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No significant differences in short-term renal prognosis between living kidney donors with and without diabetes.

Sun, 10/15/2017 - 18:48
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No significant differences in short-term renal prognosis between living kidney donors with and without diabetes.

Clin Exp Nephrol. 2017 Oct 12;:

Authors: Shinzato T, Kurosawa A, Kubo T, Shimizu T, Kimura T, Nanmoku K, Yagisawa T

Abstract
BACKGROUND: Renal prognosis in living kidney donors with diabetes is currently not known. In this study, we sought to investigate renal prognosis in living kidney donors with diabetes.
METHODS: We retrospectively investigated 241 living kidney donors who underwent nephrectomy at Jichi Medical University Hospital between January 2000 and December 2015. Donors with a follow-up period of less than 1 year were excluded. The remaining donors were divided into a diabetic group and a non-diabetic group. Their clinical parameters before donation and renal prognosis after donation were compared.
RESULTS: Of the 241 donors, 16 were excluded due to their follow-up period being less than 1 year. Of the remaining 225 donors, 14 were diabetic and 211 were non-diabetic. There were no significant differences in variables at pre-donation. The median follow-up period was 4.3 (1.5-10.7) and 4.6 (1.0-13.0) years in kidney donors with and without diabetes, respectively. At the end of follow-up, the estimated glomerular filtration rate was 51.7 ± 7.1 ml/min/1.73 m(2) in the diabetic group and 52.1 ± 12.2 ml/min/1.73 m(2) (p = 0.906) in the non-diabetic group; urine albumin excretion was 9.5 (2-251) mg/day (or mg/g creatinine) in the diabetic group and 6 (0-626) mg/day (or mg/g creatinine) in the non-diabetic group (p = 0.130); and urine protein excretion was 0.079 (0-0.41) g/day in the diabetic group and 0.051 (0-3.7) g/day in the non-diabetic group (p = 0.455).
CONCLUSIONS: There were no significant differences in short-term renal prognosis between kidney donors with and without diabetes.

PMID: 29027035 [PubMed - as supplied by publisher]

Prolonged Delayed Renal Graft Function Secondary to Venous Hypertension.

Sun, 10/15/2017 - 18:48
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Prolonged Delayed Renal Graft Function Secondary to Venous Hypertension.

Transplant Direct. 2017 Oct;3(10):e214

Authors: Mishra S, Gupta G, Moinuddin I, Strife B, Prasad U, Massey D, King A, Kumar D, Bhati CS

Abstract
The case of a 39-year-old highly sensitized woman who underwent second renal transplantation after being on warfarin because of a history of frequent thromboses of her left femoral arteriovenous graft (AVG) is reported here. The patient received a flow cytometric positive crossmatch kidney transplant from a deceased donor. Her posttransplant course was complicated by prolonged delayed graft function (DGF) lasting for 9 months. Antibody-mediated rejection occurred in the immediate postoperative period. This resolved after treatment, and resolution was confirmed by repeat biopsy. Despite this, she had persistent DGF and remained dialysis dependent. A computed tomography scan due to the development of perinephric hematoma after posttransplant biopsy demonstrated venous collateralization around the allograft. At 7 months posttransplant, a venogram during declotting of AVG revealed chronic thrombus in the inferior vena cava (IVC) above the level of native renal veins with a venous gradient of 26 mmHg. After declotting of the graft, iliac venoplasty, and subsequent IVC stent, her renal function continues to improve with a most recent creatinine of 1.4 mg/dL at 36 months posttransplant. Venous hypertension secondary to IVC thrombosis in presence of patent femoral AVG should be considered as a rare cause of prolonged DGF.

PMID: 29026877 [PubMed]

Australia and New Zealand Islets and Pancreas Transplant Registry Annual Report 2017-Pancreas Waiting List, Recipients, and Donors.

Sun, 10/15/2017 - 18:48
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Australia and New Zealand Islets and Pancreas Transplant Registry Annual Report 2017-Pancreas Waiting List, Recipients, and Donors.

Transplant Direct. 2017 Oct;3(10):e211

Authors: Webster AC, Hedley J, Patekar A, Robertson P, Kelly PJ

Abstract
This is a registry report from the Australia and New Zealand Islet and Pancreas Transplant Registry. We report data for all solid organ pancreas transplant activity from inception in 1984 to end of 2016. Data analysis was performed using Stata Software version 14 (StataCorp, College Station, Tex). From 1984 to 2016 a total of 756 solid organ pancreas transplants have been performed in Australia and New Zealand, in 738 individuals. In 2016, 55 people received a pancreas transplant. These transplants were performed in Auckland (4), Monash (22), and Westmead (29). In 2016, 50 transplants were simultaneous pancreas kidney, 4 were pancreas after kidney, and 1 was a pancreas transplant alone.

PMID: 29026874 [PubMed]

Graft Growth and Podocyte Dedifferentiation in Donor-Recipient Size Mismatch Kidney Transplants.

