Improved survival in patients with type 1 diabetes mellitus after renal transplantation compared with hemodialysis: a case-control study

Laparoscopic Hysterectomy for Uterine Adenomyosis in Patients With a History of Renal Transplant: A Case Report and Review of Literature

Renal transplantation is a viable treatment option for patients with end-stage kidney disease; however, it requires careful surgical manipulation as the transplanted kidney is placed in the iliac fossa. Herein, we report a case of a 41-year-old female with a history of two renal transplants who presented with hypermenorrhea and dysmenorrhea. Computed tomography revealed transplanted kidneys in the bilateral iliac fossae (right atrophic), and magnetic resonance imaging showed uterine adenomyosis. Three-dimensional computed tomography was performed to determine the relationship between the arteriovenous vessels, iliac vessels, and ureter of the transplanted left kidney. A diamond-shaped trocar was inserted while monitoring the transplanted kidney. Total laparoscopic hysterectomy and bilateral salpingectomy were performed without any perioperative complications. Immunosuppressants were continued postoperatively. Laparoscopic surgery for gynecological diseases can be advantageous and should be considered in patients who underwent renal transplants.

The Importance Of Avoiding Time-Dependent Bias When Testing The Prognostic Value Of An Intervening Event - Two Acute Cellular Rejection Examples In Intestinal Transplantation

In testing the prognostic value of the occurrence of an intervening event (clinical event that occurs post-transplant), 3 proper statistical methodologies for testing its prognostic value exist (time dependent covariate, landmark, and semi-Markov modelling methods). However, time-dependent bias has appeared in many clinical reports, whereby the intervening event is statistically treated as a baseline variable (as if it occurred at transplant). Using a single-center cohort of 445 intestinal transplant cases to test the prognostic value of 1^st acute cellular rejection (ACR) and severe (grade of) ACR on the hazard rate of developing graft loss, we demonstrate how the inclusion of such time-dependent bias can lead to severe underestimation of the true hazard ratio (HR). The (statistically more powerful) time dependent covariate method in Cox's multivariable model yielded significantly unfavorable effects of 1^st ACR (P<.0001; HR=2.492) and severe ACR (P<.0001; HR=4.531). In contrast, when using the time-dependent biased approach, multivariable analysis yielded an incorrect conclusion for the prognostic value of 1^st ACR (P=.31, HR=0.877, 35.2% of 2.492) and a much smaller estimated effect of severe ACR (P=.0008; HR=1.589; 35.1% of 4.531). In conclusion, this study demonstrates the importance of avoiding time-dependent bias when testing the prognostic value of an intervening event.

Impact of kidney transplant on post-operative morbidity and mortality in patients with pre-operative cardiac dysfunction

BACKGROUND

Several studies show an increase in complications, both cardiac and non-cardiac, and a higher mortality in patients with preexisting cardiac disease when they undergo elective surgery. Due to the high incidence of cardiac dysfunction in patients with concomitant chronic kidney disease, we wanted to determine if the same negative impact is demonstrated in patients undergoing kidney transplantation.

METHODS

A retrospective analysis was done on 582 patients who underwent kidney transplant from a single transplant center between 2014 and 2019. Participants for this study were divided into two groups based on cardiac ejection fraction: normal EF (≥40%) (n = 540) and low EF (<40%) (n = 33); exclusion criteria included patients undergoing multi-organ transplants (n = 9). Characteristics and outcomes of patients were compared before and after transplant using chi-square tests for categorical measures, and either Kruskal-Wallis or paired Student's t tests for continuous measures. Overall survival (OS) between groups was assessed using the Kaplan-Meier test. We compared outcomes between the normal EF and low EF groups using logistic regression in raw data, and propensity score matched sample and inverse-probability-weighting to mitigate selection bias.

RESULTS

There was no significant difference in survival between patients in the low EF and normal EF groups (p = .33). Among patients with low EF, mean EF after transplant significantly improved (mean: 55.83% ± 5.75%) compared to mean EF before transplant (38.28% ± 7.35%), (p = < .0001). Of the patients with a low EF before transplant, 1 in 5 had a history of CAD, compared to only 1 in 10 among those patients with a normal EF, p = .0657. Post-transplant complications were comparable between the groups.

CONCLUSION

Patients undergoing kidney transplantation with a low ejection fraction do not demonstrate an increased incidence of morbidity or mortality in the peri- and post-transplant follow-up compared with patients with a normal ejection fraction. Cardiac events post-transplantation is also comparable between the two groups. Of note, patients with a low EF have a significantly improved EF after kidney transplant which is likely a function of improvement in their physiologic state after the kidney transplant.

Survival for waitlisted kidney failure patients receiving transplantation versus remaining on waiting list: systematic review and meta-analysis

OBJECTIVES

To investigate the survival benefit of transplantation versus dialysis for waitlisted kidney failure patients with a priori stratification.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Online databases MEDLINE, Ovid Embase, Web of Science, Cochrane Collection, and ClinicalTrials.gov were searched between database inception and 1 March 2021.

INCLUSION CRITERIA

All comparative studies that assessed all cause mortality for transplantation versus dialysis in patients with kidney failure waitlisted for transplant surgery were included. Two independent reviewers extracted the data and assessed the risk of bias of included studies. Meta-analysis was done using the DerSimonian-Laird random effects model, with heterogeneity investigated by subgroup analyses, sensitivity analyses, and meta-regression.

