Urological malignancy in renal allograft recipients.,report of 22 clinical cases

Objective To investigate the incidence of urological malignancy in renal allograft recipients and explore the mechanism of increased incidence in China and the management. Methods A retrospective study was performed on 22 patients with urological malignancy in renal allograft recipients between 1978 and 2010.

Systematic review of ablative therapy for the treatment of renal allograft neoplasms

BACKGROUND To date,there are no guidelines on the treatment of solid neoplasms in the transplanted kidney.Historically,allograft nephrectomy has been considered the only reasonable option.More recently,nephron-sparing surgery (NSS) and ablative therapy (AT) have been proposed as alternative procedures in selected cases.AIM To review outcomes of AT for the treatment of renal allograft tumours.METHODS We conducted a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2009 Checklist.PubMed was searched in March 2019 without time restrictions for all papers reporting on radiofrequency ablation (RFA),cryoablation (CA),microwave ablation (MWA),high-intensity focused ultrasound (HIFU),and irreversible electroporation (IRE) of solid tumours of the kidney allograft.Only original manuscripts describing actual cases and edited in English were considered.All relevant articles were accessed in full text.Additional searches included all pertinent references.Selected studies were also assessed for methodological quality using a tool based on a modification of the Newcastle Ottawa scale.Data on recipient characteristics,transplant characteristics,disease characteristics,treatment protocols,and treatment outcomes were extracted and analysed.Given the nature and the quality of the studies available (mostly retrospective case reports and small retrospective uncontrolled case series),a descriptive summary was provided.RESULTS Twenty-eight relevant studies were selected describing a total of 100 AT procedures in 92 patients.Recipient age at diagnosis ranged from 21 to 71 years whereas time from transplant to diagnosis ranged from 0.1 to 312 mo.Most of the neoplasms were asymptomatic and diagnosed incidentally during imaging carried out for screening purposes or for other clinical reasons.Preferred diagnostic modality was Doppler-ultrasound scan followed by computed tomography scan,and magnetic resonance imaging.Main tumour types were: papillary renal cell carcinoma (RCC) and clear cell RCC.Maximal tumour diameter ranged from 5 to 55 mm.The vast majority of neoplasms were T1a N0 M0 with only 2 lesions staged T1b N0 M0.Neoplasms were managed by RFA (n = 78),CA (n = 15),MWA (n = 3),HIFU (n = 3),and IRE (n = 1).Overall,3 episodes of primary treatment failure were reported.A single case of recurrence was identified.Follow-up ranged from 1 to 81 mo.No cancer-related deaths were observed.Complication rate was extremely low (mostly < 10%).Graft function remained stable in the majority of recipients.Due to the limited sample size,no clear benefit of a single procedure over the other ones could be demonstrated.CONCLUSION AT for renal allograft neoplasms represents a promising alternative to radical nephrectomy and NSS in carefully selected patients.Properly designed clinical trials are needed to validate this therapeutic approach.

Tacrolimus confers lower acute rejection rates and better renal allograft survival compared to cyclosporine

AIM To compare the impact of tacrolimus(FK) and cyclosporine(CYA) on acute rejection and graft survival and to assess the predominant causes of graft loss between patients receiving these two calcineurin inhibitors(CNIs).METHODS Retrospective review of 1835 patients who received a kidney transplant(KTX) between 1999-2012. Patients were grouped based on initial CNI utilized: 1195 in FK group, 640 in CYA group. Data on baseline characteristics, clinical outcomes, and causes of graft loss in both groups were analyzed. RESULTS Cumulative acute rejection rates were 14% in the FK vs 24% in the CYA group. Despite more marginal donor characteristics in the FK group, these patients had better graft survival rates compared to the CYA group. Three and five year graft survival rates were 88% and 84% respectively in the FK group compared to 79% and 70% respectively in the CYA group(P < 0.001). After multivariate analysis, which controlled for confounders, FK use was a strong predictor for lower acute rejectionrates [odds ratio(OR) 0.60, 95%CI: 0.45-0.79] and better renal allograft survival(OR 0.740, 95%CI: 0.58-0.94). Death with a functioning graft was the most common cause of graft loss in both groups. Common causes of death included cardiovascular disease, infections, and malignancies. Chronic allograft nephropathy was also found to be an important cause of graft loss, being more prevalent in the CYA group. CONCLUSION The use of FK-based maintenance immunosuppression therapy is associated with a significantly lower rate of acute rejection and better graft survival compared to CYA-based regimen. Individualizing immunosuppression through risk-stratified CNI choice may lead to improved outcomes across all spectra of KTX patients.

