Management of pre-renal transplant secondary hyperparathyroidism: parathyroidectomy versus cinacalcet.

Background: Secondary hyperparathyroidism is a common consequence of end-stage renal disease. Despite the efficacy of kidney transplantation in treating renal failure, many transplant recipients still suffer from persistent or tertiary hyperparathyroidism. Furthermore, the impact of secondary hyperparathyroidism therapy choices on other renal transplant outcomes is poorly understood. Methods: We retrieved the clinical data of 334 patients who received a kidney allograft between January 2007 and December 2014 at the Sheffield Teaching Hospitals, NHS Foundation Trust, United Kingdom. We identified three groups: parathyroidectomy group (34 patients), including patients who had parathyroidectomy before transplantation; cinacalcet group (31 patients), including patients who received cinacalcet before transplantation; and control group (269 patients), including patients who receive a transplant in the same period but did not have any evidence of hyperparathyroidism. We reviewed the demographic data, biochemical parameters and graft survival of all groups. Results: Patients who underwent parathyroidectomy before transplantation had significantly better post-transplant calcium and parathyroid hormone levels than patients in the cinacalcet group (p=0.003). In addition, a significantly lower number of patients had tertiary hyperparathyroidism in the parathyroidectomy group than in the cinacalcet group at 1 year of follow-up (p=0.001). However, short-term and long-term graft survival was comparable in all groups. Conclusions: Renal allograft survival was comparable in all groups. However, tertiary hyperparathyroidism was less likely to occur in patients who underwent parathyroidectomy than in those who were administered cinacalcet.

Refractory CD20 Positive Cellular Rejection in Living Kidney Transplant: A Case Report and Review of Literature.

Transplant is the optimal therapy for patients with end-stage renal disease. Acute cellular rejection refractory to treatment remains a major risk factor for graft loss and poor outcomes. In this study, we describe a 39-year-old man who received a living-related kidney transplant. Two days after transplant, the patient displayed acute deterioration of graft function. Conventional anti-rejection therapy was initiated, but graft function did not improve. Biopsy revealed acute cellular rejection (grade IIA), and C4d and HLA antibodies were negative. Immunohistochemistry phenotyping revealed clusters of CD20-positive lymphocytes, with 80% being CD3 positive. Rituximab was prescribed, and graft function improved dramatically. After 1 week, a second graft biopsy was done due to lagging of graft function, shown by serum creatinine of 2.1 mg/dL. Biopsy revealed regenerating acute tubular necrosis with disappearance of the CD20-positive lymphocyte cluster infiltrates. Two year, after transplant, the patient's graft function maintained stable. Phenotyping of the cellular infiltrate is important as it may lead to a proper selection of immunosuppression and consequent improvement of graft outcome.

Possible role of nitric oxide in hepatic injury secondary to renal ischemia-reperfusion (I/R) injury.

Hepatic injury secondary to renal I/R injury has been documented in several studies. This study aimed to investigate the role of NO in hepatic injury secondary to renal I/R in rat model. Sprague-Dawley rats (n = 48) were divided into 4 equal groups; sham-operated, I/R injury group (45 min of bilateral renal ischemia), L-arginine group (I/R with 300 mg/kg L-arginine, 20 min before ischemia), L-NAME group (I/R with 50 mg/kg L-NAME, 20 min before ischemia). L-NAME (NO synthase inhibitor) caused significant elevation in serum creatinine, BUN, liver enzymes, liver histopathological damage score (p ≤ 0.05) and MDA production (p ≤ 0.001); on the other hand significantly decreased NO and GSH levels (p ≤ 0.05). L-arginine significantly decreased serum creatinine, BUN and GSH (p ≤ 0.05) and caused significant elevation in liver enzymes and NO (p ≤ 0.05), and also in MDA levels (p ≤ 0.001) in liver tissues. We conclude that endogenous NO might have protective effect against hepatic injury induced by renal I/R injury and inhibition of this endogenous NO by L-NAME or exogenous administration of NO (by L-arginine) might be harmful.

Factors affecting graft survival among patients receiving kidneys from live donors: a single-center experience.

