Planned Randomized Conversion From Tacrolimus to Sirolimus-Based Immunosuppressive Regimen in De Novo Kidney Transplant Recipients

AJT - Early Planned Randomized Conversion From Tacrolimus to Sirolimus-Based Immunosuppressive Regimen in De Novo Kidney Transplant Recipients

Abstract

Planned conversion from tacrolimus to sirolimus was evaluated in de novo kidney transplant recipients. In this multicenter, randomized, open-label study, 297 patients were initially treated with tacrolimus, mycophenolate sodium and prednisone. Of the 283 patients reaching 3 months, 97 were converted to sirolimus (SRL), 107 were maintained on tacrolimus (TAC) and 79 were patients receiving TAC without criteria to undergo intervention at month 3 (TACex). The primary objective was to show superior estimated glomerular filtration rate (eGFR) in the SRL group at month 24. Of the 258 patients who completed 24 months, 91 (94%) were in the SRL group, 101 (94%) in the TAC group and 66 (84%) in the TACex group. In the intention-to-treat population there were no differences in eGFR (66.2 ± 25.3 vs. 70.7 ± 25.1, p = 0.817) or in the severity of chronic sclerosing lesions scores in 24-month protocol biopsies. Higher mean urinary protein-to-creatinine ratio (0.36 ± 0.69 vs. 0.15 ± 0.53, p = 0.03) and higher incidence of treated acute rejection between months 3–24 (13.4% vs. 4.7%, p = 0.047) were observed in SRL compared to TAC group. In this population planned conversion from TAC to SRL 3 months after kidney transplantation was not associated with improved renal function at 24 months.

http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2Fajt.12481

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Alberto Reino Buelvas

Médico Internista Nefrólogo

Hospital San Vicente de Paul

Grupo Trasplantes Renales

Director Médico Unidad Renal

Quiz Page November 2013: An Unusual Cause of Nephrotic Syndrome

American Journal of Kidney Diseases Quiz Page November 2013: An Unusual Cause of Nephrotic Syndrome

A 56-year-old man presented after 6 months of generalized body swelling and frothy urine. He reported no history of hypertension, diabetes, or other medical conditions. He was treated with diuretics intermittently but never received steroids or other treatments for this illness. However, he reported that when he was 10 years old, he had experienced a swelling of his right leg associated with low-grade fever, which subsequently was treated by a practitioner of traditional ayurvedic Indian medicine. On examination, the patient's blood pressure was 100/70 mm Hg and he had small pleural effusions, ascites, and anasarca. Urinalysis showed proteinuria (4+), quantitated at protein excretion of 4.6 g in a 24-hour collection, and microscopy showed bland urine sediment. Laboratory values included the following: serum urea, 33 mg/dL; serum creatinine, 1.12 mg/dL; estimated glomerular filtration rate, 73 mL/min/1.73 m2 (calculated using the CKD-EPI [Chronic Kidney Disease Epidemiology Collaboration] equation); cholesterol, 438 mg/dL; albumin, 1.8 g/dL; and hemoglobin, 8 g/dL. Serology test results were negative for hepatitis B surface antigen, anti-hepatitis C virus, HIV (human immunodeficiency virus), antinuclear antibodies, and anti-streptolysin O titers, and results were normal for serum and urine electrophoresis. Results of ultrasonography of the abdomen also were normal. A kidney biopsy was performed ().


http://www.ajkd.org/article/S0272-6386(13)01105-0/abstract?rss=yes

Immunosuppression Regimen and the Risk of Acute Rejection in HIV-Infected Kidney Transplant Recipients

Transplantation - Published Ahead-of-Print Immunosuppression Regimen and the Risk of Acute Rejection in HIV-Infected Kidney Transplant Recipients

