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Living kidney donors’ follow-up is usually focused on the assessment of the surgical and medical outcomes. Whilst the psychosocial follow-up is advocated in literature. It is still not entirely clear which exact psychosocial factors are related to a poor psychosocial outcome of donors. The aim of our study is to prospectively assess the donors’ psychosocial risks factors to impaired health-related quality of life at 1-year post-donation and link their psychosocial profile before donation with their respective outcomes. The influence of the recipient’s medical outcomes on their donor’s psychosocial outcome was also examined. Sixty donors completed a battery of standardized psychometric instruments (quality of life, mental health, coping strategies, personality, socio-economic status), and ad hoc items regarding the donation process (e.g., motivations for donation, decision-making, risk assessment, and donor-recipient relationship). Donors’ 1-year psychosocial follow-up was favorable and comparable with the general population. So far, cluster-analysis identified a subgroup of donors (28%) with a post-donation reduction of their health-related quality of life. This subgroup expressed comparatively to the rest, the need for more pre-donation information regarding surgery risks, and elevated fear of losing the recipient and commitment to stop their suffering.

A 42-year-old hemodialysis (HD) patient was investigated in our department for symptomatic heart failure (HF) despite daily home dialysis. He had a history of living donor kidney transplantation at the age of 18 that lasted 7 years. Home dialysis was then started. At the age of 40, he developed acute heart failure symptoms. Echocardiography revealed severe dilated cardiomyopathy (DCM). Coronarography and myocardial perfusion scintigraphy showed no abnormal findings. Betablockers were administrated, and RAAS inhibitor dosing was optimized. Dyspnea persisted, and patient was referred to our department. At admission, blood pressure was 116/82 mmHg, and pulse 68 beats/min. No peripheral edema was observed. Dry weight was 62.5 kg. Patient was anuric. Hemoglobin level was 9.8 g/dl, highly sensitive troponin level was 62 ng/ml, and BNP level was 1527 ng/ml. The liver enzyme levels were normal. C-reactive protein was 4.2 mg/ml. Vitamin level, zinc levels, and thyroid function were normal.

Resume Les phaeohyphomycoses sont des mycoses opportunistes dues a des champignons noirs (dematies). Bien qu’ubiquitaires, ces infections sont plus frequentes dans les pays tropicaux. Presentation du cas d’un homme de 65 ans, d’origine congolaise, en France depuis 40 ans, qui consulte pour une tumefaction retro malleolaire evoluant depuis 4 mois. Dans ses antecedents, il est note une transplantation renale pour cancer un an auparavant. L’IRM revele une masse de 3 cm de diametre sans atteinte osseuse. L’examen histologique met en evidence des filaments septes. L’absence de fistules et de grains permet d’ecarter le diagnostic de mycetome. Sur un fragment de biopsie cutanee a ete realisee une PCR pan fongique. Le sequencage a permis d’identifier R. percutanea.

Introduction Le trafic d’organe, le tourisme de transplantation et le commerce de greffons ont fait l’objet d’un sommet a Istanbul au printemps 2008 aboutissant a la Declaration d’Istanbul dont le but etait de condamner et de faire cesser ces pratiques [1] . En collaboration avec l’Agence de la biomedecine, une enquete nationale aupres des medecins des centres de transplantation renale avait ete realisee entre 2008 et 2012. Patients/Materiels et methodes Nous avons reactualise, en 2017, les donnees medicales de cette cohorte, notamment les complications et la survie des greffons et des patients et evalue le nombre de nouveaux patients transplantes en France dans le cadre du tourisme de transplantation depuis 2012. Observation/Resultats Nous avons identifie 59 patients dont 41 hommes et 18 femmes, qui ont ete transplantes a l’etranger a partir de rein de donneurs remuneres, entre 1985 et 2017. Onze patients ont ete transplantes avant 2000, 38 entre 2000 et 2008 et 10 apres 2008. La duree mediane de suivi etait de 5,6 annees (3,7 ; 12,1). La creatinine moyenne etait a 111 ± 49,2 μmol/L a la date du dernier controle. Quatre patients ont presente des complications chirurgicales (deux stenoses de l’artere du greffon, une infection de cicatrice et un hematome). Les infections representaient la complication la plus frequente puisqu’elles ont concerne 34 patients. Parmi eux, il y eu une seroconversion VHC, sept reactivations VHC, deux reactivations VHB, une coreactivation VHC et VHB, deux tuberculoses dont une disseminee, trois pneumocystose, une aspergillose, deux infections fongiques. Seize patients ont presente un rejet dont 7 rejets humoraux et un rejet mixte. Quatorze patients (23,7 %) ont perdu leur greffon. Onze patients (18,6 %) sont decedes. Discussion/Conclusion Le tourisme de transplantation en France reste un phenomene marginal. Le nombre de patients transplantes avec un greffon provenant d’un donneur remunere est en nette regression depuis la conference d’Istanbul en 2008. Ces pratiques sont associees a une importante morbi-mortalite [2] . Neanmoins, chez les patients n’ayant pas presente de complications, la fonction du greffon demeure satisfaisante a long terme.

Background: The impact of major histocompatibility class I chain-related A (MICA) antibodies on renal graft outcomes is unclear. The goal of this work was to assess the impact of posttransplant MICA antibodies, assayed at 1 year, with two commercially available kits, on long-term renal graft outcomes. Methods: We retrospectively tested sera from 779 kidney transplant recipients with two single-antigen flow bead assays 1 year after transplantation. Samples were considered positive for MICA if they were positive in both tests or positive for MICA specificities that were present in one kit only. The main outcome was 4-year death-censored graft survival. Results: The prevalence of MICA antibodies was 5.4% at 1 year. MICA+ patients were more frequently human leukocyte antigen (HLA) sensitized and regrafted. Four-year death-censored graft survival was not different between MICA+ and MICA- patients (97% vs. 94%, P=0.28). By Cox multivariate analysis, independent risk factors for graft loss were as follows: number of HLA DR mismatches, acute rejection within the first year posttransplantation, 1-year serum creatinine, and the presence of HLA antibodies at 1 year, but not the presence of MICA antibodies. Conclusions: These data do not support an independent pathogenic role for MICA in long-term renal graft injury and question the interest of posttransplant monitoring of MICA antibodies with single-antigen flow bead assays currently available.

