Patients Experienced Graft Loss Research Articles

Impact of an enteral nutrition protocol in critically ill patients with burn injuries.

The objective of this study is to characterize the University of Florida (UF) Health Shands Burn Centers enteral nutrition protocol as it relates to total protein intake and clinical outcomes. This retrospective chart review study included 99 adult patients admitted to the UF Health Shands Burn Center from January 2012 through August 2016 with burns of twenty percent or greater TBSA and required enteral nutrition supplementation. Patients received an average of 137.8 g or 2.03 g/kg protein daily. Fifteen percent of patients experienced graft loss. The median length of stay was 35 days. Seventy-six percent survived to hospital discharge. There was no significant association between total protein intake and incidence of severe diarrhea (P=0.132). The institutions protocol achieved high protein administration while still being consistent with recommendations from the American Society of Enteral and Parenteral Nutrition (ASPEN).

Effect of Redosing Basiliximab in the Setting of Blood Loss in Heart Transplant Recipients on Infection and Rejection

<h3>Purpose</h3> A prior study examining the pharmacodynamics of basiliximab in liver transplant recipients revealed significant medication clearance with blood loss. Dose escalation studies have shown total doses of 40-60 mg are effective and well-tolerated. We sought to examine infection risk when giving a total basiliximab dose of 40 mg vs 60 mg in our heart transplant (OHT) population in the setting of blood loss and requirement of massive transfusion protocol (MTP). <h3>Methods</h3> A single-center retrospective cohort study was performed examining adult OHT patients who received basiliximab induction therapy between June 1, 2010 and October 31, 2019. Cases and controls were matched 1:1. Patients were excluded if they were determined to be immunocompromised prior to transplant. The primary endpoint was incidence of infection. Secondary endpoints included the incidence of cell-mediated or antibody-mediated rejection, as well as the incidence of graft loss within 12 months. <h3>Results</h3> Forty-eight patients who underwent OHT were included, 24 patients in each group (40 mg and 60 mg total dose). Baseline characteristics were similar except for a higher number of LVAD patients in the 60 mg group (16.7% vs 45.8%, p=0.03). A total of 12 patients in the 40 mg group and 18 patients in the 60 mg group experienced at least one infection within 12 months after OHT, although this difference did not meet statistical significance (50% vs 75%, p=0.07). The types of infections were similar between the groups. A stepwise logistic regression showed blood loss and presence of LVAD at the time of transplant were predictors of infection occurrence. Delayed chest closure occurred more frequently in the basiliximab 60 mg group (p=0.002). Acute cellular rejection rates did not differ between groups (p=0.62). Antibody-mediated rejection occurred less frequently in the 40 mg vs 60 mg group (16.7% vs 50%, p=0.03). Two patients experienced graft loss in each group. <h3>Conclusion</h3> In our single-center retrospective study, the administration of an additional dose of basiliximab in the setting of MTP during OHT did not demonstrate a statistically significant increase in the risk of infection nor reduce the risk of rejection. The presence of LVAD at time of transplant was associated with an increased risk of infection and careful consideration should be given to these patients when selecting their induction regimen.

Sex differences in the likelihood of pre-emptive living donor kidney transplantation, and outcomes after kidney transplantation in children and adolescents.

