Quality of Life Before and After Living Donor Kidney Transplantation
J A Lumsdaine1 A Wray2 M J Power3 N V Jamieson2 M Akyol1 J A Bradley2 JLR Forsythe1 S J Wigmore1
1Transplant Unit, Royal Infirmary of Edinburgh; 2Transplant Unit, Addenbrookes Hospital, Cambridge, 3 Department of Psychiatry, Royal Edinburgh Hospital
Aim: To assess the impact of donating and receiving a kidney before and after living kidney donor transplantation on quality of life, concerns and relationship issues.
Method: Prospective, longitudinal study in two transplants centres in the United Kingdom. Both donor and recipient were requested to complete the World Health Organisation Quality of Life questionnaire (WHOQOL) along with additional questions concerning relationships between donor and recipient and other family members. The questionnaires were completed before surgery, 6 weeks and one year after live donor transplant.
Results: Forty-eight donor-recipient pairings agreed to participate (3 declined). Six-week follow-up data is complete for 40 pairs, one year follow-up data is available for 30 pairs with the remainder due by November 2003.
The WHOQOL physical domain score of donors deteriorated at six weeks after donation but had returned to pre-operative values by one year (p=<0.0001). Recipient physical and psychological domain scores continued to improve throughout the post-operative period (p=<0.0001). The social and environmental domains were unchanged in both donor and recipient.
Additional questions concerning the relationships between donor and recipient showed a significant improvement in the recipient’s perception of relationship with the donor (p<0.015). The donor’s relationship with the recipient also improves. The concern for the donor by the recipient reduced immediately post donation. The donors’ concerns about living with a solitary kidney remained low throughout the time period. Despite some negative responses from donors, high scores both 6 weeks and one year post donation confirmed their willingness to undergo the procedure again if it were possible.
Conclusion: Reassuringly, donor physical quality of life returns to pre-donation levels and recipient physical quality of life improves significantly. Further results will clarify donor relationship issues and provide valuable data for future live kidney donors.
Outcome of Pregnancy Following Renal Transplantation in Grampian
Louise Murray, David Walbaum, Alison MacLeod
Renal Unit, Dept of Medicine & Therapeutics, Aberdeen Royal Infirmary, AB25 2ZD
Introduction: Successful renal transplantation usually restores fertility in women of childbearing age. Most studies report over 80% of pregnancies in transplant recipients result in a surviving infant; and that pregnancy does not adversely affect graft function, as long as pre-conception renal function is good.
We present a retrospective study of pregnancy following renal transplantation in Grampian, looking at both graft and obstetric outcomes.
Methods: A list of all pregnancies in transplant patients under the care of Aberdeen Royal Infirmary between 1991 and 2001 was obtained from the U.K. Transplant database. Medical and obstetric case note review gave details of graft function and hypertension, along with pregnancy outcome. Patients that completed a successful pregnancy were interviewed.
Results: During the ten-year period, 18 pregnanciesoccurred in 12 patients, representing 24% of the female transplant recipients of childbearing age (16-50 yrs).
Hypertension complicated 11 (61%) pregnancies, proteinuria of 2+ or greater developed in4 (22%),with pre-eclampsia occurring in 1(6%).
At 6 months post-partum 34% had a serum creatinine more than 10% above pre-conception levels. However, of the 10 women with a stable serum creatinine less than 150μmol/l pre-conception, only 2 (20%) had a creatinine greater than baseline +10% at 6 months post-partum, compared with 4 (50%) of the 8 women with a stable creatinine above this level pre-conception.
Live birth resulted from 15 (83%) pregnancies, spontaneous abortion occurred in 2 (11%) and therapeutic abortion was undertaken in 1(6%). For mothers with pre-conception creatinine below 150μmol/l, 90% (9) resulted in live births, compared with 75% (6) for mothers with creatinine above this level. Of pregnancies that reached 28 weeks, all 15 (100%) resulted in live births.
Of the 15 live births, 8 (53%) were delivered by caesarean section. 9 (60%) of the neonates were premature (<37 weeks), of which 4 (27%) were low birth weight (<2.5kg). One newborn had a patent ductus arteriosus (7%) and one had a single umbilical artery (7%).
Discussion: Pregnancy in renal transplant recipients remains a high-risk condition with a higher frequency of complications for both mother and neonate than in the general population. However, if pre-conception creatinine is stable below 150μmol/l the outcome for both the pregnancy and maternal graft function is good.
