End-stage Renal Disease Transplant Research Articles

Renal Transplantation in Antineutrophil Cytoplasmic Antibody-Associated Vasculitis: A Single-Center 10-Year Experience

Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a common cause of rapidly progressive glomerulonephritis resulting in end-stage renal disease. The optimal timing of kidney transplantation for end-stage renal disease due to AAV and the risk of relapse after kidney are poorly defined. Our study aimed to evaluate the clinical outcomes of AAV after kidney transplantation, namely the risk of relapse, rejection, and oncologic disease. This retrospective study included all patients with AAV submitted to a kidney transplant between January 2011 and December 2020. Twenty-seven patients (20 males/7 females; mean age 47 years) received a kidney transplant for end-stage renal disease secondary to microscopic polyangiitis (n=25) or granulomatosis with polyangiitis (n=2). All patients were in clinical remission at the time of the kidney transplant, but 11 patients were ANCA-positive. A vasculitis relapse after kidney transplantation occurred in only 1 patient (3.7%). Rejection episodes, proven by allograft biopsy, were present in 3 patients (11.1%), with graft losses in 2 (66.7%). The median time until the graft was lost after the initial rejection diagnosis was 27 ± 8 months. Oncologic complications were present in 9 patients (33.3%). Five patients died (18.5%), and the main cause of death was cardiovascular disease (n=3, 60.0%), followed by oncologic disease (n=2, 40.0%). Kidney transplantation is a safe and effective option for treating end-stage renal disease secondary to AAV. Current immunosuppression regimens make relapses and rejection infrequent but place oncologic complications at a higher incidence.

Urinary Bladder Squamous Cell Carcinoma In-Situ in a Background of Condyloma Acuminatum – A Diagnostic Challenge

Abstract Introduction/Objective Condyloma acuminatum is a rare lesion of the urinary bladder and urethra, usually associated with extensive anogenital condyloma acuminatum and immunosuppression. It is considered a risk factor for developing urinary bladder squamous cell carcinoma. Methods/Case Report We report a case of an 80-year-old male with a history of invasive squamous cell carcinoma of the anus, status-post chemoradiation ten years prior, and renal transplantation for end-stage renal disease 15 years prior. He presented with a lesion adjacent to the neoureteral orifice at the bladder dome. Biopsy revealed nonkeratinizing, hyperplastic papillary fronds of squamous epithelium with koilocytic change and viral atypia. The tumor was positive for p16, GATA3, and p40 and negative for high-risk and low-risk Human Papilloma Virus by in-situ hybridization. However, the morphology was consistent with squamous cell carcinoma in-situ arising in a background of condyloma acuminatum, which was concurred by an outside expert. Bladder condyloma acuminata are often challenging to recognize, given their extreme rarity and the possibility of negative low-risk and high-risk Human Papilloma Virus tests. Lack of prior history of anogenital condylomas can further obscure this diagnosis. Results (if a Case Study enter NA) NA. Conclusion This case raises awareness of condyloma acuminatum as a rare entity that needs to be considered in the differential diagnosis of bladder tumors, especially in immunosuppressed patients. Given that the treatment strategies for squamous cell carcinoma arising from condyloma acuminatum differ from that for urothelial carcinoma with squamous differentiation, distinguishing these lesions from one another is imperative.

Unintentional common carotid artery cannulation during attempted internal jugular venous catheter insertion

Purpose: Insertion of a central venous catheter is a common procedure, performed by anesthesiologists and other medical professionals. The preferred site for central venous cannulation is the right internal jugular vein.
 Case Report: We present the case of a male patient who underwent renal transplantation for end-stage renal disease. During preparation for surgery, the right common carotid artery was cannulated instead of the right internal jugular vein. The situation was immediately recognized and managed by a vascular surgeon. The patient recovered completely without neurological deficit.
 Conclusion: Central venous cannulation is usually performed using the landmark technique. Incidental cannulation of the common carotid artery is a rare complication that can have serious consequences if not immediately recognized and properly managed.

