[COVID-19 Pandemic: Impact and rapid reaction of Urology]. / Pandemia COVID-19: impacto y reacción rápida de la Urología.

The COVID-19 pandemic caused by the SARS-CoV-2 virus has caused tens of thousands of deaths in Spain and has managed to breakdown the healthcare system hospitals in the Community of Madrid, largely due to its tendency to cause severe pneumonia, requiring ventilatory support. This fact has caused our center to collapse, with 130% of its beds occupied by COVID-19 patients, thus causing the absolute cessation of activity of the urology service, the practical disappearance of resident training programs, and the incorporation of a good part of the urology staff into the group of medical personnel attending these patients. In order to recover from this extraordinary level of suspended activity, we will be obliged to prioritize pathologies based on purely clinical criteria, for which tables including the relevance of each pathology within each area of urology are being proposed. Technology tools such as online training courses or surgical simulators may be convenient for the necessary reestablishment of resident education.

[COVID-19 Pandemic: Impact and rapid reaction of Urology]. / Pandemia COVID-19: impacto y reacción rápida de la Urología.

The COVID-19 pandemic caused by the SARS-CoV-2 virus has caused tens of thousands of deaths in Spain and has managed to breakdown the healthcare system hospitals in the Community of Madrid, largely due to its tendency to cause severe pneumonia, requiring ventilatory support. This fact has caused our center to collapse, with 130% of its beds occupied by COVID-19 patients, thus causing the absolute cessation of activity of the urology service, the practical disappearance of resident training programs, and the incorporation of a good part of the urology staff into the group of medical personnel attending these patients. In order to recover from this extraordinary level of suspended activity, we will be obliged to prioritize pathologies based on purely clinical criteria, for which tables including the relevance of each pathology within each area of urology are being proposed. Technology tools such as online training courses or surgical simulators may be convenient for the necessary reestablishment of resident education.

Cost analysis of surgical treatment for pelvic organ prolapse by laparoscopic sacrocolpopexy or transvaginal mesh. / Análisis de costes del tratamiento del prolapso de órganos pélvicos mediante colposacropexia laparoscópica o malla transvaginal.

OBJECTIVES: The objective of this study is to compare direct costs of repairing pelvic organ prolapse by laparoscopic sacrocolpopexy (LS) against vaginal mesh (VM). Our hypothesis is the correction of pelvic organ prolapse by LS has a similar cost per procedure compared to VM. MATERIAL AND METHODS: We made a retrospective comparative analysis of medium cost per procedure of first 69 consecutive LS versus first 69 consecutive VM surgeries. We calculate direct cost for each procedure: structural outlays, personal, operating room occupation, hospital stay, perishable or inventory material and prosthetic material. Medium cost per procedure were calculated for each group, with a 95% confidence interval. RESULTS: LS group has a higher cost related to a longer length of surgery, higher operating room occupation and anesthesia; VM group has a higher cost due to longer hospital stay and more expensive prosthetic material. Globally, LS has a lower medium cost per procedure in comparison to VM (5,985.7 €±1,550.8 € vs. 6,534.3 €±1,015.5 €), although it did not achieve statistical signification. CONCLUSIONS: In our midst, pelvic organ prolapse surgical correction by LS has at least similar cost per procedure compared to VM.

Resistance index determination in the pre and post kidney transplantation time points in graft dysfunction diagnosis.