Conflict of interest: none
Funding: none
An unusual cause for anaemia in a transplant recipient!
M Subramaniam, N Joss†, RL Soutar*, BJR Junor†, LJ Buist
Renal Transplant Unit, Western Infirmary, Glasgow
†Renal Unit, Western Infirmary, Glasgow
* Department of Haematology, Western Infirmary, Glasgow
A 36 year old lady underwent cadaveric renal transplantation in July 2003. Her initial immunosuppression was prednisolone, mycophenolate mofetil and cyclosporine but this was changed to include tacrolimus when a biopsy showed cyclosporine toxicity although cyclosporin trough levels were therapeutic. She remained anaemic despite improving renal function and erythropoietin and iron were administered with no improvement. By 6 weeks post transplant her haemoglobin had fallen to 6gm% with no evidence of blood loss. White cell and platelet counts remained normal. Haematological investigations were performed and haemolysis was not detected. Bone marrow aspiration and biopsy revealed pure red cell aplasia. Mycophenolate mofetil was stopped, tacrolimus reduced and she received blood transfusions. IVIg has not been given. Although anaemic (Hb 8gm%) her haemoglobin level is no longer falling. Viral studies were positive for erythrovirus B19. Previously obtained sera showed her to have been negative for this virus and her donor to have been positive.
Although anaemia is seen in about 40% of recipients of renal transplants, reports of erythrovirus induced red cell aplasia or haemophagocytosis are rare. Could this condition be more common than we think?
Persistent dipstick haematuria following renal transplantation
K.J. McDonald, M.A. McMillan, R.S.C. Rodger, B.J.R. Junor, C.C. Geddes, J.D. Briggs and A.G. Jardine, Renal Unit, Western Infirmary, Glasgow
Despite widespread testing for dipstick haematuria following renal transplantation, there are no published series describing the prevalence and possible causes of this complication in an adult population. A cross-sectional study of 640 renal transplant recipients under review at our follow up clinic was performed. Persistent haematuria was defined as a minimum of 1+ of blood on urinalysis stick testing detected at not fewer than 75% of clinic visits since its onset, or since the start of routine testing, present over a period of at least 4 weeks. The prevalence of persistent dipstick haematuria was 13.3%. Median serum creatinine was higher in patients with persistent haematuria but age, gender and length of time since transplantation were not significantly different. Potential explanations for persistent haematuria in 21 of the 85 affected patients were chronic infection; ureteric stent without chronic infection; regular or intermittent self-catheterisation; persistent menstrual bleeding; anticoagulant therapy; graft calculus; and allograft renal cell carcinoma. Recurrent or de novo glomerular disease was confirmed by graft biopsy in 10 of the 85 patients. Among the 41 recipients whose original cause of renal failure was IgA nephropathy (IgAN), the prevalence of persistent haematuria was 31.7% compared with 12.0% in the remaining patients (relative risk 2.6, 95% confidence interval 1.6 - 4.3). Persistent haematuria in IgAN patients was not associated with gender, age or time since transplantation. After 29 months of follow up, 20.0% of patients with haematuria had progressed to graft failure or death compared to 13.2% of the unaffected group (p=0.029). However, despite the association with earlier graft failure, haematuria did not predict this endpoint independently of renal function.
KJM was supported by Darlinda’s Charity for Renal Research and the National Kidney Research Fund (Training Fellowship TF19/2002). No conflicts of interest.
The Epidemiology of Acute Renal failure treated with Renal Replacement
Therapy in Scotland; a national, population based study
Jyoti Baharani 1*, Wendy Metcalfe 3, Heather Martin 1, Lawson Loraine 1, W Cairns Smith 3, Keith Simpson 2, Alison MacLeod 1 and Izhar Khan 1
1 Medicine and Therapeutics, University of Aberdeen, Aberdeen, United Kingdom; 2 Public Health Medicine, University of Aberdeen, Aberdeen, United Kingdom and 3 Scottish Renal Registry, Glasgow, United Kingdom
Background and Methods
Acute renal failure remains a common condition affecting 5-20% of all hospitalised patients. Little is known, however, about its incidence in a fixed population base. We have conducted the first comprehensive, prospective national study of the incidence of ARF receiving RRT in Scotland. The Acute Renal Failure in Scotland study (ARFS) has registered adult patients in Scotland (population 5 122 500) with ARF, acute on chronic renal failure (ACRF) and CRF receiving their first RRT over a 9-month period. The aim being, to establish the incidence of ARF receiving RRT in a defined population and to determine the outcome of these patients at a 90-day period. All adult patients in Scotland receiving their first RRT were identified by regular phone calls and visits to all 20 Scottish hospitals offering this treatment. In addition to this, some Scottish patients may occasionally receive RRT in the north of England and these hospitals were included in our study. For the purpose of data collection we divided Scotland into 3 regions. We completed a standard data collection form for each patient registered into the study.