Sun, 10/15/2017 - 18:48
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Graft Growth and Podocyte Dedifferentiation in Donor-Recipient Size Mismatch Kidney Transplants.

Transplant Direct. 2017 Oct;3(10):e210

Authors: Müller-Deile J, Bräsen JH, Pollheimer M, Ratschek M, Haller H, Pape L, Schiffer M

Abstract
BACKGROUND: Kidney transplantation is the treatment choice for patients with end-stage renal diseases. Because of good long-term outcome, pediatric kidney grafts are also accepted for transplantation in adult recipients despite a significant mismatch in body size and age between donor and recipient. These grafts show a remarkable ability of adaptation to the recipient body and increase in size in a very short period, presumably as an adaptation to hyperfiltration.
METHODS: We investigated renal graft growth as well as glomerular proliferation and differentiation markers Kiel-67, paired box gene 2 and Wilms tumor protein (WT1) expression in control biopsies from different transplant constellations: infant donor for infant recipient, infant donor for child recipient, infant donor for adult recipient, child donor for child recipient, child donor for adult recipient, and adult donor for an adult recipient.
RESULTS: We detected a significant increase in kidney graft size after transplantation in all conditions with a body size mismatch, which was most prominent when an infant donated for a child. Podocyte WT1 expression was comparable in different transplant conditions, whereas a significant increase in WT1 expression could be detected in parietal epithelial cells, when a kidney graft from a child was transplanted into an adult. In kidney grafts that were relatively small for the recipients, we could detect reexpression of podocyte paired box gene 2. Moreover, the proliferation marker Kiel-67 was expressed in glomerular cells in grafts that increased in size after transplantation.
CONCLUSIONS: Kidney grafts rapidly adapt to the recipient size after transplantation if they are transplanted in a body size mismatch constellation. The increase in transplant size is accompanied by an upregulation of proliferation and dedifferentiation markers in podocytes. The different examined conditions exclude hormonal factors as the key trigger for this growth so that most likely hyperfiltration is the key trigger inducing the rapid growth response.

PMID: 29026873 [PubMed]

Letter to the Editor: Mobile Technology Can Improve Adherence and Lessen Tacrolimus Variability in Patients Receiving Kidney Transplants.

Sun, 10/15/2017 - 18:48
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Letter to the Editor: Mobile Technology Can Improve Adherence and Lessen Tacrolimus Variability in Patients Receiving Kidney Transplants.

Ochsner J. 2017;17(3):218-219

Authors: Torabi J, Choinski K, Courson A, Zanetti-Yabur A, Rocca JP, Graham JA

PMID: 29026350 [PubMed]

A Markov Analysis of Screening for Late-Onset Cytomegalovirus Disease in Cytomegalovirus High-Risk Kidney Transplant Recipients.

Sun, 10/15/2017 - 18:48
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A Markov Analysis of Screening for Late-Onset Cytomegalovirus Disease in Cytomegalovirus High-Risk Kidney Transplant Recipients.

Clin J Am Soc Nephrol. 2017 Oct 12;:

Authors: Puttarajappa CM, Hariharan S, Smith KJ

Abstract
BACKGROUND AND OBJECTIVES: Management strategies are unclear for late-onset cytomegalovirus infection occurring beyond 6 months of antiviral prophylaxis in cytomegalovirus high-risk (cytomegalovirus IgG positive to cytomegalovirus IgG negative) kidney transplant recipients. Hybrid strategies (prophylaxis followed by screening) have been investigated but with inconclusive results. There are clinical and potential cost benefits of preventing cytomegalovirus-related hospitalizations and associated increased risks of patient and graft failure. We used decision analysis to evaluate the utility of postprophylaxis screening for late-onset cytomegalovirus infection.
DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We used the Markov decision analysis model incorporating costs and utilities for various cytomegalovirus clinical states (asymptomatic cytomegalovirus, mild cytomegalovirus infection, and cytomegalovirus infection necessitating hospitalization) to estimate cost-effectiveness of postprophylaxis cytomegalovirus screening strategies. Five strategies were compared: no screening and screening at 1-, 2-, 3-, or 4-week intervals. Progression to severe cytomegalovirus infection was modeled on cytomegalovirus replication kinetics. Incremental cost-effectiveness ratios were calculated as a ratio of cost difference between two strategies to difference in quality-adjusted life-years starting with the low-cost strategy. One-way and probabilistic sensitivity analyses were performed to test model's robustness.
RESULTS: There was an incremental gain in quality-adjusted life-years with increasing screening frequency. Incremental cost-effectiveness ratios were $783 per quality-adjusted life-year (every 4 weeks over no screening), $1861 per quality-adjusted life-year (every 3 weeks over every 4 weeks), $10,947 per quality-adjusted life-year (every 2 weeks over every 3 weeks), and $197,086 per quality-adjusted life-year (weekly over every 2 weeks). Findings were sensitive to screening cost, cost of hospitalization, postprophylaxis cytomegalovirus incidence, and graft loss after cytomegalovirus infection. No screening was favored when willingness to pay threshold was <$14,000 per quality-adjusted life-year, whereas screening weekly was favored when willingness to pay threshold was >$185,000 per quality-adjusted life-year. Screening every 2 weeks was the dominant strategy between willingness to pay range of $14,000-$185,000 per quality-adjusted life-year.
CONCLUSIONS: In cytomegalovirus high-risk kidney transplant recipients, compared with no screening, screening for postprophylactic cytomegalovirus viremia is associated with gains in quality-adjusted life-years and seems to be cost effective. A strategy of screening every 2 weeks was the most cost-effective strategy across a wide range of willingness to pay thresholds.

