The impact of hepatitis B infection on outcome of kidney transplantation: a long-term study.

BACKGROUND: With the success of kidney transplantation, liver disease has emerged as an important cause of morbidity and mortality in kidney recipients. OBJECTIVE: To determine the impact of hepatitis B virus (HBV) infection on patients and graft survival in both short- and long-terms. METHODS: 99 renal transplant patients infected with HBV on follow-up in two major transplant centers were included in a retrospective study. These patients were grafted between 1986 and 2005 and divided into two groups: (1) those only positive for hepatitis B surface antigen (HBsAg) and (2) those who were also positive for hepatitis C virus antibodies (HCV Ab). RESULTS: There were 88 patients with HBsAg(+) and 11 with both HBsAg(+) and HCV Ab(+). The mean±SD age of patients was 38.8±13.2 years, and the median follow-up after transplantation was 19 months. Although not significant, the allograft survival rate in the first group (HBV(+)) was better compared to that in the second group (HBV(+) and HCV(+)); 1, 5 and 10 years graft survival rates were 91, 77 and 62 in the first group and 70, 56 and 28 in the second group, respectively (P=0.07). The overall mortality was 5% (4 of 88) in the first and 27% (3 of 11) in the second group (P=0.02). CONCLUSION: Renal allograft recipients with HBV and HCV infections has a poor survival rate compared to patients with only HBV infection. However, there is no significant difference in terms of renal graft survival between the two groups.

Genitourinary tumor following kidney transplantation: a multicenter study.

Renal transplantation has been advocated as the treatment of choice for end-stage renal disease. Immunosuppression increases the incidence of cancer and promotes the growth of neoplasms in solid organ recipients. There have been a few reports on the incidence of cancer from transplant registries. It is difficult to precisely compare the incidence with that in the general population using data from small, single-center studies. Thus, we sought to study the prevalence of genitourinary cancer development in Iranian renal transplant recipients. We collected data from 5 kidney transplant centers in Iran between 1984 and 2008, seeking to detect the incidence, type, and outcome of cancers after kidney transplantation. Only histologically confirmed tumors, which occurred after renal transplantation, were included in the analysis. Of the 5532 patients who underwent kidney transplantation, genitourinary tumors were detected in 21 subjects (0.38%), namely, 12 males and 9 females. Transitional cell carcinoma (TCC) of the bladder, the most common genitourinary cancer (n = 7) was followed by renal cell carcinoma (RCC; n = 5), ovarian cancer (n = 3), breast cancer (n = 3), prostate cancer (n = 1), seminoma (n = 1), and uterine cancer (n = 1). The overall mean age of the patients was 46 +/- 12 years (range, 19-72 years) and the median time to diagnosis after transplantation was 72 months (range, 4-240 months). Seven patients died during the follow-up. There was a male predominance among TCC of the bladder and RCC (5:2 and 4:1, respectively). In conclusion, TCC of the bladder was the most common genitourinary tumor following kidney transplantation. It was predominant in male patients.

Living unrelated versus living related kidney transplantation: 20 years' experience with 2155 cases.

PURPOSE: To compare the long-term results of kidney transplantation from living unrelated donors (LURDs) with that from living related donors (LRDs). MATERIALS AND METHODS: From 1984 to 2004, we performed 2155 kidney transplantations of which 374 were from LRDs and 1760 from LURDs. We reviewed and compared the long-term data from these cases. RESULTS: The LURD group included 64.2% men with an overall mean age of 33.46 +/- 14.61 (range 3 to 76) years. Laparoscopic donor nephrectomy was performed in 329 cases (18.7%) with mean follow-up of 45.68 +/- 46.80 months. The LRD group included 66.5% of male recipients with overall mean age of 28.97 +/- 9.58 (range 9 to 65) years. Laparoscopic donor nephrectomy was performed in 12 cases (3.2%) of LRDs with mean follow-up of 81.15 +/- 67.03 months. One-, 3-, 5-, 10-, and 15-year graft survivals among LRDs were 91.6%, 81.7%, 76.4%, 64.4%, and 48.4%; and for LURDs, 91.5%, 86.7%, 81.4%, 68.2%, and 53.2%, respectively (P = .07). Patient survivals for 1, 3, 5, 10, and 15 years in LRDs were 94.6%, 91.9%, 83%, 79.5%, and 73.9%, and in LURDs were 93.6%, 91.7%, 89.3%, 84%, and 76.4%, respectively (P = .14). CONCLUSION: The results of living unrelated kidney transplantation upon long-term follow-up with a large number of cases were as good as living related kidney transplantation. The organ shortage can be alleviated by using living unrelated kidney transplantation. To our knowledge this is the largest experience with long-term follow-up reported from one center to date.

Potential risk factors for hypersensitization reflected by panel-reactive antibodies in dialysis patients.

