Renal Transplantation in Romania: Where Do We Stand?

INTRODUCTION: According to the Romanian Renal Registry (RRR), only 8% of patients on renal replacement therapy (RRT) in 2012 received a kidney transplant (KTx). As not all transplant centers report to RRR, the outcome of transplanted patients in Romania is not known. Therefore, we aimed to evaluate the outcome in patients grafted in one of the largest transplant center in the country as compared to hemodialysis (HD) and peritoneal dialysis (PD) patients recorded by the RRR. METHOD: In an intention-to-treat analysis using Kaplan-Meier and Cox proportional hazard (CPH) models, survival was compared between 8050 incident HD, 1000 PD and 490 KTx patients treated between 2008 and 2011. The patients were stratified by modality at day 90 of therapy. RESULTS: As compared to HD and PD patients, the KTx recipients were younger, more often of male gender, and had glomerulonephritis as primary renal disease (PRD) more frequently. KTx patients had a higher mean survival time (57.68 [56.95-58.42] months) than HD (45.55 [45.04- 46.06] months) or PD patients (46.33 [45.01-47.65] months). In the multivariate CPH model, higher age (OR=1.03 (1.02-1.03), p<0.01) at RRT initiation, HD (OR=5.60 (3.16-9.94), p<0.01) and PD (OR=5.62 (3.14-10.08), p<0.01) as RRT and diabetic nephropathy (p<0.01) as PRD were associated with a poorer survival. CONCLUSION: The present study is the first to provide representative information about the outcome of the KTx patients in Romania. We found that patient survival after KTx is markedly better than either HD or PD. Urgent implementation of a KTx registry is needed in order to improve the national transplantation program.

Does the KDIGO CKD risk stratification based on GFR and proteinuria predict kidney graft failure?

PURPOSE: The 2012 Kidney Disease: Improving Global Outcomes (KDIGO) guidelines on chronic kidney disease (CKD) introduced risk classes for adverse outcome based on estimated glomerular filtration rate (eGFR) and albuminuria categories (low-LR, moderately-MR, high-HR, very high risk-VHR). We aimed to investigate if such risk stratification is suitable in kidney transplant (KTx) recipients. METHODS: This single-center prospective study enrolled 231 prevalent KTx recipients [36 (34-48) years, 62 % male, eGFR 53.7 (50.9-56.4) mL/min]. The patients were stratified in risk classes in January 2011; clinical and laboratory data were collected every 6 months till June 2013. Individual slope of linear regression of all eGFR and time-averaged proteinuria (TAP) were computed. The composite endpoint was defined as >30 % decline in eGFR from 6 months after KTx to June 2013, dialysis initiation or death. RESULTS: Fifty-one patients reached the endpoint. They were younger, more often female, donor specific anti-HLA antibodies positive, noncompliant and smokers. TAP was 4 time greater (p < 0.0001) and eGFR abruptly declined [eGFR slope: -3.17 (-4.13 to -2.21) vs. 0.81 (0.45-1.3) mL/min per year, p < 0.0001] in the endpoint group. At baseline: 36 % LR, 23 % MR, 23 % HR and 18 % VHR, without differences between the groups. In the binary logistic regression model, VHR as compared to the other risk classes was an independent risk factor for poorer outcome. The final model also included female gender, cardiovascular events, smoking, GFR slope and BK virus infection. CONCLUSIONS: Risk group stratification according to KDIGO guideline on CKD may prove useful in predicting graft outcome, but this should be confirmed in larger cohorts.

Polyomavirus BK-associated nephropathy after kidney transplantation: a single-center retrospective analysis.

BACKGROUND: Polyomavirus BK-associated nephropathy is a challenging and increasingly recognized cause of kidney transplant morbidity and graft failure. Reported prevalence can vary significantly between centers, averaging 5%. PATIENTS AND METHODS: The paper reports the clinical and pathologic findings in five patients with BK virus-induced nephropathy. We performed a retrospective study including adult patients with graft dysfunction admitted to our department between 2010-2013. Clinical and biological data were obtained every month during the follow-up period. The biopsies were performed in case of graft dysfunction. All biopsy specimens were examined in light microscopy, immunofluorescence and electronic microscopy. RESULTS: We studied 44 graft biopsies, and we found typical histological findings of polyoma BK nephropathy in five (11.4%) cases. All patients received immunosuppressive regimen based on calcineurin inhibitors, Mycophenolate Mofetil and Prednisone. Four of them were on Tacrolimus-based protocol and one patient was on Cyclosporine regimen. Age of transplant at diagnosis varied between 2 and 113 months (patient on Cyclosporine). In all cases, the BK virus nephropathy diagnostic was established taking into account histological findings, all patients presenting intranuclear viral inclusions seen on light microscopy and electronic microscopy. During the follow-up period, the renal dysfunction worsened in two of the five patients, one of them evolving towards ESRD, even though we minimized the immunosuppressive treatment and administered intravenous immunoglobulin. CONCLUSIONS: The prognostic for BK virus nephropathy patients is reserved. Histological picture of BK virus nephropathy is similar to the one of graft rejection, differential diagnosis being difficult in the absence of viral inclusions evidence.

Renal transplantation--substitution therapy in advanced stage uremia.

Advanced stage chronic renal failure (CRF) uremia represents one of the most severe metabolic "catastrophes" of the organism. The current therapeutic possibilities consist in: hemodialysis, peritoneal dialysis and renal transplantation. This paper presents the experience of the Urological Surgery, Dialysis and Renal Transplantation Center of the "Fundcni" Clinical Institute in renal transplantation, the single complete morphological and functional therapeutic option in CRF. During the last 10 years, renal transplantations with kidneys from brain dead donors (multiorgan harvesting) to an adult (1997), a child (1999), a diabetic recipient (1998) and an unephric child due to bilateral Wilms' tumor (2005) were performed at "Fundeni" Renal Transplantation Center as a national première. The immunosuppression protocols are complex, modern and adapted to the immunological risk. A number of 870 renal transplantations with 82% functionality rate of the grati at 10 years were performed and reported. Among these, 152 transplants were performed using kidneys harvested from brain dead donors. Owing to obtained results (60% of all transplanted and functional orgmans in Romania on December 2007) and to its achieved performances, the Fundeni Center represents a reference point on the European map of renal transplant.