RESULTS

The search identified 48 observational studies with no randomised controlled trials (n=1 245 850 patients). In total, 92% (n=44/48) of studies reported a long term (at least one year) survival benefit associated with transplantation compared with dialysis. However, 11 of those studies identified stratums in which transplantation offered no statistically significant benefit over remaining on dialysis. In 18 studies suitable for meta-analysis, kidney transplantation showed a survival benefit (hazard ratio 0.45, 95% confidence interval 0.39 to 0.54; P<0.001), with significant heterogeneity even after subgroup/sensitivity analyses or meta-regression analysis.

CONCLUSION

Kidney transplantation remains the superior treatment modality for most patients with kidney failure to reduce all cause mortality, but some subgroups may lack a survival benefit. Given the continued scarcity of donor organs, further evidence is needed to better inform decision making for patients with kidney failure.

STUDY REGISTRATION

PROSPERO CRD42021247247.

Renal transplant evaluation: multimodality imaging of post-transplant complications

With advancements in surgical techniques and immuno-suppression, renal transplantation is established as the most effective treatment option in patients with end-stage renal disease. Early detection of renal allograft complications is important for long-term graft survival. Late clinical presentation often causes diagnostic delays till the time allograft failure is advanced and irreversible. Imaging plays a key role in routine surveillance and in management of acute or chronic transplant dysfunction. Multimodality imaging approach is important with ultrasound-Doppler as the first-line imaging study in immediate, early and late post-transplant periods. Additional imaging studies are often required depending on clinical settings and initial ultrasound. Renal functional MRI is a rapidly growing field that has huge potential for early diagnosis of transplant dysfunction. Multiparametric MRI may be integrated in clinical practice as a noninvasive and comprehensive "one-stop" modality for early diagnosis and longitudinal monitoring of renal allograft dysfunctions, which is essential for guiding appropriate interventions to delay or prevent irreversible renal damage. With rapidly increasing numbers of renal transplantation along with improved patient survival, it is necessary for radiologists in all practice settings to be familiar with the normal appearances and imaging spectrum of anatomical and functional complications in a transplant kidney. Radiologist"s role as an integral part of multidisciplinary transplantation team continues to grow with increasing numbers of successful renal transplantation programs across the globe.

Quantifying spillover benefits in value assessment: a case study of increased graft survival on the US kidney transplant waitlist

AIM

To quantify the wider impacts of increased graft survival on the size of the kidney transplant waitlist and health and economic outcomes.

MATERIALS AND METHODS

The analysis employed known steady-state solutions to a double-queueing system as well as simulations of this system. Baseline input parameters were sourced from the Organ Procurement and Transplant Network and the United States Renal Data System. Three increased graft survival scenarios were modeled: decreases in repeat transplant candidates joining the waitlist of 25%, 50%, and 100%.

RESULTS

Under the three scenarios, we estimated that the US waitlist size would decrease from 91,822 to 85,461 (6.9% decrease), 80,073 (12.8% decrease), and 69,340 (24.4% decrease), respectively. Patient outcomes improved, with lifetime quality-adjusted life years (QALYs) for a 1-year cohort of transplant recipients increasing by 10,010, 16,888, and 43,345 over the three scenarios. Discounted lifetime costs for the cohort in the new steady state were lower by $1.6 billion, $2.3 billion, and $9.0 billion for each scenario, respectively. Spillover impacts (i.e. benefits that accrued beyond the patients who directly experienced increased graft survival) accounted for 41-48% of the QALY gains and ranged from cost increases of 3.3% to decreases of 5.5%.

LIMITATIONS

The model is a simplification of reality and does not account for the full degree of patient heterogeneity occurring in the real world. Health economic outcomes are extrapolated based on the assumption that the median patient is representative of the overall population.

CONCLUSIONS

Increasing graft survival reduces demand from repeat transplants candidates, allowing additional candidates to receive transplants. These spillover impacts decrease waitlist size and shorten wait times, leading to improvements in graft and patient survival as well as quality-of-life. Cost-effectiveness analyses of treatments that increase kidney graft survival should incorporate spillover benefits that accrue beyond the direct recipient of an intervention.

Implementation of the Nursing Process Based on Betty Neuman Model in Kidney Transplant Patients: A Study in the Field

Background: Proper use of nursing models and theories is an important step in improving patient care standards and quality of life. The growing trend of kidney failure and subsequent kidney transplantation in the country shows the importance of creating a proper structure in nursing patient care for transplant patients and recognizing the stressors that affect these patients. Objectives: This study aimed to investigate the ability of the Betty Neuman model to provide a comprehensive model for nursing care of clients undergoing kidney transplantation. Methods: This clinical and clinical study was performed on the client of the kidney transplant candidate based on the application of Betty Neuman system theory. During the data collection, the interactions between the client’s five variables were examined and the stressors and resources in the internal, inter, and extra-individual domains were identified. Nursing diagnoses were created in accordance with the North American International Nursing Diagnostics Association (2018 - 2018) classification, and then nursing interventions were designed and implemented at three levels of prevention. Results: The results of the study of physiological, psychological, social, evolutionary, and spiritual variables, as well as interpersonal and extra-individual stressors, were 7 potential and actual nursing diagnoses. Conclusions: Designing and applying a nursing process based on this model is a holistic and systematic attitude toward the client that requires proper, efficient, and evidence-based nursing care but increases the need for nursing human resources.

Impact of Aortoiliac Stenosis on Graft and Patient Survival in Kidney Transplant Recipients Using the TASC II Classification

BACKGROUND

Patients with end-stage renal disease and aortoiliac stenosis are often considered ineligible for kidney transplantation, although kidney transplantation has been acknowledged as the best therapy for end-stage renal disease. The clinical outcomes of kidney transplantation in patients with aortoiliac stenosis are not well-studied. This study aimed to assess the impact of aortoiliac stenosis on graft and patient survival.

