Immunological Approaches in the Treatment of Diabetic Nephropathy

Diabetic nephropathy (DN), the leading cause of end-stage renal disease, has no definite treatment so far. In fact, a combination of metabolic, hemodynamic, and immunological factors are involved in the pathogenesis of DN; therefore, effective disease management requires a holistic approach to all predisposing contributors. Due to the recent findings about the role of inflammation in the initiation and progression of kidney injury in diabetic patients and considerable advances in immunotherapy methods, it might be useful to revise and reconsider the current knowledge of the potential of immunomodulation in preventing and attenuating DN. In this review, we have summarized the findings of add-on therapeutic methods that have concentrated on regulating inflammatory responses in diabetic nephropathy, including phosphodiesterase inhibitors, nuclear factor-kB inhibitors, Janus kinase inhibitors, chemokine inhibitors, anti-cytokine antibodies, cell therapy, and vaccination.

Expression of Programmed Cell Death 1 and Helios Genes Correlates With rs872071A>G and rs12203592C>T Single-Nucleotide Polymorphisms of InterferonRegulatory Factor 4 in Patients with T-Cell-Mediated Rejection of Renal Allograft

OBJECTIVES

Acute T-cell-mediated rejection of the renal allograft is a serious posttransplant challenge that requires administration of high-dose immunosuppressive drugs with considerable side effects; therefore, specific targeting of T-cell responses may improve both prevention and treatment of T-cell-mediated rejection. A potential candidate for this purpose is interferon regulatory factor 4 because of its implication in differentiation and function of T cells. Our aim was to evaluate the frequency of the rs872071A>G and rs12203592C>T single-nucleotide polymorphisms of the interferon regulatory factor 4 gene and association of these 2 polymorphisms with the gene expression of programmed cell death 1 and Helios in patients with T-cell-mediated rejection versus stable recipients.

MATERIALS AND METHODS

Sixty recipients with T-cell- mediated rejection and 60 age-matched and sexmatched stable recipients were recruited. Two single-nucleotide polymorphisms of interferon regulatory factor 4 gene, as well as the expression of programmed cell death 1 and Helios genes in peripheral blood mononuclear cells, were investigated with real-time polymerase chain reaction.

RESULTS

Programmed cell death 1 gene expression was reduced in patients with T-cell-mediated rejection versus stable recipients (P = .03). The frequency of rs872071A>G and rs12203592C>T single-nucleotide polymorphisms showed no significant difference between groups. Presence of the rs12203592C>T single-nucleotide polymorphism was directly correlated with the expression of programmed cell death 1 gene (P = .049), and rs872071A>G positivity was directly correlated with Helios gene expression (P = .008), which suggests an inhibitory role for interferon regulatory factor 4 on programmed cell death 1 and Helios molecules.

CONCLUSIONS

Programmed cell death 1 gene expression was lower in patients with T-cell-mediated rejection versus stable recipients. Low-expressing singlenucleotide polymorphisms of interferon regulatory factor 4 could enhance the downstream gene expression of programmed cell death 1 and Helios immunoregulatory molecules. Therefore, specific inhibition of interferon regulatory factor 4 may promote tolerance induction in the allograft.

Comparing IRF-4 Gene Expression Between Acute T cell- Mediated Rejection and Stable Renal Transplant Recipients

INTRODUCTION

Renal transplant rejection is one of the clinical challenges, which usually requires administration of immunosuppressive drugs causing serious side effects. Therefore, invention of effective and specific therapeutics is necessary to control undesired immune responses particularly T-cell reactions to allograft. Interferon Regulatory Factor-4 (IRF-4) due to its implication on T cells differentiation and function might be targeted to treat T cell-mediated cellular rejection (TCMR). The aim of this study was to investigate the association between IRF-4 gene expression and acute TCMR, as well as to examine the correlation between IRF-4 gene expression and cellular expression of Programmed cell death-1 (PD-1) and Helios molecules.

METHODS

Peripheral blood samples were obtained from 30 patients with biopsy proven acute TCMR and 30 stable recipients. IRF-4 gene expression was quantified using RT-PCR, and cellular expression of PD-1 and Helios were evaluated with flowcytometry.

RESULTS

IRF-4 gene expression was significantly increased in acute TCMR patients compared with stable recipients (P < .05). Helios protein expression was slightly decreased in TCMR group but this was not statistically significant. There was a negative correlation between IRF-4 gene expression and PD-1 as well as Helios frequency in the whole studied population.

CONCLUSION

IRF-4 expression increases in acute TCMR which might also lead to a diminished expression of downstream immunoregulatory molecules such as PD-1 and Helios. Therefore, specific inhibition of IRF-4 may be helpful in managing acute TCMR.

Effects of pioglitazone on blood glucose and inflammatory markers of diabetic kidney transplant patients: a randomized controlled trial

INTRODUCTION

The aim of this study was to assess the effects of pioglitazone on blood glucose control and inflammatory biomarkers in diabetic patients receiving insulin after kidney transplantation.

MATERIALS AND METHODS

In a randomized placebo-controlled trial, 62 diabetic kidney transplant patients were followed for 4 months after randomly assigned to placebo and pioglitazone (30 mg/d) groups. All of the patients continued their insulin therapy irrespective of the group that they were assigned to, in order to evaluate the effects of addition of pioglitazone on blood glucose and inflammation biomarkers including serum C-reactive protein, high-sensitivity C-reactive protein, and interleukin-18 levels, as well as erythrocyte sedimentation rate.

RESULTS

At baseline, there were no significant differences in laboratory studies between the two groups. After 4 months of intervention, along with significant improvement in hemoglobin A1c in the pioglitazone group, daily insulin requirements also decreased and lipid profile improved significantly. In addition, erythrocyte sedimentation rate, C-reactive protein, and high-sensitivity C-reactive protein values were significantly lower in the pioglitazone group (P = .03, P < .001, and P = .01). Interleukin-18 levels were not significantly different at the end of the study between the two groups, but it had a decreasing trend in the pioglitazone group (P = .002).

