Comparison of long-term effect of thymoglobulin treatment in patients with a high risk of delayed graft function.

BACKGROUND: T-lymphocyte depletion is a strategy to reverse the impact of ischemia-reperfusion injury (IRI) in progression to chronic allograft dysfunction, especially among patients at high risk for delayed graft function (DGF). METHODS: The present work assessed the effect of thymoglobulin among a population with a high incidence of DGF. We analyzed 209 transplanted patients: 97 in the thymoglobulin and 112 in the control group. RESULTS: The main complication was DGF (59.3%), with a similar incidence in both groups (63.9% vs. 55.3%; P = .36). Acute rejection episodes (ARE) were decreased with thymoglobulin (8.2% vs. 28.5%; P < .001), but cytomegalovirus viremia was 3.4-fold more frequent (58.3% vs. 17.1%; P < .001). One-year graft function was significantly better in the thymoglobulin group (59.2 ± 17.2 vs. 51.8 ± 15.3 mL/min; P = .004), even when censored by ARE (59.7 ± 17.5 vs. 53.3 ± 14.4; P = .023). The same difference was observed at the 2-year follow-up (P = .024), even when censored for ARE (P = .045). A multivariate analysis showed thymoglobulin to be a factor strongly associated with protection of graft function (P = .039). CONCLUSION: Despite not reducing the incidence of DGF, thymoglobulin induction significantly reduced the incidence of ARE and showed a long-term profile of protection of renal graft function, independent of the reduction in ARE.

Prevalence and progression of chronic kidney disease after renal transplantation.

BACKGROUND: We studied the prevalence of chronic kidney disease (CKD) and its progression after kidney transplantation. METHODS: We retrospectively analyzed the evolution of renal graft function, as estimated by the Cockcroft-Gault equation in 567 patients. CKD was classified in accordance with the National Kidney Foundation/Kidney Disease Outcome Quality Initiative with progression estimated by calculating the slope over time. RESULTS: Creatinine clearance (CrCL) at 1 year after transplantation was 57.8 ± 15.5 mL/min with 61.9% patients presenting de novo chronic renal failure. The 1-year-CrCl provided the best correlation with the 3-year CrCl (R(2) = 0.58; P < .001). Medians of slope (MS) among all patients was -2.38 ± 5.7 mL/min/y (-11.9 mL/min over 5 years). Patients who reached a CrCl < 60 at 1 year after transplantation showed a MS of -3.92 ± 6.5, while the others, -2.03 ± 5.2 mL/min/y (P = .046). Similarly, patients who reached a CrCL < 60 at 3 years after transplantation displayed a MS of -1.49 ± 3.5 mL/min/y, while the others, 0.62 ± 3.0 mL/min/y (P < .001). CONCLUSIONS: The majority of renal transplant patients present de novo chronic renal failure already at 1 year posttransplantation. The rate of graft functional deterioration was 2.38 mL/min/y. It was worse among patients who displayed a CrCL less than 60 mL/min both at 1 and at 3 years. One-year CrCL was a good marker for 3-year CrCL.

Effects of ischemia and reperfusion injury on long-term graft function.

BACKGROUND: The clinical manifestation of ischemia/reperfusion injury in renal transplantation is delayed graft function (DGF), which is associated with an increase in acute rejection episodes (ARE), costs, and difficulties in immunosuppressive management. We sought to evaluated the DGF impact after renal transplant. METHODS: We evaluated a group of 628 patients undergoing deceased donor renal transplantation between 2002 and 2005 at 3 Brazilians institutions to define the main DGF characteristics. RESULTS: DGF incidence was 56.8%, being associated with elderly donors (P = .02), longer time on dialysis (P = .001), and greater cold ischemia time (CIT; P = .001). Upon multivariate analysis, time on dialysis >5 years increased DGF risk by 42% (P = .02) and CIT >24 hours increased it by 57% (P = .008). In contrast, DGF was associated with an higher incidence of ARE: 27.7% in DGF versus 18.4% in IGF patients (P = .047). The ARE risk was 46% higher among individuals with DGF (P = .02), 44% among patients >45 years old (P < .001), 50% among those with >5 years of dialysis time (P = .02), and 47% lower among the who were prescribed mycophenolate instead of azathioprine (P < .001). Patients with DGF showed worse 1-year graft function (54.6 ± 20.3 vs 59.6 ± 19.4 mL/min; P = .004), particularly those with ARE (55.5 ± 19.3 vs 60.7 ± 20.4; P = .009). One-year graft survival was 88.5% among DGF versus 94.0% among non-DGF patients. CONCLUSION: The high incidence of DGF was mainly associated with a prolonged CIT. There was a relationship between DGF and ARE, as well as with a negative influence on long-term graft function.

