Diabetic microangiopathy in Type 1 (insulin-dependent) diabetic patients after successful pancreatic and kidney or solitary kidney transplantation

To evaluate the beneficial effect of pancreatic grafting on peripheral microcirculation and long-term clinical outcome, we compared data of 28 Type 1 (insulin-dependent) diabetic patients either given a pancreatic and kidney graft simultaneously or given a solitary kidney graft (n=17). Peripheral microcirculation was estimated by transcutaneous oxygen pressure measurement (including reoxygenation potential after blood flow occlusion) and erythrocyte flow / velocity by a non-contact laser speckle method. All the measured parameters showed significant differences between diabetic and control subjects in the mean follow-up time of 49 (simultaneous pancreas and kidney transplantation) and 43 (solitary kidney transplantation) months. The data from patients after simultaneous pancreas and kidney transplantation revealed an improvement of transcutaneous oxygen pressure measurement (rise from 46±2 mm Hg to 63±3 mmHg), reoxygenation time (fall from 224±12s to 114±6s) and laser speckle measurement (rise from 4.2±1.7 to 5.6±1.8 relative units). The control group with solitary kidney transplantation did not show a positive evaluation. Data from patients after simultaneous pancreas and kidney transplantation revealed an improvement in transcutaneous oxygen pressure measurement, reoxygenation time and laser speckle measurement whereas the control group with solitary kidney transplantation did not show a positive evaluation. Improved microcirculation was more pronounced in patients with better microvascular preconditions. The results confirm that diabetic microangiopathy is positively influenced by pancreatic transplantation

Kidney transplantation. Modern trends in kidney transplantation.

Trends in renal transplantation stem from recognition of the virtues and drawbacks of this kind of treatment and from a better appreciation of the interrelationship between transplantation and dialysis

The association of preoperative cardiac stress testing with 30-day death and myocardial infarction among patients undergoing kidney transplantation

BACKGROUND:Although periodic cardiac stress testing is commonly used to screen patients on the waiting list for kidney transplantation for ischemic heart disease, there is little evidence to support this practice. We hypothesized that cardiac stress testing in the 18 months prior to kidney transplantation would not reduce postoperative death, total myocardial infarction (MI) or fatal MI. METHODS:Using the United States Renal Data System, we identified ESRD patients ≥40 years old with primary Medicare insurance who received their first kidney transplant between 7/1/2006 and 11/31/2013. Propensity matching created a 1:1 matched sample of patients with and without stress testing in the 18 months prior to kidney transplantation. The outcomes of interest were death, total (fatal and nonfatal) MI or fatal MI within 30 days of kidney transplantation. RESULTS:In the propensity-matched cohort of 17,304 patients, death within 30 days occurred in 72 of 8,652 (0.83%) patients who underwent stress testing and in 65 of 8,652 (0.75%) patients who did not (OR 1.07; 95% CI: 0.79-1.45; P = 0.66). MI within 30 days occurred in 339 (3.9%) patients who had a stress test and in 333 (3.8%) patients who did not (OR 1.03; 95% CI: 0.89-1.21; P = 0.68). Fatal MI occurred in 17 (0.20%) patients who underwent stress testing and 15 (0.17%) patients who did not (OR 0.97; 95% CI: 0.71-1.32; P = 0.84). CONCLUSION:Stress testing in the 18 months prior to kidney transplantation is not associated with a reduction in death, total MI or fatal MI within 30 days of kidney transplantation

Calciphylaxis following kidney transplantation: a case report

Introduction: Calciphylaxis occurring after kidney transplantation is rare and rarely reported. It results in chronic non-healing wounds and is associated with a poor prognosis and is often fatal. We present a case of proximal lower limb calciphylaxis that occurred early after kidney transplantation. The patient had no classic associated risk factors. He had previously had a total parathyroidectomy but had normal serum calcium-phosphate product and parathyroid hormone levels. The clinical outcome of this case was favorable and highlights some fundamental issues relating to management. Case prsentation: A 70-year-old British Caucasian man with end-stage renal failure secondary to IgA nephropathy presented six months post kidney transplantation with cutaneous calciphylaxis lesions involving the medial aspect of the thigh bilaterally. Conclusion: To the best of our knowledge, this is the first reported case of rapid onset cutaneous calciphylaxis occurring soon after kidney transplantation that was associated with a favorable outcome. Cutaneous calciphylaxis lesions should be promptly managed with meticulous wound care, antimicrobial therapy and the correction of calcium-phosphate product where indicated

