Kidney transplantation

This study investigates why the illegal traffic of kidneys exists and remains resilient in the Philippines. It also evaluates the efficacy of the legal and regulatory framework for kidney (and organ) transplantation, and the corresponding implications for health policy. The experiences of comparable countries are noted.Three surveys were employed in this study: 1) a review of related literature on kidney black markets; 2) questionnaire-based interviews of a multi-stage probability sample of 131 kidney vendors from the two largest supplier regions in the Philippines; and 3) a comparative content analysis of pertinent legal and regulatory measures to address the underground kidney trade.Survey results, based on a 4.0 percent statistical margin of error, indicate that kidney vendors are typically males (98.4 percent) who belong to the lower income classes/groups D and E (88.5 percent). The vast majority of vendors (89.2 percent) were unrelated to kidney recipients, many of whom were of foreign descent (60.3 percent). The study finds that certain key elements underpin the kidney black market in the Philippines: an open, brokered and compensation-based contractual system between unrelated donors and sellers. These elements are sustained and reinforced by a robust supply-and-demand interface anchored on brokerage pricing, government incapacity, policy contradictions and public tolerance or indifference.The study suggests that the relative ambiguity of, and continuity between, the legal and underground kidney transplant systems be carefully addressed prior to enacting more specific reforms. The study also calls attention to the unintended consequences of various reform efforts, which are often neglected in formulating health policy and evaluating its costs and benefits.

Ischemia-reperfusion injury is a pathophysiological event occuring after abdominal organ transplantation, and has a significant influence on prognosis and survival of the graft. It is involved in delaying the primary function or non-functioning of the graft. The objective of this study was to provide information on heat shock protein mechanisms in ischemia-reperfusion injuries in abdominal organ transplantations, and to indicate the possible factors involved that may influence the graft outcome. Several classes of heat shock proteins are part of the ischemia and reperfusion process, both as inflammatory agonists and in protecting the process. Studies involving heat shock proteins enhance knowledge on ischemia-reperfusion injury mitigation processes and the mechanisms involved in the survival of abdominal grafts, and open space to support therapeutic future clinical studies, minimizing ischemia and reperfusion injuries in abdominal organ transplantations. Expression of heat shock proteins is associated with inflammatory manifestations and ischemiareperfusion injuries in abdominal organ transplantations and may influence graft outcomes.

In this report we evaluated the association of marital status with access to renal transplantation. We analyzed data from the USRDS. In patients with ESRD aged ≥27 (mean age of first marriage in the US), we analyzed the association of marital status with two outcomes: (1) likelihood of being placed on the waiting list for renal transplantation or first transplant, (2) likelihood of receiving kidney transplant in patients already listed. We analyzed marital status as a categorical variable: (1) not married (including never been married and widowed); (2) divorced or separated; and (3) currently married. Subgroups based on age, race, sex, donor type and diabetic status were also analyzed. After adjustments for the included independent variables and compared to individuals never married or widowed, those who were divorced/separated (HR 1.55, p < 0.001) and currently married (HR 1.54, p < 0.001) had a higher likelihood of being placed on the transplant waiting list. Once listed, married individuals had higher chances of getting transplanted as well (HR 1.28, p = 0.033). This trend was consistent in most of the subgroups studied. We demonstrated that being married is associated with better access to renal transplantation compared to those who were never married/widowed.

B ECAUSE of a large number of dialysis patients in Iran who needed renal transplantation (Tx) who had no living related donors (LRD) and the absence of cadaveric organ donation program, a controlled living unrelated donor (LUD) renal Tx program was adopted in Iran in 1988. As a result, in last 12 years more than 7,000 renal Tx from LUD and more than 2500 from LRD have been performed. The waiting list for renal Tx in this country has been eliminated. The characteristics, advantages, and disadvantages of this Tx program have previously been published and will briefly be discussed below. 1,2 This study compares the socioeconomic characteristics of LUD and their recipients in this program to see which socioeconomic group of the country are being transplanted more from LUD.

The incidence of neoplastic complications after solid organ transplantation is increasing tremendously probably as the consequence of long term immunosupression. Beside usual risk factors, the oncogenic role of some viruses like Epstein-Barr virus is well established. We report a case of a primitive EBV-induced liver leiomyosarcoma after renal transplantation.