INTRODUCTION: The aim of this report is to study the graft and patient survival in a large cohort of recipients with an analysis of factors that may affect the final outcomes. METHODS: Between March 1976 and March 2008, 1967 consecutive live-donor renal transplants were carried out. Various variables that may have an impact on patients and/or graft survival were studied in two steps. Initially, a univariate analysis was carried out. Thereafter, significant variables were embedded in a stepwise regression analysis. RESULTS: The overall graft survival was 86.7% and 65.5%, at 5 and 10 years, respectively. The projected half-life for grafts was 17.5 years and for patients was 22 years. Five factors had an independent negative impact on graft survival: donor's age, genetic considerations, the type of primary immunosuppression, number of acute rejection episodes, and total steroid dose during the first 3 months after transplantation. CONCLUSIONS: Despite refinements in tissue matching techniques and improvements in immunosuppression protocols, an important proportion of grafts is still lost following living donor kidney transplantation, presumably due to chronic allograft nephropathy.

Alemtuzumab preconditioning allows steroid-calcineurin inhibitor-free regimen in live-donor kidney transplant.

OBJECTIVES: This prospective study was designed to develop a steroid and calcineurin inhibitor-free regimen for kidney transplants using alemtuzumab. MATERIALS AND METHODS: A single dose of alemtuzumab (30 mg) was given preoperatively. Phase 1: Twenty-one patients were randomized into 2 groups; the tacrolimus (n=11) and the sirolimus groups (n=10). Steroids were given for 5 days. Azathioprine (1 mg/kg) was added when white blood cells ≥ 4000 cells/cm(3). Mean follow-up was 48 ± 2.8 and 48.2 ± 1.6 months for the tacrolimus and sirolimus groups. Phase 2: Twenty patients were included and the study design was modified. Tacrolimus was given for 2 months, and was replaced by sirolimus thereafter. The mean follow-up was 28.3 ± 2.1 months. RESULTS: Phase 1: Acute rejection episodes were encountered in 5 patients of the tacrolimus versus 2 cases in the sirolimus group (P = .44). Antibody-mediated rejection was diagnosed in 2 recipients in each group. Four patients were switched from sirolimus to tacrolimus owing to resistant rejection, significant proteinuria, persistent thrombocytopenia, lymphocele, and urinary leakage. One patient was shifted from tacrolimus to sirolimus owing to Kaposi sarcoma. Glomerular filtration rate was significantly higher in the sirolimus group. Currently, 14 patients (8 tacrolimus, and 6 sirolimus) are steroid-free. One patient died from the tacrolimus group owing to fulminant hepatitis. Two grafts were lost in the sirolimus group versus 1 graft in the tacrolimus group. Phase 2: Five patients developed successfully treated borderline changes with no antibody-mediated rejection. Mean serum creatinine was 114.9 ± 17.7 µmol/L. Currently, 17 patients are steroid free and 15 of them are calcineurin inhibitor-free as well. In this phase, only 1 patient died with a functioning graft. CONCLUSIONS: This clinical trial provides a good insight into a potentially effective steroid and calcineurin inhibitor-free protocol with the use of alemtuzumab induction in combination with sirolimus.

Impact of accidental discovery of renal cell carcinoma at time of renal transplantation on patient or graft survival.

BACKGROUND: Renal tumors are common in the pretransplant end-stage renal disease population. Their impact on transplant outcome has not been well addressed. METHODS: This study is a retrospective follow-up observational study conducted in 258 renal transplant recipients. All patients had an ipsilateral native nephrectomy at the time of transplantation. We reviewed the histopathology of all native nephrectomies to gauge the prevalence of renal cell carcinoma (RCC) and to investigate the impact of accidental discovery of RCC on graft and patient outcome. RESULTS: RCC was found in 12 patients (4.7%): clear type in 9 patients, and chromophobe and combined clear and papillary type in 1 and 2 patients, respectively. There was no significant difference in human leukocyte antigen mismatch, primary immunosuppression, occurrence of rejection, graft function, and patient and graft survival between patients with or without RCC. RCC presented in the other native kidney in three patients (25%) posttransplantation and one of them developed metastasis 4 years after renal transplantation in the RCC group in comparison with eight patients in the control group (3.3%; P<0.001). The median follow-up period was 56 months for the RCC group and 65 months for the control group. CONCLUSIONS: We found that renal transplant outcome and patient survival were not adversely affected by the presence of accidently discovered RCC at the time of transplantation. These patients seem to be at significantly higher risk of the occurrence of RCC in the remaining native kidney. Further studies are warranted to confirm our results.