Data on sex-based disparities in children with kidney failure and outcomes after kidney transplantation are relatively sparse. This study examined the association between sex differences and the odds of receiving a pre-emptive living donor kidney transplantation, and post-transplant outcomes in children and adolescents. We studied all patients (aged <20years) who commenced kidney replacement therapy (KRT) between 2002 and 2017 using data from the ANZDATA Registry. Factors associated with graft loss and acute rejection after transplantation were assessed using multivariable Cox regression model. Differences in the odds of receiving a pre-emptive live donor transplant between sexes were assessed using adjusted logistic regression. Of the 757 children transplanted during the study period, 497 (65.7%) received a live donor kidney (163, 21.5% pre-emptive). In total, 168 (22.2%) patients experienced graft loss and 213 (28.1%) patients experienced a first episode of acute rejection during the median follow-up period of 6.9years (IQR 3.5-11.5years). There were no differences in the rates of graft loss or acute rejection by sex. Compared with boys, the adjusted hazard ratios (aHR) (95% confidence interval) for graft loss and acute rejection in girls were 0.97 (0.71-1.33) and 1.09 (0.82-1.44), respectively. Among children who received living donor kidney transplants, there were no sex differences in the odds of receiving a pre-emptive transplant (adjusted odds ratio (aOR) 0.90 (95% CI 0.56-1.45)). No sex differences were observed in the odds of receiving a pre-emptive living donor kidney transplant or outcomes after kidney transplantation.

Kidney transplantation outcomes in lupus nephritis: A 37-year single-center experience from Latin America.

We assessed patient and graft outcomes and prognostic factors in kidney transplantation in patients with end-stage kidney disease (ESKD) secondary to lupus nephritis (LN) undergoing kidney transplantation from August 1977 to December 2014 in a Latin American single center. The primary endpoint was patient survival, and the secondary endpoints were death-censored graft survival for the first renal transplant and the rate of recurrent LN (RLN). Kaplan-Meier method was used for survival analysis. Factors predicting patient and death-censored graft survivals were examined by Cox proportional-hazards regression analyses. 185 patients were retrospectively evaluated. Patient survival rates were 88% at one year, 82% at three years, 78% at five years, and 67% at ten years. Death-censored graft survival for the first renal transplant was 93% at one year, 89% at three years, 87% at five years, and 80% at ten years. RLN was diagnosed in 2 patients (1.08%), but no graft was lost because of RLN. Thirty-nine (21.1%) patients died, and 65 (35.1%) patients experienced graft loss during the follow-up. By multivariable analyses, older recipient age and 1-month posttransplantation eGFR <45 ml/min/1.73m2 were associated with lower patient survival and an increased risk of graft loss, while induction immunosuppressive therapy exerted a protective effect on patients' survival. In the subgroup of patients in whom disease activity was measured at the time of transplantation, a higher SLEDAI score was also associated with lower patient survival and an increased risk of graft loss. In a mostly Mestizo population, kidney transplantation is an excellent therapeutic alternative in LN patients with ESKD. Older recipient age, an eGFR <45 ml/min/1.73m2 at one month posttransplantation, and disease activity at the time of transplantation are predictive of a lower patient and death-censored graft survival, while induction immunosuppressive therapy has a protective effect on patient survival. RLN is rare and does not influence the risk of graft loss.

Statin Therapy and the Incidence of Thromboembolism and Vascular Events Following Liver Transplantation.

Statin therapy may reduce the risk of venous thromboembolism (VTE), which may impact solid organ transplant outcomes. We evaluated the incidence of VTE and other complications after liver transplantation stratified by hyperlipidemia status and statin use using a retrospective cohort study approach. We reviewed all primary orthotopic liver transplantation (OLT) records from January 2014 to December 2019 from our center. Intraoperative deaths were excluded. Recipient, donor clinical and demographic data were collected. We developed risk-adjusted models to assess the effect of statin use on the occurrence of VTE, hepatic artery complications (HACs), graft failure, and death, accounting for clinical covariates and competing risks. A total of 672 OLT recipients were included in the analysis. Of this cohort, 11.9% (n=80) received statin therapy. A total of 47 patients (7.0%) had VTE events. HACs occurred in 40 patients (6.0%). A total of 42 (6.1%) patients experienced graft loss, whereas 9.1% (n=61) of the cohort died during the study interval. Eighty OLT recipients (29.8%) were treated with statins. In the statin treated group, 0% of patients had VTE versus 7.9% of those not on statins (P=0.02). HACs were identified in 1.2% of the statin group and 6.8% of the nonstatin group. Untreated hyperlipidemia was associated with a 2.1-fold higher risk of HACs versus patients with no hyperlipidemia status (P=0.05). Statin therapy was associated with significantly better risk-adjusted thromboembolic event-free survival (absence of VTE, cerebrovascular accident, myocardial infarction, HACs, and death); hazard ratio, 2.7; P=0.01. These data indicate that statin therapy is correlated with a lower rate of VTE and HACs after liver transplantation.

