Recurrent membranoproliferative glomerulonephritis after second renal graft treated with plasmapheresis and rituximab.

We present a case of a 45-year-old man who suffered from idiopatic membranoproliferative glomerulonephritis (MPGN) in the native kidney that relapsed after his first and second renal grafts. The patient was diagnosed in 1990 with lobular MPGN type I, receiving his first renal graft in 1996. In 2001, a biopsy showed recurrence of MPGN type I (rMPGN). He underwent a second renal graft in 2008. In January 2010, he experienced increased proteinuria and creatinine. Upon electron microscopy of a renal graft biopsy we diagnosed a new rMPGN. At the time of the biopsy, complement levels were normal, although C3 and C4 decreased further. We administered 12 plasmapheresis (PP) sessions and four doses of rituximab. Due to persistent renal impairment, we performed a new biopsy 3 months later, showing less severity of the acute lessions. He received a new cycle of treatment (PP+rituximab). One year later, his renal function was stable with a creatinine ranging between 2 and 2.5 mg/dL and a protein/creatinine ratio less than 1 mg/mg. We concluded that the treatment stopped the disease progression.

Long-term survival of simultaneous pancreas-kidney transplantation: influence of early posttransplantation complications.

BACKGROUND: Complications that develop in the early posttransplantation period after simultaneous pancreas-kidney transplantation (SPKT) can contribute to poor long-term survival of grafts and patients. PATIENTS AND METHODS: We studied 86 SPKTs that were performed between 2000 and 2010 in our hospital, analyzing all complications in the early posttransplantation period and their impact on long-term survival in patients and grafts. RESULTS: The mean age of the patients was 38.77 ± 7.13 years (79.1% male). Of the 86 SPKT patients, 22.1% were on peritoneal dialysis (PD) before transplantation, 68.6% were on hemodialysis (HD), and 9.3% had not received any substitutive renal therapy. The immunosuppressive regimens consisted of induction with basiliximab followed by tacrolimus, mycophenolate mofetil, and steroid therapy. More than 75% of patients experienced an infection in the early posttransplantation period: bacteremia (37.2%), central catheter infection (7%), wound infection (4.7%), urinary tract (14%) and positive abdominal drain culture (45.3%). Approximately one third (31.4%) of patients underwent a reoperation, primarily due to bleeding (21.95%) or infection (19.51%). One fifth of patients (19.8%) experienced an acute rejection episode. The 3-year survival of the pancreas was lower among PD patients (82%) compared with patients who did not undergo dialysis before SPKT (100%). The 5-year survival rate of both grafts was lower among patients who underwent a reoperation than those who did not: pancreas survival rates, were 70% versus 93%, respectively (P = .015) and kidney graft survival rates were 75% versus 96%, respectively (P = .0017). Five-year patient survival rates were also lower among reoperated patients than those who were not (85% vs 97%, respectively), although the difference was not significant (P = .27). CONCLUSIONS: Complications in the early posttransplantation period after SPKT were frequent, increasing morbidity and inpatient stay. One third of our patients underwent a reoperation, which had a negative impact on graft survival.

Impact of recurrent glomerulonephritis on renal graft survival.

BACKGROUND: Glomerular disease causes graft loss in the intermediate and long term, especially recurrent primary renal disease, negatively impacting graft survival. Thus, it must be considered a differential diagnosis in the evaluation of chronic graft dysfunction. METHODS: The objectives of our study were to compare the impacts of primary glomerular disease on graft survival and association with interstitial fibrosis/tubular atrophy (IFTA) or transplant glomerulopathy. We examined the influence of the relapse of glomerulonephritis (GN) on renal graft survival in a retrospective study of 1057 patients undergoing renal transplantations between March 1981 and October 2009. Among this group, 128 patients were diagnosed with pretransplant GN by renal biopsy. We examined graft survival on recurrence compared with IFTA and transplant glomerulopathy using Kaplan-Meier analysis. RESULTS: We analyzed a cohort of 128 patients who were diagnosed with pretransplant GN by renal biopsy, including 28.9% (37) of whom were males. The mean age was 42.04 ± 13.82 years. The most frequent type was immunoglobulin A GN (IgAGN; 31.3%), followed by membranoproliferative GN (MPGN; 28.9%), rapidly progressive GN (RPGN; 16.4%), focal-segmental GN (FSGN; 13.3%), membranous GN (9.4%), and minimal change GN; (0.8%). Among the 16 cases (12.5%) of GN recurrence; MPGN was associated most frequently (n = 10, 28.9%), followed by FSGN (n = 4, 23.5%), RPGN (n = 1, 4.8%), and IgAGN (n = 1, 2.5%). We noted that 11.8% of subjects to be positive for hepatitis C virus; while 3.9% were hepatitis B virus(HBV)-positive. We observed no differences in hepatic serology between patients who experienced recurrence (HBV 6.3% vs hepatitis C virus [HCV] 18.8%) compared with IFTA (HBV 3.1% vs HCV 9.4%). Fifty-one patients (39.8%) were biopsied after transplantation due to impaired renal function: there were recurrences of GN in 12.5% (n = 16), IFTA in 25% (n = 32), and transplant glomerulopathy in 2.3% (n = 3) cases. The average graft survival in our cohort was 8.36 ± 0.59 years. The median patient survival among those who experienced a recurrence was 8.36 ± 1.79 years; 7.19 ± 1.01 years in IFTA patients; and 3.31 ± 0.91 years in patients with transplant glomerulopathy (log-rank P = .06). Upon multivariate analysis, recurrence of GN was not an independent predictor of renal loss. CONCLUSIONS: MPGN was the type of GN that recurred most frequently followed by FSGN. No differences in graft survival were noted between long-term recurrence of GN and other causes of chronic graft dysfunction. The recurrence of primary disease did not worsen the renal graft prognosis versus other causes of chronic graft dysfunction.

A difficult emergency surgical diagnosis: atresia of the common pulmonary vein.

A newborn female experienced severe respiratory distress immediately after delivery. She presented with intense cyanosis, refractory hypoxemia, and acidosis. The deterioration was rapidly progressive, leading to the child's demise. The autopsy showed common pulmonary vein atresia, the most severe form of pulmonary venous drainage obstruction. Subpleural and interstitial pulmonary lymphagiectasias also were present as well as evidence of pulmonary hypertension. The lung pathology probably resulted from pulmonary venous atresia during prenatal development.

Púrpura de Schönlein-Henoch: un caso complejo / Schönlein-Henoch purpura: A complex case

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