Live donor kidney transplantation. Situation analysis and roadmap.

Living donor kidney transplantation (LDKT) is the best treatment option for end stage renal disease in terms of both patient and graft survival. However, figures on LDKT in Spain that had been continuously growing from 2005 to 2014, have experienced a continuous decrease in the last five years. One possible explanation for this decrease is that the significant increase in the number of deceased donors in Spain during the last years, both brain death and controlled circulatory death donors, might have generated the false idea that we have coped with the transplant needs. Moreover, a greater number of deceased donor kidney transplants have caused a heavy workload for the transplant teams. Furthermore, the transplant teams could have moved on to a more conservative approach to the information and assessment of patients and families considering the potential long-term risks for donors in recent papers. However, there is a significant variability in the LDKT rate among transplant centers and regions in Spain independent of their deceased donor rates. This fact and the fact that LDKT is usually a preemptive option for patients with advanced chronic renal failure, as time on dialysis is a negative independent factor for transplant outcomes, lead us to conclude that the decrease in LDKT depends on other factors. Thus, in the kidney transplant annual meeting held at ONT site in 2018, a working group was created to identify other causes for the decrease of LDKT in Spain and its relationship with the different steps of the process. The group was formed by transplant teams, a representative of the transplant group of the Spanish Society of Nephrology (SENTRA), a representative of the Spanish Society of Transplants (SET) and representatives of the Spanish National Transplant Organization (ONT). A self-evaluation survey that contains requests about the phases of the LDKT processes (information, donor work out, informed consent, surgeries, follow-up and human resources) were developed and sent to 33 LDKT teams. All the centers answered the questionnaire. The analysis of the answers has resulted in the creation of a national analysis of strengths, weaknesses, opportunities, threats (SWOT) of the LDKT program in Spain and the development of recommendations targeted to improve every step of the donation process. The work performed, the conclusions and recommendations provided, have been reflected in the following report: Spanish living donor kidney transplant program assessment: recommendations for optimization. This document has also been reviewed by a panel of experts, representatives of the scientific societies (Spanish Society of Urology (AEU), Spanish Society of Nephrology Nursery (SEDEN), Spanish Society of Immunology (SEI/GETH)) and the patient association ALCER. Finally, the report has been submitted to public consultation, reaching ample consensus. In addition, the transplant competent authorities of the different regions in Spainhave adopted the report at institutional level. The work done and the recommendations to optimize LDKT are summarized in the present manuscript, organized by the different phases of the donation process.

[Living-donor renal transplant. State of the art.] / Trasplante renal de donante vivo. Estado actual.

Living donor kidney transplantation is the best therapeutic option in a patient with end-stage renal failure, because it provides excellent functionality and graft survival. Laparoscopic living donor nephrectomyis the gold-standard for obtaining the graft. In exper thands, different minimally invasive surgeries can be offered with the main advantage of improving the a esthetic results. Although there may be controversy regarding laparoscopic devices for vascular ligation during living donor nephrectomy, both endostaplers and locking clips have proven to be safe as long as the proper techniqueis performed. Living donor nephrectomy has minimal morbidity and mortality. Age and glomerular filtration rate of the donor candidate are prognostic factor of long-term renal failure. In relation to the implant surgery,robotic kidney transplantation is now probably at the beginning of its development. Published series still do not allow to clearly establish its role compared to conventional open surgery.

El trasplante renal de donante vivo suponela mejor opción terapéutica en un paciente con insuficiencia renal terminal, por su excelente funcionalidad y supervivencia del injerto. La nefrectomía laparoscópica de donante vivo es la técnica de elección para la obtención del injerto. En manos expertas, distintas variantes mínimamente invasivas pueden ofrecerse con la principal ventaja de mejorar los resultados estéticos del donante. Aunque pueda existir controversia en relación a los dispositivos laparoscópicos para la ligadura vascular durante la nefrectomía de donante vivo, tanto las endograpadoras como los clips con cierre tipo Hem-olokhan demostrado ser seguros siempre que se respete la técnica adecuada en su empleo. La nefrectomía de donante vivo no está exenta de una mínima morbi-mortalidad.La edad y el filtrado glomerular del candidato a donante son orientativas del riesgo de enfermedad renal a largo plazo. En relación a la cirugía del implante, el trasplante renal robótico se encuentra en los albores de su desarrollo. Las series publicadas no permiten aún establecer claramente su papel frente a la cirugía abierta convencional.

