Factors influencing kidney transplantation rates: a study from the ERA Registry

BACKGROUND

Large international differences exist in kidney transplantation (KT) rates. We aimed to investigate which factors may explain the total, deceased donor, and living donor KT rates over the last decade.

METHODS

KT experts from 39 European countries completed the Kidney Transplantation Rate Survey on measures and barriers and their potential effect on the KT rate in their country. In the analyses, countries were divided into low, middle, and high KT rate countries based on the KT rate at the start of study period in 2010.

RESULTS

Experts from low KT rate countries reported more frequently to have taken measures regarding staff, equipment and facilities to increase total KT rate compared with middle and high KT rate countries. For donor type specific KT, the largest international differences in measures taken were reported for deceased donor KT, with middle and high KT rate countries taking more measures, such as the use of expanded criteria donor kidneys, the presence of transplantation coordinators, and (inter)national exchange of donor kidneys. Once a measure was taken, experts' opinion on its success was similar across the low, middle and high KT rate countries. Experts from low KT rate countries more often reported potential barriers, such as patients' lack of knowledge and distrust in the health care system.

CONCLUSIONS

In particular in low KT rate countries, KT rate might be stimulated by optimizing staff, equipment, and facilities. In addition, all countries may benefit from deceased and living donor specific measures.

Drug-induced renal toxicity: diagnosis and prevention

A range of different drugs can cause renal problems, and reactions to the radiocontrast material administered for diagnostic tests are well known. This review describes factors that put patients at risk of kidney damage from drug use and outlines how to clinically diagnose adverse reactions. The most appropriate way to deal with drug-induced renal toxicity is through prevention.

Magnetic resonance angiography and detection of renal artery stenosis in a patient with impaired renal function

Diagnosing renovascular disease in patients with renal insufficiency has challenged physicians for many years. Although contrast angiography is the "gold standard," it is associated with major risks in patients with preexisting renal failure. Other noninvasive tests have not proved to have sufficient sensitivity and specificity to supplant angiography. Developments in magnetic resonance (MR) angiographic technology, however, now enable physicians to assess the vasculature noninvasively and without use of potentially nephrotoxic agents. Herein we describe a patient with hypertension and renal failure in whom MR angiography proved to be the only effective noninvasive test for diagnosing renal artery stenosis. In addition, we review the current literature on MR angiography for renovascular disease. In the setting of renal impairment, MR angiography may be useful in screening patients for renovascular disease. More studies are needed in order to refine MR angiographic techniques and, ultimately, to determine specific situations in which MR angiography may be useful.

Relation between vasa recta blood flow and renal interstitial hydrostatic pressure during pressure natriuresis

Pressure natriuresis may be mediated through increases in inner medullary vasa recta blood flow (QVR). By means of acute renal decapsulation to prevent increases in renal interstitial hydrostatic pressure (RIHP), the effect of increases in QVR in the presence and absence of changes in RIHP in the natriuretic and diuretic responses to increases in renal perfusion pressure (RPP) was evaluated. Blood flow in descending (QDVR) and ascending (QAVR) vasa recta was determined in the exposed papilla by fluorescence videomicroscopy in anesthetized euvolemic Munich Wistar rats. In rats with intact renal capsules (n = 12), increases in RPP from 101 +/- 0.5 to 132 +/- 2.9 mm Hg caused significant increases in QDVR (from 4.7 +/- 0.9 to 5.5 +/- 0.9 nl/min, p < 0.001) and QAVR (from 2.8 +/- 0.2 to 3.5 +/- 0.2 nl/min, p < 0.001) in association with increases in RIHP (from 4.6 +/- 1.3 to 7.6 +/- 1.3 mm Hg, p < 0.001), urine flow (from 16.2 +/- 2.6 to 20.2 +/- 3.2 microliters.min-1 x g kidney wt-1, p < 0.01), and urinary sodium excretion (from 2.10 +/- 0.38 to 3.36 +/- 0.62 mu eq.min-1 x g kidney wt-1, p < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Lupus anticoagulant in systemic lupus erythematosus: a clinical and renal pathological study

