American Journal of Kidney Diseases / 2016-11-17 23:55
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Transplantation - Most Popular Articles / 2016-11-20 11:07
Background: Elderly patients are the fastest-growing group in need of renal transplantation. This study puts focus on renal transplant recipients in their 80th year or longer at time of engraftment. Is there evidence to support an absolute upper age limit for renal transplantation? Methods: Recipients in their 80th year or longer, transplanted between 1983 and 2015, were included. Data were retrieved from the Norwegian Renal Registry in the end of October 2015. Graft and patient survivals were compared with recipients aged 70 to 79 years at transplantation. Results: Forty-seven patients older than 79 years were transplanted in the defined period. Median age 80.1 years, 81% were men. Median time on dialysis before transplantation was 18.5 months. All patients received an allograft from a deceased donor (median donor age, 61.8 years). In the death-censored graft survival model, there was no statistical difference between the groups. We found improved patient and graft survivals after introduction of mycophenolate mofetil and induction with basiliximab. Patients transplanted before 2000 had increased risk of death compared with those transplanted after 2000 (hazard ratio, 3.2; 95% confidence interval, 1.2-8.7). Median uncensored graft survival for patients transplanted after the year 2000 was 5.0 year (95% confidence interval, 2.4-7.6). Median patient survival was 5.0 years (3.1-6.9) and 5-year patient survival was 55%. Conclusions: Age by itself should not be an absolute contraindication against renal transplantation. An estimated 5-year survival rate of 55% post-engraftment for an 80-year-old patient is in our opinion more than acceptable.Shared via Inoreader
American Journal of Kidney Diseases / 2016-11-14 18:08
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American Journal of Transplantation / 2016-11-09 20:25
The aim of this study (NCT01744470) was to determine the efficacy and safety of two different doses of extended-release tacrolimus (TacER) in kidney transplant recipients (KTR) between 4 and 12 months post-transplantation. Stable steroid-free KTR were randomized (1:1) after 4 months: Group A 50%-reduction in TacER dose with targeted TacERC0>3μg/L; Group B no change in TacER dose (TacERC0=7-12μg/L). The primary outcome was eGFR at 1 year. Of 300 patients, intent-to-treat analysis included 186 patients (Group A 87, Group B 99). TacERC0 were lower in Group A than in Group B at 6 (4.1±2.7 vs 6.7±3.9μg/L, p<0.0001) and 12 months (5.6±2.0 vs 7.4±2.1μg/L, p<0.0001). eGFR was similar in both groups at 12 months (Group A 56.0±17.5ml/min/1.73m², Group B 56.0±22.1ml/min/1.73m²). More rejection episodes occurred in Group A (Group A 11, Group B 3; p=0.016). At one year, sub-clinical inflammation was more frequent in Group A than in Group B (i>0: 21.4% vs. 8.8%, p=0.047; t>0: 19.6% vs. 8.7%, p=0.076, i+t: 1.14±1.21 vs 0.72±1.01, p=0.038). DSA appeared only in Group A (6 patients vs. 0, p=0.008). TacERC0 should be maintained above 7μg/L during the first year post-transplantation in low immunological risk steroid-free KTR receiving moderate dose of MPA.
