Pre-emptive Renal Transplantation Research Articles

P434 Incidence of chronic end-stage renal disease in patients with inflammatory bowel disease: a population-based cohort study from the French National Health Insurance Database

Abstract Background Renal disorders are among the extra-intestinal manifestations of inflammatory bowel disease (IBD), and treatments may also lead to renal failure. However, the incidence of end-stage renal disease (ESRD), defined as the need for renal replacement therapy (dialysis and/or renal transplantation(RT)), is poorly known. The primary objective of our study was to assess the incidence of ESRD in IBD patients, and to compare it with the non-IBD population. Methods We conducted a prognostic cohort study based on data from the French National Health Insurance Database(SNDS). Prevalent cases of IBD affiliated to the general health insurance scheme during the period 2011-2020 were identified on the basis of declarations long-term diseases ALD 24 or the presence of 2 hospital stays for IBD with ICD-10 codes or a single stay with reimbursement of specific treatments. Incident cases of ESRD were identified on the basis of a stay with a RT or a period with dialysis sessions for at least 45 days. Crude incidence rates of ESRD were calculated over the period for the IBD and the non-IBD population, with their 95% confidence intervals. Results A total of 280,283 IBD patients were included in the study over the period 2011-2020, 134,567 with ulcerative colitis(UC) and 145,716 with Crohn’s disease(CD). The mean age at study inclusion was 39.8 (± 17.1) years. The M/F sex ratio was 0.9. The mean age at incidence of ESRD in the non-IBD population was 65.0 (±17.0) years, the M/F sex ratio cases was 1.7. Among IBD patients, 534 patients began replacement therapy by dialysis or RT, they were younger than non-IBD patients (60.3(±16.7)years, P<0.001).The mean incidence rate of ESRD over the period was 26.4 per 100,000 person-years (IC95% 23.1-29.6), 480 (89.9%) patients entered ESRD by dialysis, and 54 (10.1%) by preemptive RT. In the non-IBD population the mean rate of ESRD was 15.9 per 100,000 person-years (IC95% 14.8- 17.1; P<0.0001 compared with IBD): 79,606 (94.5%) patients entered ESRD by dialysis, and 4,634 (5.5%) by RT (as compared with IBD,P<0.001). In subgroup analysis, the mean incidence rate of ESRD was 22.8 per 100,000 person-years (IC95% 18.9-26.7) in UC patients and 29.5 (IC95% 25.3-33.6) in CD patients. The rates of preemptive RT were 12.4% in UC patients (87.6% dialysis) and 8.6% in CD patients (91.4% dialysis). Over a median follow-up of 6.8 years, the survival rate after ESRD was 40.8% in ESRD-IBD patients VS 34.2% in ESRD non-IBD patients (P<0.001). Conclusion This study shows that the incidence of ESRD is significantly higher in IBD than in the non-IBD population, confirming the need for regular monitoring of renal function in our patients. The high incidence of RT confirms that access to transplantation is not restricted in this population.

Posttransplant Thrombotic Microangiopathy: Unraveling a Mystery

A 24 year old lady who was diagnosed with chronic kidney disease stage 5 in 2016 underwent a pre-emptive live related renal transplant in the same year. She had kidney allograft dysfunction and eventually lost the transplant kidney in 2019 requiring hemodialysis. She underwent a deceased donor renal transplant in February 2022. She developed allograft dysfunction with a creatinine of 2.5 mg/dl in October 2022, and a renal allograft biopsy subsequently showed Thrombotic microangiopathy, arteriolar form. There were no features of rejection in the biopsy and Donor specific antibody done by Luminex lysate method was negative. Her Single antigen bead done subsequently was also negative. CMV DNA PCR was not detectable. Tacrolimus was switched to Cyclosporine, however her allograft function continued to worsen. Complement mutation analysis was negative and acquired complement defects were also not detected. Subsequently, Single antigen bead for non HLA antibodies showed positivity for MICA antibodies. She underwent 7 sessions of plasmapheresis and her renal functions did not improve and her creatinine continued to increase to 4.2 mg/dl. Complement activating assay for these MICA antibodies was positive. She was treated with two doses of 300 mg Eculizumab in December 2022, her allograft functions in February 2023 have improved to 2 mg/dl. This case highlights the extensive evaluation for post transplant TMA, the use of non HLA antibody assays and complement activating assays of these antibodies to decide on appropriate use of Eculizumab for salvaging transplant allograft.

