Expanded valganciclovir prophylaxis in kidney transplant recipients is associated with lower incidence of cytomegalovirus infection.

AIMS: The aim of this study was to compare the efficacy and safety of two subsequent CMV prophylaxis regimens for prevention of cytomegalovirus (CMV) infection and disease in our kidney transplant recipients (KTRs). METHODS: In an historic-cohort of KTRs, two CMV prophylaxis protocols were compared: short protocol in which CMV IgG seronegative recipients (R-) of CMV IgG seropositive donors (D+) received valganciclovir for 3 months post-transplant (group 1: 2005 - 2010); and expanded protocol in which prophylaxis for high-risk recipients was extended to 6 months, and a 3-month prophylaxis for D+/R+ and D-/R+ was introduced (group 2: 2011 - 2016). Incidences of CMV viremia, disease, and adverse events were assessed 12 months after transplant. RESULTS: Of 457 KTRs, 167 received short (group 1) and 290 expanded (group 2) CMV prophylaxis. The incidence of CMV viremia was significantly lower in group 2 than in group 1: 17.6% vs. 29.2%, respectively (p = 0.001). The incidence of CMV disease was 5.2% in group 2 vs. 10.2% in group 1 (p = 0.04). After comparing group 2 and group 1 according to the risk of CMV infection, incidences of CMV viremia were 50% vs. 47.4% in D+/R- (p = 0.79), 3.1% vs. 5.7% in D-/R+ (p = 0.05), and 9.7% vs. 23.6% in D+/R+ (p = 0.0004). The incidence of neutropenia was 41.7% in group 2 and 33.5% in group 1 (p = 0.09). CONCLUSIONS: The results show a significant reduction of CMV viremia in D+/R+ and D-/R+ KTRs after introduction of 3-month prophylaxis with valganciclovir. Extension of CMV prophylaxis to 6 months in D+/R- was not associated with reduction in CMV viremia at 12 months after transplant.
.

Renal Replacement Therapy in Slovenia: Excerpts From 2013 Data.

This report provides a summary of the 2013 Slovenian renal replacement therapy (RRT) data, obtained from 24 renal centers: 23 dialysis and one transplant center, referring from 31 December 2013, with 100% response rate to individual patient questionnaires. Slovenia had a population of 2 061 085 on 1 January 2014. The total number of patients treated by RRT was 2077, i.e. 1008.3 per million of population (pmp); 1349 (65%) were treated by hemodialysis, 52 (2.5%) by peritoneal dialysis, and 676 (32.5%) had a functioning kidney graft. A total of 260 incident patients, 126.2 pmp (at day one), started RRT, their median age was 69 years, 59.8% were men,. 58.5% of hemodialysis patients were treated with on-line hemodiafiltration. Vascular access was arteriovenous fistula in 79%, polytetrafluoroethylene graft in 8%, and catheter in 13% of patients, mean blood flow 276 ± 41 mL/min, 5.5% dialyzed in a single-needle mode. The crude death rate was 11.4% in all RRT patients (incident patients day 1 included, 15.9% in hemodialysis, 12.3% in peritoneal dialysis, 2.1% in transplant recipients). 60 kidney transplantations were performed in 2013, from deceased donors.

Treatment of Antibody-Mediated Rejection After Kidney Transplantation - 10 Years' Experience With Apheresis at a Single Center.

Antibody-mediated rejection (AMR) is a major cause of kidney graft failure. We aimed to analyze treatment and outcome of AMR in a national cohort of 75 biopsy-proven acute (43 patients, 57%) or chronic active (32 patients, 43%) AMR episodes between 2000 and 2015. The mean patients' age was 46 ± 16 years, the majority was treated with plasma exchange, 4% received immunoadsorption and 7% received both. The majority received pulse methylprednisolone and low-dose CMV hyperimmune globulin, 20% received bortezomib and 13% rituximab. Concomitant infection was treated in 40% of patients. The immediate treatment outcome was successful in 91%, the 1- and 3-year graft survival rates were 71% and 57%, while 3-year patient survival was 97%. Chronic active AMR was associated with worse graft survival than acute AMR (log rank P = 0.06). To conclude, intensive treatment with apheresis and additional immunosuppression was effective in reversing AMR, but long-term graft survival remains markedly decreased, especially in chronic active AMR.