Ex vivo application of carbon monoxide in UW solution prevents transplant-induced renal ischemia/reperfusion injury in pigs.

I/R injury is a major deleterious factor of successful kidney transplantation (KTx). Carbon monoxide (CO) is an endogenous gaseous regulatory molecule, and exogenously delivered CO in low concentrations provides potent cytoprotection. This study evaluated efficacies of CO exposure to excised kidney grafts to inhibit I/R injury in the pig KTx model. Porcine kidneys were stored for 48 h in control UW or UW supplemented with CO (CO-UW) and autotransplanted in a 14-day follow-up study. In the control UW group, animal survival was 80% (4/5) with peak serum creatinine levels of 12.0 +/- 5.1 mg/dL. CO-UW showed potent protection, and peak creatinine levels were reduced to 6.9 +/- 1.4 mg/dL with 100% (5/5) survival without any noticeable adverse event or abnormal COHb value. Control grafts at 14 days showed significant tubular damages, focal fibrotic changes and numerous infiltrates. The CO-UW group showed significantly less severe histopathological changes with less TGF-beta and p-Smad3 expression. Grafts in CO-UW also showed significantly lower early mRNA levels for proinflammatory cytokines and less lipid peroxidation. CO in UW provides significant protection against renal I/R injury in the porcine KTx model. Ex vivo exposure of kidney grafts to CO during cold storage may therefore be a safe strategy to reduce I/R injury.

Synergistic effect of mycophenolate mofetil and angiotensin-converting enzyme inhibitor in patients with chronic allograft nephropathy

Experimental data and few clinical non-randomized studies have shown that inhibition of the renin-angiotensin system by angiotensin-converting enzyme (ACE) associated or not with the use of mycophenolate mofetil (MMF) could delay or even halt the progression of chronic allograft nephropathy (CAN). In this retrospective historical study, we investigated whether ACE inhibition (ACEI) associated or not with the use of MMF has the same effect in humans as in experimental studies and what factors are associated with a clinical response. A total of 160 transplant patients with biopsy-proven CAN were enrolled. Eighty-one of them were on ACE therapy (G1) and 80 on ACEI_free therapy (G2). Patients were further stratified for the use of MMF. G1 patients showed a marked decrease in proteinuria and stabilized serum creatinine with time. Five-year graft survival after CAN diagnosis was more frequent in G1 (86.9 vs 67.7 percent; P < 0.05). In patients on ACEI-free therapy, the use of MMF was associated with better graft survival. The use of ACEI therapy protected 79 percent of the patients against graft loss (OR = 0.079, 95 percentCI = 0.015-0.426; P = 0.003). ACEI and MMF or the use of MMF alone after CAN diagnosis conferred protection against graft loss. This finding is well correlated with experimental studies in which ACEI and MMF interrupt the progression of chronic allograft dysfunction and injury. The use of ACEI alone or in combination with MMF significantly reduced proteinuria and stabilized serum creatinine, consequently improving renal allograft survival.

Synergistic effect of mycophenolate mofetil and angiotensin-converting enzyme inhibitor in patients with chronic allograft nephropathy.

