A case of self-improving collodion ichthyosis associated with a rare variant of the ALOX12B gene

Collodion baby is usually a manifestation of autosomal recessive congenital ichthyosis, a heterogeneous group of congenital hyperkeratotic genodermatoses with highly variable severity and genetic background. Herein, we report a case of self-improving collodion ichthyosis, a rare subtype of autosomal recessive congenital ichthyosis, characterized by an almost-complete spontaneous resolution of symptoms.

Dupilumab for atopic dermatitis: a real-world portuguese multicenter retrospective study

Introduction: Atopic dermatitis (AD) is a difficult-to-treat inflammatory skin disease with a high impact on patients' quality of life. Dupilumab, an IL-4 and IL-13 inhibitor, was the first monoclonal antibody approved for the treatment of moderate-to-severe AD and is currently approved in patients aged 6 or older.Methods: This is a nationwide, multicenter, retrospective, 48-week study designed by the Portuguese Group of AD to assess real-world efficacy and safety of dupilumab for the treatment of AD.Results: A total of 169 patients were enrolled, with a mean disease duration of 22.75 (±11.98) years. The percentage of patients achieving an improvement of at least 75% in Eczema Area and Severity Index (EASI) compared to baseline (EASI75 response) at weeks 12 and 48 was 67.6% and 74.1%, respectively. In the same timepoints, 25.0% and 44.1% achieved an EASI90 response. Patient-reported outcome measures also improved throughout the study period. Regarding safety, 32.0% of the patients developed adverse events, with conjunctivitis (26.6%), persistent facial erythema (4.7%), and arthritis/arthralgia (3.6%) as the more frequently reported.Conclusion: Data from real-world populations are crucial to guide clinicians in their daily decisions. This study provides data demonstrating that dupilumab is an effective and safe therapeutic option for AD.

FOXR1 regulates stress response pathways and is necessary for proper brain development

The forkhead box (Fox) family of transcription factors are highly conserved and play essential roles in a wide range of cellular and developmental processes. We report an individual with severe neurological symptoms including postnatal microcephaly, progressive brain atrophy and global developmental delay associated with a de novo missense variant (M280L) in the FOXR1 gene. At the protein level, M280L impaired FOXR1 expression and induced a nuclear aggregate phenotype due to protein misfolding and proteolysis. RNAseq and pathway analysis showed that FOXR1 acts as a transcriptional activator and repressor with central roles in heat shock response, chaperone cofactor-dependent protein refolding and cellular response to stress pathways. Indeed, FOXR1 expression is increased in response to cellular stress, a process in which it directly controls HSPA6, HSPA1A and DHRS2 transcripts. The M280L mutant compromises FOXR1's ability to respond to stress, in part due to impaired regulation of downstream target genes that are involved in the stress response pathway. Quantitative PCR of mouse embryo tissues show Foxr1 expression in the embryonic brain. Using CRISPR/Cas9 gene editing, we found that deletion of mouse Foxr1 leads to a severe survival deficit while surviving newborn Foxr1 knockout mice have reduced body weight. Further examination of newborn Foxr1 knockout brains revealed a decrease in cortical thickness and enlarged ventricles compared to littermate wild-type mice, suggesting that loss of Foxr1 leads to atypical brain development. Combined, these results suggest FOXR1 plays a role in cellular stress response pathways and is necessary for normal brain development.

Early Rehospitalization Post-Kidney Transplant Due to Infectious Complications: Can We Predict the Patients at Risk?

INTRODUCTION

Rehospitalization early post-kidney transplant is common and has a negative impact in morbidity, graft survival, and health costs. Infection is one the most common causes, and identifying the risk factors for early readmission due to infectious complications may guide a preventive program and improve outcome. The aim of this study was to evaluate the incidence, characterize the population, and identify the risk factors associated with early readmission for infectious complications post-kidney transplantation.

METHODS

We performed a retrospective cohort study of all the kidney transplants performed during 2015. The primary outcome was readmission in the first 3 months post-transplant due to infectious causes defined by clinical and laboratory parameters.

