Low-dose Thymoglobulin vs Basiliximab Induction Therapy in Low-Risk Living Related Kidney Transplant Recipients: A Prospective Randomized Trial.

CONTEXT: Thymoglobulin is used effectively as induction agent in kidney transplantation but the optimal dose is not well established. OBJECTIVE: Demonstrate that low-dose thymoglobulin (3 mg/kg) has similar efficacy and safety compared to basiliximab induction in low-risk kidney transplantation under standard maintenance immunosuppression DESIGN, SETTING, PARTICIPANTS: Prospective randomized study in kidney transplant patients (12/2016-05/2018). INCLUSION CRITERIA: Recipients > 18 years, first living donor transplant. EXCLUSION CRITERIA: Second and multiorgan transplant, ABO incompatibility, positive cross-match, panel reactive antibodies (PRA) > 30%, positive donor-specific antibody, human immunodeficiency virus, hepatitis B surface antigen, hepatitis C virus positive, white blood cells < 2000 cells/mm3, platelets < 75,000 cells/mm3 and malignancy. INTERVENTION: Group A: basiliximab (20 mg D0 and D4). Group B: thymoglobulin (3 mg/kg total). Maintenance immunosuppression: tacrolimus, mycophenolate mofetil, and steroids. MAIN OUTCOME MEASURES: Biopsy-proven acute rejection (BPAR), delayed graft function, slow graft function, leukopenia, infections, adverse events, graft loss, estimated glomerular filtration rate, and death within 12 months. RESULTS: 100 patients (basiliximab, n = 53) (thymoglobulin, n = 47) were included. Donor and recipient characteristics were similar except for longer dialysis (basiliximab), PRA class I (1.2% basiliximab, 4.5% thymoglobulin), HLA match (basiliximab 2.8, thymoglobulin 2.2), and cytomegalovirus status. BPAR rate was basiliximab 3.8% and thymoglobulin 6.4% (P = ns). Delayed graft function (basiliximab 3.8%; thymoglobulin 4.3%), slow graft function, and 12-month leukopenia (basiliximab 11.3%, thymoglobulin 21.3%) were similar between groups (P = ns). There was no difference in infections and adverse events between groups. Patient and graft survival were as follows: basiliximab 98.1% and 92.5%, thymoglobulin 100% and 93.6% (P = ns). CONCLUSION: Low-dose thymoglobulin induction (3 mg/kg) can be used effectively and safely in low-risk kidney transplantation with good results during the first year post-transplant.

Acute Rejection Is a Strong Negative Predictor of Graft Survival in Living-Donor Pediatric Renal Transplant: 10-Year Follow-Up in a Single Mexican Center.

OBJECTIVES: Kidney transplant is the optimal treatment for children with end-stage renal disease. Multiple factors affect patient and graft survival. We assessed determinants of long-term patient/graft survival in our center by a retrospective review of pediatric living donor (< 18 years) kidney transplants from February 2003 to December 2016. MATERIALS AND METHODS: Donor and recipient demo-graphic data and immunosuppression use were gathered for analyses. Transplant outcomes included patient/graft survival, acute rejection, and 1-year estimated glomerular filtration rate. Patient/graft survival results were analyzed by Kaplan-Meier, and Cox proportional hazards regression model was used for risk factors (univariate/multivariate). P ≤ .05 was statistically significant. RESULTS: Ninety-nine patients were included. Age was 13.4 ± 3.08 years, 64.6% were male, and 88.9% were on dialysis with time of 17.1 ± 12.6 months. Mean donor age was 36.6 ± 7.7 years, and most were females (63.6%). Donor estimated glomerular filtration rate was 89.4 ± 16.9 mL/min/1.73 m2. HLA match was 3.2 ± 1.05. Panel reactive antibody showed 8.6 ± 20.5%. Of total patients, 47.5% used induction, 88.9% used cyclo-sporine, and 100% used mycophenolate mofetil. Five- and 10-year patient survival rates were 93.2% and 93.2%. One-year acute rejection was 14.1%, with rate of 24.2% throughout follow-up. One-year estimated glomerular filtration rate was 76.4 ± 25.6 mL/min/1.73 m2. Five- and 10-year graft survival rates were 62.6% and 43.3%. Multivariate analysis confirmed donor age and acute rejection episodes throughout follow-up as risk factors for graft survival (P < .05). CONCLUSIONS: Acute rejection and donor age are important risk factors for 10-year graft survival in living-donor pediatric kidney transplant in our program.

