Outcome of desensitization in human leukocyte antigen- and ABO-incompatible living donor kidney transplantation: a single-center experience in more than 100 patients.

BACKGROUND: Antibody-mediated rejection (AMR) and inferior graft outcome remain the 2 most important obstacles to successful kidney transplantation in human leukocyte antigen (HLA)- and ABO-incompatible recipients. We report a single-center experience in the outcome of desensitized living donor HLA- and ABO-incompatible kidney transplantation. METHODS: Since 2007 we included 2 groups in our desensitization program. HLA-incompatible living donor kidney transplant candidates displaying donor-specific antibodies (DSA) with or without a positive T-cell and/or B-cell flow crossmatch (FCXM). Second, those displaying DSA with positive T-cell immunoglobulin (Ig)G AHG CDC CXM with a titer of ≤1:8, as well as all ABO-incompatible living donor kidney transplant candidates with an IgM isoagglutinin titer ≤ 256. They were risk stratified for AMR and underwent individualized desensitization protocol: ABO-incompatible and HLA-incompatible candidates with either positive AHG CDC CXM or positive T and/or B IgG flow CXM with repeat HLA mismatch from a previous transplantation were deemed to be high risk and received a single dose of Rituximab, therapeutic plasma exchange and high-dose intravenous immunoglobulin (IVIG) (2 g/kg). HLA-incompatible candidates with negative CDC but positive T and/or B IgG FCXM were deemed intermediate risk, receiving rituximab and high-dose IVIG. Those with positive DSA but negative flow and CDC CXM were deemed low risk, receiving low-dose IVIG (1 g/kg). All patients received induction with thymoglobulin and were maintained on a tacrolimus-based immunosuppressive regimen. RESULTS: Among 124 incompatible recipients, 85 received HLA-incompatible and 39 ABO-incompatible living donor kidney transplantations after desensitization. Risk stratification for HLA-incompatible transplants revealed 61 high-risk, 42 intermediate-risk, and 21 low-risk cases. Ninety-nine (80%) were primary transplants. At a median follow-up of 23 (range 1-53) months, patient survival was 98% and death censored graft survival 96%. Mean serum creatinine was 84 µmol/L (range 41-169). Acute cellular rejection was observed in 15 (12%) and AMR in 5 (4%) patients. All rejection episodes responded to treatment except 1 AMR in an ABO-incompatible transplant that led to graft failure. CONCLUSION: Our risk stratification for desensitization strategy achieved a low incidence of AMR among HLA- and ABO-incompatible kidney transplant recipients. Their 2-year data appear to be comparable to HLA- and ABO-compatible transplantations.

Repeated pregnancies in patients with non-immunoglobulin a mesangioproliferative glomerulonephritis.

AIM: To analyze the effect of repeated pregnancies on underlying MesGN and see the reciprocal effect on maternal and fetal outcome. PATIENTS AND METHODS: Pregnancy records of cases with histological diagnosis of MesGN were reviewed, and past medical histories recorded. RESULTS: Cesarean section (CS). Only two patients developed renal insufficiency after undergoing 5 and 11 pregnancies and follow-up of 9 and 20 years respectively. CONCLUSION: The outcome of repeated pregnancies in patients with MesGN is comparable to normal deliveries. A higher incidence of pre-eclampsia, LBW babies and CS was noted in the post- compared to the pre-MesGN pregnancies. Repeated pregnancies do not influence the course of the MesGN.

Electrosurgery, pacemakers and ICDs: a survey of precautions and complications experienced by cutaneous surgeons.