C-reactive Protein Positively Correlates With Metabolic Syndrome in Kidney Transplantation Patients

ObjectiveC-reactive protein (CRP) is an independent risk factor for renal allograft loss and predicts all-cause mortality in kidney transplantation patients. Metabolic syndrome has also been associated with increased mortality in kidney transplantation patients. The aim of this study was to investigate the relationship between CRP and metabolic syndrome in kidney transplantation patients.Materials and MethodsFasting blood samples were obtained from 55 kidney transplantation patients. Metabolic syndrome and its components were defined using diagnostic criteria from the International Diabetes Federation.ResultsIn total, 13 kidney transplantation patients (23.6%) had metabolic syndrome. Fasting CRP levels positively correlated with metabolic syndrome (p = 0.001). Univariate linear regression analysis indicated that fasting serum CRP values were positively correlated with body weight (p = 0.001), waist circumference (p = 0.008), body mass index (p < 0.001), and body fat mass (p = 0.042). Multivariate forward stepwise linear regression analysis of the significant variables showed that body mass index (β = 0.455, R2 = 0.207, p < 0.001) was an independent predictor of serum CRP levels in kidney transplantation patients.ConclusionCRP level positively correlated with metabolic syndrome in kidney transplantation patients. Body mass index was an independent predictor of serum CRP levels in kidney transplantation patients

Who waits longest for a kidney? : Inequalities in access to kidney transplantation among Black and Asian Minority Ethnic (BAME) groups in the UK

This version deposited with the permission of the publisher 6/15Black and Asian Minority Ethnic (BAME) groups are over-represented on active kidney transplantation waiting lists and have relatively long waiting times. This inequality arises from a particularly high need for kidney transplantation combined with a low rate of deceased donation among BAME groups which limits the availability of a well-matched graft. This paper outlines the major barriers to both registration as a potential donor and family consent to donation. It then describes initiatives to increase donation and transplantation in terms of system changes, organisational changes and community interventions, and considers requirements for effective strategies.Peer reviewedFinal Published versio

Kidney after nonrenal transplantation-the impact of alemtuzumab induction

BACKGROUND.: Calcineurin inhibitor nephrotoxicity in nonrenal allograft recipients can lead to end-stage renal disease and the need for kidney transplantation. We sought to evaluate the role of alemtuzumab induction in this population. PATIENTS AND METHODS.: We evaluated 144 patients undergoing kidney transplantation after nonrenal transplantation between May 18, 1998, and October 8, 2007. Seventy-two patients transplanted between January 15, 2003, and October 8, 2007, received alemtuzumab induction and continued their pretransplant immunosuppression. Seventy-two patients transplanted between May 18, 1998, and July 21, 2007, did not receive alemtuzumab induction, but received additional steroids and maintenance immunosuppression. Donor and recipient demographics were comparable. RESULTS.: Overall, 1-and 3-year patient survival and renal function were comparable between the two groups. One-and 3-year graft survival was 93.0% and 75.3% in the alemtuzumab group and 83.3% and 68.7% in the no alemtuzumab group, respectively (P=0.051). The incidence of acute rejection was lower in the alemtuzumab group, 15.3%, than in the no alemtuzumab group, 41.7% (P=0.0001). The incidence of delayed graft function was lower in the alemtuzumab group, 9.7%, than in the no alemtuzumab group, 25.0% (P=0.003). The incidence of viral complications was comparable. CONCLUSION.: Alemtuzumab induction with simple resumption of baseline immunosuppression in patients undergoing kidney transplantation after nonrenal transplantation represents a reasonable immunosuppressive strategy. Copyright © 2009 by Lippincott Williams & Wilkins

Reduced functional measure of cardiovascular reserve predicts admission to critical care unit following kidney transplantation