CONCLUSIONS

Pioglitazone complementing insulin in diabetic kidney transplant patients not only improved glycemic control, evidenced by hemoglobin A1c, and reduced daily insulin requirement, but also decreased inflammatory markers which may have an impact on overall cardiovascular events and mortalities beyond glycemic control.

Prevalence and risk factors of recurrent cytomegalovirus infection in kidney transplant recipients

INTRODUCTION

Recurrence of cytomegalovirus (CMV) infection following solid organ transplantation causes mortality and morbidity in allograft recipients. The aim of this study was to evaluate prevalence and risk factors of recurrent CMV infection in kidney transplant patients.

MATERIALS AND METHODS

Four hundred and twenty-seven consecutive kidney transplant recipients were included in this retrospective cohort study. Both donors and recipients were CMV seropositive. Recurrent CMV infection (symptomatic or asymptomatic) was defined as detection of CMV infection in a patient who has had previously documented infection and who had not have virus detected for an interval of at least 4 weeks during active surveillance.

RESULTS

Of 427 recipients, 71 (16.6%) had CMV infection, of which 19 (4.4%) were recurrent infection. Donor source, dialysis duration before transplantation, recipient and donor age and sex, and administration of antithymocyte globulin and prophylactic treatment ganciclovir were not associated with CMV infection or recurrence. The use of tacrolimus in the immunosuppressive regimen as compared to cyclosporine was an independent risk factor for CMV infection but not recurrent infection.

CONCLUSIONS

Intensive immunosuppressive regimen, such as using tacrolimus, might be associated with a higher risk for CMV infection, but this study was not able to document the same association for recurrent CMV disease. In patients receiving immunosuppressive regimens that include tacrolimus and antithymocyte globulin, prophylactic treatment for CMV disease with ganciclovir is recommended.

The frequency of HHV-8 infection in otherwise healthy blood donors as well as renal allograft recipients living in Iran

BACKGROUND

Different reports from Middle East countries demonstrated Kaposi's sarcoma (KS) in transplant population. This vascular malignancy occurs mostly among immunocompromised individuals. Human herpesvirus 8 (HHV-8) appears to be the causative factor for the development of this neoplasm. Transplant programs are concerned about the frequencies of HHV-8 infection either in general population or transplant patients.

METHODS

The current study was conducted in two phases. Firstly, we detected antibodies against HHV-8 in 790 otherwise healthy blood donors. Secondly, a total of 125 kidney allograft recipients evaluated as being seropositive for HHV-8. We utilized enzyme immunoassay (EIA) for serologic studies.

RESULTS

Among blood donors, the male to female ratio was 1.05 (405 vs. 385 ) while the mean age was 38.9 ± 11.7 years. The serostatus of none of these blood donors were positive for HHV-8. Among kidney recipients, the male to female ratio was 1.9 (82 vs. 43). The mean age was 39.01 ± 14.77 years. Two (1.6%) patients were seropositive for HHV-8.

CONCLUSION

The prevalence of HHV-8 infection among Iranians is likely to be low. Yet, owing to the evidence of this infection among kidney allograft recipients and its probable role in developing post- transplantation KS (PT-KS), further studies appear to be required to keep the various aspects of this infection under close surveillance.

Sirolimus versus calcineurin inhibitor-based immunosuppressive therapy in kidney transplantation: a 4-year follow-up

INTRODUCTION

Sirolimus is the one of new immunosuppressants that may be a substitute to traditional drugs such as cyclosporine. We present our investigation on sirolimus-based immunosuppression in kidney transplant recipients as compared with cyclosporine-based immunosuppression.

MATERIALS AND METHODS

We enrolled 100 patients in an open-labeled randomized clinical trial at Shahid Labbafinejad Medical Center. The patients were assigned to one of the immunosuppressive groups to receive either sirolimus or cyclosporine in combination with mycophenolate mofetil and steroids. All kidney transplant recipients were followed up by for serum creatinine and glomerular filtration rate for 4 years.

RESULTS

There was no significant differences between the two groups regarding serum creatinine level and GFR until for years posttransplant; however, serum creatinine levels were significantly lower and the GFRs were higher in the sirolimus group after 3 and 4 years. The mean serum creatinine was 1.24 ± 0.28 mg/dL in the sirolimus group and 1.57 ± 0.33 mg/dL in the cyclosporine group at 4 years posttransplant (P = .02). Also, GFR was 79.8 ± 22.3 mL/min/1.73 m2 in the sirolimus group and 70.3 ± 23.6 mL/min/1.73 m2 in the cyclosporine group B (P = .04). Acute rejection was 1.7-fold higher in the cyclosporine group than in the sirolimus group.

CONCLUSIONS

Our study demonstrated that sirolimus in the immunosuppressive regimen of kidney transplant recipients had better outcomes regarding graft and patient survival. The effectiveness of sirolimus for kidney allograft recipients should be further assessed to be implemented from the first day after transplantation.

Incidence of malignancy after living kidney transplantation: a multicenter study from iran

Malignancy is a common complication after renal transplantation. However, limited data are available on post-transplant malignancy in living kidney transplantation. Therefore, we made a plan to evaluate the incidence and types of malignancies, association with the main risk factors and patient survival in a large population of living kidney transplantation. We conducted a large retrospective multicenter study on 12525 renal recipients, accounting for up to 59% of all kidney transplantation in Iran during 22 years follow up period. All information was collected from observation of individual notes or computerized records for transplant patients. Two hundred and sixty-six biopsy-proven malignancies were collected from 16 Transplant Centers in Iran; 26 different type of malignancy categorized in 5 groups were detected. The mean age of patients was 46.2±12.9 years, mean age at tumor diagnosis was 50.8±13.2 years and average time between transplantation and detection of malignancy was 50.0±48.4 months. Overall tumor incidence in recipients was 2%. Kaposis' sarcoma was the most common type of tumor. The overall mean survival time was 117.1 months (95% CI: 104.9-129.3). In multivariate analysis, the only independent risk factor associated with mortality was type of malignancy. This study revealed the lowest malignancy incidence in living unrelated kidney transplantation.