The Management of Immunosuppression in Kidney Transplant Recipients with COVID-19 Disease: An Update and Systematic Review of the Literature.

Background and Objectives: In the era of the coronavirus disease 2019 (COVID-19) pandemic, the management of immunosuppressive (IS) therapy in kidney transplant (KT) recipients affected by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) requires attention. It is not yet understood whether IS therapy may protect from the cytokine storm induced by SARS-CoV-2 infection or a temporary adjustment/withdrawal of IS therapy to restore the immune system may be necessary. We performed a systematic literature review to investigate the current management of IS therapy in KT recipients with COVID-1. Materials and Methods: Out of 71 articles published from 1 February 2020 until 30 October 2020, 554 KT recipients with SARS-CoV-2 infection were identified. Results: Modifications of IS therapy were based on the clinical conditions. For asymptomatic patients or those with mild COVID-19 symptoms, a “wait and see approach” was mostly used; a suspension of antimetabolites drugs (347/461, 75.27%) or mTOR inhibitors (38/48, 79.2%) was adopted in the majority of patients with symptomatic COVID-19 infections. For CNIs, the most frequent attitude was their maintenance (243/502, 48.4%) or dose-reduction (99/502, 19.72%) in patients asymptomatic or with mild COVID-19 symptoms, while drug withdrawal was the preferred choice in severely symptomatic patients (160/450, 31.87%). A discontinuation of all IS drugs was used only in severely symptomatic COVID-19 patients on invasive mechanical ventilation. Renal function remained stable in 422(76.17%) recipients, while 49(8.84%) patients experienced graft loss. Eight (1.44%) patients experienced a worsening of renal function. The overall mortality was 21.84%, and 53(9.56%) patients died with functioning grafts. Conclusion: A tailored approach to the patient has been the preferred strategy for the management of IS therapy in KT recipients, taking into account the clinical conditions of patients and the potential interactions between IS and antiviral drugs, in the attempt to balance the risks of COVID-19-related complications and those due to rejection or graft loss.

Clinical outcomes of the first 300 cases of kidney transplantation: a single-center retrospective cohort study

BackgroundKidney transplantation (KT) is regarded as the most effective treatment for end-stage renal disease. The annual number of KT cases in South Korea has increased rapidly as more centers are implementing a transplantation program. The objective of this study was to determine clinical outcomes of the first 300 consecutive cases of KT in a single center.MethodsClinical data of 300 cases of KT at Seoul National University Bundang Hospital from January 2004 to March 2018 were obtained from a prospectively collected database and retrospectively reviewed.ResultsThe mean age of patients was 47.7±12.9 years, and 59% of patients were male. There were 225 living donors and 75 deceased donors. A total of 42 cases were from ABO-incompatible donors. During a mean follow-up of 68.6±43.5 months, 38 patients (12.7%) experienced rejection. The most common cause was acute T-cell mediated rejection (9.0%). Eighteen patients experienced graft loss. One-year and 5-year death-censored graft survival rates were 99% and 96.6%, respectively. One-year and 5-year patient survival rates were 98.3% and 96.6%, respectively. Multivariate analysis revealed that graft weight-to-recipient weight ratio and rejection were significant factors affecting graft survival.ConclusionsThis single-center review demonstrates clinical outcomes comparable to other major centers. Such good outcomes were obtained by good patient selection, dedicated transplant physicians, and adequate use of immunosuppressive therapy.

Influence of epidemiology, immunosuppressive regimens, clinical presentation, and treatment on kidney transplant outcomes of patients diagnosed with tuberculosis: A retrospective cohort analysis.

