Comparison of Kidney Transplant Function, Lipid Metabolism Disorders, and Glucose and Hemoglobin Concentration in Transplant Patients Treated With Proliferation Signal Inhibitor (Everolimus) or Calcineurin Inhibitor (Tacrolimus).

INTRODUCTION: After kidney transplantation (KTx) in patients with diagnosed cancers, calcineurin inhibitor tacrolimus (TAC) is replaced by sirolimus or everolimus (EV). OBJECTIVE: The objective of the study was to compare the lipid metabolism parameters, KTx function, and glucose and hemoglobin (Hgb) levels in patients treated with EV to those on TAC. MATERIAL AND METHODS: The retrospective study included 114 patients: 54 (17 women and 37 men) aged 57.6 years (18-77 years) treated with EV and 60 (18 women and 42 men) aged 49.6 years (20-77 years) treated with TAC as a control group. Their total cholesterol (TC), triglycerides (TG), fasting glucose (FG), serum creatinine (SCr), Hgb, and estimated glomerular filtration rate (eGFR) were assessed. In the patients treated with EV, the above values were evaluated before conversion, as well as 12 and 24 months following the switch and were evaluated once in the group treated with TAC. RESULTS: In the EV-treated group, the mean preconversion values after 12 and 24 months were as follows: TC 5.06, 6.59, and 5.98 mmol/L; TG 1.90, 2.48, and 2.20 mmol/L; FG 94.95, 97.85, and 104.05 mg/dL; SCr 1.46, 1.44, and 1.56 mg/dL; Hgb 12.46, 12.83, and 13.36 g/dL; and eGFR 50.3, 50.6, and 50.5 mL/min/1.73 m2. In the patients on TAC, the authors obtained the following values: TC 4.6 mmol/L; TG 1.87 mmol/L; glucose 104.13 mg/dL; SCr 1.51 mg/dL; Hgb 13.96 g/dL; and eGFR 56.6 mL/min/1.73 m2. CONCLUSIONS: After conversion from TAC to EV, increased values of TC and TG were observed after 1 year, while the increased values of TC, TG, SCr, Hgb, and FG were observed after 2 years.

Crossing Anatomic Barriers-Transplantation of a Kidney with 5 Arteries, Duplication of the Pyelocalyceal System, and Double Ureter.

During the time of organ harvest, it is crucial for the kidney procurement team to consider significant vascular anatomical variations. Multiple renal arteries are not uncommon, and unintentional injury can result in an irreversibly damaged kidney graft that needs to be discarded. We present a kidney graft with 5 renal arteries and a single vein that was successfully procured and implanted with good graft function at discharge and at 4-yr follow-up. According to the literature, additional renal arteries can be found in about 33% of kidneys. This is the first study on a kidney with 5 arteries in the published literature, especially in the context of transplantation.

Beneficial effect of kidney transplantation from a deceased donor on severe chronic refractory intradialytic hypotension - a case report.

BACKGROUND: Chronic refractory hypotension (IDH, intradialytic hypotension) is a rare but serious problem encountered in patients on hemodialysis. Patients with chronic hypotension are often disqualified by transplant teams from renal transplantation. This is due to the possibility of an enormous risk of ischemic complications. CASE PRESENTATION: We describe a 44-year old female patient with severe refractory hypotension (mean BP 60/30 mmHg, the lowest 48/28 mmHg), which appeared after bilateral laparoscopic nephrectomy of the infected kidneys. The kidney transplantation from a deceased donor, with infusion of the two pressor amines (dopamine, dobutamine) was performed without technical complications and the blood pressure measurements were 100-120/70-80 mmHg. The immunosuppression regimen was tacrolimus (TAC) + mycophenolate mophetil (MMF) and steroids (GS). Pressor amines were discontinued on the 18th day after the transplantation. Because of delayed graft function, 4 hemodialysis treatments were performed. The patient was discharged from the hospital on the 22nd day with good function of the transplanted kidney (the concentration of serum creatinine 117 µmol/l). During one-year follow-up, the patient has been remaining stable with a very good graft function (serum creatinine 84 µmol/l) and normal blood pressure (115/70 mmHg). CONCLUSIONS: Proper preparation and adequate perioperative treatment allowed for safely performing kidney transplantation in the patient with severe IDH.

[Fatty acid profile in phospholipids fraction with regard to blood pressure control in the kidney transplant patients].

