Cytomegalovirus disease in African-American kidney transplant patients.

BACKGROUND: Cytomegalovirus (CMV) disease is a serious infection after kidney transplantation. The risk factors and the impact of CMV disease in African-American (AA) kidney transplant patients have not been well characterized. METHODS: We performed a retrospective analysis on 448 AA patients transplanted between 1996 and 2005. A 3-month universal chemoprophylaxis with ganciclovir or valganciclovir was administered to CMV donor-positive/recipient-negative (D+/R-) patients and to those treated with anti-thymocyte globulin for rejection, but not routinely to those with other D/R serostatus. RESULTS: A total of 31 AA patients (7%) developed clinical CMV disease. Compared with other D/R serostatus groups, the D+/R- group had the highest 3-year cumulative incidence of CMV disease (16.9% vs. 6.3% in D+/R+, 4.9% in D-/R+, and 2.4% in D-/R-). The D+/R- group also had the worst 3-year death-censored allograft survival (75% vs. 92% in D+/R+, 94% in D-/R+, and 96% in D-/R-, log-rank P = 0.01). Multivariate analysis found that D+/R- serostatus (odds ratio [OR] 5.4, 95% confidence interval [CI] 0.6-48.2, P = 0.003) and donor age > 60 years (OR 9.1, 95% CI 1.3-65, P = 0.03) were independent risk factors for CMV disease. CONCLUSION: The D+/R- group has the highest incidence of CMV disease and the worst 3-year renal allograft survival despite 3-month universal prophylaxis. Prolonged chemoprophylaxis may be needed to prevent the late development of CMV disease and to improve allograft survival in the high-risk group of AA kidney transplant recipients.

The effect of HLA mismatch on highly sensitized renal allograft recipients.

INTRODUCTION: We examined the effects of increasing human leukocyte antigen (HLA) mismatches (MM) on long-term graft outcomes in patients transplanted with a panel reactive antibody (PRA) >80% over a 10-yr period. METHODS: A total of 142 recipients were divided into three groups based on the number of HLA MM with their allograft (0-2, 3-4 and 5-6 MM; Groups I, II and III). All patients received the same immunosuppression protocol. RESULTS: The higher MM groups had a higher incidence of rejection (4.4% vs. 11.4% vs. 31.3%, p < 0.01). A multivariate analysis showed that rejection was the only significant variable affecting graft loss (OR = 7.45, p = 0.01). There was a trend toward more CMV infection and worse graft function with higher MM. Kaplan-Meier five-yr graft survival estimates were 100% vs. 81% vs. 74% for Groups I, II and III, respectively (p = 0.14). CONCLUSIONS: In patients with PRA levels >80%, a higher HLA MM is associated with higher incidence of acute rejection. Acute rejection was the only significant variable affecting graft loss. We found a trend toward more CMV infections and worse graft outcomes with higher MM. Closer HLA matching and immunologic monitoring needs to be considered to improve graft outcomes among sensitized recipients.

Long-term outcome of single pediatric donor kidney transplants between African-American and non-African-American adults.

BACKGROUND: African-American (AA) ethnicity has been considered a risk factor for graft loss after kidney transplant. The long-term graft survival of single pediatric donor kidney transplants in AA adults has not been reported. METHODS: We retrospectively compared the outcome of 43 AA and 32 non-African-American (NAA) adults transplanted with single pediatric kidneys from donors aged 10 years or less in our center. A combination of tacrolimus, mycophenolic acid and steroid was utilized as the maintenance therapy. RESULTS: Similar immunosuppressive dose and targeted level were achieved between the AA and the NAA groups. Median body weight (BW) of donors was 20 kg (8 - 36) in the AA group and 19 kg (8.5 - 35) in NAA group. There was no statistically significant difference in the incidence of rejection between the AA and NAA groups (26 vs. 16%, p = 0.45). The surgical complications, delayed graft function, and development of proteinuria and focal and segmental glomerulosclerosis (FSGS) were similar in both groups. The patient and graft survivals in the AA group were slightly higher compared to the NAA group. The death-censored analysis demonstrated no difference in graft survival between the AA and NAA groups (p = 0.90): 86 vs. 82% at 1 year, 70 vs. 71% at 3 years, and 62 vs. 64% at 5 years. CONCLUSIONS: Single pediatric donor kidney transplant in AA adults can be achieved with acceptable complications and equivalent long-term outcomes as in NAA adults in the era of potent immunosuppressive regimen.