RESULTS

We evaluated 141 kidney transplants; 71% of subjects were men, with an overall mean age of 50.8 ± 15.4 years. Prior to transplant, 98% of the patients were dialysis dependent and 2% underwent pre-emptive living donor kidney transplant. The global readmission rate was 49%, of which 65% were for infectious complications. The most frequent infection was urinary tract infection (n = 28, 62%) and the most common agent detected by blood and urine cultures was Klebsiella pneumonia (n = 18, 40%). The risk factors significantly associated with readmission were higher body mass index (P = .03), diabetes mellitus (P = .02), older donor (P = .007), and longer cold ischemia time (P = .04). There were 3 graft losses, but none due to infectious complications.

CONCLUSION

There was a high incidence of early rehospitalization due to infectious complications, especially urinary tract infections to nosocomial agents. The risk factors identified were similar to other series.

Vimentin fibers orient traction stress

The intermediate filament vimentin is required for cells to transition from the epithelial state to the mesenchymal state and migrate as single cells; however, little is known about the specific role of vimentin in the regulation of mesenchymal migration. Vimentin is known to have a significantly greater ability to resist stress without breaking in vitro compared with actin or microtubules, and also to increase cell elasticity in vivo. Therefore, we hypothesized that the presence of vimentin could support the anisotropic mechanical strain of single-cell migration. To study this, we fluorescently labeled vimentin with an mEmerald tag using TALEN genome editing. We observed vimentin architecture in migrating human foreskin fibroblasts and found that network organization varied from long, linear bundles, or "fibers," to shorter fragments with a mesh-like organization. We developed image analysis tools employing steerable filtering and iterative graph matching to characterize the fibers embedded in the surrounding mesh. Vimentin fibers were aligned with fibroblast branching and migration direction. The presence of the vimentin network was correlated with 10-fold slower local actin retrograde flow rates, as well as spatial homogenization of actin-based forces transmitted to the substrate. Vimentin fibers coaligned with and were required for the anisotropic orientation of traction stresses. These results indicate that the vimentin network acts as a load-bearing superstructure capable of integrating and reorienting actin-based forces. We propose that vimentin's role in cell motility is to govern the alignment of traction stresses that permit single-cell migration.

What Can We Do When All Collapses? Fatal Outcome of Collapsing Glomerulopathy and Systemic Lupus Erythematosus With Diffuse Alveolar Hemorrhage: Case Report

INTRODUCTION

Collapsing glomerulopathy (CG) is a rare form of glomerular injury. Although commonly associated with human immunodeficiency virus (HIV) infection, it can occur in association with systemic lupus erythematosus (SLE).

CASE REPORT

We present the case of a 50-year-old man, with chronic kidney disease secondary to focal and segmental glomerulosclerosis, who received a cadaveric kidney transplant in 2007. There were no relevant intercurrences until May 2015, when he presented with nephrotic range proteinuria (± 4 g/d). A graft biopsy was performed and it did not show any significant pathological changes. In September, he developed a full nephrotic syndrome (proteinuria 19 g/d) and a graft biopsy was repeated. CG features were evident with a rich immunofluorescence. Antinuclear antibodies (ANA) and anti-double-stranded DNA (anti-dsDNA) antibodies were positive; the remaining immunologic study was normal. Viral markers for HIV, hepatitis C virus (HCV), and hepatitis B virus (HBV) were negative. The patient was treated with corticosteroid pulses and plasmapheresis (seven treatments). A rapid deterioration of kidney function was seen and he became dialysis dependent. He was discharged with a low-dose immunosuppressive treatment. In October, he was hospitalized with diffuse alveolar hemorrhage (DAH). The auto-immune study was repeated, revealing complement consumption and positive titers of ANA and Anti-dsDNA antibodies. Anti-neutrophil cytoplasmic antibodies (ANCAs) and antiglomerular basement membrane antibody (anti-GBM) were negative. Treatment with intravenous corticosteroids, plasmapheresis, and human immunoglobulin was ineffective and the outcome was fatal.

