Value of Doppler ultrasound hemodynamics in the assessment of renal artery stenosis in transplanted kidneys: an assessment of patients after percutaneous transluminal angioplasty.

UNLABELLED: Doppler ultrasound (USS) may allow a non-invasive early diagnosis of transplant renal artery stenosis (TRAS). Adequate Doppler sampling of the transplant renal artery is difficult, time consuming and highly operator dependent. As a result, there has been increased attention focused on the intrarenal vessels and downstream changes that occur secondary to TRAS. We evaluated Doppler USS parameters in nine patients with TRAS confirmed on angiography (significant stenosis defined as > 60% diameter narrowing). Doppler USS correctly identified all the nine stenoses. Mean peak systolic velocity (PSV) was 3.6 m/s + 1.09. Mean end-diastolic velocity (EDV) was 1.75 m/s + 0.25 with an acceleration time (AT) of 0.14 + 0.04 sec and resistivity index (RI) of 0.42 + 0.12. Early systolic peak (ESP) was lost in all cases. Percutaneous transluminal angioplasty (PTA) was successfully done in five patients with significant improvement in Doppler parameters. PSV decreased from 4.04 m/s + 1.35 to 0.76 m/s + 0.42 (p = 0.01). Similarly EDV improved from 1.71 m/s + 0.28 to 0.30 m/s + 0.17 (p = 0.001). AT improved from 0.13 + 0.01 to 0.05 + 0.01 sec (p = 0.001). RI normalized from 0.34 + 0.07 to 0.73 + 0.09 (p = 0.008). ESP was restored in all the patients. IN CONCLUSION: our results show that the Doppler USS analysis of segmental arteries is an excellent tool for the diagnosis of TRAS and follow-up of patients post PTA.

Sustained virological and histological response with pretransplant interferon therapy in renal transplant patients with chronic viral hepatitis C.

Patients who are anti-HCV positive before renal transplantation (Tx) have a significantly increased risk of posttransplant liver disease. We conducted a prospective, controlled study to evaluate the posttransplant outcome of renal graft candidates with HCV-associated chronic hepatitis (n = 30). Patients were randomly assigned to either of two groups. All patients on enrollment underwent liver biopsy, which showed mild-to-moderate hepatitis activity (mean 4.1, range 2-6). Half the patients received interferon-alpha (IFN-a) administered at a dosage of 3 million units three times weekly for 1 year. Liver biopsy was repeated for treated patients at the end of IFN-a treatment. Of these, 11 patients received renal transplant (group A). The other half did not receive IFN-a and to date 10 patients have been transplanted (group B). Renal transplant recipients were prospectively followed for a period of 12 months and a follow-up liver biopsy was also done at the end of this period (end of study). Biochemical and virological responses were evaluated and the histologic activity index (HAI) scoring according to Knodell was assessed. The mean pretreatment serum HCV RNA level was 1.14 +/- 0.84 and 1.0 +/- 0.89 mEq/ml for groups A and B, respectively (bDNA assay sensitivity threshold is <0.2 mEq/ml). HCV RNA became undetectable in 4 patients of group A. At the end of study period the mean quantitative HCV RNA titers were 1.43 +/- 4.07 and 15.18 +/- 11.08 mEq/ml in groups A and B, respectively (p < 0.0001). In group A, the mean HAI score decreased from 4.27 +/- 1.19 to 1.64 +/- 0.67 after IFN-a treatment (p < 0.0001). This score was maintained till the end of the study period with a mean of 1.82 +/- 0.6. Mean HAI score of group B on enrollment was 3.9 +/- 1.2 and at the end of study increased to 5.5 +/- 1.35 (p = 0.01). There was statistically significant difference (p value less than 0.0001) between the HAI scores at the end of the study period between the two groups. These results demonstrate that interferon therapy while on dialysis is associated with less viremia and decreased progression of chronic liver disease in renal transplant patients with hepatitis C.

Effect of vitamin-E-modified dialysers on dialyser clotting, erythropoietin and heparin dosage: a comparative crossover study.

