Highest Recorded Serum Creatinine

Serum creatinine is a commonly used laboratory marker to assess kidney function; however, there has not been an established level of serum creatinine to predict mortality. After extensive literature review, we present a case of the highest recorded serum creatinine of 73.8 mg/dL in a 23-year-old male with the history of pediatric deceased donor kidney transplant (DDKT). He initially presented with uremia and signs of acute renal allograft failure after two months of immunosuppressive medication nonadherence, ultimately requiring emergent hemodialysis, which was complicated by new onset seizures. This was the patient’s fourth episode of late acute rejection and emphasizes the need for education of immunosuppressant adherence and periodic monitoring of renal function in high-risk patients. Though there is no known creatinine level incompatible with life, this patient appears to have the highest known serum creatinine in a uremic patient on record.

The Association between Peri-Transplant RBC Transfusion and Graft Failure after Kidney Transplantation: A Nationwide Cohort Study

Background: Patients undergoing kidney transplantation (KT) often receive red blood cell (RBC) transfusion during admission for KT which may increase the risk of allosensitization. The association between peri-transplant RBC transfusion and graft survival was evaluated using a nationwide cohort. Methods: This retrospective study analyzed 13,871 patients who underwent KT in Korea between 2007 and 2015. The outcomes were graft failure rate and overall patient survival depending on the amount of RBC transfusion. Results: The overall graft failure rate was 15.5%. Compared to the graft failure rate of 13.5% in the no transfusion group, the graft failure rate was 15.4% in the 1–2 units group (sHR 1.06 (95% CI 0.97–1.17), p = 0.216), 21.4% in the 3–5 units group (sHR 1.39 (1.21–1.61), p < 0.001), and 35.3% in the 6 or more units group (sHR 2.20 (1.70–2.85), p < 0.001). The overall survival rate was 97.5% in the no transfusion group, compared to 95.9% in the 1–2 units group (HR 1.50 (1.22–1.83), p < 0.001), 92.0% in the 3–5 units group (HR 2.43 (1.87–3.15), p < 0.001), and 67.5% in the 6 or more units group (HR 6.81 (5.03–9.22), p < 0.001). Conclusions: Peri-transplant RBC transfusion was independently associated with the increased risk of renal allograft failure and death in KT patients.

Salvage after Retroperitoneal Kidney Allograft Torsion

Torsion of a transplanted kidney into the retroperitoneal space is a rare occurrence, with only three other reported cases. Failure after kidney transplantation is caused by surgical, immunological, and infective complications. Torsion is a complication that poses a serious risk of ischemic graft failure, and, if suspected, sonographic evaluation helps ascertain the diagnosis. Here, we present the case of a 69-year-old transplant recipient whose routine postoperative ultrasound confirmed vessel patency, however subsequently developed clinical signs of renal allograft compromise. Repeat ultrasound showed signs of vascular compromise and the patient was emergently re-explored. Torsion of the renal allograft about its pedicle was encountered and corrected by manual detorsion and nephropexy to the retroperitoneal wall. Clinicians should recognize pedicle torsion as a potential cause of renal allograft failure and the role of nephropexy in its management.

Chronic Allograft Dysfunction

Premature renal allograft failure is a major problem in kidney transplantation as it is associated with high morbidity, mortality, and health care costs as patients return to dialysis. The most common cause of graft loss the first year after transplantation is death with a functioning graft, closely followed by what is now termed chronic allograft dysfunction (CAD). Development of donor-specific antibodies and chronic antibody rejection are emerging as the major pathophysiologic mechanisms responsible for this entity. There are currently no validated therapies for CAD, but improving adherence and reducing risk factors for CAD may improve outcomes. This review summarizes current understanding of the epidemiology, diagnosis, and pathophysiology of CAD, as well as potential treatment strategies. This review contains 3 figures and 133 references