CONCLUSION

This case report highlights the possible association of CG and SLE. To our knowledge, it is the first case of SLE presenting with CG and DAH, with the singularity of occurring in a kidney transplant recipient receiving immunosuppression.

Diabetic foot ulcer development risk classifications' validation: A multicentre prospective cohort study

AIMS

To prospectively validate the existing classifications to stratify subjects with diabetes mellitus (DM) by their risk of diabetic foot ulcer (DFU), in high and low risk settings.

METHODS

A prospective multicentre cohort study was conducted, including 446 subjects with DM without active DFU followed in the hospital or primary care setting. Demographic, clinical characterization variables, and those included in the classifications were collected at baseline. Subjects were followed for 1year, until DFU or death.

RESULTS

In our sample, with a mean age of 65years, 52% were male; 32 developed a DFU, 7 required an amputation and 18 died. Differences were found between participants' characteristics and classifications' accuracy according to the setting. The great majority of the variables were associated with higher DFU risk. Globally, classifications were highly and equally valid, positive predictive values (PV) were inferior to 40%, negative PV superior to 90% and area under the receiver operating characteristic curve superior to 0.75.

DISCUSSION

All the existing classifications are valid to be applied in high risk clinical context and have a very high capacity to categorize as low risk those subjects that will not develop a DFU. Further research is needed in the primary care setting.

Follicular fluid PlGF/sFlt-1 ratio and soluble receptor for advanced glycation end-products correlate with ovarian sensitivity index in women undergoing A.R.T

PURPOSE

Considering potential roles of soluble receptor for advanced glycation end products (sRAGE) and placental growth factor (PlGF) in ovarian function and embryo implantation, in the present study we have evaluated the association of these factors and also PlGF/sFlt-1 ratio with the ovarian response and implantation rate by dividing patients according to the OSI.

METHODS

In a cross-sectional study, 90 infertile women who were undergoing ICSI cycle using long protocol were recruited. The patients were divided according to ovarian sensitivity index (OSI). ICSI cycle outcomes were evaluated for each patient and PlGF, sFlt-1 and sRAGE levels of follicular fluid were assayed using commercial ELISA kits.

RESULTS

Follicular fluid (FF) sRAGE levels and PlGF/sFlt-1 ratio were statistically greater in high-responder women than other responders (p < 0.05). Positive correlations were obtained between sRAGE level with the number of oocytes, follicles and OSI level. sRAGE levels with cutoff value of 4.83 (ng/ml) for evaluating the pregnancy outcome showed 81.8 % sensitivity and 60.7 % specificity. Furthermore, there were positive associations between PlGF/sFlt-1 ratio with the number of oocytes, embryos and OSI level.

CONCLUSION

In conclusion, the results of current study supported that good ovarian response is independent of pregnancy outcome. Our results showed that FF levels of sRAGE and PlGF/sFlt-1 ratio could be used as markers for determining the high-responder women. Also, FF sRAGE levels could be a good predictor for ART outcome.

Vimentin Intermediate Filaments Template Microtubule Networks to Enhance Persistence in Cell Polarity and Directed Migration

Increased expression of vimentin intermediate filaments (VIFs) enhances directed cell migration, but the mechanism behind VIFs' effect on motility is not understood. VIFs interact with microtubules, whose organization contributes to polarity maintenance in migrating cells. Here, we characterize the dynamic coordination of VIF and microtubule networks in wounded monolayers of retinal pigment epithelial cells. By genome editing, we fluorescently labeled endogenous vimentin and α-tubulin, and we developed computational image analysis to delineate architecture and interactions of the two networks. Our results show that VIFs assemble an ultrastructural copy of the previously polarized microtubule network. Because the VIF network is long-lived compared to the microtubule network, VIFs template future microtubule growth along previous microtubule tracks, thus providing a feedback mechanism that maintains cell polarity. VIF knockdown prevents cells from polarizing and migrating properly during wound healing. We suggest that VIFs' templating function establishes a memory in microtubule organization that enhances persistence in cell polarization in general and migration in particular.