BACKGROUND: Donor shortage necessitates the development of tools capable of objectively assessing kidney graft quality from expanded criteria donors and kidneys donated after cardiac death. The deteriorating donor profile is leading to a shift from cold storage toward machine perfusion preservation. Several authors found that renal resistance (RR) at the end of machine perfusion was an independent risk factor for the development of delayed graft function (DGF). In contrast, Doppler ultrasonography in the posttransplant period reveals renal hemodynamics and is useful in diagnosing renal allograft dysfunction. We sought to determine concordance between RR and the resistance index (RI) and their diagnostic value in the assessment of graft viability. METHODS: RR was determined at the end of perfusion during hypothermic machine preservation and RI was measured by Doppler ultrasonography in the early posttransplant period. Agreement between these 2 measures was established by means of the intraclass correlation coefficient (ICC). Diagnostic validity for RR and RI was determined by sensitivity, specificity and positive and negative predictive values. RESULTS: The ICC was 0.135, which indicates a slight agreement. RR and RI had limited value in the prediction of DGF for a specific kidney as reflected by a c-statistic of 0.58 and 0.66, respectively. CONCLUSIONS: There is no agreement between the RR and RI, which may be owing to the different conditions under which measurements are made. The poor predictive power of RR for DGF indicates that kidneys should not be discarded based on RR criteria alone.

Cost-effectiveness analysis of main diagnosis tools in women with overactive bladder. Clinical history, micturition diary and urodynamic study.

OBJECTIVES: The aim of the present clinical research is to analyze, in the light of the best scientific evidence, the performance and the cost of the main diagnostic tools for overactive bladder (OAB). METHODS: It is an exploratory transversal study in which 199 women diagnosed of OAB between 2006 and 2008 were selected and underwent to following prospective analyses: physical examination, urine analysis, micturition diary (MD) and urodynamic study (UDS). A percentage of 80% was assumed as highly sensitive and a diagnostic difference among tests of 10% would be considered clinically relevant. Tests' sensitivity for diagnosis of OAB was statistically established by two ways: isolated and combined. Besides, the direct and indirect costs of these tests performance were conducted. Cost-effectiveness study of clinical history (CH), MD and US for the diagnosis of OAB was performed. RESULTS: Overall sensitivity for OAB diagnosis is low for the 3 tests used in isolated way, whilst the combination of any two tests shows good overall sensitivity. The combination of CH and MD has appeared as the most cost-effective alternative to OAB diagnosis. CONCLUSIONS: For OAB diagnosis, CH-DM combination shows the same sensitivity than the association of either of them with the UDS, but unlike to these, it shows the lowest cost.

Development of urologic de novo malignancies after renal transplantation.

OBJECTIVES: The incidence of neoplasms in renal transplant recipients is higher than in general population. The increasing age of donors and recipients also increases the risk of developing malignancies, including genitourinary. The aim of this study is to analyze clinical aspects and management of this complication. MATERIALS AND METHODS: We conducted a retrospective analysis of 1365 patients who underwent renal transplantation between 1977 and 2010 who were 44.6 ± 14.9 years old at the time of transplantation. The median follow-up was 95.6 months (range, 18.0-236.0). Data were analyzed for sex, age, time from transplant to diagnosis, location, clinical stage, immunosuppression, treatment, follow-up, and evolution. RESULTS: We diagnosed 25 de novo urologic neoplasms (25/1365; 1.8%) in 24 patients, with a median follow-up of 32 months (range, 12.5-51.8) from the diagnosis. Sixteen were male (66.7%) and 8 female (33.3%), with a median age at diagnosis of 59 years (range, 56.0-65.5). The median time between the transplant and the diagnosis of the malignancy was 69 months (range, 40.0-116.5). There were 11 renal cell carcinomas (RCC; 11/25; 44%), 8 in native kidney and 3 in renal allograft; 9 prostate cancers (PCa; 9/25; 36%), 8 localized and 1 metastatic; and 5 transitional cell carcinomas (TCC; 5/25; 20%), 3 in bladder and 2 in renal allograft pelvis. Treatments performed were similar to those used in the nontransplanted population. RCC were treated with radical nephrectomy when affecting the native kidney, partial nephrectomy when affecting the allograft, or immunotherapy when metastatic. Patients with localized PCa were treated with radical prostatectomy, radiotherapy, or androgenic deprivation if there were comorbidities, and those metastatic with hormonal deprivation. Bladder TCCs were treated with transurethral resection or radical cystectomy. Pelvis TCCs affecting the allograft were treated with radical nephroureterectomy of the allograft including bladder cuff and pelvic lymphadenectomy. CONCLUSIONS: There exists an increased incidence of urologic tumors in kidney transplant recipients. Conventional treatments of these tumors are technically feasible. The risk of developing these tumors remains even in the long term. Because of their suitability for curative treatments, it is advisable to perform periodic screening for urologic cancers to achieve an early diagnosis.

