Two-year outcomes in de novo renal transplant recipients receiving everolimus-facilitated calcineurin inhibitor reduction regimen from the TRANSFORM study.

TRANSFORM (TRANSplant eFficacy and safety Outcomes with an eveRolimus-based regiMen) was a 24-month, prospective, open-label trial in 2037 de novo renal transplant recipients randomized (1:1) within 24 hours of transplantation to receive everolimus (EVR) with reduced-exposure calcineurin inhibitor (EVR + rCNI) or mycophenolate with standard-exposure CNI. Consistent with previously reported 12-month findings, noninferiority of the EVR + rCNI regimen for the primary endpoint of treated biopsy-proven acute rejection (tBPAR) or estimated glomerular filtration rate (eGFR) <50 mL/min per 1.73 m2 was achieved at month 24 (47.9% vs 43.7%; difference = 4.2%; 95% confidence interval = -0.3, 8.7; P = .006). Mean eGFR was stable up to month 24 (52.6 vs 54.9 mL/min per 1.73 m2 ) in both arms. The incidence of de novo donor-specific antibodies (dnDSA) was lower in the EVR + rCNI arm (12.3% vs 17.6%) among on-treatment patients. Although discontinuation rates due to adverse events were higher with EVR + rCNI (27.2% vs 15.0%), rates of cytomegalovirus (2.8% vs 13.5%) and BK virus (5.8% vs 10.3%) infections were lower. Cytomegalovirus infection rates were significantly lower with EVR + rCNI even in the D+/R- high-risk group (P < .0001). In conclusion, the EVR + rCNI regimen offers comparable efficacy and graft function with low tBPAR and dnDSA rates and significantly lower incidence of viral infections relative to standard-of-care up to 24 months. Clinicaltrials.gov number: NCT01950819.

[Renal Transplantation in a patient with Recessive Dystrophic Epidermolysis Bullosa: a case report] / Reporte de caso: Trasplante Renal en un paciente con Epidermolisis Bullosa.

Recessive dystrophic epidermolysis bullosa (RDEB) is a rare genodermatosis characterized by abnormalities in the anchoring fibrils which attach the basal cell layer of the epidermis to the underlying structures. A characteristic feature of this disorder is the presence of recurrent blistering or erosions, the result of even minor traction to these tissues. Patients with RDEB frequently develop chronic renal failure, and require renal replacement therapy being a major cause of morbidity and mortality. The role of renal transplantation in these patients is scarcely known. We present the case of an end-stage renal disease patient with RDEB treated by renal transplantation and his follow-up during a period of 83 months after the transplant. In this period, there were very low frequency of serious infections as well as the absence of skin tumors. Renal transplantation could be an alternative to renal replacement therapy in epidermolysis bullosa patients with end-stage renal disease, reducing the comorbidities associated with this treatment.

La epidermolisis bullosa distrófica recesiva (EBDR) es una genodermatosis extremadamente infrecuente, caracterizada por la existencia de alteraciones a nivel de las fibras de anclaje que unen la membrana basal de la epidermis a las estructuras subyacentes. Un elemento característico de esta entidad es la formación recurrente de ampollas en piel y mucosas ante traumatismos mínimos, con posterior cicatrización. Los pacientes con EBRD frecuentemente desarrollan enfermedad renal crónica y requieren de terapia de reemplazo renal, constituyendo una importante causa de morbilidad y mortalidad en estos pacientes. El rol del trasplante renal es poco conocido en este tipo de pacientes.Se presenta el caso de un paciente con enfermedad renal terminal y EBDR que es tratado con trasplante renal y su seguimiento a lo largo de un período de 83 meses luego del trasplante. Durante dicho período se observó una baja frecuencia de intercurrencias infecciosas, así como la ausencia de desarrollo de neoplasias cutáneas. El trasplante renal podría ser una alternativa a la terapia de reemplazo dialítica en los pacientes con epidermolisis bullosa asociada a enfermedad renal terminal, reduciendo las comorbilidades asociadas a las terapias dialíticas.

Management of Patients Who Receive an Organ Transplant Abroad and Return Home for Follow-up Care: Recommendations From the Declaration of Istanbul Custodian Group.

