Renal Transplant Unit Research Articles

"Green" Hemodialysis: The Centralized Acidic Concentrate from the Dialysis Center of Policlinico of Modena

Introduction and aim of the study. The centralized preparation and distribution system of acidic concentrate represents a true innovation in hemodialysis, when compared to acid bags, in terms of convenience and eco-sustainability. The aim of this study is to compare the use of traditional acid bags with the centralized distribution system of acidic concentrate, with particular attention to differences in terms of eco-sustainability and convenience. Methods. At the Nephrology Dialysis and Renal Transplantation Unit of the University Hospital of Modena was installed the Granumix system® (Fresenius Medical Care, Bad Homburg, Germany). Data collected before the introduction of the Granumix® system (including the used acid bags, boxes and pallets used for their packaging, liters of acid solution used and kilograms of waste generated from wood, plastic, cardboard and residual acid solution) were compared with those collected after the implementation of the Granumix® system. Factors such as material consumption, volume of waste generated, unused and wasted products, time required for dialysis session preparation and nurses' satisfaction were analyzed to document which system was more environmentally sustainable. Results. Data collected in 2019 at our Dialysis Center showed a consumption of 30,000 acid bags, which generated over 20,000 kg of waste from wood, plastic and cardboard, and approximately 12,000 liters of residual acid solution to be disposed of, with a handling weight by operators reaching nearly 160,000 kg. The use of the centralized distribution system of acidic concentrate resulted in a significant reduction in waste generated (2,642 kg vs 13,617 kg), residual acid solution to be disposed of (2,351 liters vs 12,100 liters) and weights handled by operators (71,522 kg vs 158,117 kg). Conclusions. The acidic concentrate appears to be better suited to the sustainability challenge that dialysis must faces today, particularly due to the significant increase in the number of patients, which leads to a higher number of treatments and, therefore, a growing demand for eco-sustainable products.

#2313 Perspectives in immunosuppression management following post renal graft failure: a Portuguese national survey

Abstract Background and Aims The best approach to immunosuppression withdrawal post renal graft failure is controversial. Maintaining immunosuppressive therapy may preserve residual diuresis and prevent allosensitization, which is beneficial for a subsequent transplant. However, prolonged maintenance is associated with an increased risk of infection, metabolic side effects and neoplasia. No standardized protocol exists and immunosuppression is center and nephrologist dependent. Our aim was to document immunosuppression practices nationally amongst Portuguese nephrologists. Method A national survey of 5 short questions was conducted among residents and specialists in Nephrology in Portugal through email distribution by the Portuguese Society of Nephrology. Results We received a total of 90 responses, with 54.4% (n = 49) of participants working at a renal transplant unit. When faced with a patient returning to dialysis after graft loss, 66.7% (n = 60) immediately discontinue the antimetabolite, maintaining the calcineurin inhibitor and prednisolone, 33.3% (n = 30) maintain only the prednisolone and no respondent maintains mycophenolate mofetil or equivalent. Among those who maintain calcineurin inhibitors and steroids, 46.6% (n = 28) wean calcineurin inhibitor within 6 months to 1 year following graft loss, 23% (n = 14) discontinue calcineurin inhibitor within 3 to 6 months, and 30% (n = 18) discontinue calcineurin inhibitors before the first three months after graft loss. Considering steroids, 36.7% (N = 32) discontinue prednisone after one year post graft loss, and 64.3% (N = 58) of the Nephrologists maintain steroids indefinitely or until graft removal or steroid associated complications. The majority (83.3%, n = 75) agreed that the risk of the toxic rejection of the graft is the main factor deciding to maintain immunosuppression, followed by the possibility of re-transplantation (56.7%, n = 51) and the risk of infection was the major concern to withdrawal (55.6%, n = 50). All the participants considered this is an important or very important issue in kidney transplantation, that needs further investigation. Conclusion Immunosuppression management is one of the most challenging issues in patients with a failing or failed graft. Several working groups are being developed to discuss the best approach of the patients with a failing graft but only the British Transplantation Society have published guidelines. In this survey we can observe important disparity of different approaches, mostly physician/centre dependent. The current evidence is weak, calling the need for larger studies and a standardized protocol-based approach.

