Mycobacterium Tuberculosis Infection after Kidney Transplantation: A Comprehensive Review

Tuberculosis (TB) in kidney transplant (KT) recipients is an important opportunistic infection with higher incidence and prevalence than in the general population and is associated with important morbidity and mortality. We performed an extensive literature review of articles published between 1 January 2000 and 15 June 2022 to provide an evidence-based review of epidemiology, pathogenesis, diagnosis, treatment and outcomes of TB in KT recipients. We included all studies which reported epidemiological and/or outcome data regarding active TB in KT, and we approached the diagnostic and treatment challenges according to the current guidelines. Prevalence of active TB in KT recipients ranges between 0.3–15.2%. KT recipients with active TB could have a rejection rate up to 55.6%, a rate of graft loss that varies from 2.2% to 66.6% and a mortality rate up to 60%. Understanding the epidemiological risk, risk factors, transmission modalities, diagnosis and treatment challenges is critical for clinicians in providing an appropriate management for KT with TB. Among diagnostic challenges, which are at the same time associated with delay in management, the following should be considered: atypical clinical presentation, association with co-infections, decreased predictive values of screening tests, diverse radiological aspects and particular diagnostic methods. Regarding treatment challenges in KT recipients with TB, drug interactions, drug toxicities and therapeutical adherence must be considered.

Immunosuppression as a Risk Factor for De Novo Angiotensin II Type Receptor Antibodies Development after Kidney Transplantation

(1) Background: Angiotensin II type I receptor antibodies (AT1R-Ab) represent a topic of interest in kidney transplantation (KT). Data regarding the risk factors associated with de novo AT1R-Ab development are lacking. Our goal was to identify the incidence of de novo AT1R-Ab at 1 year after KT and to evaluate the risk factors associated with their formation. (2) Methods: We conducted a prospective cohort study on 56 adult patients, transplanted between 2018 and 2019. Recipient, donor, transplant, treatment, and complications data were assessed. A threshold of >10 U/mL was used for AT1R-Ab detection. (3) Results: De novo AT1R-Ab were observed in 12 out of 56 KT recipients (21.4%). The median value AT1R-Ab in the study cohort was 8.5 U/mL (inter quartile range: 6.8–10.4) and 15.6 U/mL (10.8–19.8) in the positive group. By multivariate logistic regression analysis, induction immunosuppression with anti-thymocyte globulin (OR = 7.20, 95% CI: 1.30–39.65, p = 0.02), maintenance immunosuppression with immediate-release tacrolimus (OR = 6.20, 95% CI: 1.16–41.51, p = 0.03), and mean tacrolimus trough level (OR = 2.36, 95% CI: 1.14–4.85, p = 0.01) were independent risk factors for de novo AT1R-Ab at 1 year after KT. (4) Conclusions: De novo AT1R-Ab development at 1 year after KT is significantly influenced by the type of induction and maintenance immunosuppression.

A single-arm pilot study of metformin in patients with autosomal dominant polycystic kidney disease

Background

Metformin has shown promising results regarding cystogenesis inhibition in preclinical studies with autosomal dominant polycystic kidney disease (ADPKD) models. We designed a prospective, preliminary, single-arm study to evaluate the tolerability, safety and the effect of Metformin on kidney function and body mass index (BMI) in Romanian patients with ADPKD.

Methods

We enrolled 34 adult patients with ADPKD, chronic kidney disease (CKD) stages 1–5 not on dialysis and without diabetes mellitus. The primary endpoint was to assess the tolerability and safety of Metformin. The secondary endpoints evaluated changes in estimated glomerular filtration rate (eGFR), body mass index (BMI) and renal replacement therapy (RRT) necessity. Patients received an initial dose of Metformin of 500 mg/day within the first month that was increased to 1000 mg/day thereafter according to tolerability. Change in eGFR and BMI was expressed as mean difference with the corresponding 95% confidence intervals and as a percentage. For the primary endpoint, we included all 34 enrolled patients. To assess the secondary endpoint, intention-to-treat (ITT) and per-protocol (PP) analysis was performed.