Tuberculosis (TB) mortality is high among kidney transplant (KT) recipients. Although local epidemiology is an important factor, diagnostic/therapeutic challenges and immunosuppressive therapy (ISS) may influence outcomes. We analyzed the cumulative incidence (CumI) of TB in KT recipients receiving a variety of ISS with long-term follow-up. Our retrospective single-center cohort study included all KT procedures performed between January 1, 1998, and August 31, 2014, with follow-up until August 31, 2014. Induction therapy was based on perceived immunological risk; maintenance ISS included prednisone and calcineurin inhibitor (CNI) plus azathioprine (AZA), and mycophenolic acid (MPA) or mechanistic target of rapamycin inhibitor (mTORi). Thirty-four patients received belatacept/MPA. KT was performed on 11 453 patients and followed for 1989 (IQR 932 to 3632) days. Among these, 152 patients were diagnosed with TB (CumI 1.32%). Median time from KT to TB was 18.8 (IQR 7.2 to 60) months, with 59% of patients diagnosed after the first year. Unadjusted analysis revealed an increasing confidence interval (CI) of TB (0.94% CNI/AZA vs 1.6% CNI/MPA [HR = 1.62, 95% CI = 1.13 to 2.34, P=.009] vs 2.85% CNI/mTORi [HR = 2.45, 95% CI = 1.49 to 4.32, P<.001] vs 14.7% belatacept/MPA [HR = 13.14, 95% CI = 5.27 to 32.79, P<.001]). Thirty-seven (24%) patients died, and 39 (25.6%) patients experienced graft loss. Cytomegalovirus infection (P=.02) and definitive ISS discontinuation (P<.001) were associated with death. Rejection (P=.018) and ISS discontinuation (P=.005) occurred with graft loss. TB occurred at any time after KT and was influenced by ISS.

Adverse effect of tocilizumab treatment on split thickness skin graft—a case report

Tocilizumab is a biological immunosuppressive drug used in the treatment of psoriasis arthritis. It works by blocking the interleukin 6 receptor and therefor blocking the immune response caused by IL-6 which plays an important role in arthritis. Tocilizumab is commonly used in RA patients who either have experienced insufficient effect of other treatment options or who have had unacceptable side effects from previous treatment. With this case report, we would like to raise awareness of a potentially previously unheard of adverse effect of tocilizumab treatment on split thickness skin graft (STSG). We present a case of a 61-year-old man, treated with tocilizumab for severe poly-articular, erosive psoriasis arthritis. He was diagnosed with BCC on the scalp and underwent excision followed by STSG with no complications. The patient experienced graft loss after commencing tocilizumab treatment days to weeks post grafting on numerous occasions. We find this possible adverse effect of tocilizumab on skin grafts to be of great importance to report as it is not previously mentioned in any literature. We hope that this case report will increase the awareness of this possible adverse effect on STSG in patients treated with tocilizumab (TCZ). As the patient is dependent on arthritis symptoms to be well controlled, it is of great importance to both medical and surgical teams responsible for treatment to be able to collaborate to plan best treatment, timing, and strategy.Level of Evidence: Level V, risk / prognostic study Level of Evidence: Level V, risk / prognostic study.

Association between post-transplant red cell distribution width and prognosis of kidney transplant recipients

The role of elevated post-transplant red cell distribution width (RDW) as a predictive factor for graft loss remains unclear, although RDW was reported to be significantly associated with poor prognosis in various clinical fields. We performed a retrospective cohort study with 2,939 kidney transplant patients from two tertiary teaching hospitals in Korea. RDW level at transplantation and 3-months post-transplantation were collected. Those with RDW in the upper quartile range were considered to have increased RDW (>14.9%). Death-with-graft-function (DWGF), death-censored graft failure (DCGF), and composite graft loss were assessed as the study outcomes, using multivariable cox proportional hazard model. At the median follow-up duration of 6.6 (3.6–11.4) years, 336 patients experienced graft loss. There were 679 patients with elevated RDW at 3-months post-transplant. Elevated RDW was associated with composite graft loss (adjusted hazard ratio, 1.60, 95% confidence interval, 1.23–2.07, P < 0.001), even after adjusted for hemoglobin and various clinical factors. The 1% increment of post-transplant RDW was also significantly associated with the outcome, regardless of the presence of anemia. The worst prognosis was seen in patients with elevated RDW after transplantation, but not at baseline. Therefore, post-transplant RDW level may be significantly associated with patient prognosis, independent of hemoglobin values.