#1705 Central delivery of acid concentrate for haemodialysis: a single-center experience

Abstract Background and Aims Dialysate is produced by mixing ultra-purified water with acid and bicarbonate concentrates. Acidic concentrate for hemodialysis can be supplied to the dialysis machine through single-use bags or central concentrate supply. Central delivery of acid concentrate represents an innovation in hemodialysis settings in terms of practicality and eco-sustainability as this system is able to produce and distribute ready-to-use acid dialysis concentrate without the use of acid concentrate bags. The aim of our study was to compare the amount of material (including packaging) used to supply acid concentrate using a single-use bag (3.8 L or 4.5 L) or central acid supply at the Nephrology Dialysis and Renal Transplant Unit of Azienda Ospedaliero Universitaria di Modena, Modena, Italy. In particular, we reviewed the amount of consumable material before (January-December 2019) and after the implementation of central concentrate supply (July 2022-June 2023). Lastly, a survey was delivered to all dialysis nurses who work in our dialysis Center to evaluate their feedback on central concentrate supply. Method Our center is equipped with 46 dialysis stations for patients on chronic hemodialysis that in 2019 delivered 30 000 hemodialysis treatments distributed across morning, afternoon, and evening shifts. Granumix system® (Fresenius Medical Care, Bad Homburg, Germany) was installed in 2022. It produces and distributes acid concentrate fluid with two different concentrations of K+ (2 and 3 mEq/L) and a unique concentration of Ca2+ 1.5 mmol/L (see Figure). Results The data collected in 2019 at our Dialysis Center showed that 30 000 acid bags corresponding to 121 000 L of acid concentrate fluid were used to perform hemodialysis. Utilization of bags generated 3 750 kg of pallets, 4 500 kg of plastic and 5 367 kg of boxes. Considering that approximately 10% of the acid concentrate fluid remains unused during each dialysis treatment, approximately 12 000 L of unutilized acid concentrate fluid was wasted. Following the introduction of the Granumix® system, there was a significant reduction (−80.6%) in the utilization of single-use acid concentrate bags (n = 5 805) and, consequently, in the use of boxes (n = 2 294 vs. n = 11 667) and pallets (n = 40 vs. n = 208). The centralized distribution system of acid concentrate led to a significant reduction in waste including boxed, plastic and pallets (2 642 kg vs. 13 617 kg), disposal of residual acidic solution (2 351 liters vs. 12 100 liters), and handling of materials by dialysis staff (37 522 kg vs. 158 117 kg). Another advantage of this system is the optimized usage of acid concentrate fluid. This system ensures that only the required amount of acid for a specific treatment is used, effectively minimizing waste and decreasing the production of special waste. The results of the survey (response rate 75%) documented that 79.5% of the nurses received adequate training for its use; 94.9% experienced a reduction in fatigue and 84.6% declared that had more time to dedicate to patients. Lastly, the survey showed that 96.4% of the participants were completely satisfied with the implementation of this new system. Conclusion Central delivery of acid concentrate is an innovative solution with eco-sustainable potentialities in reducing the consumable materials and workload in hemodialysis. Overall, most nurses expressed satisfaction as this system reduces dialysis staff workload and allows more time for patient care.

Renal Transplantation in Rare Monogenic Urinary Stone Disease – A Single-center Experience

Introduction: Monogenic urinary stone disease (MUSD) tends to be more severe with early onset of symptoms and a higher risk of chronic kidney disease than sporadic USD. The literature on the outcome after renal transplant in patients with certain MUSD is scarce. Materials and Methods: This is a retrospective single-center observational study conducted in a tertiary care renal transplant unit in North India between 2018 and 2021. The renal transplant recipients who developed an end-stage renal disease (ESRD) due to renal calculus disease/nephrocalcinosis were included in the study. All the patients presented to us in an anuric state, and hence, a 24-h urine metabolic profile could not be performed. Ear, nose, and throat and ophthalmological evaluations were done to rule out extrarenal manifestations. These patients were subjected to genetic analysis, i.e., clinical exome sequencing using next-generation sequencing. Results: Out of 283 live renal transplants, 11 patients developed ESRD due to nephrocalcinosis/renal calculus disease. Out of 11, only 4 had genetic mutations and the rest did not have any identifiable genetic mutations. The gene mutations were identified in ADCY10, CLDN16, CaSR, and SLC3A4. The patient with ADCY10 mutation had a strong family history. The clinical phenotype and in silico parameters analysis predicted the variant to be damaging except the one with CaSR mutation which causes Hypocalciuric hypercalcemia syndrome, type 1. Three of four underwent surgical intervention at younger age. All underwent successful live-related renal transplantation, with good graft function on follow-up, without any recurrence of calculus in the allograft. Conclusion: Renal transplantation can be safely proceeded in patients with the above monogenic mutations. Genetic analysis should be a part of pretransplant evaluation in young onset nephrolithiasis and end-stage kidney disease patients to look for a monogenic cause, to assess the risk of recurrence postrenal transplant.