Eradicating transplant tourism depends on complex solutions that include efforts to progress towards self-sufficiency in transplantation. Meanwhile, professionals and authorities are faced with medical, legal, and ethical problems raised by patients who return home after receiving an organ transplant abroad, particularly when the organ has been obtained through illegitimate means. In 2016, the Declaration of Istanbul Custodian Group convened an international, multidisciplinary workshop in Madrid, Spain, to address these challenges and provide recommendations for the management of these patients, which are presented in this paper. The core recommendations are grounded in the belief that principles of transparency, traceability, and continuity of care applied to patients who receive an organ domestically should also apply to patients who receive an organ abroad. Governments and professionals are urged to ensure that, upon return, patients are promptly referred to a transplant center for evaluation and care, not cover the costs of transplants resulting from organ or human trafficking, register standardized information at official registries on patients who travel for transplantation, promote international exchange of data for traceability, and develop a framework for the notification of identified or suspected cases of transnational transplant-related crimes by health professionals to law enforcement agencies.

Cardiovascular Parameters to 2 years After Kidney Transplantation Following Early Switch to Everolimus Without Calcineurin Inhibitor Therapy: An Analysis of the Randomized ELEVATE Study.

BACKGROUND: Mammalian target of rapamycin inhibitors may confer cardioprotective advantages, but clinical data are limited. METHODS: In the open-label ELEVATE trial, kidney transplant patients were randomized at 10 to 14 weeks after transplant to convert from calcineurin inhibitor (CNI) to everolimus or remain on standard CNI therapy. Prespecified end points included left ventricular mass index and, in a subpopulation of patients, arterial stiffness as measured by pulse wave velocity. RESULTS: The mean change in left ventricular mass index from randomization was similar with everolimus versus CNI (month 24, -4.37 g/m versus -5.26 g/m; mean difference, 0.89 [p = 0.392]). At month 24, left ventricular hypertrophy was present in 41.7% versus 37.7% of everolimus and CNI patients, respectively. Mean pulse wave velocity remained stable with both everolimus (mean change from randomization to month 12, -0.24 m/s; month 24, -0.03 m/s) and CNI (month 12, 0.11 m/s; month 24, 0.16 m/s). The change in mean ambulatory nighttime blood pressure from randomization showed a benefit for diastolic pressure at month 12 (P = 0.039) but not at month 24. Major adverse cardiac events occurred in 1.1% and 4.2% of everolimus-treated and CNI-treated patients, respectively, by month 12 (P = 0.018) and 2.3% (8/353) and 4.5% by month 24 (P = 0.145). CONCLUSIONS: Overall, these data do not suggest a clinically relevant effect on cardiac end points after early conversion from CNI to a CNI-free everolimus-based regimen.

[The role of kidney transplantation in reducing mortality in a chronic dialysis program]. / Trasplante renal y disminución de la mortalidad en los programas de diálisis crónica.

For patients with chronic renal failure (CRF), kidney transplant (KT) is a better alternative to dialysis in terms of survival, life quality and costs. We studied the general characteristics, causes and survival rate of the dialysis population in 2010. We evaluated broader criteria for acceptance of transplants has affected the results of the procedure in that period. A total of 118 dialysis patients were included; mean age 56.9 ± 18.4 years, dialysis duration 45.5 ± 59.6 months, main cause of CRF was diabetes in 35 (30%), and 58 (49%) were included in waiting list for KT. Of the 34 patients who finished dialysis in 2010, 18 (53%) were KT, while 12 (35%) died (cardiovascular 50%, infectious 17%). Survival at 12 months was 85% for the total group, 98% on waiting list and 72% those who were not enrolled. During 2010 there were 88 KT, 62 with cadaveric donors (CD), 18 with living donors and 8 with double pancreas-kidney transplants. Recipients of CD were 50.7 years old, with 67 months on dialysis, 8 (13%) diabetics, and 12 (20%) with previous KT. Donors had a mean age of 45 years, 28 (45%) expanded criteria, and 27.7 hours of cold ischemia time. During an approximate follow-up of 11.4 months, 13 (21%) suffered acute graft rejection, survival was 88% for graft and 93% for patients. We emphasize KT as the main cause of success as regards dialysis. No differences in risk factors were found to significantly affect graft or patient survival.

Trasplante renal y disminución de la mortalidad en los programas de diálisis crónica / The role of kidney transplantation in reducing mortality in a chronic dialysis program

