Morphological characteristics of spermatozoa before and after renal transplantation

Aim: To investigate the changes of the spermatozoa ultrastructures before and after renal transplantation in uremic patients. Methods: The sperm of five uremic patients before and after transplantation and four healthy volunteers were collected and examined by scanning electron microscopy. Results: Abnormal spermatozoa were found in patients pre-transplantation; abnormalities included deletion of the acrosome, absence of the postacrosomal and postnuclear ring, dumbbell-like changes of the head, tail curling, and absence of the mitochondrial sheath in the mid-segment. After renal transplantation, most of the spermatozoa became normal. Conclusion: There are many abnormalities with regard to the appearance and structure of the head, acrosome, mitochondria and tail of the spermatozoa in uremic patients. The majority of the spermatozoa returned to normal after renal transplantation, but a few still presented some abnormalities possibly relating to the administration of immunosuppressants.

Hepatitis B virus infection and renal transplantation

Although the prevalence of chronic hepatitis B virus (HBV) infection has declined in renal transplant recipients (RTRs), it remains a relevant clinical problem with high morbidity and mortality in long-term follow up. A thorough evaluation, including liver biopsy as well as assessment of HBV replication in serum (i.e. hepatitis B e antigen and/or HBV DNA) is required before transplantation. Interferon should not be used in this setting because of low efficacy and precipitation on acute allograft rejection. The advent of effective antiviral therapies offers the opportunity to prevent the progression of liver disease after renal transplantation. However, as far as we are aware, no studies have compared prophylactic and preemptive strategies. To date, the majority of RTRs with HBV-related liver disease have had a high virological and biochemical response to lamivudine use. However, lamivudine resistance is frequent with a prolonged course of therapy. Considering long-term treatment, antiviral agents with a high genetic barrier to resistance and lack of nephrotoxicity are suggested. The optimal strategy in RTRs with HBV infection remains to be established in the near future.

The clinical value of enzyme-multiplied immunoassay technique monitoring the plasma concentrations of cyclosporine A after renal transplantation

The feasibility and the clinical value of the enzyme-multiplied immunoassay technique （EMIT） monitoring of blood concentrations of cyclosporine A （CsA） in patients treated with CsA were investigated after kidney transplantation. The validation method was performed to the EMIT determination of CsA blood concentration, the CsA whole blood trough concentrations （Co） of patients in different time periods after renal transplantation were monitored, and combined with the clinical complications, the statistical results were analyzed and compared. EMIT was precise, accurate and stable, also with a high quality control. The mean postoperative blood concentration of CsA was as follows： 〈1 month, （281.4± 57.9）ng/mL; 2 - 3 months, （264.5 ± 41.2） ng/mL; 4 - 5 months, （236.4 ± 38.9） ng/mL; 6 - 12 months, （206.5± 32.6）ng/mL; 〉12 months, （185.6± 28.1）ng/mL. The toxic reaction rate of CsA blood concentration within the recommended therapeutic concentration was 14.1%, significantly lower than that of the none-recommended dose group （37.2%） （P〈0.05）; the transplantation rejection rate was 4.4%, significantly lower than that of the none- recommended dose group （22.5%） （P〈0.05）. Using EMIT to monitor the blood concentration of CsA as the routine laboratory method is feasible, and is able to reduce the CsA toxicity and rejection significantly, leading to achieving the desired therapeutic effect.