Psychogenic astasia-abasia: A case report and a review of the literature

Introduction

Psychogenic movement disorders are the result of a psychiatric rather than a primary neurological disorder. Astasia-abasia refers to the inability to stand or walk despite having good motor strength and conserved voluntary coordination.

Objectives

Starting from a case report of a patient with an unusual gait disturbance the author intends to discuss the history and knowledge evolution on psychogenic gait disorders until the present time.

Aims

To debate the nosology, clinical features, diagnosis and treatment of psychogenic movement disorders.

Methods

Non-systematic review of the literature. Case presentation with the exhibition of a video showing the patient's gait.

Case presentation

A 48-year-old female was admitted to a psychiatry ward after attempting to commit suicide by cutting her throat. On day 3, she suddenly could not walk or stand without help. The neurological examination revealed some inconsistencies and all laboratory, electroencephalogram, and imaging studies performed were normal. After 2 weeks of treatment she started gradually getting better until the full recovery.

Discussion

The gait disturbance presented might be regarded as a form of astasia-abasia. This term was first coined by Paul Blocq (1888) when he described a group of patients who showed inability to maintain an upright posture. Similar movement disorders were previously described as hysteria by authors like Charcot. Nowadays, these case descriptions would be likely considered cases of conversion or psychogenic gait disorder.

Conclusion

The etiology of these disorders is still not very well understood. These patients usually benefit from a multidisciplinary approach that includes psychiatry, neurology, physiotherapy, among others. Pharmacological and non-pharmacological treatments should address the underlying psychiatric condition.

Disclosure of interest

The author has not supplied his declaration of competing interest.

Invasive Fungal Infections After Kidney Transplantation: A Single-center Experience

INTRODUCTION

Invasive fungal infections (IFI) affecting transplant recipients are associated with increased mortality and graft dysfunction.

OBJECTIVE

Describe the frequency, clinical features, and outcomes of IFI (except pneumocystis infection) in kidney transplant recipients.

METHOD

Single-center descriptive study including every kidney transplant recipient with a culture-proven or probable IFI between 2003 and 2013, according to the EORTC-MSG criteria.

RESULTS

We identified 45 IFI. There were 13 cases of invasive candidiasis (C. albicans: 6 and non-C. albicans candidial spp.: 7), 11 cases of pulmonary aspergillosis (A. fumigatus: 9 and A. flavus: 2); 11 cases of subcutaneous mycosis (Alternaria spp.: 9, Paecilomyces spp.: 1, and Pseudallescheria spp.: 1); 7 cases of cryptococcosis; 2 cases of pneumonia by non-Aspergillus molds (Mucor spp.: 1 and Cunninghamella spp.: 1); and 1 case of Geotrichum capitatum pneumonia. All patients were recipients from deceased donors. Six cases occurred in the first 3 months post-transplant, 15 cases between the third and twelfth months, and 21 cases after the twelfth month. Treatment options were fluconazole for Candida infections, voriconazole or caspofungin for aspergillosis, liposomal amphotericin for cryptococcosis, and itraconazole plus excision or cryotherapy for subcutaneous mycosis. Fifteen patients died (33%). Mortality rates were 15% for invasive candidiasis, 45% for aspergillosis, 71% for cryptococcosis, 100% for non-Aspergillus molds and G. capitatum pneumonia, and 0% for subcutaneous mycosis. Six patients who survived (14%) started regular hemodialysis.

CONCLUSION

IFI still have a high mortality and morbidity in kidney transplant recipients, as verified in this report. We reinforce the need for a high index of suspicion and prompt treatment.

