Relationship between Cytomegalovirus Viremia and Long-Term Outcomes in Kidney Transplant Recipients with Different Donor Ages.

OBJECTIVES: To explore the Cytomegalovirus (CMV) burden on the long-term post-transplant course in different donor ages, we evaluated the incidence and risk factors for CMV in our kidney-transplanted patients (KTs) with extensive adoption of expanded-criteria donors (ECDs). METHODS: Retrospective evaluation of 929 consecutive first KTs (49.5% receiving an organ from a donor ≥ 60 years) performed between 01-2003 and 12-2013. Overall survival was estimated using Kaplan-Meier curves; cumulative incidence function was additionally analyzed to consider the potential role of death with a functioning graft as a competitive event with graft dysfunction and to avoid overestimation. Apart from regular DNAemia monitoring in all patients, prophylaxis was adopted in high-risk groups (D+/R- or recipients of anti-thymocyte globulin induction), with pre-emptive therapy in the remaining groups. RESULTS: CMV incidence was 19.5% (4-34.9% according to serostatus combination: D-/R-, D-/R+, D+/R+, D+/R-). Donor and recipient age, recipient pre-transplant hypertension, DR antigen compatibility, cold ischemia time, and post-transplant early complications, including rejection, urologic and renal artery stenosis, and lower renal function and proteinuria ≥ 0.5 g/day at one year after KT were associated with CMV. CMV determined lower death-censored graft survival (DCGS) (p < 0.01), with a prominent effect in R+ (p < 0.01) and without impact in R- (p = 0.32 in D-/R- and p = 0.006 in D+/R-). Interestingly, CMV occurrence influenced DCGS only in KTs who received grafts from donors < 50 or 50-69 years old (p < 0.01), while it was not significant with older donors (p = 0.07). The analysis of the cumulative incidence of graft loss accounting for death as a competing risk confirmed all these findings. In multivariate analysis, CMV replication/disease in the first year was an independent predictor for DCGS (HR 1.73 [1.3-2.3]). CONCLUSIONS: In a large population with extensive ECD adoption, CMV viremia in the first year demonstrates its harmful effect with an independent role for graft loss and significant impact among R+ recipients and KTs with donors < 70 years.

Cutaneous allergic reaction correlates with anti-erythropoietin antibodies in dialysis patient developing pure red cell aplasia.

We describe a case of concomitant erythropoietin allergy and resistance with a possible IgE and IgG-mediated immune response, in which the local allergic cutaneous symptoms preceded the antibody-mediated anemia.

Double Glomerulonephritis in a Patient with Ankylosing Spondylitis Treated with Biologic Agent: Extrarticolar Involvement or Anti-Tumor Necrosis Factor Alpha Injury? A Case-Based Review.

With the widespreading use of biologic drugs, reports of renal injury are increasing, most of which belong to the spectrum of secondary autoimmune syndromes. We present the case of a young man affected by Ankylosing Spondylitis, treated with tumor necrosis factor alpha inhibitors (Anti-TNF) that develop a peculiar renal damage: a coexistence of 2 glomerulonephritis due to different noxae, an IgA nephropaty with a Membranous nephropathy. The first one probably related to the rheumatologic disease, the second one related to Anti-TNF. Despite the underlying mechanisms, the renal involvement both related to Ankylosing Spondylitis and secondary to biologic treatment are currently rare and not predictable. Regular control of renal function and urinalysis during treatment with anti-TNF is mandatory. A concomitant treatment with Disease Modifying Anti Rheumatic Drugs or eventually a low dose of steroids may prevent the formation of anti-drug antibodies and could limit the renal damage related to this phenomenon.

Self-Expandable Covered Metallic Stent (UVENTA) to Treat a Ureteral Stricture After Renal Transplant: A Case Report.

We present the use of a self-expandable covered metallic stent (UVENTA; TaeWoong Medical, Gyeonggi-do, South Korea) to treat a ureteral stricture after kidney transplant. In this report, we describe the procedure and short-term outcomes of a patient with a recurrent distal stricture who did not respond to percutaneous balloon dilation. We decided to place this temporary stent as an alternative to complex surgery. The aim of the procedure was to get a chronic dilation of the stricture up to 7 mm to stabilize the fibrotic tissue. The procedure was easily and quickly performed by an antegrade and retrograde combined approach. The postoperative course was uneventful. The stent was left in situ for 7 months. No complications were noted, and the renal function remained stable. The stent was easily removed, and 5 months later there were no signs of recurrence. The UVENTA device was shown to be an easy, safe, and effective minimally invasive treatment for ureteral stricture in renal transplant. Proper permanence time and long-term results need to be explored.

Relationship between early proteinuria and long term outcome of kidney transplanted patients from different decades of donor age.

BACKGROUND: Proteinuria after kidney transplantation portends a worse graft survival. However the magnitude of proteinuria related to patient and graft survival and its correlation with donor and recipient characteristics are poorly explored. METHODS: This study investigated the impact of post transplant proteinuria in the first year in 1127 kidney transplants analyzing the impact of different donor ages. Proteinuria cut off was set at 0.5 g/day. RESULTS: Transplants with proteinuria > 0.5 g/day correlated with poor graft and patient outcome in all donor age groups. In addition, 6-month-1-year proteinuria increase was significantly associated with graft outcome, especially with donors > 60 years old (p < 0.05; Odd Ratio 1.8). 1-year graft function (eGFR < or ≥ 44 ml/min) had similar impact to proteinuria (≥ 0.5 g/day) on graft failure (Hazard Ratio 2.77 vs Hazard Ratio 2.46). Low-grade proteinuria (0.2-0.5 g/day) demonstrated a trend for worse graft survival with increasing donor age. Also in kidney-paired analysis proteinuria ≥0.5 effect was more significant with donors > 50 years old (Odd Ratio 2.3). CONCLUSIONS: Post-transplant proteinuria was increasingly harmful with older donor age. Proteinuria ≥0.5 g/day correlates with worse outcomes in all transplanted patients. Prognostic value of proteinuria and eGFR for graft and patient survival was comparable and these two variables remain significant risk factors even in a multivariate model that take into consideration the most important clinical variables (donor age, rejection, delayed graft function and cytomegalovirus viremia among others).