Results
Over a recruitment period of 36 weeks, 841 patients fulfilling study criteria for ARF and ACRF were identified (mean age 62.8 years, 61% male). This equates to an incidence of 297 p.m.p/year receiving RRT for ARF in Scotland; a quarter of these cases occurred in-patients with a degree of pre-existing renal impairment (ACRF).
- No significant trend was observed in the incidence of ARF based on deprivation categories.
- There were wide differences in incidence of ARF across Health Boards.
- Almost half ARF patients were treated in ICU.
- The mortality of ARF in Scotland was 47% by 90 days of starting RRT
- Patients with ARF who had sepsis had a 1.7 times increased risk of mortality than those without sepsis.
- Of the patients that survived, 75% were discharged home without further RRT by 90 days and 25% remained RRT dependent at 90 days.
Conclusion
In this first comprehensive prospective national study of ARF receiving RRT in a defined population we have found that the incidence of ARF requiring RRT is much higher than that previously reported from the UK (Khan et al, QJM 1997 90: 781-785). The mortality for patients with ARF continues to remain high and over half the patients have their initial treatment in the intensive care unit.
Monitoring of Therapy in Takayasu’s Arteritis using MR angiography and non-invasive pulse-wave analysis
S.H.Lambie, M.Sigrist and C.W.McIntyre
Dept of Renal Medicine, Derby City General Hospital
Takayasu’s arteritis affects large arteries, primarily the aorta and its major branches, causing chronic inflammation often with a granulomatous appearance. The aetiology of this disease is unknown. It is most commonly seen in patients of Asian origin, is usually diagnosed in those aged 10 to twenty years old, and has a female to male ratio of 9:1.
A 20-year-old woman of Eastern European presented originally in 2001 with mild diarrhoea, a PUO and non-specific evidence of inflammation including a CRP of 100 and ESR of 93. An indeterminate colitis was discovered, probably Crohns, but despite treatment for this, and improvement in her GI symptoms, her pyrexia and raised inflammatory markers continued. She was noted to have weak pulses in her left arm. A diagnosis of Takayasu’s arteritis was made based on MR angiography demonstrating a short occlusion of the left subclavian artery and a long stenosis of the left axillary and brachial branches. She received immunosupression initially with prednisolone and azathioprine, and more recently with mycophenolate mofetil. Despite this treatment, her inflammatory markers have remained above normal and her disease has proven difficult to control, complicated by intercurrent infective episodes which have also caused an increase in her inflammatory markers.
Intra-arterial angiography demonstrated an improvement in her arteritis with her left subclavian artery now showing stenosis but no occlusion. Repeat MRA, done 3 months later, confirmed the improvement in appearance of the subclavian artery but continued to show active arteritis.
At this point non-invasive pulse-wave analysis and pulse wave velocity were measured using the SphygmoCor. This demonstrated blunting of the waveform in the left side and reduced pulse wave velocity on that side compared to her right side. Velocity on both sides was reduced in comparison with a normal age and sex-matched control. The Augmentation Index was increased on both sides (compared to an age and sex matched normal control).
Measurement of pulse wave velocity does show discrepancy from normal, and a difference between more and less affected vessels. It may prove to be of value as a method of tracking change and disease activity over time within this individual.
Effect of ACE Inhibition on Haemoglobin in Chronic
Renal Failure: A Randomised Controlled Trial.
Mark S. MacGregor1,2, Christopher J. Deighan1, R. Stuart C. Rodger 2
and J. Michael Boulton-Jones1.
1. Renal Unit, Walton Building,Royal Infirmary, Glasgow, G4 0SF
2. Renal Unit, Western Infirmary, Glasgow, G11 6NT
Abstract
ACE inhibitors may cause anaemia in renal transplant recipients, and indeed are used as a treatment for post transplant erythrocytosis. However, it remains controversial whether they can cause anaemia or erythropoietin resistance in chronic renal failure patients. We carried out a randomised controlled trial of ACE inhibition in progressive renal failure (STARF). Here we present an analysis of the effect of quinapril on haemoglobin in these patients.
