Neoplastic and Non-Neoplastic Complications of Solid Organ Transplantation in Patients with Preexisting Monoclonal Gammopathy of Undetermined Significance (MGUS)

Clinical Transplantation Neoplastic and Non-Neoplastic Complications of Solid Organ Transplantation in Patients with Preexisting Monoclonal Gammopathy of Undetermined Significance (MGUS)

Abstract

Monoclonal gammopathy of undetermined significance (MGUS) occurs in 3-7% of the elderly population, with higher prevalence in renal failure patients, and is associated with a 25-fold increased lifetime risk for plasma cell myeloma (PCM), also known as multiple myeloma. Using the California State Inpatient, Emergency Department, and Ambulatory Surgery Databases components of the Healthcare Cost and Utilization Project (HCUP), we sought to determine if patients with MGUS who undergo solid organ allograft (n=22,062) are at increased adjusted relative risk (aRR) for hematological malignancy and other complications. Among solid organ transplant patients, patients with preexisting MGUS had higher aRR of PCM (aRR 19.46; 95%CI 7.05, 53.73; p<0.001), venous thromboembolic events (aRR 1.66; 95%CI 1.15, 2.41; p=0.007), and infection (aRR 1.24; 95%CI 1.06, 1.45; p=0.007). However, when comparing MGUS patients with and without solid organ transplant, there was decreased aRR for PCM with transplant (aRR 0.34; 95%CI 0.13, 0.88; p=0.027), and increased venous thromboembolic events (aRR 2.33; 95%CI 1.58, 3.44; p<0.001) and infectious risks, (aRR 1.44; 95%CI 1.23, 1.70; p<0.001). While MGUS increased the risk of PCM overall following solid organ transplantation, there was lower risk of PCM development compared to MGUS patients who did not receive a transplant. MGUS should not preclude solid organ transplant.

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http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2Fctr.12595

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Alberto Reino Buelvas 

Médico Internista Nefrólogo

You Are What You Eat: Metabolites of Gut Microbiota Provide Novel Insights into Diagnosis and Development of Chronic Kidney Disease

Transplantation - Most Popular Articles You Are What You Eat: Metabolites of Gut Microbiota Provide Novel Insights into Diagnosis and Development of Chronic Kidney Disease

No abstract available


http://journals.lww.com/transplantjournal/Fulltext/2015/07000/You_Are_What_You_Eat___Metabolites_of_Gut.4.aspx

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Alberto Reino Buelvas 

Médico Internista Nefrólogo

Atlas of Renal Pathology: Minimal Change Disease

American Journal of Kidney Diseases Atlas of Renal Pathology: Minimal Change Disease

Minimal change disease (MCD) is characterized by nephrotic syndrome. It is the most common cause of nephrotic syndrome in children aged 1 to 7 years and remains a cause of nephrotic syndrome in adults.


http://www.ajkd.org/article/S0272-6386(15)00634-4/abstract?rss=yes

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Alberto Reino Buelvas 

Médico Internista Nefrólogo

Evaluation of Low- Versus High-dose Valganciclovir for Prevention of Cytomegalovirus Disease in High-risk Renal Transplant Recipients

Transplantation - Most Popular Articles Evaluation of Low- Versus High-dose Valganciclovir for Prevention of Cytomegalovirus Disease in High-risk Renal Transplant Recipients

Background: Despite proven efficacy of prolonged cytomegalovirus (CMV) prophylaxis using valganciclovir 900 mg/day, some centers use 450 mg/day due to reported success and cost savings. This multicenter, retrospective study compared the efficacy and safety of 6 months of low-dose versus high-dose valganciclovir prophylaxis in high-risk, donor-positive/recipient-negative, renal transplant recipients (RTR). Methods: Two hundred thirty-seven high-risk RTR (low-dose group = valganciclovir 450 mg/day [n = 130]; high-dose group = valganciclovir 900 mg/day [n = s7]) were evaluated for 1-year CMV disease prevalence. Breakthrough CMV, resistant CMV, biopsy-proven acute rejection (BPAR), graft loss, opportunistic infections (OI), new-onset diabetes after transplantation (NODAT), premature valganciclovir discontinuation, renal function and myelosuppression were also assessed. Results: Patient demographics and transplant characteristics were comparable. Induction and maintenance immunosuppression were similar, except for more early steroid withdrawal in the high-dose group. Similar proportions of patients developed CMV disease (14.6% vs 24.3%; P = 0.068); however, controlling CMV risk factor differences through multivariate logistic regression revealed significantly lower CMV disease in the low-dose group (P = 0.02; odds ratio, 0.432, 95% confidence interval, 0.211–0.887). Breakthrough and resistant CMV occurred at similar frequencies. There was no difference in renal function or rates of biopsy-proven acute rejection, graft loss, opportunistic infections, or new-onset diabetes after transplantation. The high-dose group had significantly lower mean white blood cell counts at months 5 and 6; however, premature valganciclovir discontinuation rates were similar. Conclusions: Low-dose and high-dose valganciclovir regimens provide similar efficacy in preventing CMV disease in high-risk RTR, with a reduced incidence of leukopenia associated with the low-dose regimen and no difference in resistant CMV. Low-dose valganciclovir may provide a significant cost avoidance benefit.


