Assessment of Kidney Graft Function Evolution Measured by Creatinine and Cystatin C.

INTRODUCTION: The 2013 Kidney Disease Outcomes Quality Initiative Clinical Practice Guideline suggests measuring cystatin C (sCys) in adults with glomerular filtration rate (GFR) based on creatinine (sCr) between 45 and 59 mL/min/1.73 m2 if confirmation of chronic kidney disease (CKD) is required. There is not enough evidence to recommend the use of sCys or sCr to estimate GFR in kidney transplant recipients. OBJECTIVES: Our aims were to describe the evolution of sCr, sCys, and GFR in a group of kidney transplant patients and to determine their association with some markers of morbidity at 1 year. METHODS: A total of 54 patients were included. Analytical and clinical data were recorded. Renal function was analyzed using the CKD Epidemiology Collaboration (EPI) sCr equation and CKD-EPI sCys equation. RESULTS: sCys-estimated GFR was higher than estimated from sCr by CKD-EPI. The values of sCys have more variability than those of sCr. The agreement between the stages of CKD by sCr or sCys-estimated GFR measured by Cohen's kappa coefficient was only fair. One-year CKD-associated variables correlated differently with sCr and sCys-estimated GFR. Hemoglobin, uric acid, calcium, and phosphorus related to sCr-estimated GFR, whereas serum albumin was associated with sCys-estimated GFR. CONCLUSIONS: sCys values have a higher variability than sCr in kidney transplant recipients. sCys- or sCr-based GFRs have a nonsimilar behavior in these patients with weak agreement to stratify CKD stages and a different relationship to CKD-related comorbid conditions.

Carbapenem-resistant Enterobacteriaceae rectal screening during an outbreak of New Delhi metallo-ß-lactamase-producing Klebsiella pneumoniae at an acute care hospital.

We describe the results of carbapenem-resistant Enterobacteriaceae (CRE) screening as part of an outbreak investigation of New Delhi metallo-ß-lactamase-producing CRE at a tertiary care university teaching hospital. The manual method for CRE screening was useful for detecting patients with asymptomatic CRE carriage but was time-consuming and costly.

[Cost-benefit analysis of a population-based cervical cancer screening program designed for Cantabria]. / Análisis coste-beneficio de un programa poblacional de diagnóstico precoz de cáncer de cuello uterino diseñado para Cantabria.

INTRODUCTION: Cervical cancer is the second most common cancer worldwide in women, with an annual mortality of 3.6 per 100.000 women in Spain. An opportunistic screening protocol is currently being developed in Cantabria. The objective of the study is to propose a population-based screening program in Cantabria and assess its cost-benefits. PATIENTS AND METHODS: The population-based program design has been carried out according to the description of the natural course of cervical cancer and its incidence and mortality in Cantabria during 2000-2009. There have been some proposals to increase participation in the program and to evaluate its quality. Costs and benefits (direct and indirect) have been analyzed in several scenarios by modifying the frequency of tests (3-5 years), the age at which the program can be accessed (21, 25 or 30 years), the coverage of the program (60-80%), and discount rates (0-3-6%). RESULTS: A program carried out with coverage of 80% and tests performed every 3 years generates annual costs of €893.000 (discount rate of 3%) compared to the current opportunistic protocol. Scenarios with tests performed every 5 years generate an annual benefit higher than €618.000, depending on the age of accessing the program. CONCLUSIONS: Scenarios with coverage lower than 60% or with women over 30 years old having access to the program are not of interest because of the lower health benefits. However, performing tests every 5 years is more economically advantageous than every 3 years, with similar health benefits.

Relation of urinary gene expression of epithelial-mesenchymal transition markers with initial events and 1-year kidney graft function.

