Recommendations for living donor kidney transplantation.

This Guide for Living Donor Kidney Transplantation (LDKT) has been prepared with the sponsorship of the Spanish Society of Nephrology (SEN), the Spanish Transplant Society (SET), and the Spanish National Transplant Organization (ONT). It updates evidence to offer the best chronic renal failure treatment when a potential living donor is available. The core aim of this Guide is to supply clinicians who evaluate living donors and transplant recipients with the best decision-making tools, to optimise their outcomes. Moreover, the role of living donors in the current KT context should recover the level of importance it had until recently. To this end the new forms of incompatible HLA and/or ABO donation, as well as the paired donation which is possible in several hospitals with experience in LDKT, offer additional ways to treat renal patients with an incompatible donor. Good results in terms of patient and graft survival have expanded the range of circumstances under which living renal donors are accepted. Older donors are now accepted, as are others with factors that affect the decision, such as a borderline clinical history or alterations, which when evaluated may lead to an additional number of transplantations. This Guide does not forget that LDKT may lead to risk for the donor. Pre-donation evaluation has to centre on the problems which may arise over the short or long-term, and these have to be described to the potential donor so that they are able take them into account. Experience over recent years has led to progress in risk analysis, to protect donors' health. This aspect always has to be taken into account by LDKT programmes when evaluating potential donors. Finally, this Guide has been designed to aid decision-making, with recommendations and suggestions when uncertainties arise in pre-donation studies. Its overarching aim is to ensure that informed consent is based on high quality studies and information supplied to donors and recipients, offering the strongest possible guarantees.

Mortality in Elderly Waiting-List Patients Versus Age-Matched Kidney Transplant Recipients: Where is the Risk?

The number of elderly patients on the waiting list (WL) for kidney transplantation (KT) has risen significantly in recent years. Because KT offers a better survival than dialysis therapy, even in the elderly, candidates for KT should be selected carefully, particularly in older waitlisted patients. Identification of risk factors for death in WL patients and prediction of both perioperative risk and long-term post-transplant mortality are crucial for the proper allocation of organs and the clinical management of these patients in order to decrease mortality, both while on the WL and after KT. In this review, we examine the clinical results in studies concerning: a) risk factors for mortality in WL patients and KT recipients; 2) the benefits and risks of performing KT in the elderly, comparing survival between patients on the WL and KT recipients; and 3) clinical tools that should be used to assess the perioperative risk of mortality and predict long-term post-transplant survival. The acknowledgment of these concerns could contribute to better management of high-risk patients and prophylactic interventions to prolong survival in this particular population, provided a higher mortality is assumed.

Effectiveness of mycophenolate mofetil in C3 glomerulonephritis.

C3 glomerulonephritis is a clinicopathologic entity defined by the presence of isolated or dominant deposits of C3 on immunofluorescence. To explore the effect of immunosuppression on C3 glomerulonephritis, we studied a series of 60 patients in whom a complete registry of treatments was available over a median follow-up of 47 months. Twenty patients had not received immunosuppressive treatments. In the remaining 40 patients, 22 had been treated with corticosteroids plus mycophenolate mofetil while 18 were treated with other immunosuppressive regimens (corticosteroids alone or corticosteroids plus cyclophosphamide). The number of patients developing end-stage renal disease was significantly lower among treated compared with untreated patients (3 vs. 7 patients, respectively). No patient in the corticosteroids plus mycophenolate mofetil group doubled serum creatinine nor developed end-stage renal disease, as compared with 7 (significant) and 3 (not significant), respectively, in patients treated with other immunosuppressive regimens. Renal survival (100, 80, and 72% at 5 years) and the number of patients achieving clinical remission (86, 50, and 25%) were significantly higher in patients treated with corticosteroids plus mycophenolate mofetil as compared with patients treated with other immunosuppressive regimens and untreated patients, respectively. Thus, immunosuppressive treatments, particularly corticosteroids plus mycophenolate mofetil, can be beneficial in C3 glomerulonephritis.

Predictors of response and relapse in patients with idiopathic membranous nephropathy treated with tacrolimus.

