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Wednesday, March 9, 2016

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
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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
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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
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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: 79–88. 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
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Monday, February 22, 2016

iChoose Kidney: A Clinical Decision Aid for Kidney Transpla... : Transplantation

journals.lww.com iChoose Kidney: A Clinical Decision Aid for Kidney Transpla... : Transplantation

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Transplantation:
doi: 10.1097/TP.0000000000001019
Original Clinical Science-General

iChoose Kidney: A Clinical Decision Aid for Kidney Transplantation Versus Dialysis Treatment

Patzer, Rachel E. PhD, MPH; Basu, Mohua MPH; Larsen, Christian P. MD, DPhil; Pastan, Stephen O. MD; Mohan, Sumit MD, MPH; Patzer, Michael BS; Konomos, Michael MS, CMI; McClellan, William M. MD, MPH; Lea, Janice MD; Howard, David PhD; Gander, Jennifer PhD, MPH; Arriola, Kimberly Jacob PhD, MPH

Supplemental Author Material

Abstract

Background: Despite a significant survival advantage of kidney transplantation compared with dialysis, nearly one third of end-stage renal disease (ESRD) patients are not educated about kidney transplantation as a treatment option at the time of ESRD diagnosis. Access to individualized, evidence-based prognostic information is needed to facilitate and encourage shared decision making about the clinical implications of whether to pursue transplantation or long-term dialysis.

Methods: We used a national cohort of incident ESRD patients in the US Renal Data System surveillance registry from 2005 to 2011 to develop and validate prediction models for risk of 1- and 3-year mortality among dialysis versus kidney transplantation. Using these data, we developed a mobile clinical decision aid that provides estimates of risks of death and survival on dialysis compared with kidney transplantation patients.

Results: Factors included in the mortality risk prediction models for dialysis and transplantation included age, race/ethnicity, dialysis vintage, and comorbidities, including diabetes, hypertension, cardiovascular disease, and low albumin. Among the validation cohorts, the discriminatory ability of the model for 3-year mortality was moderate (c statistic, 0.7047; 95% confidence interval, 0.7029-0.7065 for dialysis and 0.7015; 95% confidence interval, 0.6875-0.7155 for transplant). We used these risk prediction models to develop an electronic, user-friendly, mobile (iPad, iPhone, and website) clinical decision aid called iChoose Kidney.

Conclusions: The use of a mobile clinical decision aid comparing individualized mortality risk estimates for dialysis versus transplantation could enhance communication between ESRD patients and their clinicians when making decisions about treatment options.

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

Source
Transplantation. 100(3):630-639, March 2016.
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http://journals.lww.com/transplantjournal/Fulltext/2016/03000/iChoose_Kidney___A_Clinical_Decision_Aid_for.30.aspx

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Alberto Reino Buelvas
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http://onlinelibrary.wiley.com/doi/10.1111/tri.12759/abstract;jsessionid=85F5E803371366EB9764724E38397C90.f03t04?systemMessage=Wiley+Online+Library+will+be+unavailable+on+Saturday+27th+February+from+09%3A00-14%3A00+GMT+%2F+04%3A00-09%3A00+EST+%2F+17%3A00-22%3A00+SGT+for+essential+maintenance.++Apologies+for+the+inconvenience.

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