Search

Introduction: Simultaneous pancreas-kidney transplantation (SPK) is an option for patients with type 1 diabetes (T1D) and kidney failure but can be associated with a high complication rate. Here we describe our 10-year experience since the launch of the SPK program., Methods: This retrospective study included consecutive patients with T1D receiving SPK from March 14, 2010 to March 14, 2020 at Helsinki University Hospital. Portocaval anastomosis (i.e., systemic venous drainage) and enteric exocrine drainage were used. A specific team was trained for both pancreas retrieval and transplantation, postoperative care was standardized to include somatostatin analogues, antimicrobial treatment, and preoperatively initiated chemothrombopropylaxis. During program maturation donor criteria were expanded and logistical processes improved to minimize cold ischemia time. Clinical data were collected from a nationwide transplantation registry and patient records., Results: A total of 166 SPKs were performed (median 2 per year in the first 3 years, 17.5 per year for the following 4 years, and 23 per year for the past 3 years). Seven patients (4.1%) died with a functioning graft with a median 43 months follow-up. One-year pancreas graft survival was 97.0%, 3-year pancreas graft survival was 96.1% and 5-year was 96.1%. Mean HbA1c was 36 mmol/mol (SD 5.57) and creatinine was 107 μmol/L (SD 34.69) at 1-year after transplantation. All kidney grafts were functioning at the end of follow-up. Complications required re-laparotomy in 39 (23%) patients, mostly due to a pancreas graft related problem (N = 28). No pancreas or kidney graft failure from thrombosis occurred., Conclusion: A planned, step-wise development of an SPK program offers a safe and effective treatment for patients with T1D and kidney failure., (© 2023 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Aim: The burden of sexually transmitted infections (STI) among solid-organ transplant recipients is currently unknown. We studied the risk of STIs among kidney transplant recipients compared with the general population in a nationwide cohort., Methods: Between 2002 and 2019, all microbiological findings of Chlamydia trachomatis, Neisseria gonorrhoeae, Treponema pallidum (syphilis), and human immunodeficiency virus among kidney transplant recipients <65 years and transplanted between 1995 and 2017 in our country were captured from statutory national registries. Data from the general population of Finland, population 5.5 million, were used for comparisons. Incidence of STIs and age and sex-adjusted standardized incidence ratios (SIR) were calculated., Results: Altogether 3612 transplantations, with a total follow-up of 27 069 person-years were included. A total of 30 STIs microbiological findings of STI were confirmed in 25 patients: C. trachomatis (N = 27), N. gonorrhoeae (N = 2), and syphilis (N = 1). No hospitalizations associated with STIs were detected. The risk of STI after kidney transplantation was significantly lower compared to the general population (SIR, 0.57, 95% CI 0.39-0.80). The lower risk of STIs was more pronounced in female patients (SIR 0.40, 95% CI 0.20-0.74), whereas in male patients the difference was statistically not significant (SIR 0.69, 95% CI 0.44-1.04). Of the confirmed STI cases, 30% were detected in patients who received their transplants during adolescence., Conclusions: Within the Finnish kidney transplant population, the age and sex-adjusted incidence of sexually transmitted infections is not higher compared to the general population. Highest frequency of infections was seen among patients transplanted during adolescence., (© 2022 Wiley Periodicals LLC.)