Patient survival scale after kidney transplant from deceased donors in Veracruz, Mexico / Escala de sobrevida de pacientes después de trasplante renal de donantes fallecidos en Veracruz, México

Background: The Estimated Post Transplant Survival (EPTS) score is calculated based on age, the presence of diabetes mellitus, years on dialysis, and prior organ transplant. The EPTS score has been validated in other countries. Objective: To apply and assess the EPTS score in our population of deceased-donor kidney transplants. Materials and methods: Retrospective study of adult deceased-donor kidney transplants from January, 2003, to December, 2016. For the statistical analysis it was used Spearman's correlation, receiver-operator curves (ROC) and Kaplan-Meier curves. A p value < 0.05 was considered statistically significant. Results: 176 adult deceased-donor kidney transplants were included. Medium age was 34.7 ± 11 years; 53.4% were men, 4% diabetics; mean dialysis time was 5.5 ± 3.9 years and 4% had a prior organ transplant. The medium of EPTS score was 16.3 ± 18.7 (1 94). Spearman's correlation was −0.394 (p = 0.0001). C value (ROC) was 0.64 ± 0.6 (95% CI, 0.52-0.75) (p = 0.011). Medium survival calculated with Kaplan-Meier in patients with an EPTS score < 20, was 10.2 ± 0.3 years (95% CI, 9.5-10.9) versus patients with EPTS score > 20: 7.03 ± 0.9 years (95% CI, 5.1-8.9) (p = 0.001). Each 20% increase of EPTS, patient survival time diminished (p = 0.0001). Conclusions: The EPTS score is a useful tool for establishing survival in adult Mexican recipients of deceased-donor kidney transplants.

Introducción: la escala de sobrevida estimada postrasplante (EPTS) se calcula a partir de la edad, la presencia de diabetes mellitus, el tiempo en diálisis y el trasplante previo. La EPTS ha sido previamente validada en otros sitios. Objetivo: aplicar y evaluar la escala EPTS en nuestra población de trasplantes de donante fallecido. Material y métodos: estudio retrospectivo de trasplantes renales de donantes adultos fallecidos, llevados a cabo entre enero de 2003 y diciembre de 2016. Para el análisis estadístico se utilizaron correlación de Spearman, curvas de ROC y Kaplan-Meier y se consideró significativa una p < 0.05. Resultados: se incluyeron 176 trasplantes de donantes adultos fallecidos; 53.4% fueron hombres, 4% diabéticos; la edad media fue de 34.7 ± 11 años; el tiempo medio en diálisis fue de 5.5 ± 3.9 años y 4% tuvo trasplante previo. La media de la escala EPTS fue de 16.3 ± 18.7 (rango 1-94). La correlación Spearman fue −0.394 (p = 0.0001). El valor C de la curva ROC fue de 0.64 ± 0.6 (IC 95% 0.52-0.75) (p = 0.011). La supervivencia media calculada con Kaplan-Meier en pacientes con EPTS < 20 fue 10.2 ± 0.3 años (IC 95% 9.5-10.9) frente a los pacientes con EPTS > 20: 7.03 ± 0.9 años (IC 95% 5.1-8.9) (p = 0.001). Por cada 20% que se incrementó la EPTS, la supervivencia del paciente fue menor (p = 0.0001). Conclusiones: la escala EPTS es una buena herramienta para establecer la supervivencia en pacientes adultos mexicanos receptores de trasplante renal de donante fallecido.

[Implementation of a clinical prediction tool in renal transplant recipients]. / Aplicación de una herramienta de predicción pronóstica en receptores de trasplante renal.