El trasplante renal (TR) presenta mejor supervivencia, calidad de vida y costos que la diálisis en la insuficiencia renal crónica (IRC). Estudiamos pacientes en diálisis que recibieron TR durante 2010, las causas de finalización del tratamiento y la supervivencia en diálisis. Evaluamos si criterios más amplios para la aceptación de trasplantes hubieran afectado los resultados del procedimiento en ese período. Incluimos 118 pacientes en diálisis, edad media 56.9 ± 18.4 años, tiempo en diálisis 45.5 ± 59.6 meses, 35 (30%) presentaban diabetes como causa de IRC, y 58 (49%) estaban en espera del TR. Treinta y cuatro finalizaron diálisis, 18 por TR y 12 por fallecimiento. Las principales causas de muerte fueron cardiovasculares, 6 (50%) e infecciones, 2 (17%). La supervivencia al año fue 85% para el grupo total, 98% para los pacientes inscriptos en lista de espera y 72% para no inscriptos. Durante 2010 se realizaron 88 TR (62 con donantes cadavéricos [DC], 18 donantes vivos y 8 dobles trasplantes páncreas-riñón). Los receptores de DC tenían en promedio 50.7 años, 67 meses en diálisis, 8 (13%) eran diabéticos, 12 (20%) con TR previos y 3 cross match contra panel de anticuerpos > 20%. Los donantes tenían edad media 45 años, 28 (45%) con criterios expandidos y 27.7 h de isquemia fría. A los 11.4 meses de seguimiento, 13 (21%) presentó rechazo agudo, la supervivencia para injerto fue de 88% y 93% para pacientes. La principal causa de finalización de diálisis fue TR, sin detectarse que el empleo de DC afectara la supervivencia del TR.(AU)

For patients with chronic renal failure (CRF), kidney transplant (KT) is a better alternative to dialysis in terms of survival, life quality and costs. We studied the general characteristics, causes and survival rate of the dialysis population in 2010. We evaluated broader criteria for acceptance of transplants has affected the results of the procedure in that period. A total of 118 dialysis patients were included; mean age 56.9 ± 18.4 years, dialysis duration 45.5 ± 59.6 months, main cause of CRF was diabetes in 35 (30%), and 58 (49%) were included in waiting list for KT. Of the 34 patients who finished dialysis in 2010, 18 (53%) were KT, while 12 (35%) died (cardiovascular 50%, infectious 17%). Survival at 12 months was 85% for the total group, 98% on waiting list and 72% those who were not enrolled. During 2010 there were 88 KT, 62 with cadaveric donors (CD), 18 with living donors and 8 with double pancreas-kidney transplants. Recipients of CD were 50.7 years old, with 67 months on dialysis, 8 (13%) diabetics, and 12 (20%) with previous KT. Donors had a mean age of 45 years, 28 (45%) expanded criteria, and 27.7 hours of cold ischemia time. During an approximate follow-up of 11.4 months, 13 (21%) suffered acute graft rejection, survival was 88% for graft and 93% for patients. We emphasize KT as the main cause of success as regards dialysis. No differences in risk factors were found to significantly affect graft or patient survival.(AU)

Trasplante renal y disminución de la mortalidad en los programas de diálisis crónica / The role of kidney transplantation in reducing mortality in a chronic dialysis program

El trasplante renal (TR) presenta mejor supervivencia, calidad de vida y costos que la diálisis en la insuficiencia renal crónica (IRC). Estudiamos pacientes en diálisis que recibieron TR durante 2010, las causas de finalización del tratamiento y la supervivencia en diálisis. Evaluamos si criterios más amplios para la aceptación de trasplantes hubieran afectado los resultados del procedimiento en ese período. Incluimos 118 pacientes en diálisis, edad media 56.9 ± 18.4 años, tiempo en diálisis 45.5 ± 59.6 meses, 35 (30%) presentaban diabetes como causa de IRC, y 58 (49%) estaban en espera del TR. Treinta y cuatro finalizaron diálisis, 18 por TR y 12 por fallecimiento. Las principales causas de muerte fueron cardiovasculares, 6 (50%) e infecciones, 2 (17%). La supervivencia al año fue 85% para el grupo total, 98% para los pacientes inscriptos en lista de espera y 72% para no inscriptos. Durante 2010 se realizaron 88 TR (62 con donantes cadavéricos [DC], 18 donantes vivos y 8 dobles trasplantes páncreas-riñón). Los receptores de DC tenían en promedio 50.7 años, 67 meses en diálisis, 8 (13%) eran diabéticos, 12 (20%) con TR previos y 3 cross match contra panel de anticuerpos > 20%. Los donantes tenían edad media 45 años, 28 (45%) con criterios expandidos y 27.7 h de isquemia fría. A los 11.4 meses de seguimiento, 13 (21%) presentó rechazo agudo, la supervivencia para injerto fue de 88% y 93% para pacientes. La principal causa de finalización de diálisis fue TR, sin detectarse que el empleo de DC afectara la supervivencia del TR.