PMID: 29025787 [PubMed - as supplied by publisher]

Preoperative Cardiac Risk Assessment in Renal Transplant Recipients: A Single-Center Experience.

Sun, 10/15/2017 - 18:48
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Preoperative Cardiac Risk Assessment in Renal Transplant Recipients: A Single-Center Experience.

Exp Clin Transplant. 2017 Oct 12;:

Authors: Yilmaz KC, Akgün AN, Ciftci O, Muderrisoglu H, Sezer S, Moray G, Haberal M

Abstract
OBJECTIVES: Cardiovascular disease is the major cause of morbidity and mortality in patients on renal replacement therapy and in kidney transplant recipients. There are no specific recommendations for preoperative cardiac risk assessment before renal transplant. The aim of our study was to analyze preoperative cardiac test frequencies, test results, patient characteristics, and relations between cardiac stress test results and severe coronary artery disease.
MATERIALS AND METHODS: We retrospectively examined patients who underwent renal transplant between December 2011 and December 2016 in our hospital (Ankara, Turkey). Our study group included 216 patients. All patients had preoperative echocardiography. We recorded results of exercise stress tests, myocardial perfusion scintigraphy, and coronary angiography. For all patients, preoperative complete blood cell count, creatinine, high-density lipoprotein, triglycerides, low-density lipoprotein, and red cell distribution width values were obtained and recorded.
RESULTS: We classified patient groups according to presence or absence of severe coronary artery disease. Fourteen of 66 patients had severe coronary artery disease. In univariate analyses, age, having a history of familial coronary artery disease, diabetes mellitus, presence of coronary artery disease, and triglyceride levels were risk factors for severe coronary artery disease. In multivariate analysis, diabetes mellitus, presence of coronary artery disease, and having a history of familial coronary artery disease were statistically significant.
CONCLUSIONS: Renal transplant recipients are a special patient population, and there must be specific suggestions for this population. If patients present with more than 1 risk factor, a stress test should be performed to evaluate cardiovascular risk. In some patients, especially those whose risk factors include prior cardiovascular disease or diabetes mellitus, stress tests should be skipped and patients should directly undergo coronary angiography to look for severe coronary artery disease.

PMID: 29025386 [PubMed - as supplied by publisher]

Adenovirus Infection as a Cause of Fever of Unknown Origin and Allograft Dysfunction in a Kidney Transplant Recipient.

Sun, 10/15/2017 - 18:48
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Adenovirus Infection as a Cause of Fever of Unknown Origin and Allograft Dysfunction in a Kidney Transplant Recipient.

Exp Clin Transplant. 2017 Oct 12;:

Authors: Saliba M, Kfoury Assouf H, Abbas S, Abi Hanna P, Kamel G, Barbari A

Abstract
With the recent introduction of more potent modern immunosuppressive regimens in solid-organ transplant, new types of viral infections such as adenovirus are emerging as a potential cause for graft dysfunction and loss. We report a case of 41-year-old male patient with end-stage renal disease from recurrent kidney stones who underwent kidney transplant from a deceased 12-year-old female donor. He developed adenoviral infection with acute cystitis, microscopic hematuria, and necrotizing interstitial nephritis associated with graft dysfunction within the first month of the postoperative period. Diagnosis was made by graft biopsy that showed more than 60% necrosis with tubulointerstitial hemorrhage, thrombotic microangiopathy, and histologic features suggestive of viral infection with negative Cytomegalovirus and polyomavirus stains in the graft and elevated adenovirus PCR in the blood. Simultaneously, the patient had very low absolute total lymphocyte count of 70 cells/μL during which he received supratherapeutic tacrolimus at whole blood trough levels and mycophenolate mofetil. This prompted the tapering of immunosuppression and the discontinuation of all antimicrobial drugs. Within a 2-week period, the immune reconstitution was sufficient for the clearance of the infection and the subsequent gradual recovery of graft function.

PMID: 29025381 [PubMed - as supplied by publisher]

Low-dose oral cholecalciferol is associated with higher numbers of Helios(+) and total Tregs than oral calcitriol in renal allograft recipients: an observational study.