Experimental data and few clinical non-randomized studies have shown that inhibition of the renin-angiotensin system by angiotensin-converting enzyme (ACE) associated or not with the use of mycophenolate mofetil (MMF) could delay or even halt the progression of chronic allograft nephropathy (CAN). In this retrospective historical study, we investigated whether ACE inhibition (ACEI) associated or not with the use of MMF has the same effect in humans as in experimental studies and what factors are associated with a clinical response. A total of 160 transplant patients with biopsy-proven CAN were enrolled. Eighty-one of them were on ACE therapy (G1) and 80 on ACEI_free therapy (G2). Patients were further stratified for the use of MMF. G1 patients showed a marked decrease in proteinuria and stabilized serum creatinine with time. Five-year graft survival after CAN diagnosis was more frequent in G1 (86.9 vs 67.7%; P < 0.05). In patients on ACEI-free therapy, the use of MMF was associated with better graft survival. The use of ACEI therapy protected 79% of the patients against graft loss (OR = 0.079, 95%CI = 0.015-0.426; P = 0.003). ACEI and MMF or the use of MMF alone after CAN diagnosis conferred protection against graft loss. This finding is well correlated with experimental studies in which ACEI and MMF interrupt the progression of chronic allograft dysfunction and injury. The use of ACEI alone or in combination with MMF significantly reduced proteinuria and stabilized serum creatinine, consequently improving renal allograft survival.

Are the current chronic allograft nephropathy grading systems sufficient to predict renal allograft survival?

A major problem in renal transplantation is identifying a grading system that can predict long-term graft survival. The present study determined the extent to which the two existing grading systems (Banff 97 and chronic allograft damage index, CADI) correlate with each other and with graft loss. A total of 161 transplant patient biopsies with chronic allograft nephropathy (CAN) were studied. The samples were coded and evaluated blindly by two pathologists using the two grading systems. Logistic regression analyses were used to evaluate the best predictor index for renal allograft loss. Patients with higher Banff 97 and CADI scores had higher rates of graft loss. Moreover, these measures also correlated with worse renal function and higher proteinuria levels at the time of CAN diagnosis. Logistic regression analyses showed that the use of angiotensin-converting enzyme inhibitor (ACEI), hepatitis C virus (HCV), tubular atrophy, and the use of mycophenolate mofetil (MMF) were associated with graft loss in the CADI, while the use of ACEI, HCV, moderate interstitial fibrosis and tubular atrophy and the use of MMF were associated in the Banff 97 index. Although Banff 97 and CADI analyze different parameters in different renal compartments, only some isolated parameters correlated with graft loss. This suggests that we need to review the CAN grading systems in order to devise a system that includes all parameters able to predict long-term graft survival, including chronic glomerulopathy, glomerular sclerosis, vascular changes, and severity of chronic interstitial fibrosis and tubular atrophy.

Are the current chronic allograft nephropathy grading systems sufficient to predict renal allograft survival?

A major problem in renal transplantation is identifying a grading system that can predict long-term graft survival. The present study determined the extent to which the two existing grading systems (Banff 97 and chronic allograft damage index, CADI) correlate with each other and with graft loss. A total of 161 transplant patient biopsies with chronic allograft nephropathy (CAN) were studied. The samples were coded and evaluated blindly by two pathologists using the two grading systems. Logistic regression analyses were used to evaluate the best predictor index for renal allograft loss. Patients with higher Banff 97 and CADI scores had higher rates of graft loss. Moreover, these measures also correlated with worse renal function and higher proteinuria levels at the time of CAN diagnosis. Logistic regression analyses showed that the use of angiotensin-converting enzyme inhibitor (ACEI), hepatitis C virus (HCV), tubular atrophy, and the use of mycophenolate mofetil (MMF) were associated with graft loss in the CADI, while the use of ACEI, HCV, moderate interstitial fibrosis and tubular atrophy and the use of MMF were associated in the Banff 97 index. Although Banff 97 and CADI analyze different parameters in different renal compartments, only some isolated parameters correlated with graft loss. This suggests that we need to review the CAN grading systems in order to devise a system that includes all parameters able to predict long-term graft survival, including chronic glomerulopathy, glomerular sclerosis, vascular changes, and severity of chronic interstitial fibrosis and tubular atrophy.