348.5: Life Threatening, Cytokine Release Storm (CRS) With Antithymocyte Globulin (ATG) And Its Management

Introduction: Cytokine Release Storm (CRS) leading to fatal or near fatal hypotension has been reported in association with anti thymocyte globulin (ATG) administration. This is a very rare and unusual manifestation of ATG and early recognition and management of this unexpected manifestation will help save lives. We report a near fatal case of CRS, during renal transplantation, associated with ATG administration, its diagnosis and management. Materials and Methods: A 27-year-old, otherwise healthy male with Alport’s syndrome was undergoing live related preemptive renal transplant. Patient received morning dose of Solu-Medrol and CellCept and was getting Anti Thymocyte Globulin (ATG) slowly after the test does, as the recipient vascular bed was being prepared. Patient started to become hypotensive which was treated with IV fluids and pressors including norepinephrine, epinephrine and dopamine.There was no bleeding from recipient vascular bed.A stat chest x-ray, EKG and echocardiogram on the OR table were normal with good LV function. Despite maximum dose pressor support and IV fluids, the mean blood pressure was around 45 - 50 mm Hg and a systolic blood pressure was around 65-70 mm Hg, leading to severe metabolic acidosis and lactate buildup. The transplant was canceled and the donor was closed unharmed and the patient was moved to ICU, intubated. His response to colloids was slightly better, but transient, so he was transfused 4 units of blood as volume expander that does not leak into 3rd space.This brought his blood pressure to about 90 mm Hg. A presumptive diagnosis of ATG induced CRS was made. His inflammatory markers including IL-6, ferritin, D-dimers and CRP were very high. 400 mg of Tocilizumab (Actemra) an IL-6 inhibitor along with broad-spectrum antibiotics were given. Patient also started to developed disseminated intravascular coagulation (DIC) with deranged coagulation screen and some oozing from the wound which was treated with FFPs. In next 12 hours, the patient started to stabilize and in next 48 hours he was extubated. Discussion: Cytokine Release Storm (CRS) is a potentially fatal condition unless recognized and treated early and aggressively. In COVID pandemic, much better understanding of CRS along with its symptomatology, easy availability of its lab tests and IL- 6 inhibitors became possible. High index of suspicion is extremely important in making an early diagnosis and for early treatment. In transplant patients, use of ATG is now standard of care and very few cases of ATG induced CRS are reported. In our case, early diagnosis of CRS from ATG, use of blood as volume expander, early administration of IL-6 inhibitor and aggressive management of DIC turned out to be the life Saver. Conclusion: In patients receiving ATG, with unexplained hypotension, nonresponsive to IV fluids and pressors, high index of suspicion of ATG induced CRS with early diagnosis and aggressive management can save lives.

POS-784 DOES PRE-EMPTIVE KIDNEY TRANSPLANTATION VERSUS POST START OF DIALYSIS TRANSPLANTATION IMPROVE OUTCOMES AFTER TRANSPLANTATION?

Preemptive renal transplantation (PRT), is defined as transplantation before the initiation of dialysis. By avoiding complications associated with dialysis, preemptive renal transplantation offers significant benefits in terms of societal cost-saving. The aim of this study is to measure the outcomes of these patients in terms of death and graft loss rates, and adverse events (infection, cancer, major adverse cardiovascular events).

Preemptive renal transplant: too early is not always better-a national cohort study.