Hepatitis B virus, hepatitis C virus, and kidney transplant acute rejection and survival

The effect of hepatitis Bs-antigen (AgHBs) and anti-hepatitis C virus (HCV) positivity on renal transplant outcomes is still controversial. Some studies describe higher rates of acute rejection and allograft loss, and greater mortality in transplant recipients with hepatitis. We retrospectively evaluated data from 2284 allograft recipients who underwent transplantation at our hospital between July 1980 and December 2012. Statistical analysis was made using chi-square and Student t tests, Kaplan-Meier curves, and survival analysis. We identified 62 AgHBs+ patients, 99 anti-HCV+ patients, and 14 AgHBs+/anti-HCV+ patients; 2109 patients had "no hepatitis." Mean follow-up time was 7.93 years. No statistical differences were identified on allograft acute rejection rate or patient survival between groups. AgHBs+ patients had, however, an inferior allograft survival, with statistical significance. According to our study, hepatitis B has a harmful impact on allograft survival, although it does not compromise the patient survival.

Pretransplant biopsy in expanded criteria donors: do we really need it?

INTRODUCTION

Renal transplantation is the best treatment for end-stage renal disease, including when using expanded criteria donors (ECD) kidneys. However, these suboptimal kidneys should be evaluated rigorously to meet their usefulness. Opinions differ about the best way to evaluate them.

MATERIALS AND METHODS

We retrospectively reviewed kidneys from ECD harvested by a single academic institution between January 2008 and September 2013. Needle biopsies were performed at the time of the harvest when considered relevant by the transplant team. Two pathologists where responsible for their analysis; the Remuzzi classification has been used in all cases.

RESULTS

We evaluated 560 ECD kidneys. Biopsies were made in 197 (35.2%) organs, 20 of which were considered not usable and 36 good only for double transplantation. Sixty-three kidneys (11.3%) were discarded by the transplant team based on the biopsy result and clinical criteria. Donors who underwent a biopsy were older (P < .001) and had a worse glomerular filtration rate (GFR; P = .001). Comparing donors approved and rejected by the biopsy, the rejected donors were heavier (P = .003) and had a lower GFR (P = .002). Cold ischemia time was longer for the biopsy group (P < .001). Regarding graft function, the biopsy overall score correlated with the transplant outcome in the short and long term. Separately, glomeruli and interstitium scores were correlated with recipient's GFR in the earlier periods (3 months; P = .025 and .037), and the arteries and tubules correlated with GFR in the longer term (at 3 years P = .004 and .010).

CONCLUSION

The decision on the usability of ECD grafts is complex. At our center, we chose a mixed approach based on donor risk. Low-risk ECD do not require biopsy. In more complex situations, especially older donors or those with a lower GFR, prompted a pretransplant biopsy. The biopsy results proved to be useful as they relate to subsequent transplant outcomes, thereby allowing us to exclude grafts whose function would most probably be less than optimal.

New Recipes With Known Ingredients: Combined Therapy of Everolimus and Low-dose Tacrolimus in De Novo Renal Allograft Recipients

BACKGROUND

Calcineurin inhibitors (CNIs) are the cornerstones of immunosuppressive management in renal allograft recipients even though their nephrotoxicity may contribute to a reduced long-term graft survival. This has created a great interest in improving immunosuppressive strategies in the early post-transplantation period. Proliferation signal inhibitors (PSIs), such as everolimus, are promising alternatives, although their side effects may have a drawback in de novo renal transplant recipients, for instance, delaying renal function in the presence of renal ischemia/acute tubular necrosis and predisposing to lymphocele development.

STUDY AND METHODS

A retrospective study was developed to compare the combined therapy of low-dose tacrolimus and everolimus (study group) with mycophenolate mofetil/mycophenolic acid and standard-dose tacrolimus (control group) in the first 3 months post-transplantation. The study's end-points concerned renal graft function, proteinuria, incidence of biopsy-proven acute rejection, surgical complication rates, and incidence of new-onset diabetes after renal transplantation.

RESULTS

There was no more delayed graft function in the study group and graft function distribution was similar between groups. Median serum creatinine and eGFR were comparable as well as proteinuria levels. Generally, adverse events were rare in both groups and there were no significant statistical differences between them in terms of biopsy-proven acute rejection, surgical complication, and new-onset diabetes after renal transplantation rates.