Ten-year follow-up of basiliximab induction therapy for live-donor kidney transplant: a prospective randomized controlled study.

OBJECTIVES: The effect of basiliximab induction therapy on long-term patient and graft survival is not clear. We sought to evaluate if there is any advantage to routine basiliximab induction on the long-term outcome of living-related donor kidney transplants. MATERIALS AND METHODS: One hundred adult recipients with their first kidney allograft were randomized into 2 treatment groups; 1 group received basiliximab, and the second served as a control. All patients received a maintenance triple immunosuppressive therapy (steroids, cyclosporine, microemulsion, and azathioprine). We followed them for 10 years. RESULTS: Basiliximab reduced the proportion of patients who experienced an acute rejection in the first year (18/50) when compared with the control group (31/50) (P = .009), and in 10 years (28/50) when compared with controls (37/50) (P = .059). The cumulative steroid dosage used throughout the study was significantly lower in the basiliximab group. The overall incidence of posttransplant complications was comparable among the 2 groups. There was no significant difference in patient and graft survival; 10-year patient and graft survival were 92% and 76% for basiliximab and 90% and 68% for the control group. CONCLUSIONS: Routine basiliximab induction significantly reduces the incidence of acute rejection without any noticeable effects on the long-term renal transplant outcome.

End-stage renal disease among living-kidney donors: single-center experience.

OBJECTIVES: Renal transplant from living donors is widely accepted as a highly effective treatment for end-stage renal disease. Donors undergo a major operation with considerable perioperative risks of morbidity and mortality. Living with a single kidney also confers long-term risks. This study sought the incidence and causes of end-stage renal disease among living kidney donors. MATERIALS AND METHODS: This study included all donors who had reached end-stage renal disease among 2000 consecutive living-kidney donors. All operations and follow-up were performed in a single center. We studied the onset of renal disease, cause of end-stage renal disease, date of replacement therapy, and outcome. We also revised the donor's medical records related to their corresponding recipients. RESULTS: Of 2000 living donors, 8 developed end-stage renal disease; 6 were men (mean age, 30.87 ± 5.84 years. Renal failure occurred 5 to 27 years after donation. Renal transplant was done in 1 donor. Medical complications were proteinuria (6 patients), hypertension (7 patients), diabetes (3 patients), gout (3 patients), ischemic heart disease (5 patients), and hepatitis viral infection (4 patients). The causes of end-stage renal disease were diabetic nephropathy in 3 patients. Other possible causes included toxic nephropathy, chronic pyelonephritis, and preeclampsia. CONCLUSIONS: Living kidney donation is safe, and development of renal failure after donation is caused by the same causes as in the general population.

Continuous ambulatory peritoneal dialysis in Egypt: progression despite handicaps.

BACKGROUND: Despite the well-known advantages of continuous ambulatory peritoneal dialysis (CAPD), it continues to be grossly underutilized in many developing countries. However, some developing countries, such as Mexico, use the modality very effectively. In view of this, we started the first CAPD program in Egypt. METHODS: Since its start in 1997, our program has treated 33 patients. Straight double-cuffed Tenckhoff catheters were surgically placed in all patients. Twin-bag systems were used. All patients underwent monthly clinical and biochemical assessment and measurement of Kt/V urea. Peritonitis and exit-site infection rates were monitored. RESULTS: Most treated patients were adult and female. Mean age was 31.7 years and mean follow-up duration was 18 months. Peritonitis rate was 1 episode /21.3 months and was easily managed in most patients. Staphylococcus aureus was the most commonly isolated organism (24%) but 49% of cases were culture negative. There were no exit-site infections. Mean weekly Kt/V urea was 1.78 +/- 0.23. CONCLUSION: We report the successful development of a small CAPD program in Egypt, made possible by well-established financial support, a motivated team of doctors and nurses, and good patient selection and training.

Decline of viral hepatitis prevalence among asymptomatic Egyptian blood donors: a glimmer of hope.

