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Abstract: Background: Kidney transplant, the gold standard treatment for chronic kidney disease (CKD), is increasingly complicated by anemia. Once-monthly dosing of methoxy polyethylene glycol-epoetin beta provides stable, sustained hemoglobin levels in CKD patients. The present study evaluated anemia control in recipients treated with methoxy polyethylene glycol-epoetin beta to correct or as conversion treatment from other erythropoiesis-stimulating agents (ESAs). Patients and Methods: This observational, retrospective study included kidney transplant patients treated with methoxy polyethylene glycol-epoetin beta according to investigators'' clinical practice. Information about demographics, CKD, anemia, blood analyses, treatment, and adverse events were collected from patients'' medical charts at baseline as well as months 1, 3, and 6. Results: From October 2009 to March 2010, the 285 patients in the study included: an overall mean age of 52.8 ± 13.9 years with 146 females (51.2%) and 152 patients (55.1%) in stage 3 CKD. Forty-five patients (15.8%) were in the immediate posttransplant period; 51, naïve- treatment (17.9%) and 189, converted subjects (66.3%). Eighty-two of the converted patients (48.0%) had previously received darbepoietin; 81 (47.4%), epoetin beta; and 8 (4.7%), epoetin alfa. The mean doses of methoxy polyethylene glycol-epoetin beta at baseline were 75.0 ± 22.4 μg per month, 95.8 ± 45.5 μg per month, and 118.9 ± 58.9 μg per month among naïve, converted, and immediate posttransplant patients, respectively. Mean hemoglobin content varied from baseline to month 6, namely 10.2 ± 0.7 versus 11.8 ± 0.9 g/dL in naïve (P < .001) and 11.4 ± 1.3 versus 12.0 ± 1.2 g/dL in converted patients (P = .001). Patients in the immediate posttransplant period showed mean hemoglobin values maintained between 10.4 ± 1.7 g/dL at baseline and 11.5 ± 1.2 g/dL at month 3. The only study-drug–related adverse event was hypertension. No patient died during the study. Conclusion: These preliminary results suggested that hemoglobin stability can be achieved and maintained after correction or conversion to once-monthly methoxy polyethylene glycol-epoetin beta in kidney recipients. It was well tolerated; the safety profile was that expected and comparable with shorter acting ESAs. [Copyright &y& Elsevier]

Abstract: Comprehensive imaging evaluation of kidney donor anatomy is crucial for selecting candidates for living kidney transplantation and for determining the surgical technique to procure the renal graft. In 76 living renal donors we compared the results of preoperative magnetic resonance angiography (MRA) with the intraoperative findings of arterial anatomy. Donors were evaluated for the number of main renal arteries and the presence of any polar arteries. A total of 80 main renal arteries and five polar arteries were observed at MRA. At surgery, 90 main renal arteries and eight polar arteries were identified. MRA demonstrated a sensitivity, specificity, and overall accuracy of 18%, 98%, and 87%, respectively, for main arteries and 25%, 96%, and 88% for polar arteries. Eleven (14.5%) kidneys displayed more than one main artery and MRA only detected two cases. Eight kidneys had polar arteries and MRA only detected two cases. MRA is a reliable method for presurgical evaluation of renal arteries in potential donors, providing valuable information required by the surgeon. But, as the technique misses small-diameter vessels, it cannot be recommended as the sole diagnostic tool in unclear cases. [Copyright &y& Elsevier]

The purpose of this work was to determine the necessity for rhuEPO for 50 kidney transplant patients with stable graft function. We analyzed the red cell series, blood pressure, renal function, anthropometric data of the donor and recipient, proteinuria, and relationship with other factors, including immunosuppressants, angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARB). The patients were divided into three groups depending on renal function: group A (with plasma creatinine <150 μmol/L), group B (151–250 μmol/L), and group C (>250 μmol/L). All patients were studied for 1 year. Erythropoietin use did not affect renal function, proteinuria or number of antihypertensive drugs group. The degree of renal dysfunction determined the time necessary to reach an adequate hemoglobin level (>12 g/L) and and the mean dose of weekly rhuEPO needed. The use of ACE inhibitors or ARBs increased the rhuEPO requirements in each group. [Copyright &y& Elsevier]

