Transplant Nephrologists Research Articles

Who Is Caring for Kidney Transplant Patients? Variation by Region, Transplant Center, and Patient Characteristics

Background/Aims: Despite implications for long-term care, little is known about outpatient care for kidney transplant patients. Methods: In this retrospective observational cohort study, outpatient claims were examined for 42,078 Medicare kidney transplant patients using United States Renal Data System data to ascertain location and timing of outpatient visits and type of physician seen. Logistic regression with generalized estimating equations was used to determine the odds and clinical correlates of visits in 4 post-transplant time periods. Results: In months 1–3, 88% of patients visited their transplant centers, but this declined to 69% in months 25–36. In the adjusted analysis, Native Americans (odds ratio 0.56, 95% confidence interval 0.48–0.65) and Hispanics (OR 0.86, 95% CI 0.80–0.92) were less likely than whites to visit their transplant centers. Centers performing 18–34 (OR 1.44, 95% CI 1.30–1.59) and 35–61 transplants per year (OR 1.30, 95% CI 1.18–1.43) were more likely to see patients than centers performing <18 or >61. Almost 80% of patients saw nephrologists in months 1–3 after transplant. African-Americans (OR 0.85, 95% CI 0.80–0.90), Asians (OR 0.87, 95% CI 0.77–0.97), and Native Americans (OR 0.63, 95% CI 0.53–0.75) were less likely than whites to see nephrologists, as were Hispanics (OR 0.78, 95% CI 0.72–0.84) compared with non-Hispanics. Conclusion: Frequency of visits to transplant centers varied by center and region; most visits were to nephrologists. Patients from minority groups were less likely to visit transplant centers and nephrologists, with possibly significant public health implications.

The D&amp;T Report

The D&amp;T Report

Renal transplantation in children with thrombosis of the inferior vena cava requires careful assessment and planning

Children with end-stage renal disease and inferior vena cava (IVC) thrombosis are rare, and their condition is complex and high risk for renal transplantation. Detailed imaging studies of the recipient's abdominal vasculature should be carried out prior to transplantation, followed by careful pre-operative joint planning by the pediatric transplant surgeon and nephrologist. Critical decisions need to be made as to whether a deceased child's kidney or an adult-sized kidney is to be used, and if the latter, whether it should be from a deceased or living donor. In addition, the contemplated site of the donor's renal vein anastomosis needs to be determined with a consideration of the possible consequences of the various choices. Sixteen cases of renal transplantation in children with pre-existing IVC thrombosis are reviewed, including the three reported by Shenoy et al. in this journal. With a full understanding of the difficulties noted, renal transplantation in a small child with IVC thrombosis can be successful. However, it requires thorough recipient assessment, coupled with a careful and thoughtful examination of options, to determine the best possible approach to the transplantation.

Chronic kidney disease after liver, cardiac, lung, heart–lung, and hematopoietic stem cell transplant

Patient survival after cardiac, liver, and hematopoietic stem cell transplant (HSCT) is improving; however, this survival is limited by substantial pretransplant and treatment-related toxicities. A major cause of morbidity and mortality after transplant is chronic kidney disease (CKD). Although the majority of CKD after transplant is attributed to the use of calcineurin inhibitors, various other conditions such as thrombotic microangiopathy, nephrotic syndrome, and focal segmental glomerulosclerosis have been described. Though the immunosuppression used for each of the transplant types, cardiac, liver and HSCT is similar, the risk factors for developing CKD and the CKD severity described in patients after transplant vary. As the indications for transplant and the long-term survival improves for these children, so will the burden of CKD. Nephrologists should be involved early in the pretransplant workup of these patients. Transplant physicians and nephrologists will need to work together to identify those patients at risk of developing CKD early to prevent its development and progression to end-stage renal disease.

Care of the Kidney Transplant Recipient

Kidney transplantation is a successful treatment modality for end-stage real disease and the preferred mode of renal replacement therapy. Both patient and allograft survival at 1 yr are >90% in most transplant centers. The success of transplantation has in fact led to an increased demand for organs and an increased waiting time for deceased donor kidneys. This in turn has stimulated increased living donation and the use of extended-criteria deceased donor kidneys, including those donated after cardiac death. Moreover, although more potent and complex immunosuppressive strategies have reduced the rates of acute rejection and improved short-term graft survival, long-term graft survival rates have not improved as dramatically. This is due in part to continued graft failure caused by allograft fibrosis and atrophy (also known as chronic allograft nephropathy or CAN) as well as death with a functioning graft. Transplant nephrologists are now focusing on the medical management of their patients with more attention to the details of the medical management of comorbidities. Thus, this supplement of the Clinical Journal of the American Society of Nephrology will explore the leading medical complications after kidney transplant, with attention to etiology, detection, and management. Although cardiovascular disease is believed to be the leading cause of death in renal transplant recipients, there is ample evidence to support the idea that transplantation reduces the risk of …

