An arteriovenous fistula (AVF) remains the best choice of vascular access (VA) for hemodialysis (HD). The aim of the study was to determine the factors associated with the achievement of adequate ...blood flow (BF) of AVFs at the 4th week after creation. Created AVFs in 63 patients with chronic kidney disease (CKD) stage 4/5 and CKD stage 5 on hemodialysis (CKD5D) were analyzed in a prospective study. Doppler ultrasound (DUS) was used for measuring the diameter of the radial artery, the brachial artery and the cephalic vein before AVF creation. The BF of AVF was calculated by DUS at the 4th week after creation and adequate BF was defined as ≥ 600 mL/min. The average age of patients was 61.31 ± 12.9 years. An adequate BF of AVF at the 4th week after creation was achieved in 43.54% of patients. The BF of AVF measured in male patients was significantly higher compared to the BF of AVF obtained in females (576.03 mL/min vs 375.12 mL/min, P = 0.004). The diameter of the blood vessels with achieved adequate BF was significantly larger compared to the diameter of the blood vessels without adequate BF (radial artery: 2.45 mm vs 2.03 mm, P = 0.000; brachial artery: 4.78 mm vs 4.06 mm, P = 0.001 and cephalic vein: 3.12 mm vs 2.83 mm P = 0.018). The gender and the diameter of the blood vessels before AVF creation were significantly associated with achievement of adequate BF of AVF at the 4th week of creation.
Incidence of vascular anomalies in donor kidneys varies from 18% to 30% and presents a challenge for a transplant surgeon in kidney transplant. Here we present our personal experience for man - ...agement of the complicated and unexpected cases.
A total of 250 kidney transplants (226 living, 24 deceased) were performed in a period of 24 years; mean donor age was 55 years (range, 25-86 years), and mean recipient age was 38.6 years (range, 14-66 years). We analyzed the surgical techniques, complications and outcomes, rejection episodes, kidney function, and graft and patient survival rates.
Of 250 nephrectomies, 209 had a single artery (83.6%), 34 had 2 arteries (13.6%), and 7 had 3 arteries (2.8%). Of 34 double arteries, 14 had 2 main arteries, 15 had a main and a polar artery, and 5 had an aortic Carrel patch after deceased donation. According to the size, type, and position, the anastomoses were performed with branches of hypogastric, epigastric inferior, iliac external, and main renal artery, intracorporeally or in bench surgery. Regarding veins, 1 double inferior vena cava, 1 left-side inferior vena cava, 4 retroaortic, 2 circumaortic, 10 large lumbar veins draining into the left renal veins, and 8 cases with 2 or more different size renal veins were managed. In 9 cases with short right renal vein, an extension with vena cava (a "Barry cavoplasty") was performed in deceased donor organs. No serious surgical complications related to vascular anomalies were observed. There were no statistical differences in 1-, 6-, and 12-month graft survival rates between the groups with or without vascular anomalies.
Vascular anomalies should no longer be considered a contraindication for transplant, if careful anastomosis is performed in every case to avoid ischemia and further complications. Therefore, management of vascular anomalies could be a graftsaving procedure.
Background. Kidney transplantation (TR) is the best treatment of chronic kidney disease. Chronic cellular and antibody mediated rejections have still major impact on graft survival. Single antigen ...bead technology enabled detection of donor specific (DSA) and non-donor specific (Non-DSA) anti HLA antibodies (HLA-Ab). Our study investigates the impact of de novo HLA-Ab on graft function (GF) 12 months after TR. Material and methods. 50 pts with living (42) and deceased donor (8) transplantation were included in a 12-month prospective study. HLA-Ab were analyzed using LABScreen mixed kit in the 1st and 12th month after TR. According to the presence of HLA-Ab, pts were divided in group 1 (HLA+) and group 2 (HLA -). Both groups did not differ regarding gender, age, living or deceased donor, immunosuppression, underlying renal disease, rejection episodes, HLA mismatch, cold and warm ischemia time. Serum creatinine (SCr), GFR (Cockroft Gault) and proteinuria (Pr) were analyzed 1st and 12th month after TR. Results. HLA-Ab were detected in 17 pts (34%), 5 with DSA (10%) and 12 with Non-DSA (24%). Group 1 has a significant worsening of GFR (SCr increased from 112.1 to 141.5 ( p<0.002) compared with the group 2 where SCr decreased from 116.4 to 111.31 µol/L.( p<0.23). In the same time GFR decreased from 69.7 to 57.09 and increased from 67.8 to 69.3 while Pr increased from 0.42 to 0.58 ( p< 0.26) and decreased from 0.81 to 0.32 ( p<0.051) in the groups 1 and 2, respectively. Conclusion. De novo DSA and Non-DSA produce graft injuries in the first 12 months after TR. Regular follow- up of HLA-Ab together with systematic protocol graft biopsy could be essential for further therapeutic interventions.
