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Introduction: A significant number of patients with chronic kidney disease (CKD) have cardiac abnormalities, and left ventricular systolic dysfunction (LVSD) is a common manifestation. Our hypothesis is that a decrease in the left ventricular ejection fraction (LVEF) at the time of kidney transplantation is a factor of poor prognosis associated with poor graft evolution., Methods and Results: A total of 954 kidney transplantations were performed in our center between 2005 and 2012. Nineteen (2%) of these patients had been diagnosed with left ventricular dysfunction that was defined by the presence of LVEF <50% on echocardiography. This group of patients was compared with a control group of recipients without LVSD who had received the contralateral kidney from the same donor. During a mean follow-up of 52 ± 14 months, it was observed that the patients with LVSD had a higher incidence of delayed graft function (DGF) as well as a significantly longer renal function recovery period than in the control group until they became dialysis free (19.8 [range, 0-90] vs 12 [range, 0-36] days; P = .01). Furthermore, graft function achieved by the LVSD group was worse during the evolution (serum creatinine 2.3 ± 1.9 vs 1.4 ± 0.5 mg/dL; P = .01). Patients with LVSD showed worse kidney graft survival at the end of the follow-up when compared with the control group (79% vs 100%; P = .03)., Conclusions: Systolic dysfunction of the renal transplant recipient is associated with greater delay in graft function and worse graft survival with poorer renal function., (Copyright © 2015. Published by Elsevier Inc.)

Background: Mammalian target of rapamycin inhibitors (mTOR-i) have been proposed as possible immunosuppressants of choice in BK virus nephropathy (BKN) because of their antiviral capacity. On this basis, in 2007, our Service proposed a conversion to everolimus (EVE)-based therapy from calcineurin inhibitors with an anti-calcineurin-free therapy protocol in those patients diagnosed of BKN., Methods: A prospective, single-center case series study was performed. Fifteen cases of BKN were diagnosed from 2007 to the end of 2010. According to our protocol, immunosuppressant treatment was modified in 9 of these patients with suspension of mycophenolate and conversion from tacrolimus to EVE., Results: The renal function achieved by our patients after the transplantation was excellent. Mean serum creatinine (sCr) achieved was 1.16 ± 0.2 mg/dL. Evolution of the renal function after BKN diagnosis and conversion to mTOR-i was positive in all the patients. sCr on diagnosis was 1.85 ± 0.22 mg/dL, sCr at the point in time of conversion to EVE was 2 ± 0.21 mg/dL, and final sCr of the follow-up was 1.6 ± 0.39 mg/dL (P = .05). BK viremia became negative in 5 of our patients and decreased more than 95% in the remaining 4. None of the patients had an acute rejection episode after the change of immunosuppressant., Conclusions: Conversion to mTOR-i-based therapy could provide an added benefit in BKN and could be an effective strategy for the decrease of the viremia and increase of graft survival in selected patients., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Different strategies have been initiated to shorten the waiting list time to receive a kidney transplant. Donors with acute kidney injury (AKI) may be a new option., Methods: Fifty-nine patients received a kidney transplant from an AKI donor defined as having serum creatinine >2 mg/dL at the time of organ procurement. They were compared with a transplant group with normal kidney function defined as creatinine <1.5 mg/dL organ procurement in the same time period, paired by donor and recipient age (control group). Initial evolution, at 1 year, and at the end of the follow-up were evaluated., Results: The AKI donor group had greater delayed graft function (68% versus 36%, P < .01). Graft and recipient survival were similar in both groups at 1 year (92% versus 88%, P = NS; 97% versus 98%, P = NS) and at the end of follow-up (66% versus 66%, P = NS; 90% versus 88%, P = NS). Serum creatinine at 1 year and at the end of the follow-up did not show any differences (1.4 ± 0.5 versus 1.4 ± 0.7 mg/dL, P = NS; 1.4 ± 0.5 versus 1.6 ± 0.9 mg/dL, P = NS)., Conclusions: The transplants from donors with AKI showed greater incidence of delayed graft function, but this did not affect the short- or long-term prognosis of the graft or recipient. This type of donor may be a source of acceptable kidneys., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Experimental and clinical data strongly suggest that aldosterone may contribute to proteinuria and progressive renal disease. In fact, an aldosterone antagonist seems to be effective for controlling proteinuria in native