Multidisciplinary Insights on Clinical Guidance for the Use of Proliferation Signal Inhibitors in Heart Transplantation

Proliferation signal or mammalian target-of-rapamycin inhibitors (PSI/mTOR inhibitors), everolimus and sirolimus, provide attractive options for use in heart transplantation because they are immunosuppressive and anti-proliferative. PSI/mTOR inhibitors work synergistically with calcineurin inhibitors (CNIs) and thus permit the minimization of CNIs without compromising efficacy. This approach is advantageous for the majority of heart transplant recipients and might provide particular benefit in specific cases, such as patients with cardiac allograft vasculopathy, malignancies and renal dysfunction, or in patients intolerant to other immunosuppressive agents. Drawing on the expertise of transplant cardiologists, cardiac surgeons and nephrologists, we addressed the assessment of renal function; management of adverse events associated with this class of drugs; and clinical guidance, specifically for the use of everolimus, including patient selection, indications for treatment and practicalities of drug initiation and monitoring.

Living unrelated kidney donor transplantation in Iran

In the September and November 2006 issues of Nature Clinical Practice Nephrology, two articles regarding living unrelated kidney donor transplantation alluded to the practices in Iran. Having served in the planning, supervision and implementation of various aspects of health care in Iran, including organ transplantation (ANH), and as transplant nephrologists who have actively participated in the care of transplanted patients in Iran (ANH and NG), we feel obligated to elucidate the realities surrounding organ transplantation in Iran. So that unbiased researchers are provided with information to judge for themselves.

Symposium: evaluating the reproducibility of pathological diagnosis using the 1997 Banff classification update

The purpose of this symposium was to evaluate the reproducibility of a histological diagnosis in renal allograft nephropathy according to the Banff classification. Seven transplant nephrologists and pathologists independently diagnosed the same glass slide specimens from 10 cases (five cases of acute rejection and five cases of chronic allograft nephropathy). Their diagnoses were collated and analyzed for the reproducibility of histological diagnosis. Consequently, several issues that hinder diagnostic reproducibility were identified.

The impact of cyclosporine on the development of immunosuppressive therapy: perspective from a transplant nephrologist involved with the development of C 2

The availability of Neoral in place of Sandimmun offered better pharmacokinetics and improved results but emphasized the poor accuracy of trough levels as a tool for monitoring drug exposure and dosage adjustment. Subsequent studies confirmed that Neoral exposure correlated with clinical events and it was found that C 2 was the single point that correlated best with exposure as determined by AUC 0–4h. Single and multicenter studies have now shown that C 2 monitoring is practically feasible and that its use resulted in very low rates of acute rejection with excellent renal function. One retrospective comparison suggested that rates of acute rejection were lower with C 2 than with C 0 monitoring. This tool has now been shown to be effective in managing African-American renal transplants and those with delayed graft function. A very recent international randomized trial has shown equivalent rates of acute rejection in liver transplant recipients treated with both Neoral and Prograf. Studies now in progress will permit further refinement of target levels with the potential to improve long-term results.

Identifying and addressing potentially preventable causes of renal allograft loss

Identifying and addressing potentially preventable causes of renal allograft loss

Expanding the kidney donor pool: Ethical and medical considerations

year later, proteinuria developed. She had an uncomplicated pregnancy in 1990. Five years later, arterial hypertension required treatment with enalapril. Her serum creatinine then was 1.2 mg/dL. The serum creatinine rose to 1.3 mg/dL two years ago and to 1.5 mg/dL last year. Earlier this year, a 24-hour urine collection contained 810 mg protein; the serum creatinine was 1.6 mg/dL and the creatinine clearance was 31 mL/min/ 1.73 m 2 . Her urine sediment was benign. A further increase in her blood pressure necessitated treatment with lisinopril, 10 mg each morning, and amlodipine, 5 mg each night. She says that she has no regrets about her decision to donate despite the outcome. Five years ago, her husband’s brother developed renal failure; with her encouragement, her husband donated a kidney. Her husband, now age 44, is in good health and has normal blood pressure, normal serum creatinine, and no proteinuria.

