1
|
Barteczko MLM, Orellana HC, Santos GRF, Galhardo A, Kanhouche G, Faccinetto ACB, Júnior HT, Pestana JOM, de Paola ÂAV, Barbosa AHP. Long-term clinical outcomes of patients with nonsignificant transplanted renal artery stenosis. BMC Nephrol 2022; 23:61. [PMID: 35135498 PMCID: PMC8826676 DOI: 10.1186/s12882-022-02691-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 02/01/2022] [Indexed: 11/10/2022] Open
Abstract
Background Transplant renal artery stenosis (TRAS) is the main vascular complication of kidney transplantation. For research and treatment purposes, several authors consider critical renal artery stenosis to be greater than 50%, and percutaneous intervention is indicated in this scenario. However, there are no reports in the current literature on the evolution of patients with less than 50% stenosis. Method This retrospective study included data from all patients who underwent kidney transplantation and were suspected of having TRAS after transplantation with stenosis under 50% independent of age and were referred for angiography at a single centre between January 2007 and December 2014. Results During this period, 6,829 kidney transplants were performed at Hospital do Rim, 313 of whom had a clinical suspicion of TRAS, and 54 of whom presented no significant stenosis. The average age was 35.93 years old, the predominant sex was male, and most individuals (94.4%) underwent dialysis before transplantation. In most cases in this group, transplants occurred from a deceased donor (66.7%). The time between transplantation and angiography was less than one year in 79.6% of patients, and all presented nonsignificant TRAS. Creatinine levels, systolic blood pressure, diastolic blood pressure and glomerular filtration rate improved over the long term. The outcomes found were death and allograft loss. Conclusion Age, sex and ethnic group of patients were factors that did not interfere with the frequency of renal artery stenosis. The outcomes showed that in the long term, most patients evolve well and have improved quality of life and kidney function, although there are cases of death and kidney loss.
Collapse
Affiliation(s)
- Manoela Linhares Machado Barteczko
- Department of Medicine, Cardiology Discipline, Federal University of Sao Paulo-UNIFESP, Sao Paulo Hospital, R. Napoleão de Barros, 715 - Vila Clementino, Sao Paulo/SP, 04024-002, Brazil.
| | - Henry Campos Orellana
- Department of Medicine, Cardiology Discipline, Federal University of Sao Paulo-UNIFESP, Sao Paulo Hospital, R. Napoleão de Barros, 715 - Vila Clementino, Sao Paulo/SP, 04024-002, Brazil
| | - Gustavo Rocha Feitosa Santos
- Department of Medicine, Cardiology Discipline, Federal University of Sao Paulo-UNIFESP, Sao Paulo Hospital, R. Napoleão de Barros, 715 - Vila Clementino, Sao Paulo/SP, 04024-002, Brazil
| | - Attílio Galhardo
- Department of Medicine, Cardiology Discipline, Federal University of Sao Paulo-UNIFESP, Sao Paulo Hospital, R. Napoleão de Barros, 715 - Vila Clementino, Sao Paulo/SP, 04024-002, Brazil
| | - Gabriel Kanhouche
- Department of Medicine, Cardiology Discipline, Federal University of Sao Paulo-UNIFESP, Sao Paulo Hospital, R. Napoleão de Barros, 715 - Vila Clementino, Sao Paulo/SP, 04024-002, Brazil
| | - Ana Carolina Buso Faccinetto
- Department of Medicine, Cardiology Discipline, Federal University of Sao Paulo-UNIFESP, Sao Paulo Hospital, R. Napoleão de Barros, 715 - Vila Clementino, Sao Paulo/SP, 04024-002, Brazil
| | - Hélio Tedesco Júnior
