Survival Of Kidney Transplant Recipients Research Articles

Impact of Predialysis Psychosocial Conditions on Kidney Transplant Recipient Survival: Evidence Using Propensity Score Matching.

Background:An increased number of end-stage renal disease patients suffer psychosocial conditions and may experience delayed access to transplantation due to listing restrictions. However, it remains to be shown whether preexisting psychosocial conditions confer an independent risk factor of poor posttransplant outcomes.Objective:We addressed this gap in knowledge by conducting a retrospective cohort study to investigate an independent association between the risk of death after transplant and having a diagnosis of psychosocial conditions 1 year prior to starting dialysis.Methods:All cases of adult deceased-donor kidney transplantation performed in Ontario, Canada, between April 1, 2002, and March 31, 2013, were used. Propensity score matching was applied to adjust for potential endogenous bias of using predialysis psychosocial status to predict posttransplant mortality. Survival analysis techniques, including Kaplan-Meier curves and Cox proportional hazards modeling, were also used.Results:Our results indicate a 49.4% (hazard ratio [HR] = 1.494 [95% confidence interval (CI) = 1.168-1.913]) increased relative risk of posttransplant death to be associated with predialysis psychosocial conditions, when other factors are held constant. The effect is significant (P = .001) and is independent of other known predictors of death including advanced age.Conclusions:Findings from this study offered strong support for the development of psychosocial evaluation to screen candidates prior to transplant listing and early interventions for transplant candidates with psychosocial concerns.

Incidence, Management, and Clinical Outcomes of Prostate Cancer in Kidney Transplant Recipients.

We reviewed the incidence, management, and survival outcomes of prostate cancer among kidney transplant recipients and compared these characteristics with a national population (nonrecipients). A retrospective study was performed on all kidney transplant recipients from a National Kidney Transplant Centre who were subsequently diagnosed with prostate cancer. Primary outcome variables included comparisons of incidence and 5-year overall survival in kidney transplant recipients versus nonrecipients after treatment of prostate cancer. Secondary outcome variables were prostate-specific antigen levels at diagnosis, Gleason grade, treatment strategy, and morbidity from treatment among kidney transplant recipients. Of 4048 kidney transplants performed, 3020 were male recipients (63.9%). In total, 34 kidney transplant recipients (1.1%) were diagnosed with prostate cancer 109 ± 83 months (range, 7-372 mo) after transplant. The mean age at prostate cancer diagnosis was 64 ± 7 years, median prostate-specific antigen level was 10 ng/dL (range, 2.6-771 ng/dL), and 76% (n = 26/34) were diagnosed with localized disease. The incidence of prostate cancer was 1126/100 000 in kidney transplant recipients compared with 160/100 000 nonrecipients in Ireland (P = .01). Treatment strategies included curative radiotherapy (n = 18), curative surgery (n = 2), androgen deprivation therapy (n = 8), and watchful waiting (n = 6). Overall survival rates at 1, 3, and 5 years were not significantly different between kidney transplant recipients with prostate cancer versus nonrecipients with prostate cancer (98% vs 98%, 80% vs 79%, and 77% vs 72%, respectively, P = .8). The incidence of prostate cancer is significantly higher among kidney transplant recipients compared with nonrecipients in the general population, with most diagnosed with localized disease. Definitive management guidelines should be developed to increase awareness and optimize treatment options in this unique patient cohort.

Novel urinary exosomal biomarkers of acute T cell-mediated rejection in kidney transplant recipients: A cross-sectional study.

BackgroundAcute rejection is hazardous to graft survival in kidney transplant recipients (KTRs). We aimed to identify novel biomarkers for early diagnosis of acute T cell-mediated rejection (TCMR) in urinary exosomes of KTRs.MethodsAmong 458 graft biopsies enrolled in a cross-sectional multicenter study, 22 patients with stable graft function (STA) who had not shown pathologic abnormality and 25 patients who diagnosed biopsy-proven TCMR were analyzed. We performed proteomic analysis using nano-ultra performance liquid chromatography-tandem mass spectrometry (nano-UPLC-MS/MS) to identify candidate biomarkers for early TCMR diagnosis on urinary exosomes. We confirmed the protein levels of each candidate biomarker by western blot analysis.ResultsA total of 169 urinary exosome proteins were identified by nano-UPLC-MS/MS. Forty-six proteins showed increased expression in STA patients, while 17 proteins were increased in TCMR patients. Among them, we selected five proteins as candidate biomarkers for early diagnosis of TCMR according to significance, degree of quantity variance, and information from the ExoCarta database. We confirmed the proteomic expression levels of five candidate biomarkers by western blot analysis in each patient. Of all candidate biomarkers, tetraspanin-1 and hemopexin were significantly higher in TCMR patients (STA:TCMR ratio = 1:1.8, P = 0.009, and 1:3.5, P = 0.046, respectively).ConclusionsTetraspanin-1 and hemopexin were detected in KTR urine and could act as potential diagnostic proteins for TCMR.