Two decades of experience in mucormycosis after kidney transplantation

BACKGROUND

Invasive mucormycosis is a very rare infection after kidney transplantation. Here, we report 25 renal transplant recipients with mucormycosis; to our knowledge, this is the largest reported population of mucormycosis in these patients.

MATERIAL/METHODS

In a retrospective study, we collected all kidney transplants with mucormycosis from 9 Transplant Centers of Iran from 1990 to 2010. The definitive diagnosis of mucormycosis was established by obtaining a biopsy specimen of the involved tissue.

RESULTS

The most form of disease was rhino-cerebral (n =13), followed by pulmonary (n=7). Overall mortality rate was 52% (n=13), particularly in recipients with pulmonary infection (100%); however, the mortality rate in rhino-cerebral form of disease was low (30.8%). There was no statistically significant difference in mortality rate between male and female (P=0.8). In addition, no significant differences were seen in mortality rate with age of patients (p=0.8) and time of diagnosis since transplantation (p=0.3). Pulmonary infection was more seen in recipients received azathioprine compared to those on mycophenolate mofetil (p=0.006).

CONCLUSIONS

Mucormycosis after renal transplantation has a poor prognosis, particularly patients with pulmonary involvement.

Effect of erythropoietin on kidney allograft survival: early use after transplantation

INTRODUCTION

Erythropoietin is administered for treatment of anemia in chronic kidney disease and kidney transplantation. Erythropoietin improves oxygenation of organs and prevents them against apoptosis. The aim of this study was evaluation of erythropoietin's effect on graft survival in the early phase after transplantation.

MATERIALS AND METHODS

Forty kidney transplant candidates with a hemoglobin level of 8 g/dL to 10 g/dL were randomized to receive either erythropoietin (PD-Poietin) or placebo for the first posttransplant week. They were followed up for 6 months and serum creatinine levels, glomerular filtration rate (GFR), allograft rejection episodes, and graft loss were compared between the two groups.

RESULTS

The mean creatinine level and GFR were 1.16 ± 0.03 mg/mL and 85.1 ± 18.3 mL/min in the erythropoietin group and 1.2 ± 0.2 mg/dL and 83.3 ± 21.1 mL/min in the control group at baseline. After 6 months of follow-up, the mean of creatinine level and GFR reached to 1.11 ± 0.23 mg/dL and 86.6 ± 10.3 mL/min in the erythropoietin group and 1.31 ± 0.35 mg/dL and 79.7 ± 12.5 mL/min in the control group, respectively (P = .04 and P = .02). None of the patients lost their grafts and no death was reported. There were no adverse effects in the erythropoietin group.

CONCLUSIONS

Our findings suggest that erythropoietin may have beneficial effects on graft function if administered early after transplantation. Erythropoietin can be used for all kidney transplant recipients for protecting the allograft due to its effects on tissue oxygenation.

Role of folic acid in atherosclerosis after kidney transplant: a double-blind, randomized, placebo-controlled clinical trial

OBJECTIVES

We investigated the effects of folic acid supplementation on plasma total homocysteine levels and carotid intima-media thickness after kidney transplant.

MATERIALS AND METHODS

Sixty patients who had undergone a kidney transplant were studied in this double-blind, randomized, placebo-controlled clinical trial. Those subjects were randomized to receive either 5 mg/d of oral folic acid or an equivalent dosage of placebo. The main outcome variables were the plasma total homocysteine level and carotid intima-media thickness (determined via B-mode sonography) at baseline and 2, 4, and 6 months after kidney transplant. We used independent and paired sample t tests for data analysis.

RESULTS

The mean age of the patients was 40.9 -/+ 10 years, and 32 of those subjects (58.2%) were men. In the control group, the plasma total homocysteine levels were 19 micromol/L at baseline, 18.7 micromol/L after 2 months, 19.3 micromol/L after 4 months, and 20 micromol/L after 6 months; and the carotid intima-media thickness measurements were 0.81 mm at baseline, 0.82 mm after 2 months, 0.84 mm after 4 months, and 0.85 mm after 6 months. In the folic acid group, the plasma total homocysteine levels were 18.5 micromol/L at baseline, 4.7 micromol/L after 2 months, 12.9 micromol/L after 4 months, and 10.9 micromol/L after 6 months; and the carotid intima-media thickness measurements were 0.73 mm at baseline, 0.73 mm after 2 months, 0.72 mm after 4 months, and 0.71 mm after 6 months.

CONCLUSIONS

Folic acid supplementation reduces both the plasma total homocysteine level and carotid intima-media thickness shortly after kidney transplant.

Does CMV infection increase the incidence of infective endocarditis following kidney transplantation?

BACKGROUND

Infective endocarditis (IE) is a rare but life threatening infection after renal transplantation. In addition, coinfection of CMV and IE has not been reported. Therefore, the current study was initiated to determine whether CMV infection is a risk factor for developing of IE after kidney transplantation.

MATERIAL/METHODS

In a retrospectively study, we analyzed the medical records of 3700 kidney recipients at two transplant centers in Iran, between January 2000 and June 2008 for infective endocarditis.

RESULTS

During the study, 15 patients with IE hospitalized in our centers were included. The predominant causative microorganisms (60%) were group D non-enterococcal streptococci and enterococci. Patient survival rate in all recipients was 66% at 6 months. Data analysis showed no significant differences in 6 months patient survival from hospitalization between both groups with and without CMV infection (P=0.2). The presentation time of infective endocarditis in recipients with CMV coinfection was more likely to be early when compared to CMV negative coinfection patients (P=0.03).

CONCLUSIONS

The present study indicates that CMV infection may lead to predispose to infective endocarditis after kidney transplantation. Rapid diagnosis, effective treatment, and prompt recognition of complications in kidney transplant recipients are essential to good patient outcome.

Posttransplant lymphoproliferative disorders in kidney transplant recipients: an Iranian multicenter experience

INTRODUCTION

Limited data with adequate sample size exist on the development of posttransplant lymphoproliferative disorder (PTLD) in living donor kidney recipients. We conducted a retrospective cohort study on the data of 10 transplant centers to identify the incidence of PTLD in Iran.