Resume Face a la penurie de greffons renaux, l’alternative de la greffe a partir de donneur vivant est debattue. Le but de ce travail est de comparer, dans 16 pays europeens et d’Amerique du Nord ayant une activite consequente, les niveaux d’activite, leur historique et leur eventuel impact sur la penurie, rapportes jusqu’alors de facon parcellaire et ponctuelle. En 2009 et malgre une legere croissance, le taux francais de 3,5 greffes a partir de donneur vivant par million d’habitants (pmh) etait l’un des plus faibles devant l’Italie et la Finlande. De nombreux pays depassaient le taux de 14 pmh. D’autres comme l’Espagne et le Portugal connaissent une croissance reguliere alors que leur activite de greffe est basee sur le donneur decede. Cette croissance est aussi observee en Allemagne et en Autriche. La France malgre une activite globale de greffe en augmentation a un niveau de penurie important (2,7 inscrits en 2009 pour une greffe) avant l’Italie, qui a une tres faible activite de greffe a partir de donneur vivant, le Portugal, dont l’activite est moins ancienne, mais aussi les Etats-Unis avec une incidence importante de l’insuffisance renale terminale et le Royaume-Uni qui a un faible taux de prelevement de donneurs decedes. Pour ces derniers, la France a un des taux les plus eleves mais il semble plafonner depuis trois ans. Ce constat devrait induire une veritable politique de la greffe a partir de donneur vivant avec un soutien aux professionnels de sante, l’information du grand public, des patients et de leur famille.

Intravenous injection of angiogenesis-inhibitor drugs is used widely to treat cancers. Associated renal complications primarily involve proteinuria and hypertension, and thrombotic microangiopathies also have been described. Intravitreal anti-vascular endothelial growth factor (VEGF) therapy currently is used by ophthalmologists to treat neovascularization in age-related macular degeneration. However, there is some evidence that intravitreal anti-VEGF injections may result in systemic absorption, with the potential for injury in organs that are reliant on VEGF, such as the kidney. We report the first case to our knowledge of a patient who developed an acute decrease in kidney function, nonimmune microangiopathic hemolytic anemia with schistocytes, and thrombocytopenia after 4 intravitreal injections of ranibizumab. Light microscopy of a kidney biopsy specimen showed segmental duplications of glomerular basement membranes with endothelial swelling and several recanalized arteriolar thrombi. Because of the increasing use of intravitreal anti-VEGF agents, ophthalmologists and nephrologists should be aware of the associated risk of kidney disease. Early detection is crucial so that intravitreal injections can be stopped before severe kidney disease occurs.

It has been suggested that dual kidney transplantation (DKT) improves outcomes for expanded criteria donor (ECD) kidneys. However, no criteria for allocation to single or dual transplantation have been assessed prospectively. The strategy of DKT remains underused and potentially eligible kidneys are frequently discarded. We prospectively compared 81 DKT and 70 single kidney transplant (SKT) receiving grafts from ECD donors aged >65 years, allocated according to donor estimated glomerular filtration rate (eGFR): DKT if eGFR between 30 and 60 mL/min, SKT if eGFR greater than 60 mL/min. Patient and graft survival were similar in the two groups. In the DKT group, 13/81 patients lost one of their two kidneys due to hemorrhage, arterial or venous thrombosis. Mean eGFR at month 12 was similar in the DKT and SKT groups (47.8 mL/min and 46.4 mL/min, respectively). Simulated allocation of kidneys according to criteria based on day 0 donor parameters such as those described by Remuzzi et al., Andres et al. and UNOS, did not indicate an improvement in 12-month eGFR compared to our allocation based on donor eGFR.

BACKGROUND The purpose of this study was to determine the impact of antilymphocyte globulin (ALG)-induction on long-term outcomes of postrenal transplantation. METHODS Between January 1985 and January 1986, 123 consecutive renal transplants from deceased donors were performed at a single institution. Patients were randomized into two groups: group 1 (n=63, 40+/-10 year) received cyclosporine (CsA), prednisone, and azathioprine; and group 2 (n=60, 36+/-9 year) received ALG-induction, CsA, and prednisone and delayed initiation (45-90 days posttransplantation) of azathioprine if the CsA dose was less than 4 mg/kg per day. Target CsA trough levels were 150 to 250 ng/mL. Cytomegalovirus prophylaxis was not used. Human leukocyte antigen matching (2.4+/-1.1 vs. 2.6+/-1.2) and cold ischemia time (38+/-8 hr vs. 39+/-9 hr) did not differ. RESULTS The incidence of acute rejection was lower in group 2 (28% vs. 75%, P

Assessment of sex hormones in organ transplant recipients suggests that sirolimus may impair testicular function. The aim of this study was to evaluate the frequency and severity of sirolimus-associated alterations in sperm parameters and their impact on fathered pregnancy rate. An observational study was carried out in male patients aged 20-40 years who received a kidney transplant during 1995-2005. Patients were sent a questionnaire by post, and sperm analysis was proposed. The fathered pregnancy rates according to the immunosuppressive regimen were estimated and compared using the Poisson model. Complete information was obtained from 95 out of 116 recipients. Patients treated with sirolimus throughout the post-transplant period had a significantly reduced total sperm count compared to patients who did not receive sirolimus (28.6 +/- 31.2 x 10(6) and 292.2 +/- 271.2 x 10(6), respectively; p = 0.006), and a decreased proportion of motile spermatozoa (22.2 +/- 12.3% and 41.0 +/- 14.5%, p = 0.01). Moreover, the fathered pregnancy rate (pregnancies/1000 patient years) was 5.9 (95% CI, 0.8-42.1) and 92.9 (95% CI, 66.4-130.0) in patients receiving sirolimus-based and sirolimus-free regimens, respectively (p = 0.007). Of six patients in whom sirolimus treatment was interrupted, only three showed a significant improvement in sperm parameters. Sirolimus is associated with impaired spermatogenesis and, as a corollary, may reduce male fertility.