Arterial stiffness but not endothelial dysfunction is associated with multidrug antihypertensive therapy and nondipper blood pressure pattern in kidney transplant recipients.

Vascular injury related to chronic kidney disease results in increased arterial stiffness and endothelial dysfunction which may affect arterial blood pressure (BP) and influence patient and graft survival in kidney transplant recipients (KTRs).This cross-sectional study aims to elucidate the relationship between the above-mentioned measures of vascular damage and effectiveness of antihypertensive treatment in KTR.One hundred forty-five KTRs 7.6 ± 2.7 years after transplantation were enrolled in our study. Pulse wave velocity (PWV), flow-mediated dilation (FMD), and nitroglycerin-mediated dilation (NMD) were measured, and 24-hour ambulatory BP monitoring was performed.Overall, there were 62 patients with well-controlled or borderline BP and 83 subjects who did not achieve target BP despite antihypertensive treatment. Patients with suboptimal BP control were characterized by greater PWV (median 9.6/interquartile range: 3.9 vs 8.0/3.3 m/s, P = .002), but borderline lower FMD (8.4% ± 5.0% vs 9.9% ± 5.7%; P = .09) as compared with the group with better BP control. When patients were allocated to subgroups based on the number of current antihypertensive medications, no differences in FMD and NMD were found. However, a significant trend was observed for higher PWV values and decreased proportion of dippers along with the increasing number of drugs. PWV, diabetes, and total cholesterol level, but not FMD or NMD, were explanatory variables for systolic BP in multivariate analysis.Arterial stiffness but not endothelial dysfunction is associated with suboptimal BP control in stable KTRs. Less efficient antihypertensive treatment appears to be caused by inadequate control of nocturnal BP.

Effect of Preformed or De Novo Anti-HLA Antibodies on Function and Graft Survival in Kidney Transplant Recipients.

BackgroundDonor-specific antibodies (DSA), directed against human leucocyte antigens (HLA), are associated with increased risk for graft rejection in kidney transplantation. Anti-HLA antibodies detection by Luminex™ present high sensitivity and accuracy, but its interpretation after transplantation is not completely clear.The aim of this study was to evaluate the impact of anti-HLA antibodies, preformed or de novo, on renal function, graft survival, and incidence of antibody-mediated acute rejection (AMR).Material/MethodsA retrospective cohort of 86 kidney transplant recipients was divided into 3 groups according to the presence of anti-HLA antibodies before transplantation: donor-specific antibodies (DSA+, n=15), non-DSA (non-DSA, n=39), and negative pre-transplant panel reactive antibodies (PRA) that became positive after transplantation (PRA−, n=22). Forty-nine recipients with negative PRA pre- and post-transplantation were excluded. Antibody specificity and intensity of fluorescence (MFI) and their relationship with renal function, proteinuria, AMR, and graft failure were evaluated.ResultsAmong patients who completed 1 year of follow-up, there was no significant difference in serum creatinine, estimated glomerular filtration rate, or proteinuria. AMR incidence was 9.5% in the DSA group, 2.3% in the non-DSA group, and 9.1% in the PRA− group. There was no correlation between fluorescence intensity and/or antibodies class (I or II) with increased risk of AMR. Thirteen grafts failed within 1 year post-transplant, there were 9 deaths due to infection, and only 1 due to AMR (PRA− group, DSA de novo at 3 months).ConclusionsIn contrast to previous reports, we did not find a correlation between incidence of AMR and MFI intensity in this series.

