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Introduction: To assess the efficacy of calcineurin inhibitor (CNI)-free immunosuppression vs. calcineurin-based immunosuppression in patients receiving expanded criteria donor (ECD) kidneys. Patient and methods: Thirteen recipients of ECD kidneys were enrolled in this pilot study and treated with induction therapy and maintained on sirolimus, mycophenolate mofetil (MMF) and prednisone. A contemporaneous control group was randomly selected comprised of 13 recipients of ECD kidneys who had been maintained on CNI plus MMF and prednisone. Results: For the study group vs. the control group, two-yr graft survival was 92.3% vs. 84.6% (p = NS), two-yr patient survival was 100% vs. 92.3% (p = NS) and the acute rejection rates were 23% vs. 31% (p = NS), respectively. Renal function was significantly better in the study group compared with control up to the six-month mark, after which, it remained numerically but not statistically significant. Complications were more common in the study group, but serious adverse events requiring discontinuation were rare. Conclusion: This pilot study demonstrates that CNI-free regimens can be safely implemented in patients receiving ECD kidneys with excellent two-yr patient and graft survival and good renal allograft function. Longer follow-up in larger randomized controlled trials are necessary to establish these findings.

Background: Delayed graft function (DGF) following transplantationnecessitates support in the form of hemodialyis (HD) orperitoneal dialysis (PD). However, post-transplant PD-related complicationand failure rates are unknown.Methods: We studies patients who were on PD at the time of kidneytransplantation over a 4-year period at two separate institutions.Results: Of the 137 PD patients, 19 had their catheters removedat the time of transplant. Of the remaining 118 patients, 89% hadimmediate graft function. PD-related complications in this groupincluded peritonitis (n=5), catheter-related infections (n=2) andemergency laparotomy (n=1). Of the 15 patients requiring posttransplantPD, 33% developed peritonitis and 20% had fluid-leaksnecessitating HD. Overall, leaving a PD catheter in situ post- transplantationis associated with 7% rate of peritonitis versus 0% ifremoved (p < 0.05).Conclusions: PD catheter removal should be considered at thetime of renal transplantation, as postoperative PD-related failure/complication rates are high.

Introduction and Objectives The ImmuKnow assay measures cell-mediated immunity by quantifying ATP release from CD4+ T-cells in peripheral blood. Herein, we hypothesized that this assay could predict complications associated with over-/under-immunosuppression in patients with kidney transplant (KT). Methods Sixty-seven patients undergoing KT were recruited prospectively and had ATP levels measured preoperatively, and at specified intervals over two months. Clinicians were blinded to ATP levels. Clinical events including rejection and infection/cancer were documented with a median follow-up of 21 months. Parameters including absolute ATP levels and changes in ATP patterns (slopes, delta) were analyzed. Association between ATP parameters and clinical outcomes was compared using the likelihood-ratio test and Kaplan–Meier curves. Results Absolute ATP values postoperatively had poor predictive value with regard to rejection or infection/malignancy. As well, changes in ATP values were poorly associated with complications. Importantly, patients with pre-transplant ATP values 300 ng/mL (p

SUMMARY Irritable bowel syndrome, constipation, and diarrhea may complicate a pregnancy. Complaints of IBS and constipation may be managed by nonpharmaceutical methods. A careful history should be conducted to determine whether these complaints are of an acute or a long-standing nature. Conservative treatment of IBS is recommended and may include stool-bulking agents, a high-fiber diet, elimination of offensive foods, and the behavioral treatment of passive muscle relaxation, biofeedback or supportive psychotherapy. Constipation is generally self-limiting. It also may be treated conservatively with stool-bulking agents, increases in dietary fiber, and the addition of pelvic muscle exercises, preferably using electromyographic biofeedback. Laxatives should be used judiciously (Table 1). Diarrhea is caused most often by infectious agents in pregnancy but may also be from food poisoning or a viral disease. Infectious diarrhea may be treated by mild antidiarrheal agents and safe antibiotics. Fluid replacement is the mainstay of treatment, and care should be taken, remembering that the treatment involves two patients. These complaints can generally be managed conservatively, but persistent cases should be investigated as in a nonpregnant patient.

The acute Page kidney phenomenon occurs as a consequence of external compression of the renal parenchyma leading to renal ischemia and hypertension. Between January 2000 and September 2007, 550 kidney transplants and 518 ultrasound-guided kidney biopsies were performed. During that time, four recipients developed acute oligo-anuria following ultrasound-guided allograft biopsy. Emergent doppler-ultrasounds were performed demonstrating absence of diastolic flow as well as a sub-capsular hematoma of the kidney. Prompt surgical exploration with allograft capsulotomy was performed in all cases. Immediately after capsulotomy, intraoperative Doppler study demonstrated robust return of diastolic flow. Three patients maintained good graft function, and one kidney was lost due to acute antibody-mediated rejection. We conclude that postbiopsy anuria associated with a subcapsular hematoma and acute absence of diastolic flow on doppler ultrasound should be considered pathognomonic of APK. All renal transplant specialists should be able to recognize this complication, because immediate surgical decompression can salvage the allograft.