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Plasma Free Hemoglobin Is a Predictor of Acute Renal Failure During Adult Venous-Arterial Extracorporeal Membrane Oxygenation Support.

Wed, 08/09/2017 - 12:45
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Plasma Free Hemoglobin Is a Predictor of Acute Renal Failure During Adult Venous-Arterial Extracorporeal Membrane Oxygenation Support.

J Cardiothorac Vasc Anesth. 2016 Aug;30(4):891-5

Authors: Lyu L, Long C, Hei F, Ji B, Liu J, Yu K, Chen L, Yao J, Hu Q, Hu J, Gao G

Abstract
OBJECTIVE: Hemolysis is a common and severe complication during extracorporeal membrane oxygenation (ECMO). Increased plasma free hemoglobin (PFHb) is related to renal injury. The aim of this study was to investigate whether increased PFHb during adult venous-arterial ECMO was associated with acute renal failure (ARF).
DESIGN: A retrospective, observational, single-center study.
SETTING: Fuwai Hospital in Beijing, China.
PARTICIPANTS: The study comprised 84 venous-arterial ECMO patients.
INTERVENTIONS: None.
MEASUREMENTS AND MAIN RESULTS: A total of 84 consecutive adult patients (≥18 years) with cardiac diseases requiring venous-arterial ECMO support were studied retrospectively. Demographics of patients, clinical and ECMO characteristics, and PFHb level were collected within the first 3 days after ECMO. ARF was defined as a≥300% rise in serum creatinine from baseline or application of dialysis. Repeated measurement analysis of variance revealed that the main effect for the non-ARF group and ARF group in PFHb (p = 0.002) was significant. A significant main effect for time points (p<0.001) and time×group interaction (p = 0.014) in PFHb was obtained. In a multiple logistic regression model, peak PFHb during ECMO (odds ratio 1.052, 95% confidence interval 1.016-1.089, p = 0.005) was a risk factor for ARF during ECMO and patients who underwent heart transplantation (odds ratio 0.240, 95% confidence interval 0.060-0.964, p = 0.044) experienced less ARF. There was a linear correlation between peak serum creatinine and peak PFHb (Spearman's r = 0.223, p = 0.042).
CONCLUSIONS: Increased PFHb is a predictor of ARF among adult patients on venous-arterial ECMO support.

PMID: 27238434 [PubMed - indexed for MEDLINE]

Factors influencing withdrawal from dialysis: a national registry study.

Wed, 08/09/2017 - 12:45
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Factors influencing withdrawal from dialysis: a national registry study.

Nephrol Dial Transplant. 2016 Dec;31(12):2041-2048

Authors: Findlay MD, Donaldson K, Doyle A, Fox JG, Khan I, McDonald J, Metcalfe W, Peel RK, Shilliday I, Spalding E, Stewart GA, Traynor JP, Mackinnon B, Scottish Renal Registry (SRR)

Abstract
BACKGROUND: Dialysis withdrawal is the third most common cause of death in patients receiving dialysis for established renal failure (ERF) in Scotland. We describe incidence, risk factors and themes influencing decision-making in a national renal registry.
METHODS: Details of deaths in those receiving renal replacement therapy (RRT) for ERF in Scotland are reported to the Scottish Renal Registry via a unique mortality report. We extracted patient demographics and comorbidity, cause and location of death, duration of RRT and pertinent free text comments from 1 January 2008 to 31 December 2014. Withdrawal incidence was calculated and logistic regression used to identify significantly influential variables. Themes emerging from clinician comments were tabulated for descriptive purposes.
RESULTS: There were 2596 deaths; median age at death was 68 [interquartile range (IQR) 58, 76] years, 41.5% were female. Median duration on RRT was 1110 (IQR 417, 2151) days. Dialysis withdrawal was the primary cause of death in 497 (19.1%) patients and withdrawal contributed to death in a further 442 cases (17.0%). The incidence was 41 episodes per 1000 patient-years. Regression analysis revealed increasing age, female sex and prior cerebrovascular disease were associated with dialysis withdrawal as a primary cause of death. Conversely, interstitial renal disease, angiographically proven ischaemic heart disease, valvular heart disease and malignancy were negatively associated. Analysis of free text comments revealed common themes, portraying an image of physical and psychological decline accelerated by acute illnesses.
CONCLUSIONS: Death following dialysis withdrawal is common. Factors important to physical independence-prior cerebrovascular disease and increasing age-are associated with withdrawal. When combined with clinician comments this study provides an insight into the clinical decline affecting patients and the complexity of this decision. Early recognition of those likely to withdraw may improve end of life care.

PMID: 27190373 [PubMed - indexed for MEDLINE]

Genotypic and phenotypic predictors of inflammation in patients with chronic kidney disease.

Wed, 08/09/2017 - 12:45
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Genotypic and phenotypic predictors of inflammation in patients with chronic kidney disease.