MATERIALS AND METHODS

Data of 9917 kidney transplant recipients who received their kidneys between 1984 and 2008 were reviewed. Fifty-one recipients (0.5%) who developed PTLD were evaluated with a median follow-up of 47.5 months (range, 1 to 211) months.

RESULTS

Patients with PTLD represented 24% of all posttransplant malignancies (51 out of 211 cases). There was no relationship between PTLD and sex (P = .20). There were no statistically significance differences considering the age at transplantation between patients with and without PTLD. The late-onset PTLD (70.6%) occurred more frequently compared to the early form. There was no signification relationship between early-onset and late-onset groups in terms of clinical course and outcome. In patients who received azathioprine, PTLD was more frequent when compared to those who received mycophenolate mofetil (P < .001). The lymph nodes were the predominantly involved site (35.3%), followed by the gastrointestinal tract, brain, kidney allograft, lung, ovary, vertebrae, and palatine. Age at diagnosis and the time from transplantation to diagnosis were comparable for various involvement sites of PTLDs. The overall mortality in this series of patients was 51.0%.

CONCLUSIONS

Posttransplant lymphoproliferative disorder is a rare but devastating complication and long-term prognosis can be improved with early recognition and appropriate therapy.

Burden of chronic kidney disease in Iran: a screening program is of essential need

INTRODUCTION

The latent nature of chronic kidney disease (CKD) in primary stages precludes early diagnosis. This necessitates plans such as screening, but we should first introduce CKD as a public health problem. This study was designed to define the burden of CKD in Iran.

MATERIALS AND METHODS

We calculated disability-adjusted life years (DALYs) according to the World Health Organization's practical guidelines for national burden of disease studies. The sum of years of life lost and years lived with disability were estimated for CKD stages 1 to 4 and end-stage renal disease (ESRD) based on the national registry data and the published reports about CKD in Iran in 2004.

RESULTS

Over 700 000 people were estimated to have CKD in Iran in 2004 and 61 000 new cases of CKD were anticipated. The prevalence rate of CKD was estimated to be 1083 and its incidence rate was 173.5 per 100 000 population. Chronic kidney disease was responsible for 1 145 654 DALYs. The highest DALYs for stages 1 to 4 of CKD were due to unknown etiology, diabetes mellitus, and hypertension (382 000 years, 347 400 years, and 311 800 years, respectively). The DALY for ESRD and CKD stages 1 to 4 were 21 490 years and 1 124 164 years, respectively.

CONCLUSIONS

The present study provides an estimate of the burden of CKD in Iran. As CKD can be controlled by practical cost-effective plans, we strongly recommend the information given by this study be considered for future action plans.

Spirometry parameters in patients undergoing hemodialysis with bicarbonate and acetate dialysates

INTRODUCTION

End-stage renal disease causes impairment of all body organs including the heart and the lung. The main problems in the afflicted patients are pulmonary edema due to increased permeability of the capillaries, intravascular and interstitial volume overload, hypertension, and congestive heart failure. These changes cause altered physiologic and mechanical function of the lungs and subsequently increase in airway resistance. We aimed to study the impact of hemodialysis on spirometry parameters.

MATERIALS AND METHODS

In a cross-sectional study performed on 41 patients on maintenance hemodialysis, spirometry was done before and after the dialysis session. The patients were on either acetate or bicarbonate hemodialysis with the same method, dialysis machine, and duration of dialysis. Alterations in spirometry parameters including forced expiratory volume in the first second (FEV1), forced vital capacity (FVC), FEV1/FVC ratio, and maximal midexpiratory flow rate were determined and their relation with serum electrolytes, serum creatinine, blood urea nitrogen, and hemoglobin were analyzed.

RESULTS

Twenty-nine patients undergoing dialysis with bicarbonate dialysate and 21 on dialysis with acetate were compared. Improvement in spirometry parameters was only significant in patients undergoing dialysis with bicarbonate dialysate. All spirometry parameters showed significant increases in the bicarbonate group except for the FEV1/FVC ratio. Furthermore, significant increase in these parameters was only prominent in the men. Postdialysis weight reduction and laboratory indexes had no significant correlation with improvement of spirometry parameters.

CONCLUSIONS

Dialysis with bicarbonate dialysate causes significant improvement in spirometry parameters in men on maintenance dialysis. This effect might be independent of the effect of removing the volume overload by dialysis.

Invasive fungal infections following renal transplantation: a review of 2410 recipients

BACKGROUND

Organ transplant recipients, on long-term graft preserving immunosuppressive therapy, are at increased risk for life threatening opportunistic fungal infections.

MATERIAL/METHODS

In order to evaluate the incidence of invasive fungal infections (IFIs) and to identify the most common fungal pathogens, we conducted a retrospective study on 2410 ESRD cases undergone living kidney transplantation in three transplant centers between 1998 and 2008.

RESULTS

IFIs developed in 21 recipients (0.87%), 17 male and 4 female. Their immunosuppression was cyclosporine based. The mean age of patients was 48+/-10 (ranged from 32 to 67) years. Diagnosis was made by radiological findings, positive blood or bronchoalveolar lavage (BAL) cultures and tissue biopsies. Mucormycosis was the most common cause of IFIs in population studied (n=11), followed by disseminated candidiasis (n=4), aspergillosis (n=3), nocardiasis (n=2) and histoplasmosis (n=1). Pulmonary involvement was dominant (47.6%). The treatment was successful in only 10 patients and the rest died.

CONCLUSIONS

In our large series of kidney transplant recipients, mucormycosis was found to be the most common cause of invasive fungal infection. Prompt diagnosis and treatment are necessary to avoid the life threatening complications and may greatly improve prognosis.

Low-dose doxepin for treatment of pruritus in patients on hemodialysis

INTRODUCTION

Pruritus is one of the frequent discomforting complications in patients with end-stage renal disease. We prospectively evaluated the effectiveness of doxepin, an H1-receptor antagonist of histamine, in patients with pruritus resistant to conventional treatment.