Sun, 10/15/2017 - 18:48
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Low-dose oral cholecalciferol is associated with higher numbers of Helios(+) and total Tregs than oral calcitriol in renal allograft recipients: an observational study.

BMC Pharmacol Toxicol. 2016 Jun 14;17(1):24

Authors: Aly MG, Trojan K, Weimer R, Morath C, Opelz G, Tohamy MA, Daniel V

Abstract
BACKGROUND: Regulatory T cells (Tregs) are a cornerstone of graft acceptance. High numbers of Tregs are associated with better long-term graft survival. Recently, Vitamin D was suggested as an immunomodulator, in addition to its classical role in calcium metabolism. Vitamin D modulates Tregs and might, thereby, promote graft acceptance and long-term graft survival.
METHODS: One hundred twenty-three renal allograft recipients attending either Heidelberg nephrology or Giessen internal medicine clinic were enrolled in this cross- sectional study. Sixteen healthy controls were studied in addition. Sixty-nine patients were receiving no vitamin D, 38 calcitriol, and 16 cholecalciferol supplementations. We evaluated whether there was a difference in the absolute numbers of Helios(+), Helios(-), CTLA-4(+), IFNg(+), and total Tregs among the patient groups.
RESULTS: Cholecalciferol supplementation was associated with higher absolute numbers of Helios(+), CTLA-4(+), and total Tregs than calcitriol (p < 0.001, p = 0.004, p = 0.001 respectively). Helios(+) Tregs were also higher in cholecalciferol than no vitamin D supplementation patients (p = 0.001), whereas CTLA-4(+) and total Tregs were similar in both groups (p = NS). Helios(+), Helios(-), CTLA-4(+), IFNg(+), and total Tregs were similar in the cholecalciferol and healthy control groups (p = NS).
CONCLUSION: Our findings indicate that cholecalciferol, even when administered at low dosages, has a stabilizing effect on Tregs (particularly the Helios + subset), in contrast to calcitriol which showed neither a stabilizing nor a proliferation-inducing effect on the same cell population.

PMID: 27296673 [PubMed - indexed for MEDLINE]

Venous Thromboembolism and the Risk of Death and Graft Loss in Kidney Transplant Recipients.

Fri, 10/13/2017 - 12:45

Venous Thromboembolism and the Risk of Death and Graft Loss in Kidney Transplant Recipients.

Am J Nephrol. 2017 Oct 12;46(4):343-354

Authors: Lam NN, Garg AX, Knoll GA, Kim SJ, Lentine KL, McArthur E, Naylor KL, Bota SE, Sood MM

Abstract
BACKGROUND: The implications of venous thromboembolism (VTE) for morbidity and mortality in kidney transplant recipients are not well described.
METHODS: We conducted a retrospective study using linked healthcare databases in Ontario, Canada to determine the risk and complications of VTE in kidney transplant recipients from 2003 to 2013. We compared the incidence rate of VTE in recipients (n = 4,343) and a matched (1:4) sample of the general population (n = 17,372). For recipients with evidence of a VTE posttransplant, we compared adverse clinical outcomes (death, graft loss) to matched (1:2) recipients without evidence of a VTE posttransplant.
RESULTS: During a median follow-up of 5.2 years, 388 (8.9%) recipients developed a VTE compared to 254 (1.5%) in the matched general population (16.3 vs. 2.4 events per 1,000 person-years; hazard ratio [HR] 7.1, 95% CI 6.0-8.4; p < 0.0001). Recipients who experienced a posttransplant VTE had a higher risk of death (28.5 vs. 11.2%; HR 4.1, 95% CI 2.9-5.8; p < 0.0001) and death-censored graft loss (13.1 vs. 7.5%; HR 2.3, 95% CI 1.4-3.6; p = 0.0006) compared to matched recipients who did not experience a posttransplant VTE.
CONCLUSIONS: Kidney transplant recipients have a sevenfold higher risk of VTE compared to the general population with VTE conferring an increased risk of death and graft loss.

PMID: 29024935 [PubMed - as supplied by publisher]

Association between serum uric acid level and renal arteriolar hyalinization in individuals without chronic kidney disease.

Fri, 10/13/2017 - 12:45

Association between serum uric acid level and renal arteriolar hyalinization in individuals without chronic kidney disease.