Clinical Outcomes of Sofosbuvir-Based Direct-Acting Antiviral Therapy in Kidney Transplant Recipients Infected with Hepatitis C Virus

Introduction Hepatitis C virus (HCV) infection has an adverse effect on patient and graft survival in kidney transplant recipients. In the past, treatment of HCV infection was not effective and at the same time carried high risk of acute rejection. However, new direct-acting antiviral (DAA) therapy has transformed treatment of HCV infection and resulted in high response rate. The aim of this study was to retrospectively examine the clinical outcomes of HCV-infected kidney transplant recipients at our center who were treated with DAA therapy. Methods We identified fifteen kidney transplant recipients who had positive HCV PCR post transplantation and got treated with DAA therapy. Two patients were co-infected with hepatitis B virus and received entecavir in addition to DAA. Results The mean age of treated patients was 48 years (±12.6). 10 patients (67%) were males. 3 of the 15 patients also had liver transplant. 67% of patients acquired HCV infection post transplantation. 7 patients (47%) had HCV genotype 1, 5 patients (33%) genotype 4 and 3 patients (20%) genotype 3. None of the patients were positive for HIV infection. All patients had estimated GFR more than 30 ml/min/1.73 m2. Patients were treated with sofosbuvir-based regimen: 8 patients (53%) with ledipasvir/sofosbuvir, 6 patients (40%) with daclatasvir/sofosbuvir and 1 patient with simeprevir/sofosbuvir. The duration of DAA treatment was 3-6 months. All patients had undetected HCV at 8 weeks of treatment and 12-week sustained virologic response (SVR). The treatment was well tolerated and there was no significan graft dysfunction in any of the treated patients as shown in the figure below.Conclusion 100% of HCV-infected kidney transplant recipients at our center achieved 12-week SVR with Sofosbuvir-based DAA therapy with no major side effects or significant graft dysfunction.

Comorbidities Can Predict Mortality of Kidney Transplant Recipients: Comparison With the Charlson Comorbidity Index

BackgroundComorbid conditions are important in the survival of kidney transplant recipients. The weights assigned to comorbidities to predict survival may vary based on the type of index disease and advances in the management of comorbidities. We aimed to develop a modified Charlson comorbidity index (CCI) in renal allograft recipients (mCCI-KT), thereby improving risk stratification for mortality. MethodsA total of 3765 recipients in a multicenter cohort were included to develop a comorbidity score. The weights of the comorbidities, per the CCI, were recalibrated using a Cox proportional hazards model. ResultsPeripheral vascular disease, liver disease, myocardial infarction, and diabetes in the CCI were selected from the Cox proportional hazards model. Thus, the mCCI-KT included 4 comorbidities with recalibrated severity weights. Whereas the CCI did not discriminate for survival, the mCCI-KT provided significant discrimination for survival using the Kaplan-Meier method and Cox regression analysis. The mCCI-KT showed modest increases in c-statistics (0.54 vs 0.52, P = .001) and improved net mortality risk reclassification by 16.3% (95% confidence interval, 3.2–29.4; P = .015) relative to the CCI. ConclusionThe mCCI-KT stratifies the risk for mortality in renal allograft recipients better than the CCI, suggesting that it may be a preferred index for use in clinical practice.

Long-term Patient and Graft Survival of Kidney Transplant Recipients With Hepatitis C Virus Infection in the United States.

Hepatitis C virus (HCV) infection is common among kidney transplant (KTx) recipients. However, the impact of HCV infection on long-term graft and recipient survival after KTx from large-scale data remains to be determined. We used the Organ Procurement and Transplantation Network database to identify all adults undergoing KTx in 2004 to 2006 in the United States. A propensity score was created to match each HCV-positive recipient with an HCV-negative control for unbiased comparisons. Survival analysis was conducted to evaluate recipient and death-censored graft survival. Out of 33 357 adult primary KTx recipients, 1470 (4.4%) were HCV-positive: 1364 HCV-positive and -negative pairs were selected by propensity score matching. Based on multivariable regression models, HCV is associated with a higher risk of death (hazard ratio [HR], 1.50; 95% confidence interval [95% CI], 1.28-1.75) and graft failure (HR, 1.26; 95% CI, 1.08-1.47). Infection was a more common cause of death in HCV-positive patients than in HCV-negative recipients (HR, 1.64; 95% CI, 1.12-2.42). The incidence of death due to liver failure was 0.23% per year among HCV-positive recipients, whereas no HCV-negative recipients died from liver failure. Graft failure due to recurrent disease was higher in HCV-positive than in HCV-negative recipients (HR, 2.00; 95% CI, 1.06-3.78). HCV infection is associated with decreased long-term recipient and graft survival. Future studies are needed to examine whether recently available, safe, and effective antiviral therapy improves the long-term clinical outcome in these patients.