Immunosuppressed renal transplant recipients (RTRs) are predisposed to non-melanoma skin cancers (NMSCs), predominantly squamous cell carcinomas (SCCs). We have analyzed skin lesions from RTRs with aggressive tumors for p53 gene modifications, the presence of Human Papillomas Virus (HPV) DNA in relation to the p53 codon 72 genotype and polymorphisms of the XPD repair gene. We detected 24 p53 mutations in 15/25 (60%) NMSCs, 1 deletion and 23 base substitutions, the majority (78%) being UV-specific C to T transitions at bipyrimidine sites. Importantly, 35% (6/17) are tandem mutations, including 4 UV signature CC to TT transitions possibly linked to modulated DNA repair caused by the immunosuppressive drug cyclosporin A (CsA). We found 8 p53 mutations in 7/17 (41%) precancerous actinic keratosis (AK), suggesting that p53 mutations are early events in RTR skin carcinogenesis. Immunohistochemical analysis shows a good correlation between p53 accumulation and mutations. HPV DNA was detected in 78% of skin lesions (60% Basal Cell Carcinomas, 82%AK and 79% SCCs). Thus, immunosuppression has increased the risk of infections by HPVs, predominantly epidermodysplasia verruciformis, speculated to play a role in skin cancer development. No association is found between HPV status and p53 mutation. Moreover, p53 codon 72 or frequencies of three XPD genotypes of RTRs are comparable with control populations. The p53 mutation spectrum, presenting a high level of CC to TT mutations, shows that the UV component of sunlight is the major risk factor and modulated DNA repair by immunosuppressive drug treatment may be significant in the skin carcinogenesis of RTRs.

The organ shortage has led to extend the procurement to kidneys from ‘marginal’ donors. As a result, an increasing number of kidneys are discarded, but an extended analysis of the validity of the clinical decision to accept or decline a marginal graft remains to be determined. We have retrospectively analyzed the outcome of 170 kidney transplantations, performed in eight renal transplantation centers between 1992 and 1998. Study group included transplantation from donors accepted after refusal for poor donor or graft quality by at least two centers. Control group included 170 paired recipients from kidneys unanimously accepted by all centers. Main causes of kidney refusal included impaired donor hemodynamics (28%), abnormal pre-harvesting serum creatinine (22%), advanced age in donors (15%), and donor atheroma (14%). The 5-year patient survival (88.2% in the study group and 88.9% in controls) and graft survival (70.4% in the study group and 76.7% in controls, P=0.129) were not significantly different. Delayed graft function occurred significantly more often in the study group patients than in controls patients (63 vs 32%, P

Kidney transplantation activity in France is among the most important worldwide: in 2011, 2976 transplants have been performed (47.5 per million population), and the number of patients living with a functional graft is estimated around 30,000, representing 44.7% of all patients (n = 67,270) treated for end-stage renal failure. However, the rate of preemptive kidney transplants remains very low, only 3.3% of incident patients starting renal replacement therapy. The analysis of demand showed a progressive increase in recent years, as demonstrated by the registration rate on the kidney transplantation waiting list, increasing by 5% yearly between 2006 and 2010, but with huge differences according to age categories and regional registration areas, reflecting discrepant appreciations in indications for kidney transplantation. The median waiting time between registration and transplantation increased progressively in recent years, reaching 22.3 months with considerable variations according to regional areas and transplantation teams. Kidney transplantation activity, while increasing continuously, is far to cover the rising demand, and inexorably patients accumulate on the waiting list (around 9000 patients were registered by January 2012). This situation is the consequence of insufficient organ procurement activity. The deceased organ procurement rate remained high: 1572 harvested donors in 2011 (24.1 per million population), but the proportion of older donors rose in recent years, to reach the rate of 26% of donors older than 65 years in 2011. The procurement activity of donors after cardiac arrest was reintroduced in 2006, but increased slowly: 65 transplants were performed in 2011 using kidney procured in non heart-beating donors. The living donor kidney transplantation activity has markedly increased recently: 302 living donor transplantations were performed in 2011, representing 10.1% of the kidney transplantations. Facing the predictable increase in the number of candidates, all efforts should be put together, by increasing the living donor transplantation activity and by supporting and promoting the deceased donor procurement activity.

Background: The aims of this study were to examine systolic BP (SBP), diastolic BP (DBP), mean arterial pressure (MAP), and pulse pressure (PP) in patients with type 2 diabetes undergoing hemodialysis (HD), and to assess the relationships between these parameters and cardiovascular (CV) events such as coronary heart disease and congestive cardiac failure. Methods: A total of 80 Afro-Caribbean type 2 diabetic patients undergoing hemodialysis in three centers in Guadeloupe, French West Indies, were included in this cross-sectional study. Pre- and postdialysis BP were recorded. Logistic regression methods and areas under the receiver operating characteristic curves were used. Results: The mean age ( standard deviation) was 62.2 years (10.2 years). A total of 24 subjects (30%) had one or more CV events. Sixteen (20%) had coronary disease, 15 (18.8%) cardiac failure, and seven (8.8%) had both. The medians [interquartile ranges] for predialysis PP was higher in patients with CV comorbidity than in patients without a history of CV at 84.5 mm Hg [74.5 to 92.3]v 69.5 mm Hg [61.0 to 79.5], P .003. Areas under the ROC curves (95% confidence intervals) predialysis were significant only for SBP and PP at 0.70 (0.58 to 0.82) v 0.71 (0.59 to 0.83) without statistical differences. After adjustment for gender, age, body mass index, antihypertensive use, time on hemodialysis (2 years), and hemoglobin rate, the odds ratio was significant only predialysis, and a higher odds ratio was found for PP at 2.25 (1.22 to 4.18), P .01 , than for SBP 1.97 (1.12 to 3.49), P .02. Conclusions: Our results suggest that the strongest association of PP with CV morbidities should be considered in therapeutic strategies. These results show the necessity of targeting antihypertensive treatment to patients’ predialysis blood pressure values. Am J Hypertens 2005; 18:1457‐1462 © 2005 American Journal of Hypertension, Ltd.