Trasplante renal de donante vivo. Estado actual / Immunosuppressive drugs and protocols for transplantation

El trasplante renal de donante vivo suponela mejor opción terapéutica en un paciente con insuficiencia renal terminal, por su excelente funcionalidad ysupervivencia del injerto. La nefrectomía laparoscópica de donante vivo es la técnica de elección para laobtención del injerto. En manos expertas, distintas variantes mínimamente invasivas pueden ofrecerse con laprincipal ventaja de mejorar los resultados estéticos deldonante. Aunque pueda existir controversia en relacióna los dispositivos laparoscópicos para la ligadura vascular durante la nefrectomía de donante vivo, tanto lasendograpadoras como los clips con cierre tipo Hem-olok han demostrado ser seguros siempre que se respetela técnica adecuada en su empleo. La nefrectomía dedonante vivo no está exenta de una mínima morbi-mortalidad. La edad y el filtrado glomerular del candidato a donante son orientativas del riesgo de enfermedad renala largo plazo. En relación a la cirugía del implante, eltrasplante renal robótico se encuentra en los albores desu desarrollo. Las series publicadas no permiten aún establecer claramente su papel frente a la cirugía abiertaconvencional.(AU)

Living donor kidney transplantation is thebest therapeutic option in a patient with end-stage renalfailure, because it provides excellent functionality andgraft survival. Laparoscopic living donor nephrectomyis the gold-standard for obtaining the graft. In experthands, different minimally invasive surgeries can be offered with the main advantage of improving the aesthetic results. Although there may be controversy regardinglaparoscopic devices for vascular ligation during livingdonor nephrectomy, both endostaplers and locking clipshave proven to be safe as long as the proper techniqueis performed. Living donor nephrectomy has minimalmorbidity and mortality. Age and glomerular filtrationrate of the donor candidate are prognostic factor oflong-term renal failure. In relation to the implant surgery,robotic kidney transplantation is now probably at thebeginning of its development. Published series still donot allow to clearly establish its role compared to conventional open surgery.(AU)

Live donor kidney transplantation. Situation analysis and roadmap. / Trasplante renal de donante vivo. Análisis de situación y hoja de ruta.

Living donor kidney transplantation (LDKT) is the best treatment option for end stage renal disease in terms of both patient and graft survival. However, figures on LDKT in Spain that had been continuously growing from 2005 to 2014, have experienced a continuous decrease in the last five years. One possible explanation for this decrease is that the significant increase in the number of deceased donors in Spain during the last years, both brain death and controlled circulatory death donors, might have generated the false idea that we have coped with the transplant needs. Moreover, a greater number of deceased donor kidney transplants have caused a heavy workload for the transplant teams. Furthermore, the transplant teams could have moved on to a more conservative approach to the information and assessment of patients and families considering the potential long-term risks for donors in recent papers. However, there is a significant variability in the LDKT rate among transplant centers and regions in Spain independent of their deceased donor rates. This fact and the fact that LDKT is usually a preemptive option for patients with advanced chronic renal failure, as time on dialysis is a negative independent factor for transplant outcomes, lead us to conclude that the decrease in LDKT depends on other factors. Thus, in the kidney transplant annual meeting held at ONT site in 2018, a working group was created to identify other causes for the decrease of LDKT in Spain and its relationship with the different steps of the process. The group was formed by transplant teams, a representative of the transplant group of the Spanish Society of Nephrology (SENTRA), a representative of the Spanish Society of Transplants (SET) and representatives of the Spanish National Transplant Organization (ONT). A self-evaluation survey that contains requests about the phases of the LDKT processes (information, donor work out, informed consent, surgeries, follow-up and human resources) were developed and sent to 33 LDKT teams. All the centers answered the questionnaire. The analysis of the answers has resulted in the creation of a national analysis of strengths, weaknesses, opportunities, threats (SWOT) of the LDKT program in Spain and the development of recommendations targeted to improve every step of the donation process. The work performed, the conclusions and recommendations provided, have been reflected in the following report: Spanish living donor kidney transplant program assessment: recommendations for optimization. This document has also been reviewed by a panel of experts, representatives of the scientific societies (Spanish Society of Urology (AEU), Spanish Society of Nephrology Nursery (SEDEN), Spanish Society of Immunology (SEI/GETH)) and the patient association ALCER. Finally, the report has been submitted to public consultation, reaching ample consensus. In addition, the transplant competent authorities of the different regions in Spain have adopted the report at institutional level. The work done and the recommendations to optimize LDKT are summarized in the present manuscript, organized by the different phases of the donation process.