Renal Impairment and Complication After Kidney Transplant at Queen Rania Abdulla Children's Hospital.

Kidney transplant is the treatment of choice for end-stage renal disease, but it is not without complications. We review the medical cause of significant renal impairment and complications that developed after kidney transplant in pediatric patients who required hospital admission and intervention and/or who were followed between 2007 and 2016. A retrospective noninterventional chart review study was conducted in pediatric patients who received a kidney transplant and/or followed at the nephrology clinic at Queen Rania Abdulla Children's Hospital between 2007 and 2016. In this study, 101 pediatric patients received a total of 103 transplants. Forty-eight patients (47%) experienced deterioration of kidney function out of a total of 53 episodes of complications; 37 of these episodes occurred early (0-6 mo after transplant), and 26 episodes occurred late. The causes of kidney function deterioration were surgical complications, acute tubular necrosis, cell- or antibody-mediated rejection, diabetes mellitus, urinary leak, recurrence of original disease, and chronic allograft nephropathy. Thirteen patients experienced graft loss; 50% of these losses were secondary to noncompliance to immunosuppressant medication treatment after transplant. A total of six patients died; 2 (23%) of these deaths occurred in the first week after transplant, whereas the other 4 patients died over a period of 10 years. Pediatric kidney transplant is not without complications; however, most of these complications are treatable and reversible. The most serious complications leading to graft loss and death occur early, in the first week after transplant. Improving immunosuppressant compliance after transplant would prevent 50% of graft losses.

Surveillance Registry of Sirolimus Use in Recipients of Kidney Allografts From Expanded Criteria Donors.

The use of expanded criteria donor (ECD) kidneys has increased the overall availability of renal transplants. This study assessed the use of sirolimus in patients receiving Argentina-ECD kidneys. This observational, open-label, 1-arm, prospective, longitudinal pilot study was conducted at 8 transplant centers in Argentina. Adults receiving kidney transplants (without pancreas) from ECDs were eligible if they were converted to sirolimus 1 to 36 months' posttransplantation, with sirolimus becoming base therapy within 1 month after conversion. Patients were followed up for 1 year. Outcomes included reasons for conversion, acute rejection, patient and graft survival, graft status, and safety. The intention-to-treat population included 52 patients (mean age, 48.7 years). Calcineurin inhibitor nephropathy (40%) and chronic allograft nephropathy (25%) were the most frequent reasons for conversion. Two acute rejections occurred during follow-up, but no patients experienced graft loss. One patient died during follow-up, and 3 patients died within 1 month of the last sirolimus dose. Levels of serum creatinine and creatinine clearance remained stable from baseline to week 52/53. Mean proteinuria measured in a subset of patients was 0.2 ± 0.2 g/24 hours before conversion and increased to 0.6 ± 1.2 g/24 hours at week 24/25 and 0.5 ± 0.6 g/24 hours at week 52/53. Adverse events were consistent with those in previous conversion trials; the most common were infections and infestations (54%). This pilot study illustrates the potential benefits of sirolimus in recipients of ECD kidneys in Argentina. Larger, randomized controlled trials are needed to confirm these findings and to clarify the long-term benefits of sirolimus in this patient population.