Improved renal function after kidney transplantation is associated with heme oxygenase-1 polymorphism.

Heme oxygenase-1 (HO-1) has a microsatellite polymorphism based on the number of guanosine-thymidine nucleotide repeats (GT) repeats that regulates expression levels and could have an impact on organ survival post-injury. We correlated HO-1 polymorphism with renal graft function. The HO-1 gene was sequenced (N = 181), and the allelic repeats were divided into subclasses: short repeats (S) (<27 repeats) and long repeats (L) (>/=27 repeats). A total of 47.5% of the donors carried the S allele. The allograft function was statistically improved six months, two and three yr after transplantation in patients receiving kidneys from donors with an S allele. For the recipients carrying the S allele (50.3%), the allograft function was also better throughout the follow-up, but reached statistical significance only three yr after transplantation (p = 0.04). Considering only those patients who had chronic allograft nephropathy (CAN; 74 of 181), allograft function was also better in donors and in recipients carrying the S allele, two and three yr after transplantation (p = 0.03). Recipients of kidney transplantation from donors carrying the S allele presented better function even in the presence of CAN.

Incidence of donor and recipient toll-like receptor-4 polymorphisms in kidney transplantation.

UNLABELLED: Toll-like receptors (TLR) comprise an emerging family that recognize pathogen-associated molecular patterns and promote the activation of leukocytes. Recently, TLR has been demonstrated to play a role in experimental allograft rejection. However, the TLR-4 gene has a polymorphism that can be associated with a blunted immune response, especially to microbial pathogens. We sought to study the incidence of TLR 4 gene variants among renal transplant donors and recipients from living and deceased organs and then to correlate them with short-term and long-term outcomes. METHODS: Analysis of TLR4 polymorphisms at Asp299Gly and Thr399Ile codons were performed using restriction fragment length polymorphism. Demographic data was obtained from patient records. RESULTS: Among 201 patients, 141 were recipients from related donors (group 1) and 60 recipients from 45 deceased donors (group 2). Patients were followed for 108 +/- 85 months after transplantation. The incidence of polymorphism for TLR-4 Asp299Gly, Thr399Ile or both were 8.9% in recipients and 8.0% in donors. Patients who received a kidney with polymorphism, Asp299Gly, or Thr399Ile, or both, did not show a difference in rate of acute tubular necrosis compared with controls (no polymorphism). Acute rejection occurred in 17.6% of recipients with Asp299Gly/Thr399Ile polymorphisms and in 39.5% of wild-type recipients (P = .400). The incidence of bacterial infection was equal in both groups. CONCLUSION: The incidence of polymorphism in this study was similar in both groups, and donor or recipient polymorphisms were not associated with different renal graft outcomes.

Impact of therapeutic changes on renal graft survival with posttransplant glomerulonephritis.

INTRODUCTION: Posttransplant glomerulonephritis (GN) is the third cause of graft loss after 1 year of transplant follow-up; few approaches have been efficient in reversing this outcome. The aim of this study was to evaluate whether the modification of the immunosuppressive therapy for treating posttransplant GN had an impact on allograft survival. PATIENTS AND METHODS: Forty-nine patients who underwent renal transplantation and developed posttransplant GN were divided into two groups: group 1, 22 patients with modified immunosuppressive treatment (72.3%, pulse of methylprednisolone; 13.6%, high-dose oral corticosteroid), and group 2, where it was maintained. Additionally, the impact of the concomitant use of drugs that promote the renin-angiotensin-aldosterone system blockade (RAASB) was analyzed in terms of graft survival. RESULTS: We established the diagnosis of GN at 17.9 months (range, 0.57 to 153.4) after transplantation, when serum creatinine (Cr) was 2.2 mg/dL (range, 0.8 to 12.5) and proteinuria 3.2 g/L (range, 0.2 to 24.2). Graft survivals at 1 and 3 years after diagnosis were 69.2% and 52.9%, respectively. The patients of group 1 showed a lower prevalence of graft loss (27.2% versus 48.1%, P = .40) and better survival at the end of 1 year (73.2% versus 60.4%) and 3 years (62.5% versus 38.0%, P = .26), but the differences were not significant. RAASB showed a positive impact on survival at the end of 3 years in both groups: for group 1, 83.8% with RAASB, 41.4% without RAASB; and for group 2, 75% with RAASB and 14.8% without RAASB (P < .001). CONCLUSION: Although treatment of posttransplant GN with modification of immunosuppression seemed to improve graft survival in the first 3 years after diagnosis, RAASB improved this effect.