Resume Les regles de repartition des transplants renaux sont regulierement evaluees et modifiees en France, en fonction des avancees scientifiques, de l'evolution de la liste d'attente et des politiques de sante. Des modifications de ces regles ont ete effectuees en 2004 par l'Etablissement francais des Greffes, a l'initiative de la Commission de transplantation 1 de la Societe de Nephrologie, dans le but de diminuer le nombre des patients en attente ayant un acces difficile a la greffe en raison de leur statut immunogenetique (groupe ABO ou HLA rare, immunisation anti-HLA). Elles portent sur quatre points : 1/ une meilleure precision dans la definition de l'hyperimmunisation ; 2/ l'attribution, avec le programme dit « des antigenes permis », et non ; d'une nouvelle priorite aux patients hyperimmunises, pour qui les regles precedentes s'averaient insuffisantes ; 3/ la suppression de la priorite « full-match » aux patients non immunises ; 4/ l'attribution a certains patients immunises (anticorps anti-HLA = 5–80 %) ayant un acces difficile a la greffe, de priorites proches de celles des hyperimmunises. Le but de cet article est de presenter les nouvelles regles de repartition des greffons renaux et les raisons ayant conduit a ces modifications.

Background. The yearly increasing survival rates testify to the success of transplantation, but questions remain relating to the quality of life (QOL) associated with long-term survival. Methods. A sample of 126 liver recipients (Liver-R), 229 kidney recipients (Kidney-R), and 113 heart recipients (Heart-R) with more than 10 years posttransplant follow-up were included in the study with a response rate of 86%. Respondents were matched with healthy subjects recruited from general population (GP). The three groups of recipients and GP subjects completed a French version of the questionnaire used by the National Institute of Diabetes and Digestive and Kidney Disease, Pittsburgh, PA, and were compared for each score, with adjustments for age and sex. Results. Personal function and measures of disease by the transplant recipients were significantly worse than in the GP (P

La repartition et l’attribution des organes aux malades en attente de greffe sont fondees sur les principes d’equite et d’efficacite medicale. Alors que l’ecart entre le nombre croissant de candidats a la greffe et le nombre d’organes preleves ne cesse de croitre, les organismes charges de l’organisation du prelevement et de la greffe ont developpe des systemes, parfois complexes, qui integrent les nombreux criteres medicaux, ethiques et logistiques qui doivent etre pris en compte. Les organes peuvent etre repartis a une equipe qui se charge de les attribuer au malade de son choix, ou directement attribues a un malade. L’organisation Eurotransplant utilise un systeme informatise centralise (ETKAS) qui calcule, au moment d’un prelevement de reins, un score pour chaque malade en attente, additionnant des points affectes a chaque critere choisi : appariement HLA, duree d’attente, distance entre le lieu de prelevement et la greffe, et ponderation entre les nations. Un nouveau systeme de score (MELD) a ete recemment mis en place aux Etats-Unis pour la repartition des foies. Il utilise des criteres biologiques mis au point par une etude de modelisation de la survie des malades. De tels systemes permettent d’ameliorer la transparence de la distribution des organes, de progresser vers l’equite d’acces a la greffe, et ils ont enfin demontre leur efficacite par rapport aux objectifs de sante publique et medicaux qui leur avaient ete fixes.

Organ transplant recipients have a higher risk of Kaposi sarcoma (KS). A quantitative real-time polymerase chain reaction assay was developed to evaluate KS-associated herpesvirus (KSHV) as a prognostic tool in transplant recipients with KS. Forty-three patients who developed KS after transplantation were included in a cross-sectional study to correlate virus load with transplantation or KS parameters. Seventeen patients (40%) had KSHV viremia (>100 copies/microg of DNA; median, 6067 copies/microg of DNA). Factors associated with these levels of viremia by univariate analysis were progression of KS (P=.00002), time from KS diagnosis (P=.0007), actual stage of KS (P=.006), initial stage of KS (P=.22), graft loss (P=.013), and time from transplantation (P=.0246). Disease progression remained associated with KSHV viremia in a multivariate analysis (P=.01). Thus, quantification of KSHV load in peripheral blood mononuclear cells could represent a useful tool for monitoring transplant recipients with KS.

Background. The aim of this study was to compare the efficacy and safety of induction treatment with antithymocyte globulins (ATG) followed by tacrolimus therapy with immediate tacrolimus therapy in renal transplant recipients. Methods. This 12-month, open, prospective study was conducted in 15 centers in France and 1 center in Belgium; 309 patients were randomized to receive either induction therapy with ATG (n=151) followed by initiation of tacrolimus on day 9 or immediate tacrolimus-based triple therapy (n=158). In both study arms, the initial daily tacrolimus dose was 0.2 mglkg. Steroid boluses were given in the first 2 days and tapered thereafter from 20 mg/day to 5 mg/day. Azathioprine was administered at 1-2 mg/kg per day. Results. At month 12, biopsy-confirmed acute rejections were reported for 15.2% (induction) and 30.4% (noninduction) of patients (P=0.001). The incidence of steroid-sensitive acute rejections was 7.9% (induction) and 22.2% (noninduction)(P=0.001)). Steroid-resistant acute rejections were reported for 8.6% (induction) and 8.9% (noninduction) of patients. A total of nine patients died. Patient survival and graft survival at month 12 was similar in both treatment groups (97.4% vs. 96.8% and 92.1% vs. 91.1%, respectively). Statistically significant differences in the incidence of adverse events were found for cytomegalovirus (CMV) infection (induction, 32.5% vs. noninduction, 19.0%, P=0.009), leukopenia (37.3% vs. 9.5%, P

Hemolytic uremic syndrome (HUS) is a rare clinical and biological entity. HUS has been reported after several anticancer chemotherapies and most often after mitomycin C-based chemotherapy regimens. Little information is available concerning the occurrence and outcome of this syndrome after administration of more recent chemotherapeutic agents. We present a case of HUS in an advanced ovarian cancer patient treated with carboplatin and gemcitabine, and described its favorable outcome after chemotherapy interruption and supportive care with a 1 year follow-up.