Early surgical complications in kidney transplant recipients- A single center study

End-stage renal disease (ESRD) is becoming a significant global public health issue. The preferred course of treatment for people with ESRD is kidney transplantation, although its associated surgical complications raise serious doubts about the success rate of the procedure. Renal transplant surgical complications are frequently observed and can significantly affect graft performance, survival, and patient morbidity. This study aimed to analyze the frequency of early surgical complications, diagnoses, and treatment options in renal transplant patients. This retrospective cohort study included all transplanted patients with surgical complications from April 2017 to April 2022 at the Renal Transplant Unit of the Dow University of Health Sciences, Karachi, Pakistan. Out of 500 kidney transplant recipients, 86 patients (17.2%) experienced early post-transplant surgical complications. The most common complication was Lymphorrea (n=38, 7.6%) followed by wound infection (n=25 patients, 5%). The occurrence of these complications was associated with delayed graft function, indicating the need for careful monitoring and timely intervention in these cases. Future studies are needed to explore the predictors and risk factors of surgical complications in kidney transplantation and to identify strategies for reducing the incidence and improving the outcomes of these complications.

Renal vascular disparities among kidney donors presented at renal transplant unit- A single centre study

Renal vasculature has been reported to show anatomical variations, which may lead to surgical complications. The pattern of renal vascular variations in Pakistani population is not well reported. Thus, this study was designed to assess the renal vascularity among kidney donors and correlate with age, gender and site of vessels. A total of 223 healthy volunteers underwent evaluation for kidney donation at the Radiology Department, DOW University Hospital, Karachi, Pakistan from January 2020 to July 2022 were included. The assessment of renal vasculature was done on computed (CT) angiogram. Renal vascular variations were found in 112 (50.2%), 59.8% were seen in males and 40.2% in females. On right side 50% vascular anomalies were found followed by left side with 27% and 22% on both sides. The arterial variants included accessory renal artery seen in 76 (67.8%) individuals, out of which 13.2% had in upper polar, 26.3% in hilum, 36.8% in lower polar, while 23.7% of early branching was observed. Ten retro-aortic, fourteen accessory renal veins and six bifurcation renal veins, along with six early branching renal veins, were present. Patient who received donor nephrectomy, the outcomes of the operation were completely consistent with the results of the CTA. According to this study, Pakistani population have differences in their renal venous and arterial anatomy, which can significantly influence surgical procedures.

Evaluation of risk factors and clinical outcomes of acute respiratory failure from post renal transplant recipients: A five-year data of a single center

Acute Respiratory Failure (ARF) requiring Intensive Care Unit (ICU) admission is a common complication following renal transplant and is a diagnostic and therapeutic challenge. This study aimed to evaluate etiological factors and clinical outcomes of ARF following a renal transplant. This was a retrospective observational study. Data was recruited from last five –years’ records of Renal Transplant Unit of Dow University of Health Sciences, Karachi, Pakistan. Patients who developed ARF after renal transplantation whether requiring hospitalization (both in ICU or in ward) were included and their severity, etiologic diagnosis, and clinical outcomes were evaluated. During past five years (June 2017 till June 2023) a total of 450 kidney allografts were done and 35 patients (7.8%) developed ARF. Out of which 15 patients were shifted to the ICU. Mortality of female patients was higher as compared to males (26.1% versus 20.4%). Hypertension was found to be the most common comorbidity whereas glomerulonephritis was the most common cause of End Stage Renal Disease (ESRD). Acute rejection was observed in 20.89% (n = 94) of recipients. Bacterial pneumonia was the most common cause of ARF, one patient needed on mechanical ventilation whereas two patients were dialysis dependent survivors. ARF following renal transplant is associated with higher mortality and loss of graft function because of compromised immunity. Anti-bacterial prophylaxis and early intensive management appears to help in improving the outcome while integrating the graft function.

SP3.11 Laparoscopic Donor Nephrectomy (LDN) Training in the UK. A National Re-Audit of the Trainee Experience