Nephrol Dial Transplant. 2016 Dec;31(12):2033-2040

Authors: Luttropp K, Debowska M, Lukaszuk T, Bobrowski L, Carrero JJ, Qureshi AR, Stenvinkel P, Lindholm B, Waniewski J, Nordfors L

Abstract
BACKGROUND: In complex diseases such as chronic kidney disease (CKD), the risk of clinical complications is determined by interactions between phenotypic and genotypic factors. However, clinical epidemiological studies rarely attempt to analyse the combined effect of large numbers of phenotype and genotype features. We have recently shown that the relaxed linear separability (RLS) model of feature selection can address such complex issues. Here, it is applied to identify risk factors for inflammation in CKD.
METHODS: The RLS model was applied in 225 CKD stage 5 patients sampled in conjunction with dialysis initiation. Fifty-seven anthropometric or biochemical measurements and 79 genetic polymorphisms were entered into the model. The model was asked to identify phenotypes and genotypes that, when combined, could separate inflamed from non-inflamed patients. Inflammation was defined as a high-sensitivity C-reactive protein concentration above the median (5 mg/L).
RESULTS: Among the 60 genotypic and phenotypic features predicting inflammation, 31 were genetic. Among the 10 strongest predictors of inflammation, 8 were single nucleotide polymorphisms located in the NAMPT, CIITA, BMP2 and PIK3CB genes, whereas fibrinogen and bone mineral density were the only phenotypic biomarkers.
CONCLUSION: These results indicate a larger involvement of hereditary factors in inflammation than might have been expected and suggest that inclusion of genotype features in risk assessment studies is critical. The RLS model demonstrates that inflammation in CKD is determined by an extensive panel of factors and may prove to be a suitable tool that could enable a much-needed multifactorial approach as opposed to the commonly utilized single-factor analysis.

PMID: 27190335 [PubMed - indexed for MEDLINE]

Combination of adipose-derived mesenchymal stem cells (ADMSC) and ADMSC-derived exosomes for protecting kidney from acute ischemia-reperfusion injury.

Wed, 08/09/2017 - 12:45
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Combination of adipose-derived mesenchymal stem cells (ADMSC) and ADMSC-derived exosomes for protecting kidney from acute ischemia-reperfusion injury.

Int J Cardiol. 2016 Aug 01;216:173-85

Authors: Lin KC, Yip HK, Shao PL, Wu SC, Chen KH, Chen YT, Yang CC, Sun CK, Kao GS, Chen SY, Chai HT, Chang CL, Chen CH, Lee MS

Abstract
BACKGROUND: In this study, we tested the hypothesis that a combined adipose-derived mesenchymal stem cell (ADMSC) and ADMSC-derived exosome therapy protected rat kidney from acute ischemia-reperfusion (IR) injury (i.e., ligation of both renal arteries for 1h and reperfusion for 72h prior to euthanization).
METHODS AND RESULTS: Adult-male SD rats (n=40) were equally categorized into group 1 (sham control), group 2 (IR), group 3 [IR+exosome (100μg)], group 4 [IR+ADMSC (1.2×10(6) cells)], and group 5 (IR-exosome-ADMSC). All therapies were performed at 3h after IR procedure from venous administration. By 72h, the creatinine level and kidney injury score were the lowest in group 1 and the highest in group 2, significantly higher in group 3 than in groups 4 and 5, and significantly higher in group 4 than in group 5 (all P<0.0001). The protein expression of inflammatory (TNF-α/NF-κB/IL-1β/MIF/PAI-1/Cox-2), oxidative-stress (NOX-1/NOX-2/oxidized protein), apoptotic (Bax/caspase-3/PARP), and fibrotic (Smad3/TGF-β) biomarkers showed an identical pattern, whereas the anti-apoptotic (Smad1/5, BMP-2) and angiogenesis (CD31/vWF/angiopoietin) biomarkers and mitochondrial cytochrome-C showed an opposite pattern of creatinine level among the five groups (all P<0.001). The microscopic findings of glomerular-damage (WT-1), renal tubular-damage (KIM-1), DNA-damage (γ-H2AX), inflammation (MPO/MIF/CD68) exhibited an identical pattern, whereas the podocyte components (podocin/p-cadherin/synaptopodin) displayed a reversed pattern of creatinine level (all P<0.0001).
CONCLUSION: Combined exosome-ADMSC therapy was superior to either one for protecting kidney from acute IR injury.

PMID: 27156061 [PubMed - indexed for MEDLINE]

The comparison of intelligence levels of children born to kidney or liver transplant women with children of healthy mothers.

Tue, 08/08/2017 - 15:46
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The comparison of intelligence levels of children born to kidney or liver transplant women with children of healthy mothers.

