Long-term outcomes of percutaneous nephrolithotomy in patients with chronic kidney disease: a single-center experience.

OBJECTIVE: To present our long-term follow-up data from patients with kidney stones and chronic kidney disease to identify the factors that could help predict the likelihood of long-term deterioration in renal function. METHODS: From January 2002 to July 2010, we performed 1117 percutaneous nephrolithotomy (PNL) procedures in 1051 patients. We retrospectively analyzed 69 PNL procedures for 67 patients (47 men and 20 women) in whom the estimated glomerular filtration rate (eGFR) was <60 mL/min/1.73 m(2). Two outcomes were measured. The percentage of change in the eGFR was measured comparing the preoperative and postoperative values. A 5% change in renal function was arbitrarily chosen to divide the population into 3 groups: group 1, an eGFR change of ≤ 5%; group 2, an eGFR increase of >5%; and group 3, an eGFR decrease of <5%. The second outcome measure was the presence of chronic kidney disease progressing in the first and consecutive years. RESULTS: The mean patient age was 57 ± 14.1 years. The complication rate was 23.1% using the Clavien classification. The mean follow-up time was 45.7 ± 17.08 months. The mean eGFR before and after PNL was 37.9 ± 14.05 and 45.1 ± 16.8, respectively. Diabetes mellitus (odds ratio 15.82, P = .036) and urinary infection (odds ratio 10.6, P = .04) were predictive of renal function deterioration at 1 year on multivariate analysis. CONCLUSION: PNL in patients with chronic kidney disease is safe and results in renal function preservation for a 5-year period. Diabetes mellitus and urinary infection were independent predictive of renal function impairment. Therefore, patients with diabetes mellitus and urinary tract infection should be followed up carefully and informed about hazardous potential of those diseases.

Transplantation tourism: high risk for the recipients.

BACKGROUND: The shortage of donor organ supply is forcing patients with end-stage renal disease to alternative searches. The aim of this study is to present the clinical and laboratory data of five patients who were transplanted in Egypt from paid living-unrelated donors and followed at our institution. METHODS: Five patients (four male, one female, mean age 51 yr) were included in this retrospective study. RESULTS: All allografts still have good function with a mean serum creatinine level of 0.9 mg/dL. Surgical and medical problems were common such as wound infection (n = 3), evisceration (n = 2), deep vein thrombosis (n = 2), unexplained abdominal incision requiring removal of an abdominal surgical compress left in situ during previous surgery, placement of allograft on the side of an unrepaired indirect inguinal hernia and transplant pyelonephritis. CONCLUSION: Although recent developments increased success in renal transplantation, receiving a kidney from a paid living donor at a commercial transplant center still carries great risks for the recipient.

Comparing two ureter reimplantation techniques in kidney transplant recipients.

We compared the incidence of urological and anastomotic complications for the ureteroureterostomy and Lich-Gregoir techniques in kidney transplant recipients. Between May 2003 and February 2004, 75 kidney transplant recipients from living donors were divided into two similar groups to receive ureteroureterostomy (n = 41, 28 male, 13 female) and Lich-Gregoir techniques (n = 34, 24 male, 10 female) for ureteral reimplantation. Patients with vesicoureteral reflux (VUR) to the native kidneys were excluded from the study. The urological complications included complicated hematuria, ureteral stenosis, symptomatic VUR, recurrent urinary tract infection (UTI). There was no statistical significance between two groups in terms of gender, age, end-stage renal disease etiology, human leucocyte antigen (HLA) mismatch numbers, type and duration of dialysis, and cold ischemia time. The incidence of urologic and anastomotic complications was 12%. Complications in the Lich-Gregoir group included symptomatic VUR in 8.8% and stent migration in 2.9% of cases. Complications observed in the ureteroureterostomy group were ureteral stricture 7.3% and complicated hematuria in 4.9% of cases. However, symptomatic reflux was not observed in the ureteroureterostomy group. UTI frequency was similar in both groups. Ureteroureterostomy can be safely performed as a primary choice in kidney transplant recipients.

Low incidence of malignancy among sirolimus/cyclosporine-treated renal transplant recipients.

BACKGROUND: Malignancies, a well-known complication of immunosuppressive therapy in renal transplant recipients, represent an important cause of long-term morbidity and mortality. One approach to addressing this problem is identifying agents that display antineoplastic properties concomitant with their immunosuppressive effects. METHODS: We examined the neoplasms among 1008 renal transplant recipients treated at a single center with sirolimus-cyclosporine +/- prednisone. RESULTS: Clinical and laboratory data, including 62.3+/-26.1 months follow-up (range 27.1-131), revealed 36 tumors in 35 patients (3.6%) presenting at 32.5+/-29.8 months. The 2.4% incidence of skin tumors, the most common neoplasms, was 1.58-fold greater than the general U.S. population. In addition to a 0.4% incidence of posttransplant lymphoproliferative disorders (PTLD) and a 0.2% incidence of renal cell carcinomas, we observed single cases of breast, bladder, endometrial, lung, and brain neoplasms as well as leukemia. The mean trough drug concentrations at the time of diagnosis in affected recipients were within our putative target ranges. In addition to eleven graft losses due to death with a functioning kidney, two were related to chronic rejection following reduced immunosuppression, and one, therapeutic nephrectomy for PTLD. Five of twelve deaths were caused by malignancies; four others among 1008 patients over the entire follow-up were attributed to cardiovascular events; one, to respiratory failure; and two, at distant locations to unknown causes. CONCLUSIONS: The sirolimus-cyclosporine +/- prednisone combination appears likely to be associated with a reduced incidence of tumors.

Sirolimus: a current perspective.

Sirolimus, a macrocyclic lactone that displays a novel mechanism of immunosuppressive action, is a critical-dose drug requiring therapeutic drug monitoring for optimal outcomes. The compound was documented in two multicenter, blinded clinical trials to reduce the incidence of acute rejection episodes when used in combination with cyclosporine and steroids vs. azathioprine or placebo comparators. Furthermore, studies utilizing cyclosporine withdrawal documented a long-term benefit on renal function of chronic sirolimus therapy, albeit with a modestly enhanced incidence of acute rejection episodes. Although this application may be useful in selected cases, we believe that minimal initial cyclosporine exposures de novo mitigate the need for eventual withdrawal for chronic nephropathy, while preserving the immunosuppressive synergy during the maintenance phase. Recipients treated de novo with a sirolimus-cyclosporine combination tolerate steroid withdrawal at 1 month after living-donor or at 3 to 6 months after cadaveric kidney transplantation with only a 5% risk of acute rejection episodes and 6% incidence of chronic reactions within 3 years. However, sirolimus exacerbates the hypertriglyceridemic and hypercholesterolemic proclivities of transplant recipients, as well as exerts myelosuppressive effects, which are augmented by concomitant therapy with azathioprine or, particularly, with mycophenolate mofetil. Due to its apparent lack of nephrotoxicity, sirolimus has been employed for induction therapy in a calcineurin antagonist-free regimen in combination with either basiliximab or rabbit antilymphocyte sera for weak or strong immune responders, respectively, followed by introduction of a calcineurin antagonist upon resolution of the ischemia-reperfusion injury. Therefore, sirolimus proffers a potent and unique platform for new immunosuppressive strategies in organ transplantation.