The aim of this preliminary, observational study was to evaluate the value of ImmuKnow (IK), a new tool to measure the net state of immunefunction among renal transplant recipients, in correlation with clinical and laboratory data among unselected renal transplant recipients. Forty-nine recipients of mean age of 51 years were enrolled and followed for 1 year after transplantation. All subjects received the same immunosuppressive strategy with basiliximab induction and tacrolimus, mycophenolate mofetil and steroid maintenance therapy. Samples for IK were collected before transplantation as well as at 7, 14, 21 and 42 days and after 3, 6, and 12 months. There were 54 samples with IK Ͻ225 ng/mL, 201 samples with normal IK values, and 135 samples with Ͼ525 ng/mL. We divided recipients into 3 groups with respect to their basal IK values: Group 1 (Gr1; IK Ͻ225 ng/mL); Group 2 (Gr2; normal values of IK between 226 and 524 ng/mL); and Group 3 (Gr3; IK Ͼ525 ng/mL). At 1 year, we observed a significant difference among IK values at the start and the end of the study: Gr1 vs Gr2, P Ͻ .0001; Gr2 vs Gr3, P Ͻ .06 and Gr 1 vs Gr 3, P Ͻ .01). We observed reduced IK values to predict an increased risk of infection, particularly with cytomegalovirus (CMV) replication while higher IK value did not correlate with an increased risk of acute rejection episodes. Reduction of serum creatine levels occurred within 1 year in all groups (P Ͻ .005), but there was a significant difference between Gr 2 versus Grs 1 and 3 (P Ͻ .0001 and P Ͻ .0005, respectively). There findings suggested that more stable IK values were associated with clinical quiescence and laboratory stability. In conclusion, our preliminary analysis showed a beneficial capacity of this assay to represent the global depression of the immune system. We noted that reduced IK values, as a sign of excessive immunosuppressive therapy, were associated with an increased risk of infection. We did not confirm the predictive value of higher IK values for an increased risk of an acute rejection episode.

Background. Coeliac disease (CD) may be a risk factor for renal disease. Methods. We investigated the risk of any form of glomerulonephritis (GN) (acute, chronic and nonspecified), chronic glomerulonephritis (CGN) and renal replacement therapy including dialysis treatment and kidney transplantation (KT) in patients with CD in a general population-based cohort study. We used Cox regression to assess the risk of renal disease in 14 336 patients who had received a diagnosis of CD and 69 875 reference individuals matched for age, calendar year, sex and county. Patients were identified using the Swedish Hospital Discharge Registry. Follow-up began 1 year after study entry. Results. CD was associated with an increased risk of any form of GN (hazard ratio (HR) ¼ 1.64; 95% confidence intervals (CI) ¼ 1.01-2.66; P ¼ 0.046; 89 events), CGN (HR ¼ 2.65; 95% CI ¼ 1.34-5.24; P ¼ 0.005; 39 events), dialysis (HR ¼ 3.48; 95% CI ¼ 2.26-5.37; P<0.001; 102 positive events) and KT (HR ¼ 3.15; 95% CI ¼ 1.29-7.71; P ¼ 0.012; 22 events). Conclusion. We suggest that immune characteristics associated with CD increase the risk of chronic renal disease. Individuals with CD may also be at a moderately increased risk of any form of GN.

Diabetic muscle infarction (DMI) is a rare, long-term complication of poorly controlled diabetes (typically of type I). DMI was first described in 1965 and more than 100 cases have been reported thereafter in the English literature. Usually, there is a coexistence with concomitant nephropathy, neuropathy, and retinopathy. The etiology remains uncertain, but appears to be attributable to diabetic microangiopathy and hypercoagulability and is believed that hypoxia-reperfusion injury is involved. DMI presents with sudden onset of pain associated with a tender mass in the thigh in most instances. The diagnosis is based on magnetic resonance imaging, which is not specific but highly indicative. Treatment is conservative with relapses occurring in 50% of the patients, but not necessarily in the same muscle group. We describe a case of DMI that occurred 4 months after simultaneous kidney and pancreas transplantation in one patient with type I diabetes mellitus and end-stage renal disease.

The use of elderly donors has been advocated to expand the organ donor pool because of increased needs and organ shortage. The aim of the study was to analyse whether old age of donors affects the outcome of renal transplantation and the long term safety of retrieval for the donors. We present data of 335 consecutive living related kidney transplants, performed in our centre the last 10 years, where in 174 patients the donor was less than 60 years of age, while in the rest 161 patients the donor was more than 60 years of age. No statistical difference was noted in either group at the incidence of irreversible acute rejections, early acute tubular necrosis, vascular complications and patient deaths. The graft survival was 86.7%, 80.4% and 78.1% for the 3rd, the 5th and the 8th year for the younger group of donors, while it was 83.6%, 78.2% and 67.8% for the older group (p = 0.13). Patient survival of the younger group was 95.9%, 94.7% and 94.7%, while for the older was 94.4%, 92.0% a...