Preemptive renal transplants (PRT) confer better outcomes than renal transplants performed after initiation of hemodialysis. PRTs are occurring at progressively higher residual recipient renal function. We evaluated donor, recipient, and transplant characteristics of 26,384 preemptive transplants between 2010 and 2019 using the United Network of Organ Sharing (UNOS) database. Recipients of PRTs were divided into four distinct groups depending upon the glomerular filtration rate (GFR) (GFR [Formula: see text] 10, 10 < GFR [Formula: see text] 15, 15 < GFR [Formula: see text] 19 and > 19, ml/min/1.73 m2) at the time of transplant. We followed graft and patient survival for five years and assessed donor, recipient, and transplant characteristics such as race, gender, and type of insurance. PRTs occurring at GFR > 19ml/min (early preemptive renal transplants, ePRT) from live and deceased donors were not associated with improved graft nor patient survival compared to the other preemptive transplants. PRTs occurring at GFR range of 10-15ml/min conferred the best graft survival. Black donor-recipient pairs were 54% less likely to be involved in ePRT, while non-Hispanic White donor-recipient pairs were 20% more likely to receive ePRT. ePRT represents misallocation of valuable organ resources and a waste of native renal function. There is no evidence that ePRT is associated with superior graft or patient survival compared to the other preemptive transplants. Conversely, ePRT produces poorer graft and patient survival outcomes compared to the other PRTs. GFR range of 10-15ml/min is optimal and associated with superior outcomes.

A preemptive living donor renal transplant in an HIV positive patient from an HIV positive donor

With recent advances in the treatment of human immunodeficiency virus (HIV), renal transplantation is no longer considered a contraindication in properly selected HIV-positive patients. Several studies have demonstrated comparable patient and graft outcomes between HIV-negative and HIV-positive renal transplant recipients. Most of the information on outcomes of HIV-positive to HIV-positive transplantation is based on data from deceased donors. There are only a handful of case reports about living donor renal transplantation in an HIV-positive patient from an HIV-positive donor. Furthermore, there is no report in the world of preemptive living donor renal transplantation in this setting. Here, we report a case of successful preemptive renal transplantation in an HIV-positive recipient from an HIV-positive living donor performed at our center.

Pediatric renal transplantation; 10 years experience.

Although renal transplantation (RT) is the first treatment option for children with end-stage renal failure, the number of transplanted chil- dren remains low compared to adults. Experience of the individual pediatric transplant center is very important in the prognosis of pediatric transplant recipients. In this study, our pediatric RT experience was presented. We retrospectively analyzed the data of 27 patients who had RT in our clinic between April 2009 and April 2019. Fifteen of the patients were males, and mean age of all patients was 12.36 ± 4.18 years (range 4-17 years). The most frequent etiology for end- stage renal disease (ESRD) was vesicourethral reflux. Eighteen (66.7%) of the transplanted kidneys came from cadaveric donors and 9 (33.3%) from live donors. One patient had preemptive RT and one patient had a re-RT. Twenty-two patients were on peritoneal dialysis program and four patients were on hemodialysis program. Mean dialysis time before transplantation was 29 (3-104) months. Bleeding was the most common surgical complication. Delayed graft function developed in four patients, and all of their grafts were from cadaveric donors. Rejection developed in 12 of our patients, graft loss was observed in only four of them. Considering all patients, graft survival rates were 100% in the 1st and 3rd years, and 92% in the 5th year. Pediatric RT program is difficult to establish, maintain and develop. Complications after transplantation are not uncommon; therefore, early detection and appropriate management are needed. Strategies are still needed to increase post-transplant success.