Enteric coating of mycophenolate reduces dosage adjustments.

Mycophenolate mofetil (MMF) and enteric-coated mycophenolate sodium (EC-MPS) are bioequivalent. However, the effectiveness of MMF may be limited by gastrointestinal (GI) side effects. This study assessed the relationship between the number of medication dosage adjustments and posttransplantation side effects. In a review of 109 kidney transplant patients, 65 initially received MMF and 44 initially received EC-MPS. The incidences of patient-reported GI complications were significantly different: MMF 45.5% vs EC-MPS 35.3% (P = .0194). The proportions of patients requiring dosage adjustment due to GI complications were MMF 5.9% and EC-MPS 2.3% (P < .0001). Patients receiving MMF were more likely to experience GI complications resulting in dosage adjustment (odds ratio = 9.9; P = .0306). The incidences of acute rejection, cytomegalovirus (CMV), and leukopenia resulting in dosage adjustment were not significantly different. Patients receiving MMF required more immunosuppressive medication adjustments, which may complicate care and decrease overall compliance.

Usefulness of heart rate as an independent predictor for survival after heart transplantation.

It was unclear whether increased heart rate (HR) increased long-term mortality after heart transplantation (HT). The aim of this study was to evaluate whether HR predicted survival after HT. A retrospective analysis of patients who underwent HT at our institution was performed. Ethnicity, gender, date of birth, age at transplantation, length of follow-up after transplantation, cardiac rhythm within 3 months after transplantation, age at death, reason for transplantation, cause of death, and baseline medications after transplantation were recorded. Continuous variables, such as HR, blood pressure, cardiac ejection fraction, presence of allograft vasculopathy, and serum creatinine, were recorded at <3 months, 6 months, and 1 year after HT, then annually to 10 years after HT. Seventy-eight patients with a mean age of 50 +/- 13 years were identified. Mean survival was 8.5 +/- 6.5 years. Of 78 patients, 32 patients had an HR 90 beats/min within 3 months after HT. There was a mean decrease in HR of 6 beats/min during 10 years (p <0.03). Multivariate survival analysis showed that HR >90 beats/min was a significant predictor of early mortality (hazard ratio 2.8, 95% confidence interval 1.5 to 5.1, p <0.0013). Patients with a net increase in HR during 10 years had an increased risk of death compared with patients with no change or a net decrease in HR (hazard ratio 4.7, 95% confidence interval 1.9 to 12.0, p <0.002). No significant differences in cause of death between patients with an HR 90 beats/min existed. In conclusion, HT patients with an HR >90 beats/min within the first 3 months after HT were 2.8 times more likely to die than patients with an HR

Alcohol consumption and the risk of end-stage renal disease among Chinese men.

We examined the relationship between alcohol consumption and incidence of end-stage renal disease (ESRD) in a prospective cohort of 65 601 Chinese men aged 40 years and older. Information on the amount and type of alcohol consumed was collected at a baseline examination with follow-up evaluations conducted 8-9 years later. During the 500 876 person-years of follow-up, 176 participants initiated renal replacement therapy or died from renal failure. Compared to non-drinkers, the relative risk of ESRD was 0.67 among men consuming less than 21 drinks per week and 0.52 among men consuming this amount or more after adjustment for age, geographic region, urbanization, education, body mass index, physical activity, and cigarette smoking. The inverse association between alcohol consumption and ESRD existed even after adjustment for systolic blood pressure, and history of diabetes and cardiovascular disease. Our results suggest an inverse relationship between alcohol consumption and risk of ESRD in Chinese men. Heavy alcohol consumption, however, may lead to increased risk of morbidity and mortality from other causes; therefore, the implications from these findings should be interpreted cautiously.