- Department of Medicine, Cardiology Discipline, Federal University of Sao Paulo-UNIFESP, Sao Paulo Hospital, R. Napoleão de Barros, 715 - Vila Clementino, Sao Paulo/SP, 04024-002, Brazil.,Division of Nephrology, Hospital Do Rim E Hipertensao, UNIFESP, São Paulo/SP, Brazil
| | - José Osmar Medina Pestana
- Department of Medicine, Cardiology Discipline, Federal University of Sao Paulo-UNIFESP, Sao Paulo Hospital, R. Napoleão de Barros, 715 - Vila Clementino, Sao Paulo/SP, 04024-002, Brazil.,Division of Nephrology, Hospital Do Rim E Hipertensao, UNIFESP, São Paulo/SP, Brazil
| | - Ângelo Amato Vincenzo de Paola
- Department of Medicine, Cardiology Discipline, Federal University of Sao Paulo-UNIFESP, Sao Paulo Hospital, R. Napoleão de Barros, 715 - Vila Clementino, Sao Paulo/SP, 04024-002, Brazil
| | - Adriano Henrique Pereira Barbosa
- Department of Medicine, Cardiology Discipline, Federal University of Sao Paulo-UNIFESP, Sao Paulo Hospital, R. Napoleão de Barros, 715 - Vila Clementino, Sao Paulo/SP, 04024-002, Brazil
| |
Collapse
|
2
|
Abstract
Acute rejection (AR) seems to be less common with current immunosuppressive strategies; however, it remains a major cause of morbidity and mortality in the first year following heart transplantation. Despite great interest in noninvasive methods for detecting rejection, the endomyocardial biopsy remains the standard method for AR identification and, recently, the cardiac biopsy grading system has been reviewed. Moreover, the availability of several immunosuppressive drug combinations has generated confusion in the minds of clinicians. This review will focus on recently published studies that are related to the clinical impact of AR, combination regimens of chronic maintenance immunosuppression and specific therapeutic options for treating AR.
Collapse
Affiliation(s)
- Juan F Delgado
- Heart Failure and Transplant Unit, Cardiology Department, Doce de Octubre Universitary Hospital, Avenida de Córdoba sn, 28041 Madrid, Spain.
| | | | | |
Collapse
|
3
|
Manito N, Kaplinsky EJ, Roca J, Castells E, Saura E, Gomez-Hospital JA, Esplugas E. Heart transplant recipient clinical profile improvement following mycophenolate mofetil late incorporation into the treatment schedule. Clin Transplant 2005; 19:304-8. [PMID: 15877789 DOI: 10.1111/j.1399-0012.2005.00238.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Mycophenolate mofetil (MMF) has a better clinical profile than azathioprine in heart transplantation (HT). Forty-five recipients (aged 53 +/- 9 yr) were retrospectively evaluated (first year of follow-up) post-MMF introduction since its advent in 1997 (mean daily dose: 1.97 +/- 0.2 g). MMF was used (mean post-HT time: 40 +/- 27 months) for: (i) renal insufficiency attenuation (group 1 = 20); (ii) steroid reduction because of osteoporosis (group 2 = 12); (iii) treatment of persistent cellular rejection (group 3 = 7) and vascular graft disease (VGD) (group 4 = 6). Mean changes (groups 1-2) were: creatinine 172 +/- 59, 158 +/- 51, 153 +/- 57 mumol/L (at baseline, 6 and 12 months, respectively; p < 0.001). Cyclosporine daily dose: 219 +/- 37, 166 +/- 46, 176 +/- 98 mg, respectively (p < 0.001). Cyclosporine blood concentration: 151 +/- 40, 103 +/- 41, 83 +/- 34 ng/mL, respectively (p < 0.004). Prednisone daily dose: 8.3 +/- 2, 5.2 +/- 1, 4.1 +/- 1 mg, respectively (p < 0.001). Cellular rejection (group 3) was successfully treated (86%) but the outcome of VGD did not improve after the switch (group 4). Our limited experience (with caution) confirms the reported benefits of MMF particularly attenuating renal insufficiency.