Introduction: Hypertension is diagnosed in over 50% of renal transplant patients, and its presence is associated with significantly increased risk of cardiovascular complications. The pathogenesis of hypertension in this group of patients is complex. The use of immunosuppressive drugs is among the most important risk factors due to their hypertension-inducing properties. It is also suspected, that fatty acids may play an important role in the development of the disease; however, the mechanism of its formation has not yet been fully elucidated. Aim: Evaluation of fatty acid profile in phospholipids fraction in the blood serum of patients after renal transplantation, with respect to the blood pressure and immunosuppressive drug used. Materials and methods: The study included 65 kidney transplant patients treated with immunosuppressants: 24 patients received CsA (9 women, 15 men) and 41 were treated with Tac (15 women, 26 men). Blood pressure level was estimated by taking an average value of the last 3 measurements in an outpatient setting. Blood pressure exceeding 140/90 mmHg was considered as abnormally high. The number of antihypertensive drugs administered was based on the analysis of patients' records and direct interviews with patients. The concentration of each fatty acid was determined using gas chromatography. Statistical analysis was performed using Statistica 10. Results: There were no statistically significant differences between both: systolic blood pressure (136.16 vs. 133.31 mmHg, p=0.499) and diastolic blood pressure (80.62 vs 80.76; p=0.962) in patients treated with CsA compared to those taking Tac. Patients treated with CsA, received ­ on average ­ more antihypertensive drugs, compared to the group of patients taking Tac (2.64 vs 2.17), but this difference was also not statistically significant (p=0.174). The profile of fatty acids in renal transplant recipients treated with CsA was similar in both with normal blood pressure and with elevated blood pressure. In case of patients treated with Tac, significantly lower concentrations of C14 (p=0.015), C16:1 (p=0.039), C18:1 (p=0.043) and MUFA (monounsaturated fatty acids; p=0.049) were found in patients with higher values of blood pressure, compared to the ones whose blood pressure was within the norm. A significantly higher concentration of fatty acids: C14 (p=0.029), C16:1 (p=0.049) and C20:5 (p=0.029) was found in patients with normal blood pressure, treated with Tac as compared with treated with CsA. In contrast, regardless to the immunosuppressive drug used, no statistically significant differences were found between the patients' groups with elevated blood pressure values. Conclusion: The prevalence of hypertension in renal transplant recipients treated with CsA and Tac is similar. The fatty acid profile in phospholipids fraction depends on the blood pressure and the immunosuppressant used.

[Risk factors of non melanoma skin cancers in kidney transplant patients]. / Czynniki ryzyka rozwoju nieczerniakowych raków skóry u chorych po przeszczepieniu nerki.

UNLABELLED: Non melanoma skin cancers (NMSC) represent a major challenge within the ever growing group of different organs recipients. The aim of the study was to evaluate risk factors influencing on frequency appearance of NMSC in patients after kidney transplantation. The clinical dermatological examination was performed in 486 patients after kidney transplantation consisted of 296 man (60.9%) and 190 woman (30.1%) in the mean age 46.1 +/- 13.1 (18-74 years) with median time after transplantation 74.3 +/- 52.1 months. Most of them (80.7%) before transplantation were treated by maintenance hemodialysis. Patients after kidney transplantation were checked by dermatologist for all skin abnormalities based on iniciated skin cancers screening program. All discovered abnormalities were described, their type, size, localization and results of histopathological examination were collected. The obtained results were analyzed based on t-Student's, Mann-Whitney's, chi-square and Fisher tests. Out of 486 studied patients, 53 NMSC were diagnosed in 25 kidney recipients including 39 basal cell carcinoma (BCC), 13 squamous cell carcinoma (SCC) and 1 Bowen's disease. The proportion of BCC to SCC was 2.79. NMSC occurred more often on sun skin exposure area, especially on the face. Almost all (96.2%) of the cancers were diagnosed in patients older than 50 years of age. Patients with NMSC comparing with those without were significantly older (52.8 +/- 7.8 vs. 41.0 +/- 7.8; p < 0.0001), have longer post-transplant period and have more frequent positive anamnesis of this cancer. There was no significant relationship between NMSC appearance and sex, cause of kidney failure, HLA mismatch, blood group as well as Rh factor. CONCLUSIONS: Older age of patients while transplantation, longer time of immunosuppressive therapy and previous NMSC are independent predictors of new skin cancers appearance.

Location of nonmelanoma skin cancers in patients after kidney transplantation.

