A Longer History of Hemodialysis Can Lead to Sarcopenia in Renal Transplantation Patients.

BACKGROUND: Sarcopenia is a condition in which the amount of skeletal muscle decreases. Recent studies have suggested that sarcopenia is a risk factor for the incidence of postoperative complications, longer hospitalization, and a poorer prognosis. In this study, we examined the impact of sarcopenia in association with a history of hemodialysis in renal transplantation patients. METHODS: A total of 157 patients who underwent renal transplantation at Yokohama City University Medical Center (Yokohama, Japan) from 2005 to 2016 were analyzed in this study. We determined the presence of sarcopenia using the psoas muscle index (PMI). The PMI was calculated based on the left psoas muscle area of L3 (mm2) divided by the square of the body height (m2). RESULTS: The mean/median length of time that the patients received hemodialysis was 2059/850 days. The PMI in men was significantly higher than that in women (321.9 ± 10.0 vs 226.6 ± 17.3, P < .001). The group with a longer history of hemodialysis (≥851 days) showed a significantly lower PMI than the short-history group (≤850 days) (355.8 ± 15.1 vs 289.7 ± 11.3, P = .001). The PMI showed a negative correlation according to the dialysis period and a positive correlation according to the sex and triglyceride levels. CONCLUSIONS: A longer history of hemodialysis was shown to be associated with a lower PMI in renal transplantation patients. In addition, the higher PMI group showed higher serum triglyceride levels than the lower PMI group.

Long-term Survival in a Kidney Transplantation Patient With Progressive Multifocal Leukoencephalopathy: A Case Report.

Post-kidney transplantation progressive multifocal leukoencephalopathy (PML) is a rare disease on which there are very few published reports on record. PML is a demyelinating disease caused by a destructive infection of the oligodendrocytes by the JC polyomavirus. No effective therapeutic protocol has been established other than measures to revive the immune function by reducing or discontinuing the administration of immunosuppressive agents. Most cases are progressive and show a poor prognosis. We herein report a case in which renal function has been maintained for 2 years following the onset of PML, which was initially diagnosed 3 years after kidney transplantation.

Effective Treatment With Everolimus for Recurrent Granulomatous Interstitial Nephritis in a Renal Transplant Recipient: A Case Report.

BACKGROUND: Granulomatous interstitial nephritis (GIN) is a rare renal disease, and its etiology remains unknown. We report recurrent GIN in renal allograft successfully treated with everolimus (EVR). CASE REPORT: A 22-year-old man with GIN received a kidney from his mother. On follow-up 8 months later, his serum creatinine level was increased, from 1.3 mg/dL to 1.7 mg/dL, and he had microhematuria and proteinuria. A protocol graft biopsy at 1 year after transplantation showed epithelioid granuloma with multinucleated giant cells. He received steroid pulse therapy for recurrent GIN twice, but he developed allograft dysfunction, hematuria, and proteinuria. EVR was started in combination with maintenance immunosuppressants at 28 months after transplantation. Thereafter, the serum creatinine level decreased, from 2.1 mg/dL to 1.6 mg/dL, and microhematuria and proteinuria were stable despite reduction of steroid dose. CONCLUSIONS: Maintenance immunosuppressive therapy combined with EVR may be effective for the recurrence of idiopathic GIN in renal allograft.

Influence of cytochrome P450 3A5 polymorphisms on viral infection incidence in kidney transplant patients treated with tacrolimus.

OBJECTIVE: The aim of this retrospective study was to determine the risk of viral infection in tacrolimus-treated kidney transplant patients. METHODS: We analyzed kidney transplant recipients from 2002 to 2012, reporting all episodes of viral infection. All patients received induction with basiliximab followed by a standard regimen with tacrolimus, steroids, and antimetabolites. Genotypes of cytochrome P450 (CYP) 3A5 were determined with the use of the polymerase chain reaction method. RESULTS: Fifty-one patients (17 women, 34 men; mean age, 41.6 ± 65.7 years) underwent kidney transplantation with tacrolimus-based immunosuppressive therapy. Thirty patients were diagnosed with 34 viral infections, including herpes simplex, adenovirus, mumps, varicella, and cytomegalovirus (CMV). CMV was the most common viral infection. In multivariate analysis, the CYP3A5 1 allele (P = .049) and negative serology for CMV (P = .018) were factors independently associated with the incidence of viral infection. After excluding CMV infection in CMV-seropositive donor/CMV-seronegative (D+R-) recipients in the analysis, the presence of the CYP3A5 1 allele was found to be an independent risk factor for viral infection. Recipients with the CYP3A5 3/3 genotype (nonexpressors) showed significantly higher dose-adjusted tacrolimus trough concentrations than patients with the CYP3A5 1 allele (expressors; respectively, 104.6 ± 65.6 vs 52.6 ± 62.3 ng/mL per mg/kg/d). CONCLUSIONS: The CYP3A5 1 allele is associated with viral infection, possibly as a result of higher peak concentrations of tacrolimus. Further analyses, such as area under the concentration-time curve (AUC) for tacrolimus and polymorphisms of drug metabolism enzymes such as CYP3A4 are required to evaluate the influence of CYP3A5 on viral infection in kidney transplantation.

Long-term analysis of suprapubic cystostomy drainage in patients with neurogenic bladder.

