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1.
Transpl Int ; 34(12): 2680-2685, 2021 12.
Article in English | MEDLINE | ID: mdl-34628685

ABSTRACT

BK polyomavirus (BKPyV) reactivation is regularly monitored after kidney transplant to prevent progression to BK associated nephropathy (BKAN). The New England BK Consortium, made up of 12 transplant centres in the northeastern United States, conducted a quality improvement project to examine adherence to an agreed upon protocol for BKPyV screening for kidney transplants performed in calendar years 2016-2017. In a total of 1047 kidney transplant recipients (KTR) from 11 transplant centres, 204 (19%) had BKPyV infection, defined as detection of BKPyV in plasma, with 41 (4%) KTR progressing to BKAN, defined by either evidence on biopsy tissues or as determined by treating nephrologists. BKPyV infection was treated with reduction of immune suppressants (RIS) in >70% of the patients in all but two centres. There was no graft loss because of BKAN during the two-year follow-up. There were nine cases of post-RIS acute rejection detected during this same period. Adherence to the protocol was low with 54% at 12 months and 38% at 24 months, reflecting challenges of managing transplant patients at all centres. The adherence rate was positively correlated to increased detection of BKPyV infection and was unexpectedly positively correlated to an increase in diagnosis of BKAN.


Subject(s)
BK Virus , Kidney Transplantation , Polyomavirus Infections , Tumor Virus Infections , Humans , Kidney Transplantation/adverse effects , Polyomavirus Infections/diagnosis , Retrospective Studies , Transplant Recipients , Tumor Virus Infections/diagnosis
3.
Transpl Infect Dis ; 20(6): e12985, 2018 Dec.
Article in English | MEDLINE | ID: mdl-30175491

ABSTRACT

INTRODUCTION: BK polyomavirus (BKPyV) continues to impact renal transplant recipients (RTR). The New England BK Consortium aims to jointly optimize screening and management of BKPyV. METHODS: Our first project was to survey centers' BKPyV screening protocols and compare them to consensus guidelines. RESULTS: Thirteen of 15 centers (86.7%) returned the survey. Only two center reported using monitoring parameters that were in line with consensus guidelines for BKPyV screening, while the majority of centers reported less intensive methods and shorter duration. One center reported performing renal biopsies in all patients with plasma viral loads >10 000 copies/mL, while all other centers only perform for-cause biopsies. For presumptive nephropathy, 11 centers recommend a biopsy for confirmation. For management of documented BKPyV-associated nephropathy, 12 centers propose further immunosuppression reduction. Nine centers report CNI dose reduction as their primary treatment. More than half of centers surveyed reported use of leflunomide, cidofovir or intravenous immunoglobulin. CONCLUSIONS: There was a large variance in BKPyV screening and management strategies among centers. Due to these results, all participating centers agreed to implement uniform screening and aim to optimize management protocols.


Subject(s)
Antiviral Agents/therapeutic use , BK Virus/isolation & purification , Kidney Transplantation/adverse effects , Polyomavirus Infections/diagnosis , Tumor Virus Infections/diagnosis , Allografts/immunology , Allografts/pathology , Allografts/virology , Antiviral Agents/standards , Biopsy , Clinical Protocols/standards , Graft Rejection/immunology , Graft Rejection/prevention & control , Health Care Surveys/statistics & numerical data , Health Personnel/statistics & numerical data , Humans , Immunosuppression Therapy/adverse effects , Immunosuppression Therapy/methods , Kidney/immunology , Kidney/pathology , Kidney/virology , Polyomavirus Infections/drug therapy , Polyomavirus Infections/pathology , Polyomavirus Infections/virology , Practice Guidelines as Topic , Tumor Virus Infections/drug therapy , Tumor Virus Infections/pathology , Tumor Virus Infections/virology
4.
J Clin Apher ; 27(4): 212-4, 2012.
Article in English | MEDLINE | ID: mdl-22307916

ABSTRACT

Streptococcus pneumoniae-associated hemolytic uremic syndrome (pHUS) is an atypical form of HUS associated with microangiopathic hemolytic anemia, thrombocytopenia and acute renal failure. Although less common than diarrhea-associated HUS, incidence appears to be increasing. We report a case of a child with pHUS who underwent a course of therapeutic plasma exchange (TPE) and had complete recovery. This report adds to the existing literature supporting TPE in cases of pHUS.