BACKGROUND: Although tacrolimus is recommended by KDIGO Clinical Practice Guideline for Glomerulonephritis for the treatment of idiopathic membranous nephropathy (MN), little is known about factors that influence response and relapse of the disease after tacrolimus therapy. METHODS: Multicentre study that collected 122 MN patients with nephrotic syndrome and stable renal function treated with tacrolimus. Duration of treatment was 17.6 ± 7.2 months, including a full-dose and a tapering period. RESULTS: The percentage of remission was 60, 78 and 84% after 6, 12 and 18 months of treatment, respectively. The amount of proteinuria at baseline significantly predicted remission, the lower the baseline proteinuria the higher the probability of remission. Only 10 patients (8%) received concomitantly corticosteroids, and their rate of remission was similar (80% at 18 months). Among responders, 42% achieved complete remission (CR) and 58% partial remission (PR). Almost half (44%) of the responder patients relapsed. The amount of proteinuria at the onset of tacrolimus tapering was significantly higher in relapsing patients. By multivariable analysis, the presence of a PR versus CR at the onset of tacrolimus tapering and a shorter duration of the tapering period significantly predicted relapses. Tolerance was good and the number of adverse events low. CONCLUSIONS: Tacrolimus monotherapy is an effective and safe option for the treatment of MN with stable renal function. Relapses are frequent in patients with PR and can be partially prevented by a longer tapering period.

[Patient information: when and what]. / Información a pacientes: cuándo y qué información suministrar.

The living donor kidney transplant should be considered a priority option providing better quality of life and survival for those needing renal replacement therapy. To increase their number, both nephrologists and patients, should be informed more and better, offering this option compared with LDKT alternatives (dialysis or kidney transplant from a deceased donor). The clinical nephrology consultations or specific pre-dialysis are the space where in stages 3 and 4 of renal failure should be started on LDKT informational approaches. Later, when seeking more detailed information and/or evaluation of potential donors, this could be provided at times and spaces specifically reserved for awareness professionals with the use of brochures or Internet addresses. Information should focus especially on the additional benefits of pre-emptive LDKT, the risks of nephrectomy and long term controls for the donor. Finally, donor, recipient and family should know that the donation will only be justified and may be accepted if the studies of risk/benefit for the donor and recipient have been faithfully evaluated according to the highest ethical standards.

Información a pacientes: cuándo y qué información suministrar / Patient information: w hat type and w hen should it be provided?

El trasplante renal de donante vivo (TRDV) se debe ofrecer como opción terapéutica prioritaria porque proporciona mejores resultados en calidad de vida y supervivencia para quienes precisan tratamiento renal sustitutivo. Para aumentar su número, es preciso informar más y mejor, tanto a nefrólogos como a pacientes, ofreciendo la opción del TRDV junto a las alternativas de tratamiento con diálisis o trasplante renal de donante fallecido. Las consultas de nefrología clínica o las específicas de prediá- lisis son el espacio donde en estadios 3 y 4 de insuficiencia renal se deben iniciar planteamientos informativos sobre TRDV. Posteriormente, caso de solicitar información más detallada y/o valoración de potenciales donantes, ésta se podría facilitar en momentos y espacios específicamente reservados por profesionales concienciados, siendo de ayuda la utilización de folletos informativos o direcciones de Internet. La información debería incidir especialmente en los beneficios adicionales del TRDV anticipado, los riesgos que supone la intervención de nefrectomía, y los cuidados y controles que necesitará el donante. Finalmente, donante, receptor y familiares deben saber que la donación sólo estará justificada, y podrá ser aceptada, si los estudios de riesgo/beneficio para donante y receptor han sido fielmente evaluados de acuerdo a los mejores estándares éticos (AU)

The living donor kidney transplant should be considered a priority option providing better quality of life and survival for those needing renal replacement therapy. To increase their number, both nephrologists and patients, should be informed more and better, offering this option compared with LDKT alternatives (dialysis or kidney transplant from a deceased donor). The clinical nephrology consultations or specific pre-dialysis are the space where in stages 3 and 4 of renal failure should be started on LDKT informational approaches. Later, when seeking more detailed information and/or evaluation of potential donors, this could be provided at times and spaces specifically reserved for awareness professionals with the use of brochures or Internet addresses. Information should focus especially on the additional benefits of pre-emptive LDKT, the risks of nephrectomy and long term controls for the donor. Finally, donor, recipient and family should know that the donation will only be justified and may be accepted if the studies of risk/benefit for the donor and recipient have been faithfully evaluated according to the highest ethical standards (AU)