Iloprost in Acute Post-kidney Transplant Atheroembolism: A Case Report of Two Successful Treatments (original) (raw)
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Cholesterol embolization and severe vascular rejection in a renal allograft recipient
NDT Plus, 2010
Cholesterol embolization (CE) is a well-known cause of renal dysfunction, often leading to irreversible renal failure most often in elderly patients. However, because of its unspecific and subclinical appearance, CE is often misdiagnosed. As donors and recipients of increasing age or with prominent atherosclerotic disease are accepted for transplantation, CE in renal allografts may become more prevalent. Here, we report a case of a 31-year-old second renal allograft recipient with CE as a cause of early graft failure, followed by severe vascular rejection, eventually requiring nephrectomy.
Iloprost as an acute kidney injury-triggering agent in severely atherosclerotic patients
Cardiovascular Journal of Africa, 2016
Background: Iloprost, a stable prostacyclin analog, is used as a rescue therapy for severe peripheral arterial disease (PAD). It has systemic vasodilatory and anti-aggregant effects, with severe vasodilatation potentially causing organ ischaemia when severe atherosclerosis is the underlying cause. In this study, we retrospectively analysed renal outcomes after iloprost infusion therapy in 86 patients. Methods: Eighty-six patients with PAD who received iloprost infusion therapy were retrospectively analysed. Clinical and biochemical parameters were recorded before (initial, Cr1), during (third day, Cr2), and after (14th day following the termination of infusion therapy, Cr3) treatment. Acute kidney injury (AKI) was defined according to KDIGO guidelines as a ≥ 0.3 mg/dl (26.52 μmol/l) increase in creatinine levels from baseline within 48 hours. Results: Cr2 (1.46 ± 0.1 mg/dl) (129.06 ± 8.84 μmol/l) and Cr3 (1.53 ± 0.12 mg/dl) (135.25 ± 10.61 μmol/l) creatinine levels were significantly higher compared to the initial value (1.15 ± 0.6 mg/dl) (101.66 ± 53.04 μmol/l). AKI was observed in 36 patients (41.86%) on the third day of iloprost infusion. Logistic regression analysis revealed smoking and not using acetylsalicylic acid as primary predictors (p = 0.02 and p = 0.008, respectively) of AKI during iloprost treatment. On the third infusion day, patients' urinary output significantly increased (1813.30 ± 1123.46 vs 1545.17 ± 873.00 cm 3) and diastolic blood pressure significantly decreased (70.07 ± 15.50 vs 74.14 ± 9.42 mmHg) from their initial values. Conclusion: While iloprost treatment is effective in patients with PAD who are not suitable for surgery, severe systemic vasodilatation can cause renal ischaemia, resulting in nonoliguric AKI. Smoking, no acetylsalicylic acid use, and lower diastolic blood pressure are the clinical risk factors for AKI during iloprost treatment.
Renal allograft immunosuppression
Transplant International, 1991
Serum lipid and lipoprotein profiles were performed in order to investigate lipid abnormalities 2 years post-transplantation in first cadaveric renal allograft recipients immunosuppressed with cyclosporin (CyA), azathioprine (Aza), and methylprednisolone (MP), or with any combination of two drugs. CyA was used in low doses. Total serum cholesterol, triglyceride, L D L cholesterol, HDL cholesterol, HDL2 cholesterol, HDL3 cholesterol, apolipoprotein A1, and apolipoprotein B were determined in 88 prospectively randomized patients with functioning grafts. When considering only the patients who remained on the original randomized treatment, there were no significant differences between the four groups in any of the measured variables. Mean total cholesterolwas highest in the group receiving Aza and MP (6.8 mmol/1) and lowest in the group receiving triple therapy (5.8 mmol/1; NS). Mean triglyceride level was highest in the group receiving Aza and MP (2.3 mmol/1) versus 1.8-2.2 mmol/1 in the groups receiving triple therapy, Aza + CyA, and CyA + MP. For all patients mean triglyceride level was highest in the group receiving Aza and MP (2.7 mmol/1) and lowest in the group receiving triple therapy (1.7 mmol/1; P<0.05). Mean H D L cholesterol ranged from 1.5 to 1.6 mmol/1 in all groups. Neither CyA concentration nor CyA or MP dose correlated with cholesterol or triglyceride concentration. However, the average MP dose was twice as high in the group receiving Aza and MP as in the other two groups employing steroids. Serum cholesterol and triglyceride concentrations were related to body mass index (r = 0.28, P = 0.045 and r = 0.30, P = 0.029, respectively). Hyperlipidemia was most common in the group receiving Aza and MR The frequency of hypercholesterolemia (serum cholesterol level > 6.5 mmol/1) was 18%, 45%, 60%, and 35% for the patients continuing with the originally randomized treatment in the groups receiving triple therapy, Aza + CyA, Aza + MR and CyA + MP, respectively. In a normal Finnish reference population, 35 % of all males and 31% of all females have a serum cholesterol level above 6.5 mmol/1. Thus, only patients receiving Aza and Offprint requests to: H. Isoniemi MP had a clearly higher frequency of hypercholesterolemia than that found in a normal population. Taken together, this study shows no lipid abnormalities associated with the use of low-dose CyA for 2 years after transplantation. Hyperlipidemia occurring after transplantation is probably multifactorial and more associated with other risk factors than with the immunosuppressive therapy.