J Matern Fetal Neonatal Med. 2017 Aug 07;:1-13

Authors: Kociszewska-Najman B, Szpotanska-Sikorska M, Mazanowska N, Wielgos M, Pietrzak B

Abstract
BACKGROUND: Pregnancy after transplantation is associated with high risk of complications and prenatal exposure to immunosuppressants. The purpose of the study was to evaluate the intellectual development of children born to women after organ transplantation.
AIMS: A comparison of intelligence levels in 78 children of kidney or liver transplant women of 78 children born to healthy mothers. The assessment of intellectual level in children was conducted by psychologists and evaluated using age-adjusted intelligence tests (Psyche Cattell Infant Intelligence Scale, Terman-Merril Intelligence Scale or the Scales of Raven's Progressive Matrices).
RESULTS: No significant differences in the distribution of the quotient of intelligence between children born to kidney and liver transplant women were noted (chi(2) = 5.037; p = 0.284). Also no differences in the distribution of intelligence levels was noted between the children of transplanted and healthy mothers in infants and toddlers (chi(2) = 3.125; p = 0.537); preschool (chi(2) = 1.440; p = 0.692) and school age children (chi(2) = 4.079; p = 0.395).
CONCLUSIONS: The intellectual development of children of post-transplant women is similar to the general population. These results provide information on the low risk of intellectual disability in children of transplanted mothers and may improve counseling on the planning of pregnancy in this group of women.

PMID: 28782396 [PubMed - as supplied by publisher]

Direct-acting antiviral agent efficacy and safety in renal transplant recipients with chronic hepatitis C virus infection: A PRISMA-compliant study.

Tue, 08/08/2017 - 15:46
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Direct-acting antiviral agent efficacy and safety in renal transplant recipients with chronic hepatitis C virus infection: A PRISMA-compliant study.

Medicine (Baltimore). 2017 Jul;96(30):e7568

Authors: Chen K, Lu P, Song R, Zhang J, Tao R, Wang Z, Zhang W, Gu M

Abstract
BACKGROUND: The efficacy and safety of direct-acting antivirals (DAAs) for treating hepatitis C virus (HCV)-infected renal transplant recipients (RTRs) has not been determined.
METHODS: We searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials and assessed the quality of eligible studies using the Joanna Briggs Institute scale. DAA efficacy and safety were assessed using standard mean difference (SMD) with 95% confidence intervals (95%CIs).
RESULTS: Six studies (360 RTRs) were included. Two hundred thirty six RTRs (98.3%) achieved sustained virological response within 12 weeks; HCV infection was cleared in 239 RTRs after 24-week treatment. Liver function differed significantly pre- and posttreatment (alanine aminotransferase, SMD: 0.96, 95%CIs: 0.65, 1.26; aspartate aminotransferase, SMD: 0.89, 95%CIs: 0.60, 1.18); allograft function pre- and posttreatment was not statistically different (serum creatinine, SMD: -0.13, 95%CIs: -0.38, 0.12; estimated glomerular filtration rate, SMD: 0.20, 95%CIs: -0.11, 0.51). General symptoms (fatigue nausea dizziness or headache) were the most common adverse events (AEs) (39.3%). Severe AEs, that is, anemia, portal vein thrombosis, and streptococcus bacteraemia and pneumonia, were present in 1.1%, 0.6%, and 1.1% of RTRs, respectively.
CONCLUSION: Our findings suggest that DAAs are highly efficacious and safe for treating HCV-infected RTRs and without significant AE.

PMID: 28746204 [PubMed - indexed for MEDLINE]

Endothelial colony-forming cells ameliorate endothelial dysfunction via secreted factors following ischemia-reperfusion injury.

Tue, 08/08/2017 - 15:46
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Endothelial colony-forming cells ameliorate endothelial dysfunction via secreted factors following ischemia-reperfusion injury.

Am J Physiol Renal Physiol. 2017 May 01;312(5):F897-F907

Authors: Collett JA, Mehrotra P, Crone A, Shelley WC, Yoder MC, Basile DP

Abstract
Damage to endothelial cells contributes to acute kidney injury (AKI) by leading to impaired perfusion. Endothelial colony-forming cells (ECFC) are endothelial precursor cells with high proliferative capacity, pro-angiogenic activity, and in vivo vessel forming potential. We hypothesized that ECFC may ameliorate the degree of AKI and/or promote repair of the renal vasculature following ischemia-reperfusion (I/R). Rat pulmonary microvascular endothelial cells (PMVEC) with high proliferative potential were compared with pulmonary artery endothelial cells (PAEC) with low proliferative potential in rats subjected to renal I/R. PMVEC administration reduced renal injury and hastened recovery as indicated by serum creatinine and tubular injury scores, while PAEC did not. Vehicle-treated control animals showed consistent reductions in renal medullary blood flow (MBF) within 2 h of reperfusion, while PMVEC protected against loss in MBF as measured by laser Doppler. Interestingly, PMVEC mediated protection occurred in the absence of homing to the kidney. Conditioned medium (CM) from human cultured cord blood ECFC also conveyed beneficial effects against I/R injury and loss of MBF. Moreover, ECFC-CM significantly reduced the expression of ICAM-1 and decreased the number of differentiated lymphocytes typically recruited into the kidney following renal ischemia. Taken together, these data suggest that ECFC secrete factors that preserve renal function post ischemia, in part, by preserving microvascular function.