Ultrasound Assessraent of Intima-media Thickness and Diameter of Carotid Arteries in Patients Undergoing Hemodialysis or Renal Transplantation

Renal transplant （RT） recipients have a high risk of developing cardiovascular diseases. However, the effects of renal transplantation on the development of arteriosclerosis have been controversial. The carotid intima-media thickness （CIMT） and diameter （CD） are important indicators of vascular remodeling and arteriosclerosis. In this study, 31 patients with hemodialysis （HD）, 31 RT recipients and 84 age- and gender-matched control subjects were enrolled. Their CIMT and CD were measured by ultrasonic radiofrequency tracking, and the linear regression models and Z test were used to identify the progression of arteriosclerosis and the risk factors. Compared with HD group, RT group had significantly lower CIMT and CD. CIMT was found to be associated with age, body weight, resistance index and diastolic velocity, while CD was associated significantly with age, body weight, pulsatility index, end diastolic velocity and diastolic blood pressure （DBP）, respectively. The correlation curves between CIMT and age showed the slopes of curves were decreased successively in control, RT and HD groups, and the curves between CD and age showed the slopes were decreased in order of RT 〉 control 〉 HD groups. It was concluded that CIMT and CD were significantly correlated with age in RT and moderately with age in HD patients. RT could reduce the progress of arteriosclerosis in patients with end-stage renal disease.

Diagnosis and management of ureteral complications following renal transplantation

When compared with maintenance dialysis,renal transplantation affords patients with end-stage renal disease better long-term survival and a better quality of life.Approximately 9% of patients will develop a major urologic complication following kidney transplantation.Ureteral complications are most common and include obstruction(intrinsic and extrinsic),urine leak and vesicoureteral reflux.Ureterovesical anastomotic strictures result from technical error or ureteral ischemia.Balloon dilation or endoureterotomy may be considered for short,low-grade strictures,but open reconstruction is associated with higher success rates.Urine leak usually occurs in the early postoperative period.Nearly 60% of patients can be successfully managed with a pelvic drain and urinary decompression(nephrostomy tube,ureteral stent,and indwelling bladder catheter).Proximal,large-volume,or leaks that persist despite urinary diversion,require open repair.Vesicoureteral reflux is common following transplantation.Patients with recurrent pyelonephritis despite antimicrobial prophylaxis require surgical treatment.Deflux injection may be considered in recipients with low-grade disease.Grade IV and V reflux are best managed with open reconstruction.

ABO incompatibility in renal transplantation

ABO blood group incompatibility(ABO-I)was historically considered an absolute contraindication to kidney transplantation due to the significant risk of acute antibody-mediated rejection and early graft loss.Nevertheless,the urge to minimize the gap between the candidates’number on the waitlist for kidney transplants and the available kidney donors encourage investigation into finding ways to use organs from ABO-I kidney donors,especially in the era of using more potent immunosuppression therapies.This review aims to discuss a general overview of ABO-I kidney transplantation and the different protocols adopted by some transplant centers to meaningfully overcome this barrier.

Treatment of Donor-derived Carbapenem-resistant Klebsiella pneumoniae Infection after Renal Transplantation with Tigecycline and Extended-infusion Meropenem

Objective Donor-derived carbapenem-resistant Klebsiella pneumoniae(CRKP)infection has recently emerged as a critical early complication after renal transplantation.Although CRKP is usually sensitive to tigecycline,monotherapy with this drug is often less than effective.We investigated the efficacy of a combined regimen of tigecycline with high-dose,extended-infusion meropenem in the treatment of donor-derived CRKP infection after kidney transplantation.Methods From Jan.2016 to Dec.2017,a total of 12 CRKP isolates were detected from cultures of the organ preservation solution used for soaking the donor kidneys at our institute.Probable or possible donor-derived infection(DDI)was identified in 8 transplant recipients.Clinical data were retrospectively analyzed.Results Klebsiella pneumoniae carbapenemase-2(KPC-2)-producing CRKP was reported to be positive in organ preservation solution cultures at 3.5±0.9 days after transplantation,leading to surgical site(n=3),urinary tract(n=4),and/or bloodstream(n=2)infections in 8 recipients.The drug susceptibility tests showed that CRKP was sensitive to tigecycline,but resistant to meropenem.In 7 patients who received tigecycline combined with high-dose extended-infusion meropenem,DDIs were successfully cured.The length of hospital stay was 31(18–129)days,and the serum creatinine at discharge was 105.8±16.7µmol/L.The one remaining patient who received tigecycline combined with intravenous-drip meropenem died of septic shock.A median follow-up of 43 months(33–55)showed no recurrence of new CRKP infection in the 7 surviving recipients.Conclusion It was suggested that a prompt and appropriate combination therapy using tigecycline with high-dose extended-infusion meropenem is effective in treating donor-derived KPC-2-producing CRKP infection after renal transplantation.