Atherosclerosis. 2017 Sep 19;266:121-127

Authors: Matsukuma Y, Masutani K, Tanaka S, Tsuchimoto A, Haruyama N, Okabe Y, Nakamura M, Tsuruya K, Kitazono T

Abstract
BACKGROUND AND AIMS: Recent studies have reported an association between serum uric acid (SUA) and renal arteriolar changes in patients with chronic kidney disease (CKD). However, the association in individuals without CKD remains unclear. In this study, we investigated the relationship between SUA and renal arteriolar lesions in individuals without CKD from our living kidney donor cohort.
METHODS: Between January 2006 and May 2016, 393 living kidney donors underwent "time-zero" biopsy at Kyushu University Hospital. Patients were divided into sex-specific quartiles of SUA before donation: Q1, Q2, Q3, and Q4 (male: <5.2,5.2-5.8,5.9-6.4, and ≥6.5 mg/dL, female: <3.8,3.8-4.3,4.4-5.0, and ≥5.1 mg/dL). Renal arteriolar hyalinization and wall thickening were assessed using a semiquantitative grading system. Predictive performance was compared between models with and without SUA by calculating the net reclassification improvement (NRI).
RESULTS: In total, 158 (40.2%) patients had arteriolar hyalinization, and 148 (37.6%) had wall thickening. High SUA was significantly associated with arteriolar hyalinization in multivariable logistic analysis (odds ratio [OR] per 1-mg/dL increase in SUA, 1.24; 95% confidence interval [CI], 1.00-1.53; p = 0.048. OR for Q4 vs. Q2, 2.22; 95% CI, 1.17-4.21; p = 0.01). We found no association between SUA and wall thickening. When SUA was incorporated into a predictive model with conventional atherosclerotic factors, the NRI was 0.21 (p = 0.04).
CONCLUSIONS: High SUA was an independent risk factor for arteriolar hyalinization in individuals without CKD. SUA provided additional predictive value beyond conventional atherosclerotic factors in predicting arteriolar hyalinization.

PMID: 29024864 [PubMed - as supplied by publisher]

New Hybrid Mini-Laparoendoscopic Single-Site (Mi-LESS) Partial Nephrectomy with Early Unclamped Technique for Renal Tumors with Intermediate PADUA Score (IDEAL Phase 2A).

Fri, 10/13/2017 - 12:45

New Hybrid Mini-Laparoendoscopic Single-Site (Mi-LESS) Partial Nephrectomy with Early Unclamped Technique for Renal Tumors with Intermediate PADUA Score (IDEAL Phase 2A).

Urology. 2017 Oct 09;:

Authors: Springer C, Kawan F, La Rocca R, Mohammed N, Fornara P, Mirone V, Greco F

Abstract
OBJECTIVE: To evaluate a new hybrid technique which we defined mini-laparoendoscopic single-site partial nephrectomy (MILESS-PN) for renal masses presenting an intermediate PADUA score.
MATERIAL AND METHODS: Forty consecutive cases of MILESS-PN performed between April 2013 and November 2015 were included in this study. MILESS consisted in the simultaneous use of two 3 mm pararectal trocars and an umbilical SILS trocar; the sequence of steps of MILESS-PN was comparable to standard laparoscopic partial nephrectomy. Demographic data, main perioperative and oncologic outcome parameters were gathered and analyzed.
RESULTS: Median operative time was 134.6 (IQR 110-180) min with a median WIT of 12.1 (IQR 9.5-15.5) min. Postoperatively, 4 early complications were recorded and median hospital stay resulted to be 4.2 (IQR 3.5-6) days. Median renal tumor size was 3.6 (IQR 2.4-5.3) cm with a median PADUA score of 8.3 (IQR 8-9). The definitive pathologic results revealed a RCC in 32 cases (80%), an angiomyolipoma in 3 cases (7.5%) and an oncocytoma in 5 cases (12.5%). All tumors were removed with negative surgical margins and, at the median follow-up of 34.5 (IQR 24-48) months, all patients were alive without evidence of tumor recurrence or port-site metastasis. A statistically significant decrease of eGFR was observed postoperatively (post- vs preoperative median eGFR: 87.6 (IQR 70.4-101.8) and 104.7 (IQR 82.7-123.3), p<0.0001) and at 6 months (6-mo vs preoperative eGFR 93.6 (IQR 79.1-110.2) and 104.7 (IQR 82.7-123.3), p< 0.0001).
CONCLUSIONS: MILESS-PN for renal tumors with intermediate PADUA score in well-selected patients is not associated with increased risks for the patients, presenting excellent oncologic and functional results at mid-term follow-up. MILESS could represent a valid alternative to LESS or minilaparoscopy because of its higher surgical reproducibility.

PMID: 29024738 [PubMed - as supplied by publisher]

Accelerated humoral renal allograft rejection due to HLA-C14 mediated allosensitization to HLA-Bw6.

Fri, 10/13/2017 - 12:45

Accelerated humoral renal allograft rejection due to HLA-C14 mediated allosensitization to HLA-Bw6.