Background. The exact reasons for the high incidence of Kaposi's sarcoma (KS) after kidney transplantation are still unknown. Immunosuppression is classically considered as the main risk factor, but the relative risk contributed by the patient's geographic origin and by human herpes virus (HHV)-8 infection still has to be determined. Methods. We carried out a retrospective and a prospective study among kidney transplant recipients (TP) to identify the risk factors for posttransplantation KS. Each of 30 KS patients was matched with two controls to investigate the association with geographic origin, immunosuppressive regimen, HHV-8 antibodies before and after transplantation, and other infections. Among TP with new onset of KS, we prospectively evaluated HHV-8 serology and viremia in response to decreased immunosuppression. Results. African and Middle East origins, past infection with hepatitis B, hemoglobin level

We report a 61-yr-old kidney transplant recipient with human Parvovirus B19 (HPV B19) infection presenting as a severe pancytopenia 1 month after transplantation. Bone marrow aspiration revealed severe erythroid hypoplasia with giant and dystrophic proerythroblasts. Bone marrow cells were positive for HPV B19 DNA detected by polymerase chain reaction (PCR). Pancytopenia resolved shortly after administration of intravenous immunoglobulins. Nineteen cases of HPV B19 infection in organ transplant recipients have been so far reported in the literature. Immunocompromised patients should be considered at risk from developing symptomatic HPV B19 infections. In such patients, specific anti-HPV B19 IgM and IgG antibodies may be absent or transient and therefore their negativity cannot rule out the diagnosis of HPV B19 infestation. Bone marrow smear morphological findings may suggest the diagnosis but testing for viral DNA by PCR is mandatory. Patients may spontaneously recover. However, since specific anti-viral therapy is not currently available, intravenous immunoglobulin administration appears to be the more efficacious treatment.

Introduction La greffe renale a partir d’un donneur vivant est aujourd’hui le meilleur traitement de l’IRC terminale en termes d’esperance et de qualite de vie. Elle peut si elle est programmee avant le stade terminal de l’IRC etre realisee de facon preemptive. L’objectif principal de cette etude etait de comparer dans une population de patients ayant recu une greffe renale a partir d’un donneur vivant (DV), la qualite de vie et la reinsertion professionnelle des receveurs greffes de facon preemptive (GP) a ceux greffes apres une periode de dialyse (GD). Patients et methodes Il s’agit d’une etude transversale par questionnaire auto-administre (SF-36 et RE-TRANS-QoL) envoye en mars 2014 au domicile des patients greffes avec DV entre le 01/04/2004 et le 31/12/2011 dans 7 centres francais et vivant avec un greffon fonctionnel au 31/03/12. Les renseignements recueillis avant l’IRCT, pendant la periode de dialyse (groupe GD), au cours de la 1re annee de greffe et au moment du remplissage, ont permis de reconstituer le parcours socioprofessionnel des patients au cours du temps. Resultats Trois cent cinquante-cinq des 534 patients inclus ont renvoye le questionnaire. Les principales caracteristiques (sexe, âge a la greffe, niveau d’etudes) etaient similaires dans les 2 groupes GP et GD. Les evolutions familiales et sociales ne differaient pas entre les groupes contrairement a l’evolution professionnelle. Les patients GP ont garde plus souvent une situation professionnelle stable (81,6 % vs 10,7 %), ont eu moins souvent une perte d’activite professionnelle (12,6 % vs 42,7 %) et un arret maladie de longue duree (19,2 % vs 29,8 %). Les facteurs associes a la QV dans les 2 dimensions physique (PCS) et mentale (MCS), apres ajustement, etaient l’âge a la greffe, le niveau d’etudes, l’indice de comorbidite de Groll et certains effets secondaires. Le temps passe en dialyse a un effet deletere sur les dimensions PCS (p Discussion Chez les patients greffes avec DV, la dialyse avant greffe altere significativement le parcours professionnel et le temps passe en dialyse impacte la QV dans ses 2 dimensions. Conclusion La greffe preemptive DV permet le maintien d’une activite professionnelle et de la QV.

Background. The outcome of 60 renal transplantations in 53 patients with end-stage renal disease (ESRD) because of lupus nephritis was studied retrospectively and compared with 106 controls matched for age, sex, maximum panel-reactive antibody (PRA) level, and date of transplantation. Methods. The patients received their transplants over a 260-month period (21.5 years) between October 1971 and August 1993. The population was predominantly women (90%), and the mean age at the time of the transplantation was 33.2 years (range: 21-54 years). Fifty-six transplants (93%) were from cadaveric donors, and 4 (7%) were from living-related donors; 46 patients (86%) had primary allografts, and 7 (14%) received a second allograft. The duration of disease before transplantation was 93.6±6.2 months, and the duration of dialysis before transplantation was 48±6 months. Results. No patient had clinically active systemic lupus erythematosus (SLE) at the time of transplantation. The 1-year graft and patient survival rates were 83% and 98%, and the 5-year graft and patient survival rates were 69% and 96%. Actuarial graft and patient survival rates in SLE patients were not significantly different from those of the matched control group. Chronic rejection was the major risk factor for graft loss. Lupus nephritis recurred in the graft of one patient 3 months after transplantation, and there were extrarenal manifestations of SLE in four others. Conclusions. The present study confirms that patients with SLE can receive transplants with excellent graft and patient survival rates and a low rate of clinical recurrent lupus nephritis.

The incidence and risk factors of posttransplant diabetes mellitus were evaluated in 1325 consecutive renal transplant recipients. Thirty-three (2.5%) patients developed diabetes mellitus requiring insulin therapy. Onset occurred a mean of 5.7 +/- 1.5 months following transplantation. The patients were compared with 33 paired-control kidney recipients. The patients were significantly older than the controls (46.8 +/- 1.9 vs. 40.6 +/- 2.1 years) (P

Kidney transplantation activity in France is among the most important worldwide: in 2011, 2976 transplants have been performed (47.5 per million population), and the number of patients living with a functional graft is estimated around 30,000, representing 44.7% of all patients (n = 67,270) treated for end-stage renal failure. However, the rate of preemptive kidney transplants remains very low, only 3.3% of incident patients starting renal replacement therapy. The analysis of demand showed a progressive increase in recent years, as demonstrated by the registration rate on the kidney transplantation waiting list, increasing by 5% yearly between 2006 and 2010, but with huge differences according to age categories and regional registration areas, reflecting discrepant appreciations in indications for kidney transplantation. The median waiting time between registration and transplantation increased progressively in recent years, reaching 22.3 months with considerable variations according to regional areas and transplantation teams. Kidney transplantation activity, while increasing continuously, is far to cover the rising demand, and inexorably patients accumulate on the waiting list (around 9000 patients were registered by January 2012). This situation is the consequence of insufficient organ procurement activity. The deceased organ procurement rate remained high: 1572 harvested donors in 2011 (24.1 per million population), but the proportion of older donors rose in recent years, to reach the rate of 26% of donors older than 65 years in 2011. The procurement activity of donors after cardiac arrest was reintroduced in 2006, but increased slowly: 65 transplants were performed in 2011 using kidney procured in non heart-beating donors. The living donor kidney transplantation activity has markedly increased recently: 302 living donor transplantations were performed in 2011, representing 10.1% of the kidney transplantations. Facing the predictable increase in the number of candidates, all efforts should be put together, by increasing the living donor transplantation activity and by supporting and promoting the deceased donor procurement activity.