Celiac-like disease and celiac sprue associated with widespread use of mycophenolic acid are among the most frequent complications of renal transplant. Most cases have been observed in patients ...receiving mycophenolate mofetil; however, there have been rare instance after administration of enteric-coated mycophenolate sodium. Here, we describe 4 renal transplant recipients with celiac-like duodenopathy that occurred in association with enteric-coated mycophenolate sodium treatment in a time period of 14 to 19 years after living donor kidney transplant. Three of 4 patients had diarrhea, and all 4 patients had marked loss of body weight. Esophago-gastroduodenoscopy was not diagnostically helpful; however, randomly performed duodenal biopsies showed mild villous atrophy and intraepithelial lymphocytosis. Replacement of enteric-coated mycophenolate sodium with azathioprine was successful with stopping diarrhea, allowing regained body weight, and stabilization of renal function. This potential complication in kidney transplant recipients can occur more than a decade after transplant. Diagnosis and treatment initiation are urgent to cure this disease.
Chronic kidney disease, secondary to renal fibrogenesis, is a burden on public health. There is a need to explore new therapeutic pathways to reduce renal fibrogenesis. To study this, we used ...unilateral ureteral obstruction (UUO) in mice as an experimental model of renal fibrosis and microarray analysis to compare gene expression in fibrotic and normal kidneys. The cannabinoid receptor 1 (CB1) was among the most upregulated genes in mice, and the main endogenous CB1 ligand (2-arachidonoylglycerol) was significantly increased in the fibrotic kidney. Interestingly, CB1 expression was highly increased in kidney biopsies of patients with IgA nephropathy, diabetes, and acute interstitial nephritis. Both genetic and pharmacological knockout of CB1 induced a profound reduction in renal fibrosis during UUO. While CB2 is also involved in renal fibrogenesis, it did not potentiate the role of CB1. CB1 expression was significantly increased in myofibroblasts, the main effector cells in renal fibrogenesis, upon TGF-β1 stimulation. The decrease in renal fibrosis during CB1 blockade could be explained by a direct action on myofibroblasts. CB1 blockade reduced collagen expression in vitro. Rimonabant, a selective CB1 endocannabinoid receptor antagonist, modulated the macrophage infiltrate responsible for renal fibrosis in UUO through a decrease in monocyte chemoattractant protein-1 synthesis. Thus, CB1 has a major role in the activation of myofibroblasts and may be a new target for treating chronic kidney disease.
BACKGROUNDThe association of Donor-Specific HLA Antibodies (DSA) with antibody-mediated rejection (AMR) is already very well known and confirmed by many studies. However the role of circulating ...Non-DSA HLA antibodies (Non-DSA) is still controversial. The aim of our study is to investigate the clinical importance of Non-DSA associated with 12 month graft histology in regular patients follow up.
METHODSSixty predominantly living donor kidney transplant recipients were involved in a 12 months protocol biopsy prospective study. De Novo DSA and Non-DSA were followed before, up to 3 and 12 months after the surgery by use of Luminex SAB procedure and only those with MIF >800 were considered positive. After 12 months a routine protocol biopsy was performed in all recipients. The presence of AMR was confirmed according to the BANFF 2013 recommendation. In the same time, a semiquantitative Complement 3 (C3) Immunofluorscence (IF) on frozen section was performed in all recipients.
RESULTSIn 28 pts DSA and Non-DSA were detected, 4 in DSA and 24 in Non-DSA group. Four pts from DSA group revealed overt deterioration of kidney function and all pts were under the appropriate anti rejection treatment including plasmapheresis, IvIG and Rituximab. The graft histology confirmed predominantly glomerular lesions with a maximum C3 positivity. Twelve pts in Non-DSA group reached the histological criteria for AMR according to the BANFF 2013 with significantly impaired graft function compared with other pts in Non-DSA group (GFR 141.47+22.3 vs. 111.31+ 26.6, respectively. The usual rejection phenotypes weremicrocirculation inflammation, glomerular lesions, interstitial inflammation and C3 IF positivity. For the time being, all Non DSA pts are carefully clinically followed. Other 11 pts with non DSA did not show any significant histological lesions and any C3 positivity. The renal function remains normal in all other pts.
CONCLUSIONData from our study confirm the importance of both, DSA and Non-DSA in the follow up of kidney transplant recipients. The difference between the active and indolent DSA and Non-DSA is determined only by graft histology. Further careful clinical follow up of the recipients with impaired graft histology and detected Non-DSA is necessary regarding decision of the possible therapeutic interventions.
We describe a case of a 55-year-old woman with polycystic kidney disease who received a living donor kidney transplant 16 years earlier and was on immunosuppressive therapy with satisfactory renal ...function. The donor was her mother. The patient presented with flank pain on the right side and macrohematuria, and noncontrast computed tomography and magnetic resonance imaging led to the diagnosis of tumors in the remaining right native polycystic kidney and ureter, as well as secondary retroperitoneal dissemination. We performed right radical nephrectomy and ureterectomy with extirpation of 2 metastases; the left native kidney remained intact. Histology showed squamous metaplastic changes and invasive epithelial neoplasm in the lumen of the renal pelvis and ureter with extensive squamous differentiation positive for nuclear p63 as squamous cell immunohistochemical marker. After surgery, an immunosuppressive therapy with methylprednisolone was administered, without calcineurin inhibitors and mycophenolate mofetil. Twelve months later the patient was still alive, with a glomerular filtration rate of 29 mL/min. Needs remain for further treatment modalities in patients with primary squamous cell carcinoma in nonfunctioning kidneys and improvements in imaging technique accuracy.
The article "Chronic Kidney Disease in sub-Saharan Africa: Hypothesis for research demand" from Dr. Biruck published in this issue of the AAM put in the light many facts already very well known in ...the community of nephrologists all over the world.
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