Immunosuppression in pregnant women with renal disease: review of the latest evidence in the biologics era.

Care of pregnant woman, including fertility and procreation counseling, has become a significant part of the nephrological practice in the last years. In this context, the management of immunosuppression assumes a primary role both for autoimmune diseases and for post-transplant follow up. The present review analyzes the latest evidence on immunosuppressive drugs of current use in nephrology and kidney transplantation. Although the placenta inactivates prednisone and prednisolone, it is advisable to limit the dose to the minimal effective one, to prevent side effects. Azathioprine is generally the immunosuppressive of choice in many high-risk pregnancies in autoimmune diseases because of the safety profile and its steroid-sparing property. In lupus nephropathy, hydroxychloroquine is a current indication in the prevention of flares. Cyclosporine and tacrolimus can also be used as steroid-sparing agents as well as in post-transplant maintenance therapy. Experience on mammalian target of rapamycin inhibitors is limited and its use during pregnancy is still controversial even if initial positive data are emerging. Intravenous immunoglobulins are safe and represent an important option for relapses of lupus and vasculitis. Mycophenolate mofetil and cyclophosphamide are to avoid. An important part is reserved to biologic agents, which are having a huge impact on therapy protocols for several pathologies. Data on the utilization of these molecules during pregnancy, however, are still scant and therefore they do not yet allow a definitive evaluation of their safety profile.

Long-Term Outcomes and Discard Rate of Kidneys by Decade of Extended Criteria Donor Age.

BACKGROUND AND OBJECTIVES: Extended criteria donors represent nowadays a main resource for kidney transplantation, and recovery criteria are becoming increasingly inclusive. However, the limits of this approach are not clear as well as the effects of extreme donor ages on long-term kidney transplantation outcomes. To address these issues, we performed a retrospective study on extended criteria donor kidney transplantation. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: In total, 647 consecutive extended criteria donor kidney transplantations performed over 11 years (2003-2013) were included. Donor, recipient, and procedural variables were classified according to donor age decades (group A, 50-59 years old [n=91]; group B, 60-69 years old [n=264]; group C, 70-79 years old [n=265]; and group D, ≥80 years old [n=27]). Organs were allocated in single- or dual-kidney transplantation after a multistep evaluation including clinical and histologic criteria. Long-term outcomes and main adverse events were analyzed among age groups and in either single- or dual-kidney transplantation. Kidney discard rate incidence and causes were evaluated. RESULTS: Median follow-up was 4.9 years (25th; 75th percentiles: 2.7; 7.6 years); patient and graft survival were comparable among age groups (5-year patient survival: group A, 87.8%; group B, 88.1%; group C, 88.0%; and group D, 90.1%; P=0.77; graft survival: group A, 74.0%; group B, 74.2%; group C, 75.2%; and group D, 65.9%; P=0.62) and between dual-kidney transplantation and single-kidney transplantation except for group D, with a better survival for dual-kidney transplantation (P=0.04). No difference was found analyzing complications incidence or graft function over time. Kidney discard rate was similar in groups A, B, and C (15.4%, 17.7%, and 20.1%, respectively) and increased in group D (48.2%; odds ratio, 5.1 with A as the reference group; 95% confidence interval, 2.96 to 8.79). CONCLUSIONS: Discard rate and long-term outcomes are similar among extended criteria donor kidney transplantation from donors ages 50-79 years old. Conversely, discard rate was strikingly higher among kidneys from octogenarian donors, but appropriate selection provides comparable long-term outcomes, with better graft survival for dual-kidney transplantation.

["Getting to zero infections" in hemodialysis]. / "Getting to zero infections" in emodialisi: un obiettivo raggiungibile. Ruolo della formazione del personale sanitario e dell'impiego di nuovi presidi nella prevenzione delle infezioni cvc correlate.

INTRODUCTION: We describe two measures adopted in hemodialysis outpatient population in order to reduce Central Venous Catheter (CVC) related infections. The first is a nurse staff training in the field project and the second deals with the employment of chlorhexidine-impregnated dressing devices. These actions were performed after high infection rates were observed through a dedicated register. MATERIALS AND METHODS: In the limited assistance dialysis center, direct observation (12/2012-02/2013) quantified the gap between the observed and expected health care behaviour. Training needs were defined and a 40 hours nurse staff training in the field was performed on two occasions. In the hospital dialysis center, we introduced alcoholic 2% chlorhexidine solution and chlorhexidine-impregnated dressing devices to the exit site (CHG-Tegaderm and BioPatch). Infections (cumulatively bacteremia/sepsis/skin exit/subcutaneous tunnel) were monitored continuously. RESULTS: Infection rates at the two locations were progressively reduced, reaching a value of zero at the limited assistance center. Nurse staff training in the field produced: two patient reports and three CVC management protocols, Italian language translation of the "The 5 moments of dialysis" WHO poster, alcoholic 2% chlorhexidine adoption to exit-site medication and improvement of environment cleaning/sanitation actions. CONCLUSIONS: Our experience shows that continuously monitoring infection rates represents the first step for timely corrective action. The continuous updating of health personnel, codified prevention measures and an ongoing commitment to raise awareness in a routine practice, allows us to obtain the goal of "getting to zero infections". The staff training produced equal or superior results compared to the isolated use of new chlorhexidine-impregnated dressing devices.