A 55-year-old female underwent right nephrectomy for renal cell carcinoma (RCC). The histopathology showed clear cell carcinoma. There was no evidence of metastasis. After remaining asymptomatic for eight years, she developed pain in the right loin. Abdominal ultrasound, computerized tomography (CT) Scan and magnetic resonance imaging (MRI) were suggestive of a tumor mass in the right renal area, multiple tumor masses in the left kidney and a mass in the gallbladder. Cholecystectomy, left radical nephrectomy and right adrenal mass with excision of adjacent lymph nodes were performed. The histopathology from all sites was suggestive of RCC. She was maintained on hemodialysis. Two and half years later she died after surgical exploration for spinal cord decompression due to metastasis to the dorsal spine.
Abstract Context.—The World Health Organization classification of posttransplant lymphoproliferative disorders divides them into 4 main categories. Objective.—To classify cases of posttransplant lymphoproliferative disorders diagnosed in our institution according to the World Health Organization scheme and correlate the classification and clonality with clinical data. Design.—Cases of posttransplant lymphoproliferative disorders were reviewed. They were classified according to the World Health Organization scheme. Clonality was determined by flow cytometry and/or polymerase chain reaction. Patients' charts were reviewed. Results.—Thirty-one cases were identified. Median age was 33 years. There were 19 cases of kidney, 8 cases of liver, and 4 cases of bone marrow transplant. Immunosuppression consisted of cyclosporin A and prednisone (N = 24) or FK506 and prednisone (N = 7). Twenty cases (63%) were World Health Organization type 3, 7 cases (23%) type 2, 3 cases (6.4%) type 1, and 1 case type 4 posttransplant lymphoproliferative disorder. Ten patients received chemotherapy, 20 patients had reduction of immunosuppression, and 1 had no treatment. Follow-up was available on 25 patients. Seven (43.75%) of 16 with type 3 lesions with available follow-up died of their disease. Five of these patients received reduction of immunosuppression alone. Only 2 of 9 patients with type 3 disease who received chemotherapy died of disease. Two patients with type 2 disease died of unrelated causes. One patient is alive with disease; the remaining patients with types 1 and 2 disease are alive with no disease. Conclusions.—The World Health Organization classification of posttransplant lymphoproliferative disorders is valuable in the identification of subtypes. It helps identify early lesions (1 and 2) requiring reduction of immunosuppression and type 3 disease, which requires chemotherapy from the outset.
P184 Aims: We report our experience with desensitization and the renal transplant outcome in nine highly sensitized individuals with positive T & B cross-match (XM) (group I) and in three individuals with positive T XM (group II). Desensitization is defined as abrogation of positive T-cell IgG XM by complement dependent cytotoxicity (CDC) and flow cytometry (FC). All Transplants were from living donors. Methods: Desensitization protocol for group I consisted of: (1) pre-transplant protein A immunoadsorption (IA), and intravenous immunoglobulin (IVIG); (2) peri-transplant induction with Thymoglobulin® and Rituximab®; (3) post-transplant quadruple therapy with Tacrolimus, Rapamycin, Mycophenolate Mofitil and Prednisone. Desensitization protocol for group II was similar to group I without IA or Rituximab®. Results: All but one patient were females. All but three patients in group I were successfully desensitized and received kidneys from their historically positive XM living donors. All transplanted patients were alive with functioning grafts at the last follow up period:Figure♠ AMR: Antibody-mediated rejection ♣ SCR: subclinical rejection ◆ PB: protocol biopsy at three and six months for group II and I respectively. Conclusions: Desensitization and subsequent living donor kidney transplantation can be performed successfully in highly sensitized positive T & B XM recipients after desensitization according to the above protocols. Renal allograft functional and histological parameters at three and six months suggest that these grafts are likely to have an excellent long-term prognosis.
The occurrence of hepatitis C virus (HCV) infection amongst chronic renal failure (CRF) patients in our Nephrology Unit was investigated over a period of 1 year. A total of 71 patients was studied comprising 26 chronic haemodialysis (CHD) patients, 6 acute haemodialysis patients, 4 peritoneal dialysis patients and 35 CRF patients not on dialysis. Patients were screened before and after haemodialysis, and their baseline and postdialysis values of liver enzymes were determined. Eleven (15.5%) of the total 71 patients were HCV antibody positive. Analysis of the individual patient groups showed that 8 (30.7%) of the 26 CHD patients were positive for HCV. Our data showed a statistically significant relationship between seroconversion and duration of dialysis (p < 0.05). A high statistically significant (p < 0.0001) correlation was observed between the HCV antibodies and CRF. The relative risk of hepatitis C was about 22 times greater for those with CRF compared with the normal controls, which makes CRF an important risk factor. A high proportion of the HCV seroconverters had elevated liver enzyme (serum glutamic pyruvic transaminase). The data presented show a positive correlation between HCV seroconversion, CRF, duration on dialysis and elevated serum liver enzymes.
