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Background Cardiovascular disease (CVD) is the major cause of death after renal transplantation. Not only conventional CVD risk factors, but also transplant-specific risk factors can influence the development of CVD in kidney transplant recipients. The main objective of this study will be to determine the incidence of post-transplant CVD after renal transplantation and related factors. A secondary objective will be to examine the ability of standard cardiovascular risk scores (Framingham, Regicor, SCORE, and DORICA) to predict post-transplantation cardiovascular events in renal transplant recipients, and to develop a new score for predicting the risk of CVD after kidney transplantation. Methods/Design Observational prospective cohort study of all kidney transplant recipients in the A Coruña Hospital (Spain) in the period 1981-2008 (2059 transplants corresponding to 1794 patients). The variables included will be: donor and recipient characteristics, chronic kidney disease-related risk factors, pre-transplant and post-transplant cardiovascular risk factors, routine biochemistry, and immunosuppressive, antihypertensive and lipid-lowering treatment. The events studied in the follow-up will be: patient and graft survival, acute rejection episodes and cardiovascular events (myocardial infarction, invasive coronary artery therapy, cerebral vascular events, new-onset angina, congestive heart failure, rhythm disturbances and peripheral vascular disease). Four cardiovascular risk scores were calculated at the time of transplantation: the Framingham score, the European Systematic Coronary Risk Evaluation (SCORE) equation, and the REGICOR (Registre Gironí del COR (Gerona Heart Registry)), and DORICA (Dyslipidemia, Obesity, and Cardiovascular Risk) functions. The cumulative incidence of cardiovascular events will be analyzed by competing risk survival methods. The clinical relevance of different variables will be calculated using the ARR (Absolute Risk Reduction), RRR (Relative Risk Reduction) and NNT (Number Needed to Treat). The ability of different cardiovascular risk scores to predict cardiovascular events will be analyzed by using the c index and the area under ROC curves. Based on the competing risks analysis, a nomogram to predict the probability of cardiovascular events after kidney transplantation will be developed. Discussion This study will make it possible to determine the post-transplant incidence of cardiovascular events in a large cohort of renal transplant recipients in Spain, to confirm the relationship between traditional and transplant-specific cardiovascular risk factors and CVD, and to develop a score to predict the risk of CVD in these patients.

After transplantation, the main concerns involve immunosuppression, the prevention and treatment of infections and graft rejection, and tumor prevention. Sometimes the complications that may appear in the arteriovenous fistula are neglected following kidney transplantation. This is the reason why we are presenting the case of an angiosarcoma developing in an arteriovenous fistula after kidney transplantation. It is a very rare case and our goal is to create an alarm so that after kidney transplantation clinicians do not lose sight of the patients’ previous history.

Desensitization allows the performance of human leukocyte antigen (HLA)-incompatible transplants. However, the incidence of acute rejection (AR) is high. This study aims to analyze the incidence of AR after transplantation with HLA-incompatible living donors in patients who underwent desensitization. Patients were immunosuppressed with tacrolimus, mycophenolic acid derivatives, and steroids after being desensitized with rituximab, plasma exchange, and/or immunoadsorption with specific cytomegalovirus immunoglobulins. A negative complement-dependent cytotoxicity or flow cytometry crossmatch and a donor-specific antibody titer < 1000 mean fluorescence intensity (MFI) were used to determine desensitization efficacy. A total of 36 patients underwent desensitization, and 27 (75%) were transplanted. After a follow-up of 58 ± 58 months (Min–Max: 0.13–169.5), five episodes of AR occurred: two antibody-mediated and three T-cell-mediated. No differences were found in baseline calculated panel-reactive antibodies (cPRA), class I or II MFI, number of antibodies, or Relative Intensity Scale (RIS) between AR and non-AR patients. Patients with antibody-mediated AR had higher cPRA (NS), MFI class I (p = 0.07) and class II (p = 0.006), and RIS (p = 0.01). The two patients with antibody-mediated AR and one patient with T-cell-mediated AR lost their grafts. In conclusion, the incidence of acute antibody-mediated rejection after desensitization was 7.4%, which occurred early post-transplantation in patients with high MFI and was associated with early graft loss.