Results

Sixteen patients out of 34 completed the follow-up period at 24 months. Eighteen patients developed adverse events and 63.6% of these events were gastrointestinal related. Nausea was the most common adverse event (17.6%). Two patients (5.8%) permanently discontinued medication due to adverse events. We recorded no case of hypoglycemia, lactic acidosis or death. Mean eGFR changed by − 1.57 ml/min/1.73m² (95%CI:-22.28 to 19.14, P = 0.87) in ITT and by − 4.57 ml/min/1.73m² (95%CI:-28.03 to 18.89, P = 0.69) in PP population. Mean BMI change was − 1.10 kg/m² (95%CI:-3.22 to 1.02, P = 0.30) in ITT population and − 0.80 kg/m² (95%CI:-3.27 to 1.67, P = 0.51) in PP analysis. Three patients (8.8%) needed RRT.

Conclusions

Metformin was well tolerated, had a good safety profile even in ADPKD patients with advanced CKD and it was not associated with change in eGFR or BMI across the follow-up period.

Trial registration

The study was retrospectively registered on https://www.isrctn.com (number ISRCTN 93749377); date registered: 02/25/2019.

Primary retroperitoneal seminoma - embryology, histopathology and treatment particularities

INTRODUCTION

Retroperitoneal seminoma is a very rare form of cancer, with embryological origin represented by primordial germ cells from the urogenital ridges left behind during the fetal development. Extragenital germ cell tumors can also occur in the mediastinum or the pineal gland. The aim of this paper is to outline the particularities and draw embryological, histopatological and treatment conclusions regarding extragonadal germ cell tumors.

PATIENT AND METHODS

A 43-year-old patient without any additional pathology was admitted for anemia of unknown etiology. The clinical examination revealed through deep abdominal palpation a mass in the left flank, and normal testes. Thoraco-abdomino-pelvic computed tomography (CT) scan showed a large retroperitoneal tumor adjacent to the great vessels in the left lumbo-iliac region. The blood work revealed just a low hemoglobin and hematocrit. With the established diagnosis of retroperitoneal tumor, radical surgical removal was decided. During the surgery, we were required to dissect a large solid encapsulated tumor mass from the aorta and the common iliac artery, starting at the renal pedicle all the way to the left iliac bifurcation. The surgical access was obtained through a transperitoneal left subcostal incision prolonged pararectally. Histopathological and immunohistochemical studies revealed a seminoma of the usual type. After the histological findings, the patient's tumor markers were investigated (LDH - lactate dehydrogenase, βHCG - beta-human chorionic gonadotropin, αFP - alpha-fetoprotein), all values being within normal ranges. In addition, the left testicle was thoroughly reexamined, clinically, through ultrasound and magnetic resonance imaging (MRI) scans, and no abnormalities were observed. After the surgery, the patient followed three courses of chemotherapy (BEP - Bleomycin, Etoposide and Cisplatin).

RESULTS

The CT scan done 24 months after surgery found no signs of local or distant tumor recurrence. The patient entered a follow-up schedule consisting of periodical clinical, serological and imagistic evaluations.

CONCLUSIONS

Primary retroperitoneal seminoma is a rare entity that must be taken into account when treating a retroperitoneal tumor. It develops out of the urogenital ridge, while the testes are normal. Thorough testicular evaluation (clinical, ultrasound and serum markers) is mandatory in all retroperitoneal tumors. The histopathological analysis is crucial for an accurate diagnosis and a proper management strategy. Through radical surgery and chemotherapy, the patients that are diagnosed prior to massive visceral metastatic dissemination can be cured.