P185 Aims: The aim of this study was to evaluate the feasibility of steroid withdrawal in LRRTR. LRRTR are adult (≥18 years) recipients of first Living Donor (LD) kidney transplant who have: 0% cytotoxic antibodies (CTA): negative T & B cross-match by complement dependent cytotoxicity (CDC) and flow cytometry; and at least one haplotype HLA match with their LD. Methods: Treatment protocol consisted of induction with Daclizumab and maintenance protocol of CSA/MMF/prednisone for the first two weeks of engraftment followed by CSA withdrawal and introduction of Rapamycin. Target Rapamycin trough levels were 15-25 ng/L. Steroids are withdrawn at 3-6 months post engraftment. In the event of acute clinical or subclinical rejection post conversion to Rapamycin, patients are crossed over to Tacrolimus. Response of clinical and subclinical rejection to therapy was monitored by clinical parameters and follow up renal biopsies. In an open label, non-randomized trial, 26 LRRTR were enrolled and at the time of this interim analysis, 19 patients have undergone conversion to Rapamycin and steroid withdrawal Results: There were 15 males and 4 females. Average age was 43 years (range: 23-67):Figure* ACR: Acute clinical rejection ♣ ASR: Acute subclinical rejection ◆ FUSW: Follow up since steroid withdrawal 7/9 (80%) rejection episodes developed prior to steroid withdrawal. All rejection episodes were classified as Banff IA-IB. All patients with rejection were crossed over to Tacrolimus and all but one rejection episode resolved completely without maintenance steroids. Conclusions: With careful monitoring for clinical and subclinical rejections, steroids can be withdrawn successfully in LRRTR, following the above graded approach to immunosuppressive protocol. Tacrolimus/MMF combination appears to be more efficacious in achieving the goal of successful steroid withdrawal.
Journal Article Mucormycosis of the graft in a renal transplant recipient Get access A. Mitwalli, A. Mitwalli Departments of Nepbrology, Urology and Pathology, Security Forces HospitalRiyadh, Saudi Arabia Correspondence and offprint requests to: Dr. Ahmed Mitwalli, Security Forces Hospital, PO Box 3643, Riyadh 11481, Kingdom of Saudi Arabia Search for other works by this author on: Oxford Academic PubMed Google Scholar G. Hassan Malik, G. Hassan Malik Departments of Nepbrology, Urology and Pathology, Security Forces HospitalRiyadh, Saudi Arabia Search for other works by this author on: Oxford Academic PubMed Google Scholar J. Al-Wakeel, J. Al-Wakeel Departments of Nepbrology, Urology and Pathology, Security Forces HospitalRiyadh, Saudi Arabia Search for other works by this author on: Oxford Academic PubMed Google Scholar H. Abu Aisha, H. Abu Aisha Departments of Nepbrology, Urology and Pathology, Security Forces HospitalRiyadh, Saudi Arabia Search for other works by this author on: Oxford Academic PubMed Google Scholar S. Al-Mohaya, S. Al-Mohaya Departments of Nepbrology, Urology and Pathology, Security Forces HospitalRiyadh, Saudi Arabia Search for other works by this author on: Oxford Academic PubMed Google Scholar A. Al-Jaser, A. Al-Jaser Departments of Nepbrology, Urology and Pathology, Security Forces HospitalRiyadh, Saudi Arabia Search for other works by this author on: Oxford Academic PubMed Google Scholar H. Assaf, H. Assaf Departments of Nepbrology, Urology and Pathology, Security Forces HospitalRiyadh, Saudi Arabia Search for other works by this author on: Oxford Academic PubMed Google Scholar H. El Gamal H. El Gamal Departments of Nepbrology, Urology and Pathology, Security Forces HospitalRiyadh, Saudi Arabia Search for other works by this author on: Oxford Academic PubMed Google Scholar Nephrology Dialysis Transplantation, Volume 9, Issue 6, 1994, Pages 718–720, https://doi.org/10.1093/ndt/9.6.718 Published: 01 January 1994 Article history Published: 01 January 1994 Received: 18 February 1994 Accepted: 18 February 1994
Recombinant human erythropoietin (rHuEpo) has been shown to be both effective and usually safe in patients with chronic renal failure who have not yet reached the stage requiring dialysis. There are, however, disturbing reports on the possibility of deterioration of the reserve renal function in association with rHuEpo therapy. Most of the published studies have used rHuEpo in doses of 50-150 U/kg three times weekly subcutaneously. An open-label trial of rHuEpo therapy was conducted on 21 patients with chronic renal failure treated sequentially at a referral hospital, rHuEpo was used in doses of 50 U/kg twice weekly for 4 weeks followed by 25 U/kg twice weekly for 8 weeks subcutaneously, a regimen substantially lower than current recommendations. This was associated with a gentle but significant increase in haematocrit (P < 0.05) and haemoglobin (P < 0.05), while the serum creatinine and the reciprocal of the creatinine remained stable, with a tendency to improve rather than worsen (P = 0.06). We conclude that there is no need to aim at a rapid increase in haematocrit and haemoglobin by rHuEpo therapy; rather a gentle increase using modest doses is both effective and safe.
