Nocardiosis in a Kidney-Pancreas Transplant

34-year-old man with chronic renal and pancreas failure in complicated diabetic disease received a kidney-pancreas transplantation. On the 32nd postoperative day, an acute kidney rejection occurred and resolved with OKT3 therapy. The patient also presented refractory urinary infection by E. Fecalis and M. Morganii, and a focal bronchopneumonia in the right-basal lobe resolved with elective chemotherapy. During the 50th post-operative day, an intense soft tissue inflammation localized in the first left metatarsal-phalangeal articulation occurred (Figure 1) followed by an abscess with a cutaneous fistula and extension to the almost totality of foot area. The radiological exam revealed a small osteo-lacunar image localized in the proximal phalanx head of the first finger foot. From the cultural examination of the purulent material, N. Asteroides was identified. An amoxicillin-based treatment was started and continued for three months, with the complete resolution of infection This case is reported for its rarity in our casuistry, and for its difficult differential diagnosis with other potentially serious infections

Analisi delle serie storiche applicata all\u2019attivit\ue0 di trapianto di rene di un singolo centro.

Introduzione - La numerosit\ue0 dei trapianti di rene eseguiti da un singolo Centro \ue8 dipendente da una molteplicit\ue0 di fattori (organi offerti/accettati, composizione/dinamica della lista, matching donatore/ricevente). Nonostante la Conferenza Stato-Regioni del Febbraio 2002 abbia individuato nel valore di 30 trapianti/anno la soglia di sicurezza per un Centro autorizzato, ad oggi non risultano valutazioni sull'attivit\ue0 di trapianto di rene nelle quali sia stata estensivamente utilizzata la metodologia di analisi delle serie storiche (time series analysis, TSA). Pazienti e Metodi - Nel periodo 01/01/1983 - 31/12/2008, presso il Dipartimento Trapianti (DIT) di Genova sono stati effettuati 1428 trapianti di rene. Di questi, 52 sono stati eseguiti nell\u2019anno 2008. Il numero di trapianti/mese nel periodo 1983-2007 \ue8 stato registrato in un singolo file ".txt", codificando l'assenza di trapianti con il valore "0". L'analisi \ue8 stata effettuata mediante il software/ambiente statistico R (versione 2.8.1). Risultati - La TSA ha evidenziato un picco/anno nel numero di trapianti riferito al 1998 (n = 86). In altri cinque anni \ue8 stato registrato un numero di procedure/anno =>70. L'andamento mensile cumulativo ha rivelato come il maggior numero di trapianti sia stato effettuato nei mesi di Marzo (n = 133), Dicembre (n = 124) e Settembre (n = 123). Nel Marzo 1998 e 1999 \ue8 stato registrato il maggior numero/mese di procedure (n = 13). La TSA \ue8 stata effettuata per trend stimato con media mobile e \u201cdetrendizzazione\u201d, nonch\ue9 mediante livellamento esponenziale e decomposizione. Il numero di trapianti previsto per l\u2019anno 2008 (n = 58) in base alla TSA ha registrato un modesto scostamento rispetto al numero di procedure effettivamente eseguite (n = 52). Conclusioni - La TSA pu\uf2 rivelarsi di ausilio nella individuazione della soglia annua di trapianti di rene per singolo centro

A time series analysis performed on a 25-year period of kidney transplantation activity in a single center.

Following the example of many Western countries, where a "minimum volume rule" policy has been adopted as a quality parameter for complex surgical procedures, the Italian National Transplant Centre set the minimum number of kidney transplantation procedures/y at 30/center. The number of procedures performed in a single center over a large period may be treated as a time series to evaluate trends, seasonal cycles, and nonsystematic fluctuations. Between January 1, 1983, and December 31, 2007, we performed 1376 procedures in adult or pediatric recipients from living or cadaveric donors. The greatest numbers of cases/y were performed in 1998 (n = 86) followed by 2004 (n = 82), 1996 (n = 75), and 2003 (n = 73). A time series analysis performed using R Statistical Software (Foundation for Statistical Computing, Vienna, Austria), a free software environment for statistical computing and graphics, showed a whole incremental trend after exponential smoothing as well as after seasonal decomposition. However, starting from 2005, we observed a decreased trend in the series. The number of kidney transplants expected to be performed for 2008 by using the Holt-Winters exponential smoothing applied to the period 1983 to 2007 suggested 58 procedures, while in that year there were 52. The time series approach may be helpful to establish a minimum volume/y at a single-center level

Esplorazione e validazione di modelli di regressione di Cox nell'ambiente statistico R orientati all\u2019individuazione di potenziali predittori indipendenti di esito nel trapianto di doppio rene su casistica di singolo centro.