Subject(s)
Hemolytic-Uremic Syndrome/etiology , Hemolytic-Uremic Syndrome/therapy , Plasma Exchange , Pneumococcal Infections/complications , Atypical Hemolytic Uremic Syndrome , Child, Preschool , Female , Hemolytic-Uremic Syndrome/blood , Humans , Platelet Count , Treatment Outcome
5.
Clin J Am Soc Nephrol ; 6(5): 1185-91, 2011 May.
Article in English | MEDLINE | ID: mdl-21511835

ABSTRACT

BACKGROUND AND OBJECTIVES: Candidates for renal transplantation are at increased risk for complications related to cardiovascular disease; however, the optimal strategy to reduce this risk is not clear. The aim of this study was to evaluate the variability among existing guidelines for preoperative cardiac evaluation of renal transplant candidates. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: A consecutive series of renal transplant candidates (n=204) were identified, and four prominent preoperative cardiac evaluation guidelines, pertaining to this population, were retrospectively applied to determine the rate at which each guideline recommended cardiac stress testing. RESULTS: The rate of pretransplant cardiac stress testing would have ranged from 20 to 100% depending on which guideline was applied. The American Heart Association/American College of Cardiology (ACC/AHA) guideline resulted in the lowest rate of testing (20%). In our population, 178 study subjects underwent stress testing: 17 were found to have ischemia and 10 underwent revascularization. The ACC/AHA approach would have decreased the number of noninvasive tests from 178 to 39; it would have identified only 4 of the 10 patients who underwent revascularization. The three other guidelines (renal transplant-specific guidelines) recommended widespread pretransplant cardiac testing and thus identified nearly all patients who had ischemia on stress testing. CONCLUSIONS: The ACC/AHA perioperative guideline may be inadequate for identifying renal transplant candidates with coronary disease; however, renal transplant-specific guidelines may provoke significant overtesting. An intermediate approach based on risk factors specific to the ESRD population may optimize detection of coronary disease and limit testing.


Subject(s)
Exercise Test/standards , Kidney Failure, Chronic/surgery , Kidney Transplantation/standards , Myocardial Ischemia/diagnosis , Practice Guidelines as Topic , Preoperative Care/standards , Adult , Aged , Databases, Factual/statistics & numerical data , Exercise Test/statistics & numerical data , Guideline Adherence/statistics & numerical data , Humans , Kidney Failure, Chronic/epidemiology , Kidney Transplantation/statistics & numerical data , Middle Aged , Myocardial Ischemia/epidemiology , Myocardial Ischemia/therapy , Myocardial Revascularization/statistics & numerical data , Preoperative Care/statistics & numerical data , Retrospective Studies , Risk Factors
6.
Nephrol Dial Transplant ; 25(9): 3090-6, 2010 Sep.
Article in English | MEDLINE | ID: mdl-20299337

ABSTRACT

BACKGROUND: Early graft dysfunction is a significant complication after renal transplantation and is a marker of adverse outcomes. Although multiple predictors of graft dysfunction have been previously described, the reported prevalence of pulmonary hypertension (pulmonary HTN) in the dialysis population (40-50%), along with biologic and physiologic principles, led us to hypothesize that pulmonary HTN might be an additional risk factor for early graft dysfunction. METHODS: We performed a retrospective study that screened all adult renal transplants performed at our institution over a 3-year period and limited the evaluation to those subjects who had an estimated pulmonary artery systolic pressure on a preoperative echocardiogram report (n = 55). The primary outcome of this study was to investigate the impact of pulmonary HTN on early graft dysfunction using a combined endpoint of delayed graft function or slow graft function. RESULTS: Among patients receiving a living donor kidney, early graft dysfunction was not observed regardless of pulmonary HTN status. However, among patients receiving a deceased donor kidney, pulmonary HTN was found to be associated with a significant increased risk of early graft dysfunction (56 vs 11.7%, P = 0.01). Univariate and multivariable logistic regression supported this observation as an independent risk factor beyond potential confounding recipient, donor and graft-based risk factors for early graft dysfunction (P < 0.05). CONCLUSION: Pulmonary HTN detected on non-invasive imaging prior to renal transplantation appears to be an independent predictor of early graft dysfunction among those patients who receive a deceased donor kidney.


Subject(s)
Delayed Graft Function/diagnosis , Graft Rejection/etiology , Graft Survival , Hypertension, Pulmonary/diagnosis , Kidney Failure, Chronic/complications , Kidney Transplantation/adverse effects , Adult , Age Factors , Cohort Studies , Creatinine/metabolism , Female , Glomerular Filtration Rate , Graft Rejection/epidemiology , Humans , Kidney Failure, Chronic/mortality , Kidney Failure, Chronic/surgery , Kidney Function Tests , Male , Middle Aged , Retrospective Studies , Risk Factors , Sensitivity and Specificity , Survival Rate , Treatment Outcome
7.
Curr Opin Organ Transplant ; 14(4): 375-9, 2009 Aug.
Article in English | MEDLINE | ID: mdl-19542891

ABSTRACT

PURPOSE OF REVIEW: New-onset diabetes after transplantation (NODAT) is a serious complication of organ transplantation. Data from kidney transplant studies show that NODAT is a strong independent predictor of graft failure and cardiovascular mortality. This article reviews NODAT in context of some of the recent data on definition, incidence, risk factors, genetics, and the impact on graft survival and cardiovascular events. RECENT FINDINGS: The reported incidence of NODAT continues to be high. The variability in the incidence can be attributed to varying definitions used in studies and also to the immunosuppressive regimens used at various centers. A 5-day oral glucose tolerance test may be a better predictor for developing NODAT. Comparison studies of various immunosuppressants in contributing to this condition show variable and conflicting results. Hepatitis C has emerged as a strongly associated risk factor and sirolimus may not be less diabetogenic, as thought before. In addition to serious infections, NODAT has been associated with increased cardiovascular risk and atherosclerosis and higher graft failures. SUMMARY: New-onset diabetes continues to be a common and potentially serious complication after organ transplantation. Risk stratification, early diagnosis, and intervention for this condition may contribute to better long-term graft survival and help in reducing cardiovascular mortality.


