Thursday, January 29, 2015

Evolution of allograft fibrosis and function in kidney transplant recipients: a retrospective analysis of stable patients under CNI and mTORi

Transplant International Evolution of allograft fibrosis and function in kidney transplant recipients: a retrospective analysis of stable patients under CNI and mTORi

Abstract

Histologic evaluations of renal allograft biopsies are essential for diagnosis, but still show a low predictive value for long-term allograft function. One limitation relies on the fact that the analysis is usually based on a single biopsy sample and, therefore, no dynamic changes are considered. Using two distinct approaches, we evaluated the evolution of fibrosis and related markers in thirty-six stable kidney transplant patients under calcineurin inhibitor therapy with two indication biopsies each, prior and at least 6 months after substitution by mTORi (N=18), or maintenance on CNI (N=18). In the method comparison, both Banff Chronicity Score and the digitally assessed fibrosis were correlated with allograft function at biopsy (r=−0.36 and r=−0.72, P=0.002 and P<0.0001, respectively). However, only the progression of fibrosis digitally assessed was correlated with allograft function loss, not only within the time between biopsies (r=−0.47, P=0.004) but also in the 60 month follow-up (r=−0.47, P=0.006). In the group analysis, despite of a higher incidence of C4d positivity (P=0.05), progression of fibrosis, TGFß1 expression and allograft function decline were significantly lower after conversion to mTORi compared to maintenance on CNI (P=0.05, P=0.02 and P=0.01, respectively). PDGF, VEGF, b-FGF and HIF1A expressions remained stable over time regardless of therapy.

This article is protected by copyright. All rights reserved.




http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2Ftri.12529

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Alberto Reino Buelvas

Sunday, January 25, 2015

Transfusion Transmitted Infections in Solid Organ Transplantation

AJT - Early Transfusion Transmitted Infections in Solid Organ Transplantation

While the risk of infectious disease transmission through blood transfusion has been greatly reduced as a result of improved screening methods, transfusion-transmissible infections remain a concern for transplant recipients, especially those receiving multiple transfusions. Although transfusion and transplant recipients are at risk for similar infections, the current reporting requirements for infections transmitted by transfusions and organ transplantation vary greatly and remain distinctly separate with no communication between reporting systems. This article reviews 23 past reports of transfusion-transmitted infections in organ recipients acquired through transfusions. While cytomegalovirus was a major focus of such reports in the 1980s, more recent reports have focused on West Nile virus transmission. Additionally, this article highlights challenges in determining transfusion-transmitted infection risk in transplant recipients related to the current reporting systems.




http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2Fajt.13006

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Alberto Reino Buelvas 
Médico Internista Nefrólogo


Wednesday, January 21, 2015

Drug adherence in chronic kidney diseases and dialysis

Nephrology Dialysis Transplantation - current issue Drug adherence in chronic kidney diseases and dialysis

Poor long-term adherence and persistence to drug therapy is universally recognized as one of the major clinical issues in the management of chronic diseases, and patients with renal diseases are also concerned by this important phenomenon. Chronic kidney disease (CKD) patients belong to the group of subjects with one of the highest burdens of daily pill intake with up to >20 pills per day depending on the severity of their disease. The purpose of the present review is to discuss the difficulties encountered by nephrologists in diagnosing and managing poor adherence and persistence in CKD patients including in patients receiving maintenance dialysis. Our review will also attempt to provide some clues and new perspectives on how drug adherence could actually be addressed and possibly improved. Working on drug adherence may look like a long and tedious path, but physicians and healthcare providers should always be aware that drug adherence is in general much lower than what they may think and that there are many ways to improve and support drug adherence and persistence so that renal patients obtain the full benefits of their treatments.




http://ndt.oxfordjournals.org/cgi/content/short/30/1/39?rss=1

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Alberto Reino Buelvas 
Médico Internista Nefrólogo


Monday, January 19, 2015

Short-term Effects of Tolvaptan in Individuals With Autosomal Dominant Polycystic Kidney Disease at Various Levels of Kidney Function