Purpose Post-transplantation lymphoproliferative disorder (PTLD) is associated with significant mortality in kidney transplant recipients. We conducted a prospective survey of the occurrence of PTLD in a French nationwide population of adult kidney recipients over 10 years. Patients and Methods A French registry was established to cover a nationwide population of transplant recipients and prospectively enroll all adult kidney recipients who developed PTLD between January 1, 1998, and December 31, 2007. Five hundred patient cases of PTLD were referred to the French registry. The prognostic factors for PTLD were investigated using Kaplan-Meier and Cox analyses. Results Patients with PTLD had a 5-year survival rate of 53% and 10-year survival rate of 45%. Multivariable analyses revealed that age > 55 years, serum creatinine level > 133 μmol/L, elevated lactate dehydrogenase levels, disseminated lymphoma, brain localization, invasion of serous membranes, monomorphic PTLD, and T-cell PTLD were independent prognostic indicators of poor survival. Considering five variables at diagnosis (age, serum creatinine, lactate dehydrogenase, PTLD localization, and histology), we constructed a prognostic score that classified patients with PTLD as being at low, moderate, high, or very high risk for death. The 10-year survival rate was 85% for low-, 80% for moderate-, 56% for high-, and 0% for very high–risk recipients. Conclusion This nationwide study highlights the prognostic factors for PTLD and enables the development of a new prognostic score. After validation in an independent cohort, the use of this score should allow treatment strategies to be better tailored to individual patients in the future.

Background Living donor (LD) transplantation has increased recently, but psychosocial aspects of living donation have not been well characterized, as risk factors for the donors. ELIPSY is a project confunded by EAHC, seeking to develop a common methodology for all EU countries for LD assessment/follow-up in the psychosocial sphere ( www.eulivingdonor.eu ). Objective To evaluate current psychosocial LD assessment/follow-up practices among European centers for key aspects and differences between kidney and liver programs. Methods Within a timeline of 30 months, this phase of the project sought to identify current LD psychosocial assessment/follow-up practices. The final survey concerned two versions focused on the kidney and on liver transplant program. The survey took place in ELIPSY partner centers under their own responsibility. Each of the centers sent the survey to other ones performing LD in their country. Partners in the EULID project includes ones in the United Kingdom, Poland, and Romania. The results were analyzed separately for each program seeking to compare and define differences among them. Results The survey took place in 10 European countries including 65 centers with LD programs. Positive answers regarding psychosocial assessment/follow-up practices were obtained for 26 (42%) kidney and nine (38%) liver centers. Some centers perform several psychosocial follow-ups but did not explain their tools, whereas the centers that did explain the tools used the same ones for both programs.

Donation from alive people has been growing strongly in the recent years, thanks to the advance in the field of organ transplantation and its success as a treatment to procure quality-adjusted life years for many patients with end–stage diseases. The choice of transplantation from a living donor (LD) offers some advantages compared to that for a deceased donor. However, it also carries disadvantages related to donor risks in terms of health and safety, and there are several controversial ethical aspects to be taken into account. There is no specific pronouncement of the European Union in relation to standards to quality and safety for the living donor process, and there is a great heterogeneity among European Countries legislation, ethical concern, and protection systems and donor´s data registries on the topic. The EULID project aims to establish European common standard framework regarding living donor issues to guarantee their health and safety thorough common practices and regulation.

Today, kidney transplantation is the treatment of choice for most patients with end-stage renal failure. However, because of the organ shortage, the limiting supply and increasing demand, needing transplants do not receive them. Chronic renal disease should be efficiently screened and prevented. On the other hand, all ways of using available organs, from living and deceased donors, including those with extended criteria are needed. Finally, strategies targeting factors involved in to chronic allograft nephropathy must be pursued in the effort to improve long-term outcomes after renal transplantation.

The French rules for the attribution of a kidney transplant are regularly evaluated and modified according to scientific progress, evolution of the waiting list and of health policies. Modifications, initiated by the Transplantation Commission of the French-speaking Society of Nephrology, have been introduced in 2004 by the Etablissement français des Greffes and aim at decreasing the number of patients on the waiting list having difficult access to transplantation because of their immunogenetic characteristics (rare ABO or HLA group, HLA immunization). Four points are concerned: 1/ better definition of hyperimmunisation; 2/ introduction of a program based on "acceptable mismatches" as a new priority for hyperimmunized patients; 3/ suppression of the full-match priority to non-immunized patients; 4/ attribution to immunized patients (anti-HLA antibodies=5-80%) who have difficult access to a transplant, of priorities similar to those followed for hyperimmunized patients. This article presents the new rules for the allocation of a kidney transplant and the rationale for the current modifications.

The number of older patients living with a functioning kidney graft is increasing. However the safety of the immunosuppressive treatment and quality of life in this population have not yet been determined. All patients grafted in France since 1969, born before the January 1 1926 and living with a functioning graft on January 1 2000 were included in this national study including all 34 French transplant centers. Renal function, immunosuppressive treatment, comorbid conditions and quality of life were assessed. From the initial population of 446 patients, 113 (26.2%) were still alive in 2000 (study population). Mean age was 76 yr (range: 74-80) with a mean post-transplant follow-up of 9.9 yr (0.1-28.7). Average serum creatinine level was 129 micromol/L (55-286). Immunosuppression was heterogeneous and included triple therapy (18.6%), dual therapy (41.6%) and monotherapy (40.8%). A history of cancer was noted in 36 of the 113 patients (32.1%) whereas hypertension was the most frequent co-morbid condition (80.3%). Estimated quality of life using the Karnofsky scale was between 80 and 100 in 78.4% of the patients. The immunosuppressive regimen in older renal transplant recipients living with a functioning graft varied widely among the 34 French transplant centers. Renal function in this group of patients was good and quality of life seemed excellent. Cardiovascular disease and malignancies were the main co-morbid conditions.