Subject(s)
Cardiovascular Diseases/etiology , Diabetes Mellitus/etiology , Graft Rejection/etiology , Graft Survival , Kidney Transplantation/adverse effects , Cardiovascular Diseases/mortality , Diabetes Mellitus/diagnosis , Diabetes Mellitus/drug therapy , Diabetes Mellitus/mortality , Early Diagnosis , Genetic Predisposition to Disease , Glucose Tolerance Test , Graft Rejection/mortality , Graft Rejection/prevention & control , Hepatitis C/complications , Humans , Hypoglycemic Agents/therapeutic use , Immunosuppressive Agents/adverse effects , Incidence , Kidney Transplantation/mortality , Risk Factors
8.
JAMA ; 299(2): 202-7, 2008 Jan 09.
Article in English | MEDLINE | ID: mdl-18182602

ABSTRACT

CONTEXT: Disparities in access to organ transplantation exist for racial minorities, women, and patients with lower socioeconomic status or inadequate insurance. Rural residents represent another group that may have impaired access to transplant services. OBJECTIVE: To assess the association of rural residence with waiting list registration for heart, liver, and kidney transplant and rates of transplantation among wait-listed candidates. DESIGN, SETTING, AND PATIENTS: Five-year US cohort of 174,630 patients who were wait-listed and who underwent heart, liver, or kidney transplantation between 1999 and 2004. MAIN OUTCOME MEASURES: Rates of new waiting list registrations and transplants per million population for residents of 3 residential classifications (rural/small town population, <10,000; micropolitan, 10,000-50,000; and metropolitan >50,000 or suburb of major city). RESULTS: Compared with urban residents, waiting list registration rates for rural/small town residents were significantly lower for heart (covariate-adjusted rate ratio [RR] = 0.91; 95% confidence interval [CI], 0.86-0.96; P<.002), liver (RR = 0.86; 95% CI, 0.83-0.89; P<.001), and kidney transplants (RR = 0.92; 95% CI, 0.90-0.95; P<.001). Compared with residents in urban areas, rural/small town residents had lower relative transplant rates for heart (RR = 0.88; 95% CI, 0.81-0.94; P = .004), liver (RR = 0.80; 95% CI, 0.77-0.84; P<.001), and kidney transplantation (covariate-adjusted RR = 0.90; 95% CI, 0.88-0.93; P<.001). These disparities were consistent across national organ allocation regions. Significantly longer waiting times among rural patients wait-listed for heart transplantation were observed but not for liver and kidney transplantation. There were no significant differences in posttransplantation outcomes between groups. CONCLUSIONS: Patients living in rural areas had a lower rate of wait-lisiting and transplant of solid organs, but did not experience significantly different outcomes following transplant. Differences in rates of wait-listing and transplant may be due to variations in the burden of disease between different patient groups or barriers to evaluation and waiting list entry for rural residents with organ failure.


Subject(s)
Health Services Accessibility , Healthcare Disparities , Organ Transplantation/statistics & numerical data , Rural Population/statistics & numerical data , Urban Population/statistics & numerical data , Waiting Lists , Adult , Humans , Middle Aged , Proportional Hazards Models , Survival Analysis , Tissue and Organ Procurement , United States/epidemiology
10.
Am J Transplant ; 4(10): 1628-34, 2004 Oct.
Article in English | MEDLINE | ID: mdl-15367217

ABSTRACT

Kidney transplantation from live donors achieves an excellent outcome regardless of human leukocyte antigen (HLA) mismatch. This development has expanded the opportunity of kidney transplantation from unrelated live donors. Nevertheless, the hazard of hyperacute rejection has usually precluded the transplantation of a kidney from a live donor to a potential recipient who is incompatible by ABO blood type or HLA antibody crossmatch reactivity. Region 1 of the United Network for Organ Sharing (UNOS) has devised an alternative system of kidney transplantation that would enable either a simultaneous exchange between live donors (a paired exchange), or a live donor/deceased donor exchange to incompatible recipients who are waiting on the list (a live donor/list exchange). This Regional system of exchange has derived the benefit of live donation, avoided the risk of ABO or crossmatch incompatibility, and yielded an additional donor source for patients awaiting a deceased donor kidney. Despite the initial disadvantage to the list of patients awaiting an O blood type kidney, as every paired exchange transplant removes a patient from the waiting list, it also avoids the incompatible recipient from eventually having to go on the list. Thus, this approach also increases access to deceased donor kidneys for the remaining candidates on the list.


Subject(s)
Kidney Transplantation , Tissue Donors , Tissue and Organ Procurement , Cadaver , Humans , Living Donors , New England
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