For patients with chronic renal failure (CRF), kidney transplant (KT) is a better alternative to dialysis in terms of survival, life quality and costs. We studied the general characteristics, causes and survival rate of the dialysis population in 2010. We evaluated broader criteria for acceptance of transplants has affected the results of the procedure in that period. A total of 118 dialysis patients were included; mean age 56.9 ± 18.4 years, dialysis duration 45.5 ± 59.6 months, main cause of CRF was diabetes in 35 (30%), and 58 (49%) were included in waiting list for KT. Of the 34 patients who finished dialysis in 2010, 18 (53%) were KT, while 12 (35%) died (cardiovascular 50%, infectious 17%). Survival at 12 months was 85% for the total group, 98% on waiting list and 72% those who were not enrolled. During 2010 there were 88 KT, 62 with cadaveric donors (CD), 18 with living donors and 8 with double pancreas-kidney transplants. Recipients of CD were 50.7 years old, with 67 months on dialysis, 8 (13%) diabetics, and 12 (20%) with previous KT. Donors had a mean age of 45 years, 28 (45%) expanded criteria, and 27.7 hours of cold ischemia time. During an approximate follow-up of 11.4 months, 13 (21%) suffered acute graft rejection, survival was 88% for graft and 93% for patients. We emphasize KT as the main cause of success as regards dialysis. No differences in risk factors were found to significantly affect graft or patient survival.

Trasplante renal y disminución de la mortalidad en los programas de diálisis crónica. / [The role of kidney transplantation in reducing mortality in a chronic dialysis program].

For patients with chronic renal failure (CRF), kidney transplant (KT) is a better alternative to dialysis in terms of survival, life quality and costs. We studied the general characteristics, causes and survival rate of the dialysis population in 2010. We evaluated broader criteria for acceptance of transplants has affected the results of the procedure in that period. A total of 118 dialysis patients were included; mean age 56.9 ± 18.4 years, dialysis duration 45.5 ± 59.6 months, main cause of CRF was diabetes in 35 (30

), and 58 (49

) were included in waiting list for KT. Of the 34 patients who finished dialysis in 2010, 18 (53

) were KT, while 12 (35

) died (cardiovascular 50

, infectious 17

). Survival at 12 months was 85

for the total group, 98

on waiting list and 72

those who were not enrolled. During 2010 there were 88 KT, 62 with cadaveric donors (CD), 18 with living donors and 8 with double pancreas-kidney transplants. Recipients of CD were 50.7 years old, with 67 months on dialysis, 8 (13

) diabetics, and 12 (20

) with previous KT. Donors had a mean age of 45 years, 28 (45

) expanded criteria, and 27.7 hours of cold ischemia time. During an approximate follow-up of 11.4 months, 13 (21

) suffered acute graft rejection, survival was 88

for graft and 93

for patients. We emphasize KT as the main cause of success as regards dialysis. No differences in risk factors were found to significantly affect graft or patient survival.

High prevalence of secondary hyperparathyroidism in chronic kidney disease patients on dialysis in Argentina.

BACKGROUND: There are few data in Argentina on the prevalence and management of bone and mineral metabolism (BMM) in patients with chronic kidney disease (CKD). OBJECTIVES AND METHODS: A survey was carried out in dialysis units in 2010 to measure the prevalence of and types of treatments for BMM disorders in Argentina. The data obtained was then compared to the published results from other large population studies. We recorded characteristics of dialysis centres and participating patients, the frequency of measurements and individual results for BMM biochemical markers, as well as the type of management used to control hyperphosphataemia and secondary hyperparathyroidism. RESULTS: 1210 patients from 25 dialysis centres in Argentina participated in the study (representing 4.7% of the country's prevalent dialysis population in 2010). The mean patient age was 55.3±17.6 years, 60.8% were male, 3.3% were on peritoneal dialysis and 29.1% suffered diabetes. In all centres, phosphataemia and calcaemia were measured on a monthly basis, 60% of centres measured intact parathyroid hormone (iPTH) every 6 months, 36% every 3 to 4 months, and 4% annually. As recommended by K/DOQI, 51.6% of patients had adequate levels of calcium (8.4-9.5 mg/dl), 51.6% had adequate phosphorus (3.5-5.5 mg/dl) and 21.1% displayed acceptable iPTH levels (150-300 pg/ml). 24% had iPTH <150 pg/ml and 54.5% >300 pg/ml. iPTH ≥600 pg/ml was present in 28.3%, and 13.3% had values ≥1000 pg/ml. These figures differed from those published by the DOPPS II study, in which 51.1% of patients had iPTH <150 pg/ml, and only 26.7% had iPTH ≥300 pg/ml. Calcium-based phosphate binders were used in 83.6% of the patients, 5.6% used sevelamer and 4.0% used aluminium-containing compounds. To achieve control of hyperparathyroidism, oral or intravenous calcitriol was predominantly used (50.5%) with a small percentage of patients receiving paricalcitol or doxercalciferol. CONCLUSIONS: The present study shows a high prevalence of secondary hyperparathyroidism, which differs from that published by other large population studies. There was a high proportion of patients with BMM markers outside the ranges suggested by K/DOQI. Mainly phosphate binders based on calcium and calcitriol continue to be used for the management of hyperphosphatemia and hyperparathyroidism respectively.