MO028AUTOSOMAL DOMINANT POLYCYSTIC KIDNEY DISEASE: REGISTRY OF NORTHERN CYPRUS

Abstract Background and Aims Autosomal dominant polycystic kidney disease (ADPCK) is the most prevelant inherited kidney disease in adults, and the fourth common cause for renal replacement therapy worldwide and preventive measures should be taken to slow the decline in renal functions. From previous studies we already know that hereditary kidney diseases such as medullary kidney disease and tubular kidney diseases are frequent in Cyprus. In this study, we aim to find out the situation for ADPKC in North Cyprus and declare the overall magnitude of the problem in our region. Method From January 2004 to January 2021, we collected data from all patients with ADPCK irrespective of whether they were on RRT or not and who were followed in nephrology departments within Northern Cyprus. Clinical and demographic data of all the patients aged above 18 were collected. The affected families and their route of inheritance were determined. Need for renal replacement therapy (RRT) and types of RRT were noted. RRT rate and death rate were calculated. Results We collected information from a total of 79 patients with the diagnosis of ADPCK; 3 patients were excluded due to lost to follow up. There was no family history in 11% of patients. Inheritence was maternal in 53% and paternal in 42% whereas both maternal and paternal inheritence route were identified in 5%. 68 patients with family history were grouped in 24 families (2.8 patients/ family). The demographic and clinical data can be seen on Table 1. At some point during follow up 31 patients started with RRT. Mean age for RRT was 55 years (23-81). 5 (16%) patients initiated RRT with peritoneal dialysis, wheras 23 (74%) with hemodialysis, and 3 (10%) had preemptive renal transplantation. At the end of follow up period we found out that 35% (11/31) of patients who had RRT had transplantation, 32% (10/31) experienced peritoneal dialysis whereas 77% (24/31) experienced hemodialysis. 18 out of 76 (24%) patients died during the follow up period. The mean age of death was 71 years (53-81). Conclusion The prevalance of the disease when living patients were considered was 1.3 cases/10000 inhabitants which is low when compared with other studies. Hence ADPCK was not a common diagnosis in North Cyprus as other hereditary kidney diseases. This may show that some patients are underdiagnosed in the population. The frequency of patients without family history was high and also the number of patients per family was low when compared with other studies; these findings may also indicate an underdiagnosed problem. The patients were diagnosed late at a mean age of 47 Hence we need to perform further studies on ADPCK in our population since identifiying ADPCK patients and their families may help to adress the needs adequately, to plan lifelong supportive measures and to decrease high mortality rate of these patients.

Improved renal allograft survival for pre-emptive paediatric renal transplant recipients in the UK

BackgroundThe aim of this study was to investigate whether being on dialysis at the time of renal transplantation affected renal allograft survival in paediatric renal transplant recipients (pRTRs).MethodsRetrospective study of...

Renal Transplant in Pediatric Patients With Congenital Abnormalities of the Lower Urinary Tract

Congenital abnormalities of the lower urinary tract can result in end-stage renal disease and are responsible for a significant number of renal transplants. Management of these patients is not always consensual, and more evidence is required about the frequency of associated complications. Our aim was to report the experience of a Pediatric Renal Transplant Unit with renal transplant in pediatric patients with congenital abnormalities of the lower urinary tract. Data on renal transplants performed in pediatric patients with congenital abnormalities of the lower urinary tract between January 1, 2009, and December 31, 2019, in this center were retrospectively reviewed. Fifty-three pediatric renal transplants were performed in the institution during the considered time period. Of these, 26 transplants were performed in 24 patients with congenital abnormalities of the lower urinary tract, and 14 were male. The median age at the time of renal transplant was 10.5 years (interquartile range, 5.25-15 years), and the most frequent diagnoses were neurogenic bladder (n = 7; 29%) and posterior urethral valve (n = 7; 29%). Three patients (13%) underwent preemptive renal transplant, 15 were on peritoneal dialysis (63%), and 6 were on hemodialysis (25%). A total of 81 pyelonephritides were diagnosed in the 24 patients, mostly attributed to Escherichia coli, followed by Klebsiella pneumonia. The median follow-up was 92.5 months (interquartile range, 52.3-114 months). For patients with congenital abnormalities of the lower urinary tract, graft survival was 92.3% at 1, 5, and 10 years, with no deaths reported. Renal transplant is the treatment of choice for pediatric patients with end-stage renal disease. The procedure does not seem to be associated with worse patient outcomes. Additionally, despite the significant number of pyelonephritides cases, it does not seem to result in decreased graft or patient survival.

Graft Survival in Preemptive Renal Transplantation in Children

Graft Survival in Preemptive Renal Transplantation in Children

Does short-term dialysis significantly increase coronary artery disease burden in diabetic patients who undergo renal transplantation?