Background/Objectives: Post-transplant diabetes mellitus (PTDM) and prediabetes (PreDM) are common after renal transplantation and increase the risk of cardiovascular events and mortality. Compared to immediate-release tacrolimus (IR-Tac), the LCPT formulation, with delayed absorption, offers higher bioavailability and a smoother time–concentration curve, potentially reducing beta-cell stress. Methods: This randomized pilot trial compared de novo immunosuppression with IR-Tac (twice daily) and LCPT (once daily). At-risk recipients (age ≥ 60 years or 18–59 years with metabolic syndrome) were enrolled and followed for 3 months. The primary and secondary outcomes were the incidence of PTDM and PreDM, respectively. Results: 27 patients were randomized to IR-Tac and 25 to LCPT. The incidence of PTDM was comparable between groups [IR Tac: 18.5% (95% CI: 8.2–36.7%) vs. LCPT: 24% (95% CI: 11.5–43.4%); p = 0.7]. Although not statistically significant, the LCPT group exhibited a trend toward a reduction in PreDM incidence [IR-Tac: 40.7% (95% CI: 25–59%) vs. LCPT: 20% (95% CI: 9–39%); p = 0.1]. A sensitivity analysis showed similar results, with no significant differences in cumulative corticosteroid doses or baseline body mass index (BMI) between groups. The LCPT group showed a trend toward higher tacrolimus exposure at the end of the study [trough levels: IR-Tac group 8.3 (6.9–9.2) vs. LCPT group 9.4 (7.4–11.4) ng/mL; p = 0.05)], as well as fewer acute rejection episodes (none vs. three). Delayed graft function was more common in the IR-Tac group (37% vs. 8%; p = 0.01), and the eGFR was lower. Adverse events were comparable between groups. Conclusions: The potential biological activity of LCPT in preventing glucose metabolic alterations in at-risk patients warrants further investigation.

Viral infection has been related to post-transplantation tumour development, particularly Epstein–Barr virus, human papillomavirus, hepatitis B and C viruses, and herpes virus 8. Recently, BK virus (BKV) has emerged as an important cause of tumour formation in solid organ transplant recipients. BKV oncogenic potential relates to the ability to inactivate the functions of tumour suppression proteins p53 and pRB family, and induction of chromosomal aberrations. We report a case of urinary bladder adenocarcinoma in a pancreatico-renal transplant recipient which was diagnosed 2 years after BKV infection. Immunohistochemical staining for SV-40 was positive in neoplastic cells but negative in non-neoplastic cells.

