Renal involvement in systemic sclerosis

Systemic sclerosis is a rare autoimmune vasculopathy associated with dysregulated innate and adaptive immunity that leads to generalized systemic fibrosis. Renal involvement occurs in a significant proportion of systemic sclerosis patients, and is associated with worse outcome. Scleroderma renal crisis (SRC) is the most studied and feared renal complication described in systemic sclerosis. However, with the emergence of ACE inhibitors and better management, the mortality rate of SRC has significantly decreased. Renal disease in systemic sclerosis offers a wide array of differential diagnoses that may be challenging for the clinician. The spectrum of renal manifestations in systemic sclerosis ranges from an isolated decrease in glomerular filtration rate, increased intrarenal arterial stiffness, and isolated proteinuria due to SRC to more rare manifestations such as association with antiphospholipid antibody nephropathy and ANCA-associated vasculitis. The changes observed in the kidneys in systemic sclerosis are thought to be due to a complex interplay of various factors, including renal vasculopathy, as well as the involvement of the complement system, vasoactive mediators such as endothelin-1, autoimmunity, prothrombotic and profibrotic cytokines, among others. This literature review aims to provide an overview of the main renal manifestations in systemic sclerosis by discussing the most recent epidemiological and pathophysiological data available and the challenges for clinicians in making a diagnosis of renal disease in patients with systemic sclerosis.

OC-006 LAPAROSCOPIC TOTALLY EXTRA-PERITONEAL REPAIR OF BILATERAL INGUINAL HERNIAS WITH A LARGE SINGLE MESH: A SINGLE CENTER STUDY WITH MINIMUM 5 YEARS FOLLOW UP

Background

Laparoscopic totally extraperitoneal (TEP) surgery with a single large mesh is currently the technique of choice for repair of bilateral inguinal hernias in our institution. Most surgeons use two meshes for the TEP repair. We present our experience with a single mesh repair.

Material & Methods

Records of all patients who had bilateral inguinal hernia and underwent bilateral laparoscopic TEP repair at our institution, 2010–2016, were retrospectively reviewed. We excluded patients who had a conversion to transabdominal intraperitoneal or open approach.

Results

A total of 470 patients were identified. The median age of patients was 56 (IQR 1–3; 41–66) years and median BMI was 25.9 (IQR 1–3; 23.1–28.1). 18.7% of the cohort (88 patients) had previous abdominal surgery and 39 patients (8.41%) had a recurrent inguinal hernia. Median length of operation was 63 (IQR1–3; 48–89) minutes. Operative complication were bleeding (0.4%) and bladder injury (0.2%). Post operative complications occurred in 32 patients; among the complications were seroma (2.6%), hematoma (2.1%), surgical site infection (0.4%) urinary retention (1.5%) and intestinal obstruction (0.2%). Median length of hospitalization was 1 day (IQR1–3; 1–2). After a median follow up of 102 months, 36 patients had a recurrence. 20 patients (4.3%) had a re-operation for recurrent inguinal hernia. Post-operative groin pain was present in 48 patients.

Conclusion

The use of a large single mesh is an effective and safe technique for TEP repair of bilateral inguinal hernias. The recurrence rate and prevalence of post-operative pain is consistent with the results reported by others.

Cardiovascular Outcomes in Kidney Transplant Recipients With ADPKD

Introduction

Cardiovascular disease leads to high morbidity and mortality in patients with kidney failure. Autosomal Dominant Polycystic Kidney Disease (ADPKD) is a systemic disease with various cardiac abnormalities. Details on the cardiovascular profile of patients with ADPKD who are undergoing kidney transplantation (KT) and its progression are limited.

Methods

Echocardiographic data within 2 years before KT (1993-2020), and major adverse cardiovascular events (MACEs) after transplantation were retrieved. The primary outcome is to assess cardiovascular abnormalities on echocardiography at the time of transplantation in ADPKD as compared with patients without ADPKD matched by sex (male, 59.4%) and age at transplantation (57.2 ± 8.8 years).