Short-Term Outcomes of ABO-Incompatible Living Donor Kidney Transplantation With Uniform Protocol: Significance of Baseline Anti-ABO Titer

Antibody-mediated rejection (AMR) is one of the major causes of poor outcomes in ABO-incompatible kidney transplantation (ABOi KT). Studies investigating AMR risk factors found that anti-ABO titer is a major issue. However, the significance of antibody titer has been debated. This retrospective study analyzed AMR risk factors in 59 patients who underwent ABOi KT between August 2010 and January 2015. We also analyzed AMR risk factors in recipients with high anti-ABO baseline titers (≥1:64 on dithiothreitol at 37°C phase or ≥1:256 on antihuman globulin phase). The 2-year patient survival rate was 95.8%, and the 2-year graft survival rate was 94.9%. Nine patients (15.3%) experienced clinical (6 of 59 [10.2%]) or subclinical (3 of 59 [5.1%]) AMR. One patient experienced graft loss from hyperacute rejection. AMR risk factor analysis revealed that baseline antibody titer was associated with incidence of AMR. In patients with high baseline titers, low doses of rituximab (200-mg single-dose), an antibody against CD20, was predictive for AMR. Six patients who received pretransplant intravenous immunoglobulin did not experience AMR even when they had high baseline antibody titers. Our results indicate that a high baseline antibody titer affected the incidence of AMR. ABOi KT candidates with high baseline titers need to undergo an intensified preconditioning protocol, including high-dose rituximab (375 mg/m2) and intravenous immunoglobulin.

Quantifying Renal Allograft Loss Following Early Antibody-Mediated Rejection

Unlike antibody-mediated rejection (AMR) with clinical features, it remains unclear whether subclinical AMR should be treated, as its effect on allograft loss is unknown. It is also uncertain if AMR's effect is homogeneous across donor (deceased/live) and (HLA/ABO) antibody types. We compared 219 patients with AMR (77 subclinical, 142 clinical) to controls matched on HLA/ABO-compatibility, donor type, prior transplant, panel reactive antibody (PRA), age and year. One and 5-year graft survival in subclinical AMR was 95.9% and 75.7%, compared to 96.8% and 88.4% in matched controls (p = 0.0097). Subclinical AMR was independently associated with a 2.15-fold increased risk of graft loss (95% CI: 1.19-3.91; p = 0.012) compared to matched controls, but not different from clinical AMR (p = 0.13). Fifty three point two percent of subclinical AMR patients were treated with plasmapheresis within 3 days of their AMR-defining biopsy. Treated subclinical AMR patients had no difference in graft loss compared to matched controls (HR 1.73; 95% CI: 0.73-4.05; p = 0.21), but untreated subclinical AMR patients did (HR 3.34; 95% CI: 1.37-8.11; p = 0.008). AMR's effect on graft loss was heterogeneous when stratified by compatible deceased donor (HR = 4.73; 95% CI: 1.57-14.26; p = 0.006), HLA-incompatible deceased donor (HR = 2.39; 95% CI: 1.10-5.19; p = 0.028), compatible live donor (no AMR patients experienced graft loss), ABO-incompatible live donor (HR = 6.13; 95% CI: 0.55-67.70; p = 0.14) and HLA-incompatible live donor (HR = 6.29; 95% CI: 3.81-10.39; p < 0.001) transplant. Subclinical AMR substantially increases graft loss, and treatment seems warranted.

Eculizumab and splenectomy as salvage therapy for severe antibody-mediated rejection after HLA-incompatible kidney transplantation.

Incompatible live donor kidney transplantation is associated with an increased rate of antibody-mediated rejection (AMR) and subsequent transplant glomerulopathy. For patients with severe, oliguric AMR, graft loss is inevitable without timely intervention. We reviewed our experience rescuing kidney allografts with this severe AMR phenotype by using splenectomy alone (n=14), eculizumab alone (n=5), or splenectomy plus eculizumab (n=5), in addition to plasmapheresis. The study population was 267 consecutive patients with donor-specific antibody undergoing desensitization. In the first 3 weeks after transplantation (median=6 days), 24 patients developed sudden onset oliguria and rapidly rising serum creatinine with marked rebound of donor-specific antibody, and a biopsy that showed features of AMR. At a median follow-up of 533 days, 4 of 14 splenectomy-alone patients experienced graft loss (median=320 days), compared to four of five eculizumab-alone patients with graft failure (median=95 days). No patients treated with splenectomy plus eculizumab experienced graft loss. There was more chronic glomerulopathy in the splenectomy-alone and eculizumab-alone groups at 1 year, whereas splenectomy plus eculizumab patients had almost no transplant glomerulopathy. These data suggest that for patients manifesting early severe AMR, splenectomy plus eculizumab may provide an effective intervention for rescuing and preserving allograft function.