Background The cardiovascular risk in renal transplant patients is increased in patients who continue to smoke after transplantation. The aim of the study is to measure the effectiveness of exhaled carbon monoxide (CO) measurement plus brief advisory sessions, in comparison to brief advice, to reduce smoking exposure and smoking behavior in kidney transplant recipients who smoke. The effectiveness will be measured by: (1) abandonment of smoking, (2) increase in motivation to stop smoking, and (3) reduction in the number of cigarettes smoked per day. Methods/design Design: a randomized, controlled, open clinical trial with blinded evaluation. Scope: A Coruña Hospital (Spain), reference to renal transplantation in the period 2012–2015. Inclusion criteria: renal transplant patients who smoke in the precontemplation, contemplation or preparation stages according to the Prochaska and DiClemente’s Stages of Change model, and who give their consent to participate. Exclusion criteria: smokers attempting to stop smoking, patients with terminal illness or mental disability that prevents them from participating. Randomization: patients will be randomized to the control group (brief advisory session) or the intervention group (brief advisory session plus measuring exhaled CO). The sample target size is n  = 112, with 56 patients in each group. Allowing for up to 10 % loss to follow-up, this would provide 80 % power to detect a 13 % difference in attempting to give up smoking outcomes at a two-tailed significance level of 5 %. Measurements: sociodemographic characteristics, cardiovascular risk factors, treatment, rejection episodes, infections, self-reported smoking habit, drug use, level of dependence (the Fagerström test), stage of change (Prochaska and DiClemente’s Stages of Change model), and motivation to giving up smoking (the Richmond test). Response: the effectiveness will be evaluated every 3, 6, 9 and 12 months as: pattern of tobacco use (self-reported tobacco use), smoking cessation rates, carbon monoxide (CO) levels in exhaled air measured by CO-oximetry, urinary cotinine tests, nicotine dependence (Fagerström test), motivational stages of change (Prochaska and DiClemente’s stages) and motivation to stop smoking (the Richmond test). Analysis: descriptive statistics and linear/logistic multiple regression models will be performed. Clinical relevance will be measured as relative risk reduction, absolute risk reduction and the number needed to treat. Ethics: informed consent of the patients and Ethical Review Board was obtained (code 2011/061). Discussion Tobacco is a modifiable risk factor that increase the risk of morbidity and mortality in kidney transplant recipients. If effectiveness of CO-oximetry is confirmed to reduce tobacco exposure, we would have an intervention that is easy to use, low cost and with great implications about cardiovascular risk prevention in these patients. Trial registration Current Controlled Trials ISRCTN16615772 . EudraCT number: 2015-002009-12.

El sellado de catéteres en hemodiálisis suele ser motivo de controversia entre los distintos profesio-nales dedicados a la hemodiálisis.El objetivo del presente estudio es comparar dos soluciones de sellado de catéter para hemodiálisis: heparina al 5% y fi brilin (heparina 20ui/ml + metil y propilparaben).Estudiamos 8 pacientes (mujeres) de 69±12 años portadoras de catéter tunelizado de 17±7 meses de duración del catéter, estables y que habían dado su consentimiento para el estudio. Inicialmente se selló con fibrilin durante un mes (12 sesiones) y posteriormente con heparina al 5% el mismo periodo de tiempo. Se registró velocidad de bomba, flujo efectivo, presión venosa, KT, necesidad de utilizar fibrinolíticos, infecciones, nº de manipulaciones, hipotensiones, recirculación, KT/V, TP, TPTA. Se compararon los estudios mediante t student .Después de dos meses de estudio se observó mayor flujo efectivo 318±23 ml/m en catéteres sellados con heparina frente a 307±17 ml/m con fibrilin (p= 0,008), menor presión venosa 147±12 mm Hg en heparina frente a 168±17 en fibrilin (p=0,006), mayor KT en heparina 43±3 litros frente a 41±4 litros en fibrilin. A pesar de estas mejores condiciones, clínicamente no supusieron diferencias en la eficacia dialítica KT/V heparina 1,56±0,2 frente a 1,59 ±0,2 en fibrilin. Si se observó un mayor nº de manipulaciones del catéter en heparina 12±0,2 frente a 9,4±1,3 en fi brilin (p=0,001). No existieron diferencias en aparición de infecciones, recirculación, necesidad de fibrinoliticos o alteraciones de coagulación.Concluimos que el sellado de catéteres de Hemodiálisis con Fibrilin es una alternativa eficaz a la heparina al 5%. No se acompaña de un mayor grado de disfunción del catéter y si de un menor nº de manipulaciones, lo que podría condicionar un menor nº de infecciones asociado a catéteres.