Results

Compared with diabetic nephropathy (DN, n = 271) and nondiabetic, patients without ADPKD (NDNA) (n = 271) at the time of KT, patients with ADPKD (n = 271) had lower rates of left ventricular hypertrophy (LVH) (39.4% vs. 66.4% vs. 48.6%), mitral (2.7% vs. 6.3% vs. 7.45) and tricuspid regurgitations (1.8% vs. 6.6% vs. 7.2%). Patients with ADPKD had less diastolic (25.3%) and systolic (5.6%) dysfunction at time of transplantation. Patients with ADPKD had the most favorable post-transplantation survival (median 18.7 years vs. 12.0 for diabetic nephropathy [DN] and 13.8 years for nondiabetic non-ADPKD [NDNA]; P < 0.01) and the most favorable MACE-free survival rate (hazard ratio = 0.51, P < 0.001). Patients with ADPKD had worsening of their valvular function and an increase in the sinus of Valsalva diameter post-transplantation (38.2 vs. 39.9 mm, P < 0.01).

Conclusion

ADPKD transplant recipients have the most favorable cardiac profile pretransplantation with better patient survival and MACE-free survival rates but worsening valvular function and increasing sinus of Valsalva diameter, as compared with patients with other kidney diseases.

Guiding Kidney Transplantation Candidates for Effective Weight Loss: A Clinical Cohort Study

BACKGROUND

Obesity is increasingly common in kidney transplant candidates and may limit access to transplantation. Obesity and diabetes are associated with a high risk for post-transplant complications. The best approach to weight loss to facilitate active transplant listing is unknown, but bariatric surgery is rarely considered due to patient- and physician-related apprehension, among other factors.

METHODS

We aimed to determine the magnitude of weight loss, listing, and transplant rates in 28 candidates with a mean BMI of 44.4±4.6 kg/m² and diabetes treated conservatively for 1 year post weight-loss consultations (group 1). Additionally, we evaluated 15 patients (group 2) who met the inclusion criteria but received bariatric intervention within the same time frame. All patients completed a multidisciplinary weight management consultation with at least 1 year of follow-up.

RESULTS

In the conservatively managed group (group 1), the mean weight at the time of initial consultation was 126.5±18.5 kg, and the mean BMI was 44.4±4.6 kg/m². At 1 year post weight-loss consultation, the mean weight decreased by 4.4±8.2 kg to 122.9±17 kg, and the mean BMI was 43±4.8 kg/m², with a total mean body weight decrease of 3% (P=0.01). Eighteen patients (64%) did not progress to become candidates for active listing/transplantation during the follow-up time of 4±2.9 years, with 15 (54%) subsequently developing renal failure/diabetes-related comorbidities prohibitive for transplantation. In contrast, mean total body weight decreased by 19% at 6 months post bariatric surgery, and the mean BMI was 34.2±4 and 32.5±3.7 kg/m² at 6 and 12 months, respectively. Bariatric surgery was strongly associated with subsequent kidney transplantation (HR=8.39 [95% CI 1.71 to 41.19]; P=0.009).

CONCLUSIONS

A conservative weight-loss approach involving multidisciplinary consultation was ineffective in most kidney transplant candidates with diabetes, suggesting that a more proactive approach is needed.

Kidney Transplantation in Patients With Monoclonal Gammopathy of Renal Significance (MGRS)-Associated Lesions: A Case Series

RATIONALE & OBJECTIVE

Data on kidney transplantation outcomes among patients with monoclonal gammopathy of renal significance (MGRS) are lacking.

STUDY DESIGN

Case series of patients with MGRS, some of whom received clone-directed therapies before kidney transplantation.

SETTING & PARTICIPANTS

28 patients who underwent kidney transplantation from 1987 through 2016 after diagnosis with MGRS-associated lesions including light-chain deposition disease (LCDD), C3 glomerulopathy with monoclonal gammopathy (C3G-MG), and light-chain proximal tubulopathy (LCPT).

FINDINGS

Of the 19 patients with LCDD, 10 were treated before kidney transplantation and 9 were treatment-naive. Among the treated patients with LCDD, 3 (30%) experienced histologic recurrence, 2 (20%) grafts failed, and 2 (20%) died during a median follow-up of 70 (range, 3-162) months after transplant. In the treatment-naive LCDD group, 8 (89%) had histologic recurrence, 6 (67%) grafts failed, and 4 (44%) patients died during a median follow-up of 60 (range, 35-117) months. Of the 5 patients who had a complete response before transplant, none died, and only 1 experienced graft failure, 162 months after transplant. Of 5 patients with C3G-MG, 3 were treatment-naive before transplant. Both patients who were treated before transplant had histologic recurrence, and 1 experienced graft failure and died. Among the 3 patients with treatment-naive C3G-MG, histologic recurrence occurred in all, and graft loss and death were observed in 2 and 1, respectively. In the LCPT group (n=4), histologic recurrence was observed in all 3 patients who did not receive clone-directed therapies before transplant, and 2 of these patients died, 1 with a functioning kidney. The 1 patient with LCPT who received therapy before transplant did not have histologic recurrence or graft loss and survived.

