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BACKGROUND: Immunosuppressive nonadherence is a risk factor for worse outcomes after kidney transplantation (KT). Brazil, having the world's largest public, fully covered transplantation system and the second-highest KT volume worldwide, provides a unique setting for studying multilevel correlates of nonadherence (patient, healthcare provider, transplant center, and healthcare system levels) independent of patients' financial burden. METHODS: By applying a multistage sampling approach, we included 1105 patients from 20 KT centers. Nonadherence to immunosuppressives (implementation phase) was defined as any deviation in taking or timing adherence and dose reduction assessed by the Basel Assessment of Adherence to Immunosuppressive Medications Scale. Based on Bronfenbrenner's ecological model, we assessed multilevel factors using established instruments and measures specifically developed for this study and analyzed their independent contribution to nonadherence by performing sequential logistic regression analysis. RESULTS: The nonadherence prevalence rate was 39.7%. The following factors were independently associated with nonadherence: Patient level-having a stable partner (odds ratio [OR]: 0.75; confidence interval [CI]: 0.58-0.97), nonadherence to appointments (OR: 2.98; CI: 2.03-4.39), and nonadherence to physical activity recommendations (OR: 1.84; CI: 1.38-2.46); and transplant center level-satisfaction with the waiting room structure (OR: 0.54; CI: 0.42-0.71), consultation >30 minutes (OR: 1.60; CI: 1.19-2.14), adequacy of the consultation frequency (OR: 0.62; CI: 0.43-0.90), and centers with >500 beds (OR: 0.58; CI: 0.46-0.73). CONCLUSIONS: As the first multicenter study assessing multilevel correlates of nonadherence in KT, our findings point to the need for multilevel interventions beyond the patient level, targeting transplant center practice patterns as an approach to tackle nonadherence. ispartof: TRANSPLANTATION vol:105 issue:1 pages:255-266 ispartof: location:United States status: published

Introduction Progressive proteinuria and glomerulosclerosis characterize chronic allograft nephropathy. Podocytes are fundamental cells for maintaining the functionality of glomerular filtration barrier. Failure to achieve this task due to reduced podocyte number and results in progressive glomerular dysfunction, causing proteinuria and glomerulosclerosis and ultimately leading to end-stage kidney disease. Assessment of podocyturia and its correlation with other renal parameters could help with the diagnosis and definition of prognosis of the glomerulopathies, thus contributing to risk reduction. Objective To evaluate podocyturia and others renal parameters as functional markers in pregnant women with kidney grafts. Methods In this cross-sectional and prospective study, 43 pregnant women with kidney grafts had their Mid-stream urine samples collected to determine proteinuria, including retinol-binding protein (enzyme immunoassay using monoclonalantibodies), albumin/creatinine ratio (immunoturbidimetry), protein/creatinine ratio (the alkaline picrate colorimetric method), and podocyturia (indirect immunofluorescence). Results 43 women who got pregnant after renal transplantation were included. Podocyturia was not significantly correlated with other renal function markers. A gradual increase was observed in the following parameters during pregnancy and puerperium: serum creatinine levels (P Conclusion Proteinuria, urinary protein/creatinine ratio, and retinol-binding protein levels were elevated in patients with preeclampsia. Proteinuria (or more specifically, urinary protein/creatinine ratio) and albumin/creatinine ratio has also used as a marker of CKD progression. We observed that urinary podocyte excretion occurs in pregnant women with kidney transplant. Using these markers to assess renal function during pregnancy may be clinically useful for early diagnosis and follow-up of glomerular injury, eventually preeclampsia. It may be also associated to its severity or activity.