Urine immune profiling by measurement of multiple cytokine/chemokine mRNA levels in renal allograft dysfunction

Background: An accurate diagnosis of cause of acute renal graft dysfunction is crucial for the optimal management of transplant recipients. Currently available tests are either insensitive or nonspecific, or are invasive, such as allograft biopsy. During last decade, attempts have been made in search of non invasive markers for the evaluation of cause of graft dysfunction. We studied a set of genes expressed on cytotoxic T Lymphocytes and those related to functioning of regulatory or helper T cells. Methods: We obtained 108 urine samples from 108 renal allograft recipients at the time of graft biopsy done for the evaluation of cause of graft dysfunction. RNA was extracted from urinary cells and messenger RNA (mRNA) encoding perforin, granzyme B (GB), FoxP3, CD3?, CXCR3, TGF-?, CTLA4, PI-9, IL-10, TNF?, T-bet and 18SrRNA measured with the use of quantitative real time polymerase chain reaction (RT-PCR). The levels of expression of genes were correlated with the biopsy findings and the results compared among different groups. Renal allograft biopsies at this institution are performed when there is unexplained rise in serum creatinine of >20% from the baseline value and reported according to Banff classification. SPSS v10.0 used for analy-sis.Results: The mRNA copy numbers of GB, Perforin, FoxP3, CD3, CXCR3, TGF-?, CTL A4, PI9, IL-10, TNF?, and T-bet were log transformed and mean (± SD) levels studied. The expression of all studied genes were compared between ‘nonspecific biopsy findings’ and other specific diagnoses. GB, Perforin, FoxP3, TGF-?, CD3?, CTLA4 CXCR3 and T-bet were higher in acute cellular rejection (ACR), whereas, TGF-? was also found higher in infection, and PI-9 in chronic allograft nephropathy (CAN) and borderline rejection group. Conclusion: Measurement of mRNA levels for genes like GB, Perforin, FoxP3, TGF-β, CD3?, CTLA4, CXCR3 and T-bet in urine samples offers a non invasive means of diag-nosing cause of graft dysfunction.

The Monitoring Interest of BK Virus Load in Renal Allograft Tunisian Recipients: Prospective Study

BK virus (BKV) may cause nephropathy in renal transplant recipients receiving immunosuppressive therapy, resulting in renal dysfunction and, possibly graft loss. However, the positive and negative predictive values of BK viral load are still controversial. In this prospective, single-center study, BKV DNA was measured 1, 3 and 6 months after transplantation. The viral load in urine and plasma was quantified with the real-time Q-PCR (Argen kit) in 73 renal allograft recipients Three of them showed acute rejection. To determine the cutoff value of viral load, 60 sera samples of healthy blood donors, matched for age and sex, were tested. The mean plasmatic viral load one month post-transplantation was statistically higher in renal transplant recipients (17.23 copies/ml) compared to that in controls (2 copies/ml) (p: 0.06). This difference of the distribution of viremia values is more evident in the third and sixth month (p: 0.002 and 0.010 respectively). Furthermore, analysis of the kinetic of viral load revealed an average rise of viremia at 3 months (1589.14 copies/ml) followed by its decrease at 6 months (249.75 copies/ml). However, the difference was not statistically significant. The same is true for the distribution of values of viruria and in all cases the average viral load was statistically higher in urine than in plasma. In addition, this study did not shown significant relationsheep between viremia/viruria and the occurrence of acute rejection, the renal function deterioration, the source of allograft or immunosuppressive therapy protocol. If the results of this study demonstrate the importance of the replication of BKV in renal transplant patients from the first month compared to that in immunocompetent subjects, the screening of the DNA of this virus does not appear to have a prognostic value in the occurrence of acute rejection. However, the plasma and urine monitoring of BKV load beyond 6 months , not appear to exclude the relationsheep between these two biomarkers and the occurrence of chronic graft dysfunction.

RANDOMIZED CASE-CONTROLLED TRIAL OF ORAL LOW-DOSE ACYCLOVIR FOR PREVENTION OF VIRUS INFECTIONS IN RECIPIENTS OF RENAL ALLOGRAFTS

A randomized case-controlled trial of oral low-dose acyclovir (600-800 mg per day) has been conducted for the prevention of virus infections in 66 recipients of renal allografts since 1990. In comparison with the untreated controls, acyclovir could prevent herpes virus simplex (HSV), reduce morbidity of pneumonia from 10 cases (30%) to 3 cases (9%) (P<0.05) and lower CMV-IgM positive rate from 30% to 12%. Serum Cr and BUN in acyclovir group were lower than those in control group. These results strongly suggested that oral administration low-dose acyclovir could prevent virus infections after renal transplantation.