LIMITATIONS

Small sample size, nonstandardized clinical management, retrospective design.

CONCLUSIONS

Recurrence is very common in all MGRS-associated lesions after kidney transplant. Achieving a complete hematologic response may reduce the risks of recurrence, graft loss, and death. More studies are needed to determine the effects of hematologic response on outcomes for each MGRS-associated lesion.

Kidney Transplant Outcomes of Patients With Multiple Myeloma

Introduction

Data on kidney transplantation (KTx) outcomes of patients with multiple myeloma (MM) are very limited.

Methods

We investigated the outcomes of patients with MM who underwent KTx between 1994 and 2019.

Results

A total of 12 transplants from 11 patients were included. At the time of KTx, 6 were classified as having stringent complete response (CR), 2 as CR, 2 as very good partial response (VGPR), and 2 as partial response (PR). With a median follow-up of 40 (minimum–maximum, 5–92) months after KTx, hematologic progression occurred in 9 transplants (75%). There were 3 grafts (25%) that failed, and 5 patients (45.5%) experienced death with functioning allografts. Graft survival at 1 and 5 years was 82.5% and 66%, respectively. Progression-free survival (PFS) rates of the cohort at 1, 3, and 5 years were 83.3%, 55.6%, and 44.4%, respectively. The estimated median PFS of patients who received bortezomib at any time (pre-KTx and/or post-KTx) was not reached, whereas it was 24 months for those who never received bortezomib (P = 0.281). Overall survival (OS) rates of the cohort at 1, 3, and 5 years were 81.8%, 61.4%, and 61.4%, respectively. OS of patients who received bortezomib at any time was 87.5%, 72.9%, and 72.9%, and that for those who never received bortezomib was 66.7%, 33.3%, and 33.3% (P = 0.136). All deaths occurred owing to hematologic progression or treatment-related complications.

Conclusion

Kidney transplant outcomes of patients with myeloma who received bortezomib before or after KTx seem to be more favorable. Nevertheless, relapse after KTx in MM is still common. More studies are needed to better determine who benefits from a KTx.

Impact of extended-spectrum beta-lactamase-producing Enterobacterales (ESBL-E) rectal carriage in cancer patients admitted to the intensive care unit

Little data is available on extended-spectrum beta-lactamase-producing Enterobacterales (ESBL-E) rectal colonization in cancer patients admitted to the intensive care unit (ICU). We aimed to describe the epidemiology of ESBL-E in cancer patients hospitalized in the ICU compared with non-cancer patients. ESBL-E colonization was detected in 6.6% of 1,013 cancer patients and 6.4% of 1,625 non-cancer patients. At admission, among the 172 colonized patients: 48/67 cancer patients and 78/105 non-cancer patients developed an infection, documented with an ESBL-E for 21% and 24% of them, respectively. The in-hospital mortality rate among colonized patients was 33% in cancer patients and 12% in non-cancer patients. In cancer patients, ESBL-E infections are rare but systematic rectal screening identifies high-risk population and guides empirical antibiotic therapy. It also contributes to being aware of the ICU microbiological ecology.

Renal function outcomes and kidney biopsy features of living kidney donors with hypertension

BACKGROUND

The medium- to long-term outcomes of living kidney donors with hypertension compared to normotensive donors are not well understood, especially with the recent changes in hypertension guidelines.

METHODS

We studied a cohort of 950 living kidney donors using different definitions of hypertension based on either ≥140/90 or ≥130/80 mmHg thresholds and based on either office or ambulatory blood pressure readings. Microstructural features on kidney biopsy at the time of donation were compared using different definitions of hypertension.

