The aggregate index of systemic inflammation may predict mortality in COVID-19 patients with chronic renal failure.

OBJECTIVE: Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), was first detected in December 2019 and then spread globally, resulting in a pandemic. Initially, it was unknown if chronic kidney disease (CKD) contributed to the mortality caused by COVID-19. The immunosuppression associated with this disease may minimize the COVID-19-described hyper-inflammatory state or immunological dysfunction, and a high prevalence of comorbidities may lead to a poorer clinical prognosis. Patients with COVID-19 have abnormal circulating blood cells associated with inflammation. Risk stratification, diagnosis, and prognosis primarily rely on hematological features, such as white blood cells and their subpopulations, red cell distribution width, mean platelet volume, and platelet count, in addition to their combined ratios. In non-small-cell lung cancer, the aggregate index of systemic inflammation (AISI), (neutrophils x monocytes x platelets/lymphocytes) is evaluated. In light of the relevance of inflammation in mortality, the objective of this study is to determine the impact of AISI on the hospital mortality of CKD patients. PATIENTS AND METHODS: This study is an observational retrospective study. Data and test outcomes of all CKD patients, stages 3-5, hospitalized for COVID-19 and followed between April and October 2021 were analyzed. RESULTS: Patients were divided into two groups according to death (Group 1-Alive, Group 2-Died). Neutrophil count, AISI and C-reactive protein (CRP) levels were increased in Group-2 [10.3±4.6 vs. 7.65±4.22; p=0.001, 2,084.1 (364.8-2,577.5) vs. 628.9 (53.1-2,275); p=0.00 and 141.9 (20.5-318) vs. 84.75 (0.92-195); p=0.00; respectively]. Receiver operating characteristic (ROC) analysis demonstrated 621.1 as a cut-off value for AISI to predict hospital mortality with 81% sensitivity and 69.1% specificity [area under ROC curve 0.820 (95% CI: 0.733-0.907), p<.005]. Cox regression analysis was used to analyze the effect of risk variables on survival. In survival analysis, AISI and CRP were identified as important survival predictors [hazard ratio (HR): 1.001, 95% CI: 1-1.001; p=0.00 and HR: 1.009, 95% CI: 1.004-1.013; p=0.00]. CONCLUSIONS: This study demonstrated the discriminative effectiveness of AISI in predicting disease mortality in COVID-19 patients with CKD. Quantification of AISI upon admission might assist in the early detection and treatment of individuals with a bad prognosis.

Early Switch to Mammalian Target of Rapamycin Inhibitors Is a Sustainable Treatment Approach in Renal Transplant Recipients: 7-Year Results.

OBJECTIVE: The aim of this study was to investigate the safety and sustainability of mammalian target of rapamycin inhibitor (m-TORi)-based treatment protocols in renal transplant patients. METHODS: We retrospectively evaluated a total of 206 patients who were switched to low-dose calcineurin inhibitors (CNI) + m-TORi or mycophenolate mofetil (MMF) + m-TORi treatment protocols in the first 3 months of renal transplantation between January 2010 and August 2011 in our center. Demographic and laboratory features of the patients were recorded. RESULTS: Of the patients included in the study, 89 (43.2%) were female and 117 (56.8%) were male. The mean age was 41.9 ± 13.8 years. Panel reactive antibody was negative in 95% of the recipients. One hundred thirty-four (65%) patients received anti-thymocyte globulin induction therapy. Initially, 108 patients were treated with cyclosporine and 98 (47.6%) were treated with tacrolimus-based regimens. One hundred thirty-five patients (65.5%) were switched to low-dose CNI + m-TORi and 71 patients (34.5%) were switched to MMF + m-TORi. The mean switching time was 3 months. At the end of the study, 161 patients (78.2%) were still continuing the m-TORi treatment protocol and 45 patients (21.8%) could not continue for various reasons (11.4% proteinuria, 5.5% edema, 2.9% acute rejection, 1% acne + oral aphthae, 1% neuropathy). The biopsy-proven acute rejection rate was 4.5% (n = 9). The mean duration of sustainability of m-TORi treatment protocol was 84.15 ± 6.79 months. Mean serum creatinine of patients who were still continuing m-TORi was 1.42 ± 1.09 mg/dL. CONCLUSION: Switching to m-TORi in the early posttransplant period is a safe and sustainable treatment approach.

Absence of Inferior Vena Cava in a Renal Transplant Recipient: A Case Report.

