Wednesday, March 23, 2016

¿Qué pasa con las IPS en Colombia?

Impact of early blood transfusion after kidney transplantation on the incidence of donor-specific anti-HLA antibodies.

AJT Impact of early blood transfusion after kidney transplantation on the incidence of donor-specific anti-HLA antibodies.

Little is known about the impact of post-transplant blood transfusion on the sensitization of anti-HLA antibodies and the formation of donor-specific antibodies (DSAs). The aims of our study were to determine the 1-year incidence of DSAs (assessed using a solid-phase assay) and antibody-mediated rejection (AMR) in kidney-transplant patients who had or had not received a blood transfusion during the first year post-transplantation. Included were 390 non-HLA sensitized patients who had received an ABO-compatible kidney transplant, and had not previously or simultaneously received a non-kidney transplant. Sixty-four percent of patients received a red blood-cell transfusion within the first year post-transplantation, mostly within the first month. The overall 1-year incidence of DSAs was significantly higher in patients that had undergone transfusion (7.2% vs. 0.7% in patients with no transfusion, p<0.0001). AMR occurred more often in the transfusion group (n=15, 6%) compared to the non-transfusion group (n=2, 1.4%), p=0.04. Blood transfusion was an independent predictive factor for de novo DSA formation but not for AMR. Patients who had a transfusion and developed DSAs were more often treated with cyclosporin A (n=10, 55.5%) rather than tacrolimus (n=45, 19.4%), p=0.0001). In conclusion, early post-transplant blood transfusion may increase immunological risk, especially in under-immunosuppressed patients. This article is protected by copyright. All rights reserved.



http://www.unboundmedicine.com/medline/citation/26998676/Impact_of_early_blood_transfusion_after_kidney_transplantation_on_the_incidence_of_donor_specific_anti_HLA_antibodies_

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Wednesday, March 9, 2016

Medium-Term Renal Function in a Large Cohort of Stable Kidney Transplant Recipients Converted From Twice-Daily to Once-Daily Tacrolimus

Transplantation Direct Medium-Term Renal Function in a Large Cohort of Stable Kidney Transplant Recipients Converted From Twice-Daily to Once-Daily Tacrolimus

imageBackground: 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.


http://journals.lww.com/transplantationdirect/Fulltext/2015/08000/Medium_Term_Renal_Function_in_a_Large_Cohort_of.4.aspx

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Alberto Reino Buelvas

Native Nephrectomy in Renal Transplant Recipients With Autosomal-Dominant Polycystic Kidney Disease

Transplantation Direct Native Nephrectomy in Renal Transplant Recipients With Autosomal-Dominant Polycystic Kidney Disease

imageBackground: 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.


http://journals.lww.com/transplantationdirect/Fulltext/2015/11000/Native_Nephrectomy_in_Renal_Transplant_Recipients.4.aspx

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Alberto Reino Buelvas

Epstein-Barr Virus–Positive Posttransplant Lymphoproliferative Disease After Solid Organ Transplantation: Pathogenesis, Clinical Manifestations, Diagnosis, and Management

Transplantation Direct Epstein-Barr Virus–Positive Posttransplant Lymphoproliferative Disease After Solid Organ Transplantation: Pathogenesis, Clinical Manifestations, Diagnosis, and Management

imageAbstract: 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.


http://journals.lww.com/transplantationdirect/Fulltext/2016/01000/Epstein_Barr_Virus_Positive_Posttransplant.10.aspx

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Alberto Reino Buelvas

Long-term Follow-up of Kidney Transplant Recipients in the Spare-the-Nephron-Trial.

Transplantation - Published Ahead-of-Print Long-term Follow-up of Kidney Transplant Recipients in the Spare-the-Nephron-Trial.