Elevada prevalencia de hiperparatiroidismo secundario en pacientes con enfermedad renal crónica en diálisis en Argentina / High prevalence of secondary hyperparathyroidism in chronic kidney disease patients on dialysis in Argentina

ANTECEDENTES: Existen pocos datos acerca de la prevalencia de los trastornos del metabolismo óseo y mineral (MOM) y su forma de manejo en pacientes con enfermedad renal crónica en Argentina. Objetivos y métodos: Mediante una encuesta realizada en 2010 en centros de diálisis, determinamos la prevalencia y las formas de tratamiento de los trastornos del MOM en Argentina y los comparamos con los datos publicados por otros grandes estudios poblacionales. Consignamos las características de los centros de diálisis y de los pacientes participantes, la frecuencia de las determinaciones y los resultados individuales de los marcadores bioquímicos del MOM y el tipo de manejo utilizado para controlar la hiperfosfatemia y el hiperparatiroidismo secundario. RESULTADOS: Participaron 1210 pacientes de 25 centros de diálisis de 10 provincias de Argentina (lo cual representaba el 4,7 % de la población prevalente en diálisis del país en 2010). La población estudiada tenía una edad media de 55,3 ± 17,6 años, 60,8 % eran varones, el 3,3 % en diálisis peritoneal y el 29,1 % eran diabéticos. El 100 % de los centros determinaban calcemia y fosfatemia mensualmente, el 60 % hormona paratiroidea intacta (PTHi) semestralmente, el 36 % cada 3 o 4 meses y el 4 % de forma anual. Según las recomendaciones de K/DOQI, el 51,6 % de los pacientes tenían niveles adecuados de calcio (8,4-9,5 mg/dl), el 51,6 % de fósforo (3,5-5,5 mg/dl) y el 21,1 % de PTHi (150 a 300 pg/ml). El 24,4 % tenían PTHi < 150 pg/ml y el 54,5 % > 300 pg/ml, con un 28,3 % con valores de PTHi > 600 pg/ml y un 13,3 % > 1000 pg/ml. Estos datos diferían de los publicados por el estudio DOPPS II, donde el 51,1 % de los pacientes presentaban PTHi < 150 pg/ml, y solo un 26,7 % PTHi > 300 pg/ml. El 83,6 % utilizaban un captor del fosfato basado en calcio, el 5,6 % sevelamer y el 4,0 % compuestos con aluminio. Para el control del hiperparatiroidismo se utilizaba predominantemente calcitriol oral o endovenoso (50,5 %), con un pequeño porcentaje de pacientes recibiendo paricalcitol o doxercalciferol. CONCLUSIONES: El presente estudio muestra una elevada prevalencia de hiperparatiroidismo secundario, lo cual difiere de lo publicado por otros grandes estudios poblacionales. Existe una elevada proporción de pacientes con marcadores del MOM por fuera de los niveles sugeridos por K/DOQI. Para el control de la hiperfosfatemia y el hiperparatiroidismo, se continúan utilizando mayormente captores del fosfato basados en calcio y calcitriol, respectivamente

BACKGROUND: There are few data in Argentina on the prevalence and management of bone and mineral metabolism (BMM) in patients with chronic kidney disease (CKD). Objectives and methods: A survey was carried out in dialysis units in 2010 to measure the prevalence of and types of treatments for BMM disorders in Argentina. The data obtained was then compared to the published results from other large population studies. We recorded characteristics of dialysis centres and participating patients, the frequency of measurements and individual results for BMM biochemical markers, as well as the type of management used to control hyperphosphataemia and secondary hyperparathyroidism. RESULTS: 1210 patients from 25 dialysis centres in Argentina participated in the study (representing 4.7% of the country's prevalent dialysis population in 2010). The mean patient age was 55.3±17.6 years, 60.8% were male, 3.3% were on peritoneal dialysis and 29.1% suffered diabetes. In all centres, phosphataemia and calcaemia were measured on a monthly basis, 60% of centres measured intact parathyroid hormone (iPTH) every 6 months, 36% every 3 to 4 months, and 4% annually. As recommended by K/DOQI, 51.6% of patients had adequate levels of calcium (8.4-9.5mg/dl), 51.6% had adequate phosphorus (3.5-5.5mg/dl) and 21.1% displayed acceptable iPTH levels (150-300pg/ml). 24% had iPTH <150pg/ml and 54.5% >300pg/ml. iPTH >600pg/ml was present in 28.3%, and 13.3% had values >1000pg/ml. These figures differed from those published by the DOPPS II study, in which 51.1% of patients had iPTH <150pg/ml, and only 26.7% had iPTH >300pg/ml. Calcium-based phosphate binders were used in 83.6% of the patients, 5.6% used sevelamer and 4.0% used aluminium-containing compounds. To achieve control of hyperparathyroidism, oral or intravenous calcitriol was predominantly used (50.5%) with a small percentage of patients receiving paricalcitol or doxercalciferol. CONCLUSIONS: The present study shows a high prevalence of secondary hyperparathyroidism, which differs from that published by other large population studies. There was a high proportion of patients with BMM markers outside the ranges suggested by K/DOQI. Mainly phosphate binders based on calcium and calcitriol continue to be used for the management of hyperphosphatemia and hyperparathyroidism respectively

