Surveillance Registry of Sirolimus Use in Recipients of Kidney Allografts From Expanded Criteria Donors.

BACKGROUND: The use of expanded criteria donor (ECD) kidneys has increased the overall availability of renal transplants. This study assessed the use of sirolimus in patients receiving Argentina-ECD kidneys. METHODS: This observational, open-label, 1-arm, prospective, longitudinal pilot study was conducted at 8 transplant centers in Argentina. Adults receiving kidney transplants (without pancreas) from ECDs were eligible if they were converted to sirolimus 1 to 36 months' posttransplantation, with sirolimus becoming base therapy within 1 month after conversion. Patients were followed up for 1 year. Outcomes included reasons for conversion, acute rejection, patient and graft survival, graft status, and safety. RESULTS: The intention-to-treat population included 52 patients (mean age, 48.7 years). Calcineurin inhibitor nephropathy (40%) and chronic allograft nephropathy (25%) were the most frequent reasons for conversion. Two acute rejections occurred during follow-up, but no patients experienced graft loss. One patient died during follow-up, and 3 patients died within 1 month of the last sirolimus dose. Levels of serum creatinine and creatinine clearance remained stable from baseline to week 52/53. Mean proteinuria measured in a subset of patients was 0.2 ± 0.2 g/24 hours before conversion and increased to 0.6 ± 1.2 g/24 hours at week 24/25 and 0.5 ± 0.6 g/24 hours at week 52/53. Adverse events were consistent with those in previous conversion trials; the most common were infections and infestations (54%). CONCLUSIONS: This pilot study illustrates the potential benefits of sirolimus in recipients of ECD kidneys in Argentina. Larger, randomized controlled trials are needed to confirm these findings and to clarify the long-term benefits of sirolimus in this patient population.

Hepatitis C virus infection and outcome of renal transplantation.

Chronic hepatitis B and C viruses (HBV and HCV) are common problems in renal transplant patients. There is no uniform agreement regarding their influence on graft outcomes and patient survival. We evaluated the influence of anti-HCV and hepatitis B surface antigen-positive status; gender; age>49 years at the time of transplantation; alanine aminotransferase elevation; acute rejection; type of graft; number of transplants; and maintenance/induction immunosuppressive treatment on both graft and patient survivals among a population transplanted in our center between 1991 and 2004. Univariate analysis showed that anti-HCV-positive status, three-drug immunosuppressive therapy, and one or more episodes of acute rejection were associated with diminished graft survival. Over the age of 49 years at the time of transplantation, anti-HCV-positive status, cadaveric donor, kidney-pancreas transplantation, and three-drug immunosuppressive therapy were associated with diminished patient survival. Upon multivariate analysis, reduced patient survival was associated with the same variables as in the univariate analysis: anti-HCV-positive status, three-drug immunosuppressive therapy, and one or more episodes of acute rejection were associated with diminished graft survival. In our experience, anti-HCV-positive compared with anti-HCV-negative status was associated with a reduced graft (56% vs. 75%; P=.0002) and patient survival (68% vs. 83%; P=.0028).

[Fatal acute hepatic failure with hepatocarcinoma presentation in a patient with renal transplant with asymptomatic chronic B and C hepatitis]. / Descompensación aguda fatal como forma de presentación de un hepatocarcinoma en un transplantado renal con hepatitis crónica B y C asintomática.

Hepatocellular carcinoma is a primary tumor complicating liver disease, associated with cirrhosis in 80-90% of the cases. A kidney transplant recipient with chronic B and C viral hepatitis was admitted because of general malaise, renal function impairment and positive AST, ALT and alkaline phosphatase tests, and very high alpha-fetoprotein levels. Ascites, spontaneous bacterial peritonitis and renal failure developed. A CT showed multiple liver masses. Renal failure required hemodialysis. The patient died 17 days after the initial symptoms with hepatic encephalopathy. A postmortem liver biopsy confirmed the diagnosis of cirrhosis and hepatocellular carcinoma (HCC). This report, as well as a few others, shows the accelerated evolution of chronic viral hepatitis in kidney transplant patients and questions the convenience of kidney transplantation and the adequate follow up in chronic viral hepatitis.

Descompensación aguda fatal como forma de presentación de un hepatocarcinoma en un transplantado renal con hepatitis crónica B y C asintomática. / [Fatal acute hepatic failure with hepatocarcinoma presentation in a patient with renal transplant with asymptomatic chronic B and C hepatitis]

Hepatocellular carcinoma is a primary tumor complicating liver disease, associated with cirrhosis in 80-90

of the cases. A kidney transplant recipient with chronic B and C viral hepatitis was admitted because of general malaise, renal function impairment and positive AST, ALT and alkaline phosphatase tests, and very high alpha-fetoprotein levels. Ascites, spontaneous bacterial peritonitis and renal failure developed. A CT showed multiple liver masses. Renal failure required hemodialysis. The patient died 17 days after the initial symptoms with hepatic encephalopathy. A postmortem liver biopsy confirmed the diagnosis of cirrhosis and hepatocellular carcinoma (HCC). This report, as well as a few others, shows the accelerated evolution of chronic viral hepatitis in kidney transplant patients and questions the convenience of kidney transplantation and the adequate follow up in chronic viral hepatitis.

[Anti glomerular basement membrane disease in a renal transplant patient with Alport syndrome]. / Enfermedad antimembrana basal glomerular en un paciente transplantado renal con enfermedad de Alport.

We report a case of anti GBM disease that developed in the renal graft of a patient with Alport syndrome. After reaching abnormal values of creatinine, the patient presented with deteriorating renal function three months after a cadaver transplant and the biopsy showed crescent formation, and linear IF deposits. Circulating antibodies against alpha 5 chain of type IV collagen were found and plasmaphereses stabilized the condition for one year until a lung infection led to withdrawal of the immunosuppressive drugs and the patient returned to dialysis. We discuss the possible mechanisms underlying the specificity of the circulating antibodies in this case, which differs from the target characteristic of the idiopathic form of anti GBM disease, the alpha 3 (IV) chain.

[Renal transplantation: surgery in the patient with a functioning kidney]. / Trasplante renal: cirugía en el paciente con riñón funcionante.

One hundred and seven surgical procedures performed on 98 patients with stable renal allograft function are analyzed. They represent 35.5% of 276 patients who underwent renal transplants. The surgical procedures were not related to the graft or its arteries and vein. The procedures were gynecologic 8, urologic 24, thoracic 6, ophthalmologic 8, neurosurgical 2, general surgery 37, orthopedic 17 and plastic surgery 5. Thirty-five (32.7%) were emergency and 72 (67.3%) elective procedures. Twenty-six patients were operated on for infections. The overall operative mortality rate was 15.3%. It was significantly higher in emergency procedures (34.28%) than in elective surgery (4.16%).