American Journal of Kidney Diseases Short-term Effects of Tolvaptan in Individuals With Autosomal Dominant Polycystic Kidney Disease at Various Levels of Kidney Function

A recent study showed that tolvaptan, a vasopressin V2 receptor antagonist, decreased total kidney volume (TKV) growth and estimated glomerular filtration rate (GFR) loss in autosomal dominant polycystic kidney disease (ADPKD) with creatinine clearance≥60mL/min. The aim of our study was to determine whether the renal hemodynamic effects and pharmacodynamic efficacy of tolvaptan in ADPKD are dependent on GFR.


http://www.ajkd.org/article/S0272-6386(14)01465-6/abstract?rss=yes

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Alberto Reino Buelvas 
Médico Internista Nefrólogo


Outcomes in Kidney Transplant Recipients From Older Living Donors.

Transplantation - Published Ahead-of-Print Outcomes in Kidney Transplant Recipients From Older Living Donors.

Background: Previous studies demonstrate that graft survival from older living kidney donors (LD; age >60 years) is worse than younger LD but similar to deceased standard criteria donors (SCD). Limited sample size has precluded more detailed analyses of transplants from older LD. Methods: Using the United Network for Organ Sharing database from 1994 to 2012, recipients were categorized by donor status: SCD, expanded criteria donor (ECD), or LD (by donor age: <60, 60-64, 65-69, >=70 years). Adjusted models, controlling for donor and recipient risk factors, evaluated graft and recipient survivals. Results: Of 250,827 kidney transplants during the study period, 92,646 were LD kidneys, with 4.5% of these recipients (n = 4,186) transplanted with older LD kidneys. The use of LD donors 60 years or older increased significantly from 3.6% in 1994 to 7.4% in 2011. Transplant recipients with older LD kidneys had significantly lower graft and overall survival compared to younger LD recipients. Compared to SCD recipients, graft survival was decreased in recipients with LD 70 years or older, but overall survival was similar. Older LD kidney recipients had better graft and overall survival than ECD recipients. Conclusions: As use of older kidney donors increases, overall survival among kidney transplant recipients from older living donors was similar to or better than SCD recipients, better than ECD recipients, but worse than younger LD recipients. With increasing kidney donation from older adults to alleviate profound organ shortages, the use of older kidney donors appears to be an equivalent or beneficial alternative to awaiting deceased donor kidneys. (C) 2015 by Lippincott Williams & Wilkins


http://pdfs.journals.lww.com/transplantjournal/9000/00000/Outcomes_in_Kidney_Transplant_Recipients_From.97928.pdf

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Alberto Reino Buelvas 
Médico Internista Nefrólogo


Surgical complications after kidney transplantation: Different impact of immunosuppression, graft function, patient variables and surgical performance

Clinical Transplantation Surgical complications after kidney transplantation: Different impact of immunosuppression, graft function, patient variables and surgical performance

Abstract

The population of kidney transplant (KTx) recipients often has complex medical and immunological conditions. Surgical complications (SC) contribute to the increasing morbidity and costs in these patients.

We analyzed the risk factors for SC in 405 KTx patients treated using defined immunosuppressive regimens according to their clinical and immunological risk profile: 1) standard immunosuppression (SIS) with IL-2 receptor mAb, CNI and a) mycophenolic acid (MPA) or b) mTOR inhibitor; and 2) more intense immunosuppression (IIS) with a) ATG or b) the additional use of plasma exchange and B- and T-cell- depleting agents.

In a mixed effects logistic regression model, we identified the following risk factors for SC: male gender, diabetes and postoperative dialysis. No difference was found between the patients who received SIS with MPA and those who received mTOR inhibitors. The risk of suffering complications with IIS increases with age. In addition to IIS, diabetes was a risk for wound healing disorders. Therapeutic anticoagulation and a third or subsequent retransplantation increased the rate of bleeding. We did not identify immunosuppression or patient demographics as risk factors for lymphoceles or ureter complications; however, we demonstrated that the surgeon had a significant impact on severe complications, especially those of the ureter.

This article is protected by copyright. All rights reserved.




http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2Fctr.12513

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Alberto Reino Buelvas 
Médico Internista Nefrólogo