A comparison of long-term survivals of simultaneous pancreas-kidney transplant between African American and Caucasian recipients with basiliximab induction therapy.

African Americans (AA) have traditionally been thought to have higher immunologic risk than Caucasians (CA) for rejection and allograft loss. The impact of ethnicity on the outcome of simultaneous pancreas-kidney (SPK) transplant with basiliximab induction has not been reported. In this study, we retrospectively analyze the long-term results of 36 AA and 55 CA recipients of primary SPK. The actual patient survival rates of AA and CA groups were 91.7% vs. 90.1% at 1 year, 93.3% vs. 88.1% at 3 years, and 94.4% vs. 83.3% at 5 years. The actual kidney survival of AA and CA were 91.7% vs. 89.1% at 1 year, 90% vs. 81% at 3 years, and 83.3% vs. 75% at 5 years. The actual pancreas survival of AA and CA were 88.9% vs. 85.5% at 1 year, 83.3% vs. 78.6% at 3 years and 72.2% vs. 70.8% at 5 years. Death-censored analyses also found no difference in pancreas and kidney graft survival rates over 5 years. Higher rejection rate, but the same low CMV infection, and comparable quality of graft function were noted in AA group. AA may not have worse long-term outcomes than CA recipients of SPK with basiliximab induction and tacrolimus (TAC), mycophenolate acid (MFA) and steroid maintenance immunotherapy.

Longitudinal study of fasting serum glucose concentrations in healthy elderly. The New Mexico Aging Process Study.

BACKGROUND: The American Diabetes Association s Expert Committee on the Diagnosis and Classification of Diabetes Mellitus has made the recommendation that all individuals over the age of 45 years should be screened for diabetes every 3 years. OBJECTIVE: This study was designed to determine the necessity for screening healthy elderly (> 65 years) this frequently using fasting serum glucose (FSG) determinations. DESIGN: This is a longitudinal study of initially healthy, upper middle class, community-based volunteers, mostly age 65 years and older at entry into the study. Participants were followed longitudinally with annual FSG concentrations and body mass indices (BMI) for periods up to 18 years (mean 12.4 years). RESULTS: Only 4 of 299 individuals with entry FSG < 126 mg/dl (mean + S.D. age at entry 71.6 + 4.8 years) and 6 or more annual visits have subsequently met the Expert Committee criteria for the diagnosis of diabetes (two consecutive FSGs > 126 mg/dl unless under treatment). When one examines the slopes of FSGs plotted over time (years) for each individual, more participants had a negative slope (220) than positive slope (79), i.e., their FSGs tended to decrease with age. None of the 68 individuals entered age > 75 years subsequently developed diabetes or a significantly positive slope. CONCLUSIONS: It does not appear necessary to screen non-obese elders (excluding minorities) age >65 years with a FSG < 100 mg/dl, or those age >75 years every 3 years as recommended.

A biethnic community survey of cognition in participants with type 2 diabetes, impaired glucose tolerance, and normal glucose tolerance: the New Mexico Elder Health Survey.