Utility of bronchoalveolar lavage in assessing pneumonia in immunosuppressed renal transplant recipients

purpose: To determine if initial results obtained from diagnostic bronchoalveolar lavage (BAL) in immunosuppressed renal transplant patients with pulmonary infiltrates, fever, or hypoxemia can affect therapeutic decisions, morbidity, and mortality. design: A retrospective study of all BAL specimens obtained from renal transplant patients from January 1985 through June 1991. Initial results of Gram stain, cytology, cell differential count, and semi-quantitative bacterial cultures, all available within 24 hours of bronchoscopy, were compared with clinical outcomes and final diagnosis. setting: University hospital nephrology-transplant/pulmonary service. patients: Seventy renal transplant patients with a suspected pneumonia were stratified into 3 groups. A total of 48 patients underwent 58 bronchoscopies. Group 1 was comprised of 32 BALS that yielded 1 or more infectious organisms and was considered diagnostic. Group 2 (n = 26) were those BALs in which no organism was isolated and were thus nondiagnostic. Twenty-two additional immunosuppressed renal transplant recipients with pneumonia were considered by the admitting transplant nephrologist to have an uncomplicated community-acquired lung infection and thus were empirically treated and did not undergo BAL (Group 3). methods: BAL fluid analysis included cell differential count, cytopathologic examination, and culture for mycobacteria, legionella, fungi, viruses, and bacteria using a semi-quantitative technique. Etiologic diagnosis and the time of onset of the infectious processes were recorded. Therapeutic outcome and mortality were determined for each group. results: Thirty-nine etiologic organisms were found in 32 patients, with 6 patients having more than 1 infection. Twenty-two patients had 26 negative BALs, and 8 of these patients were clinically believed to have a volume overload state. Eight of 13 (61%) patients with bacterial pneumonia had BAL neutrophil counts greater than 20%, whereas 11 of 13 (84%) patients without bacterial pneumonia had neutrophil counts less than 20% (p <0.05). Those patients with an infectious etiology remained in the hospital longer than patients without a specific etiologic organism identified (p <0.02). Therapeutic decisions leading to the institution of specific antibiotics were more frequently made in patients with a diagnostic BAL (p <0.0001). An overall 3-month mortality (16%) was low compared with the historical rate (30%). conclusion: BAL is a useful procedure in the diagnosis of an infectious process in immunosuppressed renal transplant patients where initial results can alter therapy in more than 70% of cases.

The Impact of 1,000 Renal Transplants at One Center

A large, comprehensive renal transplant program has a major impact not only on patient care, but also on the medical center itself and the larger community. The program at this center has advanced from 15 transplants in 1964 to 141 transplants in 1976. Fifty-nine per cent of patients transplanted have functioning kidneys at this time, including 76 children. Rehabilitation was equal to prerenal disease level in 91% of 169 recipients who lived five years with a functioning graft. Basic research in such diverse areas as renal preservation and immunology, as well as clinical research in optimum immunosuppressive therapy, resulted in significant contributions. Refinement of the mixed lymphocyte culture improved living-related graft survival at two years: 100% for HLA-identical and 91% for non-HLA-identical grafts, compared to 66% reported by the Transplant Registry for the combined group. Modification of immunosuppression improved patient survival at two years: 100% and 86% for recipients of living-related and cadaver grafts, respectively, compared to 83% and 65% reported by the Transplant Registry. The complexity of care of the patient with end-stage renal failure has required active interaction between transplant surgeons and almost every major specialty. The vast clinical material has been a great asset for training transplant surgeons, nephrologists, fellows and residents of multiple specialties, and medical students. The medical center's relationship with communities within a 250 mile radius has been strengthened, as reflected in patient referrals and the development of a multi-community-supported organ procurement system, which has allowed us to perform over 100 cadaver transplants per year for the past three years. Thus the performance of 1,000 renal transplants at this center has resulted not only in rehabilitation of many renal failure patients, but also in expanded and improved research and teaching capabilities, bringing support from multiple medical disciplines and the general community.

Renal Transplantation in a Community Hospital

Eighty renal transplantations were performed at an urban community hospital over a ten-year period. Forty-two transplants were from living related donors and 38 from cadaver donors. The one-year rejection rate for cadaveric transplants was 35% and for transplants between parents and children, 31%, whereas only one of 21 (5%) transplants between siblings was rejected during the first year. These results compare favorably with those reported by others and appear to justify performance of kidney transplantation in the community hospital setting where large numbers of transplant surgeons and nephrologists are involved, and where the number of transplants never has exceeded 15 per year.

Intraoperative Esophagoscopy, Gastroscopy, Colonoscopy, and Endoscopy of the Small Bowel

Intraoperative endoscopy of the gastrointestinal tract is probably much more widely used than has been publicized in the recent literature. Application of this new tool to the surgical armamentarium depends only on the limits of the imagination of the operating surgeon and his endoscopist colleague, in most cases, the gastroenterologist. The operative maneuverability of current endoscopes make every portion of the gastrointestinal tract accessible to direct visualization without incision into it, both by the operating surgeon and by the endoscopist. For the full potential of this modality to be realized, the same sort of cooperation between gastrointestinal surgeon and gastroenterologist must be achieved as currently exists between cardiac surgeon and cardiologist and between transplant surgeon and nephrologist. Once this cooperation has been established, application of these tools to gastrointestinal diseases should become commonplace in gastrointestinal surgery.