Background: Kidney transplantation (KT) is the treatment for end-stage renal disease in appropriate HIV-positive individuals. However, acute rejection (AR) rates are over twice those of HIV-negative recipients. Methods: To better understand optimal immunosuppression for HIV-positive KT recipients, we studied associations between immunosuppression regimen, AR at 1 year, and survival in 516 HIV-positive and 93,027 HIV-negative adult kidney-only recipients using Scientific Registry of Transplant Recipients data from 2003 to 2011. Results: Consistent with previous reports, HIV-positive patients had twofold higher risk of AR (adjusted relative risk [aRR], 1.77; 95% confidence interval [CI], 1.45-2.2; P<0.001) than their HIV-negative counterparts as well as a higher risk of graft loss (adjusted hazard ratio, 1.51; 95% CI, 1.18-1.94; P=0.001), but these differences were not seen among patients receiving antithymocyte globulin (ATG) induction (aRR for AR, 1.16; 95% CI, 0.41-3.35, P=0.77; adjusted hazard ratio for graft loss, 1.54; 95% CI, 0.73-3.25; P=0.26). Furthermore, HIV-positive patients receiving ATG induction had a 2.6-fold lower risk of AR (aRR, 0.39; 95% CI, 0.18-0.87; P=0.02) than those receiving no antibody induction. Conversely, HIV-positive patients receiving sirolimus-based therapy had a 2.2-fold higher risk of AR (aRR, 2.15; 95% CI, 1.20-3.86; P=0.01) than those receiving calcineurin inhibitor-based regimens. Conclusion: These findings support a role for ATG induction, and caution against the use of sirolimus-based maintenance therapy, in HIV-positive individuals undergoing KT. (C) 2013 by Lippincott Williams & Wilkins


http://pdfs.journals.lww.com/transplantjournal/9000/00000/Immunosuppression_Regimen_and_the_Risk_of_Acute.98396.pdf

The diagnostic value of contrast-enhanced ultrasonography in the assessment of perirenal hematomas in the early post-operative period after kidney transplantation

Clinical Transplantation The diagnostic value of contrast-enhanced ultrasonography in the assessment of perirenal hematomas in the early post-operative period after kidney transplantation

Abstract

Background

Routine B-mode ultrasound examination (rB-US) is a current standard for the assessment of the transplanted kidney(KTx) in the early post-operative period. The alteration of perirenal hematoma (PH) echostructure over time limits their detectability and size assessment with rB-US. The aim of this study was to evaluate the diagnostic value of contrast-enhanced ultrasound (CE-US) in diagnosing PH of KTx in the early post-operative period.

Method

Routine B-US and CE-US of KTx, performed in 102 patients in the early post-operative period, were analyzed. CE-US was performed after intravenous administration of 2.4 mL of sulfur hexafluoride solution. The data were analyzed with respect to the occurrence and thickness of PH.

Result

The difference in echogenicity between PH and kidney parenchyma was modest in rB-US (mean of 5.7 dB). However, in CE-US, the difference in echogenicity was significantly increased (mean of 31.4 dB). Routine B-US did not allow PH to be recognized in 18 patients. The application of CE-US results in a twofold increase in PH detection when compared with rB-US (33.3% vs. 15.7%).

Conclusion

US-CE examination is a valuable method for detection and assessment of PH size. Compared with rB-US, this technique may substantially increase the detectability of hemorrhagic complications in the direct post-operative period.

http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2Fctr.12257

Results of Implementation of Preventive Recommendations for Tuberculosis After Renal Transplantation in an Endemic Area

AJT - Early Results of Implementation of Preventive Recommendations for Tuberculosis After Renal Transplantation in an Endemic Area

This retrospective cohort study assessed the results of the implementation of preventive recommendations for tuberculosis (TB) among renal transplant recipients in an endemic area (Rio de Janeiro, Brazil). Subjects were defined as at high risk for TB if they had latent tuberculosis infection (LTBI), reported recent close contact with individuals with TB or received a graft from a donor with LTBI. A 6-month course of isoniazid preventive therapy (IPT) was targeted to high-risk subjects. The study end point was TB confirmed by culture. Altogether, 535 patients were included. Median follow-up was 59 months. The overall cumulative incidence of TB was 2.1% while among the 274 patients in whom the preventive protocol was fully implemented, the incidence was only 0.7%. The incidence of TB among 75 high-risk recipients not treated with isoniazid (7%) was significantly higher than that observed in 209 untreated low-risk patients (1%, p = 0.006) and in 65 high-risk subjects that received IPT (no case, p = 0.03). In conclusion, the implementation of preventive recommendations for TB in an endemic area allowed the appropriate discrimination between high- and low-risk renal transplant recipients and was associated with long-term reduction in the incidence of this complication among high-risk subjects.

http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2Fajt.12470