Among 243 patients who received kidney transplants at our center, two patients suddenly developed a severe debilitating pain syndrome in the lower limbs. Case no. 1A 49-year-old male patient who received a deceased donor kidney transplant, in therapy with tacrolimus (plus steroids and perioperative basiliximab). One month after transplantation he reported joint pain in his ankles, knees, feet, and hands. The pain became so intense that the patient was forced to use crutches to walk. Clinical examination revealed intense pain at movement, without edema, redness, increase in temperature, or cutaneous trophic alterations. The patient was receiving tacrolimus 5 mg b.i.d. with levels between 5 and 10 ng/ml. There was no clinical or serologic evidence of rheumatic disease or rhabdomyolysis. The rise in serum creatinine was attributed to heavy non-steroidal antiinflamatory drug use. After withdrawing these agents, the serum creatinine decreased to 1.6 mg/dl. Bone radiographies showed osteoporosis at the heads of the knee, ankle, tarsal, and metatarsal bones. An ultrasound scan of the joints highlighted a minimal amount of articular effusion and a mild synovial reaction in the knee and foot joints. Magnetic resonance imaging (MRI) of the left knee showed an area of bone marrow edema in the external condyle of the femur and wearing of the cartilage (Figure 1). Computerized bone mineralometry showed a slight reduction of the bone mass, whereas bone scintigraphy revealed increased radionuclide uptake in the affected joints (Figure 2).

BackgroundSmall changes of bilirubin and liver enzymes are often detected during the acute phase of stroke, but their origin and significance are still poorly understood.MethodsOn days 0, 3, 7, and 14 after admission, 180 patients with ischemic stroke underwent serial determinations of bilirubin, GOT, GPT, γGT, alkaline phosphatase, C-reactive protein (CRP) and complete blood count. On days 0 and 7 common bile duct diameter was measured by ultrasound, and on day 3 cerebral infarct volume (IV) was calculated from CT scan slices.ResultsDuring the first week GOT, GPT, γGT (P < 0.001) and CRP (P = 0.03) increased with subsequent plateau, while significant decrements (P < 0.001) concerned unconjugated bilirubin, erythrocytes and haemoglobin. Alkaline phosphatase, direct bilirubin and common bile duct diameter remained stable. IV correlated with CRP, leukocytes, GOT, γGT (r > 0.3, P < 0.001 for all) and direct bilirubin (r = 0.23, P = 0.008). In multivariate analysis only CRP and GOT remained independently associated with IV (P < =0.001). The correlation of IV with GOT increased progressively from admission to day 14. GOT independently correlated with GPT which, in turn, correlated with γGT. γGT was also highly correlated with leukocytes. Unconjugated bilirubin correlated with haemoglobin, which was inversely correlated with CRP.ConclusionsThe changes of bilirubin and liver enzymes during ischemic stroke reflect two phenomena, which are both related to IV: 1) inflammation, with consequent increment of CRP, leukocytes and γGT, and decrease of haemoglobin and unconjugated bilirubin and 2) an unknown signal, independent from inflammation, leading to increasing GOT and GPT levels.

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Our results seems encouraging with patient and graft survival rates, complication rates, and renal function parameters being slightly worse than in expanded criteria donors, but still generally acceptable. The use of old kidneys in old recipients, bearing in mind their usual life expectancy, gives them a properly functioning kidney and improved quality of life.

Generalized lymphedema is an extremely rare effect of sirolimus therapy in renal transplant recipients. We describe the development of this complication in a 56-yr-old woman, who was given an experimental protocol with cyclosporine, sirolimus, steroids, and basiliximab. Following the protocol, after one month, the patient was randomized to the "sirolimus only" group, while cyclosporine was completely suspended and the oral steroids were continued. Three months later, the patient was admitted for severe lymphedema of the lower limbs, with significant weight increase, massive ascites and dyspnea, but excellent renal function. A chest radiography and an ultrasound study of the heart showed a moderate pleural and pericardial effusion. An abdominal ultrasound scan showed two small lymphoceles next to the transplanted kidney, confirmed with a CT scan. After sirolimus discontinuation the generalized lymphedema started to improve and three months later all the symptoms had disappeared.