RESULTS

After adjusting for years of follow-up, age, sex, and baseline eGFR, hypertension (by any definition) did not significantly predict an eGFR < 45 ml/min/1.73 m² at a median follow-up of 10 years postdonation, though there was a borderline association with ambulatory blood pressure ≥ 130/80 mmHg predicting a 40% decline in eGFR (OR = 1.53, 1.00-2.36; p = .051). Proteinuria was predicted by office blood pressure ≥ 140/90 mmHg and by nondipper profile on nocturnal ambulatory blood pressure measurements. At the time of donation, larger glomeruli and arterial hyalinosis on biopsy were associated with hypertension defined by either ≥140/90 or ≥130/80 mmHg (by office or ambulatory measurements). Nocturnal nondipper status was associated with larger glomeruli size but not arteriolar hyalinosis when compared to dippers.

CONCLUSIONS

In programs that accept donors with controlled hypertension, various definitions of hypertension are associated with histological findings in the donated kidney, but none predict a clinically significant decline in kidney function 10 years after donation. These data support allowing healthy individuals with controlled hypertension to donate a kidney. However, donors with office hypertension (≥140/90 mmHg) and nondippers (regardless of hypertension status) are at greater long-term risk for proteinuria, and particularly for these donors, longer follow-up is warranted.

Kidney Microstructural Features at the Time of Donation Predict Long-term Risk of Chronic Kidney Disease in Living Kidney Donors

OBJECTIVE

To determine whether microstructural features on a kidney biopsy specimen obtained during kidney transplant surgery predict long-term risk of chronic kidney disease in the donor.

PATIENTS AND METHODS

We studied kidney donors from May 1, 1999, through December 31, 2018, with a follow-up survey for the results of recent blood pressure and kidney function tests (estimated glomerular filtration rate [eGFR] and proteinuria). If not recently available, blood pressure and eGFRs were requested from a local clinic. Microstructural features on kidney biopsy at the time of donation were assessed as predictors of hypertension and kidney function after adjusting for years of follow-up, baseline age, sex, and clinical predictors.

RESULTS

There were 807 donors surveyed a mean 10.5 years after donation. An eGFR less than 45 mL/min/1.73 m2 in 6.4% (43/673) of donors was predicted by larger glomerular volume per standard deviation (odds ratio [OR], 1.48; 95% CI, 1.08 to 2.04) and nephron number below the age-specific 5th percentile (OR, 3.38; 95% CI, 1.31 to 8.72). An eGFR less than 60 mL/min/1.73 m2 in 42.5% (286/673) of donors was not predicted by any microstructural feature. Residual eGFR (postdonation/predonation eGFR) was predicted by nephron number below the age-specific 5th percentile (difference, -6.07%; 95% CI, -10.24% to -1.89%). Self-reported proteinuria in 5.1% (40/786) of donors was predicted by larger glomerular volume (OR, 1.42; 95% CI, 1.08 to 1.86). Incident hypertension in 18.8% (119/633) of donors was not predicted by any microstructural features.

CONCLUSION

Low nephron number for age and larger glomeruli are important microstructural predictors for long-term risk of chronic kidney disease after living kidney donation.

Kidney Structural Features from Living Donors Predict Graft Failure in the Recipient

BACKGROUND

Nephrosclerosis, nephron size, and nephron number vary among kidneys transplanted from living donors. However, whether these structural features predict kidney transplant recipient outcomes is unclear.

METHODS

Our study used computed tomography (CT) and implantation biopsy to investigate donated kidney features as predictors of death-censored graft failure at three transplant centers participating in the Aging Kidney Anatomy study. We used global glomerulosclerosis, interstitial fibrosis/tubular atrophy, artery luminal stenosis, and arteriolar hyalinosis to measure nephrosclerosis; mean glomerular volume, cortex volume per glomerulus, and mean cross-sectional tubular area to measure nephron size; and calculations from CT cortical volume and glomerular density on biopsy to assess nephron number. We also determined the death-censored risk of graft failure with each structural feature after adjusting for the predictive clinical characteristics of donor and recipient.

RESULTS

The analysis involved 2293 donor-recipient pairs. Mean recipient follow-up was 6.3 years, during which 287 death-censored graft failures and 424 deaths occurred. Factors that predicted death-censored graft failure independent of both donor and recipient clinical characteristics included interstitial fibrosis/tubular atrophy, larger cortical nephron size (but not nephron number), and smaller medullary volume. In a subset with 12 biopsy section slides, arteriolar hyalinosis also predicted death-censored graft failure.

