End-stage renal disease and hepatitis C infection: comparison of alanine aminotransferase levels and liver histology in patients with and without renal damage.

BACKGROUND AND AIM: To what extent the serum levels of alanine aminotransferase (ALT) are related to histological characteristics of liver damage caused by hepatitis C virus (HCV) infection among patients with end-stage renal disease (ESRD) remains unclear. METHODS: Patients with a positive anti-HCV antibody titer confirmed by supplemental tests were evaluated by liver biopsy. We compared ALT levels in patients with and without renal damage, with similar histological grades and stages of inflammation and fibrosis. Results: Patients were divided into two groups: patients with ESRD (n = 25) and patients without ESRD renal damage (n = 39). RESULTS: The ALT level was 42.1 +/- 24.3 IU/L for the ESRD group, compared with 109.9 +/- 55.8 IU/L for the non-ESRD group (P < 0.001). Liver inflammation (modified Knodell grade) was 4.0 +/- 2.1 in the ESRD group versus 5.2 +/- 2.4 in the non- ESRD group; fibrosis (6-point scale) was 1.1 +/- 1.2 versus 1.7 +/- 1.5, respectively. CONCLUSIONS: Despite histological evidence of liver inflammation, ALT levels in the ESRD group were normal, while ALT levels were significantly higher in the non-ESRD group with similar levels of liver inflammation. In conclusion, ALT levels are not a useful indicator of HCV infection in patients with ESRD and liver biopsies should be recommended for kidney transplant candidates.

Drug-related hepatotoxicity in a renal transplant recipient with long-term survival and hepatitis C.

Drug-related hepatotoxicity is more common in renal transplant (RT) recipients with chronic liver disease because drug metabolism is not as efficient in these individuals. We describe a long-term survivor (30 years) of renal transplantation with hepatitis C virus (HCV) and drug-related hepatotoxicity. Our patient, a 26-year-old male, developed uremic syndrome in May 1976 and received a renal allograft from a related, living donor with an identical human leukocyte antigen genotype in August 1976. Maintenance immunosuppression treatment consisted of azathioprine (AZA) and prednisone. In 1993, the patient tested negative for HCV antibody v1.0 (anti-HCV). In 2000, the patient had elevated aminotransferases, which was attributed to pravastatin treatment. Remission of this abnormality was achieved once pravastatin was discontinued. In 2003, the patient again exhibited elevated levels of aminotransferases and AZA-related hepatotoxicity was suspected; therefore, AZA was discontinued and treatment with mycophenolate mofetil was initiated, which led to normal aminotransferase levels. The patient tested positive for anti-HCV v3.0 and HCV RNA and a liver biopsy showed chronic hepatitis with moderate activity. Currently, the patient's renal transplant and liver are functional. In conclusion, hepatotoxic drugs should be used with caution in renal transplant recipients and close monitoring of liver function in patients with chronic viral hepatitis is crucial.

Risk factors and incidence of posttransplant diabetes mellitus in Mexican kidney recipients.

BACKGROUND: Many risk factors are associated with the development of posttransplant diabetes mellitus (PTDM), which has adverse effects on graft and patient survival. We report the incidence and risk factors associated with the development of PTDM in Mexican kidney recipients. METHODS: In a retrospective cohort study, we included kidney transplants performed between January 1, 1994 and December 31, 2000; all patients were followed up for at least 1 year posttransplantation. PTDM was defined as fasting blood glucose >126 mg/dL on at least two occasions. Statistical analysis included estimation of crude relative risk (RR) with 95% confidence intervals (CI). Adjusted RR and 95% CI by logistic regression were used. RESULTS: We studied 522 kidney recipients. Fifty three (10.1%) cases of PTDM were identified in this cohort. Cumulative dosage of prednisone (PDN) >13 g (RR 7.6, 95% CI 1.5-16.3 p <0.0001) and the presence of >or=1 acute rejection episodes (RR 3.7, 95% CI 1.2-11.6 p <0.001 were independent risk factors associated with the development of PTDM. Obesity (RR 2.6, 95% CI 0.8-8.7, p = 0.083) and age range of 40-49 years (RR 2.0; 95% CI 0.6-7.2, p = 0.093) were identified as marginal risk factors. CONCLUSIONS: The incidence of PTDM in kidney recipients was 10.1% in our population. Cumulative PDN dosage and presence of >or=1 acute rejection episodes were independent risk factors for the development of PTDM. These results are consistent with prior studies of the diabetogenic effect of the PDN. The relationship between acute rejection and PTDM deserves further investigation in order to learn more about the role that inflammatory mechanisms may play in this association.

The kidney transplant experience at Hospital de Especialidades, Centro Médico Nacional de Occidente, IMSS, Guadalajara México.

A total of 1,356 kidney transplants has been performed in the Hospital de Especialidades del Centro Médico Nacional de Occidente, IMSS, in Guadalajara Mexico, including 935 in the past 8 years. This represents an important increase of this activity in our country. Of the total transplants, 1,218 (90%) were from living donors and only 138 (10%) were from cadaveric donors, a number that we hope to increase. Most recipients were young adults, with an average age of 31 years old. The overall one-year graft and patient survival rates for living-donor kidney recipients were 90% and 82%, and for cadaveric kidney recipients they were 80% and 70%, respectively. Acute rejections occurred in 17% and chronic allograft nephropathy was diagnosed in 7% of our kidney transplant recipients. The main cause of patient death was infection, frequently invasive CMV. Cardiovascular complications were a relatively infrequent cause of death as has been seen in other international series. Hepatitis B and C have been widley studied. Hepatitis C is the most prevalent viral infection in our population. Both living and cadaveric donors in our series were young, which may explain the good results. We have had very few complications among living donors and no mortality. Two donors developed chronic renal insufficiency after the kidney donation (0.001%). This excellent safety record reflects the experience of our team. We hope to increase the number of cadaveric transplant donors with the renewed interest in enlarging the transplantation programs in Mexico while maintaining our high percentage of living donors in order to benefit more patients.