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Transplantation Direct - Current Issue / 2016-11-03 02:09
Background: Calcific uremic arteriolopathy (CUA), also referred to as calciphylaxis, is a rare and serious complication of kidney failure with limited treatment options. Kidney transplantation (KTX) restores kidney function and is hence a potential treatment option for CUA. We present 3 patients who had their CUA lesions successfully healed after urgent KTX. Methods: Data were retrospectively retrieved from hospital records at our national transplant center. Results: All 3 patients had previously been kidney transplanted and had experienced graft loss and were in stage 5 kidney failure when CUA developed. One patient was on warfarin treatment for pulmonary embolism. Skin lesions developed in the lower limbs in all 3 patients. Multidisciplinary care including intensified hemodialysis did not induce any clinically relevant improvement of the lesions. The recipients were enlisted on a clinically urgent waitlist for KTX and received a deceased donor kidney after 2 to 4 weeks. All recipients experienced good graft function. The lesions healed completely within 6 weeks in 2 patients. In the third patient, partial healing occurred after 2 months and complete healing was achieved 4 months after transplantation. Conclusions: These cases indicate that urgent KTX may contribute to an efficient treatment for end-stage renal disease patients with CUA.Shared via Inoreader
The New England Journal of Medicine: Search Results in Nephrology / 2016-11-03 03:12
A 72-year-old woman with poorly controlled hyperlipidemia and diabetes presented to the emergency department with a 5-day history of lower abdominal pain. She also had fever and reported nausea and vomiting. Physical examination revealed lower abdominal tenderness. Blood tests revealed leukocytosis associated with a left shift (neutrophil count of 11,800 per cubic millimeter) and elevation of the levels of C-reactive protein (24.0 mg per deciliter) and glucose (735 mg per deciliter [41 mmol per liter]). A plain radiograph of the kidneys, ureters, and bladder showed air surrounding the bladder (Panel A, arrows). An abdominal computed tomographic scan revealed an area of gas dissecting the bladder wall, bilateral hydronephrosis, and intramural gas with a cobblestone or beaded-necklace appearance (Panel B, arrows), findings consistent with emphysematous cystitis. The patient was treated with broad-spectrum antimicrobial agents and placement of a Foley catheter. Subsequently, a urine culture was positive for Escherichia coli; the patient was treated with antibiotics and recovered uneventfully. Emphysematous cystitis is a urinary tract infection that is associated with gas formation and is commonly caused by E. coli and Klebsiella pneumoniae.
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Nephrology Dialysis Transplantation - current issue / 2016-11-02 02:56
Inflammation plays an important role in polycystic kidney disease (PKD). The current study aimed to examine the efficacy of the anti-inflammatory compound resveratrol in PKD and to investigate its underlying mechanism of action.
MethodsMale Han:SPRD (Cy/+) rats with PKD were treated with 200 mg/kg/day resveratrol or vehicle by gavage for 5 weeks. Human autosomal dominant (AD) PKD cells, three-dimensional (3D) Madin-Darby canine kidney cells and zebrafish were treated with various concentrations of resveratrol or the nuclear factor B (NF-B) inhibitor QNZ.
ResultsResveratrol treatment reduced blood urea nitrogen levels and creatinine levels by 20 and 24%, respectively, and decreased two-kidney/total body weight ratio by 15% and cyst volume density by 24% in Cy/+ rats. The proliferation index and the macrophage infiltration index were reduced by 40 and 43%, respectively, in resveratrol-treated cystic kidneys. Resveratrol reduced the levels of the pro-inflammatory factors monocyte chemoattractant protein-1 (MCP-1), tumor necrosis factor-α (TNF-α) and complement factor B (CFB) in Cy/+ rat kidneys in parallel with the decreased activity of NF-B (p50/p65). The activation of NF-B and its correlation with pro-inflammatory factor expression were confirmed in human ADPKD cells and kidney tissues. Resveratrol and QNZ inhibited the expression of MCP-1, TNF-α and CFB and reduced NF-B activity in ADPKD cells. Moreover, NF-B blockage minimized the inhibition of inflammatory factor production by resveratrol treatment. Furthermore, resveratrol or QNZ inhibited cyst formation in the 3D cyst and zebrafish models.
ConclusionsThe NF-B signaling pathway is activated and partly responsible for inflammation in polycystic kidney tissues. Targeting inflammation through resveratrol could be a new strategy for PKD treatment in the future.
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Emphysematous Pyelonephritis — NEJM
http://www.nejm.org/doi/full/10.1056/NEJMicm1501812
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Yasumitsu Hirose, M.D.Hayato Kaida, M.D.