Background: Although preemptive renal transplantation decreases mortality associated with dialysis, coronary artery disease (CAD) remains the primary cause of mortality even after transplantation in patients with diabetes. We sought to determine whether short-term dialysis treatment significantly impacts CAD burden, revascularization strategy, and all-cause long-term mortality in diabetic renal transplant (RT) recipients without prior CAD. Subjects and Methods: Diabetic patients with end-stage renal disease and without prior CAD who were referred to coronary angiography before renal transplantation were retrospectively included. These patients were then divided into two groups as short-term dialyzed (nonpreemptive) and preemptive group. Angiographic findings, the severity of CAD, and long-term mortality were compared between the groups. Results: Overall, 164 included patients were included, of whom 125 (78%) were male, and the median age was 54 years (Q1–Q3 = 45–59). The mean duration of dialysis before RT was 1 year (range, 0.5–1.5 years) in the nonpreemptive group. The extent of CAD, revascularization rates, SYNTAX, and Gensini scores were similar between groups (all P > 0.05). During 4.8 years of follow-up, there were no significant differences in major adverse cardiovascular and cerebrovascular events ([hazard ratio (HR) = 0.88 (0.38–2.01), P = 0.76]) and all-cause mortality rates ([(HR) = 0.59 (0.20–1.71), P = 0.33]). Only age and hyperlipidemia were predictive of all-cause mortality (HR = 1.03 [1.001–1.07], P = 0.04 and HR = 2.75 [1.20–6.28], P = 0.01, respectively). Conclusion: Short-term dialysis does not seem to increase newly diagnosed CAD prevalence and burden in diabetic patients undergoing renal transplantation compared to patients who directly undergo renal transplantation. Moreover, long-term all-cause mortality rates did not differ between the two groups as well. Age and hyperlipidemia were independent predictors of all-cause mortality

Graft and patient survival after renal transplantation in the period from 1996-2017 in Military Medical Academy, Belgrade, Serbia

Background/Aim. Renal transplantation is the best and preferred way of treating patients with end-stage renal disease, as it offers improved survival and better quality of life compared to dialysis. The aim of this study was to present single-center (Military Medical Academy in Belgrade, Serbia) results of the kidney allograft and patient survival from 1996 to 2017. Methods. A retrospective 22-year co-hort study was conducted. Variables of interest were graft and patient survival in kidney transplanted patients. Age, gender, serum creatinine levels, and induction therapy after transplantation were analyzed in this group of patients as well. Results. Among 386 transplanted patients, 316 had a living donor and 70 patients had a deceased donor. Pre-emptive renal transplantation was done in 29 (7.5%) patients and AB0-incompatible kidney transplantation in 21 (5.4%) patients. One-year, 5-year, 10-year, and 20-year overall patient survival after kidney transplantation in the observed group was 97.7%, 95.3%, 93.8%, and 91.7%, respectively. One-year, 5-year, 10-year, and 20-year graft survival in our patients were 93.8%, 85.5%, 78.5%, and 73.3%, respectively. Conclusion. The outcome of graft and patient survival in the Belgrade Military Medical Academy kidney transplantation program is good and in line with the leading world medical centers.

Paediatric end-stage renal disease and renal replacement therapy in Switzerland: survival and treatment trends over four decades.