COVID-19 in Solid Organ Transplant Recipients in Spain Throughout 2020: Catching the Wave?

BACKGROUND: Few studies have analyzed differences in clinical presentation and outcomes in solid organ transplant (SOT) recipients with coronavirus disease 2019 (COVID-19) across different pandemic waves. METHODS: In this multicenter, nationwide, prospective study, we compared demographics and clinical features, therapeutic management, and outcomes in SOT recipients diagnosed with COVID-19 in Spain before (first wave) or after (second wave) 13 July 2020. RESULTS: Of 1634 SOT recipients, 690 (42.2%) and 944 (57.8%) were diagnosed during the first and second periods, respectively. Compared with the first wave, recipients in the second were younger (median: 63 y [interquartile range, IQR: 53-71] versus 59 y [IQR: 49-68]; P < 0.001) and less likely to receive anti-severe acute respiratory syndrome coronavirus 2 drugs (81.8% versus 8.1%; P < 0.001), with no differences in immunomodulatory therapies (46.8% versus 47.0%; P = 0.931). Adjustment of immunosuppression was less common during the second period (76.4% versus 53.6%; P < 0.001). Hospital admission (86.7% versus 58.1%; P < 0.001), occurrence of acute respiratory distress syndrome (34.1% versus 21.0%; P < 0.001), and case-fatality rate (25.8% versus 16.7%; P < 0.001) were lower in the second period. In multivariate analysis, acquiring COVID-19 during the first wave was associated with an increased risk of death (OR: 1.47; 95% confidence interval [CI], 1.12-1.93; P = 0.005), although this impact was lost in the subgroup of patients requiring hospital (OR: 0.97; 95% CI, 0.73-1.29; P = 0.873) or intensive care unit admission (OR: 0.65; 95% CI, 0.35-1.18; P = 0.157). CONCLUSIONS: We observed meaningful changes in demographics, therapeutic approaches, level of care, and outcomes between the first and second pandemic waves. However, outcomes have not improved in the more severe cases of posttransplant COVID-19.

IgA Nephropathy After Renal Transplant: Recurrences and De Novo Cases.

IgA nephropathy (IgAN) recurrence in the renal graft is variable. Several factors can influence the risk of recurrence of IgAN and renal graft failure. We carried out a retrospective observational study between the years 1990 and 2018. The study group was patients diagnosed, by means of biopsy, as having post-renal transplant (RT) IgAN in our hospital in the study period. The control group was patients with pre-RT histologic diagnosis of IgAN who did not develop recurrence of the disease after the RT. A total of 1535 RTs were performed in our center in the study period. Of those, 24 patients developed IgAN in the renal graft. The time elapsed from the RT to the development of allograft IgAN was 7 (SD, 5.3) years. The patients with allograft IgAN tended to be younger (P = .069), and HLA-DR4 was more common in these patients (P = .078). We observed a very significant difference in the use of induction immunosuppressive therapy (study group vs control group: 13.6% vs 57.7%, P < .001). The 3 patients who presented crescents in the biopsy specimen lost the renal graft. As in the native kidney, the presence of crescents is an indicator of poor prognosis. In our experience, the patients with post-RT IgAN received induction therapy less frequently; this finding would support the conclusion that such treatments should be applied to patients with pre-RT diagnosis of IgAN.

Perfil sociosanitario e información a donantes y receptores renales de vivo en tres hospitales andaluces / Socio-sanitary profile and information for living kidney donors and recipients in three Andalusian hospitals