Background The high prevalence of cardiovascular risk factors among the renal transplant population accounts for increased mortality. The aim of this study is to determine the incidence of cardiovascular events and factors associated with cardiovascular events in these patients. Methods An observational ambispective follow-up study of renal transplant recipients ( n  = 2029) in the health district of A Coruña (Spain) during the period 1981–2011 was completed. Competing risk survival analysis methods were applied to estimate the cumulative incidence of developing cardiovascular events over time and to identify which characteristics were associated with the risk of these events. Post-transplant cardiovascular events are defined as the presence of myocardial infarction, invasive coronary artery therapy, cerebral vascular events, new-onset angina, congestive heart failure, rhythm disturbances, peripheral vascular disease and cardiovascular disease and death. The cause of death was identified through the medical history and death certificate using ICD9 (390–459, except: 427.5, 435, 446, 459.0). Results The mean age of patients at the time of transplantation was 47.0 ± 14.2 years; 62% were male. 16.5% had suffered some cardiovascular disease prior to transplantation and 9.7% had suffered a cardiovascular event. The mean follow-up period for the patients with cardiovascular event was 3.5 ± 4.3 years. Applying competing risk methodology, it was observed that the accumulated incidence of the event was 5.0% one year after transplantation, 8.1% after five years, and 11.9% after ten years. After applying multivariate models, the variables with an independent effect for predicting cardiovascular events are: male sex, age of recipient, previous cardiovascular disorders, pre-transplant smoking and post-transplant diabetes. Conclusions This study makes it possible to determine in kidney transplant patients, taking into account competitive events, the incidence of post-transplant cardiovascular events and the risk factors of these events. Modifiable risk factors are identified, owing to which, changes in said factors would have a bearing of the incidence of events.

Introducción: El flujo de sangre es uno de los factores íntimamente relacionado con la eficacia de la diálisis. Flujos altos de sangre se asocia a mejor calidad de diálisis y para ello, se recomienda el uso de agujas de gran calibre. Objetivo: Analizar el efecto del calibre de las agujas utilizadas en la punción de las fístulas arteriovenosas, así como, examinar su impacto en la percepción del dolor y en el tiempo de coagulación tras su retirada al finalizar la sesión. Material y método: Se ha llevado a cabo un estudio transversal. Se han recogido datos utilizando para la punción de la fístula arteriovenosa agujas de calibre 15G y 16G. Las variables recogidas han sido velocidad de bomba, flujo efectivo, Kt/V, presión venosa, duración de la sesión, tensión arterial sistólica, tensión arterial diastólica, recirculación, grado de dolor y tiempo de coagulación. Además, se han recogido las variables edad, sexo y localización del acceso vascular. Resultados: En 52 fístulas analizadas se ha encontrado diferencias estadísticamente significativas en el uso de los distintos calibres de aguja en las variables flujo de sangre efectivo, presión venosa y duración de la sesión. Discusión: Los resultados de nuestro estudio nos permiten recomendar el uso de aguja 15G ya que nos permitirán utilizar altos flujos de sangre sin generar morbilidad para el paciente, permitiendo alcanzar la dosis de diálisis recomendada en menos tiempo de tratamiento.

Es indudable que el acceso vascular no sólo es uno de los elementos clave para poder llevar a cabo el tratamiento sustitutivo renal con hemodiálisis sino que representa una de las principales causas de morbilidad, hospitalización y coste en los enfermos tratados con esta técnica. La fístula arteriovenosa sigue siendo el acceso vascular de elección. El hecho de que el paciente acuda al menos tres veces por semana para el tratamiento, convierte a la técnica de punción de la fístula en uno de los factores más relevantes que influyen en su supervivencia y, por tanto, en la calidad de vida del paciente1,2. Los problemas relacionados con la técnica incluyen un gran abanico de contratiempos (canalización dificultosa, presiones venosas elevadas, elevada recirculación, bajo flujo, presencia y aspiración de coágulos, hemostasia prolongada, etc.) siendo el dolor un evento muy prevalente3. A pesar de que son muchos los estudios de calidad de vida relacionada con la salud que analizan el dolor del paciente en hemodiálisis, en pocas ocasiones se hace referencia al acceso vascular como variable independiente y, los que lo hacen, únicamente hacen referencia al dolor crónico o al momento de la punción4. Sin embargo, uno de los eventos que mayor ansiedad y disconfort genera al paciente es el dolor producido durante la sesión relacionado con la posición de las agujas de punción. Por tanto, el objetivo de este estudio es presentar un caso donde se describe el uso de los ultrasonidos para el manejo del dolor de la fistula arteriovenosa