BACKGROUND: Viral hepatitis is an important etiological agent of chronic hepatitis and liver disease and is a major cause of morbidity and mortality especially in Egypt since it has the highest prevalence of hepatitis C virus (HCV) infection. We aimed to assess if there is any change in the annual seroprevalence of both HCV and hepatitis B virus (HBV) infection in Egypt in the current era. METHODS: Our study included 55,922 potentially healthy asymptomatic blood donors; 52,280 males and 3642 females with mean age of 30.98+/-8.6 years. All of them were volunteers for the first time and 70% were from rural areas. We applied our own questionnaire that included past medical history, surgical history, and history of blood donation. We screened their sera for the presence or absence of anti-HCV antibodies with the 3rd generation enzyme-linked immunosorbent assay (ELISA) and the presence or absence of hepatitis B surface antigen (HBsAg) with ELISA. RESULTS: The cumulative seroprevalence of HCV and HBV infection was 11.95% and 1.3% respectively. The annual seroprevalence of both viruses showed a declining pattern throughout the study period from 17.7% to 7.4% regarding HCV and HBV infection from 2.3% to 0.9%. The decline trends for both viral infections were observed for both genders. CONCLUSION: This study carries a glimmer of hope because of a decline in seroprevalence of viral hepatitis in Egypt. However stringent implementation of infection control programs in Egypt is mandatory to face this furious health problem.

Does posttransplant anemia at 6 months affect long-term outcome of live-donor kidney transplantation? A single-center experience.

BACKGROUND/AIMS: Posttransplantation anemia (PTA) frequently occurs. We aimed to assess the prevalence of anemia at 6 months of transplantation in patients under different protocols of immunosuppression, and to determine the impact of anemia on long-term patient and graft survival. METHODS: We included 832 renal transplant recipients who were categorized at 6 months according to hemoglobin (Hb) level into two groups: the first group, with Hb >13 g/dl in males and >12 g/dl in females (group I, 385 cases); and the second group, with Hb <13 g/dl in males and <12 g/dl in females (group II, 447 cases). We compared the two groups regarding posttransplant complications as well as patient and graft survival. RESULTS: Although there was no significant difference between the two groups regarding acute rejection episodes, chronic allograft nephropathy was significantly higher in the anemic group. Other posttransplant medical complications were comparable in both groups. Graft survival was significantly higher in the nonanemic group. However, no difference in patient survival was detected. CONCLUSION: From this study, we can conclude that prevalence of PTA is high, especially in females and those receiving calcineurine inhibitors (CNI) and mycophenolate mofetil (MMF), and that it was associated with poorer graft outcome but with no effect on patient survival.

Basiliximab induction therapy for live donor kidney transplantation: a long-term follow-up of prospective randomized controlled study.

BACKGROUND/AIMS: The effect of basiliximab induction therapy on long-term patient and graft survival is not yet clear. We aimed to evaluate if there is any advantage of routine basiliximab induction on the long-term outcome of living related donor kidney transplantation. METHODS: One hundred adult recipients with their first kidney allograft were randomized into two treatment groups, one group received basiliximab and the second served as a control. All patients received a maintenance triple immunosuppressive therapy (steroids, cyclosporine (CsA) micro-emulsion and azathioprine) and were followed up thoroughly for 7 years. RESULTS: Basiliximab significantly reduced the proportion of patients who experienced acute rejection in the first year (18/50) when compared to the control group (31/50), and in 7 years (28/50) when compared to (37/50) in controls. The cumulative steroid dose used throughout the whole study period was significantly lower in the basiliximab group. The overall incidence of post-transplant complications was comparable among the two treatment groups. There was no significant difference in patient or graft survival; 7 years patient and graft survival were 92, 76% for basiliximab and 92, 80% for the control group, respectively. CONCLUSION: Routine basiliximab induction significantly reduced the incidence of acute rejection without any noticeble beneficial effect on the long-term renal transplantation outcome.

Long-term evaluation of single bolus high dose ATG induction therapy for prophylaxis of rejection in live donor kidney transplantation.

BACKGROUND/AIMS: The long-term evaluation of single bolus high dose antithymocyte globulin (ATG) induction therapy has not been adequately studied. We aimed to evaluate its long-term effects in the living related donor kidney transplantation. METHODS: Eighty adult recipients with their first kidney allograft were randomized into two equal treatment groups, one group received intraoperative single bolus rabbit ATG in a dose of 9 mg/kg and the second group served as a control. All patients were maintained on triple immunosuppressive therapy (steroids, calcineurin inhibitor and antiproliferative agent). We followed them thoroughly for minimum of 5 years. RESULTS: ATG significantly reduced the proportion of patients who experienced acute rejection episodes in the first year (9/40) when compared to the control group (26/40) and in 5 years (11/40) when compared to (30/40) in controls. The cumulative steroid dose used throughout the study was significantly lower in the ATG group. The overall incidence of posttransplant complications was comparable among the two treatment groups. There was no significant difference in patient and graft survival: 5 year survival was 100% and 85% for the ATG group, and 95% and 92.5% in the control group, respectively. CONCLUSION: Although routine single bolus ATG induction significantly reduces the incidence of acute rejection, its long-term beneficial effects on graft function and patient and graft survival are not evident.