Multimodality-imaging manifestations of primary renal-allograft synovial sarcoma:First case report and literature review

BACKGROUND Primary renal synovial sarcoma (PRSS) is an extremely rare tumor with a poor prognosis. Its imaging and immunohistochemical characteristics may overlap with other renal tumors, which renders its early diagnosis in a dilemma. The diagnosis of primary renal synovial sarcoma requires histopathology and the confirmation of SYT-SSX gene fusion using molecular techniques. Cases of primary renal synovial sarcoma have been previously reported in the literature. However, to our knowledge, primary renal allograft synovial sarcoma was never described. CASE SUMMARY A 43-year-old male patient who underwent kidney transplantation 9 months ago came to our hospital for regular follow-up. Traditional ultrasonography revealed multiple hypo-echo neoplasms in the renal allograft. Contrast-enhanced computed tomography (CECT) showed slightly hyper-density masses with slow homogeneous enhancement. Ultrasound-guided biopsy was conducted for accurate pathological diagnosis. The neoplasms were diagnosed as synovial sarcoma by pathological, immunohistochemical, and genetic analyses. Positron emission tomography/CT showed no evidence of metastasis. At approximately one week post biopsy, contrast-enhanced ultrasound was conducted to eliminate active hemorrhage. One month later, CECT showed that the biggest neoplasm grew from 3.3 cm to 5.7 cm in diameter. Parametric imaging was conducted with SonoLiver CAP to conduct further quantitative analysis, which showed that the enhancement pattern was heterogeneous hyper-vascular enhancement. Radical surgical resection of the whole renal allograft and ureter was conducted without additional adjuvant chemotherapy or external radiotherapy. Anlotinib was chosen for targeted therapy with a good response. CONCLUSION We propose multimodality imaging for accurate diagnosis of renal allograft synovial sarcoma especially when it is formed by spindle-shaped cells.

移植肾功能丧失受者的临床管理策略

随着肾移植手术技术的成熟和新型免疫抑制药的引入以及免疫抑制方案的改进,肾移植受者的短期生存率已显著提高,但长期生存并未得到显著改善。肾移植受者通常可能面临移植肾功能丧失。移植肾功能丧失后的医疗管理较为复杂,包括免疫抑制药的调整、移植肾的处理以及后续肾脏替代治疗方式的选择。这些医疗管理直接影响移植肾功能丧失患者的预后,但目前仍缺少相关指南或共识,往往根据临床医师的自身经验决定。本文对目前移植肾功能丧失后免疫抑制药的调整、移植肾的处理和后续肾脏替代治疗方式的选择等进行综述,旨在为延长患者的生存期和提高生活质量提供参考。

2023年国内肾移植文献盘点

肾移植手术在解决终末期肾病的问题上取得巨大成功,但在术后依然面临着一系列复杂而棘手的挑战,如感染、排斥反应、缺血-再灌注损伤和慢性移植肾失功等。随着科技发展,生物材料、基因测序等新兴技术的蓬勃发展,我国的研究者们在肾移植领域为解决这些问题展开了一系列引人瞩目的研究。2023年,我国肾移植研究不仅关注于解决上述挑战,更着眼于拓展新的技术和理念,推动肾移植事业走向更为辉煌的未来。本文将系统综述我国研究团队在2023年在肾移植领域取得的学术成果,涵盖基础与临床研究的前沿,以及新兴技术的应用,旨在以本土化视角,为肾移植领域的重大临床问题提供新的思路和策略,推动我国肾移植事业迈向更高峰。

Successful endovascular treatment of transplant intrarenal artery stenosis in renal transplant recipients: Two case reports

Transplant renal artery stenosis(TRAS) is a relatively rare complication after renal transplantation. The site of the surgical anastomosis is most commonly involved, but sites both proximal and distal to the anastomosis may occur, as well. Angioplasty is the gold standard for the treatment of the stenosis, especially for intrarenal lesions. We report two cases of intrarenal TRAS and successful management with angioplasty without stent placement. Both patients were male, 44 and 55 years old respectively, and they presented with elevated blood pressure or serum creatinine within three months after transplantation. Subsequently, they have undergone angioplasty balloon dilatation with normalization of blood pressure and serum creatinine returning to baseline level. Percutaneous transluminal balloon renal angioplasty is a safe and effective method for the treatment of the intrarenal TRAS.

