Renal Transplant in Obese Patients and Impact of Weight Loss Before Surgery on Surgical and Medical Outcomes: A Single-Center Cohort Study

OBJECTIVES: Previous studies have linked obesity to poor outcomes in renal transplant recipients, prompting many transplant centers to encourage weight loss pretransplant in obese patients. Here, we performed a single-center retrospective study to assess the effects of weight loss on graft and patient outcomes. MATERIALS AND METHODS: Data from 893 renal transplant recipients at our center from 2007 to 2011 were analyzed. First, renal transplant recipients with a history of obesity before transplant (42%) were compared with nonobese patients. Second, in the obese group, renal transplant recipients with significant weight loss (> 10%) before transplant were compared with other obese renal transplant recipients without significant weight loss. RESULTS: Renal transplant recipients were predominantly white, with 74% having undergone living-donor transplant. Obese patients were older (56.6 vs 46.7 y old) and had more comorbidities and more surgical complications, in particular wound complications and incisional hernias, posttransplant than nonobese patients (14.7 vs 5.5%, respectively). Patient and graft survival rates were similar to those in nonobese patients. In the obese group, patient characteristics and medical or surgical complications after transplant did not differ between those with or without significant weight loss. However, obese patient and graft survival rates were lower in patients with weight loss than in obese patients without weight loss. CONCLUSIONS: In our study, weight loss before transplant surgery in obese patients had no influence on surgical outcomes but was associated with a higher mortality rate. A prospective assessment of the impact of weight loss before surgery is needed to establish its usefulness

Cobalamin c deficiency associated with antifactor h antibody-associated hemolytic uremic syndrome in a young adult

International audienceAbstract Background Thrombotic microangiopathy (TMA) syndromes are characterized by the association of hemolytic anemia, thrombocytopenia and organ injury due to arteriolar and capillary thrombosis. Case presentation We report the first case of adult onset cobalamin C (Cbl C) disease associated with anti-factor H antibody-associated hemolytic uremic syndrome (HUS). A 19-year-old woman was admitted to the nephrology department owing to acute kidney failure, proteinuria, and hemolytic anemia with schizocytes. TMA was diagnosed and plasma exchanges were started in emergency. Exhaustive analyses showed 1) circulating anti factor H antibody and 2) hyperhomocysteinemia, hypomethioninemia and high levels of methylmalonic aciduria pointing towards Clb C disease. Cbl C disease has been confirmed by methylmalonic aciduria and homocystinuria type C protein gene sequencing revealing two heterozygous pathogenic variants. The kidney biopsy showed 1) intraglomerular and intravascular thrombi 2) noticeable thickening of the capillary wall with a duplication aspect of the glomerular basement membrane and a glomerular capillary wall IgM associated with Cbl C disease related TMA. We initiated treatment including hydroxycobalamin, folinic acid, betaine and levocarnitine and Eculizumab. Rituximab infusions were performed allowing a high decrease in anti-factor H antibody rate. Six month after the disease onset, Eculizumab was weaning and vitaminotherapy continued. Outcome was favorable with a dramatic improvement in kidney function. Conclusion TMA with renal involvement can have a complex combination of risk factors including anti-FH autoantibody in the presence of cblC deficiency

Evaluation of the efficacy of an interdialytic "ethanol 40% v/v - enoxaparin 1000 U/mL" lock solution to prevent tunnelled catheter infections in chronic hemodialysis patients: a multi-centre, randomized, single blind, parallel group study

BACKGROUND: Tunnelled dialysis catheter (TC) infections are a major health complication and are associated with increased antibiotic consumption, hospital stays, health costs and mortality. Experimental data provide evidence that Ethenox, a mixture of enoxaparine 1000 U/mL in 40% v/v ethanol, could be a promising lock solution. The aim of the study is to compare an interdialytic lock solution of Ethenox with reference lock solutions, unfractionated heparin (UFH) or citrate 4% for the prevention of TCI in hemodialysis patients. METHOD: This study will monitor a multicentre, prospective, single blind, randomized, controlled, parallel group trial. The main inclusion criteria are patients \textgreater 18 years old with end-stage renal disease, treated with chronic hemodialysis/hemodiafiltration three times a week, with incident or prevalent non-impregnated internal jugular TCs inserted for at least 2 weeks and able to give informed consent. Exclusion criteria are TCI in the previous 4 weeks and anti-infective treatment for TCI in the previous 2 weeks. Patients will be randomized to receive either study treatment Ethenox in the intervention group or reference solutions in the control group, unfractionated heparin (UFH) or citrate 4% w/v according to usual practice. The primary outcome measure will be time to first TCIs assessed by an endpoint adjudication committee blinded to the study arm according to predefined criteria. Patients will receive the study treatment for up to 12 months. Intention-to-treat analysis of the primary endpoint will be performed with a marginal Cox proportional hazard model. Prospective power calculations indicate that the study will have 90% statistical power to detect a clinical significant two-fold increase in median infection-free survival if 200 patients are recruited into each arm over a period of 24 months. DISCUSSION: Firm evidence of the efficacy of the Ethenox lock in preventing TCI could be of major clinical benefit for patients. The results of this study will allow the development of new guidelines based on a high level of evidence. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03083184 , date of registration March 17 2017 and European Clinical Trials Database Identifier: EudraCT 2016-A00180-51), date of registration July 11 2016