N Engl J Med 2016; 375:1671October 27, 2016DOI: 10.1056/NEJMicm1501812
A 51-year-old man presented with fever and general malaise of 2 weeks' duration. He had had diabetes mellitus for the preceding 20 years, and at the time of presentation this condition was poorly controlled. On admission to the hospital, his white-cell count was 10,800 per cubic millimeter (normal range, 3900 to 9800). The C-reactive protein level was 8.6 mg per deciliter, blood urea nitrogen 90 mg per deciliter (32 mmol per liter), creatinine 4.9 mg per deciliter (430 μmol per liter), and glycated hemoglobin 11.2%. Abdominal radiography (Panel A) and computed tomography (Panel B) revealed gas collection in the parenchyma (arrows) and perinephric space (arrowhead) of the left kidney. The patient received a diagnosis of emphysematous pyelonephritis, possibly caused by retrograde infection related to diabetes-associated neurogenic bladder. Escherichia coli was isolated in blood culture but not in urine cultures. The patient was treated with antibiotics; the infection resolved, and renal function improved (the blood urea nitrogen level declined to 23 mg per deciliter [8 mmol per liter] and creatinine to 2.6 ml per deciliter [230 μmol per liter]).
Yasumitsu Hirose, M.D.
Kurume University School of Medicine, Kurume, Japan
shinnichiizm@piano.ocn.ne.jp
Hayato Kaida, M.D.
Kindai University, Osakasayama, Japan
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Light chain podocytopathy mimicking recurrent focal segmental glomerulosclerosis - Khalighi - 2016 - American Journal of Transplantation - Wiley Online Library
http://onlinelibrary.wiley.com/doi/10.1111/ajt.14088/abstract;jsessionid=126DD36F68B49E3B8A1375AC92FF6189.f04t02
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This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1111/ajt.14088
Kidney injury related to paraproteinemia is common and typically occurs after the 4th decade of life in association with an underlying plasma cell dyscrasia or other lymphoproliferative disease. Kidney transplantation in paraprotein-related kidney disease can be successful in conjunction with treatment of the underlying hematopoietic process; however, when hematologic response to therapy is not achieved, recurrent kidney injury is frequently seen. We describe a young male patient who presented with end stage kidney disease at the age of 23 years thought to be secondary to focal segmental glomerulosclerosis who ultimately received two kidney allografts. He experienced recurrent proteinuria in both kidneys with a biopsy from his second allograft showing kappa-restricted crystalline light chain podocytopathy, which was identified in both his native and first allograft kidneys upon retrospective review. Recurrent light chain podocytopathy has not been previously reported but poses a diagnostic challenge as it can mimic focal segmental glomerulosclerosis, particularly in young patients where paraprotein-related kidney injury is usually not suspected.
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In this 12-month, multicenter, randomized, open-label, non-inferiority study, de novo renal transplant recipients (RTxRs) were randomized (1:1) to receive everolimus plus low-dose tacrolimus (EVR+LTac) or mycophenolate mofetil plus standard-dose Tac (MMF+STac) with induction therapy (basiliximab or rabbit anti-thymocyte globulin). Non-inferiority of composite efficacy failure rate (tBPAR/graft loss/death/loss to follow-up) in EVR+LTac versus MMF+STac, was missed by 1.4% considering the non-inferiority margin of 10% (24.6% vs 20.4%; 4.2%
[-3.0, 11.4]). Incidence of tBPAR (19.1% vs 11.2%; P<0.05) was significantly higher, while graft loss (1.3% vs 3.9%; P<0.05) and composite of graft loss/death/lost to follow-up (6.1% vs 10.5%, P = 0.05) were significantly lower in EVR+LTac versus MMF+STac groups, respectively. Mean eGFR was similar between EVR+LTac and MMF+STac groups (63.1 [22.0] vs 63.1 [19.5] mL/min/1.73 m2) and safety was comparable. In conclusion, EVR+LTac missed non-inferiority versus MMF+STac based on the 10% non-inferiority margin. Further studies evaluating optimal immunosuppression for improved efficacy will guide appropriate dosing and target-levels of EVR and LTac in RTxRs.