Since major histocompatibility (MHC) antigen matching was introduced in the early 1970s as the key factor determining kidney transplant allocation, several studies, mainly arising from organ-sharing organizations in the United States and Europe, have debated this complex issue. The first fundamental concern is the interaction of human leukocyte antigen matching with other transplant outcome risk factors, for example, prolongation of ischemia and matching for age. Much concordant data advocate restraining MHC antigen-based allocation in terms of space and time limits. The second fundamental concern is the balancing of the advantages of better antigen matching in terms of improved graft survival and the improved transplantation rate in immunologically high-risk patients with the major drawback of inequitable access for ethnic minorities and patients with rare MHC haplotypes. These issues have led to considering renewed kidney allocation rules, discarding human leukocyte antigen matching from algorithms, or modifying the specificity allocation level by using cross-reactive group matching or class II MHC antigen matching. The evolving concepts in the field of histocompatibility support the need for periodically updated, flexible, and hybrid allocation systems, as designed in France by the Etablissement francais des Greffes.

FROM AN EPIDEMIOLOGICAL POINT OF VIEW: The epidemiology of renal transplantation had greatly changed over the past 10 years. The increasing number of patients with renal failure and candidates for transplantation increases the demand for grafts, whereas the sampling rate of organs remains stable. The mean age of the donors is rising, hence underlining the question of the use of organs of so-called "borderline" quality. THE WEAK POINTS OF ELDERLY GRAFTS: Aging of the kidneys affects the structure of the parenchyma and renal function, which decreases, notably in hypertensive persons. The elderly graft exhibits a critical mass of nephrons that is insufficient to fulfil the functional requirements of a poorly equipped recipient. The recipient is more sensitive to the added agressions: prolonged ischemia and immunological and medicinal agressions. THE RESULTS OF RENAL GRAFT FROM ELDERLY DONORS: They are quantitatively and qualitatively inferior to those of renal transplants from "ideal" donors. The donor's age is a significant factor influencing negatively influences the survival of the transplanted kidney, but dependent on past vascular history. Good results regarding the maintenance of dialysis are obtained by selecting the donors and by avoiding added risk factors. THE ASSESSMENT OF A GRAFT FROM AN ELDERLY DONOR: This, basically, relies on clinical criteria: donor's history, cause of death and accurate measurement of the renal function. A biopsy of the graft, at the time of sampling, provides useful information. TRANSPLANTATION STRATEGY OF A GRAFT FROM AN ELDERLY DONOR: Donor-recipient matching by age is a common approach. Grafting of both kidneys in the same recipient is a method presently under assessment. The episode of ischemia must be reduced and the immunosuppressive therapy adapted.

Background. The results of the transplantation of marginal donor kidneys remain controversial. This study aimed to investigate the impact of donor risk factors as predictors of kidney-graft outcome. Methods. Allograft failure risk factors were studied in 7,209 cadaveric kidney-transplant recipients reporting to the Etablissement francais des Greffes (EfG) from 1996 to 2000, of which 544 (7.6%) were from donors aged over 60. Both univariate and multivariate analysis were used to assess the effect of donor risk factors and were stratified according to recipient age. Results. Overall graft survival was 91.1% (95% confidence interval [CI] 90.5-91.8) at 1 year, 88.6% (95% CI 87.8-89.4) at 2 years, and 85.6% (95% CI 84.6-86.6) at 3 years posttransplant. Univariate analysis of risk factors showed a significant reduction of graft survival in recipients transplanted with kidneys coming from donors older than 60 years, donors with a history of hypertension, a cerebrovascular cause of death, and a preharvesting serum creatinine greater than 150 μmol/L. Multivariate analysis revealed significantly higher failure rate associated with cerebrovascular cause of death (RR=1.2, P=0.02), history of hypertension (RR=1.2, P=0.04), and elevated serum creatinine (RR=1.3, P=0.03), whereas donor age greater than 60 years was not found as an independent risk factor. Conclusions. Our results suggest that cerebrovascular cause of death, history of hypertension, and elevated creatinine are significant independent donor risk factors for graft survival, whereas donor age is a statistically significant, but dependent, risk factor. This result is important for the design of allocation and transplantation strategies for kidneys procured in elderly donors.

ALARGE DISCREPANCY is observed in France between the number of patients registered on kidney transplantation waiting list and the number of available kidneys. By the end of December 1998, 4428 patients were registered on the waiting list, whereas only 1919 kidneys were harvested in 1998. Although the number of harvested donors in France is stable (16.2 per million inhabitants [pmi] in 1999), the kidney shortage will undoubtedly worsen in the near future, due to the progressive aging of the population. On the other hand, the prevalence and incidence of end-stage renal failure has increased in recent years. In 1995, the annual incidence of end-stage renal disease was 112 pmi in France, and the prevalence was 580 pmi (33,713 patients). Due to this shortage of kidney transplants, we should consider increasing the procurement in donors aged 60 years, which represented only 9% of the donors in France in 1998. This study examines the interregional variations in the harvesting of old donors, and the interregional differences in the allocation policies of such organs.