Comparison of the Pharmacological Effects of Paricalcitol Versus Calcitriol on Secondary Hyperparathyroidism in the Dialysis Population.

Management of secondary hyperparathyroidism (SHPT) in dialysis population includes the use of active vitamin D forms, among which paricalcitol was shown to be more effective at reducing parathyroid hormone (PTH) concentrations. A prospective randomized study comparing the effectiveness and safety of peroral paricalcitol and calcitriol in suppressing PTH concentrations in 20 hemodialysis patients was performed comparing the influence of agents on PTH suppression, calcium (Ca) and phosphate (P) level and calcium-phosphorus product (C×P). The study was performed in an "intent to treat" manner with primary end point in reduction of PTH level in the target area of 150 > PTH < 300 ng/L after 3 months. At the time point 3 months after therapy induction paricalcitol and calcitriol were equally efficient at correcting PTH levels, with paricalcitol showing significantly less calcemic effect than calcitriol.

Malnutrition in Renal Failure: Pleiotropic Diagnostic Approaches, Inefficient Therapy and Bad Prognosis.

Malnutrition is very common and connected with high morbidity and mortality of patients on chronic hemodialysis. A cross-sectional, longitudinal study was performed in maintenance dialysis patients intending to determine association between modified Subjective Global Assessment (SGA), serum albumin and mortality. Cross-sectional study of phase angle (PhA) values and other indices of bioelectrical impedance body analysis (BIA) were correlated to biochemical data and malnutrition-inflammation score (MIS). In the group of 184 hemodialysis patients, we found 39 malnourished patients. In overall 50 months of observation, 25 out of 39 malnourished patients died. All patients with albumin values less than 30 g/L died. The group with albumin values greater than 30 g/L (N = 26) showed higher survival rate, 12 patients died in the observed period. SGA values higher than 21 and albumin values lower than 30 g/L are useful predictors of death in malnourished dialysis patients. PhA is an independent predictor of malnutrition with promising potential to replace other diagnostic tools.

Factors affecting outcome in acute hypertriglyceridemic pancreatitis treated with plasma exchange: an observational cohort study.

OBJECTIVES: The optimal therapy for hypertriglyceridemic acute pancreatitis, especially the role of plasma exchange (PE), is not entirely clear. The aim of our large, single-center, observational, cohort study was to analyze the factors affecting outcome in hypertriglyceridemic pancreatitis treated with PE. METHODS: We included 111 episodes of hypertriglyceridemic pancreatitis treated with PE, which occurred in 103 different patients. The Acute Physiology and Chronic Health Evaluation (APACHE) II score, triglycerides, delay to first PE, and PE treatment details were retrospectively obtained from the patients' records. The main outcome measures were length of hospitalization and in-hospital mortality. RESULTS: The patients were 47±9 years old and the median APACHE II score at first PE was 4 (inter-quartile range (IQR) 2-7). There was a seasonal variation in the incidence of hypertriglyceridemic pancreatitis, and the recurrence rate was 1.6% per year. Triglycerides at presentation did not correlate with APACHE II or influence the outcome. The mean reduction in triglycerides during PE was 59% (from 44±31 to 18±15 mmol/l), which was twice the reduction observed during conservative treatment (27% daily). The median hospital stay was 16 days (IQR 10-24) and in-hospital mortality was 5%. The median delay to first PE was 35 hours (IQR 24-52), and there was no difference in mortality in the early and late PE groups (7% vs. 6%, p = 0.79). The group with citrate anticoagulation during PE had a significantly lower mortality than the group with heparin anticoagulation (1% vs. 11%, p = 0.04), and citrate was an independent predictor also in the multivariate model (p = 0.049). CONCLUSIONS: PE effectively reduced serum triglycerides faster than could be expected with conservative treatment. The delay in PE therapy did not influence survival. We found that citrate anticoagulation during PE was associated with reduced mortality, which should be confirmed in a randomized study.