PMID: 28228404 [PubMed - indexed for MEDLINE]

Effects of Direct Renin Blockade on Renal & Systemic Hemodynamics and on RAAS Activity, in Weight Excess and Hypertension: A Randomized Clinical Trial.

Tue, 08/08/2017 - 15:46
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Effects of Direct Renin Blockade on Renal & Systemic Hemodynamics and on RAAS Activity, in Weight Excess and Hypertension: A Randomized Clinical Trial.

PLoS One. 2017;12(1):e0169258

Authors: Kwakernaak AJ, Roksnoer LC, Lambers Heerspink HJ, van den Berg-Garrelds I, Lochorn GA, van Embden Andres JH, Klijn MA, Kobori H, Danser AH, Laverman GD, Navis GJ

Abstract
AIM: The combination of weight excess and hypertension significantly contributes to cardiovascular risk and progressive kidney damage. An unfavorable renal hemodynamic profile is thought to contribute to this increased risk and may be ameliorated by direct renin inhibition (DRI). The aim of this trial was to assess the effect of DRI on renal and systemic hemodynamics and on RAAS activity, in men with weight excess and hypertension.
METHODS: A randomized, double-blind, cross-over clinical trial to determine the effect of DRI (aliskiren 300 mg/day), with angiotensin converting enzyme inhibition (ACEi; ramipril 10 mg/day) as a positive control, on renal and systemic hemodynamics, and on RAAS activity (n = 15).
RESULTS: Mean (SEM) Glomerular filtration rate (101 (5) mL/min/1.73m2) remained unaffected by DRI or ACEi. Effective renal plasma flow (ERPF; 301 (14) mL/min/1.73m2) was increased in response to DRI (320 (14) mL/min/1.73m2, P = 0.012) and ACEi (317 (15) mL/min/1.73m2, P = 0.045). Filtration fraction (FF; 34 (0.8)%) was reduced by DRI only (32 (0.7)%, P = 0.044). Mean arterial pressure (109 (2) mmHg) was reduced by DRI (101 (2) mmHg, P = 0.008) and ACEi (103 (3) mmHg, P = 0.037). RAAS activity was reduced by DRI and ACEi. Albuminuria (20 [9-42] mg/d) was reduced by DRI only (12 [5-28] mg/d, P = 0.030).
CONCLUSIONS: In men with weight excess and hypertension, DRI and ACEi improved renal and systemic hemodynamics. Both DRI and ACEi reduced RAAS activity. Thus, DRI provides effective treatment in weight excess and hypertension.
TRIAL REGISTRATION: Dutch trial register, registration number: 2532 www.trialregister.nl.

PMID: 28118402 [PubMed - indexed for MEDLINE]

Serum uric acid levels contribute to new renal damage in systemic lupus erythematosus patients.

Tue, 08/08/2017 - 15:46
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Serum uric acid levels contribute to new renal damage in systemic lupus erythematosus patients.

Clin Rheumatol. 2017 Apr;36(4):845-852

Authors: Reátegui-Sokolova C, Ugarte-Gil MF, Gamboa-Cárdenas RV, Zevallos F, Cucho-Venegas JM, Alfaro-Lozano JL, Medina M, Rodriguez-Bellido Z, Pastor-Asurza CA, Alarcón GS, Perich-Campos RA

Abstract
This study aims to determine whether uric acid levels contribute to new renal damage in systemic lupus erythematosus (SLE) patients. This prospective study was conducted in consecutive patients seen since 2012. Patients had a baseline visit and follow-up visits every 6 months. Patients with ≥2 visits were included; those with end-stage renal disease (regardless of dialysis or transplantation) were excluded. Renal damage was ascertained using the SLICC/ACR damage index (SDI). Univariable and multivariable Cox-regression models were performed to determine the risk of new renal damage. Uric acid was included as a continuous and dichotomous (per receiving operating characteristic curve) variable. Multivariable models were adjusted for age at diagnosis, disease duration, socioeconomic status, SLEDAI, SDI, serum creatinine, baseline use of prednisone, antimalarials, and immunosuppressive drugs. One hundred and eighty-six patients were evaluated; their mean (SD) age at diagnosis was 36.8 (13.7) years; nearly all patients were mestizo. Disease duration was 7.7 (6.8) years. Follow-up time was 2.3 (1.1) years. The SLEDAI was 5.2 (4.3) and the SDI 0.8 (1.1). Uric acid levels were 4.5 (1.3) mg/dl. During follow-up, 16 (8.6%) patients developed at least one new point in the renal domain of the SDI. In multivariable analyses, uric acid levels (continuous and dichotomous) at baseline predicted the development of new renal damage (HR 3.21 (1.39-7.42), p 0.006; HR 18.28 (2.80-119.48), p 0.002; respectively). Higher uric acid levels contribute to the development of new renal damage in SLE patients independent of other well-known risk factors for such occurrence.