MATERIALS AND METHODS

A randomized controlled trial with a crossover design was performed on 24 patients in whom other etiologic factors of pruritus had been ruled out. They were assigned into 2 groups and received either placebo or oral doxepin, 10 mg, twice a day for 1 week. After a 1-week washout period, the 2 groups were treated conversely. Subjective outcome was determined by asking the patients described their pruritus as completely improved, relatively improved, or remained unchanged/worsened.

RESULTS

Complete resolution of pruritus was reported in 14 patients (58.3%) with doxepin and 2 (8.3%) with placebo (P < .001). Relative improvement was observed in 7 (29.2%) and 4 (16.7%), respectively. Overall, the improving effect of doxepin on pruritus was seen in 87.5% of the patients. Twelve patients (50.0%) complained of drowsiness that alleviated in all cases after 2 days in average. One patient refused to continue the treatment due to its sedative effect.

CONCLUSIONS

We suggest that doxepin, a tricyclic antidepressant with anti-H1 receptor effect, can help improve pruritus resistant to antihistamines in end-stage renal disease patients who undergo hemodialysis. A low dose of doxepin is safe while effective and its main adverse effect, drowsiness, is temporary and can be easily tolerated by the patients.

Successful treatment of infective endocarditis in four kidney transplant recipients

Infective endocarditis (IE) is a serious complication in kidney transplantation, leading to graft loss and a high mortality rate. We report 4 successfully managed cases of IE in kidney transplant recipients. Blood culture revealed Enterococcus in 2 patients, group D Streptococcus in 1, and no bacteria in 1. All of the patients were diagnosed based on at least 2 major Duke criteria for diagnosis of IE. Although a mild increase in the serum creatinine level was observed in 3 out of 4 patients, no graft rejection occurred during the follow-up. Early diagnostic and therapeutic intervention, particularly intensive antibiotic therapy and surgical management can preserve the patient and the kidney allograft. Studies on previous recurrent infections and simultaneous diseases such as cytomegalovirus in these patients are warranted.

Atherosclerosis after kidney transplantation: changes of intima-media thickness of carotids during early posttransplant period

INTRODUCTION

The aim of this study was to evaluate atherosclerotic changes in the carotid artery following kidney transplantation.

MATERIALS AND METHODS

Twenty-six nonsmoker kidney allograft recipients who did not have cardiovascular disease or diabetes mellitus were enrolled in the study. The carotid intima-media thickness (IMT) was measured at 12 points using B-mode ultrasonography. The mean of the measured values was considered as the patient's IMT. We followed the patients and changes in the carotid IMT were evaluated every 2 months up to the 6th posttransplant month.

RESULTS

The mean age of the patients at transplantation was 41.5 +/- 11.1 years. The mean baseline IMT was 0.84 +/- 0.22 mm. During the follow-up period it reached 0.85 +/- 0.22 mm, 0.87 +/- 0.23 mm (P = .01), and 0.88 +/- 0.24 mm (P = .002) after 2, 4, and 6 months, respectively. The IMT measures significantly correlated with the age and body mass index. Using the IMT cutoff points of 0.75 mm for stroke and 0.82 mm for MI, we found that 57.7% and 68% of the patients were at the risk of stroke at baseline and 6 months after transplantation (P < .001). Also, 46.2 % of the patients were at the risk of MI at baseline that rose to 53.8% at the end of the study (P < .001).

CONCLUSION

Atherosclerosis is an early event after kidney transplantation even in asymptomatic patients and those without major risk factors such as cardiovascular disease, diabetes mellitus, and smoking. Early diagnosis and treatment of atherosclerosis is of utmost importance.

Is preemptive kidney transplantation preferred? Updated study

INTRODUCTION

For eligible patients with end-stage renal disease, the dialysis stage could be bypassed by preemptive kidney transplantation (PKT), when the organ is available. We compared this treatment option with kidney transplantation in patients with pretransplant dialysis (PTD).

MATERIALS AND METHODS

We retrospectively studied on 300 patients who received PKT between 1992 and 2006 from living donors. They were compared with 300 kidney recipients with PTD matched for the time of transplantation that had been on hemodialysis for at least 6 months. Episodes of rejection, graft function, and graft and patient survivals were compared between the two groups.

RESULTS

No significant differences were noted in the sex of the recipients, age and sex of the donors, donor source, and posttransplant immunosuppressive therapy, but posttransplant follow-up was longer (P < .001) and the recipients were older (P < .001) in the PTD group. Seventy-one patients (23.7%) in the PKT group and 64 (21.3%) in the PTD had at least 1 rejection (P = .49). The kidney allografts were functional in 272 (90.7%) kidney recipients in the PKT group and 278 (92.7%) in the PTD group during their follow-ups (P = .30). Five-year graft and patient survival rates were slightly higher in the PTD group, which were not statistically significant (P = .06 and P = .07, respectively).

CONCLUSION

In addition to comparable patient and grretroper aft survivals with the PKT and kidney transplantations after a period of dialysis, PKT eliminates hemodialysis costs and complications. We recommend PKT as a better choice for transplantation whenever possible.

Plasmapheresis in the treatment of early acute kidney allograft dysfunction

OBJECTIVE

To evaluate the efficacy of plasmapheresis (PP) in kidney transplant recipients with acute humoral rejection (AHR).

PATIENTS AND METHODS

A retrospective review was conducted of all kidney allograft recipients who had undergone PP rescue therapy for early acute allograft dysfunction diagnosed as AHR at Shaheed Labbafinejad Medical Center from 1995 to 2002.

RESULTS

Twelve patients (4 men and 8 women; median age, 32 years; age range, 15-68 years) with AHR were treated with PP. The median time from transplantation to AHR was 6 days (range, 2-7 days). PP was performed in 2 to 11 sessions (median, 8.5 sessions) in the patients studied. Eight patients responded to that treatment, and their creatinine value normalized. Those responders were monitored for a median of 162.5 weeks (range, 69.3-484.7 weeks), and all had a functioning allograft during the follow-up period except for 1 patient in whom the graft failed 154 weeks after transplantation. In the 4 remaining patients (nonresponders), the allograft failed within the first posttransplant month. The median time from the acute serum creatinine elevation to the initiation of PP was 6 days in responders and 18.6 days in nonresponders (P = .37).