Collapse
Affiliation(s)
- Nicolás Manito
- Heart Transplant Unit, Bellvitge Hospital, University of Barcelona, Barcelona, Spain.
| | | | | | | | | | | | | |
Collapse
|
4
|
Sanchez V, Delgado JF, Morales JM, Tello R, Gómez MA, Escribano P, de la Cámara AG, de la Calzada CS. Chronic cyclosporine-induced nephrotoxiciy in heart transplant patients: Long-term benefits of treatment with mycophenolate mofetil and low-dose cyclosporine. Transplant Proc 2004; 36:2823-5. [PMID: 15621159 DOI: 10.1016/j.transproceed.2004.09.035] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Cyclosporine-induced nephropathy is a major limitation in heart transplant patients. Cyclosporine dose reduction may lead to substantial early improvement in renal function. Our aim was to study the long-term benefits of therapy with low doses of cyclosporine plus mycophenolate mofetil in heart transplant patients with drug-induced nephrotoxicity. METHODS Twenty-five adult heart transplant patients with cyclosporine-related nephrotoxicity (mean posttransplant = 41.7 +/- 25.7 months) were included in the retrospective analysis (22 men, mean age = 58.8 +/- 7.9 years.). Patients were switched from azathioprine to mycophenolate mofetil (1 to 3 g/d), followed by a stepwise reduction in cyclosporine dosage (trough cyclosporine level maintained around 100 ng/mL). Renal function was determined by serial measurements of serum creatinine and glomerular filtration rate at 3-month intervals. RESULTS With a mean follow-up of 30 +/- 13 months, the baseline creatinine of 2.37 +/- 0.5 mg/dL decreased to 1.59 +/- 0.40 mg/dL (P < .0001). The baseline glomerular filtration rate of 36.77 +/- 10.10 mL/min improved to 54.98 +/- 13.80 mL/min (P < .0001). The cyclosporine level was the unique independent variable associated with renal functional improvement (partial R(2) = 0.4). Within the first 3 months, renal function displayed a rapid improvement after conversion to mycophenolate mofetil (P < .001), reaching a plateau, without further significant improvement over the course of time. CONCLUSIONS Cyclosporine-induced nephrotoxicity is not a progressive, irreversible disease. Reduction in cyclosporine exposure by addition of mycophenolate mofetil is useful to achieve long-term renal functional improvement, thereby avoiding chronic renal failure. A unique, significant factor associated with this improvement was the reduction in cyclosporine level.
Collapse
Affiliation(s)
- V Sanchez
- Heart Failure Unit, Hospital Doce de Octubre, 28041 Madrid, Spain
| | | | | | | | | | | | | | | |
Collapse
|
5
|
Baryalei M, Zenker D, Pieske B, Tondo K, Dalichau H, Aleksic I. Renal function and safety of heart transplant recipients switched to mycophenolate mofetil and low-dose cyclosporine. Transplant Proc 2003; 35:1539-42. [PMID: 12826215 DOI: 10.1016/s0041-1345(03)00360-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND We evaluated cyclosporine (CSA) dose reduction and mycophenolate mofetil (MMF) treatment versus maintained CSA dosage and azathioprine (AZA) in HTX regarding renal function and safety from CSA nephrotoxicity (creatinine > 1.7 mg/dL). METHODS Fourteen recipients (group 1: 12 men, 2 women) with CSA-based immunosuppression (plus azathioprine and/or steroids) were started on 2000 mg MMF/d. Azathioprine was discontinued and CSA tapered to trough whole blood levels of 70 to 120 microg/L. Ten recipients (group 2: seven men, three women) were maintained on their CSA dosages. Creatinine clearance, serum creatinine, uric acid, urea nitrogen, and rejection were monitored. RESULTS Mean age was 58 (range 44 to 69 years) and 48 years (range 24 to 61 years) in groups 1 and 2, respectively. In group 1 creatinine fell from 2.7 +/- 0.8 to 1.9 +/- 0.5 mg/dL (baseline vs control 2: P =.001); uric acid and urea nitrogen remained constant. CSA levels decreased from 173 +/- 56 to 110 +/- 33 microg/L (P =.02). In group 2 creatinine (2.4 +/- 0.7 vs 2.3 +/- 0.5 mg/dL), uric acid, urea nitrogen, and CSA levels remained constant. Comparison between groups showed higher creatinine clearance (50 +/- 18 vs 29 +/- 14 mL/min; group 1 vs group 2: P =.02), lower CSA levels (110 +/- 33 vs 161 +/- 35 microg/L; P <.001) and a trend toward lower serum creatinine (1.9 +/- 0.5 vs 2.3 +/- 0.5 mg/dL, P =.077). There were two rejections >/= 1B according to ISHLT in the study and four in the control group. Two deaths occurred in each group. CONCLUSIONS Conversion from AZA to MMF after CSA reduction improves creatinine clearance in HTX recipients and reduces serum creatinine. No negative effect on patient safety was identified by rejection rate or survival.