http://journals.lww.com/transplantjournal/Fulltext/2015/07000/Evaluation_of_Low__Versus_High_dose_Valganciclovir.34.aspx

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Alberto Reino Buelvas 

Médico Internista Nefrólogo

Recurrent Membranoproliferative Glomerulonephritis Type I After Kidney Transplantation: A 17-Year Single-Center Experience

Transplantation - Current Issue Recurrent Membranoproliferative Glomerulonephritis Type I After Kidney Transplantation: A 17-Year Single-Center Experience

Background: Most previously published studies of patients with membranoproliferative glomerulonephritis type I are small or have short follow-up period. We report the outcome of a fairly large cohort of patients followed up for nearly 10 years. Methods: Retrospective cohort study. Graft survival, recurrence rate and risk factors for recurrence were analyzed for 43 patients transplanted between the years 1995 and 2012. Results: At a mean overall follow-up of 118±61 months (median, 127.8; range, 4.9–217), 12 patients lost their graft (28%). Death-censored actuarial 15-year graft survival rate was 56%. Membranoproliferative glomerulonephritis recurred in eight patients (19%) at a median time of 15.4 months (range, 4.4–70 months). Recurrence led to graft loss in seven patients (88%) within a median of 11.6 months (range, 1.3–54 months) from diagnosis. Median graft survival was 30.5 months for recurrence (range, 7–86). Actuarial 15-year graft survival was 71% for nonrecurrent. The risk for recurrence was higher for patients with human leukocyte antigen (HLA) B49 (odds ratio, 16.9; 95% confidence interval, 1.1–246; P=0.038) and HLA DR4 (odds ratio, 15.9; 95% confidence interval, 1.07–237; P=0.044) alleles. A trend toward increased risk was found with shorter duration of dialysis before transplantation. Four of 16 (25%) living-related versus none of the living-unrelated donors' recipients recurred. The HLA B49, acute tubular necrosis after transplantation, previous transplantations, and Arab origin were all associated with decreased graft and patient survival. Conclusion: Patients without recurrence in the first years should expect an excellent graft survival. Nonrelated living donors should be preferred. The HLA B49 and DR4 alleles may increase the risk for recurrence.


http://journals.lww.com/transplantjournal/Fulltext/2015/06000/Recurrent_Membranoproliferative_Glomerulonephritis.15.aspx

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Alberto Reino Buelvas

Rates and Determinants of Progression to Graft Failure in Kidney Allograft Recipients With De Novo Donor-Specific Antibody

AJT - Early Rates and Determinants of Progression to Graft Failure in Kidney Allograft Recipients With De Novo Donor-Specific Antibody

Understanding rates and determinants of clinical pathologic progression for recipients with de novo donor-specific antibody (dnDSA), especially subclinical dnDSA, may identify surrogate endpoints and inform clinical trial design. A consecutive cohort of 508 renal transplant recipients (n = 64 with dnDSA) was studied. Recipients (n = 388) without dnDSA or dysfunction had an eGFR decline of −0.65 mL/min/1.73 m²/year. In recipients with dnDSA, the rate eGFR decline was significantly increased prior to dnDSA onset (−2.89 vs. −0.65 mL/min/1.73 m²/year, p < 0.0001) and accelerated post-dnDSA (−3.63 vs. −2.89 mL/min/1.73 m²/year, p < 0.0001), suggesting that dnDSA is both a marker and contributor to ongoing alloimmunity. Time to 50% post-dnDSA graft loss was longer in recipients with subclinical versus a clinical dnDSA phenotype (8.3 vs. 3.3 years, p < 0.0001). Analysis of 1091 allograft biopsies found that dnDSA and time independently predicted chronic glomerulopathy (cg), but not interstitial fibrosis and tubular atrophy (IFTA). Early T cell–mediated rejection, nonadherence, and time were multivariate predictors of IFTA. Independent risk factors for post-dnDSA graft survival available prior to, or at the time of, dnDSA detection were delayed graft function, nonadherence, dnDSA mean fluorescence intensity sum score, tubulitis, and cg. Ultimately, dnDSA is part of a continuum of mixed alloimmune-mediated injury, which requires solutions targeting T and B cells.

http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2Fajt.13347

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Alberto Reino Buelvas