Abstract Purpose An Independent National-Trainee-Survey reported poor LDN training opportunities in the UK in 2014. It recommended LDN fellowships and LDN training as a part of the Transplant Curriculum. A Re-audit of the initial study was done to gauge improvement. Methods A short electronic survey was disseminated to surgical trainees via a web-based link (Survey-monkey) placed on the Herrick-Society forum and email/paper invitations to renal transplant units across the UK. Results 57 (53 in 2013) responses were received from the UK in 2022. Women in transplant training are still scarce OR 0.91 (0.40-2.06, p=0.49). 03% of units in the UK offer robotic-assisted LDN at present. In comparison to 2013, in 2022, 16%vs 20% of trainees were PGY1-3; 25% vs. 14% PGY 4-6; 17% vs. 18% post-residency training; 32 % vs. 31% IMG-non-training> 2 yr. transplant experience; 10%vs 09% IMG-non training < 2 yr. transplant experience (p=0.67). 92% vs. 91% of trainees reported that they had performed <01 LDN as primary-surgeon OR 0.87 (0.32-2.37, p=0.50). Only 33 % of trainees had been on a course for LDN. There was no correlation to seniority in training grade performing donor nephrectomies as a primary surgeon (p=0.76). There was no significant advantage to trainees on rotation (p=0.71) to service trainees (p=0.69) to perform LDN as primary surgeons. The likelihood of a trainee performing >01 LDN as a primary surgeon is <1 in 30 compared to < 1 in 25 (2013). Conclusions This study reports no improvement in training opportunities in LDN. The Trainers have yet to utilize the previous 2014 report to augment training opportunities in the UK.

P5.02: Impacts on NHS Renal Transplant Educational Service Delivery During the COVID-19 Global Pandemic

Introduction: During the current covid-19 global health pandemic the delivery esiting face-to-face patient healthcare education in extremely vulnerable patients has posed several challenges. Adaptations to the delivery of healthcare provisions have been vital to prevent unnecessary exposure of patients to risky hospital environements. Covid-19 created multiple constraints on patient care. This included our clinical teams own ability to interact directly with potential renal transplant recipients in the pre-existing conventional manner. Pre covid-19 pandemic, the renal transplant unit at Leicester General Hospital established comprehensive patient information sessions which were patient facing, forming the initial transplant recipient assessment process and the introduction for potential live kidney donors. However during the pandemic information sessions have unfortunately been postponed until the patient attends the transplant assessment clinic appointment with the surgeon, or when the potential live donor attends the hospital to be assessed by our live donor coordinator. To adhere to social distancing guidelines we developed and initiated a pilot programme for such patient’s which involved a structured virtual process delivered from an online platform. Methods: A Single centre study which involved patients attending in November 2020 accessing Microsoft Teams, listening to the live presentation from the lead transplant consultant and coordinators. The electronic equipment that patients required access to was either a laptop/computer or a smart mobile. The session allowed for live interaction and patient participation. Results: Initial pilot: 11 patients participated in the virtual session, 3 potential donor and recipient pairs. Patients included; either being assessed for suitability for renal transplantation or commencing the live donor work up process. Participants were asked to complete an online feedback survey following completion of the session. 8 questions were formally analysed, 72% answered. Patient outcome data supported the pilot study and patient feedback was favourable for this method. Conclusion: The pilot suggests that we have safely demonstrated that the delivery of healthcare can effectively be modified to safeguard patients, particularly those classified as extremely vulnerable, thus preventing unnecessary hospital exposure during the covid-19 global health pandemic. The delivery of patient facing care has successfully been adapted without compromising care standards.

P8.042: Non-melanoma Skin Cancer With an Aggressive Course in Kidney Transplant Patients Treated With Rapamycin

Introduction: Non-melanoma skin cancer (NMSC) represents the most frequent malignancy in patients with solid organ transplantation, with a high risk of metastasis (MTS) and death related to factors such as chronic immunosuppression, exposure to ultraviolet (UV) radiation, and HPV infections. Objectives: • To describe the features of non-melanoma skin cancer (NMSC). • To report the development of multiple NSCLC and metastasis in patients treated with rapamycin. • To highlight the need for dermatological control in order to assess risk factors, precancerous lesions and make an early diagnosis. Materials and methods: We present three renal transplant patients assisted by Dermatology at the Renal Transplant Unit of CRAI Sur, Hospital Interzonal General de Agudos “Gral. San Martín”, La Plata, Argentina. Patients with multiple lesions under treatment with rapamycin and aggressive evolution were chosen. Risk factors related to the multiplicity and dismal evolution of NCC (signs of photodamage, preneoplastic lesions, history of NCC) were evaluated prior to evaluation at the unit; we also analysed age of presentation, sex, transplantation timing, initial immunosuppressive regimen and subsequent modifications, type of NMSC, treatment and evolution. Patients:Case 1: 68 year-old male, with prior history of basal cell carcinomas (back and face) and actinic keratoses. He developed multiple squamous cell carcinoma 5 years post transplantation. Induction: thymoglobulin. Immunosuppression: rapamycin, MMF and steroids. Therapy: surgery. Death due to multiple lung MTS. Case 2: 69 year-old male, with prior history of actinic keratoses and basal cell carcinoma (face). He developed multiple metatypic basal cell carcinoma 9 years post-transplantation. Induction: Basiliximab. Immunosuppression: tacrolimus, MMF and steroids. Switch to rapamycin after diagnosis. Therapy: surgery and Imiquimod. Death due to acute myocardial infarction. Case 3: 43 year-old male, with prior history of actinic keratoses and squamous cell carcinoma (face). He developed squamous cell carcinoma (face) and multiple skin MTS 7 years post-transplantation. Induction: thymoglobulin. Immunosuppression: tacrolimus, MMF and steroids. Switch to rapamycin after diagnosis. Therapy: chemotherapy. Death due to multiple lung MTS. Conclusions: 1- The NMSC in these patients presented with multiple lesions and clinical and histological characteristics related to an aggressive course (MTS and death in two cases). 2- Immunosuppressive therapy with rapamycin did not modify the outcome and development of multiple lesions despite its known antiproliferative and angiogenesis effects. 3- All our patients were men and presented risk factors for NMSC (photodamage, actinic keratoses, more than five years post-transplantation, history of prior NMSC, induction and immunosuppressive therapy). 4- Dermatological control is crucial in order to identify risk factors, promote photoeducation and make a prompt diagnosis.