METHODS

This retrospective, single-center study included kidney transplant recipients transplanted between January 1, 2000, and December 31, 2016, who received contrast-enhanced imaging. Patients with aortoiliac stenosis were classified using the Trans-Atlantic Inter-Society Consensus (TASC) II classification and categorized as having TASC II A/B lesions or having TASC II C/D lesions. Patients without aortoiliac stenosis were functioning as controls.

RESULTS

A total number of 374 patients was included in this study (n = 88 with TASC II lesions, n = 286 as controls). Death-censored graft survival was similar to the controls. Patient and uncensored graft survival was decreased in patients with TASC II C/D lesions (log-rank test P < 0.001). Patients with TASC II C/D lesions had a higher risk of 90-day mortality (hazard ratio, 3.96; 95% confidence interval, 1.12-14.04). In multivariable analysis, having a TASC II C/D lesion was an independent risk factor for mortality (hazard ratio, 3.25; 95% confidence interval, 1.87-5.67; P < 0.001). Having any TASC II lesion was not a risk factor for graft loss (overall P = 0.282).

CONCLUSIONS

Kidney transplantation in patients with TASC II A/B is feasible and safe without increased risk of perioperative mortality. TASC II C/D decreases patient survival. Death-censored graft survival is unaffected.

The economic burden of kidney graft failure in the United States

Despite improvements in outcomes for kidney transplant recipients in the past decade, graft failure continues to impose substantial burden on patients. However, the population-wide economic burden of graft failure has not been quantified. This study aims to fill that gap by comparing outcomes from a simulation model of kidney transplant patients in which patients are at risk for graft failure with an alternative simulation in which the risk of graft failure is assumed to be zero. Transitions through the model were estimated using Scientific Registry of Transplant Recipients data from 1987 to 2017. We estimated lifetime costs, overall survival, and quality-adjusted life-years (QALYs) for both scenarios and calculated the difference between them to obtain the burden of graft failure. We find that for the average patient, graft failure will impose additional medical costs of $78 079 (95% confidence interval [CI] $41 074, $112 409) and a loss of 1.66 QALYs (95% CI 1.15, 2.18). Given 17 644 kidney transplants in 2017, the total incremental lifetime medical costs associated with graft failure is $1.38B (95% CI $725M, $1.98B) and the total QALY loss is 29 289 (95% CI 20 291, 38 464). Efforts to reduce the incidence of graft failure or to mitigate its impact are urgently needed.

Reduced risk of new onset stroke after kidney transplantation in Asian dialysis patients: a propensity score-matched, competing risk study in Taiwan

BACKGROUND

Kidney transplantation (KT) has been found to reduce cardiovascular events and mortality in chronic dialysis patients. There is little data, however, regarding the risk reduction of cerebrovascular events after KT in Asian populations. This study evaluates the risk of cerebrovascular events after KT in Taiwan.

METHODS

Tapping Taiwan's National Health Insurance claims data of patients with a diagnosis of end-stage renal disease (ESRD), we enrolled all KT recipients from 1999 to 2011 (n = 2908). For each KT patient, four controls (patients also diagnosed with ESRD) without KT were propensity matched by birth date, sex, selected comorbidities and duration of dialysis. All subjects were followed to the end of 2011.

RESULTS

The incidence rate for stroke in the KT recipients and comparison group were 52.63 and 137.26 per 10 000 person-years, respectively. After adjustment for age, gender and comorbidities with competing mortality, KT recipients had 60% reduction in all kinds of stroke, compared to those who did not receive procedure. They were found to have a 48 and 74% reduction in ischemic and hemorrhagic stroke risk, respectively. Subgroup analyses also showed similar trends in the improvement of stroke after KT. While elderly patients, men, and those with diabetes, hypertension and coronary artery disease are at increased risk for stroke, our log-rank test revealed those that received KT had significantly lower cumulative incidence rates of stroke than those that did not (P < 0.001).

CONCLUSIONS

KT was associated with reduced risk of new onset stroke in chronic dialysis patients in Taiwan.

Effect of post-transplant glycemic control on long-term clinical outcomes in kidney transplant recipients with diabetic nephropathy: A multicenter cohort study in Korea

PURPOSE

Diabetic nephropathy is the leading cause of end stage renal disease. The number of kidney transplantation (KT) due to diabetic nephropathy is increasing and there is debate on glycemic control after KT. In this study, we used a multi-center database to determine the relationship between post-transplant glycemic control and the outcomes of KT in patients with diabetic nephropathy.

METHODS

We conducted a retrospective chart review of kidney transplant recipients (KTRs) with diabetic nephropathy from three tertiary hospitals to analyze the association between post-transplant glycemic control and the clinical outcomes of graft failure, including patient death and biopsy-proven acute rejection (BPAR). We assessed time-averaged glucose level and hemoglobin A1c (HbA1c) for 36 months after KT.

RESULTS

Among 3,538 KTRs, a total of 476 patients received kidney transplantation because of diabetic nephropathy. Mean time-averaged glucose and HbA1c levels were 147 ± 46 mg/dl and 7.7 ± 1.5%, respectively. Patients with diabetic nephropathy had poor graft and patient survival rate compared with non-diabetic nephropathy. Among KTRs with diabetic nephropathy, the highest quartile of time-averaged glucose was related to poor graft outcomes and the 3rd quartile of time-averaged HbA1c was associated with significantly better graft outcomes than the 1st, 2nd or 4th quartiles. There were no significant differences in the risk of BPAR across the 4 quartiles of glucose and HbA1c.

CONCLUSIONS

Strict glycemic control before KT might not be related to successful outcomes but poor glycemic control after KT is associated with poor graft outcomes. There was no significant relationship between pre- or post-transplant glycemic control and BPAR.