BACKGROUND: Minimal information is available in the literature regarding the precautions implemented or complications experienced by cutaneous surgeons when electrosurgery is used in patients with pacemakers or implantable cardioverter-defibrillators (ICDs). The literature pertinent to dermatologists is primarily based on experiences of other surgical specialties and a generally recommended thorough perioperative evaluation. OBJECTIVE: To determine what precautions are currently taken by cutaneous surgeons in patients with pacemakers or ICDs, and what types of complications have occurred due to electrosurgery in a dermatologic setting. METHODS: In the winter of 2000, a survey was mailed to 419 U.S.-based members of the American College of Mohs Micrographic Surgery and Cutaneous Oncology (ACMMSCO). RESULTS: A total of 166 (40%) surveys were returned. Routine precautions included utilizing short bursts of less than 5 seconds (71%), use of minimal power (61%), and avoiding use around the pacemaker or ICD (57%). The types of interference reported were skipped beats (eight patients), reprogramming of a pacemaker (six patients), firing of an ICD (four patients), asystole (three patients), bradycardia (two patients), depleted battery life of a pacemaker (one patient), and an unspecified tachyarrhythmia (one patient). Overall there was a low rate of complications (0.8 cases/100 years of surgical practice), with no reported significant morbidity or mortality. Bipolar forceps were utilized by 19% of respondents and were not associated with any incidences of interference. CONCLUSIONS: Significant interference to pacemakers or ICDs rarely results from office-based electrosurgery. No clear community practice standards regarding precautions was evident from this survey. The use of bipolar forceps or true electrocautery are the better options when electrosurgey is required. These two modalities may necessitate fewer perioperative precautions than generally recommended, without compromising patient safety.

Living unrelated renal transplant: outcome and issues.

Living unrelated transplantation (LURT) is emerging as a practical option in renal transplantation due to shortage of living related and cadaver donors. We report a six-years (December 1991 to December 1996) follow-up of 60 LURT patients. The majority of these patients (95%) were transplanted outside the Kingdom of Saudi Arabia; 37 in India, 14 in Egypt, five in the USA and one in Pakistan. Only three patients (emotionally related) were transplanted in Saudi Arabia. Before transplantation, 50 (83.4%) patients were on chronic hemodialysis, three (5%) on peritoneal dialysis and three (5%) were transplanted pre-emptively. Post-operatively, the majority of the study patients were on three drug immunosuppressive therapy. One and five year graft survival was 93.0% and 59.6%, while patient survival at one and three years was 93.7% and 81%, respectively. Surgical complications included lymphocele in 10% of the study patients, urinary leak in 8.3%, and bleeding from the vascular anastomosis in 6.6%. There were eight episodes of acute rejection in eight (13.3%) patients and all episodes were successfully treated; two patients required monoclonal anti-lymphocyte antibodies (OKT3). Eleven (18.3%) patients developed chronic rejection, which resulted in the loss of ten (90%) allografts. Infection was the commonest cause for hospital admission; urinary tract infection (UTI) being responsible for 40% of admissions. Three patients had Cytomegalovirus pneumonia, one had Pneumocystis Carinii pneumonia and one had candida pneumonia. Two (3%) patients developed Kaposi's sarcoma. We conclude that LURT can help in overcoming the shortage of organs for transplant, however, commercial transplantion in developing countries is associated with high morbidity and mortality.

Renal cell carcinoma of contralateral kidney with secondaries in gallbladder eight years after nephrectomy.

A 55-year-old female underwent right nephrectomy for renal cell carcinoma (RCC). The histopathology showed clear cell carcinoma. There was no evidence of metastasis. After remaining asymptomatic for eight years, she developed pain in the right loin. Abdominal ultrasound, computerized tomography (CT) Scan and magnetic resonance imaging (MRI) were suggestive of a tumor mass in the right renal area, multiple tumor masses in the left kidney and a mass in the gallbladder. Cholecystectomy, left radical nephrectomy and right adrenal mass with excision of adjacent lymph nodes were performed. The histopathology from all sites was suggestive of RCC. She was maintained on hemodialysis. Two and half years later she died after surgical exploration for spinal cord decompression due to metastasis to the dorsal spine.

Acute Hydrothorax Complicating continuous Ambulatory Peritoneal Dialysis: A Case Report and Review of Literature.

We describe here hydrothorax that occurred in a patient on continuous ambulatory peritoneal dialysis (CAPD) and highlight the problems of diagnosis and management. A 48 years-old man with history of obstructive uropathy secondary to urolithiasis was stared on CAPD when he reached end-stage renal failure. Two months later, he was admitted with two days history of shortness of breath on exertion and dry cough increasing in supine position. Chest examination was suggestive of right sided pleural effusion confusion confirmed by chest X-ray. Radioisotope Technetium 99m labeled albumin instilled through the peritoneal catheter was detected in the right pleural fluid confirming the peritoneo-pleural leak. The peritoneal dialysis (PD) was discontinued and the patient was switched to hemodialysis. The pleural effusion subsided and has not recurred for the following three years.

