular pericapillary (MLMBPCT), Transplant vasculopathy and interstitial fibrosis with tubular atrophy (IFTA), with deposit of C4d in PCT and the presence of Anti-HLA Antibodies specific donor (DSA). The presence of C4d deposition in the peritubular capillary (PTC) is a diagnostic marker of ABMR greater than 50% in acute graft rejection but not in its chronic or late ABMR phenotype, so its usefulness is currently questioned in the late phase, identifying them as C4d negative. The typical characterizes cABMR is TG recognized as a glomerulopathy that manifests a double contour of the glomerular capillary,. The cABMR with duplication or MLMBG, increase of the subendothelial space, interposition of mesangial cells, loss of fenestration in the endothelial cells, and MLMBPTC as the findings most significant effects linked to the interaction of antibodies in the glomerular endothelium. Objectives Detect morphological changes of TG by ME in patients with chronic allograft dysfunction who have late biopsies for clinical indication, whose previous histopathological evaluation was by Banff classification in MO and IHC for C4d. Materials and Methods We performed a retrospective observational study of a descriptive cohort, kidney transplant patients performed in the Nephrology and Transplant Service of the CPVS, Córdoba, Argentina who presented chronic allograft dysfunction with late biopsies for clinical indication performed in the period from July 2011 to August 2016.The MO and ME analysis was performed by two different pathologists.The indication for renal biopsy was performed according to the following criteria: increase in serum creatinine ≥0.3 mg / dl or more during the post-transplant evolution. Proteinuria evaluated by Pr/Cr ratio in spot urine ≥0.3 mg / dl.3. Patients with at least 6 months of kidney transplant.4. All samples of biopsies performed should have at least 4 glomeruli for the MO and ME analysis, respectively. Results Inflammation of the glomerular endothelium (GECS) in 21/22 95%.Podocyte deletion processes in 100% of patients, 22.7% severe and in the rest 76% mild to moderate. MLMBPTC, 68% were present in 63.6% 14/22 patients mild (<3 layers) and in only 5% was moderate (7 layers). ). MLMBG in 17/22 77.2%..Conclusion The use of EM in late kidney transplant biopsies by indication allowed detecting ultrastructural changes of transplant glomerulopathy of cABMR in a high % of patients with C4d negative w/wo DSA. Prospective studies should be necessary as protocol biopsies with earlier changes suggestive of TG with EM, and anticipate the clinically evident damage.

Reliability and validity of the five-repetition sit-to-stand test in adult kidney transplant recipients

Background/Aims: To investigate the reliability and validity of the five-repetition sit-to-stand test (FRSTST) to assess lower-limb muscle strength and physical function in adult kidney transplant recipients. Methods: A cross-sectional, observational study was conducted in a secondary care centre. A convenience sample of 56 adult kidney transplant recipients were recruited following a 6-week post-transplantation recovery period. The participants were within their first 18 months of kidney transplantation. The measurements included FRSTST times, myometer measurements of isometric quadriceps muscle strength, 60-second sit-to-stand test (STS60) scores, and Duke Activity Status Index (DASI) scores. Findings: Inter- and intratester reliability of the FRSTST were excellent (intraclass correlation coefficients 0.997 and 0.970, respectively). The standard error of measurement and the minimal detectable change at 95% confidence level were 0.9 and 2.5 seconds, respectively. The best FRSTST scores by the two testers had non-significant, weak correlations with the isometric quadriceps muscle force (Spearman's rho, rs=-0.04, p=0.76), and quadriceps muscle torque (rs=0.04, p=0.76). The FRSTST correlated significantly with the STS60 (rs=-0.90, p=0.001) and DASI scores (rs=-0.49, p=0.001). Conclusions: The FRSTST can be considered to be a reliable test of physical function for adult kidney transplant recipients, but may not be used as a surrogate measure of lower limb muscle strength in this population.