Epidemiology, pathophysiology, management and outcome of renal dysfunction associated with plasmodia infection.

Malaria remains a serious health problem in many parts of the world. It causes high morbidity and claims many lives in developing countries each year. Humans are generally infected by four species of malaria parasites. However, malaria infection caused by Plasmodium malariae or P. falciparum is recognized as an important cause of acute renal failure (ARF) and other renal-related disorders (nephropathy) in infected patients. The increasing incidence of malarial ARF (MARF) and the emergence of clinical malarial infection after renal transplantation represent a serious challenge. Additionally, the impact of immunosuppressive therapies on malarial infection is intricate, complex, and not yet well defined. Pathogenesis of MARF is most likely to be due to immune complex-mediated glomerulonephritis caused by immune-complex deposition and endothelial damage, which may lead to fatal forms of quartan malarial nephropathies. Effects of mechanical, immunologic, cytokine, humoral, acute phase response, and hemodynamics factors in inducing malarial nephropathy have also been postulated. Development of preventive strategies aimed at combating MARF and other renal disorders associated with malaria infection requires (1) prevention of malarial infection, (2) early diagnosis, and (3) early referral to well-equipped centers to provide renal replacement therapy, if necessary, along with antimalarial therapy and support. These measures could significantly reduce mortality and enhance recovery of renal function.

Can intravenous immunoglobulin and simvastatin solve the problem of sensitization in renal transplant candidates?

The value of intravenous immunoglobulin (IVIG) and simvastatin as potential modalities for the treatment of sensitized patients was evaluated by testing the efficacy of these agents on a relatively large cohort of adult hemodialysis patients (11) who were waiting for renal allotransplantation at our center. The patients had persistently positive crossmatches with their living related donors and a panel reactive antibody titer of more than 20%. All patients received IVIG (500 mg/kg per day on alternate days for a total of six doses); panel reactive antibody (PRA) titer and crossmatch testing were carried out after each dose and before each subsequent one. Two months after the last dose, eight patients received simvastatin (20 mg/day) for a period of 2 months; PRA titer and crossmatch testing were carried out every two weeks. Only four patients showed an insignificant reduction of PRA activity (P = 0.36); no patient attained a negative crossmatch. Simvastatin also resulted in an insignificant reduction of anti-human leukocyte antigen (HLA) antibodies in three patients (P = 0.32). We propose that IVIG or simvastatin alone can not effectively inhibit preformed anti-HLA antibodies to allow successful renal transplantation. Further trials on the use of IVIG and simvastatin with other modalities of treatment to desensitize these patients may be warranted.

Is it worth using daclizumab induction therapy with mycophenolate mofetil-based immunosuppressive regimens in live related donor kidney transplantation? A long-term follow up.

BACKGROUND/AIMS: The aim of this work is to determine the long-term therapeutic benefit(s) of daclizumab induction therapy with triple immunosuppressive protocols including prednisolone, cyclosporine microemulsion (CsA), and mycophenolate mofetil (MMF) in the living related donor kidney transplantation. METHODS: Twenty-one adult recipients of their first kidney allograft were allocated to receive daclizumab with triple immunosuppressive therapy (steroids, CsA, and MMF). They were compared to 50 recipients of their first grafts who received a maintenance triple immunosuppressive therapy (steroids, CsA, and azathioprine). The patients were followed up for 5 years. RESULTS: Daclizumab group significantly experienced a marked reduction of acute rejection (7/21) when compared to the control group (31/50) with subsequent significant reduction of cumulative steroids doses at the end of 5 years. The overall incidence of post-transplant complications was comparable among the two treatment groups. There was no significant difference in patients and graft survival; 5-year patient and graft survival were 95.3%, 85.7% for daclizumab and 96%, 88% for control group, respectively. CONCLUSIONS: Although prophylactic daclizumab with triple immunosuppressive protocol including MMF have drastically reduced the incidence of acute rejections, the graft and patient survival are unchanged in this long-term follow up.