Introduzione - La regressione di Cox di rischio proporzionale (RCRP) ipotizza che i coefficienti del modello non dipendano dal tempo t. Tale ipotesi dovrebbe essere sistematicamente verificata prima di dichiarare la validit\ue0 di un modello. Nel presente studio si \ue8 proceduto alla esplorazione/validazione di modelli di RCRP orientati all\u2019individuazione di potenziali predittori indipendenti di esito nel trapianto di doppio rene (DKT). Pazienti e Metodi - In base al grado di completezza dei record dei donatori, sono stati arruolati nello studio 59 pazienti sottoposti a DKT presso il Centro Trapianti di Genova nel periodo 21/04/1999 \u2013 21/09/2008. Le sopravvivenze di riceventi (RS) e graft (GS) sono state assunte come variabili di esito per i modelli di RCRP. Questi ultimi sono stati testati in modalit\ue0 univariata, introducendo nelle successive esplorazioni multivariate le sole variabili con P <0.05. I modelli di RCRP sono stati analizzati/validati mediante ANOVA, calcolo dei residui (CR) ed il test di rischio proporzionale (TRP) utilizzando l\u2019ambiente statistico R (versioni 2.8.1/2.9.0). Risultati - Le RS e GS generali sono risultate nell\u2019ordine del 93.22% e dell\u201986.44%, rispettivamente. I modelli univariati per RS sono risultati significativi per la creatinina (Cr) dei donatori (P = 0.0077), la clearance della Cr dei donatori (P = 0.023) e l\u2019et\ue0 dei riceventi (P = 0.047). I modelli univariati di RCRP per GS hanno riscontrato una significativit\ue0 per la Cr dei donatori (P = 0.027) e la Cr dei riceventi misurata al 3\ub0 mese (P = 0.043) ed al 6\ub0 mese post-trapianto (Cr_6month_PTx) (P = 0.017). Nel successivo modello multivariato per RS non \ue8 stata ottenuta alcuna significativit\ue0, mentre nel modello multivariato per GS la Cr_6month_PTx \ue8 risultata ancora significativa (P = 0.034; exp = 7.24). I test di validazione hanno evidenziato come il modello ristretto alla sola variabile Cr_6month_PTx possa descrivere efficacemente la GS. Un ulteriore modello per GS stratificato sulla media della Cr_6month_PTx (1.5 mg/dl) ha confermato la significativit\ue0 di tale variabile (P = 0.040; exp = 5.65). Conclusioni - L\u2019esplorazione/validazione di modelli di RCRP ha individuato nella Cr_6month_PTx un potenziale predittore indipendente per GS in una popolazione di pazienti sottoposti a DKT

Late ureteral stenosis after kidney transplantation: a single-center experience.

In a retrospective study, we analyzed 1419 consecutive kidney transplantation procedures performed at a single center to identify potential predictive factors of ureteral stenosis. Only stenosis observed after the first month posttransplantation was considered. The Cox proportional hazard regression model was used to analyze donor age and serum creatinine concentration before procurement, recipient age, cold ischemia time, delayed graft function, number of renal arteries, and presence of a double-J stent. Follow-up evaluation included number and timing of acute rejection episodes, cytomegalovirus infection, acute pyelonephritis, renal function, and patient death. Ureteral stenosis developed in 45 patients (3.17%), and was correlated with donor age older than 65 years (P = .001), kidneys with more than 2 arteries (P = .009), and delayed graft function (P = .02). The data suggest a potential protective role of donor age, number of renal arteries, and delayed graft function in development of ureteral stenosis after kidney transplantation

Corynebacterium urealyticum infection in a pediatric kidney transplant recipient: case report.