CONCLUSION

Despite the slightly lower tendency for serum creatinine in the study group, renal allograft function wasn't statistically different between groups. Moreover, there weren't more metabolic or surgical complications in the study group. Everolimus may be a choice in tacrolimus-sparing strategies, but a larger study and a longer follow-up are still required.

Renal transplantation with donors older than 70 years: does age matter?

PURPOSE

The need for organs for renal transplantation has encouraged the use of grafts from increasingly older donors. Studies of transplantation results with donors older than 70 years are sparse. The main purpose of this study is to compare the results of transplantation with donors older and younger than 70 years old.

METHODS

This retrospective study included 1233 consecutive deceased-donor renal transplantations performed between January 1, 2001, and December 31, 2011. We compared outcomes of grafts from donors older than 70 years (group ≥ 70; n = 82) versus donors younger than 70 years (group < 70; n = 1151).

RESULTS

Univariate analysis of pretransplantation data showed statistically significant differences (P < .05) among the following variables for the group < 70 and group ≥ 70, respectively: recipient age (46 ± 13 versus 61 ± 5 years), donor age (44 ± 16 versus 73 ± 3 years), donor male gender (69.4% versus 47.6%), use of antibody induction immunosuppression (51.7% versus 70.7%), and HLA compatibilities (2.4 versus 2). The group ≥ 70 showed increased postoperative minor complications: bleeding (8.5% versus 3.4%; P = .017), lymphocele formation (3.7% versus 0.5%; P = .011), and incisional hernia (2.4% versus 0.2%; P < .001). Regarding transplantation results, we observed that mean serum creatinine was significantly lower among group < 70, at 1, 3, 6, 12, 24, and 60 months after transplantation (P < .05). Cumulative graft survival at 1, 3, and 4 years was 90%, 85%, and 83% in the group < 70 versus 87%, 79%, and 72% in the group ≥ 70. In the subgroup of recipients younger than 60 years, we did not verify statistically significant differences in allograft survival between group ≥ 70 and group < 70. Using Cox regression for survival analysis, we verified that donor age was not an independent risk factor for graft failure.

CONCLUSIONS

The group of patients who received kidneys from donors younger than 70 years achieved better transplantation outcomes. Nevertheless, kidneys from older donors represent an excellent alternative for older recipients.

New-onset diabetes after transplantation: assessment of risk factors and clinical outcomes

BACKGROUND

New-onset diabetes after transplantation (NODAT) is a serious complicatin of kidney transplantation (KT) with adverse impacts on graft and patient survivals. This study aims assess potential risk factors for development of NODAT and compare clinical outcomes of KT recipients with versus without NODAT.

METHODS

We retrospectively evaluated 648 patients who underwent KT between 2005 and 2009. From the 83 (12.8%) subjects who developed NODAT, we selected 47 for comparison with controls free of diabetes.

RESULTS

The diagnosis of NODAT was made at 4.3 ± 8.5 months after transplantation in 47 patients, including 76.6% males, with an overall mean age of 54.5 ± 10.8 years. Patients with NODAT presented higher pretransplantation fasting plasma glucose levels (P < .001) as well as cyclosporine and tacrolimus trough levels (P = .003 and P < .001, respectively). On multivariate analysis, higher pretransplantation fasting plasma glucose and higher tacrolimus, but not cyclosporine concentrations were independent predictors of NODAT. No differences were found for other potential risk factors. Upon follow-up at 6, 12, 24, 36, 48, and 60 months, renal function (estimated Glomerular Filtration Rate using Modification of Diet in Renal Disease), 24 hour proteinuria and proportions of patients with hypertension were similar between groups. Patients with NODAT showed comparable numbers of hospitalizations and infections, as well as acute rejection episodes and acute cardiovascular events as their counterparts. Event-free survival (loss of graft function/death with functioning graft) was similar between the groups (P = .418; K-M).