Superior outcomes of kidney transplantation compared with dialysis: An optimal matched analysis of a national population-based cohort study between 2005 and 2008 in Korea

Data regarding kidney transplantation (KT) and dialysis outcomes are rare in Asian populations. In the present study, we evaluated the clinical outcomes associated with KT using claims data from the Korean national public health insurance program. Among the 35,418 adult patients with incident dialysis treated between 2005 and 2008 in Korea, 1539 underwent KT. An optimal balanced risk set matching was attempted to compare the transplant group with the control group in terms of the overall survival and major adverse cardiac event-free survival. Before matching, the dialysis group was older and had more comorbidities. After matching, there were no differences in age, sex, dialysis modalities, or comorbidities. Patient survival was significantly better in the transplant group than in the matched control group (P < 0.001). In addition, the transplant group showed better major adverse cardiac event-free survival than the dialysis group (P < 0.001; hazard ratio, 0.49; 95% confidence interval, 0.32-0.75). Korean patients with incident dialysis who underwent long-term dialysis had significantly more cardiovascular events and higher all-cause mortality rates than those who underwent KT. Thus, KT should be more actively recommended in Korean populations.

Pancreatic Transplantation: Evaluation and Management

More than 2 million people in the United States have type 1 diabetes mellitus. Pancreatic transplantation has emerged as the single most effective means of achieving normal glucose homeostasis in this patient population. Newer immunosuppressive agents and surgical techniques continue to evolve, resulting in improved long-term graft and patient survival. Herein, an understanding of the evaluation, technical aspects, and perioperative management of pancreas transplantation is outlined.

Factors Affecting the Selection of Patients on Waiting List: A Single Center Study

INTRODUCTION

There is an increasing gap between organ supply and demand for cadaveric transplantation in our country. Our aim was to evaluate factors affecting selection of patients on waiting list at our hospital.

METHOD

Patients who have been waiting on list and who were transplanted were compared in order to find factors, which affected the selection of patients. Non-parametric Mann-Whitney U test was used for comparison and cox regression analysis was used to find the risk factors that decrease the probability of transplantation in this retrospective case-control study.

RESULTS

Patients in the transplanted group were significantly younger, had relatively lower body mass index than the awaiting group. Cardiovascular diseases were more in the awaiting group than the transplanted group. There was no patient with diabetes in transplanted group, despite fifteen diabetic patients were in the awaiting group. Selected patients had lower immunologic risk with regard to peak panel reactive antibody levels. No significant difference was found for gender, hypertension, hyperlipidemia, viral serology, time spent on dialysis and on waiting list between two groups. With cox regression analysis female gender, older age, diabetes mellitus, high body mass index, positive hepatitis B serology and high levels of peak class 1-2 peak panel reactive antibody positivity were found as risk factors that decrease the probability of transplantation.

CONCLUSION

A tendency for selection of low risk patients was found with this study. Time and energy consuming complications and short allograft survival after transplantation in high risk patients and the scarcity of cadaveric pool in our country may contribute to this tendency.

Explore Transplant at Home: a randomized control trial of an educational intervention to increase transplant knowledge for Black and White socioeconomically disadvantaged dialysis patients

BACKGROUND

Compared to others, dialysis patients who are socioeconomically disadvantaged or Black are less likely to receive education about deceased donor kidney transplant (DDKT) and living donor kidney transplant (LDKT) before they reach transplant centers, often due to limited availability of transplant education within dialysis centers. Since these patients are often less knowledgeable or ready to pursue transplant, educational content must be simplified, made culturally sensitive, and presented gradually across multiple sessions to increase learning and honor where they are in their decision-making about transplant. The Explore Transplant at Home (ETH) program was developed to help patients learn more about DDKT and LDKT at home, with and without telephone conversations with an educator.

METHODS AND STUDY DESIGN

In this randomized controlled trial (RCT), 540 low-income Black and White dialysis patients with household incomes at or below 250 % of the federal poverty line, some of whom receive financial assistance from the Missouri Kidney Program, will be randomly assigned to one of three education conditions: (1) standard-of-care transplant education provided by the dialysis center, (2) patient-guided ETH (ETH-PG), and (3) health educator-guided ETH (ETH-EG). Patients in the standard-of-care condition will only receive education provided in their dialysis centers. Those in the two ETH conditions will receive four video and print modules delivered over an 8 month period by mail, with the option of receiving supplementary text messages weekly. In addition, patients in the ETH-EG condition will participate in multiple telephonic educational sessions with a health educator. Changes in transplant knowledge, decisional balance, self-efficacy, and informed decision making will be captured with surveys administered before and after the ETH education.

DISCUSSION

At the conclusion of this RCT, we will have determined whether an education program administered to socioeconomically disadvantaged dialysis patients, over several months directly in their homes, can help more individuals learn about the options of DDKT and LDKT. We also will be able to examine the efficacy of different educational delivery approaches to further understand whether the addition of a telephone educator is necessary for increasing transplant knowledge.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02268682.

Negative impact of underlying non-insulin-dependent diabetes mellitus nephropathy on long-term allograft survival in kidney transplantation: a 10-year analysis from a single center

INTRODUCTION

We analyzed the relationship between underlying nephropathy and long-term outcomes in kidney transplant recipients.

METHODS

We retrospectively analyzed data from 678 patients who underwent kidney transplantation (KTx) between 1998 and 2011. Recipients with 13 major nephropathies were evaluated for graft and patient survival, and causes of graft loss.