The incidence of Corynebacterium urealyticum infection in kidney recipients is low. Its common clinical manifestation is encrusted cystitis or encrusted pyelitis. Herein, we report an unusual case of a 19-year-old kidney recipient with necrotizing pyelitis due to C urealyticum in the absence of mucosal encrustation or calculi. The patient was readmitted 30 days posttransplantation to remove a stent. Cystoscopy demonstrated a normal vesical wall without encrustation. The stent was removed without problems. Culture yielded negative findings. That night, the patient had fever and hematuria. Therapy included forced diuresis with high fluid intake, and diuretic and antibiotic administration. The patient was then discharged. However, 15 days later he was readmitted because of hematuria with a significant decrease in hemoglobin concentration. Echography demonstrated the presence of hyperechogenic material in the pelvis and ureter. Pyelography demonstrated the presence of numerous coagula obstructing the urinary tract. In addition, severe hematuria required transplant nephrectomy

Single-center experience in double kidney transplantation.

Use of organs from marginal donors for transplantation is a current strategy to expand the organ donor pool. Its efficacy is universally accepted among data from multicenter studies. Herein, we have reviewed outcomes of double kidney transplantation (DKT) over an 9-year experience in our center. The aim of this study was to evaluate possible important differences between a monocenter versus multicenter studies. Between 1999 and 2008, we performed 59 DKT. Recipient mean age was 63 +/- 5 years. Mean HLA-A, -B, and -DR mismatches were 3.69 +/- 0.922. Donor mean age was 69 +/- 7 years and mean creatinine clearance was 69.8 +/- 30.8 mL/min. Proteinuria was detected in three donors (5%). Mean cold ischemia and warm ischemia times were 1130 +/- 216 and 48 +/- 11 minutes, respectively. The right and left kidney scores were 4.18 +/- 2 and 4.21 +/- 2, respectively. Thirty patients (51%) displayed good postoperative renal function; 22 (37%), acute tubular necrosis with postoperative dialysis; 3 (5%), acute rejection episodes; 4 (7%), single-graft transplantectomy due to vascular thrombosis; 1 (2%), a retransplantation; 5 (8%), a lymphocele; 3 (5%) vescicoureteral reflux or stenosis requiring surgical correction. Cytomegalovirus infection was detected in five patients (8%). In three patients (5%) displayed de novo neoplasia. Three patients showed chronic rejection (5%), whereas we observed a cyclosporine-related toxicity in 7 (12%). Nine patients (15%) developed iatrogenic diabetes. Patient and graft survivals after 3 years from DKT were 93% and 86.3%, respectively. In this study, we applied successfully a widespread score to allocate organs to single kidney transplantation or DKT. In our experience, the score is suitable for the organ allocation but it may be overprotective, excluding potentially suitable organs for a single transplantatio

Application and validation of Cox regression models in a single-center series of double kidney transplantation.

A useful approach to reduce the number of discarded marginal kidneys and to increase the nephron mass is double kidney transplantation (DKT). In this study, we retrospectively evaluated the potential predictors for patient and graft survival in a single-center series of 59 DKT procedures performed between April 21, 1999, and September 21, 2008. The kidney recipients of mean age 63.27 +/- 5.17 years included 16 women (27%) and 43 men (73%). The donors of mean age 69.54 +/- 7.48 years included 32 women (54%) and 27 men (46%). The mean posttransplant dialysis time was 2.37 +/- 3.61 days. The mean hospitalization was 20.12 +/- 13.65 days. Average serum creatinine (SCr) at discharge was 1.5 +/- 0.59 mg/dL. In view of the limited numbers of recipient deaths (n = 4) and graft losses (n = 8) that occurred in our series, the proportional hazards assumption for each Cox regression model with P < .05 was tested by using correlation coefficients between transformed survival times and scaled Schoenfeld residuals, and checked with smoothed plots of Schoenfeld residuals. For patient survival, the variables that reached statistical significance were donor SCr (P = .007), donor creatinine cleararance (P = .023), and recipient age (P = .047). Each significant model passed the Schoenfeld test. By entering these variables into a multivariate Cox model for patient survival, no further significance was observed. In the univariate Cox models performed for graft survival, statistical significance was noted for donor SCr (P = .027), SCr 3 months post-DKT (P = .043), and SCr 6 months post-DKT (P = .017). All significant univariate models for graft survival passed the Schoenfeld test. A final multivariate model retained SCr at 6 months (beta = 1.746, P = .042) and donor SCr (beta = .767, P = .090). In our analysis, SCr at 6 months seemed to emerge from both univariate and multivariate Cox models as a potential predictor of graft survival among DKT. Multicenter studies with larger recipient populations and more graft losses should be performed to confirm our findings