Hum Immunol. 2017 Oct 09;:

Authors: Persaud SP, Duffy B, Phelan DL, Mohanakumar T, Santos RD, Gaut JP, Liu C

Abstract
OBJECTIVES: To investigate immunological mechanisms underlying accelerated antibody-mediated rejection (AMR) of a living-related renal allograft in a patient with no detectable antibodies to donor human leukocyte antigens (HLA) in pre-transplant sera.
METHODS: Pre- and post-transplant HLA antibody specificities were determined by single-antigen bead assay, and crossmatching was performed by flow cytometry- and complement-dependent cytotoxicity-based methods. Intermediate- and high-resolution HLA typing were performed by molecular methods.
RESULTS: Pre-transplant patient serum reacted weakly against Bw6-positive beads; cytotoxicity and flow crossmatches were negative. The patient was mismatched for the donor antigens B62 and C10 (Bw6-positive). Following transplantation, strong antibody responses against B62, C10, and all Bw6-positive beads were detected. This reactivity was initially masked by complement interference, but became apparent at 1:20 dilution. High-resolution typing suggested that the anti-C16 antibody reactivity detected was an allele-specific response to donor C∗16:01 (Bw6-positive) but not recipient C∗16:02 (Bw6-negative). Alloimmunization likely occurred during pregnancy, during which HLA-C14 (Bw6-positive) was the only mismatched paternal HLA Class I allele.
CONCLUSIONS: Sensitization to HLA-Bw6 via exposure to paternal HLA-C14 during pregnancy likely predisposed this patient to AMR. The case demonstrates the immunogenicity of HLA-C14-associated Bw6 epitopes in vivo and the clinical significance of low-level antibodies to HLA-Bw6.

PMID: 29024716 [PubMed - as supplied by publisher]

Remote Monitoring of Automated Peritoneal Dialysis Patients: Assessing Clinical and Economic Value.

Fri, 10/13/2017 - 12:45

Remote Monitoring of Automated Peritoneal Dialysis Patients: Assessing Clinical and Economic Value.

Telemed J E Health. 2017 Oct 12;:

Authors: Makhija D, Alscher MD, Becker S, D'Alonzo S, Mehrotra R, Wong L, McLeod K, Danek J, Gellens M, Kudelka T, Sloand JA, Laplante S

Abstract
BACKGROUND: For chronic kidney disease patients who progress to end-stage renal disease, survival is dependent on renal replacement therapy in the form of kidney transplantation or chronic dialysis. Peritoneal dialysis (PD), which can be performed at home, is both more convenient and less costly than hemodialysis that requires three 4-h visits per week to the dialysis facility and complicated equipment. Remote therapy management (RTM), technologies that collect medical information and transmit it to healthcare providers for patient management, has the potential to improve the outcomes of patients receiving automated peritoneal dialysis (APD) at home.
OBJECTIVE: Estimate through a simulation study the potential impact of RTM on APD patients use of healthcare resources and costs in the United States, Germany, and Italy.
METHODS: Twelve APD patient profiles were developed to reflect potential clinical scenarios of APD therapy. Two versions of each profile were created to simulate healthcare resource use, one assuming use of RTM and one with no RTM. Eleven APD teams (one nephrologist, one nurse) estimated resources that would be used.
RESULTS: Results from U.S., German, and Italian clinicians found that RTM could avoid use of 59, 49, and 16 resources over the 12 profiles, respectively. Estimated reduced utilization across the three countries ranged from one to two hospitalizations, one to four home visits, two to five emergency room visits, and four to eight unplanned clinic visits. Total savings across all scenarios were $23,364 in the United States, $11,477 in Germany, and $7,088 in Italy.
CONCLUSION: In a simulated environment, early intervention enabled by RTM reduced healthcare resource utilization and associated costs.

PMID: 29024613 [PubMed - as supplied by publisher]

Hemodialysis Decreases the Concentration of Accumulated Plant Phenols in the Plasma of Patients on Maintenance Dialysis: Influence of Residual Renal Function.

Fri, 10/13/2017 - 12:45

Hemodialysis Decreases the Concentration of Accumulated Plant Phenols in the Plasma of Patients on Maintenance Dialysis: Influence of Residual Renal Function.

Ther Apher Dial. 2017 Oct 11;:

Authors: Nowak PJ, Wilk R, Prymont-Przyminska A, Zwolinska A, Sarniak A, Wlodarczyk A, de Graft-Johnson J, Mamelka B, Zasowska-Nowak A, Bartnicki P, Nowak D, Nowicki M

