Chronic norovirus infection as a risk factor for secondary lactose maldigestion in renal transplant recipients: a prospective parallel cohort pilot study.

Transplantation - Published Ahead-of-Print Chronic norovirus infection as a risk factor for secondary lactose maldigestion in renal transplant recipients: a prospective parallel cohort pilot study.

Background: Chronic norovirus infection is an emerging challenge in the immunocompromised host, in whom it may be asymptomatic or present as chronic diarrhea. The mechanisms of diarrhea in chronic norovirus infection are not well understood, but in analogy to Gardia lamblia and rotavirus infections, secondary lactose maldigestion (LM) might be implicated. Methods: Adult renal transplant recipients (RTRs) who had symptomatic chronic norovirus infection with diarrhea were asked to participate in this prospective parallel cohort study. RTRs with otherwise unexplainable chronic diarrhea but absent infection served as control group. In both groups, a lactose hydrogen breath test (LHBT) and a lactose tolerance test (LTT) were performed after exclusion of primary LM by a negative lactase gene test. Results: Of approximately 800 patients in the cohort of RTRs at our institution, 15 subjects were included in the present study. Of these, 7 had chronic symptomatic norovirus infection with diarrhea (noro group) and 8 had diarrhea in the absence of norovirus (control group). LHBT and LTT were positive in all 7 patients (100%) in the noro group, whereas only 1 of 8 patients (12.5%) in the control group had a positive test. Thus, secondary LM was highly prevalent in the noro compared to the control group with an odds ratio of 75.0 (95% CI 2.6, 2153, p=0.01). Conclusions: This is the first report showing a positive association of chronic norovirus infection and secondary LM. Further studies with larger patient numbers and longer follow-up are needed to test a causative relationship between both entities. Copyright (C) 2016 Wolters Kluwer Health, Inc. All rights reserved.


http://pdfs.journals.lww.com/transplantjournal/9000/00000/Chronic_norovirus_infection_as_a_risk_factor_for.97297.pdf

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Calcineurin Inhibitor Nephrotoxicity Through the Lens of Longitudinal Histology: Comparison of Cyclosporine and Tacrolimus Eras

Transplantation - Most Popular Articles Calcineurin Inhibitor Nephrotoxicity Through the Lens of Longitudinal Histology: Comparison of Cyclosporine and Tacrolimus Eras

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.


http://journals.lww.com/transplantjournal/Fulltext/2016/08000/Calcineurin_Inhibitor_Nephrotoxicity_Through_the.26.aspx

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Alberto Reino Buelvas

Phosphate-Binding Agents in Adults With CKD: A Network Meta-analysis of Randomized Trials

American Journal of Kidney Diseases Phosphate-Binding Agents in Adults With CKD: A Network Meta-analysis of Randomized Trials

Guidelines preferentially recommend noncalcium phosphate binders in adults with chronic kidney disease (CKD). We compare and rank phosphate-binder strategies for CKD.


http://www.ajkd.org/article/S0272-6386(16)30253-0/abstract?rss=yes

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Alberto Reino Buelvas

A Randomized Study Comparing Parathyroidectomy with Cinacalcet for Treating Hypercalcemia in Kidney Allograft Recipients with Hyperparathyroidism

Journal of the American Society of Nephrology current issue A Randomized Study Comparing Parathyroidectomy with Cinacalcet for Treating Hypercalcemia in Kidney Allograft Recipients with Hyperparathyroidism

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.

http://jasn.asnjournals.org/cgi/content/short/27/8/2487?rss=1

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Alberto Reino Buelvas

AJKD Atlas of Renal Pathology: Karyomegalic Nephropathy

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.


http://www.ajkd.org/article/S0272-6386(16)30114-7/abstract?rss=yes

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Interpreting Anti-HLA Antibody Testing Data: A Practical Guide for Physicians.

Transplantation - Published Ahead-of-Print Interpreting Anti-HLA Antibody Testing Data: A Practical Guide for Physicians.

The development of sensitive methods for alloantibody detection has been a significant advance in clinical transplantation. However, the complexity of the data from solid phase and crossmatch assays has led to potential confusion about how to use the results for clinical decision making. The goal of this review is to provide a practical guide for transplant physicians for the interpretation of antibody data to supplement consultation with local tissue typing experts. Sources of variability in both the solid phase and crossmatch assay are discussed as are recent data regarding C1q binding antibodies and IgG subclass testing. Although definitive approaches to alloantibody testing are not possible with our current knowledge, we outline a pragmatic approach that we hope will enhance clinical management in this area. Copyright (C) 2016 Wolters Kluwer Health, Inc. All rights reserved.


http://pdfs.journals.lww.com/transplantjournal/9000/00000/Interpreting_Anti_HLA_Antibody_Testing_Data___A.97437.pdf

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Alberto Reino Buelvas