The 8th Banff Conference on Allograft Pathology was held in Edmonton, Canada, 15-21 July 2005. Major outcomes included the elimination of the non-specific term 'chronic allograft nephropathy' (CAN) from the Banff classification for kidney allograft pathology, and the recognition of the entity of chronic antibody-mediated rejection. Participation of B cells in allograft rejection and genomics markers of rejection were also major subjects addressed by the conference.

The aim of the present study was to evaluate the effect of hemodialysis and renal failure on serum bone markers. Serum total alkaline phosphatase (TAP), procollagen type I aminoterminal propeptide (PINP), and Β-carboxyterminal telopeptide of type I collagen (Β-CTX), as well as intact parathyroid hormone (iPTH), creatinine, and total protein were measured in 14 patients with endstage renal disease (ESRD) before and at 1, 2, and 4 h during a hemodialysis session, and at the same sampling interval in 6 renal transplant recipients. The results were compared to those obtained in 20 healthy adults. All patients showed increased baseline mean values of PINP, Β-CTX, and iPTH. Β-CTX differed significantly between hemodialysis patients and renal transplant recipients. TAP and Β-CTX were the only markers which correlated with iPTH (P ≪ 0.05) and creatinine values (P ≪ 0.001), respectively. Renal transplant recipients did not show significant variations in the evolution of mean values of bone markers throughout the study, whereas, during the dialysis period, all the bone markers analyzed in the study showed a significant change. The change differed depending on the marker considered: Β-CTX showed a significant decrease at the end of the session, TAP increased at this time and, although PINP showed an initial increase during hemodialysis, no significant changes were observed at the end of the session. We conclude that bone markers are significantly influenced by hemodialysis, especially serum TAP and Β-CTX. ESRD is associated with an increase in these bone markers, in some cases related to iPTH values and in others to glomerular function. These findings should be taken into account when evaluating bone markers in these patients.

Long-term preservation of complex engineered tissues and organs at cryogenic temperatures in the absence of ice has been prevented to date by the difficulty of discovering combinations of cryoprotectants that are both sufficiently nontoxic and sufficiently stable to allow viability to be maintained and ice formation to be avoided during slow cooling to the glass transition temperature and subsequent slow rewarming. A new theory of the origin of non-specific cryoprotectant toxicity was shown to account, in a rabbit renal cortical slice model, for the toxicities of 20 vitrification solutions and to permit the design of new solutions that are dramatically less toxic than previously known solutions for diverse biological systems. Unfertilized mouse ova vitrified with one of the new solutions were successfully fertilized and regained 80% of the absolute control (untreated) rate of development to blastocysts, whereas ova vitrified in VSDP, the best previous solution, developed to blastocysts at a rate only 30% of that of controls. Whole rabbit kidneys perfused at )3°C with another new solution at a concentration of cryoprotectant (8.4 M) that was previously 100% lethal at this temperature exhibited no damage after transplantation and immediate contralateral nephrectomy. It appears that cryoprotectant solutions that are composed to be at the minimum concentrations needed for vitrification at moderate cooling rates are toxic in direct proportion to the average strength of water hydrogen bonding by the polar groups on the permeating cryoprotectants in the solution. Vitrification solutions that are based on minimal perturbation of intracellular water appear to be superior and provide new hope that the successful vitrification of natural organs as well as tissue engineered or clonally produced organ and tissue replacements can be achieved.

This is the first case of documented treatment failure of JCV nephritis, despite a reduction of immunosuppressive agents and the use of antiviral therapy. We consistently detected high levels of JCV viremia, which correlated with the progressive deterioration of the graft and caused the final loss of the kidney, suggesting that JCV plays an etiological role in the onset of severe nephropathy in kidney transplant patients.

