Early Kidney Allograft Dysfunction (Threatened Allograft): Comparative Effectiveness of Continuing Versus Discontinuation of Tacrolimus and Use of Sirolimus to Prevent Graft Failure: A Retrospective Patient-Centered Outcome Study.

Background: Due to lack of treatment options for early acute allograft dysfunction in the presence of tubular-interstitial injury without histological features of rejection, kidney transplant recipients are often treated with sirolimus-based therapy to prevent cumulative calcineurin inhibitor exposure and to prevent premature graft failure.

Methods: We analyzed transplant recipients treated with sirolimus-based (n = 220) compared with continued tacrolimus-based (n = 276) immunosuppression in recipients of early-onset graft dysfunction (threatened allograft) with the use of propensity score-based inverse probability treatment weighted models to balance for potential confounding by indication between 2 nonrandomized groups.

Results: Weighted odds for death-censored graft failure (odds ratio [OR], 1.

Current State of Immunosuppression: Past, Present, and Future.

The success of solid-organ transplantation was made possible by recognizing that destruction of the graft is caused by an alloimmune-mediated process. For the past decade, immunosuppressive protocols have used a combination of drugs that significantly decreased the rate of acute organ rejection. Despite advances in surgical and medical care of recipients of solid-organ transplants, long-term graft survival and patient survival have not improved during the past 2 decades.

Efficacy and safety of carvedilol in treatment of heart failure with chronic kidney disease: a meta-analysis of randomized trials.

Background: The safety and efficacy of different types of β-blocker therapy in patients with non-dialysis-dependent chronic kidney disease (CKD) and systolic heart failure (HF) are not well described. We assessed whether treatment of systolic HF with carvedilol is efficacious and safe in adults with CKD.

Methods And Results: We performed a post hoc analysis of pooled individual patient data (n=4217) from 2 multinational, double-blinded, placebo-controlled, randomized trials, CAPRICORN (Carvedilol Postinfarct Survival Control in Left Ventricular Dysfunction Study) and COPERNICUS (Carvedilol Prospective Randomized, Cumulative Survival study).

Minimizing the risk of chronic allograft nephropathy.

Chronic allograft nephropathy, now defined as interstital fibrosis and tubular atrophy not otherwise specified, is a near universal finding in transplant kidney biopsies by the end of the first decade posttransplantation. After excluding death with functioning graft, caused by cardiovascular disease or malignancy, chronic allograft nephropathy is the leading cause of graft failure. Original assumptions were that this was not a modifiable process but inexorable, likely due to past kidney injuries.

Chronic allograft dysfunction: can we use mammalian target of rapamycin inhibitors to replace calcineurin inhibitors to preserve graft function?

Purpose Of Review: Graft loss after first year of transplantation can be due to composite of factors that may include immunological and nonimmunological factors. Among the nonimmunological factors, toxicity of immunosuppression drugs, especially calcineurin inhibitor (CNI) toxicity is perhaps the leading cause of graft dysfunction. The most common phenotype associated with progressive graft dysfunction is the development of interstitial fibrosis and tubular atrophy not otherwise specified, a hallmark finding of chronic allograft nephropathy as well as CNI toxicity.

Cholesterol embolization syndrome induced by thrombolytic therapy.

Cholesterol embolization syndrome (CES) induced by thrombolytic therapy is a rare syndrome with a high incidence of morbidity and mortality. The variability in clinical presentations may cause a delay in diagnosis of CES. This article presents a comprehensive review of the English literature from January 1980 to December 2007 identifying all published case reports of CES induced by thrombolytic therapy.

Spontaneous cutaneous ulcers in a patient with a moderate degree of chronic kidney disease: a different spectrum of calciphylaxis.

Calciphylaxis is characterized by the development of spontaneous skin ulcers that often progress to deep tissue necrosis. We present a case of calciphylaxis in a patient with chronic kidney disease (CKD) prior to the initiation of dialysis. We conclude that calciphylaxis should be considered in the differential diagnosis of skin ulcerations in patients with any degree of CKD.

Polyomavirus BK versus JC replication and nephropathy in renal transplant recipients: a prospective evaluation.

Background: JC virus (JCV) viruria is more common than BK virus (BKV) viruria in healthy individuals but in kidney transplants (KT), polyomavirus nephropathy (PVAN) is primarily caused by BKV. Few cases of PVAN have been attributed to JCV. Systematic studies on JCV replication in KT are lacking.

Acute renal failure and nephrotic range proteinuria due to amyloidosis in an HIV-infected patient.

Amyloidosis is an uncommon cause of renal disease in HIV-positive patients. Diagnosis is challenging, treatment options are limited, and prognosis remains poor. We discuss an HIV-positive patient with acute renal failure and nephrotic range proteinuria.

Chronic kidney disease: a risk factor for cardiovascular disease.

The goal of risk stratification of CVD inpatients with CKD is to lead to effective and early intervention and to prevent the adverse outcomes associated with this complex multisystem disease that is characteristic of growing number of patients with CKD in the general population and of patients receiving dialysis therapy or kidney transplantation. By 2030, there will be 2.24 million patients with ESRD in the United States, and approximately 1.

Effect of kidney transplantation on left ventricular systolic dysfunction and congestive heart failure in patients with end-stage renal disease.

Objectives: We examined the impact of kidney transplantation on left ventricular ejection fraction (LVEF) in end-stage renal disease (ESRD) patients with congestive heart failure (CHF).

Background: The ESRD patients with decreased LVEF and a poor New York Heart Association (NYHA) functional class are not usually referred for transplant evaluations, as they are considered to be at increased risk of cardiac and surgical complications.

Methods: Between June 1998 and November 2002, 103 recipients with LVEF < or =40% and CHF underwent kidney transplantation.

BK virus-associated nephropathy in renal allograft recipients: rescue therapy by sirolimus-based immunosuppression.

Background: BK virus nephritis (BKN) in recipients of renal allografts has reemerged during the past 5 years. Despite increased incidence, therapeutic options remain limited and progression of the disease often leads to allograft failure.

Methods: From May 2002 to July 2002, we performed protocol biopsies in 25 recipients of kidney allografts with progressive allograft dysfunction; three patients demonstrated unexpected histopathologic features of BKN.

Retransplantation in patients with graft loss caused by polyoma virus nephropathy.

The characteristics and outcome in 10 patients who underwent retransplantation after losing their renal grafts to BK virus-associated nephropathy (BKAN) are described. The patients underwent retransplantation at a mean of 13.3 months after failure of the first graft.

Expression of NHERF-1, NHERF-2, PDGFR-alpha, and PDGFR-beta in normal human kidneys and in renal transplant rejection.

Sodium-hydrogen exchanger regulatory factor-1 and -2 (NHERF-1 and NHERF-2) are adaptor proteins that regulate renal electrolyte transport and interact with the platelet-derived growth factor receptors (PDGFR). The distribution of the NHERF proteins and PDGFR was studied in normal human kidneys and in renal transplant rejection using immunocytochemistry. In normal kidneys, NHERF-1 was detected in proximal tubules.

Recent developments in toxic nephropathy.

Toxic nephropathy is an important cause of reversible renal injury if detected early. Renal damage can be due to several different mechanisms affecting different segments of the nephron, renal microvasculature or interstitium. Clinical signs may not be apparent in the early stages and assessment of renal function should include thorough evaluation of glomerular filtration rate, proximal and distal tubular function.