Profile of Renal Transplant Patients Associated with Social Security or Continuous Cash Benefit and Labor Status

Abstract: Chronic kidney disease consists of kidney damage and the progressive and irreversible loss of kidney function. Thus, when the kidneys are no longer able to maintain their functions, it is imperative that the individual access some benefit to facilitate treatment. Thus, the objective of this article was to analyze the social security or welfare and labor situation of the patient transplanted by a renal transplant unit. The research was carried out by means of a questionnaire with patients who attended the specialties outpatient clinic in October and November 2021. The project was approved by the Research Ethics Committee of the Faculdade de Medicina de São José do Rio Preto, Brazil, and the patients who agreed to participate in the research signed the informed consent form, complying with the ethical principles of the National Health Council and the Ethics Code of the Social Worker. For analysis purposes, after data collection, the variables age, gender and education made up the social profile of the interviewees (n = 20) with the distribution of the variables of social security status and work status, associated with the surveyed profile. In the social profile of the group studied, the female gender contrasted with the literature researched. The variation in the frequency detected of patients in social security or welfare assistance status confirms the impossibility of resuming conditions for professional exercise and, unfortunately, although small, it is an expressive portion of patients with no income or away from the labor market.

MO964: High Urgency Renal Transplantation for Patients With Exhaustion Of Vascular Access for Haemodialysis: Experience from A Tertiary Center

Abstract BACKGROUND AND AIMS When faced with exhaustion of vascular access for haemodialysis (EVAH), allocation for High Urgency Renal Transplantation (HURT) is the appropriate solution. Patients with EVAH usually have multiple comorbidities and an increased risk of cardiovascular and thrombotic events. The aim of this study is to analyze the characteristics and outcomes of patients undergoing HURT due to EVAH. METHOD Data from the Renal Transplant Unit since January 2006 were retrospectively analyzed. Eleven patients undergoing HURT were identified. RESULTS In the population studied, 45.5% (n = 5) were male, 63.6% (n = 7) were Caucasian and the mean age at the time of transplantation was 41.6 ± 7.8 years. Ninety % (n = 10) were hypertensive, 27.3% (n = 3) were diabetic and 27.3% (n = 3) had previous cardiovascular disease. Patients were on renal replacement therapy for 5.8 ± 2.7 years prior to transplantation. The mean transplant time was 75.5 ± 53.7 months. The mean follow-up period was 90.6 ± 51.9 months. During this period, 63.6% (n = 7) of patients lost their renal graft and mortality was 63.6% (n = 7). Renal graft survival was 81.8% (n = 9) at the first year, 72.7% (n = 8) at the third year and 63.6% (n = 7) at the fifth year of follow-up. At discharge, mean creatinine was 1.8 ± 1.1 mg/dL. At the first year, mean creatinine was 1.9 ± 0.8 mg/dL, at the third year was 2.3 ± 1.9 mg/dL and was 1.6 ± 0.4 mg/dL at the fifth-year post-transplant. The mean time to graft loss was 54.1 ± 49.3 months. Overall survival was 90.9% (n = 10) at the first year, 90.9% (n = 10) at the third year and 81.5% (n = 9) at the fifth-year post-transplantation. Two patients died from a cardiovascular event, one from neoplasia and other from an infectious cause. Two patients died with a functioning kidney allograft. CONCLUSION Kidney graft survival in patients undergoing HURT was significantly lower. Portuguese Transplantation Society reporting an overall graft survival of 92.9% at the first year and 85.0% at the fifth year. The mortality of these patients is quite high; however, the fact that they are patients with EVAH, whose life expectancy would be greatly reduced if they were not transplanted, makes HURT continue to be an indicated option in this population of more vulnerable patients.