We performed a crossover study to compare the effects of different dialysis membranes on 20 patients with frequent dialyser clotting and requiring > or = 5,000 units of heparin per dialysis session. Low-flux dialysers are C15NL (cellulose - Terumo) and E15NL (vitamin-E-coated - Terumo) while high-flux dialysers were F60 (polysulphone) and EE15NL (vitamin-E-coated - Terumo). Ten patients underwent dialysis for 2 months with C15NL then switched to E15NL for 2 months. Similarly, the other 10 patients were started on the high-flux dialyser F60 and then switched over to EE15NL for 2 months. The following parameters were measured at the beginning of the study, 2 weeks, 1 month and then at 2 months: hemoglobin, prothrombin time (PT), partial thromboplastin time (PTT), fibrinogen, protein C, protein S, antithrombin III (ATIII) and factor 12 activity. Dialyser clotting, heparin and erythropoietin requirements were assessed during each dialysis session. There was a significant reduction in clotting with E15NL in comparison to C15NL (22.8 +/- 17 and 44.1 +/- 22.8 (p = 0.0233), respectively). Similarly, heparin requirements were less in the vitamin-E-coated (E15NL) dialysers, 4, 754 +/- 1,427 vs. 6,011 +/- 856 units (p = 0.0281) and erythropoietin usage was also significantly reduced, 4,630 +/- 2,620 vs. 7,850 +/- 4,069 units (p = 0.049). There was a significant increase in hemoglobin with E15NL compared to C15NL, 115 +/- 10.4 vs. 108 +/- 13.1 (p = 0.0343). When the high-flux dialysers were compared there was a tendency towards less dialyser clotting with the EE15NL compared to F60, though this did not achieve statistical significance (p = 0.0561). We could not demonstrate any significant changes between the different dialysers with regards to PT, PTT, fibrinogen factor 12 activity, protein C, protein S and ATIII. In conclusion, we have shown that the use of vitamin-E-modified dialysers is associated with less clotting in patients with persistent clotting problems. In addition, this was associated with less heparin and erythropoietin requirements.

Successful late conversion to mycophenolate mofetil and prednisone immunosuppression therapy in a renal transplant recipient.

A 35-year old male patient developed elevated transaminases about an year after cadaveric donor renal transplantation maintained on triple immunosuppression therapy. Azathioprine was discontinued and the liver enzymes normalized. Three years later, he showed evidence of cyclosporin (CyA) nephrotoxicity as well as sclerosing cholangitis. The dose of CyA was therefore reduced. This was followed shortly by deterioration of his renal function and mycophenolate mofetil (MMF) (3 gm daily) was therefore introduced. He developed intractable diarrhea, which improved on reducing the dose of MMF to 2 gm per day. Eventually, the patient seemed to stabilize on low dose CyA and prednisone (Pred) along with 2 gm of MMF. Four months later, the patient discontinued CyA on his own but continued with MMF and Pred. Over the following two years, his renal functions have remained stable with serum creatinine of around 120 micromol/L, despite the low immunosuppression being administered.

The Effect of Vitamin E-Modified Dialyzers on Acute Intra-dialytic Symptoms: A Comparative Crossover Study.

We performed a crossover study to compare the effect of vitamin E-modified dialyzers on acute intra-dialytic symptoms, with other membranes. Twenty patients on hemodialysis were studied. They were divided into two equal groups of low-flux (C15NL, E15NL) and high-flux (F60, EE15NL) membrane dialyzers. Within each group, a vitamin E-modified dialyzer was compared with another dialyzer in a crossover design over a two-month period. All study patients were seen during each dialysis session by a physician and the occurrence of intra-dialytic symptoms were recorded. There was a significant overall improvement in the incidence of acute intra-dialytic symptoms with the use of vitamin E-modified dialyzers as compared with the other membranes. This effect was more for cuprophane than polysulfone. The occurrence of hypotensive episodes did not differ. Our study indicates that we can achieve a reduction in the incidence of acute intra-dialytic symptoms with the use of vitamin E-modified membrane as compared to cuprophane and polysulfone.

Interferon-alpha in chronic hepatitis C infection in dialysis patients.

This study assesses the efficacy and adverse effects of interferon-alpha (IFN-alpha) administered at a dosage of 3 million units three times weekly for 1 year in 17 hemodialysis patients with hepatitic C virus (HCV)-associated chronic hepatitis (biopsy proven). The patients were prospectively followed up for a period of 18 months. Liver biopsy was repeated after 6 months of treatment in 13 patients. Patients were classified according to the histological activity index. Biochemical and virological responses were evaluated at the end (end-of-treatment response) and 6 months after completion of therapy (sustained response). HCV RNA became negative in 76% of the patients after 12 weeks of treatment, in 88% after 12 months of treatment, and in 71% of the patients 6 months after completion of therapy. HCV genotype 4 was found in 60% of our population. Alanine aminotransferase (ALT) levels were initially increased in only 6 patients and normalized in 4 of these patients after 12 weeks of therapy, with end-of-treatment and sustained biochemical responses of 83% and 67%, respectively. Of 13 patients who underwent liver biopsies after 6 months of therapy, 11 patients (85%) showed histological improvement. One patient could not tolerate therapy because of marked lethargy and myalgia; the other patients had minor side effects that did not require discontinuation of treatment. Two patients received a cadaveric renal transplant after 1 year of IFN treatment, and they continued to maintain biochemical and virological responses after a follow-up of 17 and 28 months, respectively.