New immunosuppressive drugs used in kidney transplantation decreased the incidence of acute rejection. It was hypothesized that, with their power, the importance of HLA matching was decreased. To evaluate the influence of HLA matching, immunosuppression, and other possible risk factors, we analyzed data of 1314 consecutive deceased donor kidney transplantation. We divided the patient population into 4 cohorts, according to the era of transplantation: era 1, before 1990, azathioprine (Aza) and cyclosporine (Csa) no microemulsion; era 2, between 1990 and 1995, Csa microemulsion; era 3, between 1996 and 2000, wide use of mycophenolate mofetil (MMF) and anti-thymocyte globulin (ATG); and era 4, after 2000, marked by sirolimus and tacrolimus (TAC) use. Multivariate analysis compared death-censored graft survival. Using as reference the results obtained with 0 HLA mismatches, we verified, during era 1 and era 2, an increased risk of graft loss for all of the subgroups with HLA mismatch Ͼ0. However, during era 3 and era 4, the number of HLA mismatches did not influence graft survival. Although acute rejection and delayed graft function, which decreased in the later periods, remained as prognostic factors for graft loss. Considering the immunosuppressive protocol with CsaϩAzaϩPred as reference, protocols used after 1995 with PredϩCsaϩATG, with PredϩCsaϩMMF, and with PredϩTacϩMMF presented better survival results. Results showed that the significance of HLA matching decreased while the results improved with the new immunosuppressant drugs. These observations support the hypothesis that the weakened importance of HLA matching may be a consequence of the increasing efficacy of the immunosuppression.

Limited data are available for outcomes of simultaneous liver-kidney (SLK) transplantation using donation after cardiac death (DCD) donors. The outcomes of 12 DCD-SLK transplants and 54 SLK transplants using donation after brain death (DBD) donors were retrospectively compared. The baseline demographics were similar for the DCD-SLK and DBD-SLK groups except for the higher liver donor risk index for the DCD-SLK group (1.8 6 0.4 versus 1.3 6 0.4, P 5 0.001). The rates of surgical complications and graft rejections within 1 year were comparable for the DCD-SLK and DBD-SLK groups. Delayed renal graft function was twice as common in the DCD-SLK group. At 1 year, the serum creatinine levels and the iothalamate glomerular filtration rates were similar for the groups. The patient, liver graft, and kidney graft survival rates at 1 year were comparable for the groups (83.3%, 75.0%, and 82.5% for the DCD-SLK group and 92.4%, 92.4%, and 92.6% for the DBD-SLK group, P 5 0.3 for all). The DCD-SLK group had worse patient, liver graft, and kidney graft survival at 3 years (62.5%, 62.5%, and 58.9% versus 90.5%, 90.5%, and 90.6%, P 5 0.03 for all) and at 5 years (62.5%, 62.5%, and 58.9% versus 87.4%, 87.4%, and 87.7%, P < 0.05 for all). An analysis of the Organ Procurement and Transplantation Network database showed inferior 1-and 5-year patient and graft survival rates for DCD-SLK patients versus DBD-SLK patients. In conclusion, despite comparable rates of surgical and medical complications and comparable kidney function at 1 year, DCD-SLK transplantation was associated with inferior long-term survival in comparison with DBD-SLK transplantation.

Donation criteria have been becoming more flexible over the years. Currently, the only absolute exclusion criteria are human immunodeficiency virus infection (HIV), uncontrolled tumor disease and bacterial or viral infections. Clinical conditions dictate organ viability criteria: biochemical, morphological and functional, that must be fulfilled by the donors and their organs in order to focus the decision on which donor organs can be used. These criteria attempt to assure that the transplanted organs function after the extraction, transformation, implantation and reperfusion process without transmitting any infectious or tumour disease. In recent years, the gross and microscopic appearance has become one of the fundamental criteria for selection of potentially viable organs. At present, there is no age limit for hepatic and renal donation; the principal contra-indication is chronic organ damage. The use of each organ must be decided individually after a profound analysis of all the viability criteria, weighing the advantages and disadvantages of the implant of a certain organ for the recipient.

Results: Early postoperative mortality (in the first 30 days) was 3.4% (n = 1). The overall estimated Kaplan–Meier survival was 56.7% at 36 months, 46.7% at 60 months, and 43.3% at 96 months. HD program was discontinued for two patients after renal transplantation in the ...