[Associated factors and clinical implications of post transplant renal anemia]. / Factores asociados y consecuencias clínicas de la anemia post trasplante renal.

A considerable percentage of patients exhibit anemia post kidney transplant. Its origin is multifactorial and the main causes involved depend on the post transplant period considered. We studied in a group of 134 consecutive patients the associated factors and the clinical implications of "late anemia" (6 months post transplant). Multiple regression analysis showed that post transplant oliguria and acute rejection episodes were significantly associated with anemia. Graft survival at 36 months was significantly reduced in the anemic group (83 % versus 96%, p < 0.01). No differences in patients survival or rate of cardiovascular events were observed. We concluded that anemia at 6 months post transplant is independently and significantly associated with events that reduced functioning renal mass and kidney survival.

Factores asociados y consecuencias clínicas de la anemia post trasplante renal / Associated factors and clinical implications of post transplant renal anemia

Un porcentaje considerable de pacientes presentan anemia post trasplante renal. Su origen es multifactorial y sus principales etiologías dependen de la etapa post trasplante que se considere. Estudiamos en un grupo de 134 pacientes los factores asociados con anemia tardía (6 meses post trasplante) y sus implicaciones clínicas a mediano plazo. En el análisis de regresión múltiple, la duración de la oliguria post trasplante y el número de episodios de rechazo fueron las variables significativamente asociadas con esta complicación. La supervivencia del órgano mostró una diferencia significativa a los 36 meses entre los grupos (83% en los anémicos versus 96% de los no anémicos p < 0.01). No observamos diferencias en mortalidad o eventos cardiovasculares. Concluimos que la presencia de anemia al sexto mes post trasplante renal está independiente y significativamente asociada con factores que condicionan la masa renal funcionante que explicarían además la menor supervivencia del injerto renal observada en estos pacientes.(AU)

A considerable percentage of patients exhibit anemia post kidney transplant. Its origin is multifactorial and the main causes involved depend on the post transplant period considered. We studied in a group of 134 consecutive patients the associated factors and the clinical implications of "late anemia" (6 months post transplant). Multiple regression analysis showed that post transplant oliguria and acute rejection episodes were significantly associated with anemia. Graft survival at 36 months was significantly reduced in the anemic group (83 % versus 96%, p < 0.01). No differences in patients survival or rate of cardiovascular events were observed. We concluded that anemia at 6 months post transplant is independently and significantly associated with events that reduced functioning renal mass and kidney survival.(AU)

Factores asociados y consecuencias clínicas de la anemia post trasplante renal / Associated factors and clinical implications of post transplant renal anemia

Un porcentaje considerable de pacientes presentan anemia post trasplante renal. Su origen es multifactorial y sus principales etiologías dependen de la etapa post trasplante que se considere. Estudiamos en un grupo de 134 pacientes los factores asociados con anemia tardía (6 meses post trasplante) y sus implicaciones clínicas a mediano plazo. En el análisis de regresión múltiple, la duración de la oliguria post trasplante y el número de episodios de rechazo fueron las variables significativamente asociadas con esta complicación. La supervivencia del órgano mostró una diferencia significativa a los 36 meses entre los grupos (83% en los anémicos versus 96% de los no anémicos p < 0.01). No observamos diferencias en mortalidad o eventos cardiovasculares. Concluimos que la presencia de anemia al sexto mes post trasplante renal está independiente y significativamente asociada con factores que condicionan la masa renal funcionante que explicarían además la menor supervivencia del injerto renal observada en estos pacientes.