Paritaprevir/Ritonavir/Ombitasvir Plus Dasabuvir Regimen in the Treatment of Genotype 1 Chronic Hepatitis C Infection in Patients with Severe Renal Impairment and End-Stage Renal Disease: a Real-Life Cohort

Background/Aims: Chronic hepatitis C (HCV) virus infection reactivates under immunosuppressive drugs and therefore has a negative impact on long-term survival of kidney transplant recipients. Treatment-induced clearance of hepatitis C virus (HCV) in kidney transplant candidates prevents virus reactivation after transplantation. Paritaprevir/Ritonavir/Ombitasvir with Dasabuvir (PrOD) represents a highly effective treatment regimen for HCV genotype 1 (GT1), also suitable for patients with end-stage renal disease (ESRD). Serious drug-drug interactions may represent a limiting factor of this regimen. The aim of this retrospective study was to evaluate safety, efficacy and drug-drug interactions management associated with PrOD treatment in the Czech real-world cohort. Methods: Emphasizing concomitant medication adjustment, we described the treatment course with PrOD regimen in 23 patients (4 with CKD4 and 19 on maintenance haemodialysis) infected with HCV GT1 (21 GT1b, 2 GT1a), 18 males and 5 females with an average age of 53.7 years. Six patients had compensated liver cirrhosis and 3 of them were liver transplant recipients. Results: All 23 patients completed the 12-week treatment and achieved sustained virological response 12 weeks after the treatment (SVR12 rate 100%). None of the patients presented with a significant decrease in haemoglobin level, white blood cell and platelet count during the treatment period. The most frequent adverse events were nausea, hypotension, diarrhoea, and hyperkalemia. Four patients presented with a serious adverse event unrelated to the antiviral drugs (salmonellosis, non-functional kidney graft rejection, early gastric cancer, renal cyst infection, initiation of haemodialysis). Concomitant medication had to be modified with the treatment initiation in 10 out of 23 (43.5%) patients (calcium channel blockers, ACE inhibitors, statins, diuretics, tacrolimus); four patients required further adjustment of antihypertensive drugs or tacrolimus dosage on-treatment. Conclusion: PrOD regimen demonstrated an excellent efficacy and good tolerability. Both prospective adjustment of concomitant medication and further on-treatment adjustment allowed for a safe treatment course.

Treatment of Posttransplantation Anemia.

Kidney transplantation represents a renal replacement therapy for end-stage renal failure, with outcomes improving from year to year. With the improved survival prognosis, treatment of complications of chronic kidney disease after transplantation is becoming increasingly important. In particular, posttransplantation anemia (PTA) is often protracted, which could be related to a variety of factors, including the renal function status, graft rejection episodes, and infectious causes. PTA occurs in about 30-40% of transplant recipients, and is known to affect the function of the transplanted kidney as well as patient survival. Early PTA is associated with a risk of death and cardiovascular disorders, however, during this phase, priority is given to the appropriate maintenance of immunosuppression rather than to the treatment of anemia. Maintenance-phase PTA exerts a strong influence on the survival, prognosis of the transplanted kidney, quality of life, etc. Unlike the disease state and treatment of usual renal anemia, it has been suggested that PTA may possibly reflect the functional state of the transplanted kidney. Therefore, it has been suggested that proper renal function may be maintained by ensuring a normal hemoglobin level in kidney transplant recipients. Proper management of PTA could be expected to be associated with an improved prognosis of the transplanted kidney and improved patient survival in kidney transplant recipients. It is advisable to provide appropriate treatment by setting target levels in accordance with the dialysis vintage, primary disease, cardiovascular complications, and kidney transplant function and delineation of the transplant recipient characteristics.

The impact of repeated mismatches in kidney transplantations performed after nonrenal solid organ transplantation.

The aim of this study was to determine whether kidney transplantations performed after previous nonrenal solid organ transplants are associated with worse graft survival when there are repeated HLA mismatches (RMM) with the previous donor(s). We performed a retrospective cohort study using data from the Scientific Registry of Transplant Recipients. Our cohort comprised 6624 kidney transplantations performed between January 1, 1990 and January 1, 2015. All patients had previously received 1 or more nonrenal solid organ transplants. RMM were observed in 35.3% of kidney transplantations and 3012 grafts were lost over a median follow-up of 5.4years. In multivariate Cox regression analyses, we found no association between overall graft survival and either RMM in class 1 (hazard ratio [HR]: 0.97, 95% confidence interval [CI] 0.89-1.07) or class 2 (HR: 0.95, 95% CI 0.85-1.06). Results were similar for the associations between RMM, death-censored graft survival, and patient survival. Our results suggest that the presence of RMM with previous donor(s) does not have an important impact on allograft survival in kidney transplant recipients who have previously received a nonrenal solid organ transplant.