INTRODUCTION Delayed graft function (DGF) is a consequence of ischemia-reperfusion injuries in kidney allografts, for which no definite treatment is available. The neutrophil gelatinase-associated lipocalin (NGAL) and interleukin-18 (IL-18) are introduced as the most promising urine biomarkers to detect DGF. N-acetylcysteine (NAC) and vitamin C, well-known potent antioxidants that scavenge free radicals, may alleviate kidney injury. This study investigated the protective effects of NAC alone and in combination with vitamin C on DGF, by measuring IL-18 and NGAL in living donor kidney transplantations. MATERIALS AND METHODS Patients transplanted between January 2011 and February 2013 were randomly divided into 3 groups to receive routine anti-rejection medication only (n = 32), NAC plus routine immunosuppressive regimen (NAC group; n = 33), and NAC and vitamin C plus routine regimen (NAC and vitamin C group; n = 19). Urine samples were taken 4 hours and 24 hours after transplantation....

The Clinical Practice Guideline on evaluation of the kidney donor and transplant recipient was developed following a rigorous methodological approach aiming to provide information and aid decision-making to the transplant professionals. Thus, this document should help caregivers to improve the quality of care they deliver to patients with no intention it is defined as a standard of care. In this short version of the guidelines we present 112 statements about the evaluation of the kidney transplant candidate as well as the potential deceased and living donor, the immunological work-up of kidney donors and recipients and the perioperative recipient care. The extended version of the guidelines with methods, rationale and references is published in Nephrol Dial Transplant (2013) 28: i1-i71; doi: 10.1093/ndt/gft218 and can be downloaded freely from http://www.oxfordjournals.org/our_journals/ndt/era_edta.html.

Today successful kidney transplantation procedures, techniques and immunosuppression protocols are a consequence of extensive research on animal models. During every transplantation surgery there are two crucial points for the success of the entire procedure: vascular (arterial end venous) and ureteral or ureterovesical anastomosis. Renal artery and vein of the donor kidney can be anastomosed end-to-side to the abdominal aorta and vena cava of the recipient (heterotopic transplantation), or end-to-end to the remains of renal artery and vain of the recipient (orthotopic transplantation) after nephrectomy. The ureter can be anastomosed also end-to-end or we can connect it directly to the urinary bladder (ureterocystoneostomy). The aim of this study was to elucidate which technique has better results according to: animal survival, reperfusion and perfusion of the transplanted kidney, elimination of the urine from the transplanted kidney and procedure costs. The study included 240 (120 ...

A rejection occurs commonly in simultaneous pancreas/kidney (SPK) transplant recipients and continues to be a cause of graft loss despite the potent immunosuppressive agents available. The induction of peripheral tolerance via bone marrow (BM) infusion has been successful in experimental animals. In the 1960s and 197Os, Anthony P. Monaco pioneered the concept of the establishment of a hematopoietic chimera to set the stage for a state of tolerance toward allogeneic transplants (skin, vascularized whole organ, etc) experimentally.'

The complete area under the time-concentration curve (AUC) is considered to be the gold standard for cyclosporin-A (CyA) monitoring. However, complete AUC is time-and cost-consuming. For this reason, we reviewed 259 4-h AUC (AUC 0ª4 ) performed in 74 renal transplanted patients in order to construct an equation to calculate AUC 0ª4. All samples were drawn from one adult population 13 days following transplantation, in order to allow the cyclosporin metabolism to stabilize. Regression analysis was done either with each or with a combination of two variables. Cyclosporin-A blood concentration at the second hour after the oral dose (C2) was the best predictor of AUC 0ª4 , where AUC 0ª4 Ω451 π (2.73 ¿ C2), R 2 Ω 0.87, p ∞ 0.001. The combination of C1 and C2 only, offered a better mathematical improvement to the C2 equation. This equation was further validated in 33 other CyA pharmacokinetic profiles performed in eight patients who had not participated in the equation development. In this new population, the C2 equation excellently predicted the trapezoidal AUC 0ª4 (R 2 Ω 0.81). Our data shows that C2 can be safely used to estimate AUC 0ª4. The C2 equation simplifies CyA monitoring because of its high-predictive value and clinical feasibility.