Seventy three patients with progressive non-diabetic chronic renal failure were randomised to quinapril (Q; n=28), amlodipine (A; n=28) or both drugs (QA; n=17) and followed for four years. Haemoglobin was measured quarterly, and erythropoietin use recorded. Follow-up was censored if patients were put on renal replacement therapy, died or if an ACE inhibitor was stopped (groups Q, QA) or started (group A).
Renal function was poor, but equal between the three groups (GFR 20.3±10.5 ml/min/1.73m2). Eighteen patients had polycystic kidney disease. Excluding them from the analysis did not change the results. Haemoglobin was equal in all three groups at baseline (Q 11.7±1.9 g/dl, A 12.0±2.2 g/dl, QA 12.1±2.0 g/dl). Baseline use of erythropoietin was similar (Q n=1, dose 4000 units/week; A n=1, dose 2000 units/week; QA n=2, mean dose 1500 units/week). The quinapril groups had a consistently lower mean haemoglobin than group A from months 3 to 27 (0.27-1.06 g/dl), but this was not significant. Erythropoietin use was generally higher in the quinapril groups, but only significantly at month 6. Group Q had a lower mean haemoglobin than group A from months 3 to 36 (0.19-1.46 g/dl), which approached significance in months 3, 15 and 21. Erythropoietin use was significantly higher in group QA compared to group A in months 6, 9 and 12. There was no correlation between baseline GFR and change in haemoglobin at 3, 6 or 12 months in any of the groups.
Quinapril appeared to worsen anemia or increase erythropietin use during this four year trial. However the effect of ACE inhibition on haemoglobin in chronic renal failure is likely to be too small to be of clinical significance, even in patients with relatively advanced renal failure. It should nevertheless, be considered as a cause of anaemia in individual patients.
Outcomes of Atherosclerotic Renal Artery Disease in a Low Intervention Unit.
Samira Siddiqui, Mark S. MacGregor, Christopher J. Deighan
Renal Unit, Walton Building, Glasgow Royal Infirmary, G4 0SF.
Introduction
The natural progression of atherosclerotic renal artery disease remains unclear. The Renal Unit at Glasgow Royal Infirmary historically has adopted an aggressive approach towards blood pressure and lipid control but has had a low incidence of renal artery stenting. This has allowed us to assess the progression of renal disease and outcome in a group of patients whose management has been primarily medical.
Methods
We identified retrospectively, using the electronic patient record, all patients attending the out-patient clinic at GRI who had evidence of renovascular disease on MRA scanning up until the first patient randomised into the ASTRAL trial. Baseline data and data over follow up for Creat, Creat Clearance, BP, cholesterol, CRP and eosinophil count were extracted. End points studied were death, death and dialysis and rate of progression of renal failure. We also looked at co-morbid vascular disease, anti-platelet, statin, ACE inhibitor and ARA therapy.
Results
112 patients with renal artery stenosis on MRA were identified. Only 9% (10) of these underwent renal artery stenting.16% (18) commenced RRT. 35% (39) died of whom 30 died before commencing RRT. Overall median follow-up was 37.5 months (IQR 9.8-40.2). Baseline SBP was 151 29 mmHg and fell to 147 21 mmHg over follow-up (p<0.02). DBP was 77 16 mmHg at baseline and fell to 75 11 mmHg at follow-up, (p<0.03). Cholesterol fell over follow up from 4.9 at baseline to 4.6 over follow-up (p<0.02).
56% (55) of patients were on statin therapy at the time of MR scanning, increasing to 96% (99) patients during follow-up. 63% (62) were on anti-platelet therapy at diagnosis increasing to 86% (85) patients during follow-up. 24% (24) were on an ACE inhibitor with a further 5% (5) on an angiotensin receptor antagonist.
Rate of progression was slow (median 2.2ml/min/yr) and 28% showed no progression. Median CRP and mean cholesterol were the only 2 variables with an independent effect on the rate of progression (p<0.001 and p=0.012). There was a significant difference in survival between unilateral versus bilateral disease for the combined end-point of death or dialysis (p=0.02). Baseline ECC was lower in the bilateral group (p=0.027) but there was no significant difference in rate of progression between the 2 groups.