Intraventricular and brachial artery thrombosis in nephrotic syndrome.

A 23-year-old Saudi female presented with nephrotic syndrome. On renal biopsy she had primary focal and segmental glomerulosclerosis which was resistant to steroids. Two years later she presented with absent left arm pulses and on investigation a diagnosis of left ventricular thrombosis and thromboembolism of left brachial artery was made. Low antithrombin III, high fibrinogen levels and diuretic therapy were the possible causative factors for hypercoagulable state. On anticoagulation therapy initiated with heparin and continued with warfarin for 8 weeks there was complete dissolution of intraventricular and improvement of left brachial artery thrombosis. An early diagnosis and treatment of this potentially serious complication of nephrotic syndrome are stressed.

Bartter's syndrome in two successive generations of a Saudi family.

Bartter's syndrome (BS) is characterized by primary renal tubular hypokalemic metabolic alkalosis, hyperreninemia, hyperaldosteronism and normal blood pressure. The parents and siblings of a BS patient were evaluated for renal tubular function. The father and all 9 siblings of the patient had biochemical features of BS. His mother, a first cousin of his father, had hypokalemia and hyperkaluria but no other features of BS and could have been a 'carrier'. The mother and all 9 siblings were asymptomatic. Including the patient, hypomagnesemia was present in 8 of 12 family members. Therapy with a combination of potassium chloride and magnesium increased the serum potassium and magnesium levels to within normal limits. The familial occurrence in BS is well known, and reports of the disorder in siblings and the first generation of children of consanguineous marriages and normal parents have been taken to suggest an autosomal recessive inheritance. One affected parent and involvement of all siblings of the patient raise the possibility of an autosomal dominant inheritance in the present family.

Liver disease in dialysis patients with antibodies to hepatitis C virus.

Eighty-three patients with chronic end-stage renal failure, including 65 on haemodialysis and 18 on intermittent peritoneal dialysis, were evaluated for hepatitis B virus profile and antibodies to hepatitis C virus (HCV). All those positive for HBsAg were excluded from the study. Nineteen patients were found to be positive for antibodies to HCV by the ELISA II test. Eight cases were already positive for HCV antibody when they started dialysis in our unit, the other 11 became positive during dialysis in our unit. Only one of the patients on peritoneal dialysis was positive for HCV. A liver biopsy was obtained from 17 patients, who consented to the procedure. All the cases were evaluated for the number of blood transfusions received, HIV infection and the approximate time of contracting the HCV infection. Liver enzymes were determined every month. Only three patients had abnormally raised serum aminotransferase at the time of biopsy. The various histopathological lesions detected were chronic active hepatitis (n = 3, including one with changes consistent with cirrhosis), chronic persistent hepatitis (n = 4), non-specific hepatitis (n = 3) and haemosiderosis (n = 3); four biopsy samples were normal. There was no correlation between the biochemical and histopathological changes. Moreover, patients with normal serum aminotransferase levels had abnormal histopathological changes. All were negative for HIV and none of the patients had received a renal graft. Twelve patients had received blood transfusions varying from 2 to 12 units, four had not received any blood, and in one the history of blood transfusion could not be confirmed. The four patients with anti-HCV antibodies who had not received blood transfusion had relatively mild disease--non-specific hepatitis (n = 2) or normal biopsy (n = 2). One patient with cirrhosis died 30 months after liver biopsy from hepatic insufficiency and three received renal transplants. Others are continuing on dialysis and their biochemical tests are within normal limits 12-45 (30 +/- 14) months after biopsy. In conclusion, biochemical tests are poor indicators of liver disease, and liver biopsy is a definitive way of evaluating the patients of dialysis with positive HCV antibodies for prognosis.

Anatomic considerations for dorsal sacral plate-screw fixation.