A 27-year-old woman was admitted to our department with end-stage renal failure due to reflux nephropathy. She had no history of deep venous thrombosis. After pretransplantation evaluation, her father was accepted for kidney donation. We observed intraoperatively that the patient's iliac veins and inferior vena cava (IVC) were absent. There were many venous collaterals, but none of them was dilated enough for renal vein anastomosis. Since we could not find a suitable vein for venous drainage of the allograft, we decided to stop donor surgery and postpone renal transplantation (RT) for detailed radiologic examination. Contrast-enhanced computed tomography revealed the absence of an infrahepatic segment of IVC. Superior mesenteric vein was thin. Portal and splenic veins were normal, but we decided not to use them for venous drainage because of increased risk of torsion. We informed the patient and her family about the situation and cancelled RT. Iliac vein and IVC anomalies are not absolute contraindications for RT, but when a dilated collateral vein is not present or when there is no option for safe renal vein anastomosis as in our case, RT may not be possible.

Paired exchange kidney transplantation experience of Turkey.

OBJECTIVE: Paired-exchange kidney transplantation (PKD) has gained in importance because of the difficulty to obtain suitable organs. The aim of this study was to compare the biochemical and clinical parameters of PKT with those of living-related kidney transplantation (LD). METHOD: We compared 272 PKD performed in 3 transplant centers with 1885 LD. The 2 groups were compared for graft and patient survivals, rejection episodes, serum creatinine levels, and other biochemical parameters. RESULTS: The median human leukocyte antigen, mismatch was similar: PKD, 4 (95% confidence interval [CI], 3-4) and LD; 3 (95% CI, 3-4; P = .1292). The mean creatinine level among the PKT group of 1.07 ± .37 was lower then the LD group 1.17 ± .56 (P = .0043), but after the second year it was lower in the LD group (1.39 ± 0.61 and 1.16 ± 0.43; P < .0001). The rates of patient death (PKT, 3.31% vs LD 3.58; P = .9603), graft loss (2.74% vs 2.71%; P = .8647) and acute rejection episodes (19.48% vs 19.36%; P = 0.9719), were similar between the 2 groups. CONCLUSIONS: Paired donation expands the living donor pool and decreases the number of waiting list patients. It is cost effective according to ABO incompetible transplantation.

Exchange donor transplantation: ethical option for living renal transplantation.

PURPOSE: Taking in consideration the opinion of our team, which necessitates obligation of a relative relation between donors and recipients (genetic or matrimonial), we performed donor exchanges as an ethical alternative in living donor transplantations. We reviewed the outcomes of our exchange series. METHODS: Between July 2003 and August 2010 we performed 110 exchange donor transplantations in four hospitals: one four-way, two three-way, and 100 two-way cases. Donors were mostly spouses (n = 71) or mothers (n = 15). The mean age of the donors was 48.8 (range = 23-69) and the recipients 41.4 years (range = 5-66). Two were transplanted preemptively and the others had a mean dialysis duration of 43 months (range = 1-120). RESULTS: Among 110 patients, three compatible pairs joined the group voluntarily; 71, due to ABO incompatibility and 36, due to crossmatch positivity. Induction therapy was used in 92 patients. HLA mismatches (MM) were: one MM in three; two MM in three; three MM in 18, four MM in 36; five MM in 34; and six MM in 18. Among 90 patients tested for panel-reactive antibodies PRA, five showed class I and 10, class II positivity. In 11 patients, B-cell positivity was detected by flow cytometry. Delayed graft function (n = 2), acute rejection (n = 11), BK virus infection (n = 1), and cytomegalovirus infection (n = 3) were seen postoperatively. Three (2.7%) patients died due to sepsis. Five patients returned to dialysis program due to interstitial fibrosis tubular atrophy (IFTA) (n = 2), renal vein thrombosis (n = 1), de novo glomerulopathy (n = 1), or primary nonfunction (n = 1). The 1- and 5-year patient and graft survival rates were 96% and 96%, 95% and 89%, respectively. CONCLUSION: We believe that exchange donor transplantation is as successful as direct transplants; it is a good, ethical alternative to unrelated living transplantations.

Conversion to proliferation signal inhibitors-based immunosuppressive regimen in kidney transplantation: to whom and when?