Renal replacement therapy for paediatric end-stage renal disease (ESRD) has developed steadily since its introduction five decades ago. Continuous and long-term analysis of patient outcomes is essential for quality control. The Swiss Paediatric Renal Registry, founded in 1970, includes patients diagnosed with ESRD, defined as dialysis for more than three months or renal transplantation, at age &lt;20 years. Here we describe the incidence, primary renal disease, treatment modalities and long-term outcomes over 45 years. This paper reports on 367 children and adolescents treated with chronic renal replacement therapy in Switzerland. Incidence was 5.4 per million children per year, with a tendency to increase over time. The primary renal disease was congenital anomalies of the kidney and the urinary tract in 133 (36%), monogenetic hereditary diseases in 122 (33%) and acquired diseases in 112 (31%) patients. The first renal replacement therapy was haemodialysis in 194 (53%), peritoneal dialysis in 116 (32%) and pre-emptive renal transplantation in 57 (15%) patients. Over the years, pre-emptive renal transplantation became more frequent (34% of all first renal replacement therapies in 2006&ndash;2015), reducing the duration of dialysis. Median time on dialysis until transplantation decreased from 1.60 years in 1981&ndash;90 to 0.34 years in 2010&ndash;15. Over the four decades 1970&ndash;80, 1981&ndash;90,1991&ndash;2000 and 2001&ndash;10, the one-year graft survival rate improved from 0.76 to 0.80, 0.89 and then 0.96; and the five-year graft survival rate improved from 0.44 to 0.64, 0.84 and 0.89, respectively. The five-year patient survival rates for the four decades were 0.83, 0.99, 0.93 and 0.94; and the 10-year patient survival rates were 0.75, 0.96, 0.88 and 0.94, respectively. In the four cohorts starting renal replacement therapy in the 70s, 80s, 90s and 00s, the number of children alive after five years of renal replacement therapy increased from 15 to 24, 47 and then 45 respectively. In total, 29 patients (8%) died during chronic renal replacement therapy with ESRD before the age of 20 years. Over time, a higher number of children on renal replacement therapy survived, graft survival improved, and the duration of dialysis before renal transplantation decreased.

Immunosuppression-induced clonal T-cell lymphoproliferative disease causing severe diarrhoea mimicking coeliac disease following renal transplantation: a case report

BackgroundPost-transplant lymphoproliferative disease is a recognized complication following solid organ transplantation. This is usually a B cell disease and frequently associated with Epstein Barr virus infection, although T cell PTLD can occur. T cell PTLD is usually a monomorphic, lymphomatous disease associated with an adverse prognosis.Case reportWe report a 52 year old male pre-emptive renal transplant recipient who developed severe diarrhea with weight loss following intensification of his immunosuppression due to antibody mediated rejection 3 years after transplantation. Duodenal biopsy demonstrated monoclonal CD8+ T cell duodenitis leading to increased intraepithlieal lymphocytes and sub-total villous atrophy mimicking coeliac disease. Coeliac disease was excluded by negative anti-tissue transglutaminase antibody, HLA-DQ2 and HLA-DQ8 testing. There was no evidence of lymphoma either on biopsy or CT enterography and no FDG avid disease on PET. Symptoms did not improve with reduction of immunosuppression, but resolved fully on complete withdrawal of treatment. The transplant failed and he was established on dialysis. The diagnosis was early PTLD.ConclusionsOesophagogastroduodenoscopy with small bowel biopsies is a useful investigation for determining the cause of diarrhoea in renal transplant patients when more common causes have been excluded. This is the first report that we are aware of clonal T cell PTLD mimicking coeliac disease which only resolved after complete withdrawal of immunosuppression. As treatments for lymphoma are aggressive they are only initiated in the malignant phase and management of early stage PTLD is to minimise risk of progression by reducing immunosuppression. Any plans to retransplant will have to take into consideration the possibility that PTLD will recur.

