Second and Third Chance to Stop Having Diabetes. Pancreas Retransplant With Functional Kidney Graft: A Single-Center Experience.

BACKGROUND: Simultaneous pancreas-kidney (SPK) transplant is the primary option in patients with type 1 diabetes mellitus who develop end-stage kidney disease. Pancreas retransplant (PRt) has become an alternative in patients who experience pancreas graft failure (PGF). There is a lack of evidence regarding PRt in international registers. There are small series of published research with indeed heterogeneous results. We aim to compare PRt outcomes with primary SPK transplant in our center. METHODS: The study was designed as a descriptive study of a cohort of 234 patients who received SPK transplant and received another PRt because of PGF at Reina Sofía University Hospital between 1988 and 2021. Kaplan-Meier analysis was performed to calculate patient and allograft survival. RESULTS: Of these 234 SPK transplants, 53 pancreas grafts (22.6%) were lost initially. In total, 15 PRts were performed. The major cause of first PGF was surgical, whereas the medical cause was the most frequent in the PRt group. There were 60 deaths in the SPK group compared with only 1 in the PRt group. In Kaplan-Meier analysis, the PRt group showed worse survival than the SPK group, with statistically significant difference between groups (P = .05). Patient survival was not different between both groups. CONCLUSIONS: PRt constitutes a viable option for recipients who experience PGF in the absence of formal contraindication. Although graft retransplant survival seems to be inferior to first graft in our series, these results are difficult to compare because of the scarce number of procedures performed.

Long-term Kidney Function Evolution in Living Kidney Donors: A Single Center Experience.

Living donor kidney transplant is the best treatment for end-stage kidney disease, posing minimal perioperative morbimortality for the donor, although long-term consequences are subject of debate if donor acceptance widens. We present a retrospective observational study analyzing clinical, demographic, and analytical variables throughout the follow-up period of 60 kidney donors whose procedures were performed between 1985 and 2021 at our hospital. Donors were divided according to their previous high blood pressure status, analyzing kidney function and other clinical parameters throughout follow-up. There were no statistically significant differences, although there was a trend toward a higher uric acid levels and lower high-density lipoprotein cholesterol in predonation patients with hypertension, not yielding an excess of end-stage kidney disease between groups at the end of the follow-up. We also analyzed the evolution of estimated glomerular filtration rate (eGFR), dividing patients into tertiles, which resulted in none of the parameters associating a higher rate of progression. All donors had an eGFR >71 mL/min/1.73 m2 at the time of donation. Over time, a decline in eGFR <60 mL/min/m/1.73 m2 was observed in 26 patients (53.6%), measured by Chronic Kidney Disease Epidemiology Collaboration estimation and in 55.4% of the total (31 patients) by Modification of Diet in Renal Disease. At our center, kidney donors with adequate predonation eGFR, although presenting a reduction in postnephrectomy eGFR, remain stable afterward, with none of them reaching an eGFR <30 mL/min/1.73 m2. We found no differences in the impact of high blood pressure on long-term eGFR, nor predictive factors influencing the rate of eGFR decline. Studies with larger number of patients are needed to confirm these results.

First Report in the Literature of Biopsy-Proven Noncollapsing Focal Segmental Glomerulosclerosis Relapse in a Second Renal Transplant Presenting With Thrombotic Microangiopathy: A Case Report.

Primary focal segmental glomerulosclerosis (FSGS) is a podocytopathy with an irregular response to immunosuppressive therapies. FSGS relapse occurs in 30% to 80% of kidney grafts, and poor survival outcomes include large proteinuria and the nephrotic syndrome's cardinal clinical features. Thrombotic microangiopathy (TMA) is caused by endothelial injury due to complement dysregulation including acute kidney injury, proteinuria, and severe hypertension common renal presentations. Both pathologies have well-described genetic forms, but their relationship remains uncertain. FSGS lesions can be found in kidney biopsy specimens in patients with TMA, and TMA has been reported in patients with collapsing glomerulopathy. However, this combination has not been clearly described in renal transplant recipients. We present the case of a 22-year-old man who received his second kidney allograft and developed an early graft disfunction with nephrotic syndrome and clinical TMA. His background was remarkable for primary, biopsy-confirmed FSGS in childhood, and he started hemodialysis in 2006 and received a living donor kidney graft the same year. He presented with a FSGS relapse with malignant hypertension and seizures in the first posttransplant month and had an irregular response to plasma exchange and rituximab, and dialysis was reinitiated 10 years later. A total of 3 biopsies were performed after his second kidney transplant showing the evolution of a FSGS relapse with histologic and clinical TMA in the absence of identified genetic mutations. Partial responses to treatments with plasma exchange, eculizumab, and rituximab were obtained, but the allograft was lost after 26 months. This case is the first report of concomitant FSGS and TMA in a renal transplant recipient.

A Single-Center Experience With Third and Fourth Kidney Transplants and Second Kidney Transplant After Pancreas-Kidney Transplant: Surgical Aspects and Outcomes.