Results of cataract surgery in renal transplantation and hemodialysis patients

AIMTo compare the effect of cataract surgery in renal transplantation and hemodialysis patients.METHODSWe evaluated 51 eyes of 31 renal transplantation patients, 41 eyes of 29 hemodialysis patients and 45 eyes of 32 normal control patients who received phacoemulsification and intraocular lens (IOL) implantation from January, 2000 to August, 2014 in the Beijing Friendship Hospital. Each individual underwent a blood routine and a kidney function examination. Routine ophthalmologic examination included best-corrected visual acuity (BCVA), a slit-lamp examination to detect cataract type, determination of intraocular pressure, a corneal endothelial count, and fundus examination. All patients received phacoemulsification and an IOL implantation.RESULTSFor the types of cataract in the three groups, transplantation group was significantly different from normal control group (P=0.04), the most kind is posterior subcapsular cataract (PSC) in transplantation group 33 (64.7%), hemodialysis group had no significantly difference from normal control group (P=0.43), and the difference between transplantation group and hemodialysis group also had significantly difference (P=0.02). For postoperative BCVA in the three groups, transplantation group had significantly difference from normal control group (P=0.03), hemodialysis group was significantly different from normal control group (P=0.00), and the difference between transplantation group and hemodialysis group also had significantly difference (P=0.00). The multiple linear regression equation is Y=0.007 hemoglobin (Hb)-0.000233 serum creatinine (Cr), R2=0.898. Postoperative fundus examination showed that hemorrhage, exudation, and macular degeneration were greater in the hemodialysis group.CONCLUSIONThis study showed that the PSC was more in the renal transplantation patients. BCVA was better and fundus lesions were less frequent in the renal transplantation group than in the hemodialysis group after cataract surgery. The multiple linear regression was showed that the Hb was positively correlated with postoperative BCVA, while Cr was negatively correlated with postoperative BCVA. These results may act as indicators in predicting visual acuity for the renal transplantation and hemodialysis patients.

Dynamic regulation of anti-oxidation following donation repairing after circulatory determined death renal transplantation with prolonged non-heart-beating time

Donation after circulatory-determined death(DCD)is an important part of renal transplantation.Therefore,DCD renal transplantation animal model should be established to study the mechanism of organ injury.Here,we established a stable DCD rat renal transplantation model and investigated the dynamic regulation of graft self-repairing and antioxidant capacities with different non-heart-beating times(NHBTs).Male Sprague-Dawley rats were randomly divided into four groups with the NHBT of the donors from 0 to 15,30,and 45 minutes.Recipients in long NHBT groups had a significantly lower survival rate and poorer graft function than those in short NHBT groups.Grafts from the 15-minute and 30-minute NHBT groups showed light and severe injury respectively at an early stage after transplantation and recovered within 7 days after transplantation,whereas the self-repairing of the grafts in the 45-minute NHBT group was delayed.The expressions of proliferating cell nuclear antigen(PCNA)and von Willebrand factor(vWF)were dependent on NHBT.The expression of antioxidant proteins paralleled graft recovery.In conclusion,the recipients can up-regulate antioxidant capacity to enhance graft self-repairing in DCD renal transplantation.Prolonged NHBT can delay the self-repairing and antioxidation of grafts.