INTRODUCTION: The panel-reactive antibody (PRA) test has been considered to be a routine index of sensitization to human leukocyte antigens (HLA) in kidney transplant candidates. This study investigated the effect of potential risk factors and the time of blood sampling on PRA tests. METHODS: A total of 98 patients at two dialysis centers in Tehran were tested for PRA levels before and after dialysis sessions. We evaluated their history of potential sensitizing events and patient interviews for their association with PRA levels. Also we compared PRA levels obtained before and after dialysis. RESULTS: The mean age of the patients was 58.33 +/- 15.85 years. Only age and kidney transplantation history were correlated with PRA levels (r = .246, P = .014 and P = .0001, respectively). Logistic regression analysis revealed an association between age and PRA level (P = .037). Transplantation history was weakly correlated with PRA level (P = .076). History of pregnancy and transfusion, dialysis duration, gender, donor relation, and kidney allograft duration were not associated with PRA. PRA before dialysis sessions was significantly lower than that after dialysis (P = .0003). However, no difference was seen when divided into groups of negative/positive (PRA < 10% as negative) and high/low (PRA < 60% as low). CONCLUSION: Many factors expose patients to HLA as sensitizing factors. However, it seems that PRA level is not always predictable by such conditions. Furthermore, dialysis as a confounding procedure impacts PRA results; thus, when to obtain a blood sample is a crucial question.

Kidney retransplantation in comparison with first kidney transplantation.

INTRODUCTION: The aim of this study was to depict the outcome of second and third kidney allografts in comparison with first kidney allografts. METHODS: Among 2150 kidney transplantations are 103 second and 5 third transplantations. Demographic characteristics and survivals of retransplanted patients were compared with a randomly selected group of first kidney recipients, consisting of two cases matched with each retransplanted patient for age, gender, and date of transplantation. RESULTS: Retransplanted patients consisted of 78 men and 30 women of mean age 32.63 +/- 11.92 years. They had received kidneys from 91 living-unrelated and 17 living-related donors. Median followup was 27 months. One-, 2-, 3-, and 5-year graft survivals were 81.4%, 78.9%, 78.9%, and 73.7% among retransplants, versus 92.9%, 91.5%, 89.8%, and 85.3% in the control group, respectively (P = .0037). Patient survival was 96%, 94.6%, 92.4%, and 87.8% in the retransplant group versus 93.1%, 92.4%, 90.9%, 87.4% in the control group, respectively (P = .63). Also, graft survivals were slightly lower in female compared to male retransplant patients (P = .09). No significant difference in survival rates was seen in different age groups. CONCLUSION: It seems that kidney retransplantation can yield desirable outcomes, albeit relatively lower graft survivals.

Renal allograft accumulation of technetium-99m sulfur colloid as a predictor of graft rejection.

Differentiation between rejection (the most common cause) and many other possibilities for detrimental effects on graft function represents a difficult issue to diagnose the cause of renal allograft dysfunction. This study was designed to determine whether technetium-99m sulfur colloid (TSC) accumulation predicted graft rejection. We prospectively studied 54 episodes of allograft dysfunction in 53 kidney transplant recipients who underwent TSC scintiscanning and graft biopsy. Visual analysis of TSC uptake compared uptake, in the allograft with that in the marrow of the fifth lumbar vertebra (L5). A 3+ result meant that allograft uptake was greater than L5 marrow uptake; 2+, the same; 1+, less and finally 0, no allograft uptake. Transplant accumulation of 2+ or more was considered consistent with rejection (P = .01). Allograft biopsies interpreted based on the Banff Working Classification showed rejection in 45 of 54 renal biopsies with 42 the biopsy-proven rejection episodes showing at least 2+ graft uptake. Furthermore, this nuclear medicine technique had a sensitivity of 93.3%, a specificity of 44.4%, a positive predictive value of 89.3%, a negative value of 57.1% and an efficiency of 83.3% for the diagnosis of renal allograft rejection.

Impact of Ramadan fasting on renal allograft function.

Fasting during the holy month of Ramadan is a religious duty for all healthy adult Muslims. They are only allowed to eat and drink between sunset and dawn. This study was designed to find the effect of Ramadan fasting on allograft function. We prospectively studied 19 kidney transplant recipients who voluntarily chose to fast during Ramadan versus 20 matched recipients, who had not fasted for 3 consecutive years. Data were recorded before, during, and after the fasting month. The mean posttransplant periods in the fasting and control groups were 52.6 +/- 30.3 and 56.6 +/- 30.0 months, respectively. A statistical analysis showed no significant changes in serum creatinine concentrations before and after Ramadan 1.07 +/- 0.24 versus 1.08 +/- 0.22 mg/dL (P > .05) and 1.00 +/- 0.24 versus 1.03 +/- 0.28 mg/dL (P > .05) in fasting and control groups, respectively. The results did not show any adverse effects of fasting in recipients with stable renal function. In conclusion, our study suggests that fasting during the month of Ramadan is safe and has no significant harmful effects on kidney transplant recipients with normal renal function.