BACKGROUND: Kasiske developed a tool for predicting the risk of 5-year graft loss. We analyzed our results using this model. METHODS: 109 deceased donor kidney transplants were included. 5-year probability of graft survival was calculated during transplantation, seven days after transplantation and 1-year after transplantation. Z-test and ROC curves were used for proportion differences and discrimination ability. RESULTS: Mean age of donor and recipient was 33.7 and 33.9 years, respectively. 59.6% died due to trauma. Mean of years on dialysis was 3.7. 22.9% of patients had delayed graft function (DGF). Calculated 5-year probability of graft survival during transplantation time was 74.1%; 7 days after transplantation, 74.9%; and one year after transplantation, 76.4%. 5-year death censored graft survival was 64.9%. There were no differences between death-censored graft survival and calculated probabilities (Z-test), with a C-statistic value of 0.54 ± 0.6 (95%CI 0.42-0.65, p = 0.5) and 0.51 ± 0.6 (0.39-0.63, 95% CI, p = 0. 7) for transplant time and seven days after. C-statistic value 1-year after transplantation was 0.68 ± 0.8 (95%CI 0.52-0.84, p = 0.02). CONCLUSION: Only calculated 5-year graft survival one year after transplantation had modest prediction ability.

Introducción: Kasiske desarrolló una herramienta para predecir el riesgo de pérdida del injerto a cinco años. Se analizaron los resultados utilizando este modelo. Métodos: se incluyeron 109 pacientes trasplantados de donantes fallecidos. La probabilidad de sobrevida del injerto a cinco años fue calculada al momento del trasplante, a los siete días y al año. La prueba Z y las curvas ROC fueron utilizadas para diferencias de proporción y capacidad de discriminación. Resultados: la media de edad del donador y del receptor fue 33.7 y 33.9 años, respectivamente. El 59.6% falleció de trauma. La media de años en diálisis fue de 3.7. El 22.9% tuvo retraso en la función del injerto. La probabilidad de sobrevida a cinco años del injerto en el momento del trasplante fue de 74.1%; siete días después fue de 74.9% y al año 76.4%. La sobrevida actuarial a cinco años del injerto fue 64.9%. No hubo diferencias entre la sobrevida del injerto y las probabilidades calculadas (prueba Z) con valor estadístico C de 0.54 ± 0.6 (intervalo de confianza al 95% [IC 95%] 0.42-0.65, p = 0.5) y 0.51 ± 0.6 (IC 95% 0.39-0.63, p = 0.7) para el tiempo de trasplante y al séptimo día. El valor estadístico C después del trasplante a un año fue de 0.68 ± 0.8 (IC 95% 0.52-0.84, p = 0.02). Conclusión: existió una predicción modesta al calcular la sobrevida del injerto a cinco años a un año posterior al trasplante.

Shift of high-density lipoprotein size distribution toward large particles in patients with proteinuria.

BACKGROUND: The potential atheroprotective role of the different HDL subclasses may depend on the metabolic factors that affect their plasma concentrations. The kidney is supposed to be one of the main catabolic sites for these lipoproteins. However, little is known about the impact of proteinuria on HDL size distribution and HDL structure. The aim of this study is to establish the influence of proteinuria on HDL size distribution and cholesterol plasma concentration of HDL subclasses. METHODS: Forty patients within a range of proteinuria from 0.2 to 10.0 g/g estimated by the urinary protein-to-creatinine ratio and 40 healthy controls were enrolled in the study. HDL subclasses were separated by sequential ultracentrifugation followed by a polyacrylamide gradient electrophoresis; gels were stained enzymatically for cholesterol and with Coomasie blue for proteins. HDL size distribution and plasma concentration of the five HDL subclasses were calculated by optical densitometry. RESULTS: When determined by protein, large HDL2b and HDL2a relative proportions were higher in patients than in control subjects, whereas the contrary was observed for small HDL3b and 3c. Consistently, HDL3a, 3b, and 3c were negatively correlated with proteinuria when data were adjusted by age, gender, body mass index, and blood pressure. Size distribution followed a different pattern when determined by cholesterol, suggesting an abnormal lipid composition that was further supported by a protein-to-cholesterol ratio significantly higher in most of the HDL subclasses in proteinuric patients than in the control group. Moreover, proteinuria statistically explains the HDL2b and HDL3c cholesterol plasma concentrations. CONCLUSIONS: Proteinuria is associated with a shift of HDL size distribution towards large particles and cholesterol-poor HDL subclasses. These results support the idea of a selective loss by the kidney of small HDL in patients with proteinuria; whether these abnormalities reflect an impaired reverse cholesterol transport and an increased risk of coronary heart disease remains to be elucidated.