Hypophosphatemia caused by renal phosphate loss occurs frequently after kidney transplantation. In assumption of systemic phosphorus depletion, the presumed deficit commonly is replaced by oral phosphate supplements. However, such treatment is debatable, because intracellular phosphorus stores have not been assessed in this setting and may not be accurately reflected by serum phosphate concentrations. Moreover, disturbances in mineral metabolism from chronic renal failure, such as hypocalcemia and hyperparathyroidism, may be prolonged with oral phosphate supplements. Conversely, a neutral phosphate salt might improve renal acid excretion and systemic acid/base homeostasis for its properties as a urinary buffer and a poorly reabsorbable anion. Twenty-eight patients with mild early posttransplantation hypophosphatemia (0.3-0.75 mmol/L) were randomly assigned to receive either neutral sodium phosphate (Na 2 HPO 4 ) or sodium chloride (NaCl) for 12 weeks and examined with regard to (1) correction of serum phosphate concentration and urinary phosphate handling; (2) muscular phosphate content; (3) serum calcium and parathyroid hormone (PTH); and, (4) renal acid handling and systemic acid/base homeostasis. Mean serum phosphate concentrations were similar and normal in both groups after 12 weeks of treatment; however, more patients in the NaCl group remained hypophosphatemic (93% versus 67%). Total muscular phosphorus content did not correlate with serum phosphate concentrations and was 25% below normophosphatemic controls but was completely restored after 12 weeks with and without phosphate supplementation. However, the percentage of the energy-rich phosphorus compound adenosine triphosphate (ATP) was significantly higher in the Na 2 HPO 4 group, as was the relative content of phosphodiesters. Also, compensated metabolic acidosis (hypobicarbonatemia with respiratory stimulation) was detected in most patients, which was significantly improved by neutral phosphate supplements through increased urinary titratable acidity. These benefits of added phosphate intake were not associated with any adverse effects on serum calcium and PTH concentrations. In conclusion, oral supplementation with a neutral phosphate salt effectively corrects posttransplantation hypophosphatemia, increases muscular ATP and phosphodiester content without affecting mineral metabolism, and improves renal acid excretion and systemic acid/base status. 1999 by the National Kidney Foundation, Inc. INDEX WORDS: Hypophosphatemia; renal transplantation; renal phosphate handling; muscular phosphate content; parathyroid hormone; calcium; acid/base homeostasis.

Donor gender plays a role in the outcome of renal transplantation, but the mechanisms responsible for this effect are unclear. In this study, actuarial graft survival in 1049 recipients transplanted at Montefiore Medical Center between 1979 and 1994 was examined. It was found that donor gender had no influence on graft survival in recipients treated with precyclosporine immunosuppressive agents. In contrast, graft survival time was greater in cyclosporine-treated recipients of male donor kidneys compared with female kidneys (p &lt; 0.05). This survival time difference was evident in the early post-transplant period and was entirely accounted for by the survival advantage of kidneys from white male donors. There was no gender-related difference in graft survival time among recipients of African-American donor kidneys. Recent attention has focused on the hypothesis that a mismatch between female donor kidney nephron supply and male recipient functional demand results in hyperfiltratio...

P OST-TRANSPLANTATION lymphoproliferative disorder (PTLD) is increasingly recognised as an important and potentially devastating complication of organ transplantation. 1 The condition occurs in 1% to 10% of patients, depending on the type of organ transplant. 2 It has been associated with a poor clinical outcome, namely, median survival times ranging between 5 and 14 months. The pathogenesis of PTLD in most cases appears to be related to B-cell proliferation induced by Epstein-Barr virus (EBV) infection in the setting of chronic immunosuppression. 5 EBV-encoded RNAs (EBER-1 and -2) have been demonstrated by in situ hybridisation in between 59% and 100% of PTLD tumours. 6,7 These observations prompted the use of antiviral therapy, such as high-dose acyclovir. Although there is some anecdotal support for this strategy, 7,8 acyclovir has been associated with disappointing outcomes in other studies. Similarly, early studies reported that conventional combination chemotherapy and/or radiotherapy were ineffective in the setting of PTLD, resulting in complete remission rates of between 11% and 31%. 3,4,10 The dismal outcomes for PTLD reported in these studies, however, generally have been limited by small numbers, organ transplant heterogeneity, outdated data, and delayed initiation of combination chemoradiotherapy (often following a failed response to immunosuppression reduction and antiviral therapy).

Posttransplant bacterial infections are important because of their influence on patient and graft outcomes. Therefore, prevention of infection as well as prompt diagnosis and appropriate treatment are crucial. In this retrospective analysis, we reviewed all posttransplant bacterial infections occurring during the admission of kidney transplant patients from January 2000 to May 2004. Of our patients, 25% had at least one episode of infection. Patients with immunosuppression based on an mTOR inhibitor showed the highest rate of wound infections compared to those receiving a calcineurin inhibitor (odds ratio 5.6, P Ͻ .001). Patients with renal failure caused by a urologic disease revealed a increased risk of a urinary tract infections (odds ratio 5.9, P Ͻ .001). Although infection complications are an important cause of morbidity in renal transplantation, the extensive use of antibiotics should be avoided in favor of a strict policy for infection prevention and control.