Abstract: Since calcineurin inhibitors (CNI) have been introduced, they have become the cornerstone of immunosuppression for renal transplant patients, but their cardiovascular and neurological toxicities, and primarily their renal toxicity, have brought about an increased effort to find combinations of immunosuppressants that are either CNI-free or that use minimum doses of these drugs. The weight of immunosuppression therefore lies with drugs that have a better toxicity profile. The POP observational transverse study including 213 renal transplant patients was designed to study CNI minimization strategies. The mean time of transplant evolution to the time of reduction was 9.9 ± 11.8 months. The acute rejection rate to the start of reduction was 9.4%. Almost all the patients were undergoing treatment with CNI + mycophenolate mofetil (MMF) + steroids in the immediate posttransplantation period. When reduction was chosen, all patients were undergoing treatment with MMF (mean dose at the start of reduction = 1490.7 ± 478.0 mg/d). Among the cohort, 66.7% of patients were being treated with tacrolimus (mean C0 levels 13.3 ± 6.6 ng/mL) and 33.3% with cyclosporine (mean C0 levels 192.2 ± 94.0 ng/mL; mean C2 levels 1097.5 ± 457.6). The main reasons for withdrawal were nephrotoxicity (55.9% of the cases), as well as prevention of adverse effects (21.6%). The mean target CNI dose reduction was 41.4% ± 21.45% in the tacrolimus group and 28.6 ± 10.0% in the cyclosporine group. In conclusion, CNI toxicity, primarily renal toxicity, makes reduction of these drugs based on the use of full MMF doses an alternative to manage renal transplant patients. [Copyright &y& Elsevier]

The aim of this study was to establish the relationship between vascular lesion chronic allograft nephropathy (CAN) and the presence of cytomegalovirus (CMV) in kidney transplanted patients. We studied 259 consecutive kidney transplant recipients with a minimum follow-up of 6 months; the induction immunosuppressive therapy included a calcineurin inhibitor, mycophenolate mofetil, steroids, and the use of an antilymphocyte serum if the patients developed delayed graft function. CMV early antigen detection (pp65) was performed on a weekly basis between days 30 and 90 post transplantation. Prophylactic treatment was administered in the donor +/recipient-risk group, and preemptive therapy delivered for positive antigenemia namely 3 days of intravenous [IV] gancyclovir [GCV] plus 11 days of oral therapy [in the case of infection], or 14 days of IV GCV [in the case of disease]). An acute kidney allograft rejection episode preceded CMV in 64.3% of the patients, and CMV preceded acute rejection in 35.7% of the cases. We conclude that CMV disease is an independent risk factor for CAN. CMV infection is probably associated with CAN, suggesting that the greater the viral load, the higher the risk of CAN. It may be advisable to perform universal prophylaxis to lower the viral load and CAN. [Copyright &y& Elsevier]

The aim of the study was to compare the efficacy and safety of induction immunosuppression therapies based on tacrolimus or cyclosporine (CsA) in kidney transplantation. The 240 kidney allograft recipients were divided into two groups: group 1 (n = 94) received tacrolimus (.01 mg/kg per day), mycophenolate mofetil (MMF, 2 g/d), and steroids (30 mg/d); and group 2 (n = 146) CsA (6 mg/kg per day), MMF (2 g/d), and steroids (30 mg/d). Antilymphocyte serum was administered in cases of acute tubular necrosis. The acute rejection rate was higher among group 2 (30.6%) compared with group 1 patients (12.2%) (P = .001). There were no significant differences between the groups in terms of age, gender, body surface area, serologic virus markers (in donor and recipient), baseline creatinine levels, cause of death, HLA incompatibilities, response to acute tubular necrosis, and number of dialysis sessions. We conclude that both immunosuppressive regimens are effective and safe in kidney transplantation. The survival rates of patients and grafts were similar, but the incidence and degree of acute rejection events were reduced in group 1; this finding may forecast a decreased incidence of chronic renal allograft nephropathy. [Copyright &y& Elsevier]