DISCUSSION

In our population, higher pretransplantation fasting plasma glucose levels and higher tacrolimus concentrations were independent predictors of NODAT. During a mean follow-up of 3 years, NODAT was not associated with worse clinical outcomes.

Conversion to everolimus in kidney transplant recipients: to believe or not believe?

INTRODUCTION

Immunosuppression with calcineurin inhibitors (CNI) in renal transplantation is associated with chronic graft dysfunction, increased cardiovascular risk, and malignancies. Everolimus (EVR) appears to permit a CNI-sparing regimen among stable kidney recipients.

AIM

The aim of this study was to analyze the efficacy and safety of conversion from CNI to EVR.

MATERIAL AND METHODS

This was a retrospective registry-based study of all kidney transplant recipients converted from CNI to EVR between 2006 and 2010. One hundred fifty-one patients, including 69.5% males and with an overall mean age of 50.2 ± 12.7 years, underwent conversion to EVR at 37.0 ± 49.8 (16) months after transplantation with 33.7% during the first 6 months. Reasons for conversion included: CNI nephrotoxicity prevention (54.3%), chronic graft dysfunction (25.8%), malignant tumors (10.6%), CNI-adverse reactions (6.6%), and biopsy-proven CNI nephrotoxicity (2.6%). During a follow-up of 17.9 ± 9.9 months (range, 6-58.5), 18 patients (11.9%) were reconverted to CNI, 2 died with functioning grafts, and 2 lost kidney function.

RESULTS

We observed a significant (P < .001) increase in estimated glomerular filtration rate-Modification of Diet in Renal Disease (eGFR-MDRD) by 11.3% within 6 months: 56.7 ± 22.1 to 64.1 ± 23.4 mL/min/1.73 m(2). At final evaluation it was 13.7%, namely, to 65.5 ± 23.0 mL/min/1.73 m(2). At the end of follow-up the proportion of patients with >300 mg/d proteinuria increased from 7.9% to 23.3% (P = .001). Dyslipidemia prevalence increased from 69.5% to 77.5% (P = not significant [NS]) and arterial hypertension increased from 49% to 65.9% (P < .001) at the end of follow-up. Other reported side effects included oral ulcers (2.6%), edema (5.3%), interstitial pneumonitis (1.3%), and toxic hepatitis (1.3%), some of them leading to EVR discontinuation.

CONCLUSION

In our population, renal function improved significantly after conversion from CNI to EVR. Although side effects were common, most were mild, withdrawal of EVR was necessary in a low percentage of cases. EVR appears to be an effective, safe alternative to CNI for maintenance therapy in selected kidney transplant recipients.

Does multiorgan versus kidney-only cadaveric organ procurement affect graft outcomes?

INTRODUCTION

The majority of kidney grafts in most European countries still come from deceased donors who provide other organs. We analyzed whether multiorgan procurement portends a worse functional outcome compared with kidney-only harvesting.

METHODS

We performed a retrospective analysis of 1043 consecutive brain-dead donor kidney transplantations performed at a single academic institution from September 2002 to June 2011. The graft outcomes using kidney-only donors (n = 243) were compared with multiorgan donor grafts (n = 800) analyzing donor age, gender, cause of death, duration of mechanical ventilation, renal function, and cold ischemic interval. We compared delayed graft function and serum creatinine values at 1, 3, 6, and 12 months posttransplantation as well as graft survivals. This methodology was also applied to the subset of expanded criteria donors: 179 kidney-only versus 474 multiorgan. The influence of donor variables on graft survival was also analyzed in a Cox regression model. Immunosuppressive regimens and preservation solutions were similar in both groups.

RESULTS

Kidney-only donors were older than their multiorgan counterparts (53.1 versus 44.8, P < .0005) and predominantly male (76.5% versus 62.6% male donors, P < .0005). Other donor variables were comparable. Kidney-only donor grafts showed a slightly higher incidence of delayed function (27.2 versus 21.1%, P = .049), but the mean serum creatinine values were similar at all intervals. No differences were observed in 7-year graft survival: 80.7% versus 79.9%. Expanded criteria donor grafts showed overlapping results, except for a higher rate of donor oligoanuria and a lower 1-month mean creatinine among kidney-only donors. Multivariate analysis revealed that the number of harvested organs did not influence graft survival.