Although the calcineurin inhibitors (CNI) cyclosporine (CsA) and tacrolimus are highly effective immunosuppressants, they are associated with serious side effects. There is great interest in immunosuppressive regimens that permit reduction or elimination of CNIs, while maintaining adequate immunosuppression and acceptable acute rejection rates. Patients (n = 536) receiving their first renal allograft were randomized to one of three immunosuppressant regimens: daclizumab, mycophenolate mofetil (MMF), corticosteroids (CS) and low-dose CsA (target trough levels of 50-100 ng/mL), weaned from month 4 and withdrawn by month 6; daclizumab, MMF, CS and low-dose CsA; or MMF, CS and standard-dose CsA. Mean GFR 12 months after transplantation (primary end point) was not statistically different in the CsA withdrawal and low-dose CsA groups (both 50.9 mL/min/1.73 m(2)) vs. the standard-dose CsA group (48.6 mL/min/1.73 m(2)). At 12 months, the incidence of biopsy-proven acute rejection was significantly higher in the CsA withdrawal group (38%) vs. the low- or standard-dose CsA groups (25.4% and 27.5%, respectively; p &amp;lt; 0.05). In summary, a regimen of continuous low-dose CsA with MMF, CS and daclizumab induction is a clinically safe and effective immunosuppressive regimen in renal transplant recipients.

INTRODUCTION Tuberculosis reactivation is one of significant complications after transplantation. Tuberculin skin test (TST) has been the major available screening test in end-stage renal disease patients, but it is associated with a low accuracy. Recently, an interferon-gamma release assay (IGRA) has been approved as a substitution test in diagnosis of Mycobacterium tuberculosis infection. This study aimed to compare the ability of the TST and IGRA in the diagnosis of latent tuberculosis in hemodialysis patients and investigate risk factors of having positive test results. MATERIALS AND METHODS Forty-seven hemodialysis patients underwent the IGRA and TST tests. Demographic data and blood samples were collected and chest radiography was done for all participants. RESULT Abnormal chest radiography was reported in 24% of the study group. The IGRA and TST were positive in 11 (23.4%) and 20 patients (43.5%), respectively. The agreement coefficient (kappa) between the IGRA and TST was 0....

Background: Renal transplantation is the treatment of choice for selected patients with end-stage renal disease. In this study, we present our experience and follow up data of renal transplantations done at this center with special emphasis on demographic characteristics, outcome and its complications.
Materials and Methods: All those patients who underwent renal transplantations and had been followed up at this center were studied and their details were recorded. For living donor transplantation, donor and recipient were evaluated in detail. Graft loss was defined as the patient became dialysis-dependent or underwent second renal transplantation.
Results: A total of 250 renal transplantations were done during the study period. 16.4% of total transplantations were cadaveric transplants. Recipients mean age was 38.5±11.64 yrs and donor mean age was 42.25 ±10.79 yrs. The majority of the recipients were male (72.4%) while female donors were predominant among living donors(59.3%). Mean graft survival time was 98.2 months (95% confidence interval [CI]:72.2-114.4). Mean patient survival time was 104.5 months (95% confidence interval [CI]:82.4-126.2).
Conclusion: There is increasing no. of cadaveric renal transplants due to well established deceased donation programs in the state. Our patient and graft survival are comparable. Most of the immediate graft loss was due to acute rejection and late graft loss was due to chronic antibody-mediated rejection

Background: Few studies have examined the possible role of blood pressure (BP), independent of acute rejection and graft function, on outcomes after kidney transplantation. Methods: We investigated the prevalence, treatment, control, and clinical correlates of hypertension and its association with outcomes, using multivariate analyses with timedependent covariates, in a retrospective cohort of 1,666 kidney transplant recipients. Results: Hypertension was common, and its control was poor. For example, at 1 year, only 55.5% had a BP less than 140 mm Hg. Control improved only slightly in 1993-2002 compared to 1976-2002, even as patients administered 2 or more antihypertensive medications at 1 year increased from 43.5% to 54.6%. Independent correlates of higher BP included male sex, age, donor age, diabetes, body mass index, the presence of native kidneys, and delayed graft function. Previous acute rejection was associated with higher BP at virtually all times after transplantation, and these associations were independent of estimated creatinine clearance (C Cr ). Conversely, an association between BP and subsequent acute rejection was not statistically significant when differences in C Cr were taken into account. After adjusting for the effects of acute rejection, C Cr , and other variables, each 10 mm Hg of systolic BP was associated with an increased relative risk for graft failure (1.12; 95% confidence interval, 1.08 to 1.15; P < 0.0001), death-censored graft failure (1.17; 1.12 to 1.22; P < 0.0001), and death (1.18; 1.12 to 1.23; P < 0.0001). Conclusion: High BP is closely tied to graft function, but nevertheless is an independent risk factor for graft failure and mortality. Better strategies are needed to control BP after kidney transplantation. Am J Kidney Dis 43:1071-1081.