CONCLUSIONS

We suggest that PP with or without other therapeutic measures may have a role in the salvage of grafts with early acute dysfunction that is resistant to conventional therapy. Our findings indicate that graft survival in patients with AHR who respond to PP can be comparable to that in other kidney recipients.

Living unrelated versus living related kidney transplantation: 20 years' experience with 2155 cases

PURPOSE

To compare the long-term results of kidney transplantation from living unrelated donors (LURDs) with that from living related donors (LRDs).

MATERIALS AND METHODS

From 1984 to 2004, we performed 2155 kidney transplantations of which 374 were from LRDs and 1760 from LURDs. We reviewed and compared the long-term data from these cases.

RESULTS

The LURD group included 64.2% men with an overall mean age of 33.46 +/- 14.61 (range 3 to 76) years. Laparoscopic donor nephrectomy was performed in 329 cases (18.7%) with mean follow-up of 45.68 +/- 46.80 months. The LRD group included 66.5% of male recipients with overall mean age of 28.97 +/- 9.58 (range 9 to 65) years. Laparoscopic donor nephrectomy was performed in 12 cases (3.2%) of LRDs with mean follow-up of 81.15 +/- 67.03 months. One-, 3-, 5-, 10-, and 15-year graft survivals among LRDs were 91.6%, 81.7%, 76.4%, 64.4%, and 48.4%; and for LURDs, 91.5%, 86.7%, 81.4%, 68.2%, and 53.2%, respectively (P = .07). Patient survivals for 1, 3, 5, 10, and 15 years in LRDs were 94.6%, 91.9%, 83%, 79.5%, and 73.9%, and in LURDs were 93.6%, 91.7%, 89.3%, 84%, and 76.4%, respectively (P = .14).

CONCLUSION

The results of living unrelated kidney transplantation upon long-term follow-up with a large number of cases were as good as living related kidney transplantation. The organ shortage can be alleviated by using living unrelated kidney transplantation. To our knowledge this is the largest experience with long-term follow-up reported from one center to date.

Erythrocytosis after renal transplantation: review of 101 cases

Posttransplant erythrocytosis is increasingly recognized as a complication of kidney transplantation. In a retrospective analysis of 500 recipients, we observed 101 patients (20.2%) with persistent elevation of hematocrit value. It was more frequent in men (82.2%) than women (17.8%). It occurred 2 to 50 months after engraftment (mean value was 11.2 +/- 8.9 months), but most often developed in the first 24 months (86%). Spontaneous remission of established erythrocytosis was observed in all cases within 3 to 93 months. It frequently occurred in patients with a well-functioning renal graft; in 82.2% of cases the serum creatinine concentration was less than 1.5 mg/dL. It was 1.5 to 2 mg/dL in 15.8% of patients. There was no correlation between diabetes mellitus and erythrocytosis, compared with a control group. It was more common in patients who received cyclosporine compared to those who were not on cyclosporine. Predisposing factors included male gender, retention of native kidneys, cyclosporine use, and a rejection-free course with a well-functioning renal graft. In conclusion, posttransplantation erythrocytosis, a frequent problem in renal transplant patients, is a self-limited complication that can result in thromboembolic disease.

Kidney retransplantation in comparison with first kidney transplantation

INTRODUCTION

The aim of this study was to depict the outcome of second and third kidney allografts in comparison with first kidney allografts.

METHODS

Among 2150 kidney transplantations are 103 second and 5 third transplantations. Demographic characteristics and survivals of retransplanted patients were compared with a randomly selected group of first kidney recipients, consisting of two cases matched with each retransplanted patient for age, gender, and date of transplantation.

RESULTS

Retransplanted patients consisted of 78 men and 30 women of mean age 32.63 +/- 11.92 years. They had received kidneys from 91 living-unrelated and 17 living-related donors. Median followup was 27 months. One-, 2-, 3-, and 5-year graft survivals were 81.4%, 78.9%, 78.9%, and 73.7% among retransplants, versus 92.9%, 91.5%, 89.8%, and 85.3% in the control group, respectively (P = .0037). Patient survival was 96%, 94.6%, 92.4%, and 87.8% in the retransplant group versus 93.1%, 92.4%, 90.9%, 87.4% in the control group, respectively (P = .63). Also, graft survivals were slightly lower in female compared to male retransplant patients (P = .09). No significant difference in survival rates was seen in different age groups.

CONCLUSION

It seems that kidney retransplantation can yield desirable outcomes, albeit relatively lower graft survivals.

Signs and symptoms of cytomegalovirus disease in kidney transplant recipients

PURPOSE

To investigate the range of clinical presentations of cytomegalovirus (CMV) disease in kidney transplant recipients.

MATERIALS AND METHODS

We retrospectively reviewed the records of hundred kidney recipients who developed CMV disease between 1984 and December 2002 for demographic characteristics, laboratory findings, and presenting signs and symptoms.

RESULTS

The most common presentations were elevated serum creatinine in 74 patients, fever in 71, thrombocytopenia in 43, nausea in 32, vomiting in 25, elevated alkaline phosphatase in 24, leukocytosis in 22, and leukopenia in 21. Tissue involvement was relatively rare, but six patients had pneumonia, two had conjunctivitis, and one had vascular dermatitis. Four percent of the patients had received intravenous ganciclovir prophylaxis, and 7% had received oral ganciclovir prophylaxis. Fever was associated with number of hospitalizations (P = .006), elevated creatinine (P = .006), nausea (P = .017), vomiting (P = .031), and previous posttransplantation infections (P < .001). All the patients with conjunctivitis, pneumonia, pulmonary symptoms, and abnormal heart sounds and most of those with arthralgia, nausea, and vomiting were febrile during their CMV disease course.

CONCLUSION

Our findings showed that leukocytosis should be considered as much as leukopenia when CMV disease is suspected. CMV-induced pneumonia is not common in renal transplant recipients compared to other organ transplant recipients. CMV invasion to other tissues is also rare. Finally, fever is a common symptom and important in assessing the severity and prognosis of the disease.