Advanced glycation end products and oxidative stress as a basis for metabolic abnormalities in patients with type 1 diabetes after successful simultaneous pancreas-kidney transplantation

To compare advanced glycation end-products (AGE, RAGE) and 3-nitrotyrosine (3-HT) in patients with DM 1 after successful simultaneous pancreas-kidney transplantation (SPK) and kidney transplantation alone (KTA). To assess relationship between levels of AGE, RAGE, 3-HT and renal transplant (RT) function, carbohydrate and mineral metabolism. The study included 58 patients who received kidney transplantation in end-stage renal disease (ESRD). 36 patients received SPK. There were performed routine laboratory, examination of AGE, RAGE, 3-NT, parathyroid hormone (PTH), 25(OH)vitamin D, calcium, phosphorus, FGF23, osteoprotegerin (OPG), and fetuin-A levels. All patients after SPK reached normoglycemia (HbA1c 5.7 [5.3; 6.1] %; C-peptide 3.24 [2.29; 4.40] ng/ml) with the achievement of significant difference vs patients after KTA. Arterial hypertension (AH) was more frequent in recipients of SPK before transplantation than after (p=0.008). AH also persisted in greater number of cases in patients after KTA than after SPK. Patients after SPK had higher AGE (р=0.0003) and lower RAGE (р=0.000003) levels. OPG in patients after SPK was significantly higher (р=0.04). The correlation analysis revealed significant positive correlation between 3-HT and OPG (p0.05; r=0.30), RAGE and eGFR (r=-0.52), HbA1c (r=0.48), duration of AH (r=0.34), AGE with HbA1c (r=0.51). The results of the "metabolic memory" markers analysis may indicate their contribution to the persistence of the metabolic consequences of CKD and DM 1 after achievement of normoglycemia and renal function restoration and their possible participation in development of recurrent nephropathy, vascular calcification, and bone disorders.

Technologies and Health Inequities

Health technologies aim to improve individual and population health, but they may also exacerbate health disparities. Focusing on the specific design features of technologies, their availability, and their use, we present a conceptual framework to examine how health technologies may benefit some groups more than others by combining the theory of fundamental causes with a technology-in-practice approach. We examine three classes of technologies that have been associated with health inequities: once-advanced technologies such as kidney dialysis and transplantation for end-stage renal disease, which have been plagued by issues of scarcity and fair distribution, generating racial disparities; the highly anticipated precision medicine promising to change the focus from population to individualized medicine; and digital technologies, which may herald a democratization of health care.

A Rare Cause of Mitral Valve Dysfunction in End-Stage Renal Disease

A 60-YEAR-OLD, 154 cm, 88 kg woman with essential hypertension, poorly controlled type II diabetes mellitus, and a previous kidney transplantation for end-stage renal disease resulting from diabetic nephropathy presented to a community hospital for evaluation of dyspnea and exercise intolerance. The physical examination was notable for an irregularly irregular rhythm and a grade II of VI holosystolic murmur best heard at the left lower sternal border. An electrocardiogram demonstrated new atrial fibrillation.

Fibromyalgia frequency and course in renal transplantation patients

AbstractBackground/Aims: Musculoskeletal complications such as fibromyalgia syndrome may occur following renal transplantation. However, frequency and the course of this condition have not been deeply assessed in this group of patients. This study aimed to investigate the frequency of fibromyalgia syndrome and identify the factors associated with its occurrence in patients who underwent renal transplantation for end-stage renal disease. Methods: The demographic, clinical, and laboratory characteristics were recorded. All patients were assessed in outpatient setting for the presence of fibromyalgia and classified into three groups in the following order: Group 1, normal patients; Group 2, possible fibromyalgia; Group 3, fibromyalgia syndrome. In addition, Fibromyalgia Impact Questionnaire was administered.Results: A total of 128 patients who underwent renal transplantation were included. Three groups did not differ with regard to the age, marital status, smoking history, etiology of the renal failure and laboratory findings (p>0.05). However, female gender was more frequent among patients with fibromyalgia. Fatigue, sleep disturbance, irritable colon syndrome, depression and antidepressant use were also more common and Fibromyalgia Impact Questionnaire score was higher in patients with fibromyalgia. A multivariate logistic regression analysis identified Fibromyalgia Impact Questionnaire score and antidepressant use as significant independent predictors of fibromyalgia syndrome and possible fibromyalgia.Conclusion: Fibromyalgia syndrome shows a tendency to occur more commonly in renal transplant patients than in normal population, where depression is accompanied by these conditions. Fibromyalgia Impact Questionnaire scoring system is a useful tool to assess the presence of fibromyalgia syndrome or possible fibromyalgia syndrome in this group of patients.

