[Causes of death with a functioning graft among kidney allograft recipients]. / Causas de muerte en pacientes con un injerto renal funcionante: ¿Han ocurrido cambios en las últimas décadas?

BACKGROUND: Death with a functioning graft (DWGF) is now one of the main causes of renal transplant (RTx) loss. AIM: To determine whether the causes of DWGF, characteristics of donors and recipients and complications of RTx have changed in the last two decades. SUBJECTS AND METHODS: Cooperative study of a cohort of 418 kidney grafts performed between 1968 and 2010. Patients were divided into two groups according to whether their kidney transplants were performed between 1968 and 1992 (Group 1) or 1993 and 2010 (Group 2). RESULTS: Sixty eight patients experienced DWGF. Infections were the leading cause of DWGF in both groups (38 and 41%, respectively), followed by cardiovascular diseases (24 and 23% respectively), gastrointestinal disorders (21 and 26% respectively) and cancer (17 and 10% respectively). There were no significant differences in causes of death between the two groups according to the time elapsed since the renal transplantation. In patients in Group 1, the interval between diagnosis of renal failure and dialysis (HD) and the interval between the start of HD and kidney transplantation were significantly lower than in Group 2. The former had also an increased number of acute rejections in the first five years of kidney transplantation (p < 0.001). In Group 2, patients more often received their kidneys from deceased donors, had previous kidney transplantation, higher rate of antibodies to a panel of lymphocytes and an increased incidence of cardiovascular disorders after five years of RTx. CONCLUSIONS: The proportion of graft loss due to DWGF has increased over the last 2 decades, but its causes have not changed significantly. Infections are the most common causes of DWGF followed by cardiovascular and digestive diseases.

Causas de muerte en pacientes con un injerto renal funcionante: ¿Han ocurrido cambios en las últimas décadas? / Causes of death with a functioning graft among kidney allograft recipients

Background: Death with a functioning graft (DWGF) is now one of the main causes of renal transplant (RTx) loss. Aim: To determine whether the causes of DWGF, characteristics of donors and recipients and complications of RTx have changed in the last two decades. Subjects and Methods: Cooperative study of a cohort of 418 kidney grafts performed between 1968 and 2010. Patients were divided into two groups according to whether their kidney transplants were performed between 1968 and 1992 (Group 1) or 1993 and 2010 (Group 2). Results: Sixty eight patients experienced DWGF. Infections were the leading cause of DWGF in both groups (38 and 41%, respectively), followed by cardiovascular diseases (24 and 23% respectively), gastrointestinal disorders (21 and 26% respectively) and cancer (17 and 10% respectively). There were no significant differences in causes of death between the two groups according to the time elapsed since the renal transplantation. In patients in Group 1, the interval between diagnosis of renal failure and dialysis (HD) and the interval between the start of HD and kidney transplantation were significantly lower than in Group 2. The former had also an increased number of acute rejections in the first five years of kidney transplantation (p < 0.001). In Group 2, patients more often received their kidneys from deceased donors, had previous kidney transplantation, higher rate of antibodies to a panel of lymphocytes and an increased incidence of cardiovascular disorders after five years of RTx. Conclusions: The proportion of graft loss due to DWGF has increased over the last 2 decades, but its causes have not changed significantly. Infections are the most common causes of DWGF followed by cardiovascular and digestive diseases.

Kidney transplantation during a twin pregnancy. Case report and review of the literature.

Kidney transplant in a pregnant woman is exceptional, with only six cases being reported. Pregnancy was not known at the time of the transplant in five of these cases. We report the case of a 26-year-old woman who was diagnosed as carrying a twin pregnancy 4 months after starting hemodialysis. In order to improve the survival chances for the twins, she underwent an orthotopic renal transplant from a living donor at 20 weeks of gestation. The allograft functioned immediately and 4 weeks passed without incident. At the 26th week of gestation, the patient had a precipitous labor, delivering two male babies with no malformations, weighing 755 and 890 g, who died due to respiratory failure. The allograft worked normally afterwards. Sixteen months later, the patient delivered a normal 37 weeks' gestation baby. The renal graft continued working normally for the next 20 years, after which signs of chronic allograft nephropathy developed. Azathioprine was replaced with mycophenolate mofetil. At the last evaluation, 23 years after transplant, the patient's serum creatinine was 2.9 mg/dl and her estimated glomerular filtration rate (eGFR) was 22 ml/min/1.73 m2. This unique case demonstrates that it is possible to perform an orthotopic kidney transplant in a 20-week twin-gestation, with a long graft survival time.

Hyperbaric oxygen therapy in a patient with autosomal dominant polycystic kidney disease with a perinephritic abscess.

A 68-year-old female in hemodialysis due to autosomal dominant polycystic kidney disease underwent resection of cysts in her right kidney via a laparoscopic approach due to abdominal pain. Three weeks after surgery, she was admitted with sepsis. A CT scan showed a large abscess around the right kidney. Percutaneous drainage of abscess was performed. The pus smear showed Gram-positive cocci and the culture contained methicillin-resistant Staphylococcus aureus. Ciprofloxacin, clindamycin and vancomycin were given. In the 3 weeks following admission, she remained febrile and septic and showed a progressive deterioration in her general condition, along with malnutrition and persistent drainage of purulent material from her right flank. The antibiotic therapy was changed to vancomycin, metronidazole and meropenem, but no improvement was observed. Because of the high risk associated with carrying out an open nephrectomy, we decided to use hyperbaric oxygen therapy (HBOT) as a potentially useful measure to control her infection. The patient underwent 26 daily sessions of 100% hyperbaric oxygen (2.5 atm). The use of HBOT induced a notable break in the clinical course of this patient's retroperitoneal infection. She was discharged after day 58 without any signs of inflammatory activity, and she has not presented reactivation of infection since then. We think that this case suggests that this therapy could be a new therapeutic tool in the management of patients with similar clinical features when all other therapeutic measures have failed. We did not find any other reports of the use of HBOT in infections of renal cysts.