Percutaneous coronary interventions and antiplatelet therapy in renal transplant recipients
Therapeutic Advances in Cardiovascular Disease, 2015
Cardiovascular disease is the leading cause of mortality and morbidity following renal transplantation (RT), accounting for 40-50% of all deaths. After renal transplantation, an adverse cardiovascular event occurs in nearly 40% of patients; given the dialysis vintage and the average wait time, the likelihood of receiving coronary revascularization is very high. There is a significant gap in the literature in terms of the outcomes of prophylactic coronary revascularization in renal transplantation candidates. Current guidelines on myocardial revascularization stipulate that renal transplant patients with significant coronary artery disease (CAD) should not be excluded from the potential benefit of revascularization. Compared with percutaneous coronary intervention (PCI), however, coronary artery bypass grafting is associated with higher early and 30-day mortality. About one-third of renal transplant patients with CAD have to be treated invasively and so PCI is currently the most popular mode of revascularization in these fragile and compromised patients. A newer generation drug-eluting stent (DES) should be preferred over a bare metal stent (BMS) because of its lower risk of restenosis and improved safety concerns (stent thrombosis) compared with first generation DES and BMS. Among DES, despite no significant differences being reported in terms of efficacy, the newer everolimus and zotarolimus eluting stents should be preferred given the possibility of discontinuing, if necessary, dual antiplatelet therapy before 12 months. Since there is a lack of randomized controlled trials, the current guidelines are inadequate to provide a specifically tailored antiplatelet therapeutic approach for renal transplant patients. At present, clopidogrel is the most used agent, confirming its central role in the therapeutic management of renal transplant patients undergoing PCI. While progress in malignancy-related mortality seems a more distant target, a slow but steady reduction in cardiovascular deaths, improving pharmacological and interventional therapy, is nowadays an achievable medium-term target in renal transplant patients.
Annals of Thoracic and Cardiovascular Surgery, 2013
Renal dysfunction remains a serious complication of coronary artery bypass grafting (CABG) surgery and is associated with increased mortality and morbidity. To date, a number of different strategies, including new pharmacologic agents, off-pump and cardiopulmonary bypass techniques have been used to avoid it, but none of them proves the excellent result. Methods: Between April 2009 to September 2011, 185 consecutive patients with multivessel coronary artery disease undergoing elective CABG were included the study. Iloprost was given with the onset of rewarming period at a dose of 1.25-2.5 ng/kg/min and it was ended together with the ending of CPB in 94 patients and remaining were in the control group. Creatinine clearance (CCr) and GFR were measured at the time of hospitalisation and on day first and fifth postoperatively. Serum potassium level was determined every 6 hours, during the first 24 hours postoperatively, and every 12 hours for the next 72 hours, and glomerular filtration rate was estimated. Results: There was no statistically significant difference in preoperative comorbidity. There were no significant differences in postoperative morbidity or mortality between either of the two groups that completed the study. However, urine output during the operation was significantly higher in the study group. An increase in creatine levels was more common in the control group. Development of a new CCr less than 50 ml/min was also significantly higher in the control group, postoperatively. Conclusion: Our study demonstrates that prophylactic intravenous iloprost administration after initiation of a rewarming period during CPB in patients undergoing CABG surgery is associated with improved renal function, compared with conventional treatment in wellhydrated patients. It also has a good safety profile and is generally well tolerated.
Journal of The American Society of Nephrology, 1993
Hypercholesterolemia occurs commonly in renal transplant recipients and may contribute to the high cardiovascular morbidity and mortality in these patients. Although an effective hypolipidemic agent, lovastatin has been associated with rhabdomyolysis and acute renal failure in patients on cyclosporin A (CsA). In this study, lovastatin was administered at I 0 mg/day for 8 wk followed by 20 mg/day for I 2 wk to six renal transplant recipients who were receiving CsA concomitantly. The 10-mg/day dose was effective, but an additional lipid-lowering effect was seen with the 20-mg/day dose. Both serum total choles-I
Atheroembolic renal disease as a cause of allograft primary non-function
Atheroembolic renal disease, also referred to as cholesterol crystal embolization, is a rare cause of renal failure, secondary to occlusion of renal arteries, renal arterioles and glomerular capillaries with cholesterol crystals, originating from atheromatous plaques of the aorta and other major arteries. This disease can occur very rarely in kidney allografts in an early or a late clinical form. Renal biopsy seems to be a reliable diagnostic test and cholesterol clefts are the pathognomonic finding. However, the renal biopsy has some limitations as the typical lesion is focal and can be easily missed in a biopsy fragment. The clinical course of these patients varies from complete recovery of the renal function to permanent graft loss. Statins, acetylsalicyclic acid, and corticosteroids have been used to improve the prognosis. We report a case of primary allograft dysfunction caused by an early and massive atheroembolic renal disease. Distinctive histology is presented in several co...