Patterns and Significance of Renal Replacement Therapy Use after Kidney Transplantation

Introduction: The use of renal replacement therapy (RRT) among kidney transplant recipients may associate with delay graft function (DGF) and acute graft loss in the first 6-month post-transplant follow-up or chronic graft loss in late post-transplant period. However, its epidemiological pattern and clinical significance remain undescribed in the current literature. Methods: We constructed a population-based kidney transplantation cohort using the Taiwan National Health Insurance claims data between year 2004 and 2012. Renal replacement therapy (RRT) includes hemodialysis or peritoneal dialysis. We estimated time to RRT since discharge from transplant admission to describe the distribution of RRT after kidney transplant. Delayed graft function or acute graft loss was defined as reviving RRT in the first 6 months after transplant whereas chronic graft loss was defined as receiving RRT after 6 months of transplant. Results: During the study period, a total of 2,506 patients (2,547 person-times) received kidney transplantation. Mean age was 43.8 ± 12.7 years and 52% were men. Four hundred and seventy (18.9% of the study cohort) kidney transplant recipients experienced at least one session of renal replacement therapy (RRT) [hemodialysis (HD) vs. peritoneal dialysis (PD), 91.5% vs. 8.5%]. About 30% of graft recipients received their first RRT (HD vs. PD, 88.3% vs. 11.7%) within the first 90 days after transplantation and 40% (HD vs. PD, 87.6% vs. 12.4%) within 180 days. The median time to RRT was 540 days (1.48 years). Compared to those without need of RRT support, recipients who ever received RRT tended to have higher mortality proportion (23% vs. 8%). Conclusion: The incident proportion of receiving RRT therapy was about 40 % in the first 6 months of kidney transplantation. The need of hemodialysis support is a critical factor associated with mortality outcome. Characteristics associated with RRT use, particularly immunosuppressant utilization, require further investigation.

Risk Factors for BK Virus Replication During the First Three Months of Kidney Transplantation: Does It Matter to Consider a High AUC of Mycophenolic Acid?

Introduction: BK virus (BKv) infection is a threat to renal allograft survival. BKv nephropathy had largely been described since more potent immunosuppressive drugs appeared. An overimmunosuppression is often advocated for risk factor. Therapeutic drug monitoring may better assess individual immunosuppression. The aim of this study is to seek risk factors for significant BKviruria (> 10ˆ5 copies/ml) because there is no BK viremia under this threshold and to determine whether a high AUC of mycophenolic acid (MPA) is one of them. Method: we retrospectively observed 255 kidney recipients with a 1-year follow-up treated by mycophenolate mofetil between July 2006 and June 2011. BKv was regularly sought in blood and urine samples by quantitative PCR. Different risk factors were sought between group with significant BK viruria and without. Results: Fifty recipients (19.9%) had a BK viruria, 38 (14.9%) had a sustained BK viruria during the first 3 months and 25 (9.8%) had a BK viremia during the first year. Six (2.6%) patients underwent BKv nephropathy. Threshold for significant BK viruria was 56 h.mg/L determined by ROC equation. In univariate analysis, significant BK viruria occured more frequently in male recipients (81,6 vs 62,6%; p=0,02), older (54,6±14,3 vs 49,5±13,3 years; p=0,03) with a greater MPA AUC (54,1±21,1 vs 44,6±20,7 hr.mg/L; p=0,02). Nephroangiosclerosis and focal segmental glomerular sclerosis were more frequent when significant BK viruria occurred: 18,4 vs 7,1% (p=0,02) and 13,2 vs 4,3% (p=0,03) respectively. In multivariate analysis, male gender (relative risk (RR) 3,1; p<0,02) age above 58 years old (RR 2,6; p<0,02) and MPA AUC greater than 56 h.mg/l (RR 2,8; p<0,001) were risk factors for significant BK viruria. Conclusion: a high MPA AUC (>56 h.mg/l) seems to be a risk factor for significant BKviruria as male gender and age. It could be reasonable to not exceed MPA AUC > 55 h.mg/l to prevent significant BK viruria and BK viremia.