CONCLUSIONS

Subclinical nephrosclerosis, larger cortical nephron size, and smaller medullary volume in healthy donors modestly predict death-censored graft failure in the recipient, independent of donor or recipient clinical characteristics. These findings provide insights into a graft's "intrinsic quality" at the time of donation, and further support the use of intraoperative biopsies to identify kidney grafts that are at higher risk for failure.

Larger nephron size, low nephron number, and nephrosclerosis on biopsy as predictors of kidney function after donating a kidney

It is unclear whether structural findings in the kidneys of living kidney donors predict postdonation kidney function. We studied living kidney donors who had a kidney biopsy during donation. Nephron size was measured by glomerular volume, cortex volume per glomerulus, and mean cross-sectional tubular area. Age-specific thresholds were defined for low nephron number (calculated from CT and biopsy measures) and nephrosclerosis (global glomerulosclerosis, interstitial fibrosis/tubular atrophy, and arteriosclerosis). These structural measures were assessed as predictors of postdonation measured GFR, 24-hour urine albumin, and hypertension. Analyses were adjusted for baseline age, gender, body mass index, systolic and diastolic blood pressure, hypertension, measured GFR, urine albumin, living related donor status, and time since donation. Of 2673 donors, 1334 returned for a follow-up visit at a median 4.4 months after donation, with measured GFR <60 mL/min/1.73 m² in 34%, urine albumin >5 mg/24 h in 13%, and hypertension in 5.3%. Larger glomerular volume and interstitial fibrosis/tubular atrophy predicted follow-up measured GFR <60 mL/min/1.73 m² . Larger cortex volume per glomerulus and low nephron number predicted follow-up urine albumin >5 mg/24 h. Arteriosclerosis predicted hypertension. Microstructural findings predict GFR <60 mL/min/1.73 m² , modest increases in urine albumin, and hypertension shortly after kidney donation.

Is there an association between mesenteric panniculitis and lymphoma? A case control analysis

AIM

To determine the prevalence and association of mesenteric panniculitis (MP) in a group of patients with non-Hodgkin's lymphoma (NHL) compared to control group.

MATERIALS AND METHODS

We retrospectively evaluated computed tomography (CT) and combined positron-emission tomography (PET) with CT examinations of a total of 166 patients who were diagnosed with NHL over a period of 5 years (2008-2013). The control group consisted of 332 subjects who were matched for gender and age at the time period the examinations were performed on the study group. A combination of radiological signs and absence of 2-[¹⁸F]-fluoro-2-deoxy-d-glucose (FDG)-uptake was used to establish the diagnosis of MP and distinguish it from the involvement of mesentery by lymphoma.

RESULTS

MP was identified in three patients (prevalence 1.8%) from the study group as compared to seven subjects out of 332 (2.1%) in the control group (p=0.556). During the course of follow-up no changes in the imaging features of MP were seen in either group. Additionally, 27 (16.2%) patients from the study group were found to have changes in the mesentery, which were attributed to the involvement of the mesentery in the primary disease.

CONCLUSION

The prevalence of MP among patients with NHL was found to be 1.8%, which corresponds to the range of its prevalence in the general population. This is contrary to the proposition that MP is associated with NHL.

Graft infection after a Bentall procedure: A case series and systematic review of the literature

INTRODUCTION

The Bentall procedure is a cardiac surgery involving graft replacement of the aortic valve, aortic root and ascending aorta. Graft infection after Bentall's procedure (BGI) is infrequent but severe, and often difficult to diagnose and treat.

PATIENTS AND METHODS

A retrospective cohort study was performed using the Bordeaux endocarditis database of adult patients admitted to the Bordeaux University Medical Hospital for BGI between 2008 and 2014. Published case reports were identified in the literature.

RESULTS

We identified 10 BGI patients in the database and 13 in the literature. The majority of infections were late-onset (20/23) and occurred as a result of gram positive cocci bacterial infection (16/22). Detailed diagnoses of the described BGI were determined using echocardiography, computed tomography (CT) and positron emission tomography/CT (PET/CT). Labeled-leukocyte scintigraphy was not reported in any case. Prolonged antibiotic therapy and surgery were found to be the treatment of choice for BGI; however it was not always possible to perform a surgical intervention. Clinical relapses occurred even with a negative PET/CT, while PET/CT consistently positive for BGI occurred in the absence of clinical relapse. This suggests that the use of PET/CT for follow-up is questionable.