Idiopathic acute superior mesenteric venous thrombosis after renal transplantation: A case report

BACKGROUND Acute superior mesenteric venous thrombosis(MVT)is a rare condition associated with a high mortality rate.The treatment strategy for MVT is clinically challenging due to its insidious onset and rapid development,especially when accompanied by kidney transplantation.CASE SUMMARY Here we present a rare case of acute MVT developed 3 years after renal transplantation.A 49-year-old patient was admitted with acute abdominal pain and diagnosed as MVT with intestinal necrosis.An emergency exploratory laparotomy was performed to remove the infarcted segment of the bowel.Immediate systemic anticoagulation was also initiated.During the treatment,the patient experienced bleeding,anastomotic leakage,and sepsis.However,after aggressive treatment was administered,all thrombi were completely resolved,and the patient recovered with his renal graft function unimpaired.CONCLUSION The present case suggests that accurate diagnosis and timely surgical treatment are important to improve the survival rate of MVT patients.Bleeding with anastomotic fistula needs to be treated with caution because of grafts.Also,previously published cases of mesenteric thrombosis after renal transplantation were reviewed.

Coronavirus disease 2019 and renal transplantation

Ever since the severe acute respiratory syndrome virus causing coronavirus disease 2019(COVID-19)struck the world,global health strategies have changed significantly.According to the Centers for Disease Control and Prevention,kidney transplant recipients are stratified as being high risk of developing fatal illness from COVID-19 infection.Kidney transplant is the gold-standard treatment for end-stage kidney disease subjects.During the pandemic,significant concerns have emerged regarding continuation of kidney transplant surgeries and management of kidney transplant recipients post-transplant.The added risk of immunosuppression in this cohort was and remains a theoretical concern,posing a potential risk of transplantation rather than benefit.This comprehensive review aims to cover most of the faced challenges in kidney transplantation in different stages of the pandemic.In addition,it will elucidate the epidemiology,nature,course of the disease,surgical consideration in donors and recipients as well as role of immunosuppression and management of COVID-19 infected kidney transplant recipients during these extraordinary circumstances.

Microbiota,renal disease and renal transplantation

Aim of this frontier review has been to highlight the role of microbiota in healthy subjects and in patients affected by renal diseases with particular reference to renal transplantation.The microbiota has a relevant role in conditioning the healthy status and the diseases.In particular gut microbiota is essential in the metabolism of food and has a relevant role for its relationship with the immune system.The indigenous microbiota in patients with chronic renal failure is completely different than that of the healthy subjects and pathobionts appear.This abnormality in microbiota composition is called dysbiosis and may cause a rapid deterioration of the renal function both for activating the immune system and producing large quantity of uremic toxins.Similarly,after renal transplantation the microbiota changes with the appearance of pathobionts,principally in the first period because of the assumption of immunosuppressive drugs and antibiotics.These changes may deeply interfere with the graft outcome causing acute rejection,renal infections,diarrhea,and renal interstitial fibrosis.In addition,change in the microbiota may modify the metabolism of immunosuppressive drugs causing in some patients the need of modifying the immunosuppressant dosing.The restoration of the indigenous microbiota after transplantation is important,either to avoiding the complications that impair the normal renal graft,and because recent studies have documented the role of an indigenous microbiota in inducing tolerance towards the graft.The use of prebiotics,probiotics,smart bacteria and diet modification may restore the indigenous microbiota,but these studies are just at their beginning and more data are needed to draw definitive conclusions.

Medical nutritional therapy for renal transplantation in the COVID-19 pandemic

Nutritional therapy is very important at renal transplantation.Nutrition has become more vital for transplantation patients owing to the coronavirus disease 2019(COVID-19)pandemic.Inadequate nutrition can negatively affect the immune system.For this reason,adequate protein and energy intake should be provided to the patients.Also,overconsumption of saturated fat,sugar,and refined carbohydrates can both negatively affect the immune system and trigger chronic diseases in transplantation patients.In addition,vitamins and minerals should be monitored and inadequacy should be prevented due to immunomodulatory effects.Applying nutritional therapy suitable for the symptoms of renal transplantation patients and preventing comorbidities may reduce the risk and severity of COVID-19 infection.