Association Between Pretransplant Cancer and Survival in Kidney Transplant Recipients.

Kidney transplantation in recipients with a previous malignancy is often deferred 2 to 5 years after cancer treatment due to fear of cancer recurrence. In Norway, the required waiting period has been 1 year. We compared patient and graft survival of recipients with pretransplant cancer to the outcomes of matched recipients without such cancer (comparators) using Cox regression. From 1963 to 2010, 377 (6.4%) of 5867 recipients had a pretransplant cancer. During a median follow-up of 6.8 years, 256 recipients died, 35 (13.7%) from recurrent cancer and 27 (10.5%) from de novo cancer. Uncensored and death-censored graft loss occurred in 263 and 46 recipients, respectively. All-cause mortality was similar as in comparators (hazard ratio [HR], 1.06; 95% confidence interval [CI], 0.93-1.20]; P = 0.40), death-censored graft loss was lower (HR, 0.63; 95% CI, 0.47-0.84; P = 0.002), and uncensored graft loss was similar (HR, 0.99; 95% CI, 0.87-1.12; P = 0.87). Cancer mortality was higher than in comparators (HR, 1.97; 95% CI, 1.51-2.56; P < 0.001), particularly during the first 5 years of follow-up (HR, 3.44; 95% CI, 2.36-5.03; P < 0.01). Waiting period was not associated with recurrent cancer mortality or all-cause mortality (both P > 0.45). Results were similar within cancer subgroups, with most data in patients with a history of kidney cancer, prostate cancer, urothelial cancer, and skin squamous cell carcinoma. Kidney transplant recipients with a pretransplant cancer had a similar overall patient and graft survival as recipients without such cancer. Cancer mortality was increased, particularly during the first 5 years after transplantation. A short waiting period was not associated with mortality.

Long-term allograft and patient outcomes of kidney transplant recipients with and without incident cancer - a population cohort study

The excess risk for cancer in kidney transplant recipients is substantial, but the allograft and patient survivals after cancer development are under-studied. This is a population-based cohort study of all primary live and deceased donor kidney transplant recipients in Australia and New Zealand between 1990-2012. The risks of overall graft loss and death with a functioning graft in kidney transplant recipients with and without incident cancer were determined using adjusted Cox regression analysis, with incident cancer considered as a time-varying covariate in the models. In those with incident cancer, types and cancer stage at diagnoses were reported. Of 12,545 transplant recipients followed for a median of 6.9 years (91,380 patient-years), 1184 (9.4%) developed incident cancers at a median of 5.8 years post-transplant. Digestive, kidney and urinary tract cancers were the most common cancer types, although digestive and respiratory tract cancers were more aggressive, with 40% reported as advanced cancers at time of cancer diagnosis. Cancer-related deaths accounted for approximately 80% of recipients with a prior cancer history. Compared with recipients with no prior cancer, the adjusted hazard ratios (HR) for overall graft loss and death with functioning graft were 4.34 (95%CI 3.90, 4.82; p<0.001) and 9.53 (95%CI 8.30, 10.95; <0.001) among those with a prior cancer. Incident cancer after kidney transplantation is a significant risk factor for death with a functioning graft, with the majority of deaths attributed to cancer. A greater understanding of the barriers to screening and treatment approaches following cancer diagnosis may lead to improve survival in kidney transplant recipients with cancer.

Transplantation: Desensitization and survival in kidney transplant recipients.

Elimination of donor-specific antibodies against HLA has been used to enable transplantation of HLA-incompatible kidneys from living donors. In contrast to two previous US studies, a UK study now reports that desensitization does not offer a survival benefit over remaining on the waitlist for a compatible organ.

1941 - Post-transplant cancers negatively affect survival of kidney transplant recipients: Results from the Italian multicentric cohort study

1941 - Post-transplant cancers negatively affect survival of kidney transplant recipients: Results from the Italian multicentric cohort study

Conversion to mammalian target of rapamycin inhibitors in kidney transplant recipients with de novo cancers.

