Outcomes of kidney retransplantation in recipients with prior post-transplant lymphoproliferative disorder.

Post-transplant lymphoproliferative disease (PTLD) is an uncommon but serious complication of solid organ transplantation. Reduction in immunosuppression is the mainstay of PTLD treatment, but it may precipitate graft loss. Retransplantation remains controversial, as immunosuppression resumption may trigger PTLD relapse. Herein, we describe the experience of eight patients who underwent kidney retransplantation after successful PTLD treatment. Epstein-Barr virus (EBV) serology was not known before the first transplantation. PTLD was diagnosed 62.5 months (range 5-323 months) after transplantation and was confined to the renal allograft (n = 1), lymph nodes (n = 2), gastrointestinal tract (n = 4), or central nervous system (n = 1). Immunosuppression tapering (8/8), chemotherapy (6/8), oral cavity lymphoma excision (1/8), and allograft nephrectomy (1/8) led to hematological remission in all patients. Retransplantation was performed at a median of 55.5 months (range 29-95 months) after PTLD diagnosis. After a median follow-up of 62.5 months (range 2-125 months) allograft survival was 87.5% (seven functioning grafts, one failed graft from chronic rejection), with no recurrence of PTLD. In all, five patients remain alive; the other three died from causes other than PTLD. In conclusion, kidney retransplantation appears to be safe in patients with prior PTLD and without major risk of hematological recurrence provided that PTLD has remitted.

Screening for, monitoring, and treatment of chronic kidney disease stages 1 to 3: a systematic review for the U.S. Preventive Services Task Force and for an American College of Physicians Clinical Practice Guideline.

BACKGROUND: Screening and monitoring for chronic kidney disease (CKD) could lead to earlier interventions that improve clinical outcomes. PURPOSE: To summarize evidence about the benefits and harms of screening for and monitoring and treatment of CKD stages 1 to 3 in adults. DATA SOURCES: MEDLINE (1985 through November 2011), reference lists, and expert suggestions. STUDY SELECTION: English-language, randomized, controlled trials that evaluated screening for or monitoring or treatment of CKD and that reported clinical outcomes. DATA EXTRACTION: Two reviewers assessed study characteristics and rated quality and strength of evidence. DATA SYNTHESIS: No trials evaluated screening or monitoring, and 110 evaluated treatments. Angiotensin-converting enzyme inhibitors (relative risk, 0.65 [95% CI, 0.49 to 0.88]) and angiotensin II-receptor blockers (relative risk, 0.77 [CI, 0.66 to 0.90]) reduced end-stage renal disease versus placebo, primarily in patients with diabetes who have macroalbuminuria. Angiotensin-converting enzyme inhibitors reduced mortality versus placebo (relative risk, 0.79 [CI, 0.66 to 0.96]) in patients with microalbuminuria and cardiovascular disease or high-risk diabetes. Statins and ß-blockers reduced mortality and cardiovascular events versus placebo or control in patients with impaired estimated glomerular filtration rate and either hyperlipidemia or congestive heart failure, respectively. Risks for mortality, end-stage renal disease, or other clinical outcomes did not significantly differ between strict and usual blood pressure control. The strength of evidence was rated high for angiotensin II-receptor blockers and statins, moderate for angiotensin-converting enzyme inhibitors and ß-blockers, and low for strict blood pressure control. LIMITATIONS: Evidence about outcomes was sometimes scant and derived from post hoc analyses of subgroups of patients enrolled in trials. Few trials reported or systematically collected information about adverse events. Selective reporting and publication bias were possible. CONCLUSION: The role of CKD screening or monitoring in improving clinical outcomes is uncertain. Evidence for CKD treatment benefit is strongest for angiotensin-converting enzyme inhibitors and angiotensin II-receptor blockers, and in patients with albuminuria combined with diabetes or cardiovascular disease. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.

Should peritoneal dialysis be the preferred therapy pre-kidney transplantation?

The impact of pre-transplant dialysis modality on kidney transplant outcomes has been the impetus for many discrepant reports. Although candidacy for kidney transplantation may not necessarily be the main factor in deciding the choice of pre-transplant dialysis modality, certain complications are thought to be associated with one dialysis modality compared with the other and should be acknowledged. Most of the evidence to date, especially that for lower rates of delayed graft function, indicates an advantage for peritoneal dialysis (PD) over hemodialysis. More importantly, some groups of recipients clearly benefit more from receiving PD pre-transplant, a finding that was recently reported for high-risk adult recipients of expanded-criteria donor organs and pediatric recipients of living-donor organs. On the other hand, PD may be associated with a higher risk of early graft thrombosis. Moreover, the published literature highlights the need for caution in older candidates with a family history of diabetes mellitus because of potential higher risk for new-onset post-transplantation diabetes mellitus in PD patients. Interestingly, prospective studies validating those findings are scarce; most of the published reports have been limited by either small patient numbers or a lack of consideration of other confounding risk factors. In the present review, we examined the available literature related to the influence of pre-transplant dialysis modality on post-transplant allograft and recipient outcomes.