Renal transplantation in gigantism: A case report

BACKGROUND Gigantism,characterized by excessive growth and height is due to increased secretion of growth hormone,most commonly from a pituitary adenoma.In addition to the surgical and anesthetic complexity,the extreme stature of these patients presents a unique challenge for kidney transplantation in deciding whether to proceed with a single or dual kidney transplantation.The lack of relevant literature further adds to the dilemma.CASE SUMMARY A 45-year-old patient with untreated gigantism and end stage renal failure on renal replacement therapy was waitlisted for a deceased donor dual kidney transplantation due to the extreme physical stature(Height-247 cm and weight-200 kg).He was offered 2 kidneys from a 1-0-1 HLA mismatched 24-year-old DCD donor(Height-179 cm and weight-75 kg),and was planned for a bilateral retroperitoneal implantation into the recipient external iliac vessels.The immunosuppression consisted of alemtuzumab induction(50 mg)and steroidfree maintenance with tacrolimus.The donor’s right kidney was uneventfully implanted extra-peritoneally into the right external iliac vessels.On contralateral exposure,the left common and external iliac arteries were ectatic and frail.A complex vascular reconstruction was not preferred in order to preserve the arterial supply to the left lower limb,to minimise the cold ischemia time and prevent additional warm ischemic insult to the second kidney.Hence,it was decided not to proceed with dual transplantation.Amidst concerns of nephron mass insufficiency,the graft function was remarkable with a serum creatinine of 120μmol/L within a month from transplantation and 94μmol/L at 1-year post transplantation,and without proteinuria.CONCLUSION To our knowledge,this is the first case report on kidney transplantation in gigantism.Although it is believed that dual kidney transplantation is ideal,a single kidney transplantation from an appropriately selected donor can provide sufficient functioning nephron mass in patients with gigantism.

Tacrolimus once daily (Advagraf) vs twice daily (Prograf) in De Novo renal transplantation:a multicentre,randomized,open label,parallel control phase Ⅲ study

Objective To compare the efficacy and safety of twice - daily tacrolimus ( Tacrolimus BID; Prograf) vs once - daily prolonged release tacrolimus ( Tacrolimus QD; Advagraf) ,combined with steroids and mycophe-nolate mofetil in preventing acute rejection in De

Comparison of clinical value of dynamic contrast-enhanced MRI and SPECT renal dynamic imaging of GFR measurement in the evaluation of renal function in renal transplantation

Objective:To compare the clinical value of dynamic contrast-enhanced MRI(DCE-MRI)and single-photon emission computed tomography(SPECT)renal dynamic imaging in the measurement of glomerular filtration rate(GFR)in the evaluation of renal function in renal transplantation.Methods:A total of 70 recipients who underwent renal transplantation in Baogang Hospital of Inner Mongolia from April of 2015 to April of 2018 were selected as research objects.GFR was measured in renal transplant recipients by use of DCE-MRI and SPECT(GFR-MRI and GFR-SPECT respectively),and was compared with creatinine clearance rate(Ccr).The safety of contrast media was evaluated in DCE-MRI detection.Results:The bias of GFR-MRI against Ccr value was higher than that of GFR-SPECT against Ccr value,with 30%and 50%accuracy of GFR-MRI higher than that of GFR-SPECT,and the difference was statistically significant(p<.05).Pearson correlation analysis showed that GFR-MRI and GFR-SPECT values were positively correlated to Ccr(p<.05),and the correlation coefficient of GFR-MRI and Ccr was higher than that of GFR-SPECT and Ccr,with the difference statistically significant(p<.05).By Bland-Altman analysis,95%confidence interval of GFR-SPECT was 95.49 ml/(min·1.73 m^(2)),and 95%confidence interval of GFR-MRI was 62.35 ml/(min·1.73m^(2)),which was much narrower.Only 2 cases of patients developed mild rash among 70 cases of patients,and recovered spontaneously without any treatment.Conclusions:Compared with SPECT,the bias of GFR measured by DCE-MRI against Ccr is much greater.However,DCE-MRI has a higher accuracy,correlation and consistency in comparison with Ccr,and it has a narrower confidence interval.DCE-MRI can more accurately evaluate renal function in renal transplantation by measuring GFR,and it has a high safety.