RESULTS

The best 10-year graft survival rates (100%) were in the patients with autosomal-dominant polycystic kidney disease, preeclampsia, Alport syndrome, and purpura nephritis. The worst rate (50.8%) was in patients with non-insulin-dependent diabetes mellitus nephropathy (NIDDMN; P = .039). Causes of graft-loss in the NIDDM patients included chronic rejection (6 cases), acute rejection (3 cases), infection (2 cases), and cardiovascular event (2 cases). Significant risk factors for graft loss were donor age (P < .01) and NIDDMN (P < .01).

CONCLUSION

Underlying NIDDMN before KTx was a significant risk factor for long-term graft function. Immunologic factors and nonimmunologic factors influenced the long-term outcomes in patients with underlying NIDDMN.

MDCT evaluation of potential living renal donor, prior to laparoscopic donor nephrectomy: What the transplant surgeon wants to know?

As Laparoscopic Donor Nephrectomy (LDN) offers several advantages for the donor such as lesser post-operative pain, fewer cosmetic concerns and faster recovery time, there is growing global trend towards LDN as compared to open nephrectomy. Comprehensive pre-LDN donor evaluation includes assessment of renal morphology including pelvi-calyceal and vascular system. Apart from donor selection, evaluation of the regional anatomy allows precise surgical planning. Due to limited visualization during laparoscopic renal harvesting, detailed pre-transplant evaluation of regional anatomy, including the renal venous anatomy is of utmost importance. MDCT is the modality of choice for pre-LDN evaluation of potential renal donors. Apart from appropriate scan protocol and post-processing methods, detailed understanding of surgical techniques is essential for the Radiologist for accurate image interpretation during pre-LDN MDCT evaluation of potential renal donors. This review article describes MDCT evaluation of potential living renal donor, prior to LDN with emphasis on scan protocol, post-processing methods and image interpretation. The article laid special emphasis on surgical perspectives of pre-LDN MDCT evaluation and addresses important points which transplant surgeons want to know.

New hepatitis B vaccine formulated with an improved adjuvant system

A new hepatitis B vaccine (FENDrix, GlaxoSmithKline Biologicals) containing as active substance 20 microg of recombinant hepatitis B virus surface antigen produced in Saccharomyces cerevisiae has recently been licensed in Europe. It is prepared with a novel adjuvant system: aluminum phosphate and 3-O-desacyl-4 -monophosphoryl lipid A. It is intended for use in adults from the age of 15 years onwards for active immunization against hepatitis B virus infection for patients with renal insufficiency (including prehemodialysis and hemodialysis patients). It is applied in a four-dose scheme: day 0, month 1, 2 and 6 after day 0. Due to the improved adjuvant system it induces higher antibody concentrations that reach protective levels in a faster fashion. Furthermore, due to higher titers reached after the primary immunization course, protective levels are retained for a longer period of time. Vaccination with FENDrix induces more transient local symptoms, with pain at the injection site being the most frequently reported solicited local symptom. Other symptoms such as fatigue, gastrointestinal disorders and headaches were also frequently observed but resolved without sequelae. The higher risk of hepatitis B transmission in patients with end-stage renal disease and the often immunocompromised status of these patients afford a tailored vaccination strategy that, up to now, has consisted of injecting double doses of ordinary hepatitis B vaccines. With the introduction of FENDrix there now exists an efficient alternative with superior immunogenicity that is, despite comparatively higher reactogenicity, well tolerated.

Novel views on new-onset diabetes after transplantation: development, prevention and treatment

New-onset diabetes after transplantation (NODAT) is associated with increased risk of allograft failure, cardiovascular disease and mortality, and therefore, jeopardizes the success of renal transplantation. Increased awareness of NODAT and the prediabetic states (impaired fasting glucose and impaired glucose tolerance, IGT) has fostered previous and present recommendations, based on the management of type 2 diabetes mellitus (T2DM). Unfortunately, the idea that NODAT merely resembles T2DM is potentially misleading, because the opportunity to initiate adequate anti-hyperglycaemic treatment early after transplantation might be given away for 'tailored' immunosuppression in patients who have developed NODAT or carry personal risk factors. Risk factor-independent mechanisms, however, seem to render postoperative hyperglycaemia with subsequent development of overt or 'full-blown' NODAT, the unavoidable consequence of the transplant and immunosuppressive process itself, at least in many cases. A proof of the concept that timely preventive intervention with exogenous insulin against post-transplant hyperglycaemia may decrease NODAT was recently provided by a small clinical trial, which is awaiting confirmation from a multicentre study. However, because early insulin therapy aimed at beta-cell protection seems to contrast the currently recommended, stepwise approach of 'watchful waiting' prior to pancreatic decompensation, we here aim at reviewing recent concepts regarding the development, prevention and treatment of NODAT, some of which seem to challenge the traditional view on T2DM and NODAT. In summary, we suggest a novel, risk factor-independent management approach to NODAT, which includes glycaemic monitoring and anti-hyperglycaemic treatment in virtually everybody after transplantation. This approach has widespread implications for future research and is intended to tackle NODAT and also ultimately cardiovascular disease.

Access to renal transplantation in the diabetic population-effect of comorbidities and body mass index

BACKGROUND

In this study, we hypothesized that higher level of comorbidity and greater body mass index (BMI) may mediate the association between diabetes and access to transplantation.

METHODS

We used data from the United States Renal Data System (01/01/2000-24/09/2007; n = 619,151). We analyzed two outcomes using Cox model: (i) time to being placed on the waiting list or transplantation without being listed and (ii) time to transplantation after being listed. Two primary Cox models were developed based on different levels of adjustment.