fused patients; 6 out of 31, 19.4% in patients transfused with Multicenter trial of one HLA-DR–matched or mismatched one DR-matched blood; and 13 out of 39, 33.3% in patients blood transfusion prior to cadaveric renal transplantation. transfused with mismatched blood. Background. The beneficial effect of blood transfusions beConclusion. The results of our prospective randomized trial fore cadaveric renal transplantation on allograft survival, al- showed that in a population of naive patients, one transfusion though previously well documented, has become controversial mismatched or matched for one HLA-DR antigen given prior in light of their adverse effects. Recently, it has been suggested to renal transplantation had no significant effect on the incithat their clinical benefits are due to HLA-DR sharing between dence and severity of acute rejection, and did not influence the blood donor and recipient. overall long-term graft outcome. Considering the potentially Methods. In this prospective study, 144 naive patients were deleterious adverse effects of blood transfusions, the costs, and randomly assigned to receive one unit of blood matched for the considerable logistical efforts required to select and type one-HLA-DR antigen (N 49), or one unit of mismatched blood donors, such a procedure cannot be recommended in a blood (N 48), or to remain untransfused (N 47). Graft routine practice for patients awaiting cadaveric kidney transsurvival and acute rejection rate were analyzed in 106 cadaveric plantation. renal allograft recipients receiving the same immunosuppressive protocol. Results. Graft survival was similar in the three groups at The history of the transfusion of blood is an essential one and five years: 91.7 and 80% in untransfused patients, 90.3 and 79.3% in patients transfused with one DR-antigen– part of the history and development of transplantation. matched unit, and 92.3 and 83.7% in patients transfused with When the modern era of renal transplantation started HLA-mismatched blood. The difference in the incidence of in the 1960s, the old concept of deleterious sensitization six-month post-transplant acute rejections was not statistically of the patient to foreign proteins persisted, leading clinisignificant in the three groups: 12 out of 36, 33.3% in nontrans- cians managing dialysis patients to the absolute avoidance of blood products. This was the case until 1973, when Opelz found that untransfused cadaveric renal 1

RENAL FAILURE associated with end stage hepatopathy has been, until recently, considered as a contraindication for orthotopic liver transplantation (OLT).1 This was because of the high mortality rate and the serious complications found during the posttransplant period.2 Because the global results of combined kidney and liver transplantation (CKLT) have improved and there are increasing numbers of patients in dialysis who have chronic liver diseases, CKLT has emerged as the technique of choice.3 This study reports our single-center experience of 22 CKLTs performed between April 1986 and December 1995 in patients with end stage chronic renal failure or with biopsy-proven kidney disease associated with end stage liver failure. This study also compares these results with a control series of 785 kidney-transplanted patients in the same unit during the same period.

We report the cases of two patients with spondylodiskitis due to Candida albicans who were successfully treated with fluconazole. On the basis of findings from these cases and a review of 52 mycologically proven cases in the literature, we describe the main characteristics of candidal spondylodiskitis. In 60% of the cases, candidal spondylodiskitis was a late complication of candidemia (mean delay, 5.2 months) ; it was determined to be a complication on the basis of the results of previously positive blood cultures (19 cases), and it was presumed to be a complication in iv drug addicts (12 cases). As spondylodiskitis can be a late complication of candidemia, all episodes of candidemia should be treated with systemic antifungal agents. Clinical and radiological signs of candidal spondylodiskitis were nonspecific. Any bone or joint symptoms in a patient who has had candidemia should be considered to be of fungal origin at the time of presentation. The definitive diagnosis of candidal spondylodiskitis was made on the basis of the results of percutaneous puncture in 26 of 30 cases. The overall prognosis for patients with candidal spondylodiskitis was good, with the full recovery rate ranging from 67% to 100%. The preliminary results of treating candidal spondylodiskitis with triazole derivatives, particularly fluconazole, were satisfactory ; there was excellent tolerance of this drug.

Immunoglobulin A nephropathy (IgAN) frequently recurs in patients after renal transplantation (RT) on a conventional regimen of immunosuppressive therapy, but little is known about the influence of cyclosporine (Cs) on such a recurrence. We studied 84 patients retrospectively who underwent RT for renal failure attributable to IgAN (n = 71) or Henoch-Schonlein purpura nephropathy (HSPN) (n = 13) in two transplantation units, between January 1985 and June 1991 and were treated with Cs. Four patients died 3 months to 8 years after RT. Graft survival was 88% at 1 year, 75.2% at 5 years, and 63% at 8 years. Fifty patients underwent at least one graft biopsy, but studies with immunofluorescence were performed on only 28 (23 IgAN and 5 HSPN). After a mean follow-up of 68.1 +/- 37.2 months, mesangial IgA deposits recurred in 13 of the 28 patients (12 IgAN and 1 HSP) (prevalence, 46.4%). Among the 13 patients with recurrence of IgA deposits, all but 4 had urinary abnormalities. Light microscopy showed mesangial deposits and focal and segmental glomerular changes in 9 cases. Four patients lost their graft function 69 to 119 months after RT, and 2 had severe graft dysfunction. The rates of graft failure and mean serum creatinine at 1, 5, and 8 years were similar in the 13 patients with recurrence and the 15 patients without proven recurrence. In conclusion, Cs did not reduce the incidence or severity of IgAN recurrence. The latter was the cause of graft loss or dysfunction in 46.1 % of the patients with recurrent IgA deposits. Recurrent glomerulonephritis did not influence the 8-year graft survival in patients with IgAN or HSPN, but it may be an important cause of graft loss as evidenced by more extended follow-up.

A variety of renal diseases can be associated with end-stage liver diseases requiring orthotopic liver transplantation (OLT), including cirrhosis-associated glomerulonephritis (GN), and nephropathy unrelated to the liver disease. A retrospective survey showed that nine patients undergoing liver transplantation in our centre had histologically proven GN or interstitial nephritis with renal failure and/or nephrotic-range proteinuria, and experienced severe complications post-OLT since nephrotoxic immunosuppressive drugs (CsA and FK506) could not be adequately given. Four of the nine patients died. Therefore, combined liver-kidney transplantation has been suggested as first choice treatment in such patients. From January 1990 to February 1994, in patients with end-stage liver disease referred for OLT, and who presented with unexplained renal function impairment and/or significant proteinuria, severe nephropathy was confirmed by renal biopsy in nine : four mesangiocapillary GN with immune deposits, one membranous nephropathy, two diabetic glomerulosclerosis and two interstitial nephritis. All underwent liver transplantation immediately followed by kidney transplantation. The postoperative period was uneventful, and neither death nor renal failure were recorded. Combined transplantation resulted in all patients in the normalization of renal function, and in the disappearance of proteinuria within the first postoperative month. From 6 months to 4 years post-transplant, the renal function remained within normal ranges in all patients. Routine renal transplant biopsy was performed in two patients with pre-transplant cirrhosis-associated GN, and showed no evidence of recurrence of the original nephropathy. We conclude that combined liver-kidney transplantation is an adequate therapeutic option in patients with end-stage liver disease associated with advanced kidney disease. This procedure avoids severe complications due to renal failure or nephrotic syndrome, especially as nephrotoxic immunosuppressive drugs are mandatory in OLT.