Renal transplantation in HIV-infected patients: experience at a tertiary hospital in Spain and review of the literature.

BACKGROUND: The use of highly active antiretroviral therapy (HAART) has decreased the morbidity and mortality in HIV-infected patients. The kidney transplantation (KT) survival rate is similar to that of HIV-negative transplant recipients. The consensus criteria for the selection of HIV patients for transplantation include: no opportunistic infections, CD4 lymphocyte count greater than 200 cells/µL, and an undetectable viral load. In Spain, HIV-infected patients present with different characteristics compared to American recipients; this could influence posttransplantation outcomes. OBJECTIVE: This study analyzed the outcome and the clinical characteristics of HIV-infected patients who received KT in Spain in the HAART era. METHODS: We retrospectively reviewed the clinical charts of seven adult HIV-infected recipients of primary renal allografts between January 2001 and June 2012. Patient inclusion criteria met the American and Spanish guidelines. The immunosuppressive protocol consisted of tacrolimus, mycophenolate mofetil, and steroids. RESULTS: The median age was 44.8 years (interquartile amplitude = 9.4). The predominant mode of transmission was intravenous drug use (71.4%) and hepatitis C virus coinfection (71.4%). The most frequent cause of end-stage renal disease was glomerulonephritis (57.1%). Six patients (85.7%) were on HAART. All patients had controlled HIV infections with undetectable viral load and a median CD4 lymphocyte count of 504 cells/µL (IQA 599). Patients were followed for a median of 16.0 months (range, 3.0 to 96.6 months). Delayed graft function and acute rejection rates were 60% and 40%, respectively. The median creatinine level at the last follow-up was 1.58 mg/dL (IQA 1.15). In one case, a high-grade Epstein-Barr virus-related B cell lymphoma was diagnosed at 83 months after renal transplantation. CONCLUSIONS: Kidney transplantation in HIV-infected patients is a safe, effective treatment for selected patients. Midterm graft survival was comparable to that of HIV-negative patients.

Economic impact of the introduction of machine perfusion preservation in a kidney transplantation program in the expanded donor era: cost-effectiveness assessment.

BACKGROUND: Kidney transplantations (KT) from expanded criteria donors (ECD) show a higher rate of delayed graft function (DGF) that increases postoperative costs because of the prolonged hospital stay as well as the needs for dialysis and additional diagnostic procedures. Hypothermic machine perfusion (MP) might be superior to cold storage (CS) to reduce the relative risks of DGF and primary nonfunction (PNF) as well as to increase 1-year graft survival. OBJECTIVE: The aim of the study was to determine the relative cost-effectiveness of two different storage methods: MP versus CS. METHODS: A probabilistic decision tree was developed to compare MP and CS as graft preservation methods. The structure of the model was populated by review of the literature and outcomes of KT from ECD in our center. The model estimated budget impact and incremental cost-effectiveness ratio in terms of DGF and PNF cases. The cost comparison of methods for KT preservation included: hospitalization and intermediate care unit stay; post-KT dialysis; graft removal; immunosuppressive regimen; treatment of acute rejection episodes; as well as costs of preservation solutions and pulsatile preservation device or storage containers. RESULTS: Resource consumption for CS stratified by graft function varied from $8,159 for immediate graft function (IGF) recipients to $10,865 for DGF recipients to $25,933 for PNF recipients. Meanwhile, resource consumption for MP varied from $9,522 for IGF to $12,228 for DGF to $27,297 for PNF recipients. The main components of resource consumption were hospitalization stay (41.5%-53.9%); graft explantation (20.2%), and the need for dialysis (16.0%). The budget impact per patient for the introduction of MP was $505. However, the incremental cost-effectiveness ratio was $3,369 for each DGF- or PNF- saved case. CONCLUSIONS: The introduction of the MP preservation technology in a KT program form ECD is cost-effective in terms of savings for DGF and PNF cases.