A considerable percentage of patients exhibit anemia post kidney transplant. Its origin is multifactorial and the main causes involved depend on the post transplant period considered. We studied in a group of 134 consecutive patients the associated factors and the clinical implications of "late anemia" (6 months post transplant). Multiple regression analysis showed that post transplant oliguria and acute rejection episodes were significantly associated with anemia. Graft survival at 36 months was significantly reduced in the anemic group (83 % versus 96%, p < 0.01). No differences in patients survival or rate of cardiovascular events were observed. We concluded that anemia at 6 months post transplant is independently and significantly associated with events that reduced functioning renal mass and kidney survival.

Factores asociados y consecuencias clínicas de la anemia post trasplante renal. / [Associated factors and clinical implications of post transplant renal anemia].

A considerable percentage of patients exhibit anemia post kidney transplant. Its origin is multifactorial and the main causes involved depend on the post transplant period considered. We studied in a group of 134 consecutive patients the associated factors and the clinical implications of "late anemia" (6 months post transplant). Multiple regression analysis showed that post transplant oliguria and acute rejection episodes were significantly associated with anemia. Graft survival at 36 months was significantly reduced in the anemic group (83

versus 96

, p < 0.01). No differences in patients survival or rate of cardiovascular events were observed. We concluded that anemia at 6 months post transplant is independently and significantly associated with events that reduced functioning renal mass and kidney survival.

CKD-EPI instead of MDRD for candidates to kidney donation.

BACKGROUND: The determination of the glomerular filtration rate (GFR) is critical for the selection of a potential kidney donor. The complex and impractical techniques for the measurement of GFR have led to the development of equations to estimate GFR. Modification of diet in renal disease (MDRD) formula is the most widely used but its performance is poor because it systematically underestimates GFR above 60 mL/min. A new formula called the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) seems to overcome this limitation but needs to be tested in healthy potential kidney donors. METHODS: From 2007 to 2011, a cross-sectional study was performed on 85 adults who were candidates for living-related kidney donation. GFR was measured by nonradiolabeled iothalamate clearance determined by high-performance liquid chromatography, and renal function was estimated by using CKD-EPI and MDRD equations. The overall performance of the equations was analyzed, and the estimation for GFR above 90 mL/min was studied by means of receiver operating characteristic curves. RESULTS: The mean (SD) (range) of the measured GFR was 116 (24) (64-160) mL/min per 1.73 m(2), estimated GFR with CKD-EPI was 108 (22) (64-153) mL/min per 1.73 m(2), and MDRD was 99 (28) (46-157) mL/min per 1.73 m(2). CKD-EPI presented lower bias (3.3 vs. 10.2 mL/min/1.73 m(2)), higher precision [interquartile range (minimum value-maximum value), 25 (53-140) vs. 32 (43-161) ml/min] and higher accuracy (100% vs. 89%) compared with MDRD. CONCLUSION: The CKD-EPI equation showed a higher performance than the MDRD equation in the GFR estimation of healthy population. CKD-EPI is applicable instead of MDRD, to subjects or candidates for kidney donation to avoid wrong GFR underestimates, which may lead to an inappropriate exclusion of candidates.

New options for the management of hyperparathyroidism after renal transplantation.

The persistence and severity of hyperparathyroidism (HPT) post-renal transplantation is relatively frequent and primarily associated with the timing and its magnitude in the pre-transplant period and with the presence of parathyroid adenomas. HPT after renal transplantation is clinically manifested with hypercalcemia, hypophosphatemia, bone pain, fractures, and in more serious cases with cardiovascular calcifications that affect the survival. The primary clinical objective for patients with secondary HPT after renal transplantation is to obtain a level of parathyroid hormone (PTH) adequate to the renal transplanted function and to normalize levels of calcium, phosphorus and vitamin D. In many cases during this period, the development of hypercalcemia and/or hypophosphatemia makes it necessary to take different therapeutic measures. The use of vitamin D or its analogues has been extrapolated from the management of pre-transplant HPT obtaining variable outcomes, although its use is limited by its capacity to produce hypercalcemia. Calcimimetics are drugs that have proven be effective in reducing PTH levels in patients with HPT on dialysis and has been effective in reducing up to 50% PTH levels in moderate to severe HPT in post-renal transplantation.When HPT persists after renal transplantation and does not respond to medical treatment, invasive management by percutaneous ethanol injection therapy of parathyroid glands or parathyroidectomy should be considered. The emergence of new methods for the management of HPT expands the availability of therapeutic tools for transplant patients.

High-dose steroid treatment increases free water transport in peritoneal dialysis patients.