RESULTS

In Cox models adjusted for a priori defined potential confounders, history of diabetes was associated with reduced transplant access (compared with non-diabetic population) - both for wait-listing/transplant without being listed (hazard ratio, HR = 0.80, p < 0.001) and for transplant after being listed (HR = 0.72, p < 0.001). In Cox models adjusted for BMI and comorbidity index along with the potential confounders, history of diabetes was associated with shorter time to wait-listing or transplantation without being listed (HR = 1.07, p < 0.001), and there was no significant difference in time to transplantation after being listed (HR = 1.01, p = 0.42).

CONCLUSION

We demonstrated that higher level of comorbidity and greater BMI mediate the association between diabetes and reduced access to transplantation.

Systematic review: kidney transplantation compared with dialysis in clinically relevant outcomes

Individual studies indicate that kidney transplantation is associated with lower mortality and improved quality of life compared with chronic dialysis treatment. We did a systematic review to summarize the benefits of transplantation, aiming to identify characteristics associated with especially large or small relative benefit. Results were not pooled because of expected diversity inherent to observational studies. Risk of bias was assessed using the Downs and Black checklist and items related to time-to-event analysis techniques. MEDLINE and EMBASE were searched up to February 2010. Cohort studies comparing adult chronic dialysis patients with kidney transplantation recipients for clinical outcomes were selected. We identified 110 eligible studies with a total of 1 922 300 participants. Most studies found significantly lower mortality associated with transplantation, and the relative magnitude of the benefit seemed to increase over time (p < 0.001). Most studies also found that the risk of cardiovascular events was significantly reduced among transplant recipients. Quality of life was significantly and substantially better among transplant recipients. Despite increases in the age and comorbidity of contemporary transplant recipients, the relative benefits of transplantation seem to be increasing over time. These findings validate current attempts to increase the number of people worldwide that benefit from kidney transplantation.

Diabetes as the cause of end-stage renal disease affects the pattern of post kidney transplant rehospitalizations

INTRODUCTION

Although there are reports that link diabetes-induced end-stage renal disease (ESRD) with several post renal transplantation complications and conditions, few studies have directly focused on this issue. This study compared the pattern of rehospitalizations after renal transplantation among diabetic versus nondiabetic ESRD patients, measuring causes, length of stay, outcomes and costs.

METHODS

We retrospectively reviewed 366 randomly selected rehospitalization records of kidney transplant recipients between 1994 and 2006, including 69 who underwent renal transplantation due to diabetic nephropathy and 297, due to nondiabetic ESRD. We compared the two groups with respect to demographic and clinical variables: donor source, readmission pattern, rehospitalization cause, time interval between transplantation and hospitalization (T-H time), length of hospital stay (LOS), and intensive care unit (ICU) admission, hospital charges, and inpatient outcomes of graft loss and mortality.

RESULTS

The diabetes group, compared with nondiabetic group, had a greater mean age (53 +/- SD vs. 39 +/- SD years), proportion of admissions due to infections (44.9% vs. 32%) or renal dysfunction (14.5% vs. 29.6%), mean hospital charges ($5056 vs. $3046), and hospital mortality (18% vs. 4.3%; P<.05). Diabetic patients were readmitted sooner after transplantation than nondiabetic patients (11 vs. 18 months; P<.05). There was no difference between the groups with regard to gender, donor source, LOS, ICU admission, and graft loss.

CONCLUSION

The etiology of ESRD should be considered for scheduling post renal transplantation follow-up. Renal transplant recipients with diabetes-induced ESRD need further attention in follow-up programs.

Improved survival rate in patients with diabetes and end-stage renal disease in Denmark

AIMS/HYPOTHESIS

We investigated the survival rate of Danish diabetic patients with end-stage renal disease (ESRD) between 1990 and 2005 and evaluated possible predictors of survival rate.

MATERIALS AND METHODS

Data were obtained from the Danish National Register on Dialysis and Transplantation and from the Scandiatransplant database. Survival rates in different patient groups and association with age, sex, calendar time, waiting-list status and renal transplantation were evaluated using a multivariate Cox regression model.

RESULTS

During the study period 8,421 patients (13% type 1 diabetic, 9% type 2 diabetic and 78% non-diabetic) started renal replacement therapy. The overall survival rate improved by 15% per five calendar years (hazard ratio [HR]=0.85, 95% CI: 0.81-0.88). The percentage of patients within each group who received renal transplantation was: type 1 diabetic: 26%, type 2 diabetic: 5%, non-diabetic: 24%. The survival rate of transplanted patients with diabetes mellitus (types 1 and 2) compared with non-diabetic patients at 1 year was: 95 vs 93%, at 5 years: 80 vs 85% and at 10 years: 52 vs 71%. Among diabetic patients survival rate was better in transplanted than in waiting-list patients (HR = 0.21, 95% CI 0.13-0.34), whereas the survival rate in waiting-list patients seemed to be superior to the survival rate among non-transplantation candidates (HR = 0.75, 95% CI 0.53-0.1.02, p = 0.07).

CONCLUSIONS/INTERPRETATION

The survival rate of diabetic patients with ESRD has improved during the last 15 years. Although some selection bias may exist, significantly improved survival rate was observed among transplanted patients compared with dialysis patients on the waiting-list for transplantation. Renal transplantation should therefore be offered to diabetic patients with ESRD whenever possible.

Cardiovascular benefits of simultaneous pancreas-kidney transplant versus kidney alone transplant in diabetic patients

The aim of our study was to demonstrate the cardiovascular benefits of simultaneous pancreas-kidney transplantation when compared to kidney-alone transplants in diabetic recipients.

PATIENTS AND METHODS

A total of 386 renal transplants were performed from 1985 to 2004, including 262 (68%) in diabetic recipients and 124 (32%) in nondiabetics. Among the former group, 200 kidneys were transplanted simultaneously to the pancreatic graft (KP group) and 62 were kidney-alone transplants (KA group). The mean time on dialysis was 31 +/- 20 months (range 0-126 months). The duration of diabetes was 24 +/- 7 years (range 5-51 years). Ninety-nine percent of the patients were on renal replacement therapy (79% on hemodialysis and 20% on peritoneal dialysis).