kidneys. However, there is little information about this approach in renal transplant patients, a population in whom the presence and amount of proteinuria represent risk factors for graft loss, cardiovascular disease, and death. The aim of our study was to evaluate whether addition of an aldosterone antagonist, spironolactone, provided an additional antiproteinuric effect to the angiotensin-converting enzyme inhibitor (ACEI) and angiotensin type I receptor antagonists (ARB). We evaluated the effects on severe proteinuria (4.4±1.4 g/d) at 6 months after prescription of spironolactone (25 mg/d) among 11 renal transplant patients with serum creatinine values less than 3 mg/dL who were under treatment with an ACEI plus an ARB. Patients were examined in the renal transplant outpatient clinic every week for the first month and twice a month thereafter. Nine patients showed a more than 50% (mean=81.5%) reduction in proteinuria not only early, but also sustained at 6 months (4.4±1.4 to 2.3±1.1 g/d) with a mild, nonsignificant deterioration in renal function (serum creatinine 1.6±0.32 to 1.7±0.54 mg/dL). This study showed that spironolactone decreased severe proteinuria among patients treated with an ACEI plus an ARB. This therapy is not recommended for patients with glomerular filtration rates below 40 mL/min. Therefore, it is suggested that using triple blockade of RAS is feasible in selected renal transplant patients to reduce proteinuria, although caution is required to avoid severe hyperkalemia., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Background: Living kidney donor transplantation, a treatment option for end-stage kidney failure, may achieve better results than cadaveric donor transplantation. Although its significant use in some countries is due to the scarcity of cadaveric donors, it is also useful because it reduces waiting time for young recipients and avoids dialysis when performed before starting renal replacement therapy. Due to the high rate of cadaveric donation in Spain, there has only been a limited increase in the number of living donor kidney transplantations., Methods: In February 2004, we initiated a program to promote living kidney donation (LKD) through an information plan that was transmitted to the patients by dialysis nephrologists and chronic kidney failure outpatient clinics., Results: From February 2004 to March 2010, we evaluated 109 donor and recipient pairs: parent to child (n=48 cases; 44%), spouses (n=32 cases; 29.3%), siblings (n=27; 24.7%), and uncle and nephew (n=2; 1.8%). The mean donor age (49±9 years) was significantly higher than the 39±13 years of the recipients (P<.01). In 45 cases (41.3%), the procedure led to of living kidney donor transplantation but in 58 (53.2%), a transplantation was not performed due to recipient problems (n=53) or donor problems (n=5). In 6 cases (5.5%), the evaluation is still pending. With the initiation of this project, it has been possible to significantly increase the rate of living kidney donor transplantation in our hospital from 0.8% (March to January 2004: 16/1964) to 4.2% (February 2004 to March 2010: 43/1022 transplants; P<.01)., Conclusion: A policy of active information together with adequate studies of the potential donor and recipient significantly increased the number of living kidney donor transplantations. The profitability of the study procedure was 50%. The most frequent cause of noncompletion of the procedure was recipient-related problems., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Background: Available data for extended-release tacrolimus (Tac) except in clinical trials are limited., Objective: To describe our initial experience with once-daily Tac in combination with corticosteroids and mycophenolate mofetil therapy in patients undergoing de novo renal transplantation., Patients and Methods: In this retrospective, observational, single-center study, data were obtained for 49 adult recipients treated with extended-release Tac and 30 patients treated with standard-release Tac (control group). Mean (SD) follow-up in the 2 groups was 3.5 (2.5) months and 4.0 (2.6) months, respectively. The primary characteristics were comparable between the groups., Results: The acute rejection rate in the extended-release group was 10%, and 13% in the standard-release group. Patient and graft survival rates were 98% and 96% vs 100% and 90%, respectively. Renal function in the 2 groups was comparable: serum creatinine concentration 1.3 (0.2) mg/dL vs 1.45 (0.4) mg/dL. At day 14 posttransplantation, Tac doses were 0.17 mg/kg/d vs 0.14 mg/kg/d, and blood concentrations were 9.0 ng/mL vs 14.0 ng/mL. In recipients older than 60 years, lower dosages of Tac resulted in blood concentrations similar to those in younger patients, with less variation in