The effects of mineral metabolism markers on renal transplant outcomes.

BACKGROUND: Hyperparathyroidism is a common complication of chronic renal failure. A functioning kidney graft improves hyperparathyroidism but it can persist to some degree for years. Persistent hyperparathyroidism associated with hypercalcemia and hyperphosphatemia have been associated with poor graft and patient survivals. The purpose of the present work was to assess the association between calcium/phosphate mineral metabolism markers and graft outcomes. PATIENTS AND METHODS: Among 389 renal transplantations performed in our center between January 2000 and June 2008, 331 patients had functioning grafts at 12 months, the subjects of this study. Measurements of intact parathyroid hormone (iPTH), serum calcium and phosphate, tubular phosphate reabsorption, and urinary calcium excretion were performed at 1, 3, 6, and 12 months. The mean follow-up was 84.0 ± 31.8 months. RESULTS: During the follow-up period, 63 grafts (19.0%) were lost, 30 patients (9.0%) died, and 80 recipients (24.2%) presented at least one cardiovascular event. Univariate Cox proportional analysis showed high iPTH levels at 1 and 12 months after transplantation to not be associated with worse patient or graft survival or an higher risk of cardiovascular events. Serum phosphate and calcium concentrations as well as calcium-phosphate products during the first year after transplantation were not associated with graft and patient outcomes or cardiovascular events. However, serum calcium at 12 months showed an inverse association with graft survival after adjusting for other variables (hazard ratio 0.61; 95% confidence interval 0.40-0.94; P = .026). CONCLUSIONS: iPTH levels and serum phosphate concentrations and calcium-phosphate products during the first year after transplantation were not associated with graft outcomes. The inverse association between adjusted calcium and graft survival should be studied further.

Anemia at 1 year after kidney transplantation has a negative long-term impact on graft and patient outcomes.

BACKGROUND: Anemia, a common complication after kidney transplantation, has a controversial impact on graft or patient survivals or the appearance of cardiovascular disease. The present study investigated the incidence and risk factors for anemia in the first year after transplantation and its effects on graft and patient outcomes. PATIENTS AND METHODS: Among 389 patients transplanted between January 2000 and June 2008, the 331 with functioning grafts at 1 year were included in the study. The mean follow-up was 84 ± 31.8 months. Anemia was defined according to the World Health Organization as a hemoglobin < 13 g/dL in men and < 12 g/dL in women. RESULTS: The 88 patients (26.6%) with anemia included 21 (6.3%) who were receiving erythropoiesis stimulant agents. The predictive factors for anemia were: initial immunosuppression with cyclosporine (odds ratio [OR] 2.08, 95% confidence interval [CI] 1.25-3.47; P = .005), serum creatinine (mg/dL) at discharge (OR 1.7; CI 95% 1.26-2.15 P = .000), and 1-year serum albumin (g/dL; OR 0.21; CI 95% 0.10-0.71 P = .001). Donor age in years (OR 1.02; CI 95% 1.00-1.03, P = .054) was close to significance. Cox multivariate analysis showed 1-year hemoglobin (g/dL) to be associated with graft (hazard ratio [HR] 0.81, 95% CI 0.69-0.96, P = .003) and patient survivals after adjusting for other variables (HR 0.74; 95% CI 0-59-0.96, P = .023). But it was only a cardiovascular risk factor when serum creatinine was not included in the model. CONCLUSIONS: Approximately one quarter of patients with functioning grafts show anemia at 1-year. Graft function, initial immunosuppression, serum albumin, and perhaps donor age were risk factors for anemia, which had a negative impact on graft and patient survival, and could be a risk factor for cardiovascular disease.

Utilization of elderly kidney donors (>70 years) does not affect graft survival in the medium term.