Sequential cytomegalovirus antigenemia monitoring in kidney transplant patients treated with antilymphocyte antibodies.

BACKGROUND: Antilymphocyte antibodies (ALA) use is related to disseminated cytomegalovirus (CMV) disease after kidney transplantation. Strict surveillance of CMV infection, preemptive antiviral treatment or concomitant ganciclovir and ALA use are proposed as an attempt to prevent related clinical complications. Our objective was to describe the pattern of CMV infection, based on sequential antigenemia detection, after ALA treatment. PATIENTS AND METHODS: Thirty renal transplant patients were prospectively screened for CMV infection after ALA treatment. CMV antigenemia (pp65 antigen detection) was monitored twice a week in the first month and weekly until 60 days after the beginning of ALA therapy. Any positive value of antigenemia was considered CMV infection. RESULTS: Twenty-eight (93.3%) patients were CMV positive (IgG) before transplantation. The mean duration of ALA treatment was 12.1+/-2.4 days. Positive antigenemia was detected in 24 (80%) patients, a mean of 52.5+/-15 days after transplant and 44.7+/-14 days after the beginning of ALA treatment. The median antigenemia count was 7 positive cells/300,000 neutrophils (range: 1-227). Antigenemia preceded clinical symptoms by 5.8 days (0-28 days). Eighteen (75%) of 24 positive patients received ganciclovir treatment: 8 patients (26.7%) for viral syndrome, 2 patients (33.3%) for invasive disease, and 8 patients (26.7%) as part of preemptive therapy, asymptomatic with high antigenemia values. Six pp65-positive patients with low counts were followed up until a negative result and remained asymptomatic without any specific treatment. CONCLUSION: CMV infection was frequent after ALA treatment in this group and generally occurred late after completion of treatment. Antigenemia was a reliable tool to guide preemptive treatment in these patients, and such strategy is an alternative option compared to the prophylactic use of ganciclovir with ALA treatment.

[Detection of hepatitis C virus antibodies in a pool of 5 sera: their use in seroepidemiologic studies]. / Pesquisa de anticorpos contra o vírus da hepatite C em pool de 5 soros: sua utilização em inquéritos soroepidemiológicos.

In order to evaluate the reduction in the cost of testing for antibodies against hepatitis C (EIA) by the pool method, we tested serum samples from a rural population and from patients in a hemodialysis program. Two thirds of the high risk groups were positive. Pooling reduced the reagent use by 80% in the rural population and by 13% in the hemodialysis patients. We conclude that pool testing reduces the cost of anti-HCV detection in low-risk groups.

[The diagnosis of severe disseminated paracoccidioidomycosis in a bone marrow aspirate: a case report]. / Diagnóstico de paracoccidioidomicose disseminada grave em aspirado de medula óssea: relato de caso.

Acute or chronic disseminated paracoccidioidomycosis can be associated with changes in blood and bone marrow cell counts, mainly in the severe forms of this disease. However, there are few reports about the microbiological confirmation of the mycosis in bone marrow tissue. The present report describes a case of an adult patient with severe chronic multifocal paracoccidioidomycosis, whose etiological diagnosis has been done by the microscopical exam and culture fo the bone marrow aspirate. The authors emphasize the importance of these exams as an alternative way for the diagnosis of suspected cases of severe paracoccidioidomycosis.