Kidney, heart, liver, and, to a lesser extent, pancreas and lung transplants have become routine treatments for end‐stage organ failure. The short‐term success rate is high. Graft loss from allograft rejection, the traditional enemy of transplantation, has been greatly reduced. These improved results have yielded patient survival rates at 1 and 3 years that exceed 90%.

We sought to examine the utilization of and expenditure for immunosuppressants among transplant recipients under the Taiwan global budget system updated from 2004 to 2006, as provided by the Taiwan Longitudinal Health Insurance Database (2005). By using all ambulatory care orders (OO) of files from 2002 to 2006, we identified immunosuppressive agents by the Anatomic Therapeutic Chemical (ATC) code. We selected and analyzed all immunosuppressants classified into the L04 group. For the analytic work, a generalized linear model was developed to examine the effect of time and different ATC subgroup immunosuppressants on drug expenditures. Compared with the previous report covering 1999–2003, wherein the most frequently prescribed immunosuppressive agents were cyclosporine (43%), mycophenolate (30.8%), and tacrolimus (21.3%), the updated information showed cyclosporine 36.8%, tacrolimus 30.17%, and mycophenolate 21.46%. In 2005, the total drug expenditure for tacrolimus was higher than for cyclosporine which was the major immunosuppressive agent used previously. Wald chi-square tests on the effect of time from 2001 to 2006 with different immunosuppressive drug classes showed a significant result (P < .01), namely, increased drug expenditures over time owing to different ATC classes of immunosuppressants. Projecting drug expenditure using a pharmacoepidemiology approach could show the overall picture of cost utilization, including the complex determinants of price inflation, utilization, and physician behavior.

OBJECTIVE:Immunocompromised patients, such as female renal transplant recipients, have an increased incidence of neoplasms involving the lower genital tract (i.e., cervix, vagina, vulva). The relationship between lower genital tract neoplasms and human papillomavirus (HPV) infection has been established and high-risk oncogenic subtypes have been identified (HPV 16, 18, 45, and 56). The purpose of this study is to evaluate HPV subtypes present in lower genital tract neoplasms of post renal transplant women and compare HPV subtypes found in these patients with immunocompetent patients having similar neoplasms and normal immunocompetent controls.METHODS:Twenty specimens from lower genital tract neoplasms of 16 renal transplant patients, 13 specimens from 13 immunocompetent patients with similar histology, and 13 patients with normal lower genital tract histology were analyzed for the presence of HPV using polymerase chain reaction. HPV primers including the L1 (late) region consensus primers and primers specific for the HPV E6 (early) region for subtypes 6, 11, 16, and 18 were amplified with DNA from the above patient samples.RESULTS:Overall, HPV was detected in 21/46 specimens tested. Thirteen of the HPV-positive specimens were from transplant patients, and 8 were from immunocompetent patients (5 immunocompetent with disease and 3 normal patients). This difference in the total number of HPV-positive cases was statistically significant between the transplant and immunocompetent group (P = 0.02). Although no difference in HPV 6 and/or 11 was detected between the two groups, HPV subtypes 16 and/or 18 approached statistical significant difference (P = 0.06).CONCLUSIONS:High-risk oncogenic HPV subtypes 16 and/or 18 were found at a higher rate in transplant patients compared with their immunocompetent counterparts. The combination of immunocompromise and increased HPV 16 and/or 18 positivity may place these patients at increased risk for aggressive lower genital tract neoplastic progression.

A 49-year-old man developed disseminated histoplasmosis 6 1/2 years after transplantation. The organism was initially present in the urine and in a tongue lesion. Treatment with itraconazole was instituted. However, there was further dissemination of the disease and worsening of renal function. Allograft biopsy showed extensive involvement with the organism. Amphotericin B was started, resulting in a rapid resolution of the disease. However, renal function deteriorated, leading to permanent hemodialysis.

Cyclosporine (CSA) nephrotoxicity remains a major concern for clinicians. Experimental animal and human studies indicate that CSA causes an increase in renal vascular resistance, a decrease in renal blood flow and a reduction in glomerular filtration rate (GFR). A retrospective analysis of fractional excretion of sodium (FENa) was done in 126 renal allograft recipients treated with CSA to determine whether or not the pattern of FENa in CSA‐treated patients differed from that observed in patients treated with conventional immunosuppression, and to study the behavior of FENa in relation to episodes of acute reversible CSA nephrotoxicity (17 cases). It was shown that CSA induced a significant transient early decline in FENa compared with conventional immunosuppression, and that 76% of cases of acute reversible CSA nephrotoxicity were associated with a drop in FENa, which occurred an average of 2.5 days before the rise in serum creatinine. Close monitoring of FENa may provide a clinically useful early warning for incipient CSA nephrotoxicity in renal allograft recipients.

This report describes the development of anti-glomerular basement membrane (GBM) glomerulonephritis after kidney transplantation in related males with Alport syndrome. Antibodies in sera from one of these patients stained normal GBM, Bowman's capsule, tubular basement membranes, and epidermal basement membranes but did not stain tissues from an unrelated Alport male. The target antigen was found to be a 26 kd peptide of the noncollagenous domain of basement membrane collagen. This study provides further evidence of the importance of abnormalities of basement membrane collagen in the pathogenesis of the Alport nephropathy. We speculate that certain mutations at the Alport locus, such as large intragenic deletions or frame-shift mutations, may be associated with failure to develop immune tolerance to epitopes on this 26kd peptide. In the setting of permissive immune response and regulation, transplantation of a normal kidney may result in the generation of anti-GBM antibodies.

Wegener's granulomatosis was diagnosed in a 42-year-old female 16 years ago. From the outset there was upper respiratory, pulmonary, and renal involvement. Over the years she received varying combinations of glucocorticoids and azathioprine. Renal function deteriorated, and she was treated by hemodialysis and living related donor transplantation 9 and 10 years, respectively, after the onset of the disease. 3 months prior to transplantation, the patient had a right pneumonectomy for bronchial stenosis, bronchiectasis and repeated sepsis. 5 years' posttransplantation, she is well and has no signs of activity of original disease.

Heavy proteinuria and/or the nephrotic syndrome rarely occur late in pregnancy. We report the clinical and renal biopsy findings on 11 patients with the nephrotic syndrome occurring during pregnancy in whom light and electron microscopic findings were characteristic of pre-eclampsia. Immunofluorescent microscopy revealed deposits of IgG, IgM, IgA, beta 1C globulin, and fibrinogen, predominantly in the subendothelial position. Only two patients were primigravid; three were in their second or third pregnancy; in six, pre-eclampsia first occurred in the fourth to eighth pregnancy. Clinical abnormalities appeared first between the 23rd and 39th week of gestation. All patients had marked elevation of blood pressure and of serum uric acid levels. Of the 12 infants, eight were alive and well, including one set of twins; four were stillborn. Following delivery, clinical resolution was similar to that in less severe pre-eclampsia. The findings suggest the possible importance of the role of intravascular coagulation in the genesis of pre-eclampsia.