BACKGROUND: The need for organs for renal transplantation has encouraged the use of grafts from increasingly older donors. Earlier studies performed in Spain have shown the suitability of donors aged 60-65 years. In this single-center study, we evaluated our results using donors >70 years old. METHODS: We evaluated 401 primary transplantations performed from January 2000 to December 2009. Their initial immunosuppression was a tacrolimus-based (n = 324), cyclosporine-based (n = 70) or calcineurin inhibitor-free (n = 7) regimen patients. Recipients were classified according to the donors age: <50 (42.6%); 50-70 (39.7%) and >70 (17.5%) years. RESULTS: There were no differences in recipient or donor gender, time on dialysis, cold ischemia, delayed graft function, or acute rejection episodes. However, the mean age was higher among patients who received grafts from donors >70 years old; 42.5 ± 12.4 years for <50, 58.1 ± 8.2 years for 50-70, and 65.7 ± 7.2 years for >70; (P = .000). The serum creatinine at 12 months was increased according to the age of the donor; 1.4 ± 0.6, 1.8 ± 0.6, 70 and 1.7 ± 0.5 mg/dL, respectively (P = .001). The graft survival rates at 5 years were 81%, 74%, and 70%, respectively (P = .519). Upon multivariate analysis only HLA-DR mismatches, delayed graft function, and acute rejection episodes were associated with graft loss. Patient survival rates (86%) at 5 years were similar among recipients from donors aged 50-70 and >70 years, but higher (96%) for those who received a graft from a donor <50 years (P = .003). CONCLUSIONS: Nearly 20% of donors were >70 years old in our study. Their kidneys displayed excellent short-term outcomes.

Cholecalciferol supplements improve vitamin D deficiency in renal transplant recipients.

Most renal transplant recipients display vitamin D deficiency or insufficiency. The KDIGO guidelines suggest that this deficit should be treated as in the general population. Since there are few studies about the effects of cholecalciferol in de novo renal transplant recipients, we sought to assess these effects in long-term kidney graft recipients. Among 37 renal transplant recipients (19 males, 18 females) at a mean of 105±82 months posttransplantation, vitamin D insufficiency or deficiency was treated with cholecalciferol (400-800 IU/d) plus calcium supplements (600-1200 mg/d of elemental calcium). These subjects were compared with 37 untreated recipients for a period between 6 and 12 months. At baseline, there were no differences between the groups in age at transplantation, sex, length of follow-up after grafting, function measured by estimated glomerular filtration rate (44.4±16.8 treated vs 42.0±15.0 mL/min/1.73 m2 untreated; P=.527); iPTH (157±103 treated vs 176±118 pg/mL untreated; P=.461); 25OHD (14.7±4.7 treated vs 15.7±9.7 ng/mL untreated; P=.584); or 1.25OHD (34.1±26.0 treated vs 34.0±13.0 pg/mL untreated; P=.950). When compared with baseline values, iPTH (157±103 vs 144±89 pg/mL; P=.11) and 1.25OHD levels at 6 months (34.1±26.0 vs 35.9±26.3 pg/mL; P=.282) showed no change but 25OHD levels (14.7±4.7 vs 22.6±7.4 ng/mL; P=.000) and phosphate tubular reabsorption (64%±17% baseline vs 69%±14% at 6 months; P=.030) were increased in the treated patients. There were no differences in the parameters studied in untreated patients. Among the 27 recipients followed at 12 months, iPTH was decreased compared with baseline values (157±103 vs 124±62 pg/mL; P=.024) and 25OHD remained stable with respect to the values at 6 months (21.1±5.3 ng/mL). No adverse effects of cholecalciferol were observed such as those to increase urinary calcium excretion. Low doses of cholecalciferol improved vitamin D status and decreased iPTH levels at 12 months. Higher doses than those used in our study are needed to increase serum 25OHD concentrations above 30 ng/mL.

Effects of the new immunosuppressive agents on the occurrence of malignancies after renal transplantation.