Outcome of Kidney Transplantations Performed With Preformed Donor-Specific Antibodies of Unknown Etiology

The detection of preformed donor-specific alloantibodies (DSA) with multiplex-bead arrays has led to the common observation that individuals without a history of pregnancy, transfusion or transplantation can have circulating anti-HLA antibodies of unknown etiology. We retrospectively analyzed the risk of antibody-mediated rejection (AMR) and graft outcome in 41 kidney transplant recipients with DSA of unknown etiology (DSA cause-unk) at the time of transplantation. Twenty-one patients received a posttransplantation desensitization protocol, and 20 received standard immunosuppressive therapy. The mean number of DSA was 1.4 ± 0.8, ranging from 1 to 5. Complement-dependent cytotoxicity crossmatches were negative for all the patients. Flow cytometry crossmatches were positive in 47.6% of cases. The incidence of acute AMR was 14.6% at 1 year, regardless of the immunosuppressive regimen. No patients experienced graft loss following AMR. At month 12, across the entire population of patients with DSA cause-unk, the outcomes were favorable: the measured glomerular filtration rate was 63.8 ± 16.4 mL/min/1.73 m2, the screening biopsies showed low frequencies of microvascular inflammation and no transplant glomerulopathy, and graft and patient survival were 100%. In conclusion, patients with DSA cause-unk are able to mount AMR but have favorable 1-year outcomes.

Left Atrial Diameter and Survival among Renal Allograft Recipients

Sequential echocardiography is routinely performed in patients with ESRD listed for transplantation. The benefit of this labor- and time-intensive measure, however, remains unclear. Thus, this study elucidated the various obtained routine echocardiography parameters that best predicted mortality and graft survival after renal transplantation. This study investigated 553 first renal transplant recipients listed in the Austrian Dialysis and Transplant Registry between 1992 and 2011 who had echocardiographic analysis at transplantation and survived at least 1 year. Cox proportional hazards models with the purposeful selection algorithms for covariables were used to identify predictors of mortality and graft loss. A Fine and Gray model was used to evaluate cause-specific death. During a median follow-up of 7.14 years, 81 patients died, and 59 patients experienced graft loss after the first year. The Kaplan-Meier analysis showed that 85% of patients with a left atrial diameter below the median of 53 mm were alive 10 years after transplantation, whereas only 70% of those patients with a left atrial diameter equal to or above the median had survived (P<0.001). In the multivariable model, left atrial diameter (per millimeter) independently predicted overall mortality (hazard ratio, 1.06; 95% confidence interval, 1.03 to 1.08; P<0.001) and cause-specific cardiac death (hazard ratio, 1.04; 95% confidence interval, 1.00 to 1.08; P=0.04). Functional graft loss was predicted by the right atrial diameter (hazard ratio, 1.04; 95% confidence interval, 1.02 to 1.07; P=0.001). The left atrial diameter determined at transplantation predicted overall and cardiac mortality. Patients with widely enlarged left atria exhibit a considerably reduced life expectancy. It remains to be determined, however, whether renal transplantation is futile in these patients.