dosage., Conclusions: Short-term experience with extended-release Tac therapy in de novo renal recipients confirms its efficacy and safety. Adjusting blood concentrations in the immediate posttransplantation period is less difficult with extended-release Tac compared with the twice-daily formulation., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Renal transplantation provides the best quality of life for the patients with chronic end-stage renal failure. However, the immunosuppression necessary for graft survival may give rise to infectious complications, an increased risk of cardiovascular and neoplastic diseases, all of which can shorten the patient's survival. The objective of this study was to evaluate the efficacy and safety of the proliferation signal inhibitor immunosuppressant drugs everolimus among patients who develop neoplasms after renal transplantation. This retrospective study included 25 patients (mean age -56.5 +/- 14.1 years) who were diagnosed with posttransplant neoplastic disease and immunosuppressed with calcineurin inhibitors (CNIs). Treatment was initiated with everolimus with or without CNIs. During the follow-up, the renal function (initial serum creatinine 1.4 mg/dL vs final serum creatinine 1.3 mg/dL) and proteinuria levels (initial 0.3 g/d vs final 0.4 g/d) remained stable. There was a low percentage of patients with relapse of their tumor. One patient had a relapse of bladder cancer with tumor progression at 3 years; another patient with melanoma developed lymph node invasion. There were neither acute rejection episodes nor cardiovascular complications. The results suggested that tumor relapse was low. The results suggested that immunosuppression with everolimus combined with low doses of CNIs or in single-drug therapy is safe immunosuppression for patients who develop posttransplant malignant diseases.

Although deceased donors older than 60 years of age (D > 60) are increasing in number, little information exists on the rate of discarded kidneys from these aged individuals. This study sought to analyze causes of discard of kidneys from D > 60. Since 1997, we have transplanted kidneys from D > 60 into elderly recipients after assessing their functional and anatomical viability. Among 3444 renal offers for transplantation between 1997 and 2005, 1967 (57%) came from D > 60. Of these, 1145 offers were discarded, because the kidney donor was not adequate (n = 470) or because there was no elderly recipient on our waiting list (n = 675). We also examined 1745 kidneys, 822 (47%) of which came from D > 60. The percentage of discarded kidneys due to macroscopic or microscopic alterations was 46% in the D > 60 group compared with 14.7% in the donor group younger than 60 years of age (D < 60; P < .01). We transplanted 443 kidneys from D > 60 (85 dual, 273 single) to 358 recipients of matching age and 900 kidneys from D < 60. Three-year death-censored actuarial graft survival rate was 83% for D > 60 compared with 89% for D < 60 transplant (P = not significant). In conclusion, kidneys from D > 60 were discarded for transplantation mainly because there was no elderly recipient on the waiting list and due to macroscopic or microscopic alterations. Given the increasing offer of kidneys from D > 60 and the good results of transplantation with these aged kidneys in elderly recipients, the indications for kidney transplantation should be expanded to include more of the elderly population on dialysis to the waiting list.

Introduction: Family refusal is an important factor that limits the number of organ donors. Cultural and religious factors as well as perception of brain death are the principal reasons for these refusals. We examined whether the type of potential donor, that is brain-dead or non-heart-beating, had an influence on family refusal. In July 2005, we initiated a program of non-heart-beating donors who had died in the street or at home., Materials and Methods: We compared family refusals among these potential donors with those among potential brain-dead donors from July 2005 to October 2008., Results: The mean time of stay in the hospital was significantly greater for brain-dead donors than those who were non-heart-beating: 4 +/- 2 versus 0.23 +/- 0.01 days (P < .01). The rate of family refusals was significantly greater among the families of potential brain-dead donors, that is 24% (24/99) than non-heart-beating donors, that is, 4% (2/47; P < .01). Donor age was similar in both groups., Conclusion: The rate of family refusals among potential non-heart-beating donors was significantly lower than that among families of brain-dead individuals. Greater understanding of death because the heart is not beating, less time of uncertainty about death, and shorter hospital stay could explain this difference.