INTRODUCTION: Long -term use of immunosuppressant therapy makes kidney transplant recipients particularly susceptible to infections and skin cancers. OBJECTIVES: The aim of the study was to evaluate the type and location of nonmelanoma skin cancers (NMSCs) in patients after kidney transplantation. PATIENTS AND METHODS: The study included 486 patients (296 men and 190 women; mean age, 46.1 ±13.1 years) after deceased -donor kidney transplantation, most of whom received triple immunosuppressive therapy. Patients underwent skin examination. All suspicious lesions were thoroughly described in terms of their type, size, and location. Only patients with histologically confirmed malignancy were included in the study. RESULTS: Of all 486 patients, 25 were diagnosed with 53 NMSCs, including 39 basal cell carcinomas, 13 squamous cell carcinomas, and 1 case of Bowen's disease. The lesions were observed on the face (n = 34), upper limb (n = 8), neck (n = 6), and trunk (n = 5). CONCLUSIONS: Most NMSCs were located on the sun -exposed areas, emphasizing the effect of ultraviolet radiation on the pathogenesis of skin cancers. The presence of lesions on the skin that had not been exposed to the sun indicates that a physical examination of the entire skin is necessary.

[Reccurent Clostridium difficile infection in patient after kidney transplantation on rituximab therapy due to PTLD (Post-Transplant Lymphoprolipherative Disorder). First experience with Fidaxomicin use--case report]. / Nawracajaca infekcja Clostridium difficile u chorego po przeszczepieniu nerki leczonego rytuksymabem z powodu PTLD (Post- Transplant Lymphoprolipherative Disorder). Pierwsze doswiadczenie ze stosowaniem fidaksomycyny--opis przypadku.

Clostridium difficile infection (CDI) is an increasingly problem in everyday clinical practice. The most important risk factor of this infection is antibiotics use. The incidence of Clostridium difficile associated diarrhea (CDAD) in patients after renal transplantation is estimated to be about 6% in the early postoperative period. Due to the applied immunosuppression and frequent infections requiring intensive, broad spectral antibiotics, the later prevalence of CDAD may remain at a similar level. Massive diarrhea caused by Clostridium difficile may lead to fluctuations in immunosuppressive drugs concentration, in renal transplant patients. The authors present a case study of a 23-year old patient after kidney transplantation from deceased donor, with diagnosed polymorphic PTLD (Post-Transplant Lymphoproliferative Disorder). During biological treatment with rituximab in this patient 4 recurrences of CDI were observed. In this article the clinical manifestation of recurrent CDAD are presented. The authors discuss therapeutic procedure with fidaxomicin use, its results and influence on immunosuppressive drugs concentration.

[Factors influencing on the prevalence frequency of infectious skin changes of bacterial and fungal origin in patients after kidney transplantation]. / Czynniki wplywajace na czestosc wystepowania infekcyjnych zmian skórnych o etiologii bakteryjnej i grzybiczej u chorych po przeszczepieniu nerki.

UNLABELLED: Infective skin changes are frequent complications in patients after kidney transplantation receiving immunosuppressive therapy. The aim of the study was to evaluate factors influencing on frequency and type of skin infections of bacterial and fungal origin in patients after kidney transplantation. The study was performed in 486 patients, 296 male (60.9%) and 190 female (39.1%) aged 46.1 +/- 13.1 years (18-74 years) 74.3 +/- 52.1 months after kidney transplantation remain mainly on triple immunosupresive therapy. Type, size and localization of skin changes revealed during dermatological evaluation were described according age, sex, and applied immunosuppression. The obtained results were analyzed based on t-Student's, Mann-Whitney's, chi-square and Fisher tests. It was shown that fungal infective skin changes in patients after kidney transplantation are more frequent in older population (48.4 +/- 11.8 vs. 45.2 +/- 13.4 years; p < 0.017). The significant differences concern interdigitale mycoses 49.7 +/- 11.1 vs. 45.4 +/- 13.3 years; p < 0.009, nail mycoses 51.5 +/- 10.4 vs. 45.5 +/- 13.2 years; p < 0,004 and foot mycoses 51.8 +/- 10.7 vs. 45.5 +/- 13.2 years; p < 0.0005. In male more frequent as compare with female were also fungal infections (30.7% vs. 18.4%; p < 0.002) including pityriasis versicolor 37.0% vs. 9.5%; p < 0.016 and interdigitale mycoses 18.6% vs. 9.0%; p < 0.004. CONCLUSIONS: Infective skin changes frequency in patients after kidney transplantation on immunosuppressive therapy depends on advanced age, male sex, and applied immunosuppressive therapy.