Pregnancy in Kidney Transplant Recipients

PURPOSE

Our aim was to investigate kidney allograft, obstetric, and maternal outcomes in pregnant women undergoing kidney transplantation in our center.

METHODS

Retrospective data on 74 pregnancies in 60 patients were reviewed and completed through phone interviews were compared with information on a control group of female kidney recipients.

RESULTS

Mean age of patients at transplantation was 26.55 +/- 4.72 years and the median interval between transplantation and pregnancy was 27.5 months. Gestational period was 8 months. Live birth was the outcome in 43.2% of pregnancies; 9.5% led to still birth, 24.3% were aborted, and obstetrical data of the remaining were unavailable. Among the 11 patients who became pregnant within 12 months after transplantation, we observed seven live births and four abortions. None of pregnancies that were accompanied by acute rejection episodes (ARE) were successful. Twenty-six patients experienced at least one ARE versus 23 patients of the control group (P = NS). However, the first ARE occurred later in the pregnant group (P = .028). Chronic rejection and graft loss were seen in 24 and 18 study group cases and 17 and 17 control cases, respectively (P = NS). One-, 3-, 5-, and 10-year graft survivals were 100%, 96.5%, 94.5%, and 77.1% in the pregnant group versus 93.2%, 85.7%, 81%, and 64.7% in the control group, respectively (P = .07).

CONCLUSION

Pregnancy in kidney recipients seems to be safe for kidney allograft recipients even within the first year posttransplant. Nonetheless, the outcomes of pregnancy in this group of patients is not always favorable, especially when rejection occurs simultaneously.

Outcome of Kaposi’s Sarcoma and Graft Following Discontinuation of Immunosuppressive Drugs in Renal Transplant Recipients

PURPOSE

Owing to the use of immunosuppressive drugs, renal transplant recipients are at risk for malignancies including Kaposi's sarcoma (KS). Following the diagnosis, physicians tend to decrease the doses of immunosuppressive drugs to lower tumor progression rate. On the other hand, those who receive lower doses of immunosuppressive drugs are at a higher risk for acute rejection. In this study, we evaluated the outcome of KS on renal allografts following discontinuation or decrease in the doses of drugs.

METHODS

Since 1984, 14 (nine men and five women) among 2000 cases of renal transplantation have been diagnosed as KS. In 11 patients, cyclosporine was completely discontinued, the dosage was decreased to half of the initial dose in other cases. Except one case, we discontinued either azathioprine or mycophenolate mofetil.

RESULTS

During 57 months of follow-up on average, the serum creatinine level remained normal in 10 but increased in four cases. Kidney function deteriorated in two of these four patients at the beginning of study. Three patients died with normal serum creatinine levels. Discontinuation of immunosuppressive drugs caused complete remission of KS in all patients except one who received chemotherapy.

CONCLUSION

Discontinuation of immunosuppressants following the diagnosis of KS caused complete remission of this cancer in almost all patients and seemed to be relatively safe for kidney graft function.

Renal Allograft Accumulation of Technetium-99m Sulfur Colloid as a Predictor of Graft Rejection

Differentiation between rejection (the most common cause) and many other possibilities for detrimental effects on graft function represents a difficult issue to diagnose the cause of renal allograft dysfunction. This study was designed to determine whether technetium-99m sulfur colloid (TSC) accumulation predicted graft rejection. We prospectively studied 54 episodes of allograft dysfunction in 53 kidney transplant recipients who underwent TSC scintiscanning and graft biopsy. Visual analysis of TSC uptake compared uptake, in the allograft with that in the marrow of the fifth lumbar vertebra (L5). A 3+ result meant that allograft uptake was greater than L5 marrow uptake; 2+, the same; 1+, less and finally 0, no allograft uptake. Transplant accumulation of 2+ or more was considered consistent with rejection (P = .01). Allograft biopsies interpreted based on the Banff Working Classification showed rejection in 45 of 54 renal biopsies with 42 the biopsy-proven rejection episodes showing at least 2+ graft uptake. Furthermore, this nuclear medicine technique had a sensitivity of 93.3%, a specificity of 44.4%, a positive predictive value of 89.3%, a negative value of 57.1% and an efficiency of 83.3% for the diagnosis of renal allograft rejection.

A Randomized Prospective Trial of Oral Versus Intravenous Ganciclovir for Prophylaxis of Cytomegalovirus Infection and Disease in High-Risk Kidney Recipients

PURPOSE

This study was designed to compare the efficacy and safety of oral versus intravenous ganciclovir in high-risk kidney recipients.

METHODS

Thirty-four, cytomegalovirus (CMV) seropositive recipients of kidneys from seropositive donors who had undergone antilymphocytic immunosuppressive therapy were assigned randomly to oral (1000 mg, three times a day, 12 weeks) versus intravenous (5 mg/kg, 2 weeks) ganciclovir prophylaxis. Follow-up was performed for 12 months. The patients were evaluated for clinical and laboratory outcomes regarding CMV serostatus, CMV disease, graft outcome, and ganciclovir side effects.

RESULTS

Sixteen patients in the oral group and 14 in the intravenous group completed the study. CMV infection occurred in 6 (37.5%) and 5 (35.7%) cases in the oral and intravenous groups, respectively (P = NS). The mean interval between prophylaxis initiation and the first positive CMV Ag result was 3 +/- 2.19 months, with no significant difference between the two groups. Only two patients in the intravenous group experienced CMV diseases, which were not tissue-invasive. Acute rejection episodes were observed in nine out of 30 recipients, but it did not show any association with the prophylaxis regimen or CMV serostatus. The patients tolerated oral ganciclovir well; the compliance percent was 81.6%. No complication was reported.

CONCLUSION

Oral and intravenous ganciclovir showed no significant difference to reduce the rate of CMV infection among high-risk kidney recipients. Oral ganciclovir was also effective and safe for the prevention of CMV disease. Moreover, it seems that CMV infection was not associated with acute rejection episodes.