BACKGROUND: Despite significant advances in kidney transplantation, long-term graft survival has not dramatically improved leading to strategies to change immunosuppression during the posttransplantation period. Proliferation signal inhibitors (PSI) sirolimus or everolimus possess immunosuppressive and antiproliferative properties. METHODS: We evaluated 62 kidney transplant recipients who underwent conversion from a calcineurin inhibitors (CNI)- to a PSI-based regimen for various reasons. The statistical analysis used SPSS v.15.0 software. We compared calculated glomerular filtration rates (GFRs) before initiation of PSI (baseline) and at 6 months after conversion. RESULTS: We converted to a PSI-based triple regimen at 172.0 ± 116.5 days after transplantation. The mean serum creatinine at the time of conversion was 2.0 ± 1.1 mg/dL, and it was 1.5 ± 0.7 mg/dL at 6 months after conversion. The rate of change in serum creatinine was -17.1 ± 23.5%. The mean calculated GFR at the time of conversion was 53.6 ± 25.5 mL/min and at 6 months after conversion was 65.8 ± 23.7 mL/min. The rate of change in calculated GFR was 37.9 ± 71.7% (16.4/59.4) at 6 months. Thus we observed significant improvements in creatinine and GFR (P values <.001) after conversion. The Improved GFR significantly correlated with prior dialysis duration and time to conversion (P = .025; P = .012). Patients who had a shorter duration on dialysis and shorter time to conversion experienced more benefit from conversion. Four of the 62 patients reported gastrointestinal toxicity, which resolved with dose reduction in 3 patients: 15 patients experienced acne; 16 reported oral ulcers. None of these toxicities resulted in discontinuation of PSI therapy. Serum cholesterol and tryglyceride levels tended to increase among the conversion group, but they did not show statistical significance. CONCLUSION: We observed that minimization or withdrawal of CNI with addition of a PSI was a good treatment for deterioration of renal allograft function.

The influence of hepatitis B and C virus infections on patient and allograft outcomes in kidney transplantation.

BACKGROUND: Hepatitis B virus (HBV) and hepatitis C virus (HCV) infections are the most important causes of chronic liver diseases among end-stage kidney disease patients. Our aim was to evaluate the influence of HBV and HCV infections on patient and allograft outcomes after successful kidney transplantation. PATIENTS AND METHODS: We retrospectively analyzed 592 kidney transplantations performed between December 2008 and August 2010. We compared patient and graft survivals as well as age, gender, immunosuppression status, pretransplant dialysis duration, chronic allograft dysfunction, and causes of death. RESULTS: Thirty-two patients (5.4%; group 1) were positive for HCV antibody, whereas 16 (2.7%) were positive for hepatitis B surface antigen (HBsAg) (group 2). Two patients (0.3%) were positive concurrently for both HCV antibody and HBsAg. Five hundred forty-two patients (91.6%; group 3) were negative for both. Patients were divided into groups with respect to viral infection. The groups were analyzed for age, gender, immunosuppression, pretransplant dialysis duration, chronic allograft dysfunction, and causes of death, as well as patient and graft outcomes. There were no differences in patient and graft survivals among the groups. None of the patients showed signs of hepatic failure. No patient or graft loss was observed among hepatitis groups when compared with disease-free patients. CONCLUSION: Graft and patient survivals were not influenced by HBV and/or HCV infections. HBV and HCV infections are not contraindications for kidney transplantation.

Intensive polyoma virus nephropathy treatment as a preferable approach for graft surveillance.

BACKGROUND: Polyoma BK virus nephropathy (BKVN) is one of the important causes of graft failure and loss among renal transplant patients. Reduction of immunosuppression is the most important preferred treatment approach; however, there is no agreed protocol for additional treatments. OBJECTIVE: Our aim was to investigate the effects on graft survival of intensive treatment protocols for BKVN among renal transplant patients. METHODS: 214 patients were included in the study. All patients underwent investigation for the presence of BKV in plasma samples every 3 months starting from the third month after transplantation. Biopsies were obtained upon detection of graft dysfunction or viremia. If BKVN was positive, viremia was investigated monthly. RESULTS: Plasma plus biopsy-proven BKVN were detected in 19 patients (8.9%), whose mean age was 45.8 ± 12.0 years; 68.4% (n = 13) were male and 94.7% (n = 18) were recipients of a living-donor kidney. There were 5.2% (n = 1) diabetic subjects, and the mean time prior to dialysis was 39.6 ± 44.8 (3-125) months. BKVN was observed at a mean of 6.8 ± 2.9 (4-14) months after the transplantation. It positively correlated with the baseline serum creatinine level (r = 0.159; P = .02), application and cumulative dose of antithymocyte globulin (r = 0.177; r = 0.165; respectively; P = .01), mean tacrolimus dose (r = 0.303; P < .001), and hepatitis B virus positivity (r = 0.169; P = .01). Immunosuppression was decreased in all patients who developed BKVN. In addition, leflunomide was applied in 68%, intravenous immunoglobulin in 74%, and cidofovir in 32% of patients. Acute rejection rates did not increase significantly after lowering immunosuppression (P > .05). CONCLUSION: BKVN is one of the important problems in renal transplant patients. Intensive treatment of BKVN with heterogeneous regimens, including combined treatment with leflunamide + IVIG together with immunosuppressive dose reduction, was an effective approach to prolong graft survival.