Eighty-three patients with chronic end-stage renal failure, including 65 on haemodialysis and 18 on intermittent peritoneal dialysis, were evaluated for hepatitis B virus profile and antibodies to hepatitis C virus (HCV). All those positive for HBsAg were excluded from the study. Nineteen patients were found to be positive for antibodies to HCV by the ELISA II test. Eight cases were already positive for HCV antibody when they started dialysis in our unit, the other 11 became positive during dialysis in our unit. Only one of the patients on peritoneal dialysis was positive for HCV. A liver biopsy was obtained from 17 patients, who consented to the procedure. All the cases were evaluated for the number of blood transfusions received, HIV infection and the approximate time of contracting the HCV infection. Liver enzymes were determined every month. Only three patients had abnormally raised serum aminotransferase at the time of biopsy. The various histopathological lesions detected were chronic active hepatitis ( n =3, including one with changes consistent with cirrhosis), chronic persistent hepatitis ( n = 4), non-specific hepatitis ( n = 3) and haemosiderosis ( n =3); four biopsy samples were normal. There was no correlation between the biochemical and histopathological changes. Moreover, patients with normal serum aminotransferase levels had abnormal histopathological changes. All were negative for HIV and none of the patients had received a renal graft. Twelve patients had received blood transfusions varying from 2 to 12 units, four had not received any blood, and in one the history of blood transfusion could not be confirmed. The four patients with anti-HCV antibodies who had not received blood transfusion had relatively mild disease-non-specific hepatitis ( n =2) or normal biopsy ( n =2). One patient with cirrhosis died 30 months after liver biopsy from hepatic insufficiency and three received renal transplants. Others are continuing on dialysis and their biochemical tests are within normal limits 12−45 (30± 14) months after biopsy. In conclusion, biochemical tests are poor indicators of liver disease, and liver biopsy is a definitive way of evaluating the patients of dialysis with positive HCV antibodies for prognosis.
Introduction: Antibody mediated rejection (AMR) and inferior graft outcome remain the two most important obstacles to successful kidney transplantation in HLA and ABO incompatible recipients. We report a single center experience in the outcome of desensitized living donor HLA and ABO incompatible kidney transplantation. Methods: Since 2007, we included all HLA incompatible living donor kidney transplant candidates with T cell IgG AHG CDC crossmatch (CXM) titer of £1:8 and all ABO incompatible living donor kidney transplant candidates with IgM isoagglutinins titer of £ 256 in our desensitization program. All candidates were risk stratified for AMR and were subjected to an individualized desensitization protocols as follows: ABO incompatible and HLA incompatible candidates with positive AHG CDC CXM and positive donor specific antibody (DSA) by solid phase immunoassay (SPI) were deemed as high risk and received single dose Rituximab®, therapeutic plasma exchange (TPE) and high dose IVIG (2 gm/kg of body weight). HLA incompatible candidates with negative CDC and positive T and/or B IgG flow CXM and positive DSA by SPI were deemed as intermediate risk and received Rituximab® and high dose IVIG. HLA incompatible candidates with negative CDC and flow CXM and positive DSA by SPI were deemed as low risk and received small dose IVIG (1 gm/kg body weight). At transplant, all patients received induction with Thymoglobulin® and were maintained on Tacrolimus based immunosuppressive regimen. Results: There were 108 incompatible recipients; 33 received ABO incompatible and 75 received HLA incompatible living donor kidney transplantation after desensitization. Risk stratification for HLA incompatible transplant revealed 24 patients as high risk, 34 as intermediate risk, and 17 as low risk. 57 (53%) of the study population were females; average age was 43 (range: 15-83) years; 15 (14%) received pre-emptive kidney transplantation and 85 (79%) were primary transplants. Over a median follow up of 652 (range: 8-1444) days, patient survival was 98% and death censored graft survival was 96%. Average serum creatinine was 85 (32-160) mmol/L. Clinical and subclinical ACR was observed in 14 (13%) patients and clinical and subclinical AMR in 4 (3.7%) patients. All rejection episodes responded to treatment except one AMR in ABO incompatible transplant which led to graft failure. Conclusion: Within our inclusion criteria, risk stratification scheme and desensitization strategy, the short and intermediate outcome of HLA and ABO incompatible living donor kidney transplantation appears not to be different from those reported in HLA and ABO compatible transplantation. These excellent results are likely to positively impact the long term outcome.
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