Cytomegalovirus (CMV) infection remains a major challenge in solid organ transplantation. Ganciclovir has changed the prognosis, but with the expense of possible viral resistance. New antiviral drugs, such as letermovir, have not been studied sufficiently in kidney and pancreas transplant recipients. We reviewed abdominal organ transplants recipients with CMV infection from the national transplant registry and identified patients treated with letermovir from electronic medical records. We report on letermovir treatment in one kidney and three simultaneous pancreas and kidney (SPK) transplant patients with refractory or ganciclovir-resistant CMV infection (UL54/ UL97 mutation). In SPK patients, persistent leukopenia undermined immunosuppressive and antiviral treatment, favoring life-threatening bacterial infections or ganciclovir resistance. All patients achieved viral clearance after letermovir monotherapy of 1.5-6 months. Letermovir was well tolerated and leukopenia resolved. Adjustments of calcineurin inhibitor doses were challenging. One acute rejection occurred because of under immunosuppression. After the end of treatment, recurrent low-grade CMV-DNAemia was common requiring reinitiating antiviral therapy to achieve viral clearance. To conclude, letermovir was a well-tolerated valuable option for the treatment of refractory or resistant CMV infection in kidney and pancreas transplantation., (© 2021 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Cytomegalovirus continues to be a concern after transplantation despite prophylaxis regimens. Our aim was to analyse post-prophylaxis primary cytomegalovirus infections among kidney transplant recipients after 6-month valganciclovir prophylaxis and to determine the usefulness of surveillance after prophylaxis. Data from all cytomegalovirus D+/R- kidney transplant recipients from January 2004 to October 2018 at our center who received 6-month prophylaxis with valganciclovir were retrospectively analysed (N = 481). Detailed analyses were performed for 136 patients who were monitored every 2-4 weeks for DNAemia after the discontinuation of prophylaxis. Post-prophylaxis primary cytomegalovirus infection occurred in 182/481 (38%) patients median 264 days after transplantation (IQR: 226-367) and median 84 days after the end of prophylaxis (IQR: 46-187). In 49% patients, cytomegalovirus infection occurred over 3 months after the end of prophylaxis. Cytomegalovirus infection was not associated with lower patient or graft survival and no independent risk factors for infection were found. From patients monitored closely, 71/136 (52%) patients developed post-prophylaxis primary cytomegalovirus infection. Altogether, 52/136 (38%) patients were diagnosed with probable post-prophylaxis cytomegalovirus disease and 19/136 (14%) patients had asymptomatic CMV infection. Recurrent infection occurred in 38/71 (39%) patients. The incidence of post-prophylaxis primary cytomegalovirus infection among D+/R- kidney transplant recipients remains high despite 6-month prophylaxis. Surveillance after prophylaxis was challenging as a considerable portion of the infections occurred late and already symptomatic., (© 2021 The Authors. Transplant Infectious Disease published by Wiley Periodicals LLC.)

Background: Simultaneous pancreas-kidney transplantation (SPK) carries a high risk of major postoperative complications, but knowledge on early warning signs and surrogate markers for postoperative complications is scarce., Aims: Our aim was to analyze the complication-predictive value of different laboratory tests in pancreas transplantation., Materials & Methods: All SPKs in Finland between January 2010 and February 2020 were retrospectively analyzed. Levels of first three-day plasma amylase, drain fluid amylase, C-reactive protein, C-peptide, plasma trypsinogen, and white blood cell count were assessed for their performance predicting cumulative postoperative complications (assessed using the Comprehensive Complication Index) within 90 days from transplantation by using ROC analyses., Results: Of the 164 SPK patients included, 39 suffered at least one complication requiring laparotomy. First-day plasma amylase had the best value in predicting complications based on its high AUC value and easy clinical applicability, with an optimum cutoff of six times the upper normal limit. Negative predictive values (NPVs) and positive predictive values of this cutoff were 0.81 and 0.71 for any relaparotomy, and 0.91 and 0.71 for the Comprehensive Complication Index >47.7 (which equals the morbidity of two relaparotomies), respectively., Conclusion: In conclusion, first-day plasma amylase could be able to detect patients at risk of complications after SPK., (© 2021 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

The value of myocardial single-photon emission computed tomography (SPECT) in pre-transplant evaluation of kidney transplant recipients is controversial. We assessed whether myocardial SPECT predicts major adverse cardiac events (MACE) and determined whether SPECT findings affected transplant recipients' medical and invasive treatment. We analyzed 301 patients referred for myocardial SPECT before kidney transplantation and combined the results with information from patient files and the Transplantation Registry. During the median follow-up time of 96 months (IQR 70.75-118.25 months), the incidence of MACE was higher in patients (n = 37) with severely abnormal SPECT (>10% reversible perfusion defect) than in patients (n = 35) with mildly abnormal or normal SPECT (51.4%, 29.4%, and 27.0%, respectively, P = .011). Severely abnormal SPECT findings predicted long-term MACE in a univariable analysis but not after adjusting for other risk factors. Following SPECT, 29 patients (9.6%) underwent coronary angiography and 14 (4.6%) were revascularized. New antithrombotic or statin medication was prescribed to 7.3% of patients with ischemia in SPECT. Kidney transplantation patients are at high long-term risk of MACE even with normal preoperative myocardial SPECT. Abnormal SPECT did not predict MACE when adjusted for other risk factors. Minority of the patients underwent coronary revascularization or had changes in preventive medication before transplantation., (© 2020 John Wiley & Sons A/S . Published by John Wiley & Sons Ltd.)