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We, the investigators of the National Transplantation Pregnancy Registry (NTPR), read with concern King and colleagues' Pregnancy Outcomes Related to Mycophenolate Exposure in Female Kidney Transplant Recipients [1], based on a limited subset of our data, which concludes that first trimester exposure to mycophenolate (MPA) may not be associated with increased fetal risks. We disagree with their interpretation of the data and feel strongly that their conclusions convey false information regarding MPA safety during pregnancy. In contrast, our analysis of this data finds: (1) the significant risks to pregnancies exposed to MPA any time in the first trimester are miscarriage and phenotypic birth defects, and (2) no association between discontinuing MPA products <6 weeks preconception and the risk of graft loss at 5 years. We attribute the authors' invalid conclusions to systematic errors in assigning recipients to their comparison groups and missing information.
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Abstract: Transplant recipients are at increased risk for tuberculosis (TB), which can adversely affect graft viability and patient survival. Scientific societies and official organizations have therefore issued guidelines and consensus statements for TB prevention and treatment. However, due to the poor supporting evidence, the current recommendations largely rely on expert opinion rather than on properly designed studies. In this overview, we aim to gather together the previous experience and compare and contrast the main current guidelines on the prevention and treatment of TB in solid organ transplantation and hematopoietic stem cell transplantation.Sent with Reeder
Transplantation - Current Issue Recurrent IgA Nephropathy After Kidney Transplantation
Abstract: Large numbers of patients with end-stage kidney disease caused by IgA nephropathy are transplanted every year, and each of these patients faces the risk of recurrence in their kidney graft. We review the epidemiology, diagnosis, and outcomes of recurrent IgA nephropathy. Mechanistic insights, therapeutic options, and knowledge gaps are reviewed, and we discuss future options to better understand and manage this disorder.Sent with Reeder
Abstract: Transplant recipients are at increased risk for tuberculosis (TB), which can adversely affect graft viability and patient survival. Scientific societies and official organizations have therefore issued guidelines and consensus statements for TB prevention and treatment. However, due to the poor supporting evidence, the current recommendations largely rely on expert opinion rather than on properly designed studies. In this overview, we aim to gather together the previous experience and compare and contrast the main current guidelines on the prevention and treatment of TB in solid organ transplantation and hematopoietic stem cell transplantation.Sent with Reeder
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Background: The contribution of calcineurin inhibitors (CNI) nephrotoxicity to progressive kidney transplant injury remains debated, with little long-term data from the modern tacrolimus (TAC) era using lower doses. Methods: This longitudinal cohort study evaluated histological evidence of CNI nephrotoxicity from normal donor kidneys of successful kidney-pancreas transplant recipients during cyclosporine (CSA) and TAC eras, analyzed by intention-to-treat. Results: From 200 patients, 1622 adequate prospective protocol (84.3%) and indication (15.7%) kidney biopsies yielded 8.1 ± 4.1 samples per patient, over 7.4 ± 4.4 years posttransplant. The TAC era demonstrated less rejection and reduced early immune-mediated tubular damage, compared with CSA (P < 0.001). The incidences of acute mild arteriolopathy, striped interstitial fibrosis, glomerular congestion, and tubular microcalcification were all greater with CSA (hazard ratios of 1.70, 9.35, and 3.78, respectively) and maximal within the first posttransplant year, compared with TAC-treated patients (P < 0.001). However, the 1-, 5-, and 10-year prevalence moderate arteriolar hyalinosis was similar: CSA was 5.4%, 38.4%, and 79.1%; and TAC was 4.3%, 33.6% and 77.2%, respectively (P = NS). Morphometric measurement demonstrated lumenal narrowing from inwards collapse of hyalinized arteriolar walls unable to maintain its structural integrity. Severe hyalinosis was calculated to reduce arteriolar blood flow to 20 ± 34% of normal. Severity of arteriolar hyalinosis correlated with contemporaneous glomerulosclerosis (r = 0.44, P < 0.001), and subsequent progression in 1356 sequential biopsy pairs, consistent with glomerular ischemia. Conclusions: Tacrolimus-based therapy appeared superior to the CSA era, with less early CNI nephrotoxicity and fewer rejection episodes, but comparable chronic arteriolar toxicity. Calcineurin inhibitors are imperfect long-term maintenance immunosuppressive agents because of frequent and irreversible chronic toxicity.Sent with Reeder