[Comparison of the prevalence frequency of infectious skin changes in dialyzed patients and after kidney transplantation]. / Porównanie czestosci wystepowania infekcyjnych zmian skórnych u chorych leczonych dializami oraz przeszczepieniem nerki.

UNLABELLED: Due to graft preserving immunosuppressive therapy, renal transplant recipients are predisposed to the development of a variety of skin infections and skin cancers. The aim of the study was to compare prevalence frequency of infective skin changes among patients after kidney transplantation and the dialyzed population. Clinical dermatological examination was performed in 486 patients after renal transplantation. The group consisted of 296 men (60.9%) and 190 women (30.1%), of mean age 46.1+/-13.1 (18-74 years) with median time after transplantation of 74.3+/-52.1 months. Most of the patients (80.7%) before transplantation were treated by maintenance hemodialysis. The most frequent immunosuppression regiments were combination of cyclosporine A (CsA) with mycofenolate mofetil (MMF) and steroids (GKS)-207 patients (42.5%); tacrolimus (TAC) with MMF and GKS-102 (20.9%) and CsA with azathiopine and GKS-53 patients (10.9%). The group of 112 dialyzed patients consisted of: 57 males (50.9%) and 55 females (49.1%), aged 57.4+/-15.4 years without history of immunosuppressive therapy and were on maintenance dialysis for 63.2+/-74.0 months. Most of this group (77.7%) was on maintenance hemodialysis, while the remaining 22.3% on peritoneal dialysis. The obtained results were analyzed based on t-Student's, Mann-Whitney's, chi-square and Fisher tests. It was shown that infective skin changes were significantly more frequent in the group of patients after kidney transplantation as compared with the dialyzed population. They were observed in 53.9% and 9.8% of the studied populations, respectively (p<0.0001). In the studied group after kidney transplantation the most frequent were viral changes (38.9%). Fungal infection was observed in 25.9% of these patients, while bacterial in 1.2% of this study group. In the dialyzed population fungal infections were diagnosed in 8.9%, while viral in 3.6% of patients. No bacterial changes were observed in this group. Acne was observed in 16.5% of patients after kidney transplantation. CONCLUSIONS: 1. In the group of patients after kidney transplantation receiving immunosuppressive therapy viral, fungal and bacterial infective skin changes were significantly more frequent as compared with the dialyzed patients. 2. The most frequent skin changes observed in patients after kidney transplantation were viral warts.

[Evaluation of immunosuppressive treatment on homocystein levels in patients after kidney transplantation during a 2 year observation period]. / Ocena wplywu rodzaju stosowanego leczenia immunosupresyjnego na stezenia homocysteiny u pacjentów po przeszczepieniu nerki w trakcie dwurocznej obserwacji.