INTRODUCTION: The risk of malignancies in renal transplant recipients is considerably greater than in the general population. The purpose of the present study was to investigate the effects on the appearance of malignancies of 3 immunosuppressive periods: azathioprine (AZA), cyclosporine (CsA), and tacrolimus (TAC). PATIENTS AND METHODS: This study included 1029 first renal transplant recipients of mean age at transplantation of 44.6±14.9 years with a mean follow-up of 95.6±84.2 months. Initial immunosuppression was AZA-based (n=198), CsA-based (n=524), and TAC (n=307). A total of 280 recipients were also treated with mycophenolate mofetil or mycophenolic acid. RESULTS: There were 157 patients (15.3%) who displayed≥1 malignancy; there were 95 skin (9.2%) and 74 (7.8%) non-skin malignancies with presentations at 74±62 and 107±77 months, respectively (P=.003). The skin malignancies included squamous cell carcinomas (n=41), basal cell carcinomas (n=41), Kaposi sarcomas (n=7), and melanomas (n=4). Among the solid tumors, lymphoproliferative disorders (n=15), digestive tract (n=14), kidney and urinary tract (n=11), lung (n=10), and breast (n=3) carcinomas. The cumulative incidences at 5, 10, and 15 years were 6%, 10%, and 18% for skin and 3%, 7%, and 14% for non-skin malignancies, respectively. Multivariate analysis showed that age at transplant in years (P=.000) and male gender (P=.000) were the only variables associated with skin malignancies; age at transplant in years (P=.004) and treatment with OKT3 (P=.000) were associated with non-skin malignancies. Malignancies were the cause of death in 18% of recipients who died with functioning grafts. CONCLUSION: Malignancies are an important cause of morbidity and mortality among renal transplant recipients. The new immunosuppressive agents do not increase the risk of malignancies. Special surveillance is needed for older, male recipients.

Evolution of rejection rates and kidney graft survival: a historical analysis.

INTRODUCTION: New immunosuppressive regimens have dramatically reduced rejection rates but this positive effect has not been followed by an improvement in long-term graft outcomes. The aim of the present work was to investigate the incidence of graft rejection and graft outcomes with various immunosuppressive protocols. PATIENTS AND METHODS: Included in our study were 1029 first renal transplantations performed at our unit between November 1979 and December 2007. Basal immunosuppression included azathioprine (AZA) in 198 recipients, cyclosporine (CsA) in 524 recipients, and tacrolimus (TAC) in 307 recipients. RESULTS: Recipient and donor ages increased progressively from the AZA to the TAC era. Delayed graft function was less frequent among AZA than CsA and TAC recipients (29.8 vs 39.3% vs 42.0%; P = .014). The incidence of acute rejection episodes was 68.7% on AZA, 38.2% on CsA, and 11.4% on TAC (P = .000). Graft survival rates at 1, 5, and 10 years were 69%, 56%, and 46% on AZA, 82%, 69%, and 54% on CsA, and 88%, 77%, and 60% on TAC, respectively (P = .001). However, the differences disappeared when only grafts surviving >12 months were analyzed. On multivariate analysis, the variables associated with worse graft outcomes after 12 months were older recipient age, male gender, longer time on dialysis, lower body weight, and higher serum creatinine level at 6 months. CONCLUSIONS: New immunosuppressants have decreased the incidence of acute rejection. But this was not followed by a significant improvement in graft outcomes after 12 months. The beneficial effects on rejection are possibly affected by the older age of donor and recipient and the worse early graft function.

Vitamin D deficiency in kidney transplant recipients: risk factors and effects of vitamin D3 supplements.