CONCLUSION

Diagnosis of BGI is difficult, due to the combination of clinical, biological, and radiological observations obtained through transesophageal echocardiography and CT. PET/CT is an alternative method to diagnosis BGI, but its impact on clinical management remains unclear. Current data suggests that if surgical replacement of the prosthesis is not possible, patients should be treated with prolonged antibiotic therapy.

Renal Function Profile in White Kidney Donors: The First 4 Decades

Previous studies reported the risk of ESRD after kidney donation, but not the renal outcomes that precede ESRD. Here, we estimated the risk of proteinuria, reduced GFR, and ESRD in 3956 white kidney donors, assessed the contribution of postdonation hypertension and diabetes to these outcomes, and developed a risk calculator. After a mean±SD follow-up of 16.6±11.9 years, 215 (6.1%) donors developed proteinuria. Men had a higher risk of proteinuria (hazard ratio [HR], 1.56; 95% confidence interval [95% CI], 1.18 to 2.05; P<0.001) as did those with higher body mass index (HR, 1.10; 95% CI, 1.06 to 1.13; P<0.001). In all, 1410 (36%) donors reached an eGFR<60 ml/min per 1.73 m(2), and 112 (2.8%) donors had either an eGFR<30 ml/min per 1.73 m(2) or ESRD (28 donors developed ESRD). An eGFR<30 ml/min per 1.73 m(2) or ESRD associated with older age (HR, 1.07; 95% CI, 1.05 to 1.09; P<0.001), higher body mass index (HR, 1.08; 95% CI, 1.04 to 1.13; P<0.001), and higher systolic BP (HR, 1.02; 95% CI, 1.00 to 1.04; P=0.01) at donation. Postdonation diabetes and hypertension associated with a fourfold higher risk of proteinuria and a >2-fold higher risk of ESRD. Models predicting proteinuria and reduced eGFR performed well (C-index 0.77-1.00). In conclusion, severe reduction in GFR and ESRD after kidney donation were uncommon and were highly associated with postdonation diabetes and hypertension. Furthermore, information available before donation may predict long-term renal outcomes in white living kidney donors.

[Leptospirosis and thrombocytopenia]

INTRODUCTION

Leptospirosis is a worldwide zoonosis caused by the spirochete Leptospira interrogans. The spectrum of symptoms reported in leptospirosis is extremely broad. Thrombocytopenia is common during the acute phase of leptospirosis but its pathophysiological mechanism remains not well defined.

CASE REPORT

We report a 56-year-old man hospitalized for severe sepsis with acute kidney injury and liver failure. Because of the recent flood of his house, we suspected leptospirosis. The diagnosis was rapidly confirmed. Blood tests revealed thrombocytopenia at 9 G/L associated with hyperferritinemia and hypertriglyceridemia. Cytological examination of bone marrow showed abundance of megakaryocytes and hemophagocytosis which confirmed the diagnosis of hemophagocytic syndrome. Clinical symptoms resolved and blood tests returned to normal values in the same time.

CONCLUSION

We suggest that hemophogocytosis is a possible mechanism of thrombocytopenia in leptospirosis and that examination of bone marrow should be performed to confirm the diagnosis.

Medical outcomes of adolescent live kidney donors

Living kidney donation from donors <18 yr of age is uncommon. The majority of donations from adolescents took place several decades ago providing a unique opportunity to study true long-term consequences of donation. We compared survival, renal outcomes, and rates of hypertension and diabetes among 42 adolescent donors and matched older controls. Adolescent donors were matched with donors 18-30 yr on the following: gender, relation to the recipient, BMI at donation, eGFR at donation, and year of donation. After a mean follow-up of 31.8 ± 8.0 yr, 94.9% of adolescent donors were alive vs. 93.8% of controls. There was no significant difference in having eGFR (MDRD) <60 mL/min/1.73 m(2) (26.1% vs. 40.9%), hypertension (35.9% vs. 39.4%), diabetes (5.1% vs. 12.5%), or proteinuria (15.4% vs. 14.1%): adolescent donors vs. controls for all comparisons. These data suggest that adolescent donors are not at a higher risk of shortened survival, hypertension, diabetes, or proteinuria. Nevertheless, they probably should donate only when other options are exhausted as they have to live with a single kidney for decades and longer follow-up is needed.