Marginal Zone Lymphoma, Immune Dysregulation, and High-Grade Transformation

Abstract Marginal zone lymphoma (MZL) is a low-grade B-cell lymphoma, which includes mucosa-associated lymphoid tissue lymphoma, splenic MZL, and nodal MZL. Of these, mucosa-associated lymphoid tissue lymphoma is the most frequent. While all 3 subtypes are typically indolent, a subset undergoes transformation to an aggressive B-cell lymphoma resulting in treatment challenges and a worse prognosis. We present a patient with systemic lupus erythematosus and Sjögren disease who developed MZL while on cyclophosphamide and steroids for treatment of her autoimmune disease. Her MZL was associated with a relatively indolent initial course. Unfortunately, her systemic lupus erythematosus continued to progress, and she ultimately required a renal transplant for end-stage renal disease due to lupus nephritis. At transplant, her MZL was thought to be in remission, but shortly thereafter, she developed an enlarging neck mass. A biopsy demonstrated background MZL with focal transformation to diffuse large B-cell lymphoma. Evidence is emerging that the underlying biology of a subset of MZL based on mutational profile, gene expression, and/or cytogenetic factors may affect the risk of transformation. Immune status has not been linked to progression, but chronic inflammation and immune dysregulation in the setting of chronic infection or autoimmune disease may underlie MZL development. In addition, iatrogenic immunosuppression for solid organ transplant or acquired immunodeficiency in the setting of human immunodeficiency virus may also result in increased risk or unusual presentations of MZL. This article features a case-based approach to explore factors related to MZL progression in a patient with a complex history of autoimmunity and immune suppression.

Complete biopsy-proven resolution of deposits in recurrent proliferative glomerulonephritis with monoclonal IgG deposits (PGNMIGD) following rituximab treatment in renal allograft

BackgroundProliferative glomerulonephritis with monoclonal IgG deposits (PGNMIGD) is a disease entity classified under the group of “Monoclonal gammopathy-related kidney diseases”, and can recur after transplant. Clinical remission of proteinuria in patients with PGNMIGD has been previously shown following anti-B cell and/or anti-plasma cell therapies. Our case is the first to show complete histologic resolution of the glomerular monoclonal IgG kappa deposits in a case of recurrent PGNMIGD in renal allograft after rituximab and steroid treatment. This is a novel finding and it shows that the deposits are amenable to therapy. This case also highlights the importance of IgG subclass staining in the recognition of the monoclonal nature of the deposits. It is particularly important in PGNMIGD because only 20 to 30% of patients with this disease are reported to have detectable monoclonal gammopathy, and the deposits do not have any organized substructure on electron microscopic examination. Morphologically, they resemble polyclonal immune-type deposits seen in other immune complex glomerulonephritides such as lupus nephritis, infection-associated glomerulonephritis, and membranoproliferative glomerulonephritis (MPGN type I).Case presentationThe patient is a 44 year old Caucasian male who received a living unrelated donor kidney transplant for end-stage renal disease diagnosed 7 years before transplant. The reported native kidney biopsy diagnosis was membranoproliferative glomerulonephritis (MPGN) with IgG, C3 and kappa restricted deposits. Fourteen months post-transplant, he presented with abrupt worsening of graft function, proteinuria and serum IgG kappa monoclonal spike. Allograft biopsy was consistent with recurrent PGNMIGD, considering the native kidney diagnosis and interval post-transplant. He underwent plasmapheresis, IV pooled immune globulin, steroid pulse and taper, and anti-CD-20 Rituximab therapy. Patient had gradual decline in proteinuria and complete resolution of the immune deposits on repeat biopsy 3 months later. Unfortunately he subsequently developed chronic antibody-mediated rejection and transplant glomerulopathy and graft failure 34 months post-transplant.ConclusionsIn a transplant setting, repeat allograft biopsies are frequently performed for graft dysfunction. This provides a good opportunity to study the evolution of the immune deposits following treatment. Our case shows complete histologic resolution of the deposits in allograft PGNMIGD.