Background Non-adherence to immunosuppressive therapy is a prevalent risk factor for poor clinical and after kidney transplantation (KT), and has contributed to the lack of improvement in long-term graft survival over the past decade. Understanding the multilevel correlates and risk factors of non-adherence is crucial to determine the optimal level for planning interventions, namely at the patient, health care provider, KT centre, and health care system level. Brazil, having the largest public transplantation program in the world and with regional differences regarding access to health services and service implementation, is in a unique position to study this multilevel approach. Therefore, the Adhere Brazil Study (ADHERE BRAZIL) was designed to assess the prevalence and variability of non-adherence to immunosuppressants and to health behaviours among adult KT recipients in Brazil, and to assess the multilevel correlates of non-adherence to immunosuppressive medication. We describe the rationale, design, and methodology of the ADHERE BRAZIL study. Methods/Design This is an observational, cross-sectional, multicentre study that includes 20 Brazilian KT centres. A stratified sampling approach is used, based on strata, with the following characteristics considered: geographical region and transplant activity (number of KTs per year). A random sample of patients (proportional to the size of the centre within each stratum) is selected from each centre. The prevalence of different health behaviours is assessed through self-report. The assessment of multilevel correlates of non-adherence is guided by the ecological model that considers factors at the level of the patient, health-care professional, and transplant centre, using established instruments or instruments developed for this study. Data will be collected over an 18-month period, with information obtained during the regular follow-up visits to the transplant outpatient clinic and directly entered into the Research Electronic Data Capture (RedCap) system. Data entry is performed by a trained professional who is part of the transplant team. The data collection began in December 2015. Discussion This multicentre study is the first to evaluate multilevel correlates of non-adherence in KT patients and will provide a reliable estimate of non-adherence in Brazilian KT patients. Trial registration ClinicalTrials.gov on 10/10/2013, NCT02066935. Electronic supplementary material The online version of this article (10.1186/s12882-018-0840-6) contains supplementary material, which is available to authorized users.

Poor vascular access due to previous surgery can be a major obstacle in pancreas transplantation for which new exocrine and vascular outflow techniques might be useful. A 34-year-old female with early onset type 1 diabetes who underwent living donor kidney transplantation 20 years ago and a failed pancreas transplantation 2 years ago presented for pancreas retransplantation. The inferior vena cava was used in the previous deceased donor pancreas transplantation and both iliac arteries had intense perivascular fibrosis, making arterial anastomosis impossible. The only remaining option for the implant was the infrarenal aorta, with venous drainage to the superior mesenteric vein and exocrine drainage to the gastric antrum The patient had an uneventful recovery and graft function appeared normal. This report shows that when the recipient’s abdominal cavity does not provide clear access for the usual surgical techniques regarding exocrine drainage, the stomach drainage procedure is an option. Duodenum–stomach anastomosis might be an alternative to portal enteric drainage because there is easy access for graft biopsies and even for procedures involving the papilla major.

Background Mycophenolate mofetil (MMF), compared to azathioprine (AZA), reduces acute rejection and treatment failure in cyclosporine (CsA) and steroid regimens, but its effect on graft survival is unproven from prospective studies and prolonged use is costly. This study evaluated the efficacy and tolerability of replacing MMF by AZA after 3 months. Methods. This 28 center, prospective, 12-month, parallel group, open-label study, randomized patients to three groups with microemulsion formulation of CsA (ME-CsA) and steroids as baseline therapy. Group 1 (n = 158) received MMF for 3 months, replaced by AZA for 9 months; group 2 (n=162) received MMF for 12 months; and group 3 (n=157) received AZA for 12 months. Results. Treatment failure and the cumulative rate of acute rejection were significantly lower in the MMF groups compared with the AZA group (P=0.007 and P=0.03, respectively). Graft loss, death, and safety profiles of all three treatments were similar over 12 months, as were mean serum creatinine levels. Switching from MMF to AZA did not affect treatment failure. No patient in group I experienced a recurrent rejection after month 3, one patient died, and nine patients experienced first rejection episodes. Most rejections (6/9) were steroid-sensitive and histologically mild. Conclusions. Replacement of MMF by AZA after 3 months of therapy with ME-CsA and steroids provides comparable efficacy and safety profiles to continuous MMF over 12 months. Although apparently a cost-effective option, long-term studies are required to assess the benefit/risk ratio of this therapy switch in different patient subpopulations.

A 10-month-old child presented with a lack of extension at the distal interphalangeal joint. Despite the absence of trauma, a provisional diagnosis of mallet finger led to treatment using a short dorsal splint. Four months later the flexion had increased and included the proximal interphalangeal joint. Palpation revealed a palmar cord on the lateral aspect of the finger. Surgery disclosed a typical Dupuytren cord and the histology supported this diagnosis. There was no known family history of the disease. There was no sign of recurrence 27 months after surgery in this case of Dupuytren's disease that was present at birth.