UNLABELLED: The aim of the study was to evaluate the influence of the type of prescribed immunosuppression: cyclosporine A (CsA) vs. tacrolimus (Tac) on remote homocystein levels in patients (pts) after kidney transplantation (Ktx). PATIENTS AND METHODS: The study included 51 pts (17 F, 34 M) aged 15 to 62 years (mean 38.1) after cadaver Ktx. The mean observation period equaled 21.2 months (6 -24); while total observation period was 90 personlyears. Before Ktx, 46 pts were treated with maintenance hemodialysis (HD), while 5 by peritoneal dialysis (PD). After Ktx, patients had immunosuppression prescribed according to the following schemes: prednisone (P) + CsA + azathioprine (AZA) - 12 pts; P + CsA + mycophenolate mofetil (MMF) -26 pts; P + Tac + MMF - 11 pts; and P + Tac + AZA - 2 pts. Hcy level was measured using high performance liquid chromatography (HPLC). Serum creatinine level was measured by standard method using the Hitachi 917 analyzer. Creatinine clearance was calculated based on the Cockcroft-Gault formula. Patient's blood was drawn before Ktx and 3, 6, 9, 12,15, 18, 21 and 24 months post procedure. RESULTS: Delayed graft function (DGF) after Ktx was diagnosed in 29 pts (56.9%) and this group required from 4 to 28 HD sessions (mean 14 sessions). Hcy level did not significantly differ between pts requiring (29 pts) and not requiring (22 pts) HD treatment after Ktx. It was also noted that the number of performed HD sessions did not significantly correlate with Hcy levels 24 months after Ktx (R =0.04, p=0.81). No relationship was found (non-parametric Spearman test) between the drop in Hcy level 3 months after Ktx as compare with value before Ktx and ischemia time (R=0.09, p=0.49), number of compatible HLA A and B (R=0.07, p=0.63), and DR antigens (R=0.09, p=0.51). Decrease in Hcy level (before Ktx and 24 months after Ktx) did not significantly correlate with the above parameters, respectively: R=-0.14, p=0.40; R=0.06, p=0.73; R=0.12, p=0.45; R=0.11, p=0.50. Decrease in Hcy level (before Ktx and 3 months after) did not differ significantly when compared to pts receiving immunosuppressive therapy CsA vs. Tac (p=0.18). Even though notable differences were observed in the drop in Hcy level (immunosuppressive treatment scheme CsA vs. Tac) in measurements before Ktx and 24 months post (respectively: 27% and 57.6%), no statistical significance was noted (p=0.13). Using the Mann-Whitneys' Test, no statistical significance was noted (p=0.13) when comparing differences in creatinine clearance between the group of pts receiving CsA and Tac 24 months after Ktx. Patients treated with Tac achieved a higher creatinine clearance by 16.5% when compared with those receiving CsA. No significant differences were observed between these two groups (p=0.65) when serum creatinine levels were evaluated. CONCLUSIONS: Incidence of DGF, as well as prescribed immunosuppressive therapy does not have an influence on remote Hey levels in pts after Ktx. Graft function seems to be the main predictor that influences Hcy levels after Ktx in this group of pts.

[Post transplant lymphoproliferative disorder (PTLD)--10 years follow-up]. / Potransplantacyjna choroba limfoproliferacyjna (PTLD)--obserwacja 10 letnia.

PTLD is a very severe, life threatening complication after organ transplantation. A 17 years old female patient with kidney transplanted (KTx) 7th months ago on immunosuppression therapy: Tacrolimus (TAC), Cell Cept (MMF), Encorton (Enc) was described. She was admitted to the hospital due to: fever, abdominal pain, diarrhea and enlarged cervical and inguinal lymph nodes on palpation. Histopathological diagnosis revealed monomorphic PTLD; diffuse large B cell lymphoma, immunoblastic. Treatment of PTLD was started immediatly after the final diagnosis. MMF was stopped, dose of TAC was reduced (blood level 3-4 ng/ ml), Enc were continued. Anti-CD20 antibodies (Rituximab) were administered. After 7 days of treatment the patient developed signs of diffuse peritonitis. In the course of surgery, perforation in six sites of the small intestine and sigmoid colon were discovered. The Hartman's surgery was performed (sigmoidectomy) with formation of temporary sigmoideostomy. Resected parts of intestine and sigmoid colon were infiltrated by immnunoblasts and revealed diffuse necrosis - the same process was seen in lymph nodes. After the wounds healed, Rituksymab was continued (8 doses) and chemotherapy was started - CHOP - 6 cycles every month. Eight months after surgery, full remission was obtained, TAC was change to rapamycine (RAP) and closure of sigmoideostomy was performed. At present, almost 10 years after first symptoms of PTLD, the patient remains in full remission of the disease.

[Kaposi's sarkoma in solid organ recipients]. / Miesak Kaposiego u biorców przeszczepów narzadów litych.

Kaposi's sarkoma (KS) is a malignancy with hyperplastic angio-proliferative lesions with inflammatory changes usually associated with human Herpesvirus 8 (HHV-8) infection. The predominant is skin localization with dark-blue or purplish colour nodules and plaques. Cutaneous changes may be associated with visceral involvement, which as a isolated form is rare. KS is not frequent disease in general population however risk of its development is substantially increased in immunocompromised patients including AIDS or receiving immunosuppression transplant organ recipients. The potency of immunosuppression is a highly relevant factor in the development of KS after transplantation. Patients receiving more intense immunosuppression are at a significantly higher risk of developing post transplant KS. Localized disease may be treated by surgery, kriotherapy or radiotherapy while widespread envolvement usually needs systemic therapy. Reduction or cessation of immunosuppression, especially calcineurin inhibitors, in transplant organs recipients gives positive therapeutic results. Swich from calcineurin inhibitors to rapamycin, immunosuppressive agent with anti-neoplastic activity, is a novel therapeutic option for solid rorgans recipients.