Background: There is currently no effective preoperative assessment for patients undergoing kidney transplantation that is able to identify those at high perioperative risk requiring admission to critical care unit (CCU). We sought to determine if functional measures of cardiovascular reserve, in particular the anaerobic threshold (VO2AT) could identify these patients. Methods: Adult patients were assessed within 4 weeks prior to kidney transplantation in a University hospital with a 37-bed CCU, between April 2010 and June 2012. Cardiopulmonary exercise testing (CPET), echocardiography and arterial applanation tonometry were performed. Results: There were 70 participants (age 41.7614.5 years, 60% male, 91.4% living donor kidney recipients, 23.4% were desensitized). 14 patients (20%) required escalation of care from the ward to CCU following transplantation. Reduced anaerobic threshold (VO2AT) was the most significant predictor, independently (OR = 0.43; 95% CI 0.27–0.68; p,0.001) and in the multivariate logistic regression analysis (adjusted OR = 0.26; 95% CI 0.12–0.59; p = 0.001). The area under the receiveroperating- characteristic curve was 0.93, based on a risk prediction model that incorporated VO2AT, body mass index and desensitization status. Neither echocardiographic nor measures of aortic compliance were significantly associated with CCU admission. Conclusions: To our knowledge, this is the first prospective observational study to demonstrate the usefulness of CPET as a preoperative risk stratification tool for patients undergoing kidney transplantation. The study suggests that VO2AT has the potential to predict perioperative morbidity in kidney transplant recipients

A Clinical Prediction Score to Guide Referral of Elderly Dialysis Patients for Kidney Transplant Evaluation.

IntroductionDialysis patients aged ≥70 years derive improved life expectancy through kidney transplantation compared to their waitlisted counterparts, but guidelines are not clear about how to identify appropriate transplantation candidates. We developed a clinical prediction score to identify elderly dialysis patients with expected 5-year survival appropriate for kidney transplantation (&gt;5 years).MethodsIncident dialysis patients in 2006-2009 aged ≥70 were identified from the United States Renal Data System database and divided into derivation and validation cohorts. Using the derivation cohort, candidate variables with a significant crude association with 5-year all-cause mortality were included in a multivariable logistic regression model to generate a scoring system. The scoring system was tested in the validation cohort and a cohort of elderly transplant recipients.ResultsCharacteristics most predictive of 5-year mortality included age &gt;80, body mass index (BMI) &lt;18, the presence of congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), immobility, and being institutionalized. Factors associated with increased 5-year survival were non-white race, a primary cause of end stage renal disease (ESRD) other than diabetes, employment within 6 months of dialysis initiation, and dialysis start via arteriovenous fistula (AVF). 5-year mortality was 47% for the lowest risk score group (3.6% of the validation cohort) and &gt;90% for the highest risk cohort (42% of the validation cohort).ConclusionThis clinical prediction score could be useful for physicians to identify potentially suitable candidates for kidney transplantation

Body mass index before kidney transplantation — principal risk factor for NODAT

Purpose. Pretransplant obesity is a well-known risk factor for post-transplant outcomes such as patient and graft survival, delayed graft function, rejection, and wound complications. According to the recommendations of the European Renal Best Practice, patients who have body mass index (BMI) value of more than 30 kg/m2 before kidney transplantation should reduce their weight. Materials and methods. In the group of 297 patients who had undergone primary kidney transplantation from post-mortem donors, we found that assessed the impact of BMI on the development of new onset diabetes after transplantation (NODAT). Additionally, relationships between immunosuppression, weight gain and BMI in patients after kidney transplantation were also analysed. We measured the value of the patients’ BMI and weight before kidney transplantation, 12 months after kidney transplantation, and 5 years after kidney transplantation. The group contained only those patients who, at the time of the kidney transplantation, did not suffer from diabetes mellitus. According to the development of NODAT in the monitored period, the group of patients was divided into the control group and NODAT group. We detected analysed the data on the type of immunosuppression (tacrolimus, cyclosporine A, mTOR inhibitor) and the average levels in the monitored period and identified whether BMI or increased weight 12 months and 5 years after kidney transplantation is related to the level (or dose) of the used immunosuppression. Results. In our group, the patients who developed NODAT in the post-transplant period were significantly older in the 12-month analysis (p &lt; 0.0001) and also in the 5-year analysis (p = 0.0001); had higher BMI at the time of transplantation (p = 0.0003) and higher BMI 12 months after kidney transplantation (p = 0.0004) and a significantly higher weight gain 12 months after kidney transplantation (p = 0.0469). We discovered that neither the level of immunosuppression nor the dose of prednisone had any effect on the increase in BMI or weight gain during the monitored period. Conclusion. The patients in the waiting list, who have any risk factors for the development of diabetes mellitus, should be informed how to eliminate these risk factors (weight control, diet, physical exercises, etc.). In addition to the above, all candidates for kidney transplantation are recommended to stop smoking, to control blood pressure, and perform a lipidogram