OBJECTIVE: To determine whether elderly individuals with type 2 diabetes or impaired glucose tolerance are at increased risk for cognitive impairment compared with individuals with normal glucose tolerance. RESEARCH DESIGN AND METHODS: Elderly Hispanic individuals (n = 414) and non-Hispanic white individuals (n = 469) aged > or =65 years, randomly selected from the Medicare rolls of Bernalillo County (Albuquerque), NM, were recruited for an interview/examination that included an evaluation of glucose tolerance. Information on nine tests of cognitive function and two measures of depression allowed comparisons between diabetic status and these functions. Comparisons also were made between glycosolated hemoglobin concentrations and these cognitive tests in the 188 participants with diabetes. RESULTS: None of the mean scores on the tests of cognitive function was significantly lower in the participants with diabetes compared with those participants with normal glucose tolerance after adjustments for ethnicity, sex, age, level of education, and presence of depression, with or without elimination of those with dementia (Mini-Mental State Exam <18). Interestingly, participants with impaired glucose tolerance tended to score higher than those with normal glucose tolerance. No significant associations were found between glycosolated hemoglobin concentrations and cognitive test scores in participants with diabetes. CONCLUSIONS: We could not show any increased risk for cognitive impairment in participants with diabetes compared with those with normal glucose tolerance after adjustments for ethnicity, sex, age, education, and presence of depression, before or after elimination of dementia in this random sample from a biethnic population of predominantly community-dwelling elders.

Treatment of chronic nightmares in adjudicated adolescent girls in a residential facility.

PURPOSE: To evaluate imagery rehearsal therapy for the treatment of chronic nightmares in a sample of adolescent girls. METHODS: Adolescent girls ranging in age from 13 to 18 years were recruited from the Wyoming Girls School in Sheridan, Wyoming (treatment group, n = 9; control group, n = 10). These girls had previously suffered a high prevalence of unwanted sexual experiences in childhood and adolescence, and thus many suffered from nightmares, sleep complaints, and posttraumatic stress symptoms. Imagery rehearsal therapy was provided in a 1-day (6-h) workshop. Imagery rehearsal consists of three steps, all of which are performed in the waking state: (a) select a nightmare, (b) "change the nightmare any way you wish," and (c) rehearse the images of the new version ("new dream") 5 to 20 min each day. Control participants received no intervention. RESULTS: At baseline, these girls had been suffering from nightmares, on average, for 4.5 years, and they reported experiencing 20 nightmares per month, which occurred at a frequency of at least one bad dream every other night. At 3 months, self-reported, retrospectively assessed nightmare frequency measured in nights per month decreased 57% (p =.01, d = 1.4) and measured in nightmares per month decreased 71% (p =.01, d = 1.7) in the treatment group, compared with no significant changes in the control group. No significant changes were noted for sleep and posttraumatic stress disorder measures in either group. CONCLUSION: Imagery rehearsal therapy was an effective treatment option for chronic nightmares in this adjudicated adolescent population.

Prevalence of mild impairment in renal function in a random sample of elders from a biethnic community survey.

The purpose of this study was to compare the prevalences of renal impairment, notably an elevation in serum urea nitrogen and/or serum creatinine concentration, in a randomly selected, biethnic population of Hispanic and non-Hispanic white men and women, and to determine the associations with coronary heart disease and its risk factors (diabetes, hypertension, and dyslipidemia). A survey of health and health-related issues was conducted on 883 volunteers, mean age 74.1 years, randomly selected from the Medicare rolls of Bernalillo County (Albuquerque), New Mexico. Equal numbers of Hispanic and non-Hispanic white men and women were selected and recruited. A fasting serum creatinine and serum urea nitrogen was included in the battery of laboratory tests. Mild elevations of SUN and serum creatinine concentrations are common (9.2%) in an aging, randomly selected population (mean age 74.1 years). Males were more commonly affected than females. There were no differences between Hispanics and non-Hispanic whites, even though diabetes was twice as prevalent in Hispanics. Mild elevations of SUN and serum creatinine were more common in participants with coronary heart disease and its risk factors (diabetes, hypertension, and dyslipidemia). All participants with mild renal impairment had either increased total cholesterol or decreased HDL-cholesterol. One cannot determine from a cross-sectional study whether the dyslipidemia consistently associated with mild renal impairment was a cause of the renal impairment or a result of the renal impairment; however, biological explanations do exist to explain how the dyslipidemias can lead to progressive glomerulosclerosis.