ANTECEDENTES: La información suministrada por profesionales sanitarios a posibles donantes y receptores es fundamental para una decisión autónoma y objetiva de donar un riñón en vida. OBJETIVOS: Conocer las características de la información que reciben los donantes y receptores renales de vivo, averiguando su perfil sociosanitario, sus características sociodemográficas, económico-laborales, de salud y la actividad cuidadora de dichos donantes y receptores. MÉTODOS: Estudio observacional, descriptivo, transversal, de la población de donantes y receptores renales de vivo, de los Hospitales Universitarios Puerta del Mar (Cádiz), Virgen del Rocío (Sevilla) y Complejo Hospitalario Universitario de Granada, entre el 8 de abril de 2014 y el 8 de junio de 2015. RESULTADOS Y CONCLUSIONES: Según los 40 donantes y 40 receptores renales de vivo encuestados, los facultativos de nefrología son principalmente quienes dan a conocer e informan sobre la donación renal en vida. Casi la mitad de receptores demandan más información, por lo que se deberían actualizar los procesos de evaluación y de información antes de la donación. En general, el donante renal vivo es mujer, de 50 años, con estudios de Primaria/ESO, vive en pareja, está emparentado con el receptor del riñón, realiza un trabajo remunerado, tiene sobrepeso, percibe su salud como muy buena o buena, y no fuma ni consume alcohol. Sin embargo, el receptor renal tipo es hombre, con 44 años, tiene estudios de bachillerato/FP, no trabaja, percibe su salud como buena o regular, y son personas independientes para las actividades de la vida diaria

BACKGROUND: Information provided by health professionals to potential donors and recipients is essential for an autonomous and objective decision to make a living kidney donation. OBJECTIVES: To determine the characteristics of the information received by living kidney donors and recipients, to find out their socio-sanitary profile, their socio-demographics, financial and labour characteristics, health and the caregiving activity of these donors and recipients. METHODS: Observational, descriptive and cross-sectional study of the population of living kidney donors and recipients from the University Hospitals Puerta del Mar (Cádiz), Virgen del Rocío (Seville), and the University Hospital Complex of Granada, between 08/04/2014 and 08/06/2015. RESULTS AND CONCLUSIONS: According to the 40 living kidney donors and their 40 recipients surveyed, it is mainly nephrologists who make people aware and provide information about living kidney donation. Almost half of recipients require more information so the evaluation processes and pre-donation information should be updated. In general, the living kidney donor is female, aged 50, with primary/secondary education, lives with a partner and is related to the kidney recipient. Also, the living kidney donor is in paid employment, is overweight, perceives her health as very good or good, and does not smoke or drink alcohol. However, the typical living kidney recipient is male, aged 44 and has completed secondary school studies and vocational training. Furthermore, he does not work, perceives his health as good or regular, and he is an independent person for activities of daily living

Socio-sanitary profile and information for living kidney donors and recipients in three Andalusian hospitals. / Perfil sociosanitario e información a donantes y receptores renales de vivo en tres hospitales andaluces.

BACKGROUND: Information provided by health professionals to potential donors and recipients is essential for an autonomous and objective decision to make a living kidney donation. OBJECTIVES: To determine the characteristics of the information received by living kidney donors and recipients, to find out their socio-sanitary profile, their socio-demographics, financial and labour characteristics, health and the caregiving activity of these donors and recipients. METHODS: Observational, descriptive and cross-sectional study of the population of living kidney donors and recipients from the University Hospitals Puerta del Mar (Cádiz), Virgen del Rocío (Seville), and the University Hospital Complex of Granada, between 08/04/2014 and 08/06/2015. RESULTS AND CONCLUSIONS: According to the 40 living kidney donors and their 40 recipients surveyed, it is mainly nephrologists who make people aware and provide information about living kidney donation. Almost half of recipients require more information so the evaluation processes and pre-donation information should be updated. In general, the living kidney donor is female, aged 50, with primary/secondary education, lives with a partner and is related to the kidney recipient. Also, the living kidney donor is in paid employment, is overweight, perceives her health as very good or good, and does not smoke or drink alcohol. However, the typical living kidney recipient is male, aged 44 and has completed secondary school studies and vocational training. Furthermore, he does not work, perceives his health as good or regular, and he is an independent person for activities of daily living.

Effect of paricalcitol on mineral bone metabolism in kidney transplant recipients with secondary hyperparathyroidism.