A randomized prospective trial of oral versus intravenous ganciclovir for prophylaxis of cytomegalovirus infection and disease in high-risk kidney recipients.

PURPOSE: This study was designed to compare the efficacy and safety of oral versus intravenous ganciclovir in high-risk kidney recipients. METHODS: Thirty-four, cytomegalovirus (CMV) seropositive recipients of kidneys from seropositive donors who had undergone antilymphocytic immunosuppressive therapy were assigned randomly to oral (1000 mg, three times a day, 12 weeks) versus intravenous (5 mg/kg, 2 weeks) ganciclovir prophylaxis. Follow-up was performed for 12 months. The patients were evaluated for clinical and laboratory outcomes regarding CMV serostatus, CMV disease, graft outcome, and ganciclovir side effects. RESULTS: Sixteen patients in the oral group and 14 in the intravenous group completed the study. CMV infection occurred in 6 (37.5%) and 5 (35.7%) cases in the oral and intravenous groups, respectively (P = NS). The mean interval between prophylaxis initiation and the first positive CMV Ag result was 3 +/- 2.19 months, with no significant difference between the two groups. Only two patients in the intravenous group experienced CMV diseases, which were not tissue-invasive. Acute rejection episodes were observed in nine out of 30 recipients, but it did not show any association with the prophylaxis regimen or CMV serostatus. The patients tolerated oral ganciclovir well; the compliance percent was 81.6%. No complication was reported. CONCLUSION: Oral and intravenous ganciclovir showed no significant difference to reduce the rate of CMV infection among high-risk kidney recipients. Oral ganciclovir was also effective and safe for the prevention of CMV disease. Moreover, it seems that CMV infection was not associated with acute rejection episodes.

Signs and symptoms of cytomegalovirus disease in kidney transplant recipients.

PURPOSE: To investigate the range of clinical presentations of cytomegalovirus (CMV) disease in kidney transplant recipients. MATERIALS AND METHODS: We retrospectively reviewed the records of hundred kidney recipients who developed CMV disease between 1984 and December 2002 for demographic characteristics, laboratory findings, and presenting signs and symptoms. RESULTS: The most common presentations were elevated serum creatinine in 74 patients, fever in 71, thrombocytopenia in 43, nausea in 32, vomiting in 25, elevated alkaline phosphatase in 24, leukocytosis in 22, and leukopenia in 21. Tissue involvement was relatively rare, but six patients had pneumonia, two had conjunctivitis, and one had vascular dermatitis. Four percent of the patients had received intravenous ganciclovir prophylaxis, and 7% had received oral ganciclovir prophylaxis. Fever was associated with number of hospitalizations (P = .006), elevated creatinine (P = .006), nausea (P = .017), vomiting (P = .031), and previous posttransplantation infections (P < .001). All the patients with conjunctivitis, pneumonia, pulmonary symptoms, and abnormal heart sounds and most of those with arthralgia, nausea, and vomiting were febrile during their CMV disease course. CONCLUSION: Our findings showed that leukocytosis should be considered as much as leukopenia when CMV disease is suspected. CMV-induced pneumonia is not common in renal transplant recipients compared to other organ transplant recipients. CMV invasion to other tissues is also rare. Finally, fever is a common symptom and important in assessing the severity and prognosis of the disease.

Outcome of Kaposi's sarcoma and graft following discontinuation of immunosuppressive drugs in renal transplant recipients.

PURPOSE: Owing to the use of immunosuppressive drugs, renal transplant recipients are at risk for malignancies including Kaposi's sarcoma (KS). Following the diagnosis, physicians tend to decrease the doses of immunosuppressive drugs to lower tumor progression rate. On the other hand, those who receive lower doses of immunosuppressive drugs are at a higher risk for acute rejection. In this study, we evaluated the outcome of KS on renal allografts following discontinuation or decrease in the doses of drugs. METHODS: Since 1984, 14 (nine men and five women) among 2000 cases of renal transplantation have been diagnosed as KS. In 11 patients, cyclosporine was completely discontinued, the dosage was decreased to half of the initial dose in other cases. Except one case, we discontinued either azathioprine or mycophenolate mofetil. RESULTS: During 57 months of follow-up on average, the serum creatinine level remained normal in 10 but increased in four cases. Kidney function deteriorated in two of these four patients at the beginning of study. Three patients died with normal serum creatinine levels. Discontinuation of immunosuppressive drugs caused complete remission of KS in all patients except one who received chemotherapy. CONCLUSION: Discontinuation of immunosuppressants following the diagnosis of KS caused complete remission of this cancer in almost all patients and seemed to be relatively safe for kidney graft function.