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Tertiary hyperparathyroidism is a common cause of hypercalcemia after kidney transplant. We designed this 12-month, prospective, multicenter, open–label, randomized study to evaluate whether subtotal parathyroidectomy is more effective than cinacalcet for controlling hypercalcemia caused by persistent hyperparathyroidism after kidney transplant. Kidney allograft recipients with hypercalcemia and elevated intact parathyroid hormone (iPTH) concentration were eligible if they had received a transplant ≥6 months before the study and had an eGFR>30 ml/min per 1.73 m2. The primary end point was the proportion of patients with normocalcemia at 12 months. Secondary end points were serum iPTH concentration, serum phosphate concentration, bone mineral density, vascular calcification, renal function, patient and graft survival, and economic cost. In total, 30 patients were randomized to receive cinacalcet (n=15) or subtotal parathyroidectomy (n=15). At 12 months, ten of 15 patients in the cinacalcet group and 15 of 15 patients in the parathyroidectomy group (P=0.04) achieved normocalcemia. Normalization of serum phosphate concentration occurred in almost all patients. Subtotal parathyroidectomy induced greater reduction of iPTH and associated with a significant increase in femoral neck bone mineral density; vascular calcification remained unchanged in both groups. The most frequent adverse events were digestive intolerance in the cinacalcet group and hypocalcemia in the parathyroidectomy group. Surgery would be more cost effective than cinacalcet if cinacalcet duration reached 14 months. All patients were alive with a functioning graft at the end of follow-up. In conclusion, subtotal parathyroidectomy was superior to cinacalcet in controlling hypercalcemia in these patients with kidney transplants and persistent hyperparathyroidism.
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American Journal of Kidney Diseases AJKD Atlas of Renal Pathology: Karyomegalic Nephropathy
Karyomegalic nephropathy is a rare autosomal recessive disease due to mutation in the FAN1 gene, resulting in low-grade proteinuria and slowly progressive GFR loss starting in the third decade of life, culminating in end-stage kidney disease.Sent with Reeder
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The indication of antimicrobial treatment for asymptomatic bacteriuria (AB) after kidney transplantation (KT) remains controversial. Between January 2011 and December 2013 112 KT recipients that developed ≥1 episode of AB beyond the second month post-transplantation were included in this open-label trial. Participants were randomized (1:1 ratio) to the treatment group (systematic antimicrobial therapy for all episodes of AB occurring up to 24 months post-transplantation [53 patients]) or control group (no antimicrobial therapy [59 patients]). Systematic screening for AB was similarly performed in both groups. The primary outcome was the occurrence of acute pyelonephritis at 24-month follow-up. Secondary outcomes included lower urinary tract infection, acute rejection, Clostridium difficile infection, colonization/infection by multidrug-resistant bacteria, graft function, and all-cause mortality. There were no differences in the primary outcome in the intention-to-treat (7.5% [4/53] in treatment group versus 8.4% [5/59] in control group; odds ratio [OR]: 0.88; 95% confidence interval [CI]: 0.22-3.47) or per-protocol populations (3.8% [1/26] in treatment group versus 8.0% [4/50] in control group; OR: 0.46; 95% CI: 0.05-4.34). We found no differences in any of the secondary outcomes either. In conclusion, systematic screening and treatment of AB beyond the second month after transplantation provide no apparent benefit among KT recipients (NCT02373085).