In the Spare-the-Nephron (STN) Study, kidney transplant recipients randomized about 115 days posttransplant to convert from CNI (calcineurin inhibitor)/MMF to sirolimus (SRL)/MMF had a significantly greater improvement in measured GFR (mGFR) at 12 months compared with those kept on CNI/MMF. The difference at 24 months was not statistically significant. From 14 top enrolling centers, 128 of 175 patients identified with a functioning graft at 2 years consented to enroll in an observational, noninterventional extension study to collect retrospectively and prospectively annual follow-up data for the interval since baseline (completion of the parent STN study at 24 months posttransplant). Overall, 11 patients died, including 5 (7.6%) in the SRL/MMF group and 6 (9.7%) in the CNI/MMF group. Twenty-two grafts have been lost including 10 (15.2%) in the SRL/MMF arm and 12 (19.4%) in the CNI/MMF arm. Death and chronic rejection were the most common causes of graft loss in both arms. There were modestly more cardiovascular events in the MMF/SRL group. Estimated creatinine clearance (Cockcroft-Gault) from baseline out to 6 additional years (8 years posttransplant, ITT analysis, SRL/MMF, n = 34; CNI/MMF, n = 26) was 63.2 +/- 28.5 mL/min/1.73 m2 in the SRL/MMF group and 59.2 +/- 27.2 mL/min/1.73 m2 in the CNI/MMF group and was not statistically significant, but there is a clinically meaningful trend for improved long-term renal function in the SRL/MMF group compared with the CNI/MMF group. The long-term decision for immunosuppression needs to be carefully individualized. Copyright (C) 2016 Wolters Kluwer Health, Inc. All rights reserved.


http://pdfs.journals.lww.com/transplantjournal/9000/00000/Long_term_Follow_up_of_Kidney_Transplant.97490.pdf

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Alberto Reino Buelvas

Tuesday, March 8, 2016

Fewer cytomegalovirus complications after kidney transplantation by de novo use of mTOR inhibitors in comparison to mycophenolic acid - Radtke - 2016 - Transplant Infectious Disease - Wiley Online Library

onlinelibrary.wiley.com Fewer cytomegalovirus complications after kidney transplantation by de novo use of mTOR inhibitors in comparison to mycophenolic acid - Radtke - 2016 - Transplant Infectious Disease - Wiley Online Library

Original Report

Fewer cytomegalovirus complications after kidney transplantation by de novo use of mTOR inhibitors in comparison to mycophenolic acid

  1. J. Radtke1,†,
  2. N. Dietze1,†,
  3. V.N. Spetzler1,
  4. L. Fischer1,
  5. E.-G. Achilles1,
  6. J. Li1,
  7. S. Scheidat2,
  8. F. Thaiss2,
  9. B. Nashan1 and
  10. M. Koch1,*

Article first published online: 3 FEB 2016

DOI: 10.1111/tid.12494

© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Issue

Transplant Infectious Disease

Volume 18, Issue 1, pages 79–88, February 2016


Additional Information

How to Cite

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: 7988. All rights reserved

Author Information

  1. 1

    Department of Hepatobiliary and Transplant Surgery, University Medical Center Hamburg-Eppendorf UKE, University Transplantation-Center UTC, Hamburg, Germany

  2. 2

    Department of Internal Medicine III, University Medical Center Hamburg-Eppendorf UKE, University Transplantation-Center UTC, Hamburg, Germany

  1. 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

Publication History

  1. Issue published online: 15 FEB 2016
  2. Article first published online: 3 FEB 2016
  3. Accepted manuscript online: 27 DEC 2015 10:41PM EST
  4. Manuscript Accepted: 17 OCT 2015
  5. Manuscript Revised: 10 OCT 2015
  6. Manuscript Revised: 11 SEP 2015
  7. Manuscript Received: 29 JUL 2015

Funded by

  • Novartis
  • Astellas

Keywords:

  • cytomegalovirus;
  • CMV prophylaxis;
  • kidney transplantation;
  • immunosuppression;
  • everolimus;
  • mTOR inhibitors

Abstract

Background

Cytomegalovirus (CMV) is a risk factor for patient and graft survival after kidney transplantation.

Methods

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.

Results

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).

Conclusion

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.




http://onlinelibrary.wiley.com/doi/10.1111/tid.12494/abstract?campaign=woletoc

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Alberto Reino Buelvas