RESULTS

Among 262 patients, 28 (11%) died due to a cardiovascular event, which was higher among KA patients compared with the KP group (P = .004). Overall patient survival was significantly higher in the KP group when compared with the KA group (log-rank: P = .0004). Patient survivals were 80% and 70% versus 70% and 40% at 5 and 10 years in the KP and KA groups, respectively. Kidney graft survivals were 81% and 60% versus 63% and 26% at 5 and 10 years in the KP and KA groups, respectively. Pancreas graft survival was 70% and 50% at 5 and 10 years, respectively.

CONCLUSIONS

This clinical evaluation, even if retrospective, confirmed that simultaneous pancreas-kidney transplantation has a protective effect against cardiovascular mortality in diabetic recipients affected by end-stage renal disease.

Renal Transplantation in Diabetic Patients

OBJECTIVE

Diabetes is one of the main causes of end-stage renal disease (ESRD) and admission to hemodialysis, and the demand for kidney transplantation in this population has increased. Our aim was to evaluate the clinical aspects and survival of diabetic patients with kidney transplants by comparing them with the nondiabetic population.

MATERIALS AND METHODS

Patients transplanted during the period from 1994 to 2003 were evaluated for this study. The transplant and demographic characteristics were analyzed by the chi-square test and Student t test according to the type of variable. Kaplan-Meier curves and the log-rank test were used to evaluate the graft and patient survival.

RESULTS

From a total of 523 consecutive renal transplants, 35 (6.6%) were diabetics who were older than nondiabetics (47 +/- 11 years vs 37 +/- 16, P < .002). Patients received immunosuppression with cyclosporine (84.3%), tacrolimus (11.2%), azathioprine (46.6%), mycophenolate mofetil (43.5%), and steroids (all patients). The diabetic patients had a higher percentage of living donors (33.5% vs 17.2%; P = .04). Graft survival rates at 1, 3, and 5 years were 82.7%, 70.9%, and 63.0% in the diabetic patients and 87.6%, 79.0%, and 72.5% (P = .6) in the nondiabetic patients. Patient survival at 5 years was 90.5% in diabetic patients vs 89.0% in nondiabetic patients (P = .9).

CONCLUSIONS

No differences were found in our series in transplant complications or survival in the diabetic patients compared with the nondiabetic patients. Kidney transplants, even with living donors, must be offered to well-selected diabetic patients without reservations.

Post-transplant diabetes mellitus: risk factors, frequency of transplant rejections, and long-term prognosis

BACKGROUND

Estimates of the incidence of new-onset diabetes after renal transplantation vary between 2% and 54%. It was the aim of the present trial to study the prevalence of post-transplant diabetes mellitus (DM), the risk factors, the frequency of transplant rejections, and the long-term prognosis.

METHODS

We studied all consecutive patients with endstage renal disease, but without DM who received kidney transplantation at our center since 1992 (n = 253; age, 52.2 +/- 12.6 years; body mass index, 22.0 +/- 7.9 kg/m2). Follow up was 3.3 +/- 1.6 years (range, 0.1-17.7) years.

RESULTS

In total, 43/253 patients (17%) developed new-onset DM after transplantation. Patients with new-onset diabetes were significantly older (58.3 +/- 11.4 vs 50.9 +/- 12.5 years; P < 0.01) and had a tendency to a higher body mass index (24.0 +/- 8.5 vs 21.6 +/- 7.8 kg/m2; P = 0.077). There were no differences between the groups in respect of blood pressure control (137.7 +/- 19.0/81.8 +/- 14.2 vs 137.1 +/- 21.9/83.9 +/- 13.1 mmHg; P = 0.89/0.39), glomerular filtration rate (58.0 +/- 28.1 vs 64.1 +/- 22.1 ml/min per 1.73 m2; P = 0.13), steroid dosage (4.5 +/- 1.2 [n = 21] vs 4.6 +/- 2.2 [n = 135] mg/day; P = 0.13), or the frequency and dosage of immunosuppressive drugs such as cyclosporine, tacrolimus, and sirolimus during the follow up. However, more patients with post-transplant diabetes received steroids (83.7% vs 64.3%; P = 0.021) and azathioprine (41.9% vs 24.3%; P = 0.030). Patients with new-onset diabetes had higher serum creatinine values (163.4 +/- 67.9 vs 138.7 +/- 59.5 micromol/l; P = 0.017). The mean hemoglobin (Hb)A1c in patients with DM was 6.28 +/- 1.29% (Tosho HPLC; mean normal, 5.15%). In 18 patients (7.1%) transplant rejections occurred (16 patients without DM [7.6%] vs 2 patients with new-onset DM [4.7%]; P = 0.39). On performing multivariate analysis, the only parameter found to be associated with new-onset DM was the body mass index (R2 = 0.05; beta = 0.23; P = 0.02), and the only factor associated with transplant rejection was fasting blood glucose (R2 = 0.07; beta = 0.28; P = 0.02). None of the other parameters included in the models (age, duration after transplantation, diabetes duration, immunosuppressive therapy, HbA1c, HLA mismatches) showed any associations.

CONCLUSIONS

The prevalence of new-onset DM after renal transplantation was 17%. The most important parameter associated with new-onset diabetes was a higher body mass index, and the most important parameter associated with transplant rejection was an elevated fasting blood glucose level. To prevent transplant rejections and to improve patients' outcome, in addition to providing optimal immunosuppressive therapy and HLA matching, good blood pressure control and HbA1c, but also near normal fasting blood glucose levels, should be achieved.