Rotavirus Infection in Adult Small Intestine Allografts: A Clinicopathological Study of a Cohort of 23 Patients

Rotavirus enteritis (RVE) is increasingly recognized as a cause of small bowel allograft dysfunction but its significance in adult patients is unknown. We have studied 23 adult small bowel transplant patients aged 19.8-59 years (mean = 38.2 years), who were presented with diarrhea and tested positive for rotavirus by enzyme-linked immunosorbent assay methods. Serial follow-up biopsies, as well as clinical data, are documented and analyzed. These patients were followed up for an average of 168 days (range 33-534 days). Mean time of rotavirus diagnosis from transplant day was 794 days (range 38-2907 days). Self-limited diarrhea lasting 6-13 days (mean = 9 days) was the main presentation. Sixteen (69.6%) patients developed acute cellular rejection either concurrently with (i.e. six patients) or after (10 patients) RVE, often characterized by prominent mucosal plasmacytosis at an average of 22 days (range 0-94 days) from the day RVE was diagnosed. One-third of patients with acute rejection (i.e. five out of 16) required muromonab-CD3 rescue therapy. Two patients experienced graft loss (one from chronic rejection, another from sepsis). Rotavirus infection is a cause of diarrhea in adult small bowel transplant patients. The infection appeared to trigger cellular rejection that was associated with mucosal plasmacytosis, and sometimes required aggressive rescue therapy.

Visceral leishmaniasis in the early post-transplant period after kidney transplantation: clinical features and therapeutic management

Visceral leishmaniasis (VL) is a rare complication of kidney transplantation, with <100 cases reported in the literature. It is a life-threatening condition and usually occurs as a late complication after transplantation, with a median delay of 18 months between transplantation and onset of disease. We report the clinical features and management of 5 kidney transplant recipients who presented with VL in the early post-transplant period. All patients were successfully treated with liposomal amphotericin B (L-AMB), but 2 patients experienced graft loss. VL should be considered in the differential diagnosis in kidney transplant recipients living in endemic areas, who present with unexplained fever and pancytopenia in the early post-transplant period. Leishmania serology should be included in the screening of all transplant recipients, in order to identify a group of patients who could benefit from preemptive anti-Leishmania therapy. Therapy with L-AMB is highly effective and well tolerated in kidney transplant recipients with VL.

Results of the Conversion to Everolimus in Renal Transplant Recipients With Posttransplantation Malignancies

Management of posttransplantation malignancies should include control of the neoplasia and preservation of renal function. Conversion to everolimus (EVL) would potentially have both effects. Twenty-one patients were converted to EVL due to posttransplantation neoplasms. We have presented herein descriptive data and postconversion (PC) outcomes among subjects of mean age 53.6 ± 10.1 years (range, 36–69), 57.1% were males, undergoing conversion at 108.2 ± 74.7 (range, 5–316) months after transplantation. All patients received standard immunosuppressive therapy and 9.5% had been induced with thymoglobulin. Malignant neoplasms were as follows: skin (n = 7), gynecological (n = 3), gastrointestinal (n = 3), PTLD (n = 2), renal (n = 2), CNS (n = 1), seminoma (n = 1), Kaposi's sarcoma (n = 1), and prostate cancer (n = 1). PC to EVL, calcineurin inhibitors (CNIs) were discontinued in 18 of 19 patients, mycophenolate in 9/12, and azathioprine in 5/7; all patients continued to receive steroids. In 16 patients (79%) tumors were removed. Chemotherapy was performed in 2 patients with PTLD and radiotherapy was performed in 1 patient with prostate cancer. Mean follow-up was 505 days (range, 59–1151); baseline glomerular filtration rate (GFR) was 53.5 ± 21.6 mL/min versus 48.5 ± 25.7 mL/min ( P = not significant [NS]) at the last control. One patient experienced graft loss at day 744 after conversion due to chronic rejection. Adverse events were observed in 57% of patients and 28% displayed infections; no patient discontinued EVL. There were 2 deaths: 1 due to an infection and the other due to postsurgical complication. No deaths due to cancer progression were observed. The results observed in this series suggested that conversion to EVL for a posttransplantation neoplasm is a valid therapeutic alternative to preserve graft function and control disease progression.