Low birthweight and risk of albuminuria in living kidney donors

Low birthweight is linked to hypertension, chronic kidney disease and even end-stage renal disease. We hypothesized that living kidney donors born with lower birthweight may be at increased risk of hypertension, albuminuria, or reduced GFR beyond what is typical following uninephrectomy. Two hundred fifty-seven living kidney donors who donated at the University of Minnesota between 1967 and 2005 underwent iohexol GFR and urinary albumin excretion measurements. Predictors of iohexol GFR <60 mL/min/1.73 m(2), albuminuria, and hypertension were examined using logistic regression. Predictors examined include age at GFR measurement, time since donation, BMI, gender, serum creatinine level (at donation and GFR measurement), systolic and diastolic blood pressure, race, and birthweight. The latter was obtained through self-report and verified through birth certificates and family members. Older age, higher BMI, and time from donation were associated with reduced GFR. Older age and higher BMI were also associated with hypertension. Birthweight was not associated with GFR <60 mL/min/1.73 m(2): OR=0.70, 95% CI (0.28, 1.74), p = 0.45 or hypertension: OR=0.92, 95% CI (0.46, 1.84), p = 0.82 but was associated with albuminuria: OR=0.37, 95% CI (0.15, 0.92), p = 0.03. These data further strengthen the link between low birthweight and potential adverse renal outcomes.

Cystatin C enhances glomerular filtration rate estimating equations in kidney transplant recipients

BACKGROUND

The glomerular filtration rate (GFR) estimating equation incorporating both cystatin C and creatinine perform better than those using creatinine or cystatin C alone in patients with reduced GFR. Whether this equation performs well in kidney transplant recipients cross-sectionally, and more importantly, over time has not been addressed.

METHODS

We analyzed four GFR estimating equations in participants of the Angiotensin II Blockade for Chronic Allograft Nephropathy Trial (NCT 00067990): Chronic Kidney Disease Epidemiology Collaboration equations based on serum cystatin C and creatinine (eGFR (CKD-EPI-Creat+CysC)), cystatin C alone (eGFR (CKD-EPI-CysC)), creatinine alone (eGFR (CKD-EPI-Creat)) and the Modification of Diet in Renal Disease study equation (eGFR (MDRD)). Iothalamate GFR served as a standard (mGFR).

RESULTS

mGFR, serum creatinine, and cystatin C shortly after transplant were 56.1 ± 17.0 ml/min/1.73 m(2), 1.2 ± 0.4 mg/dl, and 1.2 ± 0.3 mg/l respectively. eGFR (CKD-EPI-Creat+CysC) was most precise (R(2) = 0.50) but slightly more biased than eGFR (MDRD); 9.0 ± 12.7 versus 6.4 ± 15.8 ml/min/1.73 m(2), respectively. This improved precision was most evident in recipients with mGFR >60 ml/min/1.73 m(2). For relative accuracy, eGFR (MDRD) and eGFR (CKD-EPI-Creat+CysC) had the highest percentage of estimates falling within 30% of mGFR; 75.8 and 68.9%, respectively. Longitudinally, equations incorporating cystatin C most closely paralleled the change in mGFR.

CONCLUSION

eGFR (CKD-EPI-Creat+CysC) is more precise and reflects GFR change over time reasonably well. eGFR (MDRD) had superior performance in recipients with mGFR between 30 and 60 ml/min/1.73 m(2).

Peritoneal dialysis immediately after kidney transplantation

Approximately 10% - 20% of adult kidney transplant recipients and as many as 40% of pediatric recipients receive peritoneal dialysis (PD) before kidney transplantation. An important aspect of perioperative kidney transplant care is management of the PD catheter. Peritoneal dialysis can be performed immediately after transplantation for delayed graft function (DGF), which can occur with as many as 20% of deceased-donor kidney grafts, especially when expanded criteria or organs from donation after cardiac death are used. However, leaving the PD catheter in place has been associated with an increased risk for infections such as peritonitis and exit-site infection, even when the catheter is not used. Although no consensus has been reached about the management of PD catheters after kidney transplantation, transplant centers should have a low threshold for PD catheter removal at the time of surgery, especially in recipients with a low risk for DGF. In individuals with high risk for DGF the PD catheter can be left in place, but it must be removed in a timely manner once it is no longer needed.