Whole organ sheep kidney tissue engineering and in vivo transplantation: Effects of perfusion-based decellularization on vascular integrity

IntroductionDuring the past decade, increased efforts have been made to develop alternative management options instead of dialysis and homograft renal transplantation for end-stage renal disease. State-of-the-art methods employ tissue engineering to produce natural acellular scaffolds that could resolve the concern of allograft rejection and obviate the need for immunosuppressive therapy. Complete decellularization of kidney with intact extracellular matrix is crucial for in vivo compatibility and success of transplantation. Herein, we evaluate the efficacy of two different whole organ decellularization protocols, vasculature integrity, and in vivo transplantation of sheep kidneys. Materials and methodsEight sheep kidneys were decellularized by perfusion-based method utilizing two different protocols (Protocol 1: 1% Triton X-100 and 0.5% SDS vs. Protocol 2: 1% SDS). The samples were evaluated by histopathology in terms of decellularization and extracellular matrix preservation. Computerized tomography angiography was performed to evaluate vasculature. Subsequently, both methods were transplanted in four sheep and monitored for vascular integrity and extravasations in short-term. ResultsScaffolds obtained from both protocols were entirely decellularized. However; the extracellular matrix was better preserved in protocol 1 compared to protocol 2. In addition, the vascular integrity was intact in decellularized scaffolds treated with Triton X-100 plus SDS (protocol 1). After transplantation, the samples treated with protocol 2 showed extravasation of fluid in the interstitial space while the samples treated with protocol 1 showed intact extracellular matrix and vasculature. ConclusionsThis study demonstrated the efficacy of well-preserved acellular scaffold and vasculature network in post renal transplant outcome in a sheep model. These results have potential to pave the road for further investigations in acellular whole organ transplantation.

Management of hepatitis C in a patient undergoing solid organ (kidney) transplant

Many patients with hepatitis C (HCV) suffer from concurrent renal disease requiring dialysis and eventual renal transplant. HCV treatment with direct-acting antivirals (DAA) is safe and effective in the context of renal transplant, but the optimal timing of treatment in proximity to transplant remains a focus of debate. We present the case of a 60-year-old male with HCV genotype 3 infection. He failed two prior interferon-based treatments, underwent previous separate liver and kidney transplants, and is currently under evaluation for a second kidney transplant for end-stage renal disease (ESRD). Using this illustrative case, we discuss topics pertinent to the evaluation and clinical care of HCV-infected renal transplant candidates including evaluation for a simultaneous liver-kidney transplant in the context of HCV infection, optimal timing of HCV treatment with respect to transplantation, and the safety and monitoring requirements during DAA treatment in renal transplant candidates.

Allograft and patient survival after sequential HSCT and kidney transplantation from the same donor-A multicenter analysis.

Tolerance induction through simultaneous hematopoietic stem cell and renal transplantation has shown promising results, but it is hampered by the toxicity of preconditioning therapies and graft‐versus‐host disease (GVHD). Moreover, renal function has never been compared to conventionally transplanted patients, thus, whether donor‐specific tolerance results in improved outcomes remains unanswered. We collected follow‐up data of published cases of renal transplantations after hematopoietic stem cell transplantation from the same donor and compared patient and transplant kidney survival as well as function with caliper‐matched living‐donor renal transplantations from the Austrian dialysis and transplant registry. Overall, 22 tolerant and 20 control patients were included (median observation period 10 years [range 11 months to 26 years]). In the tolerant group, no renal allograft loss was reported, whereas 3 were lost in the control group. Median creatinine levels were 85 μmol/l (interquartile range [IQR] 72‐99) in the tolerant cohort and 118 μmol/l (IQR 99‐143) in the control group. Mixed linear‐model showed around 29% lower average creatinine levels throughout follow‐up in the tolerant group (P < .01). Our data clearly show stable renal graft function without long‐term immunosuppression for many years, suggesting permanent donor‐specific tolerance. Thus sequential transplantation might be an alternative approach for future studies targeting tolerance induction in renal allograft recipients.