P1786THE HIGHWAY TO KIDNEY TRANSPLANTATION

Abstract Background and Aims Close cooperation between nephrologist, nurse coördinator and social workers in a large non academic hospital. By timely starting the process of education and examinations we have increased the possibilities of pre-emptive transplantation Method When a patiënt needs to be informed about renal replacement therapy, the digital program is used by the nephrologist to inform all necessary disciplines involved. They each will make an appointment within the given time slot with te patient. At first the social worker start the education process, preferably, in the home situation. General information about the procedures and actions to be taken in the coming period, is given to the patient and his family/friends. They support patients in making difficult dicisions. Secondly, the nurse coordinator in the process, gives information about all options in renal transplantation and gives an explanation about the test procedures which are necessary to decide if patients are able te receive a kidney and donors are appropriate candidates. In case of availability of a potential donor, information is directly given about living donation and the procedure can directly be started. The nurse coordinator ensures that the patient and potential donor complete all required tests in the shortest time possible in their own hospital. The close cooperation consists of daily deliberation between all disciplines and quickly changing the process of a patient or donor when needed. The progress is reported in the digital file and everyone involved will be informed. Results From 2013 until 2020 516 patients entered the program. 575 donors ( for 348 recipients) entered the program. 191 couples have been approved ans presented for transplantation of which 87 couples have been transplanted, 61 couples have been put on hold because of a stabilised kidney function. 40 couples are still in the work up program. 44 recipients were not transplantable due to medical/psychological reasons. The median work up time of the procedure of the recipients was 260 days from start of the process to transfer tot he transplant centre. (2017) Various patient/medical retarding factors are discribed. The median work up time fort he donors was 191 days (2017) days from start of the process to transfer tot the transplant centre. Various donor/medical retarding factors are discribed. Conclusion Patients and family are well informed about the treatment options, with a special attention for kidney transplantation. The efficient work up program in the patients treating hospital, results in a significant improvement of the possibility of pre-emptive renal transplantation, or otherwise, patients are earlier registered on the waiting list.

Lower prevalence of aortic dilatation among preemptive pediatric renal transplant recipients - A cross-sectional cohort study.

Aortic dilatation is a cardiovascular complication in pediatric renal transplant recipients and may have an increased risk of aortic dissection, aortic rupture, and death. Studies failed to show an association between blood pressure and aortic dilatation; however, 24-hours ambulatory blood pressure monitoring (ABPM) was not performed. There was also no comparison between preemptive transplantation and dialysis. After ethics approval, a retrospective cross-sectional study was performed on all prevalent pediatric renal transplant recipients from a single tertiary care center. The presence of aortic dilatation was determined using standard echocardiographic measurements, and those with other risk factors for aortic dilatation were excluded. Associations between 24-hours ABPM, renal function, dialysis history, and aortic dimensions were determined. We enrolled 37 participants with the following characteristics: 46% female, mean age 14.5±3.7years, 16% preemptive transplantation, and median end-stage renal disease (ESRD) combined vintage (time from ESRD onset to echocardiogram) 597days (range 289-1290days). We found 16/37 patients (43%) with aortic dilatation at any level, mostly mild. There was no association between 24-hours ABPM measurements and aortic dilatation. None of the preemptively transplanted children had aortic dilatation. This study confirms a high prevalence of aortic dilatation among pediatric renal transplant recipients, which appears to be independent of hypertension on 24-hour ABPM. Patients with preemptive renal transplantation did not have aortic dilatation, suggesting that the effects of dialysis may contribute to the high prevalence of this complication. Pediatric cardiologists need to carefully assess aortic dimensions in these at-risk patients.

SUN-191 The Creatinine, the Crib and the Manometer - Navigating the Labyrinth of Primary Aldosteronism

A 21-year-old Ethiopian female with a five-year history of hypertension presented to medicine clinic with headaches and fatigue for two weeks. She was hypertensive to 163/113 mmHg. She had recently moved to the US and no prior medical records were available. She had been taking an unknown antihypertensive until three weeks prior. She was found to have a creatinine of 3.49 mg/dL. Renal ultrasound revealed bilateral, small echogenic kidneys without any evidence of renal artery stenosis. An intrauterine pregnancy was also incidentally discovered. Her aldosterone level was elevated to 486 ng/dL and her renin activity was 1.3 ng/ml/hr, with a ratio of 373, diagnostic of primary aldosteronism. Due to the markedly high ratio, a saline suppression test was deemed unnecessary for confirmation. Her serum potassium was normal at 3.6 mEq, likely due to poor renal clearance. Given renal failure, a CT non-contrast of the adrenal glands was performed with normal findings. She elected to terminate the high-risk pregnancy.Based upon her young age at presentation, family history of early onset hypertension, grossly elevated aldosterone: renin ratio and unrevealing workup for a primary tumor or hyperplastic adrenals, a diagnosis of familial hyperaldosteronism was considered. She failed a month-long trial of dexamethasone therapy, therefore glucocorticoid remediable aldosteronism was excluded. She was subsequently started on spironolactone with good response. Adrenal vein sampling was considered to find a surgical target for adrenalectomy but could not be performed given worsening kidney function. After discussion with Nephrology she opted for a pre-emptive renal transplant evaluation, rather than pursuing dialysis. Genetic testing for subclassification has been negative for mutations in KCNJ5 and CACNA1H with ongoing testing for novel mutations.Primary aldosteronism (PA) usually presents with recalcitrant hypertension, hypokalemia and an elevated aldosterone: renin ratio. It is commonly attributed to adrenal adenomas or hyperplasia with familial hyperaldosteronism (FH) remaining a rare etiology. FH is sub-divided into glucocorticoid remediable, type I, and non- glucocorticoid remediable, types II – IV. The initial diagnosis of such a condition during pregnancy and in the setting of worsening kidney disease presents a diagnostic and management challenge as this precludes adrenal vein sampling and contrast imaging. Our case highlights the importance of early screening for PA and illustrates the need for updated guidelines on aldosteronism workup in the setting of ESRD and pregnancy.