A national survey on enhanced recovery for renal transplant recipients: current practices and trends in the UK.

Enhanced recovery after surgery (ERAS) is well established in many specialties but has not been widely adopted in renal transplantation. The aim of this survey was to understand current national practices and sentiment concerning ERAS for renal transplant recipients in the UK. A national web-based survey was sent to consultant surgeons at all 23 UK adult renal transplant units. Completed questionnaires were collected between May and July 2020. Data were analysed according to individual responses and grouped according to the existence of formal ERAS pathways within units. All transplant units were represented in this survey. Three units had a formal ERAS pathway for all recipients. Of the remaining units, 65.9% considered implementing an ERAS pathway in the near future. The most commonly perceived barrier to ERAS implementation was 'embedded culture within transplant units' (54.8% of respondents). A fifth of respondents insert surgical drains selectively and 11.7% routinely discontinue patient-controlled analgesia on postoperative day 1. Most respondents routinely remove urinary catheters on day 5 (70%) and ureteric stents 4-6 weeks post-transplantation (81.7%). Median length of stay for deceased donor kidney transplant recipients was lower in units with ERAS programmes (5-7days versus 8-10days, respectively). The main cited barriers for discharge were 'suboptimal fluid balance' and 'requirement of treatment for rejection'. Despite slow uptake of ERAS in kidney transplantation, appetite appears to be increasing, particularly in the post-COVID-19 era. The current practice and opinions of transplant specialists highlighted in this survey may help to establish nationally agreed ERAS guidelines in this field.

POS-794 Conversion to sirolimus in kidney transplant patients: the main indications

The mTOR inhibitors (Sirolimus) has been used in kidney transplantation for very specific indications, essentially in case of neoplastic complications after transplantation secondary to calcineurin inhibitors.Then, the indications have been extended.To describe the different indications of sirolimus conversion in renal transplant patients in Tunisia, we carried out a multicenter study. This is a retrospective multicentric cross-sectional and analytical study performed over a period of 30 years (from 1986 to 2017), which collected all kidney transplant patients who received mTOR inhibitors during any time of their follow-up for a minimum period of 6 months. During study period, 89 patients were collected from the different Tunisian renal transplantation units. The majority of patients came from the SAHLOUL and CHARLES NICOLLES hospitals. The average age of patients at the time of transplantation was 34.71 years. Seventy percent were male. Initial nephropathy was indeterminate in 39 % of patients. All patients received sirolimus during their post-transplant follow-up with a mean of 3.13 +/- 4.73 years. The first indication (49% of cases) of Sirolimus initiation in our study was the diagnosis of neoplastic and pre-neoplastic lesions. Neoplastic lesions were noted in 36 patients (40%) and pre-neoplastic lesions in 08 patients. The most frequent neoplasia was Kaposi's sarcoma in diagnosed in 22.5% of patients. The second indication for switching to sirolimus was calcineurin inhibitors toxicity. In fact, 21 patients in our study had received Sirolimus because of calcineurin inhibitors toxicity. Tacrolimus toxicity was noted in 13 patients (15%) and Ciclosporin toxicity was found in 08 patients (9%). On the other hand, seven patients in our study had received Sirolimus after renal transplantation because of BK virus nephritis. Two patients had presented a thrombotic micro angiopathy related to tacrolimus requiring switching to Sirolimus. One patient presented with severe leuko-neutropenia with white blood cell count of 880/mm³ and neutrophils of 150/mm³. The etiological investigation was negative. In front of persistence of this leuko-neutropenia despite decreasing and then withdrawing MMF, a switch to Sirolimus was decided. In addition, Sirolimus was administered to one patient because of a primary CMV infection that occurred after 04 months of renal transplantation and was resistant to treatment with Foscavir and Ganciclovir. Furthermore, 13 patients had been programmed to be converted to Sirolimus. The conversion was decided, in 04 cases, in front of past history of lesions providing degeneration before the transplantation. These antecedents were: villous atrophy, a colloid thyroid nodule, Bourneville's tuberous sclerosis causing degeneration of skin nodules, and a mixed germ cell tumor. In 09 patients, the systematic conversion to Sirolimus was a part of a national protocol. Conversion from calcineurin inhibitor to sirolimus is one of the major thrusts of the current development of immunosuppression in kidney transplantation. The aim is to minimize the side effects of calcineurin inhibitors and ensure better graft and patient survival. According to our study, neoplastic complications and calcineurin inhibitors toxicity are the main indications of conversion to Sirolimus in Tunisia.