Abstract
Plant phenols may accumulate in end-stage kidney disease. The effect of hemodialysis on their plasma concentration remains poorly determined. Contingent on concentration, health-promoting or noxious effects occur; therefore, we assessed plasma concentration in hemodialyzed patients. In total, 21 maintenance hemodialyzed patients with diuresis < 500 mL per day (with oliguria), nine hemodialyzed patients with diuresis ≥ 500 mL per day (without oliguria) and 31 healthy volunteers were included. Nine phenolic acids were identified with high-performance liquid chromatography and total polyphenol concentration was determined with the Folin-Ciocalteu method in pre- or post-hemodialysis plasma and pre- or intra-hemodialysis dialysate. The concentration of total polyphenols was 27% higher in pre-hemodialysis plasma than in that of controls (0.95 ± 0.18 mmol/L [P < 0.0001]). The concentration of total polyphenols was higher in patients with oliguria (1.01 ± 0.17) than in those without (0.84 ± 0.13 mmol/L), despite the former having more intense hemodialysis (Kt/V 1.29 ± 0.31 and 0.77 ± 0.25, respectively). Pre-hemodialysis phenolic acid concentration in patients undergoing dialysis exceeded reference values by 3 to 34 times (3-hydroxyphenylacetic acid and vanillic acid, respectively), from 0.69 (dihydrocaffeic acid) to 169.3 μmol/L (hippuric acid). The concentration of six phenolic acids (3-hydroxyhippuric, caffeic, dihydrocaffeic, hippuric, homovanillic, and vanillic acid) was 1.1 (homovanillic) to 11.3 (3-hydroxyhippuric) times higher in patients with oliguria than in those without. 4-hydroxyhippuric acid occurred more in the plasma of patients with oliguria than in those without oliguria. A single hemodialysis session decreased total polyphenol concentration by 16% and phenolic acids from 30% (caffeic) to 58% (vanillic and 3-hydroxyphenylacetic acid) and these compounds appeared in the dialysate. The percentage decrease (Δ%) of creatinine concentration correlated with the Δ% of total polyphenols and five phenolic acids (3-hydroxyphenylacetic, dihydrocaffeic, hippuric, homovanillic, and vanillic acid). Urea Δ% and Kt/V correlated only with the Δ% of homovanilic acid. The results demonstrate that phenols accumulate variably in hemodialyzed patients and are differently eliminated during hemodialysis. Residual renal function ensures a lower concentration of plasma phenols.

PMID: 29024501 [PubMed - as supplied by publisher]

Prevalence and outcomes of cystic lesions of the transplant pancreas: The University of Wisconsin Experience.

Fri, 10/13/2017 - 12:45

Prevalence and outcomes of cystic lesions of the transplant pancreas: The University of Wisconsin Experience.

Am J Transplant. 2017 Oct 11;:

Authors: Al-Qaoud TM, Martinez EJ, Sollinger HW, Kaufman DB, Redfield RR, Welch B, Leverson G, Odorico JS

Abstract
Literature on the behavior of cystic lesions in pancreas transplants is scarce, and hence a better understanding is warranted. Data on recipients and their respective donors that underwent simultaneous kidney and pancreas, pancreas transplant alone, and pancreas after kidney between 1994-2015 were reviewed (n=1185). Cystic lesions of the transplant pancreas developed in 22 patients (1.8%): 12 pseudocysts, 2 cysts/remnants, 4 intraductal papillary mucinous neoplasms (IPMN), 2 adenocarcinomas, 1 low grade intraepithelial pancreatic neoplasia, and 1 case of polycystic kidney disease. The median size was 3.6cm (1.6-5.5cm), and occurred at a median time of 65.5mos (2-183mos) post transplant. The median age of the graft at time of diagnosis was 42yrs (25.7-54.5), with 17 of 22 grafts (77%) functioning at time of diagnosis. Triggers for investigation were elevations in pancreatic enzymes, re-admissions for abdominal pain, and incidentalomas. High resolution imaging and diagnostic biopsy/aspiration with ancillary tests were the main diagnostic tests. Most pseudocysts were managed by percutaneous drainage, and although no firm inference can be made from such a small series, we have observed that the behavior and management of IPMN and adenocarcinoma in the pancreas graft appears congruent to that of the native pancreas. This article is protected by copyright. All rights reserved.

PMID: 29024476 [PubMed - as supplied by publisher]

Combined Liver-kidney Perfusion Enhances Protective Effects of Normothermic Perfusion on Livers Grafts from Donation after Cardiac Death.

Fri, 10/13/2017 - 12:45

Combined Liver-kidney Perfusion Enhances Protective Effects of Normothermic Perfusion on Livers Grafts from Donation after Cardiac Death.

Liver Transpl. 2017 Oct 10;:

Authors: He X, Ji F, Zhang Z, Tang Y, Yang L, Huang S, Li W, Su Q, Xiong W, Zhu Z, Wang L, Lv L, Yao J, Zhang L, Zhang L, Guo Z