The effect of prostaglandin E_1 on recovery of early renal graft functions after transplantation

Objective To investigate the effect of prostaglandin E1 (PGE1) on recovery of early renal graft functions after transplantation. Methods One hundred and seven patients after renal transplantation were allocated in the treated group, and treated by conventional treatment with injection of 10 μg prostaglandin E1 additionally twice a day for 14 days. And eighty-eight patients who received conventional treatment alone after renal transplantation at the corresponding period were allocated in the control group. Indexes of the two groups, including incidence of delayed graft function and acute rejection reaction, volume of urine, serum certaintie (SCr), endogenous certainties clearance rate (CCr), the blood flow resistance in graft as well as blood viscosity (BV), and platelet aggregation rate (PAR), were determined. Results The urinary volume and endogenous certainties clearance rate of the treated group were significantly higher, but the level of SCr, incidence of renal function recovery retardation, BV, PAR and blood flow resistance in graft were significantly lower than those of the control group (P<0.05). The difference of incidence of acute rejection reaction between the two groups was insignificant (P>0.05). Conclusion Prostaglandin E1 can improve blood microcirculation and decrease the incidence of renal function recovery retardation. These effects are helpful for recovery of renal function after renal transplantation.

Efficacy and safety of treatment of hepatitis C virus infection in renal transplant recipients

AIM: To assess the efficacy and safety of combinedpegylated interferon and ribavirin therapy in hepatitis C virus (HCV) infection in renal transplant recipients. METHODS: This is a retrospective chart review of post renal transplant patients who were positive for anti-HCV and HCV-RNA, and who have received treatment with combination of pegylated interferon and ribavirin between October 2003 and December 2008. Only patients with stable graft function and absence of evidence of cirrhosis and who received the therapy for continuous 48 wk were included. Nineteen patients (13 male and 6 female) were identified and included. The patient's complete blood count, liver and kidney prof ile, and cal- culated glomerular f iltration rate (GFR) were monitored every 6-8 wk while on treatment. HCV-RNA was tested at 12 wk for early virological response, at 48 wk for end of treatment response (ETR), and then retested at 24, and 48 wk after completion of therapy for sustained virological response (SVR). Liver biopsies were obtained before treatment from all patients and graft kidney biopsies were performed as required. RESULTS: Of the entire cohort, 9 patients (47.4%) showed an ETR and 8 had SVR (42.1%). Of the 8 patients with abnormal alanine aminotransferase (ALT) levels at baseline, 78.9% had their ALT normalized (including the virological non responders). ALT was normal in all responders at the end of therapy and at 24 wk post therapy (100%). Only one patient (5.3%) developed an increase in creatinine and decline in GFR from baseline towards the end of treatment. This patient's kidney biopsy revealed borderline rejection. There was no impact on response by HCV-genotype, initial HCV RNA load, age or sex of the patient or duration post transplant before commencement of therapy. All patients tolerated treatment in the same way as non-transplant with no unusual or increased occurrence of side effects. CONCLUSION: The combination of pegylated interferon and ribavirin is effective in suppressing HCV-RNA,with a low risk of graft rejection or failure in HCV infected renal transplant recipients.

Acute Appendicitis Confined to an Incisional Hernia Following Renal Transplantation

We present a case of a 57 years old moderately obese woman with a known 12 cmincisional hernia, who subsequently developed an incarcerated acute appendicitis. The patient underwent an uneventful orthotopic liver and renal transplant five years prior, and was compliant with ongoing immunosuppression without rejection. She presented with 8 hours of acute onset right lower quadrant pain, associated with anorexia, documented fevers, and nausea. Noncontrast CT demonstrated a blind-ending tubular structure with an enhancing and thickened wall within a hernia defect of the right lower quadrant. The patient underwent emergent laparotomy and a non-perforated appendix was completely excised at its base. Discussion: There have been documented reports of an acute appendicitis associated with inguinal hernias, given the eponym Amyand’s hernia. Appendicitis may present within hernias, and there should be a low threshold for radiologic assessment of its components when there is clinical doubt about the symptoms associated with the hernia. Our recommendation prompts early use of non-contrast CT scan in transplant patients with known hernias on examination and abdominal tenderness over the renal allograft considering the high risk of perforation of acute appendicitis and strangulation.