OBJECTIVE: We assessed the roles of suprapubic cystostomy in patients with neurogenic bladder and analyzed the complications and their courses. PATIENTS AND METHODS: We reviewed 118 patients with neurogenic bladder managed with suprapubic cystostomy. The original diseases were spinal cord injury in 90, degenerative disease of the central nervous system in 15, spina bifida in 6, cerebral palsy in 3, pontine bleeding in 1, Parkinson's disease in 1, brain tumor in 1, and dysgenesis of the external sphincter in 1. Fifty-six (62.2%) of spinal cord-injured patients demonstrated cervical damage. Renal function, urinary pH and white blood cell values were measured and evaluated after insertion. The stone-free rate after insertion was estimated by the Kaplan-Meier method. RESULTS: Indications for cystostomy were failure of clean intermittent catheterization in 62 (52.5%) and Credé's maneuver in 2, severe urethral damage in 30 (25.4%), replacement of urethral catheter in 3, worsening of the original disease in 15 (12.7%), deterioration of the general condition in 2, mental retardation in 2, and traumatic vesical rupture in 1. Frequent complications were formation of the bladder calculi in 30 (25%) and urinary leakage through the urethra in 11 (10%). No fatal complications occurred. The stone-free rates 5 and 10 years after insertion were 77 and 64%, respectively. The urinary pH of the stone-forming group was significantly higher than that of the stone-free group. The high urinary pH group (>7.24) had a higher risk of stone formation. CONCLUSIONS: Although continuous cystostomy drainage is not considered to be ideal management for bladder emptying, some patients with neurogenic bladder may benefit from this procedure.

[Intraoperative and follow-up color Doppler echocardiography for evaluating the surgical results of aortic valvuloplasty in a patient with bicuspid aortic valve].

A 21-year-old man underwent aortic valvuloplasty for aortic regurgitation due to bicuspid aortic valve. After the initial procedure for valvuloplasty of the anterior cusp, transesophageal color Doppler flow imaging revealed a significant regurgitant jet directed posteriorly as observed preoperatively. After an additional valvuloplastic procedure for the anterior cusp, the size of the regurgitant signal was reduced and directed to the center of left ventricular outflow tract. The surgery was then completed. On the 5th postoperative day, an aortic regurgitant murmur reappeared and color Doppler echocardiography showed a mild but significant regurgitant jet directed toward the interventricular septum, which may have been due to contraction of the anterior cusp treated by valvuloplasty. Aggravation of the aortic regurgitation in the early stage after plastic surgery is important and requires consideration in the intraoperative assessment.

A new approach for evaluation of left ventricular diastolic function: spatial and temporal analysis of left ventricular filling flow propagation by color M-mode Doppler echocardiography.

OBJECTIVES: To evaluate left ventricular diastolic function and differentiate the pseudonormalized transmitral flow pattern from the normal pattern, the propagation of left ventricular early filling flow was assessed quantitatively using color M-mode Doppler echocardiography. BACKGROUND: Because the propagation of left ventricular early filling flow is disturbed in the left ventricle with impaired relaxation, quantification of such alterations should provide useful indexes for the evaluation of left ventricular diastolic function. METHODS: Study subjects were classified into three groups according to the ratio of early to late transmitral flow velocity (E/A ratio) and left ventricular ejection fraction: 29 subjects with an ejection fraction > or = 60% (control group); 34 with an ejection fraction < 60% and E/A ratio < 1 (group I); and 25 with ejection fraction < 60% and E/A ratio > or = 1 (group II). The propagation of peak early filling flow was visualized by changing the first aliasing limit of the color Doppler signals. The rate of propagation of peak early filling flow velocity was defined as the distance/time ratio between two sampling points: the point of the maximal velocity around the mitral orifice and the point in the mid-left ventricle at which the velocity decreased to 70% of its initial value. High fidelity manometer-tipped measurement was performed in 40 randomly selected subjects. RESULTS: The rate of propagation decreased in groups I and II compared with that in the control group (33.8 +/- 13.8 [mean +/- SD] and 30.0 +/- 8.6 vs. 74.3 +/- 17.4 cm/s, p < 0.001, respectively) and correlated inversely with the time constant of left ventricular isovolumetric relaxation and the minimal first derivative of left ventricular pressure (peak negative dP/dt) (r = 0.82 and r = 0.72, respectively). CONCLUSIONS: Spatial and temporal analysis of filling flow propagation by color M-mode Doppler echocardiography was free of pseudonormalization and correlated well with the invasive variables of left ventricular relaxation.

[Evaluation of valvular lesions by three-dimensional echocardiography].

A recently developed, on-line image processing system (Tomtec EchoScan) for three-dimensional (3D) echocardiography was compared with conventional two-dimensional examination and our own off-line 3D system. Transesophageal echocardiography was performed in 10 cardiac patients using an omniplane transducer which was automatically rotated under the control of the 3D system. At each angle of the transducer, the respiration-gated image of one cardiac cycle was acquired and transferred into the computer, where the dynamic 3D images of mitral and/or aortic valve were reconstructed. The EchoScan system enabled 3D recognition of the structural and dynamic abnormalities of the valves, such as mitral valve prolapse, although tissue information, which is expressed as a gray scale in the conventional echocardiography, cannot be evaluated from the 3D image. Average times were 5.4 min for the data acquisition, 11.8 min for the 3D processing and 5.7 min for the rendering. Although it seems necessary to improve the efficacy of data acquisition, to shorten the calculation time and to minimize the artifacts, this system enables assessment of 3D cardiac structures at the bedside and to fully recognize valvular lesions preoperatively in patients with valvular heart disease.