Circulating lupus anticoagulant (LA) is associated with thrombosis in large and small vessels. To determine how often the presence of LA is associated with thrombosis within the renal microcirculation, 33 patients with systemic lupus erythematosus (SLE), renal dysfunction, and LA were identified over a 25-year period (LA group) and 32 patients with renal SLE but with normal gross coagulation screen were matched for age, sex, and biopsy timing (C group). Prevalences of serositis, neuropsychiatric illness, leukopenia, thrombocytopenia, hemolysis, anti-DS-DNA elevation, and complement reduction were similar. Arthritis was less and biologic false-positive (BFP) syphilis serology more common in LA. More LA patients had thrombotic events (LA 39% v C 13%; P = 0.014); bleeding episodes, including postbiopsy, were similar. At biopsy, hypertension (LA 55%, C 41%), serum creatinine (mean +/- SD: LA 186 +/- 168 mumol/L [2.1 +/- 1.9 mg/dL] v C 150 +/- 168 mumol/L [1.7 +/- 1.9 mg/dL]) and proteinuria (LA 2.6 +/- 3.1 g/24 h v C 3.1 +/- 2.7) were similar. Lesions by World Health Organization (WHO) class, activity, and chronicity indices, as well as immunofluorescence (IF) and electron microscopy (EM) findings, were not significantly different. Occlusive glomerular, arteriolar, and arterial fibrin thrombi, along with varying degrees of renal thrombotic microangiopathy, were seen in five of 33 patients with LA, but zero of 32 C patients (P = 0.053); three of these five patients died soon after biopsy. Overall, mortality was not different between LA and C. We conclude that the majority of patients with SLE, renal dysfunction, and LA exhibit renal morphologic findings indistinguishable from patients without LA. However, a significant minority of LA patients have thrombotic microangiopathy in their biopsy, which is accompanied by a worse prognosis.

Management and prevention of cytomegalovirus infection after renal transplantation

We reviewed the epidemiologic characteristics, diagnosis, clinical features, and management of cytomegalovirus (CMV) infection after renal transplantation. CMV, the major viral pathogen after renal transplantation, increases patient morbidity and mortality. The spectrum of CMV infection ranges from latent infection to asymptomatic viral shedding to life-threatening multisystem disease. The two major risk factors for the development of CMV infection in renal transplant recipients are (1) preexisting CMV antibody seropositivity of either the organ donor or the recipient and (2) host immunosuppression. Blood cultures (but not urine cultures) positive for CMV predict the progression of asymptomatic infection to CMV disease, characterized by fever, malaise, myalgia, leukopenia, abnormal transaminase levels, and often involvement of the lung and gut. New genomic methods of viral detection now offer diagnostic advantages, including methods of detecting only actively replicating CMV. No evidence shows that CMV directly causes allograft rejection or glomerulonephritis, but patients with tissue-invasive CMV disease have higher rates of allograft loss and mortality than do those without the disease. Therapy for established CMV disease includes decreasing the immunosuppressive therapy and administering the antiviral agent ganciclovir sodium. Proven prophylactic strategies include limitation of exposure to the virus from CMV seropositive blood or organ donors, administration of CMV-specific immune globulin, and use of high-dose acyclovir therapy. Preemptive therapy with ganciclovir is a promising alternative to prophylaxis for patients at highest risk for progression to symptomatic CMV disease, such as those with CMV viremia and seropositive recipients receiving antilymphocyte therapy.

Drug-induced renal toxicity. Help in recognizing offending agents

Drug-induced kidney disease is common, especially in hospitalized patients, and prompt recognition of the various nephrotoxic syndromes is important because many are reversible. Risk factors should be assessed before patients are given an agent that may cause acute renal failure (eg, nonsteroidal anti-inflammatory drug, aminoglycoside antibiotic, angiotensin-converting enzyme inhibitor, radiocontrast agent). Discontinuation of the responsible drug is often the only necessary therapy.