Abstract
It has been showed that combined liver-kidney normothermic machine perfusion (NMP) is able to better maintain the circuit's biochemical milieu. Nevertheless, whether the combined perfusion is superior to liver perfusion alone in protecting livers from donation after cardiac death (DCD) is unclear. We aimed to test the hypothesis and explored the mechanisms. Livers from 15 DCD pig donors were subjected to either static cold storage group (Group A), liver alone NMP group (Group B), or combined liver-kidney NMP group (Group C). Livers were preserved for six hours and re-perfused ex vivo for two hours to simulate transplantation, or transplanted in situ. During perfusion, Group C showed improved acid-base and biochemical environment in the circuit over Group B. After re-perfusion, the architecture of liver grafts was best preserved in group C, followed by Group B, then Group A, as shown by the histology and TUNEL staining of both hepatocytes and biliary epithelium. Ki-67 staining showed substantial hepatocyte proliferation and biliary epithelial regeneration after perfusion in Group B and Group C. Group C produced more bile in reperfusion phase than those in Group A and Group B, with more physiological bile composition and less severe biliary epithelium injury. vWF positive endothelial cells and E-selectin expression decreased in both Group B and Group C. Combined liver-kidney NMP not only produced more ATP, protected the NO signaling pathway, but also diminished oxidative stress (HMGB1 and 8-OHdG levels) and inflammatory cytokine (IL-6 and IL-8) release when compared to liver alone NMP and CS. In addition, the 7-day survival rate of liver transplant recipient was higher in Group C than those in Group A and B.
CONCLUSION: Combined liver-kidney NMP perfusion can better protect DCD livers from warm ischemia and reperfusion injury probably by maintaining the stability of internal environment and abolishing oxidative stress injury. This article is protected by copyright. All rights reserved.

PMID: 29024427 [PubMed - as supplied by publisher]

Is the kidney donor profile index (KDPI) universal or UNOS-specific?

Fri, 10/13/2017 - 12:45

Is the kidney donor profile index (KDPI) universal or UNOS-specific?

Am J Transplant. 2017 Oct 11;:

Authors: Ekser B, Powelson JA, Fridell JA, Goggins WC, Taber TE

Abstract
With the introduction of the KDPI scoring system on June 2013, allocation of kidney allografts and predicted outcomes in the United Network for Organ Sharing (UNOS) have changed. Although the hope was to reduce the discard rate of 'marginal' or 'extended criteria donor (ECD)' kidneys allocating them in a better way, the discard rate did not differ compared to the ECD era [1]. The transplantation community continues to seek ways to improve kidney allocation in order to provide acceptable (or even better) outcomes using the most possible deceased donor kidneys reducing the discard rate. One way to boost the use of higher risk kidneys is allocating them as dual kidney transplantation (DKT) [2]. DKT could provide increased nephron mass and therefore better expected outcomes compared to single use of ECD kidneys. This article is protected by copyright. All rights reserved.

PMID: 29024392 [PubMed - as supplied by publisher]

An unjustified benefit: immortal time bias in the analysis of time-dependent events.

Fri, 10/13/2017 - 12:45

An unjustified benefit: immortal time bias in the analysis of time-dependent events.

Transpl Int. 2017 Oct 11;:

Authors: Gleiss A, Oberbauer R, Heinze G

Abstract
Immortal time bias is a problem arising from methodologically wrong analyses of time-dependent events in survival analyses. We illustrate the problem by analysis of a kidney transplantation study. Following patients from transplantation to death, groups defined by the occurrence or non-occurrence of graft failure during follow-up seemingly had equal overall mortality. Such naive analysis assumes that patients were assigned to the two groups at time of transplantation, which actually are a consequence of occurrence of a time-dependent event later during follow-up. We introduce landmark analysis as the method of choice to avoid immortal time bias. Landmark analysis splits the follow-up time at a common, pre-specified time point, the so-called 'landmark'. Groups are then defined by time-dependent events having occurred before the landmark, and outcome events are only considered if occurring after the landmark. Landmark analysis can be easily implemented with common statistical software. In our kidney transplantation example, landmark analyses with landmarks set at 30 and 60 months clearly identified graft failure as a risk factor for overall mortality. We give further typical examples from transplantation research and discuss strengths and limitations of landmark analysis and other methods to address immortal time bias such as Cox regression with time-dependent covariables. This article is protected by copyright. All rights reserved.

PMID: 29024071 [PubMed - as supplied by publisher]

Is kidney transplantation safe after careful selection of the recipients with a history of psychotic disorder?

Fri, 10/13/2017 - 12:45

Is kidney transplantation safe after careful selection of the recipients with a history of psychotic disorder?

Transpl Int. 2017 Oct 11;:

Authors: Molnar MZ

Abstract
The prevalence of both bipolar disorder and schizophrenia is around 1-4% in the general population and represents a relative contraindication for kidney transplantation. There are several reasons for this, including concerns in relation to relapse of psychiatric illness, medication and other post-transplant treatment non-adherence, inadequate social support, emotional and cognitive capability, and potential drug interactions between psychotropic and immunosuppressant medications. Only a small proportion of recipients with psychotic disorder has eventually been transplanted. Almost half of these recipients will have psychotic relapses after transplantation and these relapses illustrate a strong association with graft loss and death. The published data on post-transplant outcomes in patients with pre-transplant psychotic disorders are extremely limited. However, the emerging data suggests that after careful recipient selection and a very close follow-up after transplantation, recipients with history of bipolar disorder and schizophrenia have similar patient and graft survival when compared to recipients without psychotic disorders. Further data are urgently needed to confirm these mainly retrospective results from small studies. This article is protected by copyright. All rights reserved.

PMID: 29024009 [PubMed - as supplied by publisher]

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