Pathologic analysis of donor grafts in 482 cases of renal transplantation recipients

Objective To evaluate the correlation between the pathologic findings of donor renal grafts and the post-transplantative diseases throuth the biopsies of donor grafts in 482 cases. Methods The renal structures of biopsies of the donor grafts in 482 cases were observed under microscope, and the pathologic findings combined with the post-transplantative conditions were analysed. Results After transplantation, acute rejection occurred in 71 cases,of when 16(22.5%) had adverse changes in donor grafts; chronic allograft nephropahty developed in 17 cases, of whom 7 (41.2% ) had adverse changes in donor grafts; elevated sera creatinine levels with unknown causes occurred in 39 cases, of whon 7(18.0% ) had adverse changes in donor grafts. The lesion of donor renal grafts had nothing to do with the acute rejection or other abnormalities after operation ( r≤ 0.3) but some kind of lesion had certain correlation with chronic allograft nephropathy(CAN, r 】0.3). Conclusion Routine biopsy of donor renal graft is

The Effect of Non-Invasive Goal Directed Fluid Administration on Graft Function in Deceased Donor Renal Transplantation: A Pilot Study

Background: Non-invasive goal directed fluid therapy during deceased donor renal transplant (CRT) may reduce the incidence of delayed graft function. Plethysmograph Variability Index (PVI) has been shown to predict fluid responsiveness during surgery. This pilot study evaluated the feasibility of goal directed fluid administration protocol based upon PVI studying the incidence of delayed graft function (DGF) in renal transplant recipients. Methods: Twenty patients underwent primary CRT. The Control group received intravenous fluid (IVF) at a calculated constant rate. The Treatment group received a baseline IVF infusion throughout the surgery. PVI values greater than 13% were treated with 250 ml boluses of IVF. Primary end point was DGF;total IVF administration and urinary biomarker NGAL levels were secondary endpoints. Results: Treatment group at every time point received significantly less IVF. There was no significant difference in incidence of DGF between the groups. 2 patients in the Control group and 6 in the Treatment group developed DGF. NGAL was not associated with the group assignment or total IVF given (p < 0.2). Conclusions: The effectiveness of goal directed fluid therapy with non-invasive dynamic parameters has not been validated in renal transplant surgery and larger prospective studies are needed to determine its utility in renal transplantation.

Management strategies for common viral infections in pediatric renal transplant recipients

Viral infections have been considered as a major cause of morbidity and mortality after kidney transplantation in pediatric cohort.Children are at high risk of acquiring virus-related complications due to immunological immaturity and the enhanced alloreactivity risk that led to maintenance of high immunosuppressive regimes.Hence,prevention,early detection,and prompt treatment of such infections are of paramount importance.Among all viral infections,herpes viruses(herpes simplex virus,varicella zoster virus,Epstein-Barr virus,cytomegalovirus),hepatitis B and C viruses,BK polyomavirus,and respiratory viruses(respiratory syncytial virus,parainfluenza virus,influenza virus and adenovirus)are common in kidney transplant recipients.These viruses can cause systemic disease or allograft dysfunction affecting the clinical outcome.Recent advances in technology and antiviral therapy have improved management strategies in screening,monitoring,adoption of prophylactic or preemptive therapy and precise treatment in the immunocompromised host,with significant impact on the outcome.This review discusses the etiology,screening and monitoring,diagnosis,prevention,and treatment of common viral infections in pediatric renal transplant recipients.