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Background: There is some evidence pointing toward better renal function in kidney transplant recipients (KTR) treated with once-daily tacrolimus (QD-TAC) vs. twice-daily tacrolimus (BID-TAC). Methods: This is an extension study of a 1-year, single arm prospective study of stable KTR who were converted from BID-TAC to QD-TAC (4.9 ± 4.0 years after transplantation) in Spanish routine clinical practice. Patient and graft survival, renal function, acute rejection episodes, and other analytic parameters were assessed at 24 and 36 months after conversion. Results: A total of 1798 KTR were included in the extension study. Tacrolimus doses at 36 months were significantly lower compared to those at time of conversion (−0.2 mg/day; P = 0.023). Blood levels were lower than baseline during all the study (P < 0.001). Graft and patient survival at 3 years after conversion were 93.9% and 95.1%, respectively. Compared with baseline, the mean estimated glomerular filtration rate (eGFR) remained very stable at all timepoints (56.7 ± 19.8 vs 58.1 ± 24.6 mL/min per 1.73 m2 at month 36; P = 0.623). Even when patients reinitiating dialysis were counted as eGFR = 0, the mean eGFR was very stable. In fact, a small but significant increase was observed at 36 months versus baseline (+0.1 mL/min per 1.73 m2; P = 0.025). An increase in proteinuria was observed at 36 months versus baseline (+0.11 g/24 h; P < 0.001). Acute rejection rates were low during the study. Conclusions: Conversion from BID-TAC to QD-TAC in a large cohort of stable KTR was safe and associated with a very stable renal function after 3 years. Comparative studies are warranted to assess the feasibility of such conversion.Sent with Reeder
Background: Native nephrectomy (NNx) is often done in patients with autosomal-dominant polycystic kidney disease. Controversy exists concerning the need and timing of nephrectomy in transplant candidates. We hypothesize that posttransplant NNx does not negatively impact patient and graft survival. Methods: Among 470 autosomal-dominant polycystic kidney disease transplant recipients included in the study, 114 (24.3%) underwent pretransplant (30.7%) or posttransplant (69.3%) NNx. Clinical data were retrieved from electronic records. Follow-up was until death, graft loss or June 2014. Perioperative complications were compared between the surgical techniques (open or laparoscopic) and between the pretransplant and posttransplant nephrectomy groups. The effect of nephrectomy on graft survival was analyzed as a time-dependent covariate when performed posttransplant. Results: Mean age at transplant was 52.4 years, 53.8% were men, 93% white, 70% were from living donors, and 56.8% were preemptive. Nephrectomy was done laparoscopically in 31% and 86% in the pretransplant and posttransplant nephrectomy groups, respectively. Complications were less common in those who underwent nephrectomy posttransplant (26.6% vs 48%, P = 0.03) but were similar regardless of surgical technique (open, 33.3% vs laparoscopic, 33%; P = 0.66). Patient and graft survivals were similar between those who underwent pretransplant nephrectomy and the rest of the recipients. In the posttransplant nephrectomy group, nephrectomy did not affect patient (hazards ratio, 0.77; 95% confidence interval, 0.38-1.54; P = 0.45) or graft survival (hazards ratio, 1.0; 95% confidence interval, 0.57-1.76; P = 0.1). Conclusions: Nephrectomy does not adversely affect patient or graft survival. Posttransplant nephrectomy is feasible when indicated without compromising long-term graft outcome and has fewer complications than pretransplant nephrectomy.Sent with Reeder