PMID: 28101832 [PubMed - indexed for MEDLINE]

A Follow-Up Study on the Renal Protective Efficacy of Telbivudine for Hepatitis B Virus-Infected Taiwanese Patients After Living Donor Liver Transplant.

Tue, 08/08/2017 - 15:46
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A Follow-Up Study on the Renal Protective Efficacy of Telbivudine for Hepatitis B Virus-Infected Taiwanese Patients After Living Donor Liver Transplant.

Exp Clin Transplant. 2017 Feb;15(1):65-68

Authors: Lin KH, Chen YL, Lin PY, Hsieh CE, Ko CJ, Lin CC, Ming YZ

Abstract
OBJECTIVES: Preservation of renal function is an important issue after living donor liver transplant. We aimed to examine the renal protective efficacy of telbivudine in hepatitis B virus-infected patients after living donor liver transplant.
MATERIALS AND METHODS: In this retrospective study, we compared 18 patients who received telbivudine 600 mg once per day and 23 patients who received entecavir 1 mg once per day after living donor liver transplant. Clinical data were obtained through chart review and included Model for End-Stage Liver Disease score and pre- and postoperative aspartate aminotransferase, alanine aminotransferase, and creatinine levels and estimated glomerular filtration rate.
RESULTS: Posttransplant estimated glomerular filtration rates and creatinine levels were calculated, and improvement of renal function was found in the group of patients who received telbivudine. Significant improvements were shown in estimated glomerular filtration rates started after 9 months of administration and creatinine levels after 12 months compared with patients who received entecavir.
CONCLUSIONS: In our study, long-term telbivudine therapy is associated with a sustained improvement of renal function in patients with hepatitis B virus infection after living donor liver transplant.

PMID: 28004999 [PubMed - indexed for MEDLINE]

Hepatitis C Virus in the Renal Transplant Population: An Update With Focus on the New Era of Antiviral Regimens.

Tue, 08/08/2017 - 15:46
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Hepatitis C Virus in the Renal Transplant Population: An Update With Focus on the New Era of Antiviral Regimens.

Exp Clin Transplant. 2017 Feb;15(1):10-20

Authors: Gheith O, Halim MA, Othman N, Al-Otaibi T, Nair P, Nampoory N

Abstract
Chronic hepatitis C virus infection is a global health problem, especially among renal transplant recipients. Herein, we present an overview of hepatitis C virus among renal transplant patients, with a focus on some updated aspects concerning types of viral genotypes, methods of diagnosis, the effects of renal transplant on hepatitis C virus infection, and summary of hepatitis C virus-related complications after renal transplant. We also discuss patient and graft survival rates and the present and future therapeutic options with special focus on new antiviral and possible interactions with immunosuppressive medications.

PMID: 27915966 [PubMed - indexed for MEDLINE]

Posttransplant De Novo Hepatitis C Virus Infection in Renal Transplant Recipients: Its Impact on Morbidity and Mortality.

Tue, 08/08/2017 - 15:46
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Posttransplant De Novo Hepatitis C Virus Infection in Renal Transplant Recipients: Its Impact on Morbidity and Mortality.

Exp Clin Transplant. 2017 Feb;15(1):56-60

Authors: Hanif FM, Laeeq SM, Luck NH, Aziz T, Abbas Z, Mubarak M

Abstract
OBJECTIVES: The clinical effects of hepatitis C virus infection acquired after transplant have not been thoroughly studied. We aimed to study hepatitis C virus-related morbidity and mortality with de novo hepatitis C virus infection after renal transplant.
MATERIALS AND METHODS: Data from mortality files were retrospectively collected from January 2011 to January 2015. Patients were divided into 2 groups: hepatitis C virus positive (group A) and hepatitis C virus negative (group B).
RESULTS: Eighty-one patients were included, with median duration of survival of 39 months after transplant. In group A (32 patients), 78.1% of patients were males, with mean age of 36.83 ± 9.15 years. The mean survival duration was better in group A than in group B (67.59 ± 67.1 vs 58.10 ± 59.6 mo; P = .58). Acute cellular rejection was 25% in group A versus 20.4% in group B, whereas chronic allograft nephropathy was 20.4% for group A versus 18.4% for group B. Hepatitis C virus-related death was observed in 7 patients (21.9%). Infection was the main cause of death, with 40.6% of patients in group A versus 53% of patients in group B. On multivariate analyses, better patient survival was associated with greater interval of acquiring HCV after transplant (P = .038).
CONCLUSIONS: HCV infection acquired after renal transplant is not associated with increased HCV-related mortality, and prognosis is related to the time interval of acquiring infection after transplant.