INTRODUCTION: The Kidney Disease Outcome Quality Initiative (K/DOQI) clinical practice guidelines in chronic kidney disease (CKD) give some recommendations about diagnosis and treatment of vitamin D deficiency. These guidelines may also be applied to renal transplant recipients. The aim of the present study was to assess the vitamin D status and the effects of vitamin D3 supplements among a cohort of kidney graft recipients. PATIENTS AND METHODS: Five hundred nine renal transplant recipients with a follow-up of more than 12 months were included in this retrospective cross-sectional study. A total of 189 patients were treated with vitamin D3 supplements, 171 with calcitriol (0.25 or 0.5 microg x 3 weekly) and 18 with cholecalciferol (400 IU/d). RESULTS: 25OHD deficiency was present in 38.3% of patients, insufficiency in 46.9%, and normal levels in 14.7%. There were no differences in the prevalence of deficiency or insufficiency between patients who were not treated or those who were treated with vitamin D3 supplements. Upon multivariate analysis, 25OHD concentrations correlated with gender, length of follow-up, season of 25OHD determination, iPTH and 1.25OHD concentrations, and treatment with ACEI/ARB (R(2) = 0.17; P = .000). CONCLUSIONS: 25OHD deficiency or insufficiency is frequent after renal transplantation even in sunny regions. The clinical significance of such a high prevalence of apparent 25OHD deficiency/insufficiency is unclear and requires further study.

Secondary hyperparathyroidism after kidney transplantation: a cross-sectional study.

INTRODUCTION: The purpose of the present study was to investigate the prevalence of hyperparathyroidism among a population of kidney graft recipients. PATIENTS AND METHODS: We investigated biochemical bone parameters of 509 renal transplant recipients with a mean follow-up of 113 +/- 76 months. Among these patients, 257 patients were treated with either vitamin D or calcium supplements or both. RESULTS: The mean estimated glomerular filtration rate (eGFR) was 47.2 +/- 18.4 mL/min/1.73 m(2) and the mean intact parathyroid hormone (iPTH) level was 144 +/- 149 pg/mL. A total of 70 patients (13.7%) had hypercalcemia defined by a corrected serum calcium >10.2 mg/dL. When the patients were classified according to iPTH concentrations following the Kidney Disease Outcome Quality Initiative (K/DOQI) clinical practice guidelines: 22.4% had iPTH <70 pg/mL; 30.8% between 70 and 110 pg/mL; 16.5% between 110 and 150 pg/mL; 24.3% between 150 and 300 pg/mL; and 6.9% >300 pg/mL. There were no differences in biochemical bone parameters between those that were or were not on calcium and vitamin D supplements, but there was a higher percentage of patients with normal iPTH among the treated group (28.0% vs 16.7%; P = 0.003). In patients not receiving calcium and/or vitamin D supplements, multiple linear regression demonstrated that only time on dialysis, eGFR, and serum 25-hydroxyvitamin D (25OHD) levels were significantly predictive of iPTH concentrations (R(2) = 0.21; P = .000). CONCLUSIONS: About 80% of patients displayed high iPTH concentrations. The persistence of hyperparathyroidism was associated with graft dysfunction, longer time on dialysis, and low concentrations of 25OHD. Treatment with vitamin D produced a slight improvement in the prevalence of hyperparathyroidism.

Management of chronic kidney disease after renal transplantation: is it different from nontransplant patients?

BACKGROUND: The Kidney Disease Quality Initiative (K/DOQI) of the National Kidney Foundation has published guidelines for the diagnosis and management of chronic kidney disease (CKD). Renal transplant recipients frequently have CKD and complications similar to native kidney disease patients. The purpose of the present study was to compare the management of CKD complications of transplant recipients and nontransplant patients. PATIENTS AND METHODS: Eighty three renal transplant recipients with CKD stages 4T and 5T were compared with 83 nontransplant CKD patients matched by CKD stage. RESULTS: There were no differences between the groups in serum hemoglobin, prevalence of anemia, and percentage of patients treated with erythropoiesis-stimulating agents, but serum ferritin levels were higher among recipients (186.3 +/- 161.3 vs 119.1 +/- 113.4 ng/mL; P = .003). Mean blood pressure (BP) was similar in both groups but a systolic BP > 130 mm Hg was more frequent among recipients (83.3% vs 72.6%). More recipients were treated with either angiotensin-converting enzyme (ACE)-inhibitors or angiotensin receptor antagonist (43.3% vs 8.4%; P < .001). Low-density lipoprotein cholesterol was lower in recipients (108.9 +/- 30.3 vs 120.8 +/- 39.5 mg/dL; P = .033) and a higher percentage was on statin treatment (44.6% vs 28.9%; P = .053). Serum calcium was higher in transplant recipients (9.5 +/- 0.8 vs 8.9 +/- 0.7 mg/dL; P < .005) and phosphate was lower (3.9 +/- 0.9 vs 4.2 +/- 1.1; P = .043); there were no differences in intact parathyroid hormone blood levels. CONCLUSIONS: The management of renal transplant recipients is no worse than that of nontransplant patients. However, in both populations, some parameters are far from the target recommended by the guidelines.