Abstract: Posttransplant lymphoproliferative disease (PTLD) is a potentially fatal complication after (solid organ) transplantation, which is highly associated with Epstein-Barr virus (EBV). The EBV-specific cytotoxic T cell response that is essential in controlling the virus in healthy individuals is suppressed in transplant recipients using immunosuppressive drugs. A primary EBV infection in EBV-seronegative patients receiving an EBV-seropositive donor organ or a reactivation in those who are already latently infected pretransplantation can lead to uninhibited growth of EBV-infected B cells and subsequently to PTLD. Effective preventive strategies, such as vaccines and antiviral agents, are lacking. Because not every transplant recipient with increasing EBV viral load develops PTLD, it is hard to decide how intensively these patients should be monitored and how and when a preemptive intervention should take place. There is a need for other tools to help predict the development of PTLD in patients at risk to make timing and strategy of preemptive intervention easier and more reliable. The cornerstone of the treatment of patients with PTLD is restoring the host's immunity by reduction of immunosuppressive drug therapy. American and British guidelines recommend to add rituximab monotherapy or rituximab in combination with cyclophosphamide, doxorubicin, vincristine, and prednisolone, depending on histology and clinical characteristics. Although response to these therapies is good, toxicity is a problem, and PTLD still has a relatively high mortality rate. An evolving therapy, especially in PTLD occurring in allogeneic stem cell transplantation, is restoring the host's immune response with infusion of EBV-specific cytotoxic T cells. This may also play a role in the future in both prevention and treatment of PTLD in SOT.Sent with Reeder
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1399-3062/asset/TID_centre.gif?v=1&s=987f397a733bdc030e3da046f3a805206b7763e1)
Original Report
Article first published online: 3 FEB 2016
DOI: 10.1111/tid.12494
© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Additional Information
J. Radtke, N. Dietze, V.N. Spetzler, L. Fischer, E.-G. Achilles, J. Li, S. Scheidat, F. Thaiss, B. Nashan, M. Koch. Fewer cytomegalovirus complications after kidney transplantation by de novo use of mTOR inhibitors in comparison to mycophenolic acid. Transpl Infect Dis 2016: 18: 79–88. All rights reserved
Department of Hepatobiliary and Transplant Surgery, University Medical Center Hamburg-Eppendorf UKE, University Transplantation-Center UTC, Hamburg, Germany
Department of Internal Medicine III, University Medical Center Hamburg-Eppendorf UKE, University Transplantation-Center UTC, Hamburg, Germany
These authors contributed equally to this article.
* Correspondence to:
Prof. Martina Koch, Department of Hepatobiliary and Transplant Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
Tel: +(0)-40-7410-56137
Fax: + (0)-40-7410-40051
E-mail: martina.koch@uke.de
Cytomegalovirus (CMV) is a risk factor for patient and graft survival after kidney transplantation.
We retrospectively analyzed risk factors for CMV infection in 348 patients who received a kidney transplant donated after brain death (n = 232) or by living donation (n = 116) between 2008 and 2013. Of the 348 patients analyzed, 91 received a mammalian target of rapamycin inhibitor (mTORi)-based immunosuppressive regimen. A total of 266 patients were treated with standard immunosuppression (Group 1) consisting of basiliximab induction, calcineurin inhibitor (CNI), and either mycophenolic acid (MPA, n = 219) or everolimus (EVE) (n = 47). We also included 82 patients who received more intense immunosuppression (Group 2) with lymphocyte depletion, CNI, plus either MPA (n = 38) or EVE (n = 44). Only patients in the high-risk constellation received CMV prophylaxis in Group 1, while all patients in Group 2 received prophylaxis for 6 month.
The overall rate of CMV infections was low with 10.1% in all patients. Despite the different prophylaxis strategies applied, no difference was seen in CMV infections between Group 1 (10.9%) and Group 2 (13.6%). A multivariate analysis revealed that patients on EVE had fewer CMV complications compared with patients on MPA (P = 0.013, odds ratio [OR] 4.8, confidence interval [CI] 1.4–16.5). Donor and recipient age >65 years was an independent risk factor (P = 0.002, OR 3.2, CI 1.5–6.7) for CMV infections. Patients with CMV infections had significantly worse graft function after 2 years (P = 0.001).
CMV is a significant risk factor for long-term graft outcome. Patients treated with EVE developed fewer CMV complications compared to patients on MPA. The use of mTORi is useful in patients at high risk of developing CMV infections.
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