INTRODUCTION: Secondary hyperparathyroidism is highly prevalent in kidney transplant recipients, and commonly results in hypercalcaemia; an association to osteopenia and bone fractures has also been observed. Paricalcitol has proved effective to control secondary hyperparathyroidism in chronic kidney disease in both dialysed and non-dialysed patients, with a low hypercalcaemia incidence. Currently available experience on paricalcitol use in kidney transplant recipients is scarce. Our main aim was to show the effect of paricalcitol on mineral bone metabolism in kidney transplant recipients with secondary hyperparathyroidism. MATERIAL AND METHODS: A retrospective multicentre study in kidney transplant recipients aged>18 years with a 12-month or longer post-transplantation course, stable renal function, having received paricalcitol for more than 12 months, with available clinical follow-up for a 24-month period. RESULTS: A total of 69 patients with a 120 ± 92-month post-transplantation course were included. Baseline creatinine was 2.2 ± 0.9 mg/dl y GFR-MDRD was 36 ± 20 ml/min/1.73 m(2). Paricalcitol doses were gradually increased during the study: baseline 3.8 ± 1.9 µg/week, 12 months 5.2 ± 2.4 µg/week; 24 months 6.0 ± 2.9 µg/week (P<.001). Serum PTH levels showed a significant fast decline: baseline 288 ± 152 pg/ml; 6 months 226 ± 184 pg/ml; 12 months 207 ± 120; 24 months 193 ± 119 pg/ml (P<.001). Reduction from baseline PTH was ≥30% in 42.4% of patients at 12 months y in 65.2% of patients at 24 months. Alkaline phosphatase showed a significant decrease in first 6 months followed by a plateau: baseline 92 ± 50 IU/l; 6 months 85 ± 36 IU/l, 12 months 81 ± 39 IU/l (P<.001). Overall, no changes were observed in serum calcium and phosphorus, and in urine calcium excretion. PTH decline was larger in patients with higher baseline levels. Patients with lower baseline calcium levels showed significantly increased levels (mean increase was 0.5-0.6 mg/dl) but still within normal range, whereas patients with baseline calcium>10mg/dl showed gradually decreasing levels. Fifteen (21.7%) patients had received prior calcitriol therapy. When shifted to paricalcitol, such patients required paricalcitol doses significantly larger than those not having received calcitriol. Paricalcitol was used concomitantly to cinacalcet in 11 patients with significant PTH reductions being achieved; clinical course was similar to other patients and paricalcitol doses were also similar. CONCLUSIONS: Paricalcitol is an effective therapy for secondary hyperparathyroidism in kidney transplant recipients. Overall, no significant changes were observed in calcium and phosphorus levels or urinary excretion. Patients having previously received calcitriol required higher paricalcitol doses. When used in patients receiving cinacalcet, paricalcitol results in a significant PTH fall, with paricalcitol doses being similar to those used in patients not receiving cinacalcet.

Efecto de paricalcitol sobre el metabolismo mineralóseo en pacientes trasplantados renales con hiperparatiroidismo secundario / Effect of paricalcitol on mineral bone metabolism in kidney transplant recipients with secondary hyperparathyroidism

Introducción: El hiperparatiroidismo secundario es muy prevalente en pacientes trasplantados renales. Cursa con frecuencia con hipercalcemia y se ha asociado al desarrollo de osteopenia y fracturas óseas. El paricalcitol ha mostrado su eficacia en el control del hiperparatiroidismo secundario en la enfermedad renal crónica con y sin diálisis, con una baja incidencia de hipercalcemia. La experiencia con paricalcitol en trasplantados renales es muy escasa. El objetivo de este trabajo fue mostrar el efecto sobre el metabolismo mineralóseo del paricalcitol en trasplantados renales con hiperparatiroidismo secundario. Material y métodos: Estudio retrospectivo multicéntrico con trasplantados renales de más de 18 años de edad y más de 12 meses de evolución postrasplante, con función renal estable, que hayan sido tratados con paricalcitol durante más de 12 meses, con seguimiento clínico hasta los 24 meses de tratamiento. Resultados: Se incluyó a 69 pacientes, con 120±92 meses postrasplante, con creatinina inicial de 2,2±0,9mg/dl y FG-MDRD 36±20ml/min/1,73 m2. La dosis de paricalcitol se incrementó progresivamente durante el estudio: basal 3,8±1,9μg/semana, 12 meses 5,2±2,4μg/semana; 24 meses 6,0±2,9μg/semana (p<0,001). Los niveles séricos de PTH descendieron de forma rápida y significativa: basal 288±152 pg/ml; 6 meses 226±184 pg/ml; 12 meses 207±120; 24 meses 193±119 pg/ml (p<0,001). Observamos una reducción sobre PTH basal ≥30% en el 42,4% de los pacientes a los 12 meses y en el 65,2% de los pacientes a los 24 meses. La fosfatasa alcalina descendió también significativamente en los 6 primeros meses para luego estabilizarse: basal 92±50 UI/l; 6 meses 85±36 UI/l, 12 meses 81±39 UI/l (p<0,001). Globalmente no hubo modificaciones en el calcio o fósforo séricos ni en la excreción urinaria de calcio. La reducción de PTH fue más importante en trasplantados con niveles séricos más elevados de partida. Observamos que los pacientes con calcio basal más bajo mostraron un incremento significativo de sus cifras de 0,5-0,6 mg/dl en promedio aunque manteniéndose en rango de normalidad, mientras que pacientes con calcio basal > 10 mg/dl mostraron una reducción progresiva de sus cifras. Quince (21,7%) pacientes seguían tratamiento previo con calcitriol y al cambiarlos a paricalcitol precisaron dosis significativamente mayores que los pacientes que no habían recibido calcitriol. El paricalcitol fue asociado a cinacalcet en 11 pacientes, con reducciones significativas de PTH, con evolución similar al resto de la población y con dosis de paricalcitol también similares. Conclusiones: Paricalcitol es eficaz en el tratamiento del hiperparatiroidismo secundario de trasplantados renales. Globalmente no observamos modificaciones significativas de los niveles de calcio ni de fósforo, ni en su excreción urinaria. Los pacientes en tratamiento previo con calcitriol precisaron dosis mayores de paricalcitol. Cuando el paricalcitol se administra a pacientes tratados con cinacalcet, se observa un descenso significativo de la PTH con dosis de paricalcitol similar a pacientes sin cinacalcet (AU)