Background Pharmacists have important responsibilities inside a multi-professional renal transplant team. Purpose This work aimed to evaluate the impact of pharmaceutical intervention in the education process and compliance to immunosuppressive therapy. Material and methods This project was approved by the local ethics committee and conducted in a large transplant-specialised hospital. Adult kidney transplant recipients were identified and recruited by a trained pharmacist within two days after the transplant surgery and received standard immunosuppression therapy. After signing the informed consent patients were randomised to receive a planned intervention of the transplant pharmacist (group 1) or to follow the regular orientation offered by nurses only (group 2). The pharmaceutical-planned intervention consisted of detailed education about indications, doses, frequencies, and schedules for administration of immunosuppressive drugs and these actions were performed at day 3, 5, 7, 14, 21, 28, 60 and 90 days after transplant. A formal evaluation was applied using a standardised scale and a predefined questionnaire to assess compliance and knowledge at days 10, 28 and 90. Results So far, 89 patients were randomised, 43 in group 1 and 46 in group 2. Preliminary results showed a mean age of 46, 62% male and 40% Caucasian. Regarding the education level, 52% and 30% of patients had not achieved the ninth grade in group 1 and 2, respectively. At day 28 and 90, 85% and 82% of patients showed compliance to immunosuppression in group 1 vs. 77% and 60% in group 2, respectively. Regarding the patients’ knowledge about the use of immunosuppressive at days 10, 28 and 90, 85%, 88% and 95% of patients in group 1 showed well understanding about immunosuppressive medication vs. 73% (p = 0.049), while 82% and 80%, in group 2 respectively. Conclusion These preliminary results showed that the intervention of the pharmacist trends to improve the compliance and knowledge of immunosuppression therapy. References and/or acknowledgements Acknowledgements Hospital do Rim. No conflict of interest.

MONOCLONAL anti-CD3 antibodies have been widely used for the treatment of acute allograft rejection (AR) episodes and for induction therapy (IT). Their impact on long-term survival has been demonstrated mainly in high-risk patients. Recent data have suggested that this antibody may be used at reduced doses without compromising its efficacy. We report here our experience with 58 kidney transplant (Tx) patients in which low daily doses of OKT3 were used as IT or for the treatment of severe or steroid-resistant AR.

Background Renal transplant recipients previously treated by sotrastaurin (STA) had their immunosuppressive regimen changed because the STA development programme was interrupted. It is not established in the literature which immunosuppressive regimen is the most appropriate for late conversion. Purpose To evaluate the efficacy and safety of changing immunosuppressive treatment in renal transplant recipients previously treated with STA. Materials and methods A prospective study with 38 renal transplant recipients previously enrolled in clinical trials of the STA development program who were converted to other immunosuppressive regimens. The safety and efficacy data related to conversion were collected 2 weeks before conversion until 12 months after the conversion. Patients on STA and tacrolimus (TAC) were converted to mycophenolate sodium (MPS) and TAC and those who used STA and everolimus (EVL) changed to TAC and everolimus. Results The mean age was 43 years and mean time of transplant 2.9 ± 1.0 years. A majority were women (53%) and living donor recipients (76%). In 29 (76%) patients, STA was replaced by TAC and in 9 patients (24%) by MPS. Six months after the conversion, the mean creatinine had increased 20% (1.17 vs. 1.40, p 2 , p 2 p = 0.089) after conversion. When these same parameters were compared to baseline values for each group there was a significant worsening of creatinine and renal function in the group using TAC and EVL (p Two patients discontinued the use of everolimus due to lack of efficacy and one due to dyslipidaemia. One patient discontinued the use of tacrolimus due to nephrotoxicity. The MPS dose was reduced in 4 (44%) patients with gastrointestinal adverse events. We observed that after conversion from STA to TAC serum levels of EVL decreased (8.6 vs. 6.0, p Conclusions The late conversion of STA to TAC or MPS reduced the effectiveness and safety of immunosuppressive regimens. The fluctuation of tacrolimus exposure and loss of synergistic effect between the pharmacokinetic of STN and EVL in the first weeks may have been the reason for these results. No conflict of interest.