Collapse
Affiliation(s)
- M Baryalei
- Department of Thoracic and Cardiovascular Surgery, Georg-August-University, Göttingen, Germany
| | | | | | | | | | | |
Collapse
|
6
|
Tedoriya T, Keogh AM, Kusano K, Savdie E, Hayward C, Spratt PM, Wilson M, Macdonald PS. Reversal of chronic cyclosporine nephrotoxicity after heart transplantation-potential role of mycophenolate mofetil. J Heart Lung Transplant 2002; 21:976-82. [PMID: 12231368 DOI: 10.1016/s1053-2498(02)00422-9] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Chronic cyclosporine nephrotoxicity (CCN) after heart transplantation is a progressive condition that may lead to end-stage renal failure. The extent to which CCN is reversible with reduction or withdrawal of cyclosporine therapy is unknown. The aim of this study was to assess the reversibility of CCN and to assess the safety and efficacy of a strategy of cyclosporine dosage reduction, combined with conversion from azathioprine to mycophenolate mofetil (AZA/MMF switch) to maintain immunosuppression. METHODS An AZA/MMF switch followed by cyclosporine dose reduction was undertaken in 30 heart transplant recipients (23 men, 7 women; mean age, 54 +/- 2 years) with established CCN at a mean of 90 +/- 9 months after transplantation (range, 17-182 months). The mean maintenance MMF dosage was 2.3 +/- 0.1 g/day (n = 28). Mean cyclosporine dosage was decreased from 2.3 +/- 0.2 mg/kg/day before AZA/MMF switch to 1.6 +/- 0.2 mg/kg/day. RESULTS Three patients (10%) were withdrawn from MMF, 2 because of diarrhea and the third because of severe pneumonia that developed within 2 weeks of AZA/MMF switch. All 3 were restabilized with AZA. One patient (4%) experienced acute rejection 7 months after AZA/MMF switch. This resolved after an oral pulse of prednisolone. Systemic infections occurred in 6 patients within 12 months of AZA/MMF switch. Actuarial survival 1 year after AZA/MMF switch was 86% +/- 6%. One patient died of infection and 3 of other causes. Serum creatinine concentration decreased from 248 +/- 15 micromol/liter before cyclosporine dosage reduction to 193 +/- 11 micromol/liter and 206 +/- 19 micromol/liter at 3 and 12 months after dosage reduction (both p < 0.01 versus baseline, n = 23). Of the 23 patients who remained on MMF at 12 months, a decrease in serum creatinine was documented in 19 (83%). Four patients showed no improvement or showed deterioration in renal function, and three of these progressed to end-stage renal failure. CONCLUSIONS Chronic cyclosporine nephrotoxicity has a significant reversible component in most patients. A strategy of AZA/MMF switch combined with cyclosporine dosage reduction is generally well tolerated and results in short-term improvement in renal function in most patients. Close vigilance is required during the first 12 months after AZA/MMF switch because both acute rejection and infection may occur.
Collapse
Affiliation(s)
- Takeo Tedoriya
- Heart and Lung Transplant Unit, St. Vincent's Hospital, Sydney, Australia
| | | | | | | | | | | | | | | |
Collapse
|