Cryptococcosis is the third most common invasive fungal infection in organ transplant recipients after candidiasis and aspergillosis. Reports indicate that cryptococcosis usually presents as symptomatic disease, and despite therapy the mortality remains high. In addition, some data suggest that there might be differences in the incidence and clinical manifestations of cryptococcosis, depending on the specific transplant organ. The incidence of cryptococcosis in our transplant center is significantly higher in heart transplant recipients than in other transplant groups (p Ω0.0001). Although the primary risk factor contributing to cryptococcosis in organ transplant recipients is probably the immunosuppressive therapy used to prevent allograft rejection, environmental factors may also play a role. This is indicated by studies that demonstrate differences in the rate of cryptococcosis according to geographic region. Moreover, data point out differences in the isolation of the fungus from soil samples with higher concentrations of Cryptococcus in areas frequented by birds or contaminated by bird droppings. Therefore, it is prudent to recommend that organ transplant recipients avoid birds or areas contaminated with bird droppings. The current review provides an overview of the changes in the incidence, clinical manifestations, and management of cryptococcosis in organ transplant recipients.

Purpose: Electron beam computed tomography (EBCT) is a relatively new technology that has been used primarily to detect coronary artery calcification in adult patients. EBCT has several potential advantages over traditional CT: (1) fast acquisition times resulting in less need for sedation, (2) decreased radiation exposure, and (3) robust software enabling real-time interactive 3-dimensional visualization of anatomic relationships. In this series of case reports, the authors describe their initial experience with the use of EBCT in pediatric noncardiac imaging.

Although evidence is far from being conclusive, several studies have suggested that infections could trigger rejection in different transplant settings. In this review we examine the evidence linking cytomegalovirus (CMV), adenovirus, enterovirus, parvovirus, and herpes simplex virus infections to the vasculopathy leading to cardiac allograft rejection, the association between CMV and chronic kidney, lung, and liver graft rejection, and the association of human herpesvirus 6 reactivation with CMV-related disease in kidney and liver transplant recipients. We also review the numerous antiviral prophylactic or pre-emptive treatments in use to control CMV infection, and suggest that they do not limit immune reactions leading to graft rejection or lower the risk of developing post-transplantation atherosclerosis in allograft recipients. Finally, we emphasise the need for prospective, international studies to clarify the role of infections in transplant rejection, to look at virus-to-virus interactions, and to establish specific therapeutic strategies. Such strategies must not rely exclusively on expensive antiviral agents but also on vaccination or other, innovative approaches, such as the use of agents able to inhibit the activity of natural killer cells, which might have an important role in acute allograft rejection.

Neutropenic episodes in kidney transplant patients are poorly characterized. In this retrospective study, neutropenia was experienced by 112/395 patients (28%) during the first year posttransplant. The only factor found to be significantly associated with the occurrence of neutropenia was combined tacrolimusmycophenolate therapy (p < 0.001). Neutropenic patients experienced more bacterial infections (43% vs. 32%, p = 0.04). Grade of neutropenia correlated with the global risk of infection. Discontinuation of mycophenolic acid (MPA) due to neutropenia was associated with an increased incidence of acute rejection (odds ratios per day 1.11, 95% confidence intervals 1.02-1.22) but not with reduced renal function at 1 year. The time from onset of neutropenia to MPA discontinuation correlated with the duration of neutropenia. Granulocyte colony-stimulating factor (G-CSF) administration was safe and effective in severely neutropenic kidney graft recipients, with absolute neutrophil count >1000/lL achieved in a mean of 1.5 ± 0.5 days. Neutropenia is an important and frequent laboratory finding that may exert a significant influence on outcomes in kidney transplantation. As well as leading to an increased incidence of infection, it is associated with a higher rate of allograft rejection if MPA is discontinued for >6 days (p = 0.02). G-CSF accelerates recovery of neutropenia and may be a good therapeutic alternative for severely neutropenic patients.