Management of sensitized patients awaiting renal transplantation: does sequential therapy of intravenous immunoglobulin and simvastatin offer a solution?

The value of intravenous immunoglobulin and simvastatin as potential modalities for the treatment of sensitized patients was studied. We aimed to test their efficacy as solo agents to inhibit anti-human leukocyte antigen (HLA) antibodies. We tested samples from 11 adult hemodialysis patients who were waiting for renal allotransplantation at our center, all of whom had persistently positive crossmatches with their living related donors and panel reactive antibody titers more than 20%. All patients received intravenous immunoglobulin (500 mg/kg/day on alternate days for 6 doses). Panel reactive antibody titer measurement and crossmatch testing were carried out after each dose and before each subsequent one. Two months later, 8 patients received simvastatin (20 mg/day) for 2 months. Panel reactive antibody measurement titer and crossmatch testing were carried out every 2 weeks. Only 4 patients showed an insignificant reduction in panel reactive antibody activity (P=0.36). None of them attained a negative crossmatch. Furthermore, simvastatin also resulted in an insignificant reduction of HLA antibodies in 3 patients (P=0.32). We concluded that intravenous immunoglobulin or simvastatin alone cannot effectively inhibit preformed anti-HLA antibodies to allow successful renal transplantation. Further trials of the use of intravenous immunoglobulin and simvastatin with other modalities to desensitize these patients may be warranted.

Endothelial dysfunction in geriatric diabetic patients: the role of microalbuminuria in elderly type 2 diabetic patients? A randomized controlled study.

BACKGROUNDS/AIMS: Microalbuminuria is considered a marker of extensive endothelial dysfunction and is associated with excess of other cardiovascular risk factors. Our aim is to assess the importance of the presence of microalbuminuria in elderly diabetic patients. METHODS: A total of 40 normotensive elderly type 2 diabetic patients of both genders with mean age >65 years were randomly included and were further subdivided according to the presence of persistent microalbuminuria into microalbuminuric and normoalbuminuric groups. PATIENTS AND METHODS: All patients in both groups were subjected to thorough clinical and laboratory investigations including the assay of serum thrombomodulin (TM) and glycosylated hemoglobin level. Early-morning midstream urine samples were evaluated for levels of beta 2 microglobulin, alpha 1 microglobulin, TM, and N-acetyl-beta-D-glucosaminidase (NAG). RESULTS: There was no significant difference between both groups regarding the clinical demographic characteristics. There were statistically significant higher values for glycosylated hemoglobin percentage, serum triglycerides and serum TM and urinary B2 microglobulin, urinary alpha 1 microglobulin, urinary NAG and urinary thrombomodulin in microalbuminuric group in comparison to normoalbuminuric group (P < 0.05). CONCLUSION: Microalbuminuria is associated with markers of endothelial dysfunction in elderly normotensive type 2 diabetic patients. We recommend incorporation of periodic testing for microalbuminuria in this sector of patients.

Histologic and clinical findings in living donor allografts with long-term stable function.

BACKGROUND/AIMS: Protocol biopsy is an important strategy which assesses the histological changes that can occur in the renal allograft and adversely affect its outcome. We aimed to evaluate histological changes in long-term living donor transplants. METHODS: Elective biopsies were done for 120 live donor renal transplant recipients with well-functioning grafts and no rejection history at least 1 year or more after transplant. All patients had serum creatinine levels <2 mg/dl. The histopathological findings using the chronic allograft damage index score were correlated with different clinical and immunological parameters. RESULTS: Chronic tubulointerstitial fibrosis was the most prevalent finding (85% of cases), mostly of mild degree. Normal biopsies were reported in only 7.5% of cases, whereas chronic cyclosporine nephrotoxicity was detected in 5.8% of biopsies. Posttransplant hypertension was significantly correlated with glomerulosclerosis, and posttransplant diabetes with glomerulosclerosis, mesangial matrix increase, tubular atrophy and interstitial fibrosis. The main risk factors associated with a high chronic allograft damage index score were DR mismatching, posttransplant diabetes and time of biopsy. All histopathological changes increased with advancing donor age and declining graft function. CONCLUSION: Elective biopsies showed that histopathological findings do exist even with stable renal function that may pave the way for predicting long-term graft outcome.