Pregnancy in kidney transplant recipients.

PURPOSE: Our aim was to investigate kidney allograft, obstetric, and maternal outcomes in pregnant women undergoing kidney transplantation in our center. METHODS: Retrospective data on 74 pregnancies in 60 patients were reviewed and completed through phone interviews were compared with information on a control group of female kidney recipients. RESULTS: Mean age of patients at transplantation was 26.55 +/- 4.72 years and the median interval between transplantation and pregnancy was 27.5 months. Gestational period was 8 months. Live birth was the outcome in 43.2% of pregnancies; 9.5% led to still birth, 24.3% were aborted, and obstetrical data of the remaining were unavailable. Among the 11 patients who became pregnant within 12 months after transplantation, we observed seven live births and four abortions. None of pregnancies that were accompanied by acute rejection episodes (ARE) were successful. Twenty-six patients experienced at least one ARE versus 23 patients of the control group (P = NS). However, the first ARE occurred later in the pregnant group (P = .028). Chronic rejection and graft loss were seen in 24 and 18 study group cases and 17 and 17 control cases, respectively (P = NS). One-, 3-, 5-, and 10-year graft survivals were 100%, 96.5%, 94.5%, and 77.1% in the pregnant group versus 93.2%, 85.7%, 81%, and 64.7% in the control group, respectively (P = .07). CONCLUSION: Pregnancy in kidney recipients seems to be safe for kidney allograft recipients even within the first year posttransplant. Nonetheless, the outcomes of pregnancy in this group of patients is not always favorable, especially when rejection occurs simultaneously.

Is HLA-DR6 a protective factor against posttransplantation diabetes mellitus?

BACKGROUND: Posttransplant diabetes mellitus (PTDM) has several pre- and posttransplant risk factors. METHODS: The incidence and risk factors of PTDM were retrospectively evaluated in 2117 kidney allograft recipients from June 1984 to March 2004. Type and dosage of immunosuppressive agents, pretransplant weight and human leukocyte antigen (HLA) phenotypes in PTDM patients were compared with 61 matched controls. RESULTS: Sixty-one cases (2.8%) developed PTDM requiring insulin or oral hypoglycemic therapy, out of which 47.5% were men and 52.5% were women, although only 35% of our overall recipients are women. Onset occurred at a mean of 489 days following transplantation. Patients receiving more than 15 mg/d prednisolone developed PTDM more often than those on less than 15 mg/d (P = .000). Similarly PTDM was more frequent among patients who received more than 300 mg/d cyclosporine compared with those on less than 300 mg/d (P = .015). Mean weight in PTDM cases and controls was 65 +/- 13.4 kg and 57 +/- 13.6 kg, respectively (P = .005). HLA-DR6 was observed in 12.2% of nonaffected subjects but in none of the PTDM group (P = .002). Conversely, HLA-DR8 was seen only in PTDM patients (P = .012). In addition HLA-A26 was more common among PTDM patients (P = .02) and HLA-DR52 more frequent in nonaffected subjects (P = .025). CONCLUSION: Our findings suggest that female sex, dosages of prednisolone and cyclosporine, pretransplant weight, and genetic factors are associated with an increased risk of PTDM. The rate of PTDM appeared to be independent of weight gain in the first year posttransplant. Protection against PTDM may be afforded by HLA-DR6 and possibly HLA-DR52. Conversely and higher incidence of diabetes has been associated with HLA-DR8 and HLA-A26.

Erythrocytosis after renal transplantation: review of 101 cases.

Posttransplant erythrocytosis is increasingly recognized as a complication of kidney transplantation. In a retrospective analysis of 500 recipients, we observed 101 patients (20.2%) with persistent elevation of hematocrit value. It was more frequent in men (82.2%) than women (17.8%). It occurred 2 to 50 months after engraftment (mean value was 11.2 +/- 8.9 months), but most often developed in the first 24 months (86%). Spontaneous remission of established erythrocytosis was observed in all cases within 3 to 93 months. It frequently occurred in patients with a well-functioning renal graft; in 82.2% of cases the serum creatinine concentration was less than 1.5 mg/dL. It was 1.5 to 2 mg/dL in 15.8% of patients. There was no correlation between diabetes mellitus and erythrocytosis, compared with a control group. It was more common in patients who received cyclosporine compared to those who were not on cyclosporine. Predisposing factors included male gender, retention of native kidneys, cyclosporine use, and a rejection-free course with a well-functioning renal graft. In conclusion, posttransplantation erythrocytosis, a frequent problem in renal transplant patients, is a self-limited complication that can result in thromboembolic disease.