Introduction: Electrocardiographic (ECG) changes before and after kidney transplantation are not well-defined. Our aim was to describe the evolution of ECG in patients on dialysis before and after successful kidney transplantation and to explore the association between ECG findings and major cardiovascular (CV) events and mortality after kidney transplantation., Patients and Methods: Electrocardiographics were collected retrospectively 3 times: at entry to the transplantation waiting list, at transplantation, and 1 year after the transplantation from 212 kidney transplantation recipients. Altogether 19 ECG variables were analyzed., Results: Left ventricular hypertrophy was present in 10.2% by the Cornell voltage-duration product criteria and 10.7% by the Sokolow-Lyon voltage criteria before kidney transplantation. The presence of ST depression (OR 3.12, 95% CI 1.12 -8.7 and P = .03) at entry to the waiting list and Q wave at the time of transplantation (OR 3.28, 95% CI 1.06-10.10 and P = .04) were both independently associated with major CV events after the transplantation. In addition, the presence of Q wave at entry to the waiting list was a risk factor of premature death after the transplantation (OR 2.92, 95% CI 1.06-8.05 and P = .04)., Discussion: Careful analysis of the ECG before transplantation can be used to estimate cardiovascular events and mortality risk after kidney transplantation., (© 2018 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Introduction: The clinical course of cytomegalovirus (CMV) infections in the current era is poorly described. We characterized the symptoms and outcome of all CMV infections in a large cohort of kidney transplant recipients. Among 1129 kidney transplant recipients transplanted between 2004 and 2011 in Charité Universitätsmedizin Berlin and Helsinki University Hospital, 297 patients with CMV infection were characterized., Results: CMV disease occurred in 217/1129 patients (19.2%), and CMV infection in 297/1129 (26.3%). Gastrointestinal symptoms were recorded in 58% and fever in 47% patients with primary CMV disease, compared to 46% and 27% patients with symptomatic CMV reactivation, whereas leukopenia or thrombocytopenia were seen in only 17-28% patients, and malaise in 9-10%. Tissue-invasive CMV gastroenteritis was confirmed in 11% and CMV pneumonia in only 1% of patients with CMV disease. Only 1 patient died because of CMV infection (mortality 0.3%). Virus-related factors or the use of secondary prophylaxis did not predict the risk of recurrence, which occurred in 33% patients., Conclusion: In conclusion, CMV disease remains a common problem after kidney transplantation. Gastrointestinal symptoms were common, especially in patients with primary CMV infection, whereas bone marrow suppression, hepatopathy, or malaise were seen less frequently., (© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

The incidence and clinical course of polyomavirus-associated nephropathy (PyVAN) in our well-HLA-matched kidney transplant population mainly on low-dose cyclosporine-based triple-drug immunosuppression has not been described in detail. We aimed to characterize our patients with PyVAN and BK virus (BKV) viremia. Among 166 kidney transplantations between January 2007 and February 2011 followed up at Helsinki University Hospital nephrology clinic, 136 were screened for BKV viremia by quantitative analysis of BKV DNA in plasma. PyVAN was diagnosed by biopsy histopathology and SV40 T-antigen detection. BKV viremia or PyVAN were treated by reducing immunosuppression. BKV viremia was detected in 12 (9%) patients. PyVAN was diagnosed in six patients (4%). In the six patients with no PyVAN, four had low-level viremia (<10,000 copies/mL) of short duration (<2 months), one had high-level viremia, and one had sustained low-level viremia. After reduction of immunosuppression, all except one patient were able to clear viremia. No grafts were lost due to PyVAN. Even in a low-risk population, BKV viremia and PyVAN occur, highlighting the importance of monitoring viral loads. Reduction of immunosuppression was successful, and no grafts were lost due to PyVAN., (© 2012 John Wiley & Sons A/S.)