Abstract: The incidence of de novo malignancies is an accepted complication of organ transplantation. Renal cell carcinoma (RCC) was 4.6% of cancers occurring de novo in organ allograft recipients compared with 3% in the general population. Less than 10% of these renal cancers affected the renal allograft. Among patients developing a renal tumor in the kidney allograft, transplant nephrectomy reduced the quality of life. For these patients for whom preservation of renal function is a relevant clinical consideration, partial nephrectomy may be considered the choice for treatment. Fifteen cases have been reported regarding conservative surgery on kidney transplant tumors. Herein we have reported three cases of renal masses in well-functioning kidney transplants that were successfully treated with nephon-sparing surgery. Our experience demonstrated that in selected patients, nephron-sparing surgery on a renal allograft represents a feasible approach for tumor removal with preservation of graft function. [Copyright &y& Elsevier]

Abstract: Introduction: Ureteral fistulae in renal transplants may develop as a consequence of compromised ureteral vascularity or from a technical factor related to the ureteroneocystostomy, the latter typically developing within the first 72 hours posttransplant. Recently, percutaneous nephrostomy drainage has been used with increasing frequency for the initial management. It alone can lead to resolution of the fistula in at least some patients. The aim of the study was the evaluation of endourological management of ureteral fistulae in renal transplants. Material and methods: Between August 1981 and February 2004, 1000 adult recipients underwent renal transplantation. Sixteen out of 29 patients who developed ureteral fistulae were managed endourologically; 13, open surgery. The items recorded on these patients included the type of ureteroneocystostomy, the time to fistula diagnosis, the image technique, the type of ureteral stents, and the clinical evolution. Results: The 13 patients who underwent open surgery did well. Endourological management of ureteral fistula was successfully performed in 10 of 16 cases. In all of them percutaneous nephrostomy drainage with stenting of the ureter with a double-J catheter did not prove any advantage to no stent (66.6% vs 57%). In 13 of these 16 patients in which the passage of contrast into the bladder was demonstrated, the fistula resolved in 10 cases (77%), while none of the three cases with no flow into the bladder were helped by this approach. Conclusion: Percutaneous techniques can provide definitive management for 62% of renal allograft patients who develop ureteral fistula beyond 72 hours after renal transplant. [Copyright &y& Elsevier]

Abstract: Introduction: The incidence of ureteral stenosis in kidney transplant recipients is 3%–8%. The treatment of ureteral stenosis has been traditionally operative reconstruction, although such intervention is associated with high rates of serious complications, including graft loss and even perioperative mortality. More recently, endourological treatment has been proposed due to its low morbidity. Objective: The objective of this study was to assess the usefulness of balloon percutaneous dilatation as a treatment technique for ureteral stenosis in kidney transplant recipients. Patients and Methods: Among 1000 kidney transplantations performed between 1980 and 2004, the coexistence of high creatinine values and urinary tract dilatation in the postoperative period, after discarding concomitant causes, was managed with a percutaneous nephrostomy. Once renal function recovered, antegrade pyelography was performed to confirm the presence and determine the location of ureteral stenosis. Ureteral dilatation was performed using a 5-French balloon-fitted angioplasty catheter. Results: Fifty-six patients were diagnosed with ureteral stenosis during follow-up, an incidence of 5.6%. Transluminal balloon dilatation was the first therapeutic option in 45 cases, whereas surgery was performed directly on 11 patients. Disappearance of the stenosis as well as maintenance of an improved creatinine level was verified in 45% of cases (20 patients). Two patients experienced graft loss. Both a short time to diagnosis after transplantation (P = .06) and the presence of a previous acute rejection episode (P < .05) were good prognosis factors for the endourologic solution of a ureteral stricture. Conclusions: Balloon dilatation may be considered the definitive procedure for treatment of ureteral stenosis in selected cases. Percutaneous nephrostomy should be used for initial diagnosis and improvement in the renal function before attempting an open procedure. [Copyright &y& Elsevier]