Five cadaveric pelves and 40 dry bony specimens were used to assess the feasibility of the lumbosacral plate fixation extending to beyond the S1 region and quantitatively to evaluate the posterior sacroiliac region and the dimensions of S1 and S2 pedicle and lateral mass. Partial removal of the posterior ilium was undertaken to measure the surface area available for plate fixation on the dorsal aspect of the sacrum. The results showed that the average distances between the outer edges of S1 and S2 dorsal foramina and the medial edge of the posterior ilium increased from 11.3 mm before removal of a portion of the medial posterior ilium to 16.6 mm after removal at the S1 level, and from 8.4 mm before removal of partial medial posterior ilium to 13 mm after removal at the S2 level, respectively. The average depths of the S1 and S2 pedicles were 37.1 and 32.2 mm in the direction anteromedial to the sagittal plane, respectively. The average depths of the S1 and S2 lateral mass were 37.3 and 33.9 mm in the direction anterolateral to the sagittal plane, respectively. In cases of vertebral metastases or osteoporosis, plating extending to S2 may be needed if good bony purchase cannot be achieved by the S1 pedicle or lateral mass screw. This study suggested also that partial removal of the posterior ilium enhances the space on the posterior aspect of the sacrum without severe compromise of the sacroiliac joint.

Anatomic considerations for anterior approaches to the ulna.

Anterior approaches to the ulna were studied on 22 cadaveric forearms as alternative approaches to the ulnar shaft. An anterior approach is indicated when there is extensive posterior scar tissue, or extensive soft tissue loss in the posterior forearm as in some fresh fractures, or when a tumor is resected from the anterior ulna. This study describes and compares the traditional anteromedial approach to the ulna with a proposed anterior approach, and defines the exact relations of the different anatomic structures seen in each approach.

Erythropoietin therapy in a pregnant woman on maintenance hemodialysis.

A 25 year old Saudi female, sixth gravida, para four, on renal replacement therapy with regular dialysis for nearly two years, was diagnosed to be pregnant at 12 weeks, with a single viable fetus. She was managed with increased frequency of dialysis and increased doses of anti-hypertensive drugs. For the control of anemia, which was further worsened by the pregnancy, she was treated with r-HuEPO 125 to 150 u/kg 3 times/week along with iron and vitamin supplements to maintain hemoglobin of 90 gm/L. The pregnancy continued to 36 weeks and she had a spontaneous normal delivery of a male baby without any congenital defects, weighing 1605 grams with Apgar score of four at one minute and nine at five minutes.

Effectiveness of low-dose erythropoietin in predialysis chronic renal failure patients.

Recombinant human erythropoietin (rHuEpo) has been shown to be both effective and usually safe in patients with chronic renal failure who have not yet reached the stage requiring dialysis. There are, however, disturbing reports on the possibility of deterioration of the reserve renal function in association with rHuEpo therapy. Most of the published studies have used rHuEpo in doses of 50-150 U/kg three times weekly subcutaneously. An open-label trial of rHuEpo therapy was conducted on 21 patients with chronic renal failure treated sequentially at a referral hospital, rHuEpo was used in doses of 50 U/kg twice weekly for 4 weeks followed by 25 U/kg twice weekly for 8 weeks subcutaneously, a regimen substantially lower than current recommendations. This was associated with a gentle but significant increase in haematocrit (P < 0.05) and haemoglobin (P < 0.05), while the serum creatinine and the reciprocal of the creatinine remained stable, with a tendency to improve rather than worsen (P = 0.06). We conclude that there is no need to aim at a rapid increase in haematocrit and haemoglobin by rHuEpo therapy; rather a gentle increase using modest doses is both effective and safe.

Hepatitis C in chronic renal failure patients.

The occurrence of hepatitis C virus (HCV) infection amongst chronic renal failure (CRF) patients in our Nephrology Unit was investigated over a period of 1 year. A total of 71 patients was studied comprising 26 chronic haemodialysis (CHD) patients, 6 acute haemodialysis patients, 4 peritoneal dialysis patients and 35 CRF patients not on dialysis. Patients were screened before and after haemodialysis, and their baseline and postdialysis values of liver enzymes were determined. Eleven (15.5%) of the total 71 patients were HCV antibody positive. Analysis of the individual patient groups showed that 8 (30.7%) of the 26 CHD patients were positive for HCV. Our data showed a statistically significant relationship between seroconversion and duration of dialysis (p < 0.05). A high statistically significant (p < 0.0001) correlation was observed between the HCV antibodies and CRF. The relative risk of hepatitis C was about 22 times greater for those with CRF compared with the normal controls, which makes CRF an important risk factor. A high proportion of the HCV seroconverters had elevated liver enzyme (serum glutamic pyruvic transaminase). The data presented show a positive correlation between HCV seroconversion, CRF, duration on dialysis and elevated serum liver enzymes.