Introduction: Secondary hyperparathyroidism is highly prevalent in kidney transplant recipients, and commonly results in hypercalcaemia; an association to osteopenia and bone fractures has also been observed. Paricalcitol has proved effective to control secondary hyperparathyroidism in chronic kidney disease in both dialysed and non-dialysed patients, with a low hypercalcaemia incidence. Currently available experience on paricalcitol use in kidney transplant recipients is scarce. Our main aim was to show the effect of paricalcitol on mineral bone metabolism in kidney transplant recipients with secondary hyperparathyroidism. Material and methods: A retrospective multicentre study in kidney transplant recipients aged > 18 years with a 12-month or longer post-transplantation course, stable renal function, having received paricalcitol for more than 12 months, with available clinical follow-up for a 24-month period. Results: A total of 69 patients with a 120 ± 92-month post-transplantation course were included. Baseline creatinine was 2.2 ± 0.9 mg/dl y GFR-MDRD was 36 ± 20 ml/min/1.73m2. Paricalcitol doses were gradually increased during the study: baseline 3.8 ± 1.9 g/week, 12 months 5.2 ± 2.4 g/week; 24 months 6.0 ± 2.9 g/week (P<.001). Serum PTH levels showed a significant fast decline: baseline 288 ± 152 pg/ml; 6 months 226 ± 184 pg/ml; 12 months 207 ± 120; 24 months 193 ± 119 pg/ml (P<.001). Reduction from baseline PTH was ≥30% in 42.4% of patients at 12 months y in 65.2% of patients at 24 months. Alkaline phosphatase showed a significant decrease in first 6 months followed by a plateau: baseline 92 ± 50 IU/l; 6 months 85 ± 36 IU/l, 12 months 81 ± 39 IU/l (P<.001). Overall, no changes were observed in serum calcium and phosphorus, and in urine calcium excretion. PTH decline was larger in patients with higher baseline levels. Patients with lower baseline calcium levels showed significantly increased levels (mean increase was 0.5-0.6 mg/dl) but still within normal range, whereas patients with baseline calcium > 10 mg/dl showed gradually decreasing levels. Fifteen (21.7%) patients had received prior calcitriol therapy. When shifted to paricalcitol, such patients required paricalcitol doses significantly larger than those not having received calcitriol. Paricalcitol was used concomitantly to cinacalcet in 11 patients with significant PTH reductions being achieved; clinical course was similar to other patients and paricalcitol doses were also similar. Conclusions: Paricalcitol is an effective therapy for secondary hyperparathyroidism in kidney transplant recipients. Overall, no significant changes were observed in calcium and phosphorus levels or urinary excretion. Patients having previously received calcitriol required higher paricalcitol doses. When used in patients receiving cinacalcet, paricalcitol results in a significant PTH fall, with paricalcitol doses being similar to those used in patients not receiving cinacalcet (AU)