OBJECTIVES: Overall, 25% to 33% of patients on kidney transplant wait lists present with prior graft loss. In addition, the number of patients who require a retransplant seems to be increasing. Here, we describe our experience with patients who had a second kidney transplant after a previous pancreas-kidney transplant or a third or fourth kidney transplant. We focused specifically on the technical aspects and outcomes related to this patient group. MATERIALS AND METHODS: A single-center retrospective study was performed. The cohortincluded 15 patients > 18 years old who had received a second kidney graft after pancreas-kidney transplant or a second or greater kidney graft between 2013 and 2019. RESULTS: Median age of recipients was 45 years (range, 20-58 y). In 10 patients, the transperitoneal approach was selected. In 5 patients, the retroperitoneal heterotopic kidney retransplant technique was used. Early surgical complications (≤ 30 days posttransplant) were reported in 4 patients. Three patients had late ureteral stenosis (> 90 days posttransplant). All grafts were functioning at time of patient discharge. Mean creatinine level was 2.69 mg/dL (range, 1.23-6.26 mg/dL). The 1-year and 2-year graft survivalrates were 85% and 75%, respectively. No grafts were lost because of surgical complications. CONCLUSIONS: Retransplant of a second graft after pancreas-kidney transplant or retransplant of a third or fourth renal graft is challenging but feasible, with evidence of reasonably positive outcomes after retransplant.

Análisis de las complicaciones de la biopsia renal en el paciente trasplantado renal / Analysis of renal biopsy complications in renal transplant patients

Antecedentes: La biopsia renal es una técnica fundamental en el estudio de la patología del injerto renal. Es fundamental conocer sus complicaciones ya que es el procedimiento más agresivo por su morbimortalidad. Objetivos: El objetivo principal de nuestro estudio fue analizar e identificar las complicaciones clínicas derivadas de la biopsia renal percutánea en pacientes trasplantados renales. Evaluamos si algún factor clínico de los pacientes influye en la aparición de dichas complicaciones. Pacientes y Métodos: Se realizó un estudio observacional, retrospectivo de todos los pacientes a los que se les realizó una biopsia renal percutánea de injerto renal entre enero de 2009 y enero 2012. Se analizaron: edad, sexo, hipertensión arterial, creatinina sérica, proteinuria y hemoglobina previa y posterior a la biopsia. Definimos complicaciones menores (caída hemoglobina mayor 1 g/dl, hematuria macroscópica) y complicaciones mayores (necesidad de transfusión, cirugía, nefrectomía, arteriografía, embolización o muerte). Todas las biopsias se realizaron con control ecográfico. Resultados: El número de biopsias realizadas fue de 92. La edad media de los pacientes fue de 47.9 ± 13.2 años y el 70.7% eran hombres. Se observaron 2 complicaciones mayores (2.2%) y en ambas los pacientes presentaron sangrado y sepsis urológica, precisando uno de ellos de transfusión. Las complicaciones menores fueron del 14.1%. No se encontró ninguna pérdida del injerto ni muerte por biopsia renal. Conclusión: La biopsia percutánea en injerto renal realizada por médicos nefrólogos con experiencia y bajo control ecográfico en tiempo real, es un procedimiento con bajo riesgo, semejante al observado en riñón nativo. La cumplimentación cuidadosa de nuestro protocolo de biopsia renal, optimiza la relación riesgo beneficio de esta técnica (AU)

Background: Renal biopsy is a fundamental technique in the study of renal allograft pathology. It is essential to know its complications since it is the more aggressive procedure morbidity and mortality. Objectives: The main objective of our study is to analyze and identify clinical complications resulting from percutaneous renal biopsy in renal transplant patients. To assess whether a patient clinical factor influencing the onset of these complications. Patients and Methods: An observational, retrospective study of all patients who underwent percutaneous renal biopsy renal graft between January 2009 and January 2012. Were analyzed: age, sex, hypertension, serum creatinine, proteinuria and hemoglobin before and after the biopsy. We defined minor complications (hemoglobin drop greater than 1 g / dl) and major complications (requiring transfusion, surgery, nephrectomy, arteriography, embolization or death). The biopsy was performed by the nephrology team with ultrasound guidance and withdrawing the antiplatelet therapy. Results: The number of biopsies performed was 92. The mean age of patients was 47.9 ± 13.2 years and 70.7% were men. There were 2 major complications (2.2%) and both patients had urological bleeding and sepsis, one need a transfusion. Minor complications were 14.1%. The graft loss or patient death was not observed. Conclusion: Percutaneous renal graft biopsy performed by physicians experienced nephrologists under ultrasound guidance in real time, is a low risk procedure, similar to that observed in native kidney. The careful completion of our protocol renal biopsy, optimize the risk benefit ratio of this technique (AU)

Reversible acute encephalopathy with mutism, induced by calcineurin inhibitors after renal transplantation.

The incidence of neurotoxicity from calcineurin inhibitors varies by the organ transplanted. Akinetic mutism is characterized by the inability to perform voluntary movements and express language, without alterations in mental status. This process has been reported in neurotoxicity due to high serum levels of calcineurin inhibitors, but in rare cases, it presents as a form of tacrolimus toxicity after renal transplantation, despite normal serum levels. We report a clinical case of a renal transplant patient in whom reversible acute encephalopathy and akinetic mutism developed. Brain lesions appeared on magnetic resonance imaging, and the condition resolved after the drug was withdrawn.