Impact of Ramadan Fasting on Renal Allograft Function

Fasting during the holy month of Ramadan is a religious duty for all healthy adult Muslims. They are only allowed to eat and drink between sunset and dawn. This study was designed to find the effect of Ramadan fasting on allograft function. We prospectively studied 19 kidney transplant recipients who voluntarily chose to fast during Ramadan versus 20 matched recipients, who had not fasted for 3 consecutive years. Data were recorded before, during, and after the fasting month. The mean posttransplant periods in the fasting and control groups were 52.6 +/- 30.3 and 56.6 +/- 30.0 months, respectively. A statistical analysis showed no significant changes in serum creatinine concentrations before and after Ramadan 1.07 +/- 0.24 versus 1.08 +/- 0.22 mg/dL (P > .05) and 1.00 +/- 0.24 versus 1.03 +/- 0.28 mg/dL (P > .05) in fasting and control groups, respectively. The results did not show any adverse effects of fasting in recipients with stable renal function. In conclusion, our study suggests that fasting during the month of Ramadan is safe and has no significant harmful effects on kidney transplant recipients with normal renal function.

Potential Risk Factors for Hypersensitization Reflected by Panel-Reactive Antibodies in Dialysis Patients

INTRODUCTION

The panel-reactive antibody (PRA) test has been considered to be a routine index of sensitization to human leukocyte antigens (HLA) in kidney transplant candidates. This study investigated the effect of potential risk factors and the time of blood sampling on PRA tests.

METHODS

A total of 98 patients at two dialysis centers in Tehran were tested for PRA levels before and after dialysis sessions. We evaluated their history of potential sensitizing events and patient interviews for their association with PRA levels. Also we compared PRA levels obtained before and after dialysis.

RESULTS

The mean age of the patients was 58.33 +/- 15.85 years. Only age and kidney transplantation history were correlated with PRA levels (r = .246, P = .014 and P = .0001, respectively). Logistic regression analysis revealed an association between age and PRA level (P = .037). Transplantation history was weakly correlated with PRA level (P = .076). History of pregnancy and transfusion, dialysis duration, gender, donor relation, and kidney allograft duration were not associated with PRA. PRA before dialysis sessions was significantly lower than that after dialysis (P = .0003). However, no difference was seen when divided into groups of negative/positive (PRA < 10% as negative) and high/low (PRA < 60% as low).

CONCLUSION

Many factors expose patients to HLA as sensitizing factors. However, it seems that PRA level is not always predictable by such conditions. Furthermore, dialysis as a confounding procedure impacts PRA results; thus, when to obtain a blood sample is a crucial question.

Is HLA-DR6 a Protective Factor Against Posttransplantation Diabetes Mellitus?

BACKGROUND

Posttransplant diabetes mellitus (PTDM) has several pre- and posttransplant risk factors.

METHODS

The incidence and risk factors of PTDM were retrospectively evaluated in 2117 kidney allograft recipients from June 1984 to March 2004. Type and dosage of immunosuppressive agents, pretransplant weight and human leukocyte antigen (HLA) phenotypes in PTDM patients were compared with 61 matched controls.

RESULTS

Sixty-one cases (2.8%) developed PTDM requiring insulin or oral hypoglycemic therapy, out of which 47.5% were men and 52.5% were women, although only 35% of our overall recipients are women. Onset occurred at a mean of 489 days following transplantation. Patients receiving more than 15 mg/d prednisolone developed PTDM more often than those on less than 15 mg/d (P = .000). Similarly PTDM was more frequent among patients who received more than 300 mg/d cyclosporine compared with those on less than 300 mg/d (P = .015). Mean weight in PTDM cases and controls was 65 +/- 13.4 kg and 57 +/- 13.6 kg, respectively (P = .005). HLA-DR6 was observed in 12.2% of nonaffected subjects but in none of the PTDM group (P = .002). Conversely, HLA-DR8 was seen only in PTDM patients (P = .012). In addition HLA-A26 was more common among PTDM patients (P = .02) and HLA-DR52 more frequent in nonaffected subjects (P = .025).

CONCLUSION

Our findings suggest that female sex, dosages of prednisolone and cyclosporine, pretransplant weight, and genetic factors are associated with an increased risk of PTDM. The rate of PTDM appeared to be independent of weight gain in the first year posttransplant. Protection against PTDM may be afforded by HLA-DR6 and possibly HLA-DR52. Conversely and higher incidence of diabetes has been associated with HLA-DR8 and HLA-A26.

Frequency of infectious skin lesions in kidney transplant recipients

INTRODUCTION

This study was performed to evaluate the frequency of skin lesions in kidney transplant recipients.

MATERIALS AND METHODS

A total of 681 kidney transplant recipients were followed at Shaheed Labbafinejad transplant center in Tehran, Iran. Skin lesions were evaluated, and diagnoses were made clinically and confirmed by lesion smear, tissue biopsy, tissue culture, and serologic examinations, as indicated.

RESULTS

Skin lesions were found in 54 patients (7.9%), and their frequencies were as follows: dermatomal herpes zoster (18 patients, 2.6%, 13 men and 5 women), herpes simplex infection of face and lips (15 patients, 2.2%, 5 men and 10 women), chickenpox (6 patients, 0.9%, 5 men and 1 woman), Kaposi's sarcoma (5 patients, 0.7%, 3 men and 2 women), warts (4 women, 2 of whom had genital warts), pyoderma gangrenosum (1 man, 0.14%), multiple fungal abscesses of the leg (1 man, 0.14%), mucormycosis (1 man, 0.14%), and molluscum contagiosum (1 man, 0.14%). Moreover, 2 women (0.3%) had generalized herpes simplex lesions.

CONCLUSION

Frequencies of herpes zoster (3.5%), herpes simplex (2.5%), and human papillomavirus (0.6%) infections in our kidney transplant recipients were low. We recommend that all kidney transplant candidates be evaluated and immunized for herpes zoster virus before transplantation, all herpetic-form lesions of these patients be reported to physicians (even mild lesions), and finally, that all human papillomavirus lesions be diagnosed and treated promptly to prevent more serious lesions such as malignancies.