PMID: 27915964 [PubMed - indexed for MEDLINE]

Esophageal tuberculosis with coexisting opportunistic infections in a renal allograft transplant recipient.

Tue, 08/08/2017 - 15:46
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Esophageal tuberculosis with coexisting opportunistic infections in a renal allograft transplant recipient.

Transpl Infect Dis. 2017 Feb;19(1):

Authors: Kumar S, Minz M, Sinha SK, Vaiphei K, Sharma A, Singh S, Kenwar DB

Abstract
We report a renal allograft transplant recipient with esophageal tuberculosis (TB) coinfected with herpes simplex virus (HSV) and Candida. The patient presented with oropharyngeal candidiasis and was started on fluconazole. Upper gastrointestinal endoscopy showed whitish patches with mucosal ulcers in the esophagus. Histopathological examination confirmed TB and HSV infection. The patient recovered after antiviral, antifungal, and anti-tubercular therapy with reduction in immunosuppression. In a TB-endemic zone, TB can coexist with opportunistic infections in an immunocompromised host.

PMID: 27885762 [PubMed - indexed for MEDLINE]

Cryptococcal infections in solid organ transplant recipients over a 15-year period at a state transplant center.

Tue, 08/08/2017 - 15:46
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Cryptococcal infections in solid organ transplant recipients over a 15-year period at a state transplant center.

Transpl Infect Dis. 2017 Feb;19(1):

Authors: Gassiep I, McDougall D, Douglas J, Francis R, Playford EG

Abstract
BACKGROUND: The aim of this research paper was to determine the incidence, risk factors, and clinical outcome of solid organ transplant (SOT) recipients diagnosed and treated for cryptococcosis at our institution.
METHODS: Retrospective analysis of all patients with SOT diagnosed and treated for cryptococcal infection occurring between January 2001 and December 2015.
RESULTS: Of 102 patients diagnosed with cryptococcal infection, 23 were SOT recipients. Renal transplant accounted for 22/23 cases, of which 13 had meningitis. The annual incidence of infection has risen significantly, and is now greater than 2/1000 prevalent renal transplant recipients. As expected, biochemical factors associated with meningitis include lower glucose on cerebrospinal fluid (CSF) analysis, median 2.4 vs 4.5 mmol/L (P=.02); CSF white blood cell median 50 vs 1/μL (P<.001); CSF protein, median 950 vs 335 mg/L (P=.04). Serum cryptococcal antigen titers were higher in the meningitis cohort, median 512 vs 32 (P=.03). Clinically, headache on admission (odds ratio: 9 [1.29-63.03], P=.03) and a prolonged length of stay (median of 36 vs 13 days) in the meningitis cohort (P=.02) were significant.
CONCLUSION: Cryptococcal infection in SOT recipients remains rare; however, there has been a marked increase in cases since 2014. This study reveals a need for increased vigilance for a potential emerging infectious disease. It furthermore highlights the need for ongoing research to further aid early diagnosis, prognostication, management, and screening cost-effectiveness.

PMID: 27875016 [PubMed - indexed for MEDLINE]

Impact of type of calcineurin inhibitor on post-transplant tuberculosis: Single-center study from India.

Tue, 08/08/2017 - 15:46
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Impact of type of calcineurin inhibitor on post-transplant tuberculosis: Single-center study from India.

Transpl Infect Dis. 2017 Feb;19(1):

Authors: Agarwal SK, Bhowmik D, Mahajan S, Bagchi S

Abstract
INTRODUCTION: Tuberculosis (TB) is an important cause of morbidity and mortality in renal transplant recipients. Immunosuppressive drugs are one of the most important risk factor for post-transplant tuberculosis (PTTB). A paucity of data exists about the impact of the type of calcineurin inhibitor on PTTB.
METHODS: In this retrospective study, all adult patients on calcineurin inhibitor-based immunosuppression were included. Patients receiving TB chemoprophylaxis were excluded. Diabetes, duration of dialysis, hepatitis B and C, past treated TB, induction therapy, type of antimetabolite, acute rejection, new onset of diabetes after renal transplantation (RT) (NODAT) and cytomegalovirus (CMV) were analyzed in tacrolimus (Tac) and cyclosporine (CsA) groups. Primary outcome was incidence of TB and secondary outcomes were timeline of development of TB after RT and pattern of TB in the two groups.
RESULTS: Of the 1664 patients included, 582 patients received CsA-based immunosuppression while 1082 received Tac-based immunosuppression. Duration of dialysis, positive tuberculin skin test, use of induction, mycophenolate mofetil use, CMV infection, and NODAT were significantly more, and hepatitis B infection, past treated TB, and acute rejection episodes were significantly less in the Tac group. At the end of follow-up, incidence of TB in the Tac group was significantly less than in the CsA group (6.1% vs 19.9%, P<.001). Mean time for development of TB after RT was similar in both the groups and nodal and disseminated TB were more common in the Tac group.
CONCLUSION: In conclusion, our study shows that use of Tac as compared to CsA significantly decreases incidence of PTTB. Time of infection since transplant was similar in both the groups. However, nodal and disseminated TB were more common in the Tac group.