Oncocytoma managed by active surveillance in a transplant allograft kidney: a case report

BackgroundThe ethical implications of the utilization of kidneys with solid renal masses (SRMs) in transplantation are the subject of lively debate in the transplantation community and beyond. One of such implications is that as the life expectancy of renal transplant patients improve, the prevalence of SRMs in donors is likely to increase. We report a case of an oncocytoma in a renal allograft complicating a deceased-donor kidney transplant.Case presentationA 60-year-old woman received and underwent deceased-donor renal transplantation for end-stage renal disease after a waiting-list period of 11 years. Kidney Doppler ultrasound (DUS) of the deceased donor was negative for any nodular lesion. The finding of the DUS, done on postoperative day 1, to assess the patency of the graft, was suspicious for an acute arterial thrombosis but did not reveal any focal irregularities. An ensuing computed tomography (CT) scan did not show any arterial complications but serendipitously revealed a 2.4-cm lesion on the upper pole of the renal allograft, which was not detected during the back-table or ultrasonography monitoring. Histology of the biopsied lesion was consistent with oncocytoma. However, because the eosinophilic variant of chromophobe renal cell carcinoma may morphologically resemble renal oncocytoma, immunohistochemical staining was performed. The results were negative, ruling out chromophobe RCC. After discussing the therapeutic options and potential related outcomes with the patient, we found no reason for resection of the lesion or an allograft nephrectomy, given the low risk of malignant transformation in an oncocytoma. Active surveillance of the benign tumor was done with ultrasonography, every 2 months, for the first year and, then, with magnetic resonance imaging, every year. The patient received mycophenolate-mofetil, tacrolimus, and prednisone throughout the 5-year follow-up period, and the regimen for immunosuppression was not changed despite the presence of the renal mass. After 60 months, we report that none of the radiological findings have shown any morphological changes of the lesion, and the patient is well.ConclusionTo the best of our knowledge, we report the first case of an oncocytoma in a renal allograft complicating a deceased-donor kidney transplant, which was successfully managed by active surveillance.

Improved survival with renal transplantation for end-stage renal disease due to granulomatosis with polyangiitis: data from the United States Renal Data System

BackgroundRenal transplantation is the optimal treatment for selected patients with end-stage renal disease (ESRD). However, the survival benefit of renal transplantation among patients with ESRD attributed to granulomatosis with polyangiitis...

How to grow up with chronic kidney disease?

The aim of this paper was to provide information on the best practice to allow children with chronic kidney disease (CKD) to attain normal adult physical and psychological development as well as social rehabilitation. Growth and development of children with CKD is associated with many problems that arise from the primary disease, the stage of CKD and complications of the disease and therapy. Only comprehensive treatment, which includes correction of metabolic disorders and anemia, normalization of growth and blood pressure, management of mineral and bone disease, psychosocial rehabilitation and renal replacement therapy by dialysis or renal transplantation in end-stage renal disease, can allow these patients to grow up. A multidisciplinary care team, including pediatricians, psychologists, dieteticians and social workers, can help to address these important needs of both patients and their caregivers. Adolescents with CKD, and especially those with end-stage renal disease (ESRD), face many additional challenges concerning their physical, emotional, educational and social demands, and they also need to take responsibility for their own care in order to achieve a good outcome and longer survival. The well-organized process of transition from pediatric to adult care institutions is important to raise the level of self-confidence, self-control and treatment compliance in adolescent patients. Conclusion – Pediatric CKD has many long-term consequences, of which treatment is best carried out by a multidisciplinary team. Kidney transplantation is the best therapeutic option for children with ESRD. The transition of adolescents from a pediatric to an adult institution must be gradual, and well prepared.

PT014 - The risk of tumour recurrence in patients undergoing renal transplantation for endstage renal disease after previous treatment for a urological cancer: A systematic review

PT014 - The risk of tumour recurrence in patients undergoing renal transplantation for endstage renal disease after previous treatment for a urological cancer: A systematic review

Medical complications of liver transplantation

Orthotopic liver transplantation has become the standard of care for adult patients with endstage liver diseases. Knowledge in post-transplant medical complications has grown considerably in the last few decades. Graft rejection occurs in both early and late settings, and its diagnosis is confirmed and severity graded by a core needle liver biopsy. Acute rejections should be treated appropriately to avoid graft loss whereas chronic ductopenic rejection carries a poor prognosis without re-transplantation. The causes of acute kidney injuries are different from that of the chronic renal disease in post-transplant setting. With increasing prevalence of non-alcoholic fatty liver disease (NAFLD) and older transplant recipients, de novo diabetes and metabolic bone disease are becoming more recognized in the post-transplant era. De novo malignancy, post-transplant lymphoproliferative disorder, although less common, signals significant mortality in this population. The outcomes of graft rejection, renal dysfunction, diabetes, bone disease and de novo malignancy are dependent on timely recognition, alterations of the immunosuppression regimen, and occasionally liver re-transplantation in the setting of irreversible graft rejection and kidney transplantation in end-stage renal disease (ESRD). There is still significant mortality and morbidity associated with these medical complications despite our medical advances.