POS-189 Urinary tract infection in renal transplant recipients:Experience of a single departement

Urinary tract infection (UI), is the most common cause of infectious complications in kidney transplant recipients.These infections remain suspect due to their impact on graft survival and therefore on the morbidity and mortality of this population .These can occur at any time but with the highest incidence in the first 3–6months after transplantationour aims were as follow: 1. Assess the prevalence of UI in kidney transplant recipients. 2. Identify the risk factors for UI in kidney post transplantation.3. Study the microbiological profile and therapeutic attitudes of these UIs This is a descriptive and analytical retrospective study, carried out between January 2017 and November 2019 at the renal transplant unit in the nephrology department of Fattouma Bourguiba Hospital in Monastir. we included all kidney transplant patients hospitalized during this period During this period 360 patients were hospitalized, IU was diagnosed in 32 patients. The average age of our population was 35.5 ± 9.6 years with a sex ratio of 1. The prevalence of IU in kidney transplant recipients was estimated at 8.8%. The graft acute pyelonephritis was the most frequent presentation. The most incriminated germs were the bacillus gram negative (BGN) represented mainly by Klebsielle pneumonae (47.7%). The most prescribed antibiotics were carbapenemes in 34% of cases followed by third generation cephalosporin (C3G) mainly cefotaxime (21.5%). The only UI risk factor found in our study with a statistically significant p was ureteric vesic reflux complicating a kidney transplant. View Large Image Figure ViewerDownload Hi-res image Download (PPT)View Large Image Figure ViewerDownload Hi-res image Download (PPT) Several other risk factors have been identified in the literature not objectived in our study, their recognition is important to identify kidney transplant recipients who are more likely to develop urinary tract infections and to minimize the risk with personalized care. for example, adequate screening and prophylaxis.

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.

Intraoperative infusion of lidocaine 2% reduces postoperative fentanyl requirements for pain control in renal transplantation surgery

BackgroundIntravenous lidocaine has been shown to be an analgesic and anti-inflammatory medication with modulation of excessive inflammatory response.We investigated the efficacy of intraoperative lidocaine 2% infusion in reducing the postoperative Fentanyl requirements for analgesia in renal transplant recipients. Patients were assigned equally into two groups by computer-generated list compiled before the start of the study. Control group: fentanyl (F) group and study group: lidocaine 2% (L) group. Medication used is either lidocaine in the dose of 2 mg/kg/h and the other syringe contained saline both have been infused by rate of 10 ml/h. Fentanyl induction dose given for the two groups was 1.5 mcg/kg. Both groups have received extra fentanyl according to their intraoperative analgesic requirements, patients in the lidocaine group received the fentanyl induction dose accompanied by lidocaine 2% 1.5 mg/kg as loading dose, followed by maintenance dose of lidocaine 2% infusion 2 mg/kg/h. After transfer to the PACU nursing staff administered fentanyl 0.5 mcg/kg boluses for postoperative pain relief every 10 min up to 2 mcg/kg, the recovery nurse used the pain numerical score to assess pain. The recovery nurse referred the patient to the responsible anesthesiologist covering the recovery unit if he required more than 2 mcg/kg of fentanyl to control postoperative pain. Patient was then transferred to the RTU (renal transplant unit), postoperative pain and fentanyl PCA consumption were followed up during the first 24 h.ResultsOur study detected increased fentanyl consumption in the recovery for the fentanyl group more than the lidocaine group. The request of the first dose of analgesic was significantly longer in lidocaine group than in fentanyl group.ConclusionThe usage of intraoperative lidocaine infusion decreased postoperative fentanyl requirements as analgesic in patients undergoing renal transplantation.Trial registrationRegistration on ANZCTR number ACTRN12618001335280, REGISTERED 08 August 2018.

Renal Transplant Unit, National Institute of Solid Organ and Tissue Transplantation, Dow University of Health Sciences, Karachi, Pakistan: On a Road to Minimize ESRD Burden

End Stage Renal Disease (ESRD) is clinically defined as the progressive and irrevocable impairment of kidneys to perform life-sustaining functions and represents the final stage of Chronic Kidney Disease (CKD). With bulging morbidity and mortality and rampant rise in economic burden globally, ESRD is now recognized as a major public health issue. Certainly, it goes without saying that coming decades will observe a high prevalence of ESRD, and chronic non-communicable diseases such as hypertension and diabetes mellitus, with accumulating aging population as the driving force. This prognosticated upsurge in ESRD pool has been gauged to occur mainly in the developing countries.