INTRODUCTION: Renal dysfunction due to acute rejection (AR), acute tubular necrosis, or calcineurin inhibitors toxicity is related to development of interstitial fibrosis/tubular atrophy (IF/TA) and graft survival. Determination of serum creatinine (sCr) displays poor sensitivity as a marker for early detection of graft dysfunction. Kidney biopsy is an accurate but invasive procedure for the diagnosis. The levels of urinary mRNA of genes that regulate epithelial-mesenchymal transition (EMT) can reflect early damage and detect the development of IF/TA. Repeated studies of these genes can provide noninvasive information about the evolution of the graft, facilitating early diagnosis and treatment. OBJECTIVE: To analyze the relationships between early and 1-year graft evolution in relation to gene expression of EMT biomarkers. METHODS: Seventy-one kidney transplant recipients were monitored during 1 year recording analytical, clinical, and histological (if available) data. We determined RNA gene expression of EMT, angiotensinogen, E-cadherin, N-cadherin, transforming growth factor (TGF) beta and bone morphogenetic patients 7 (BMP7). RESULTS: At 3 months, angiotensinogen (mean [standard deviation]), (2.42 [.66] versus 8.58 [3.24]; P = .017) and N-cadherin (0.59 [0.26] versus 3.15 [1.35]; P = .016) discriminate a good evolution from AR episodes BMP-7 discriminated a good evolution versus AR (0.72 [0.29] versus 4.53 [2.23]; P = .006) and delayed graft function versus AR (1.14 [0.79] versus 4.53 [2.23]; P = .049). After 1 year, the ratio TGF-beta/BMP7 discriminated patients with an sCr > 1.5 mg/dL (6614.6 [1063.6] versus 3378.7 [1019]; P = .034). There was a positive correlation between urinary and tissue TGF-beta [r = 59; P = .003]. CONCLUSION: The expression of studied genes reverting EMT at 3 months postransplantation showed differences in initial graft evolution. At 1 year, the TGF-beta/BMP7 ratio suggested activation of EMT, possible early marker of renal dysfunction.

Analysis of urinary gene expression of epithelial-mesenchymal transition markers in kidney transplant recipients.

INTRODUCTION: Renal graft dysfunction due to acute rejection, acute tubular necrosis, or anticalcineurin toxicity with development of interstitial fibrosis or tubular atrophy are the primary causes of graft failure. Determination of kidney function using the serum creatinine concentration demonstrates low sensitivity as a marker for the diagnosis, and kidney biopsy is an invasive procedure. The levels of urinary messenger RNA of genes that regulate epithelial-mesenchymal transition (EMT) can reflect early kidney damage. Thus, repeated transcriptome studies of these genes can provide information about the evolution of the graft, and possibly enable early diagnosis and treatment. OBJECTIVE: To analyze the temporal relationships between early graft evolution and gene expression of EMT biomarkers. METHODS: Of 70 kidney transplant procedures performed between January 1, 2007 and December 31, 2008, 42 were analyzed prospectively for 3 months. Analytical and clinical data were recorded, as well as histologic findings if available. Urine mRNA extraction was performed using a commercially available kit. RNA gene expression of EMT, angiotensinogen, epidermal growth factor receptor, E-cadherin, N-cadherin, transforming growth factor-ß, and bone morphogenetic protein 7 was determined at real-time quantitative polymerase chain reaction. ß2-Microglobulin was used as a reference gene. RESULTS: At 75 days posttransplantation, analysis revealed that angiotensinogen (mean [SD], 2.91 [0.70] vs 6.04 [1.24]; P=.04) and N-cadherin (1.01 [0.43] vs 4.31 [0.92]; P=.01) discriminate good evolution from acute rejection. Epidermal growth factor receptor (2.78 [0.66] vs 6.02 [1.09]; P=.33) and bone morphogenetic protein 7 (0.85 [0.33] vs 3.07 [1.37]; P=.04) discriminate good evolution vs delayed graft function. CONCLUSION: Differential gene expression at 75 days posttransplantation reflects differences related to initial histologic damage. This observation encourages design of a long-term longitudinal analysis with multiple markers to obtain early diagnosis and forecast the prognosis of graft dysfunction.

Pulmonary zygomycosis in solid organ transplant recipients in the current era.