Comparative urologic complications of ureteroneocystostomy in kidney transplantation: transvesical Leadbetter-Politano versus extravesical Lich-Gregoir technique

BACKGROUND

The incidence of urologic complications after kidney transplantation remains high despite improvements in diagnosis and operative techniques. Urinary tract reconstruction is usually done by ureteroneocystostomy (UCNS), and several techniques are available. In this study, we evaluated the outcomes of 2 different UCNS techniques performed in our department, the transvesical Leadbetter-Politano (L-P) and the extravesical Lich-Gregoire (L-G) technique.

MATERIAL AND METHODS

We evaluated the outcomes of 2 different UCNS techniques, L-P versus L-G, performed in our department between July 1, 2006, and December 31, 2011. During this period, we performed 524 consecutive renal transplantations-264 cases using the L-P technique (50.3%) and 260 cases with L-G technique (49.7%). Renal grafts were obtained from cadaveric donors in 146 cases (27.86%) and from living-related donors in 378 cases (72.14%). Recipient mean age was 35.64 years and the male to female ratio was 1.63:1.

RESULTS

Urologic complications after kidney transplantation occurred in 22 cases in the L-P UCNS group (8.33%). The most common complications were ureteral stenosis (3.41%) and leakage (2.65%). Other complications recorded were lymphoceles (1.89%) and hematoma with secondary ureteral obstruction (0.38%). Compared with the L-P UCNS technique, the L-G technique was associated with fewer overall complications (6.15% vs 8.33%; P = .06), a lesser rate of ureteral stenosis (2.31% vs 3.41%; P = .08), and a similar rate of leakage. However, statistical analysis revealed no differences between the 2 techniques (P = .06). In addition, we did not note any differences in graft and patient survival between the 2 groups.

CONCLUSIONS

In our study, the extravesical L-G technique has a lower complication rate compared with transvesical L-P procedure, but without statistical differences. Furthermore, the L-G technique is easier and faster to perform, it avoids a separate cystotomy, and requires a shorter ureteral length. In conclusion, we recommend L-G technique as technique of choice in kidney transplantation.

Testicular histopathological changes following sodium fluoride administration in mice

It has been revealed that excessive fluoride intake on long-term is associated with toxic effects and can damage a variety of organs and tissues in the human body, including the male reproductive system. However, the molecular mechanisms of fluoride-induced male reproductive toxicity are not well understood. The study wants to get news concerning the effects of natrium fluoride on testicular tissues when this substance is administrated to a population of mice. The study was conducted on NMRI mice descending from the pregnant females treated with 0.25 mg and 0.5 mg natrium fluoride by daily gavage, from the beginning of pregnancy until the lactation is ceased. Then, the mice, males and females, were divided in six groups, three groups descending from the pregnant females treated with 0.5 mg natrium fluoride (Groups A, B and C) and three groups from the pregnant females with 0.25 mg natrium fluoride (Groups D, E and F). From the moment when the lactation is finished until the adulthood, the animals received the following treatments: homeopathic (a CH7 solution of natrium fluoride - Groups A and D), allopathic-homeopathic (0.25 mg‰ natrium fluoride administered like drinking water ad libitum and CH7 solution of natrium fluoride - Group E; 0.5 mg‰ natrium fluoride administered like drinking water ad libitum and CH7 solution of natrium fluoride - Group B), and allopathic administration of natrium fluoride (0.25 mg‰ natrium fluoride like drinking water ad libitum - Group F; 0.5 mg‰ natrium fluoride like drinking water ad libitum - Group C). When the males reached the adulthood, the administration of natrium fluoride was stopped and, by randomization, they where selected for euthanasia. The euthanasia was realized by cervical dislocation. The testes for the histopathological examination were preserved in a 10% formalin solution. The preparation of samples for optical microscopy was realized with Hematoxylin-Eosin staining. The results indicate that natrium fluoride administered in different doses, even at homeopathic dose or at allopathic-homeopathic dose, determined vacuolar dystrophy of epididymal epithelial cells, vacuolar dystrophy of linear seminal cells and necrosis.