Bloodstream infections by gram-negative bacteria in kidney transplant patients: Incidence, risk factors, and outcome.

Kidney transplant recipients (KTRs) are at increased risk of infections. The aims of this study were to describe the incidence of bloodstream infections (BSIs) by gram-negative bacteria in a cohort of KTRs, the risk factors for BSI due to multi-drug-resistant (MDR) gram-negative bacteria, and the predictors for unfavorable outcome, defined as death or nephrectomy or return to dialysis, within 30days from BSI. We conducted a retrospective cohort study at the renal transplant unit of a tertiary care hospital in Athens, Greece. In a total of 1962 KTRs, we recorded 195 BSI episodes in 182 single patients (male/female=97/85), with a median (interquartile range) age of 57.2 (44-64.9) years. The incidence was 1.393/100 patient-years. The most common source of infection was urinary tract (70.9%), and Escherichia coli (63.7%) was the most common pathogen. 19.2% of the infecting organisms were MDR; previous antibiotic use (OR 8.2; CI 2.1-32.9) and previous stay in the intensive care unit (OR 34.2; CI 1.6-730.2) were associated with MDR BSIs. 6% of patients died, and 2.2% underwent nephrectomy, while no patients had to return to dialysis. Diabetes mellitus (OR 8.1; 95% CI 1.3-50.3), Pseudomonas aeruginosa BSI (OR 46.1; 95% CI 3.9-552.3), and septic shock (OR 46.7; 95% CI 1.7-1304.9) were independent predictors of unfavorable outcome. Bloodstream infections in KTRs have a significant impact on allograft and patients outcome.

P1862USE OF NOVEL E-HEALTH TECHNOLOGIES AND ITS ACCEPTABILITY BY KIDNEY TRANSPLANTED PATIENTS: FIRST EXPERIENCE IN NORTHEAST BRAZIL

Abstract Background and Aims The World Health Organization defines eHealth as the use of information and communication technologies for health purposes. One of its 4 components, mHealth or mobile health, refers more specifically to the provision of health information and services through mobile and wireless technologies. With approximately 7 billion mobile subscriptions worldwide, in many places people are more likely to have access to a smartphone than to drinking water. The aim of this study was to investigate the acceptability of renal transplanted patients to the use of eHealth technologies for their treatment. Method This is a cross-sectional study, performed in a reference hospital located in northeastern Brazil, from January to March 2019, including renal transplant patients older than 18 years old. Data collection was performed through interviews at the post-transplant outpatient clinic in the period preceding the follow-up appointments. The following variables were studied: sociodemographic (gender, age, marital status, race, religion, origin, education, occupation and income), use of technologies (communication devices ownership and / or internet access mobile or at home), purpose and frequency of use, reasons for non-use, and interest in using eHealth tools to assist in post-transplant treatment. We have also interviewed physicians and nurses from the renal transplantation unit regarding this subject. Results A total of 147 patients were interviewed, 63.2% were male, age varied from 13 to 45.1±13 years old, 41.5% were single, with 4 to 10 years of schooling, family income of 2 to 3 minimum wages in Brazil (approximately 400 to 700 US dollars). The patients had had been transplanted around 5 to 6 years ago. As for handset ownership, 90.5% had a smartphone, 39.5% a notebook, 36% a home computer and 12.2% a tablet. As for use, 13% used only for calls. Among the other purposes, 85% used for messaging, 72.1% for internet searches and 74.8% for social networks. Regarding frequency of use, 61.2% used these technologies many times a day. Concerning their interest in using eHealth tools, 93.2% pointed that they would like the tool to be developed for smartphones, and 96.6% said they would use eHealth tools to help them cope with their treatment. The health professionals (10 physicians and 3 nurses) pointed as the main barriers that difficult treatment post-renal transplantation were: patient’s adherence to treatment (76.9%) and low health literacy (53.8%). These professionals pointed that the eHealth technologies can help to increase patients’ adherence, and 23% of them had doubts about effective acceptability by patients. Conclusion To our knowledge, this is the first study in Brazil that addresses the acceptability of eHealth tools among kidney transplanted patients. Transplant recipients were found to already use information technology and are interested in using eHealth tools to help them with the treatment. Health professionals support this initiative and believe these technological tools can increase patient compliance. The next steps of this study are to develop and test eHealth technologies directed for kidney transplanted patients.