Endourologic implants to treat complex ureteral stenosis after kidney transplantation.

OBJECTIVE: To evaluate the safety and efficacy of nitinol stents and the Detour extra-anatomical ureteral bypass graft in treatment of ureteral stenosis after kidney transplantation. PATIENTS AND METHODS: Eighteen kidney transplant recipients with complex stenosis caused by failure of primary treatment or with high surgical risk or a poorly functioning graft (serum creatinine concentration >2.5 mg/dL) were treated using antegrade percutaneous implantation of nitinol stents (n = 16) or extra-anatomical ureteral bypass grafts (n = 3); 1 patient was treated with both techniques. RESULTS: Mean (range) follow-up of ureteral stents was 51.2 (3-118) months. Patency rate at last follow-up, resumption of dialysis therapy, or death was 75% (12 of 16 patients). In 4 patients (25%), stent occlusion developed, which was treated using a double-J catheter in 2 patients, stent removal and pyeloureterostomy using the native ureter in 1 patient, and implantation of an extra-anatomical bypass graft in 1 patient. Mean follow-up in patients with extra-anatomical ureteral bypass grafts was 32 (8-64) months. One patient developed a urinary tract infection, and another had encrustation with obstruction. CONCLUSIONS: Use of nitinol ureteral stents and extra-anatomical ureteral bypass grafts is a safe and effective alternative to surgery for treatment of post-kidney transplantation ureteral stenosis in patients with chronic graft dysfunction, those at high surgical risk, and those in whom previous surgical treatment has failed.

Changes in visceral flow induced by laparoscopic and open living-donor nephrectomy: experimental model.

Increased intra-abdominal pressure during laparoscopy changes visceral flow. The objective of the present study was to analyze the changes in peripheral and intra-abdominal flow induced by laparoscopic living-donor nephrectomy in an experimental model. Twenty pigs underwent left-sided nephrectomy, 10 at laparoscopy and 10 in an open approach. Renal blood flow (RBF), hepatic arterial flow (HAF), portal flow (PF), and carotid flow (CF) were measured using an electromagnetic probe placed around these vessels. Comparative analysis between the groups demonstrated increased CF (mean [SD], 125.73 [41.69] vs 291.70 [51.52] mL/min; P < .001) and decreased PF (973.67 [131.70] vs 546.83 [217.53] mL/min; P = .001) and HAF (278.00 [94.71] vs 133.33 [112.32] mL/min; P = .03) in pigs that underwent laparoscopy compared with those who underwent open surgery; no significant differences were observed in RBF. In conclusion, laparoscopic nephrectomy induces increased CF and decreased total hepatic flow, at the expense of PF and HAF. With adequate intravascular volume expansion, no differences were observed in RBF between the laparoscopic and open approaches.

Risk factors for early renal graft thrombosis: a case-controlled study in grafts from the same donor.

Renal graft thrombosis is an important cause of early graft loss. In a case-controlled analysis including only thrombosed kidneys and their counterparts from the same donors, we found that the right kidney as opposed to the left kidney was the only risk factor for early graft vascular thrombosis. No other recipient, donor, or perioperative factor was significantly associated with the complication. Our findings suggested that implantation of a right kidney might be followed by prophylactic anticoagulant or antiaggregant therapy.