PMID: 27775825 [PubMed - indexed for MEDLINE]

Experience with miltefosine for persistent or relapsing visceral leishmaniasis in solid organ transplant recipients: A case series from Spain.

Tue, 08/08/2017 - 15:46
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Experience with miltefosine for persistent or relapsing visceral leishmaniasis in solid organ transplant recipients: A case series from Spain.

Transpl Infect Dis. 2017 Feb;19(1):

Authors: Pérez-Jacoiste Asín MA, Carrasco-Antón N, Fernández-Ruiz M, San Juan R, Alonso-Moralejo R, González E, Andrés A, López-Medrano F, Aguado JM

Abstract
The incidence of visceral leishmaniasis (VL) after solid organ transplantation (SOT) is increasing. The optimal therapy for post-transplant VL remains unclear, as relapses after liposomal amphotericin B (L-AmB) are common. Miltefosine has been shown to be effective for treating VL in immunocompetent patients, although data in the specific population of SOT recipients are lacking. In the setting of an outbreak of leishmaniasis occurring in Southwest Madrid, we reviewed our experience in 6 SOT recipients with persistent or relapsing VL who received a 28-day course of miltefosine (2.5 mg/kg/day) as salvage therapy. All patients had been treated previously with L-AmB as first-line therapy. The incident episode of VL occurred at a median of 14 months after transplantation. Two patients experienced persistent infection and the remaining 4 had a relapse after a median interval of 168 days since the completion of the course of L-AmB. All the patients had an apparent initial clinical improvement with miltefosine. However, VL relapsed in 3 of them (after a median interval of 46 days), which required retreatment with L-AmB-based regimens. Miltefosine therapy was followed by a prolonged secondary prophylaxis with L-AmB in the only 2 cases with sustained clinical response and ongoing immunosuppression. No adverse effects associated with miltefosine were observed. Albeit limited, our experience suggests that miltefosine monotherapy likely has a limited utility to obtain a long-lasting clinical response in complicated (persistent or relapsing) forms of post-transplant VL, although its role in association with L-AmB-based secondary prophylaxis may merit further investigation.

PMID: 27768239 [PubMed - indexed for MEDLINE]

Intestinal Perforation in Renal Transplant Recipients: A Single Center Experience of 2123 Recipients.

Tue, 08/08/2017 - 15:46
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Intestinal Perforation in Renal Transplant Recipients: A Single Center Experience of 2123 Recipients.

Exp Clin Transplant. 2016 Oct;14(5):497-502

Authors: Kakavia K, Moris D, Karatza E, Bokos J, Vernadakis S, Barlas A, Sotirchos G, Diles K, Drakopoulos S, Zavos G

Abstract
OBJECTIVES: Intestinal perforation remains a clinical challenge and potentially lethal complication in renal transplant recipients. Immunosuppression not only places the patient at risk for intestinal perforation but also masks classic clinical symptoms and signs of acute abdominal pain, leading to delayed diagnosis and proper treatment. The aim of our study is to present the experience of our center on the treatment of intestinal perforation in renal transplant recipients.
MATERIALS AND METHODS: This study reported 11 patients (0.52%) with intestinal perforation among a group of 2123 patients who received renal transplants in the Transplantation Unit at Laikon General Hospital in Athens, Greece from 1983 to August 2015.
RESULTS: One patient died from septic shock before any surgery, and 3 patients died during the early postoperative period, resulting in a morality rate of 36.3%. All patients who died had a functioning graft. From the patients who were discharged, the mean follow-up was 16 months (range, 4-32 months).
CONCLUSIONS: Intestinal perforation after renal transplant is a major and potentially lethal complication. Clinical presentation is usually equivocal, and the transplant surgeon should be highly suspicious when treating a renal transplant recipient with acute abdominal pain, even in cases without other predisposing factors (diverticulitis, ischemic colitis, and so forth), so that this condition could be investigated and unmasked.

PMID: 27228089 [PubMed - indexed for MEDLINE]

Disparate rates of acute rejection and donor-specific antibodies among high-immunologic risk renal transplant subgroups receiving antithymocyte globulin induction.

Tue, 08/08/2017 - 15:46
Related Articles

Disparate rates of acute rejection and donor-specific antibodies among high-immunologic risk renal transplant subgroups receiving antithymocyte globulin induction.