Fifty-eight solid organ transplant recipients with zygomycosis were studied to assess the presentation, radiographic characteristics, risks for extra-pulmonary dissemination and mortality of pulmonary zygomycosis. Pulmonary zygomycosis was documented in 31 patients (53%) and developed a median of 5.5 months (interquartile range, 2-11 months) posttransplantation. In all, 74.2% (23/31) of the patients had zygomycosis limited to the lungs and 25.8% (8/31) had lung disease as part of disseminated zygomycosis; cutaneous/soft tissue (50%, 4/8) was the most common site of dissemination. Pulmonary disease presented most frequently as consolidation/mass lesions (29.0%), nodules (25.8%) and cavities (22.6%). Patients with disseminated disease were more likely to have Mycocladus corymbifer as the causative pathogen. The mortality rate at 90 days after the treatment was 45.2%. In summary, pulmonary zygomycosis is the most common manifestation in solid organ transplant recipients with zygomycosis, and disseminated disease often involves the cutaneous/soft tissue sites but not the brain.

Vitamin K deficiency in children pre-bone marrow transplantation.

This study examined the prevalence of vitamin K deficiency in children pre-bone marrow transplantation (BMT). Vitamin K status was measured by the PIVKA-II assay and prothrombin times. Blood samples were obtained before vitamin-containing TPN was infused. Results indicated that eight of 26 patients (31%) were vitamin K deficient; four cases were attributed to drug antagonism (phenytoin) and four were due to inadequate vitamin K intake, synthesis or malabsorption. Only one patient had a prolonged prothrombin time. Prothrombin time, in our study, is shown to be an ineffective screening tool to determine vitamin K status. All patients receiving phenytoin and chemotherapy are at increased risk of vitamin K deficiency.

Invasive mycotic infections caused by Chaetomium perlucidum, a new agent of cerebral phaeohyphomycosis.

We report the first two cases of invasive human mycoses caused by the phaeoid ascomycete, Chaetomium perlucidum, and review the English literature regarding invasive Chaetomium infections. Fatal disseminated disease involving the brain, heart, lungs, and spleen is described in an acute myelogenous leukemia patient. A second patient with a history of asthma and chronic bronchiectasis experiencing right-middle-lobe syndrome grew C. perlucidum from lung tissue. This study adds C. perlucidum to the list of other known neurotropic Chaetomium species, C. atrobrunneum and C. strumarium, and also documents this organism's ability to disseminate beyond the central nervous system.

Efficacy and safety of radiologically placed gastrostomy tubes in paediatric haematology/oncology patients.

BACKGROUND: The treatment of malnutrition, which is of great concern in paediatric haematology/oncology patients, is fraught with problems. The goals of our study were to document the complications and assess the weight gain with gastrostomy tubes (G-tubes) in this population. PROCEDURE: Patient data were acquired by retrospective review of all haematology, oncology, and bone marrow transplant (BMT) patients (n = 44) who received radiologically placed G-tubes at our institution over a 4-year period. RESULTS: Forty-four G-tubes were placed (59% peri-BMT). At tube placement, 55% of patients were malnourished and 45% were nourished. Seventy-five percent of patients had the procedure without general anaesthetic. Localized G-tube-site infection was the most common complication (41%). Major complications occurred in 3 patients; 2 patients experienced localized peritonitis, and 1 patient developed a localized collection of pus in the abdominal wall. There were no G-tube-related deaths. At 1 month after the tube insertion, 39% of patients had gained, 54% maintained, and 7% lost weight. At 3 months, 69% had gained, 28% maintained, and 3% lost weight. There was a statistically significant weight gain from the time of the G-tube placement to both 1 month (P < 0.018) and 3 months (P < 0.0001) after G-tube placement. Patients in all diagnosis categories showed improvement from 1 to 3 months. CONCLUSIONS: We conclude that retrograde tube placement is safe and can frequently be done without general anaesthetic and that G-tube feeding effectively reverses malnutrition and prevents weight loss in this patient population.