Objective:To investigate the impact of mammalian target of rapamycin (mTOR) inhibitor conversion together with minimization of calcineurin inhibitor on allograft outcome and patient survival in kidney transplant recipients with post-transplant cancers.Methods:A retrospective study of all kidney transplant recipients diagnosed to have post-transplant cancers between the period 1/1/1994 and 30/6/2015. Patients were divided into 2 groups: mTOR inhibitor group and non-conversion group. Outcome included allograft function, patient survival, graft survival, acute rejection and cancer recurrence.Results:115 patients (56 in mTOR inhibitor group and 59 in non-conversion group) were analyzed. Median follow up was 28 months (range: 1 month – 20 years). The allograft function at 1-year remained similar between both groups. There was no significant difference in the patient survival, graft survival and rejection free survival between both groups. More patients in the non-conversion group developed recurrence of cancers than mTOR inhibitor group but statistically not significant.Conclusions:Use of mTOR inhibitors together with calcineurin inhibitor minimization offer a reasonable option in kidney transplant recipients who developed post-transplant cancers in view of stable renal function, low rejection rate and low cancer recurrence rate.

Is it time to rethink combined liver-kidney transplant in hepatitis C patients with advanced fibrosis?

AIMTo reduce hepatic and extrahepatic complications of chronic hepatitis C in kidney transplant recipients.METHODSWe conducted a systematic review of kidney only transplant in patients with hepatitis C and advanced fibrosis.RESULTSThe 5 year patient survival of kidney transplant recipients with and without hepatitis C cirrhosis ranged from 31% to 90% and 85% to 92%, respectively. Hepatitis C kidney transplant recipients had lower 10-year survival when compared to hepatitis B patients, 40% and 90% respectively. There were no studies that included patients with virologic cure prior to kidney transplant that reported post-kidney transplant outcomes. There were no studies of direct acting antiviral therapy and effect on patient or graft survival after kidney transplantation.CONCLUSIONData on kidney transplant only in hepatitis C patients that reported inferior outcomes were prior to the development of potent direct acting antiviral. With the development of potent directing acting antiviral therapy for hepatitis C with high cure rates studies are needed to determine if patients with hepatitis C, including those with advanced fibrosis, can undergo kidney transplant alone with acceptable long term outcomes.

Kidney transplant recipients after nonrenal solid organ transplantation show low alloreactivity but an increased risk of infection.

The number of kidney transplant recipients (KTRs) after nonrenal solid organ transplantation (SOT) has increased to almost 5%. Knowledge on patient and allograft outcomes, infections, and alloreactivity, however, remains scarce. We studied 40 KTRs after nonrenal SOT. Seven hundred and twenty primary KTRs and 119 repeat KTRs were used for comparison. Samples were collected pretransplantation, at +1, +2, and +3months post-transplantation. Alloreactive and CMV-specific T cells were measured by interferon-γ ELISPOT assay. Patient survival in KTRs after SOT, primary and repeat KTRs was comparable. While death-censored allograft survival was comparable between KTRs after SOT and primary KTRs, KTRs after SOT showed superior 5-year death-censored allograft survival of 92.5% compared to 81.2% in repeat KTRs. Interestingly, KTRs after SOT show less preformed panel-reactive antibodies, frequencies of alloreactive T cells, and acute rejections compared to repeat KTRs. KTRs after SOT, however, show higher incidences of EBV viremia and PTLD, sepsis, and death from sepsis. Impaired CMV-specific cellular immunity was associated with more CMV replication compared to repeat KTRs. Our results suggest comparable patient and allograft outcomes in KTRs after SOT and primary KTRs. The observed low alloreactivity may contribute to excellent allograft outcomes. Caution should be taken in KTRs after SOT regarding infectious complications due to overimmunosuppression.