Transpl Int. 2016 Aug;29(8):897-908

Authors: Patel SJ, Suki WN, Loucks-DeVos J, Graviss EA, Nguyen DT, Knight RJ, Kuten SA, Moore LW, Teeter LD, Gaber LW, Gaber AO

Abstract
Lymphocyte-depleting induction lowers acute rejection (AR) rates among high-immunologic risk (HIR) renal transplant recipients, including African Americans (AAs), retransplants, and the sensitized. It is unclear whether different HIR subgroups experience similarly low rates of AR. We aimed to describe the incidence of AR and de novo donor-specific antibody (dnDSA) among HIR recipients categorized by age, race, or donor type. All received antithymocyte globulin (ATG) induction and triple maintenance immunosuppression. A total of 464 HIR recipients from 2007 to 2014 were reviewed. AR and dnDSA rates at 1 year for the entire population were 14% and 27%, respectively. AR ranged from 6.7% among living donor (LD) recipients to 30% in younger AA deceased donor (DD) recipients. De novo donor-specific antibody at 1 year ranged from 7% in older non-AA LD recipients to 32% in AAs. AA race remained as an independent risk factor for AR among DD recipients and for dnDSA among all HIR recipients. Development of both AR and dnDSA within the first year was associated with a 54% graft survival at 5 years and was an independent risk factor for graft loss. Despite utilization of recommended immunosuppression for HIR recipients, substantial disparities exist among subgroups, warranting further consideration of individualized immunosuppression in certain HIR subgroups.

PMID: 27196395 [PubMed - indexed for MEDLINE]

Red Blood Cell Distribution Width Increases During Infection in Renal and Liver Graft Recipients.

Tue, 08/08/2017 - 15:46
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Red Blood Cell Distribution Width Increases During Infection in Renal and Liver Graft Recipients.

Exp Clin Transplant. 2017 Feb;15(1):61-64

Authors: Kayipmaz AE, Findik M, Kavalci C, Akdur A, Moray G, Haberal M

Abstract
OBJECTIVES: Organ transplant is an effective treatment for patients with end-stage renal and hepatic failure. Increased use has introduced more emergency department admissions of infectious origin after transplant. Because infections usually manifest with simple complaints and fever, emergency physicians need laboratory tests and radiologic imaging procedures to quickly detect the presence and source of infection. Our aim was to analyze fever-related emergency admissions of renal and hepatic graft recipients and determine whether admitted patients had increased red blood cell distribution width and mean platelet volume levels.
MATERIALS AND METHODS: We reviewed the medical records of renal and hepatic graft patients who presented to our emergency department with fever during a 4-year period. Our analyses included 150 patients in which complete blood count and C-reactive protein results were available and the source of infection was determined. We compared results with a control group of 150 transplant patients without any infectious findings.
RESULTS: In the 150 solid-organ graft recipients who presented to our emergency department with fever, significant differences were observed versus control patients with respect to white blood cell count, neutrophil-to-lymphocyte ratio, red blood cell distribution width, mean platelet volume, and C-reactive protein levels (P < .05). We determined that C-reactive protein levels, red blood cell distribution width, mean platelet volume, and lymphocyte count were independent indicators of infection on multiple logistic regression analyses. We also determined that red blood cell distribution width had a specificity of 94% and a sensitivity of 26%.
CONCLUSIONS: We found a significantly higher red blood cell distribution width in emergency admissions of infectious origin of renal and hepatic graft recipients than in the control group (P < .001), suggesting that this measurement is a suitable marker of infection for the emergency setting by virtue of rapid availability of test results and lack of extra costs.

PMID: 26767568 [PubMed - indexed for MEDLINE]

Resolution of Benign and Malignant Sebaceous Neoplasms, in a Renal Transplant Patient Treated With Everolimus.

Tue, 08/08/2017 - 15:46
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Resolution of Benign and Malignant Sebaceous Neoplasms, in a Renal Transplant Patient Treated With Everolimus.

Exp Clin Transplant. 2017 Feb;15(1):100-102

Authors: Donati M, Paolino G, Muscardin L, Panetta C, Donati P

Abstract
Nonmelanoma skin cancers are the most common malignancies in transplant recipients under immunosuppression; nevertheless, appendage tumors also may appear. The onset of several cutaneous neoplasms in transplant patients can cause deterioration in quality of life of these patients. A 62-year-old white woman patient developed several malignant and benign sebaceous neoplasms during an immunosuppressive treatment for a renal transplant. The genetic study showed a mutation in MSH6-eson 1 (c116G>A), without mutations in MLH1 gene and MSH2. A final diagnosis of multiple sebaceous tumors in an immunosuppressed patient without Muir -Torre syndrome was made. The spreading of further cutaneous neoplasms led to a change in immunosuppression: namely, that clinicians suspended tacrolimus and add everolimus. After 2 months, all tumor lesions on the face and on the limbs have disappeared, and no further lesions occurred. Everolimus could represent a valid therapeutical treatment for transplant patients at high risk for cutaneous tumors. A genetic consult and a consequent study of the genetic profile should be performed on each of these patients, to avoid risks of recurrent cutaneous tumors and negative effects on the quality of life.

PMID: 25924010 [PubMed - indexed for MEDLINE]

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