DISCUSSION

Immediate and long-term outcomes of kidney grafts did not correlate with the number of organs harvested from the donor. The longer explantation time associated with multiorgan procurement did not seem to affect graft function.

Uncommon cause of chest pain in a renal transplantation patient with autosomal dominant polycystic kidney disease: a case report

Autosomal dominant polycystic kidney disease (ADPKD) is a common cause of end-stage renal disease (ESRD) and, because of its intrinsic systemic involvement, its treatment can be a medical and surgical challenge. This condition is often associated with the presence of hepatic cysts and their prevalence generally increases with age. Most patients remain asymptomatic, but some of these will develop complications associated with enlargement and infection of their cysts. Chest pain is a rare manifestation of these complications and, after exclusion of more common cardiovascular and pulmonary causes, should raise the suspicion of an infected hepatic cyst in these patients. We report the case of a 62-year-old male who underwent a kidney transplantation from a cadaveric donor in 1997 (etiology of the ESRD was ADPKD), and was admitted to the emergency department with complaints of chest pain radiating to both shoulders and the interscapular region. An echocardiogram was showed compression of the right atrium by a large liver cyst without associated ventricular dysfunction. Computer tomography-guided drainage of the cyst was performed and an Enterobacter aerogenes sensitive to carbamapenemes was isolated from respective cultures. The patient presented a favorable clinical outcome with prolonged administration of antibiotic therapy according to the antibiotic susceptibility testing. There was no need for surgical intervention.

Do intraoperative hemodynamic factors of the recipient influence renal graft function?

PURPOSE

To assess the importance of intraoperative management of recipient hemodynamics for immediate versus delayed graft function.

METHODS

The retrospective study of 1966 consecutive renal transplants performed in our department between June 1980 and December 2009 analyzed several perioperative hemodynamic factors: central venous pressure (CVP), mean arterial pressure (MAP) as well as volumes of fluids, fresh frozen plasma (FFP), albumin, and whole blood transfusions. We examined their influence on renal graft function parameters: immediate diuresis, serum creatinine levels, acute rejection, chronic transplant dysfunction, and graft survival.

RESULTS

Mean CVP was 9.23 ± 2.65 mm Hg and its variations showed no impact on graft function. We verified a twofold greater risk of chronic allograft dysfunction among patients with CVP ≥ 11 mm Hg (P < .001). Mean MAP was 93.74 ± 13.6 mm Hg; graft survivals among subjects with MAP ≥ 93 mm Hg were greater than those of patients with MAP < 93 mm Hg (P = .04). On average, 2303.6 ± 957.4 mL of saline solutions were infused during surgery. Patients who received whole blood transfusions (48%) showed a greater incidence of acute rejection episodes (ARE) (P = .049) and chronic graft dysfunction (P < .001). Patients who received FFP (55.7%), showed a higher incidence of ARE (P < .001). Only 4.6% of patients (n = 91) received human albumin with a lower incidence of ARE (P = .045) and chronic graft dysfunction (P = .024). Logistic binary regression analysis revealed that plasma administration was an independent risk factor for ARE (P < .001) and chronic dysfunction (P = .028). Volume administration (≥ 2500 mL) was also an independent risk factor for chronic allograft dysfunction (P = .016). Using Cox regression, we verified volume administration ≥ 2500 mL to be the only independent risk factor for graft failure (P < .001).

CONCLUSION

MAP ≥ 93 mm Hg and perioperative fluid administration <2500 mL were associated with greater graft survival. Albumin infusion seemed to be a protective factor, while CVP ≥ 11 mm Hg, whole blood, and FFP transfusions were associated with higher rates of ARE and chronic graft dysfunction.