The water channel aquaporin-1 (AQP1) is the molecular counterpart of the ultrasmall pore that mediates free water transport during peritoneal dialysis (PD). Proof-of-principle studies performed in rats have shown that treatment with corticosteroids upregulates the expression of AQP1 in the peritoneal capillaries, causing a significant increase in free water transport. Whether such a beneficial effect could be observed in end-stage renal disease patients treated by PD remains unknown. Peritoneal transport parameters were evaluated in three patients on PD, shortly before and after living-donor renal transplantation and treatment with high-dose methylprednisolone (1.0-1.2 g/m(2)). As compared with pre-transplantation values, the post-transplantation test revealed an ∼2-fold increase in the sodium sieving and ultrasmall pore ultrafiltration volume, suggesting an effect on AQP1 water channels. In contrast, there was no change in the parameters of small solute transport. The direct involvement of AQP1 in these changes is suggested by the expression of glucocorticoid receptors in the human peritoneum and the presence of conserved glucocorticoid response elements in the promoter of the human AQP1 gene.

Use of percutaneous ethanol injection therapy for recurrent secondary hyperparathyroidism after subtotal parathyroidectomy.

We evaluated the efficacy of percutaneous ethanol injection therapy (PEIT) as a therapeutic option for recurrence of secondary hyperparathyroidism after subtotal parathyroidectomy in ESRD patients. Six patients underwent PEIT. A mean of 1.3 ± 0.8 ethanol injections was performed. Nodular volume was 1.5 ± 1.7 cm(3), and 2.8 ± 2.8 cm(3) of ethanol was injected per patient. After ethanol injection PTH decreased significantly (1897 ± 754 to 549 ± 863 pg/mL (P < .01)). There was also a reduction in serum calcium, phosphorus and calcium-phosphorus product. A positive and significant correlation was found between nodular volume with ethanol injected and time from parathyroidectomy. Only one patient required hospitalization due to severe hypocalcaemia. In other two cases, local discomfort and temporary mild dysphonia were registered. PEIT is an effective treatment to control recurrences of secondary hyperparathyroidism postsubtotal parathyroidectomy.

Evidence of closely related picobirnavirus strains circulating in humans and pigs in Argentina.

BACKGROUND: On the basis of the published literature, it is still difficult to draw conclusions as to whether picobirnavirus (PBV) circulation is influenced by host species restriction. OBJECTIVE: To provide data regarding the genetic relatedness between porcine and human PBV strains present in Argentina as a means of defining the host range and epidemiology of these viruses. METHODS: Fecal specimens (n = 74) collected from kidney transplant patients (n = 55) and piglets (n = 19) were analyzed by RT-PCR using primers designed to amplify the porcine PBV genomic segment 2. Amplified sequences were further examined phylogenetically. RESULTS: By RT-PCR amplification 14 of 74 samples rendered amplicons of the expected 282 base pair size (8 detected from humans and 6 from pigs). Eleven amplicons (5 from humans and 6 from pigs) were selected for sequencing and subjected to phylogenetic analysis. The eleven amplicons revealed similarities between human and porcine viral sequences that ranged between 94.7 and 100% in identity. Phylogenetic analysis identified these 11 strains as PBV genogroup I-related strains and showed that they grouped as a single separate clade distinct from other PBV strains detected in humans and porcine from other countries. CONCLUSIONS: The present study suggests that closely related PBV strains infect both pigs and humans in Argentina and that the epidemiology of PBVs is not species restricted.

Switching from calcineurin inhibitor-based regimens to a belatacept-based regimen in renal transplant recipients: a randomized phase II study.

BACKGROUND AND OBJECTIVES: Prolonged use of calcineurin inhibitors (CNIs) in kidney transplant recipients is associated with renal and nonrenal toxicity and an increase in cardiovascular risk factors. Belatacept-based regimens may provide a treatment option for patients who switch from CNI-based maintenance immunosuppression. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This is a randomized, open-label Phase II trial in renal transplant patients with stable graft function and receiving a CNI-based regimen. Patients who were ≥6 months but ≤36 months after transplantation were randomized to either switch to belatacept or continue CNI treatment. All patients received background maintenance immunosuppression. The primary end point was the change in calculated GFR (cGFR) from baseline to month 12. RESULTS: Patients were randomized either to switch to belatacept (n=84) or to remain on a CNI-based regimen (n=89). At month 12, the mean (SD) change from baseline in cGFR was higher in the belatacept group versus the CNI group. Six patients in the belatacept group had acute rejection episodes, all within the first 6 months; all resolved with no allograft loss. By month 12, one patient in the CNI group died with a functioning graft, whereas no patients in the belatacept group had graft loss. The overall safety profile was similar between groups. CONCLUSIONS: The study identifies a potentially safe and feasible method for switching stable renal transplant patients from a cyclosporine- or tacrolimus-based regimen to a belatacept-based regimen, which may allow improved renal function in patients currently treated with CNIs.