Perioperative Comparison of Preemptive and Non-Preemptive Renal Transplant Recipients.

ObjectivePreemptive transplantation cannot be performed for all patients because of the limited number of donors. This study aimed to evaluate the perioperative effects of dialysis before renal transplantation.MethodsIn this study, we retrospectively investigated 666 patients who underwent kidney transplantation at our centre. We divided patients into two groups: patients with pre-transplant dialysis (67.3%, n=448) and patients with preemptive transplant (32.7%, n=218). We carried out preoperative, intraoperative and postoperative comparisons between groups.ResultsNo difference was observed in terms of intraoperative blood transfusion, crystalloid and colloid requirement, inotropic-vasopressor agent administration and hemodynamic parameters between the patients with pre-transplant dialysis and preemptive transplant. It was observed that dialysis requirement, delayed graft function and acute rejection development were significantly higher during the postoperative period in patients who underwent dialysis before transplantation. In patients with non-preemptive transplant, the decrease of serum creatinine levels at the first postoperative month was more prominent when compared to patients with preemptive transplant; however, that difference disappeared in the first year follow-up. No significant difference was found for serum albumin levels and proteinuria alterations of the patients in long-term follow-up. Additionally, patient and graft survival comparisons between patients with non-preemptive and preemptive transplant on three-year follow-up revealed no significant difference.ConclusionWe think that preemptive transplantation treatment is a better option for patients with end-stage renal failure since patients with preemptive transplantation appear to have less metabolic function impairment, complication risk and more successful outcomes in terms of cost-effectiveness.

A Case Report of Recurrent Lupus Nephritis 15 Days After Renal Transplantation

Renal transplantation is an ever-growing therapeutic option for patients with end-stage renal disease due to lupus nephritis. Outcomes for these patients are comparable to those of patients receiving renal transplantation for other causes. A known complication for these patients is recurrence of lupus nephritis in the renal graft (recurrent lupus nephritis [RLN]). Although disease severity at the time of recurrence is usually milder, a small number of cases have been reported to progress to allograft failure. There is a trend toward preemptive renal transplantation in patients with lupus nephritis, as more favorable outcomes have been observed with this treatment modality. While clinicians usually seek clinical remission of lupus prior to proceeding with renal transplantation, no guidelines are established regarding how often to check for serologic activity of lupus in patients with end-stage renal disease due to lupus nephritis and whether these serologic markers should be taken into account when deciding on the timing of transplantation. We present a case of early RLN co-occurring with acute cellular rejection 15 days after renal transplantation. The patient had been in clinical remission for more than 5 months prior to transplantation but had a rise in anti–double-stranded DNA antibody titers and a decrease in complement C3 level at the time of surgery. Although additional studies are needed to establish the extent to which serologic markers of lupus correlate with renal graft dysfunction, this case suggests hypocomplementemia and high double-stranded DNA antibody titers may be a risk factor for early RLN.