Maintenance intravenous iron therapy in hepmodialysis patients receiving recombinant human erythropoientin.

Iron Supplementation is crucial in raising hematocrit as well as dosage saving for recombinant human erythropoietin therapy (rHuEPO) in maintenance hemodialysis patients. Intravenous iron has proved to be both safe and efficacious in this patient's population. However, the exact iron requirement has not been worked our. In this study we found that 1000 mg of element iron (given as iron saccharate) per moth was effective in maintaining hematocrit and hemoglobin at 33% and 110 gm/L respectively, and reducing the erythropoietin (EPO) dosage by about 20% in maintenance hemodialysis patients who were iron-replete. The serum ferritin increased from 219+/-144 to 320+/-234 microg/L (P< 0.05). There were no major side effects and patients tolerated the monthly iron therapy well. Our study suggests that intravenous iron saccharate (100 mg/month) is effective and safe in patients on maintenance hemodialysis receiving RHUEPO.

Effect of intravenous alfacalcidol on lymphocyte phenotyping in hemodialysis patients.

Chronic renal failure is associated with decreased production of active vitamin D and also results in altered lymphocyte population. We studied the effect of alfacalcidol on lymphocyte phenotype. There were 15 patients (10 males, 5 females) with a mean age of 54.3+/-14.4 years who had been on chronic maintenance haemodialysis for a mean period of 3.2+/-1.5 years. Intravenous alfacalcidol was given three times weekly during dialysis for a duration of 6 months. Our results show a significant increase in NK cells from 0.20+/-0.12 to 0.27+/-0.28 (P=0.001), without a significant change in CD2, CD19, CD4, CD8 population, and CD4/CD8 ratio.

Absence status: an overlooked cause of acute confusion in hemodialysis patients.

Epileptic seizures are a known complication of uremia, but non-convulsive seizures appear to be rare. We describe a patient with absence status presenting with acute confusion who responded well to intravenous diazepam. Attention is drawn to this rare cause of acute confusional state in the hemodialysis population.

Evaluation of a dialyzer reuse system in a developing country.

Dialyzer reuse affords a means of reducing the cost of hemodialysis with little risk, but surprisingly not widely practised in Nigeria. To provide an evaluation of a simply constructed dialyzer reprocessing system, we measured dialyzer blood compartment volume loss dialyzer urea clearance in 21 patients during reuse to determine the viability of the proc Cuprophan hollow fibre dialyzers were used. Mean dialyzer blood volume decreased from 46.4 +/- 1.5 ml on first use to 35.5 +/- 1.3 mL on fifth use, though fourth and fifth uses were obtainable in only 9 and 2 cases respectively. Three uses were obtainable in all 21 cases. Mean dialyzer urea clearance fell from 144+/-8 ml/min to 140+/-5 nL on third use, and 135+/-7 mL/min on fifth use against the rated value of 160mL/min. Patient side effects were minimal. Dialyzer membrane rupture occurred in 5 cases during the fourth use. There was 80% reduction in cost of mater on reuse. The study establishes the viability and safety of a reuse system in a developing count using a locally constructed reuse device.

Neurological disorders in renal transplant recipients.

The charts of 175 renal transplant recipients were retrospectively reviewed. The mean duration of follow up since the transplantation was 4.17 +/- 1.66 years. Apart from cyclosporin induced tremor, which occurred almost in all patients, 22 patients (12.5%) had neurological disorders during their follow up (mean annual incidence of 3%). Eight patients had epileptic seizures, seven had strokes, four had neurological infections, two developed a pseudotumor cerebri syndrome, two neuropathies, one myopathy and one conus medullaris infarction. This study demonstrates that neurological disorders are not uncommon in renal transplant recipients and that their mechanisms are variable and may be related to the underlying diseases such as hypertension and diabetes; to the operation itself; to the side effects of immunosuppression agents or rarely, they can accompany graft rejection.