A review of the possibility of adopting financially driven live donor kidney transplantation.

ABSTRACTKidney transplantation for end-stage renal disease remains the preferred solution due to its survival advantage, enhanced quality of life and cost-effectiveness. The main obstacle worldwide with this modality of treatment is the scarcity of organs. The demand has always exceeded the supply resulting in different types of donations. Kidney donation includes pure living related donors, deceased donors, living unrelated donors (altruistic), paired kidney donation and more recently compensated kidney donation. Ethical considerations in live donor kidney transplantation have always created a debate especially when rewarding unrelated donors. In this paper, we examine the problems of financially driven kidney transplantation, the ethical legitimacy of this practice, and propose some innovative methods and policies that could be adopted to ensure a better practice with accepted ethical guidelines.

Case Report and Review of the Literature: Resolution of Lithium-Induced Nephrogenic Diabetes Insipidus with Pre-Emptive Living Related Kidney Transplantation for End-Stage Renal Disease

Long-term lithium therapy is known to cause renal dysfunction, including nephrogenic diabetes insipidus (nDI) and chronic tubulointerstitial nephropathy, which may progress to end-stage renal disease (ESRD) in approximately 1% of patients. We report a case of resolution of lithium-induced nDI following living related kidney transplantation for ESRD secondary to chronic lithium toxicity. A 63-year-old male presented with ESRD and a 22-year history of severe nDI following 11 years of oral lithium treatment for bipolar disorder. He underwent a preemptive 1-haplotype matched living related kidney transplant from his son. Prior to the transplant, he had a daily urine output of 10-14 L. One month following transplant, the patient’s daily urine output decreased to 2-3 L. His kidney function stabilized with a serum creatinine of 1.4 mg/dl (6.4 mg/dl pre-operatively). Doppler ultrasound supports a functional shift from native kidneys to renal allograft. This case report demonstrates reversal of nDI with kidney transplantation in a patient with ESRD secondary to lithium nephropathy, and highlights our poor understanding of this functional shift.

Kidney transplantation for end-stage renal disease in lupus nephritis, a very safe procedure: a single Latin American transplant center experience.

Background Lupus nephritis (LN) is one of the most frequent complications of SLE and occurs in up to 50% of cases depending on the studied population. Of these, approximately 20% progress to end-stage renal disease (ESRD), with the treatment of choice being a kidney transplant. Objective The objective of this study was to describe the clinical outcome of patients transplanted due to LN, compared with patients transplanted for other causes, in a Latin American population from the Fundación Valle del Lili in Cali, Colombia. Methods Observational, retrospective case study with controls matched by age, sex and type of donor in a single center between 1996 and 2014. Results Sixty-five kidney transplants were performed in patients with LN and ESRD. The survival of patients with LN was 98% at 1, 10 and 15 years ( p = .99). For controls by age and sex, survival was also 98% at 15 years post-transplant, and for controls by donor, the survival rate was 100% at 5 years and 98% at 15 years. Graft survival in patients with LN to 1, 5 and 15 years was 92%, 83% and 71%, respectively; for controls by age and sex, it was 90%, 84% and 64%, respectively, and for the controls by donor, it was 89%, 86% and 79%, respectively ( p = .7718). There were no statistically significant differences found in the cumulative incidence of acute graft rejection in the first year, but it was found that acute rejection is a factor that relates to the loss of function of the renal graft ( p = .032). Of the patients transplanted for LN, two (3.1%) experienced a recurrence of the disease. One patient died after a diagnosis of recurrence of LN due to an infection. Conclusions Kidney transplantation is a good option for patients with ESRD due to LN. In this Hispanic population, the survival of patients, graft survival, and cumulative incidence of graft rejection are not different from those of other transplanted patients. In addition, recurrence of LN was rare, showing the benefits of renal transplantation in LN patients with ESRD.