Mycophenolate mofetil vs. azathioprine is associated with decreased acute rejection, late acute rejection, and risk for cardiovascular death in renal transplant recipients with pre-transplant diabetes

Outcomes specifically in mycophenolate mofetil (MMF)-treated diabetic renal transplant patients have not been previously reported. This study compared acute rejection (AR), late acute rejection (LAR), patient survival [and specifically death from cardiovascular (CV), infectious and malignant causes], incidence of post-transplant malignancies, and graft loss in MMF- or azathioprine (AZA)-treated renal transplant patients with pre-transplant diabetes. Outcomes were compared between MMF- (n = 14 144) and AZA- (n = 3001) treated diabetic patients using the Scientific Registry of Transplant Recipients data on all U.S. adult renal transplants performed between 1995 and 2002. Statistical analyses included Kaplan-Meier survival analysis, Cox multivariable regression and chi-square tests. MMF patients had less AR compared with AZA-treated patients (23.5% vs. 28.3%, p < 0.001) and less risk for LAR over 4 yr [hazard ratio (HR): 0.64, 95% CI 0.44, 0.92; p = 0.02]. While time to any-cause death did not differ between the groups, MMF treatment was associated with a 20% decreased risk of CV death (HR: 0.80, 95% CI 0.67, 0.97; p = 0.020) compared with AZA treatment. MMF patients also had a lower incidence of malignancies than AZA patients (2.2% vs. 3.7%, p < 0.001). These results suggest treatment with MMF compared with treatment with AZA in diabetic transplant patients is associated with less AR, less risk of LAR, a decreased risk of CV death, and a lower incidence of malignancies.

Long-term prognosis of patients after kidney transplantation: a comparison of those with or without diabetes mellitus

BACKGROUND

Compared with non-diabetic subjects, patients with type 2 diabetes and end-stage renal disease (ESRD) have seldom been selected for renal transplantation. It was the aim of this study to compare the long-term prognoses of the two groups of patients after transplantation and to identify factors associated with allograft rejection.

METHODS

In a retrospective analysis, we studied all 333 consecutive patients who received a kidney transplant at our centre since 1992. Mean follow-up in 302 out of 333 patients (91%) was 3.3+/-1.5 (0.1-11.7) years. At the time of transplantation, diabetes mellitus (type 1, n=3; type 2, n=46) was known in 49 patients.

RESULTS

Patients with diabetes mellitus were older [patients without diabetes (n=253) vs patients with diabetes (n=49), 52.2+/-12.6 vs 58.8+/-13.1 years, respectively; P=0.002], but they had very good diabetes control [haemoglobin A1c (HbA1c) of patients with diabetes 6.3+/-0.9% vs those without diabetes 5.2+/-1.0%, P=0.03]. Even during their follow-up, patients with diabetes showed a tendency to further improvement (HbA1c for patients with diabetes 5.7+/-0.9% vs those without diabetes 5.5+/-0.9%, P=0.30). At the end of follow-up also, there were no differences between the groups with respect to blood pressure control (patients with diabetes 135.3+/-28.2/79.6+/-17.2 mmHg vs patients without diabetes 130.9+/-28.7/78.8+/-17.1 mmHg, P=0.33/0.78) and renal function (creatinine, 142.9+/-61.6 vs 151.8+/-68.2 micromol/l, P=0.38; glomerular filtration rate, 63.1+/-23.3 vs 59.1+/-24.0 ml/min/1.73 m(2), respectively, P=0.30). In total, 26 patients had acute transplant rejections [eight patients with diabetes (prevalence 16.3%) vs 18 patients without diabeteses (prevalence 7.1%), P=0.11]. In multivariate analysis, the most important parameter associated with the incidence of transplant rejections was the preceding fasting blood glucose (R2=0.044, beta=0.21, P=0.009). All other parameters included in the model (body mass index, time since transplantation, diabetes duration, immunosuppressive therapy, HbA1c and HLA mismatch) revealed no associations.

CONCLUSIONS

Following kidney transplantation, the prevalence of rejections in patients with diabetes mellitus is slightly but not significantly higher than in non-diabetic subjects. One of the most important risk factors seems to be fasting blood glucose. Hence, following renal transplantation, treatment strategies should focus not only on optimal immunosuppressive therapy and HLA matching, good HbA1c and blood pressure control, but also on maintaining near-normal fasting blood glucose levels.

Kidney transplantation: recent developments and recommendations for anesthetic management

Kidney transplantation is the treatment of choice for patients with end-stage renal disease. After receiving a transplant, survival rates are higher and comorbidities may resolve. As a consequence, more patients with significant comorbidities such as advanced cardiovascular disease will present for transplantation. This review highlights commonly encountered issues in patients undergoing kidney transplantation and recommendations are made for their anesthetic management.

Evaluation of the living kidney donor: current perspectives

Living kidney donation is increasing because of prolonged waiting times on the transplant list, as well as improved outcomes for recipients. In 2001, the number of living donors surpassed the number of deceased donors; this trend likely will continue with ever-increasing margins. Because of this increase, as well as changes in our society's health, it is time to re-review the guidelines for selecting living kidney donors established by Kasiske et al in 1995. A conference will be held this year to review updated literature on medical conditions that impact on renal health. From this, new guidelines for the medical evaluation of living renal donors will be constructed. This review discusses information known to date on the outcomes of individuals undergoing unilateral nephrectomy, the impact of lifestyle on renal function in the setting of nephrectomy, and advancements in the detection of genetically transmitted renal diseases that impact on today's decisions on living donation.