Cytomegalovirus pneumonia after living-related donor kidney transplantation : the experiences of one single center within 10 years

Objective To report one-center experience on diagnosis and treatment of cytomegalovirus (CMV) pneumonia in recipients after living-related donor kidney transplantation (LDKT). Methods The clinical and follow-up data of 168 recipients after LDKT from April 2005 to September 2014 were analyzed retrospectively. We analyzed the general information, clinical manifestation, treatment and outcomes of 34 recipients who were diagnosed as CMV pneumonia. Of the 34 patients, 26 were male and 8 were female. The average age were 32.0 years old. Thirty-four patients developed CMV pneumonia between 12 to 402 days with an average of (91.7±60.8) days post-transplant. It was (6.4±3.7) d(range 1-14 d) from the onset of illness to seeking medical intervention. All cases presented with fever, 18 cases with dyspnea, 11 cases with cough and 6 cases with myalgia or fatigue. The highest temperature was (38.8±0.5)℃ (range 38.0-40.0℃). Leukocyte count was (10.5±4.4)×109/L, elevated in 18 cases, normal in 14 cases, reduced in 2 cases. Quantitative polymerase chain reaction(PCR) assay for CMV DNA was (9.3-15.8)×103 copies/ml for active CMV infection. Chest X ray or CT of all cases demonstrated patchy shadow or interstitial pneumonia. The etiological examination showed that 12 cases were complicated with other microorganism, including 8 cases with Pneumocystis carinii, 3 cases with Streptococcus A, 3 cases with Neisseria, 3 cases with candida albicans, 2 cases with klebsiella pneumoniae, Staphylococcus aureus, enterococcus faecium, Pseudomonas aeruginosa varied 1 case. Results In antiviral therapy, patients were treated by introvenous ganciclovir 5 mg/kg every 12 h for 14-21d and then 5 mg/kg every day. Glucocorticoid treatment included intravenous methylprednisolone 200 mg/kg for 3-5 d, then gradually reduced to 160 mg/kg for 3-5 d, 120 mg/kg for 3 d, 80 mg/kg for 3 d, 40 mg/kg for 3-5 d, until to the original oral dose. Early application of broad-spectrum antibiotics was to prevent bacterial infection, and routine application of compound sulfamethoxazole to prevent Pneumocystis carinii pneumonia. Treatment options were adjusted according to periodic bacteria and fungal culture in blood, urine or sputum, and effective anti bacterial, viral or fungal treatment was selected. After administration of antiviral therapy, methylprednisolone, treatment for other microorganism, as well as adjusted immunosuppressive drugs, 30 cases were cured. The total course of the pneumonia lasted for (28.5±9.4) days on average. However, 4 patients complicated with other microorganism died of severe pneumonia and acute respiratory distress syndrome(ARDS). Conclusion CMV infection was a common complication of living-related donor kidney transplantation. CMV infection often complicated with other microbial infections, and became one of the causes of death after renal transplantation. Early diagnosis, early antiviral therapy combined with effective anti bacterial, fungal treatment would improve the survival of kidney transplant recipients. Key words: Cytomegalovirus; Kidney transplantation; Living donors; Pneumonia

A Comparison of Allograft Survival Between Cyclosporine and Tacrolimus Based Immunosuppressive Therapy in Kidney Transplantation: BIRDEM General Hospital Experience

Introduction and Aims: Calcineurin inhibitors (CNIs), cyclosporine and tacrolimus, are one of the three major components of basic immunosuppressive therapy of kidney transplantation. Our aims were to study and compare the early and long-term graft survival in kidney transplant recipients who were receiving either of these two CNIs.Methods: A questionnaire was formed and data were collected from the hospital records. We divided the patients in group 1 (patients on cyclosporine) and group 2 (patients on tacrolimus). We retrospectively evaluated patients’ clinical and laboratory findings.Results: Group 1 included 50 patients who were on cyclosporine and group 2 included 61 patients who were on tacrolimus. Patients receiving tacrolimus showed almost similar renal function as cyclosporine receiving patients; serum creatinine was 1.27 ± 0.56 versus 1.42 ± 0.91mg/dL (p = 0.258), but they required less time for serum creatinine to become normal (4.71 ± 2.3 versus 7.26 ± 5.6 days, p=0.001) and less duration of post-transplant hospital stay (11.38 ± 3.33 versus 13.65 ± 5.0 days, p = 0.005). New onset diabetes was more pronounced in group 2 (29.5% versus 12 %, p = 0.025). On the other hand, acute rejection was only noted in group 1 (2 versus 0, p = 0.014). One-year and three-year graft survival for cyclosporine was 92.0% and 83.3%, and for tacrolimus was 96.2% and 89.2% respectively.Conclusions: Tacrolimus is relatively favourable to cyclosporine in preventing acute allograft rejection and better immediate post-transplant graft function recovery.Birdem Med J 2015; 5(2): 78-81