Limited data exist about Clostridium difficile colitis (CDC) in solid organ transplant patients. Between 1/1/99 and 12/31/02, 600 kidney and 102 pancreas-kidney allograft recipients were transplanted. Thirty-nine (5.5%) of these patients had CDC on the basis of clinical and laboratory findings. Of these 39 patients, 35 have information available for review. CDC developed at a median of 30 days after transplantation, and the patients undergoing pancreas-kidney transplantation had a slightly higher incidence of CDC than recipients of kidney alone (7.8% vs. 4.5%, P> 0.05). All but one patient presented with diarrhea. Twenty-four patients (64.9%) were diagnosed in the hospital, and CDC occurred during first hospitalization in 14 patients (40%). Treatment was with oral metronidazole (M) in 33 patients (94%)and M + oral vancomycin (M + V) in 2 patients. Eight patients had recurrent CDC, which occurred at a median of 30 days (range 15-314) after the first episode. Two patients (5.7%) developed fulminant CDC, presented with toxic megacolon, and underwent colectomy. One of them died; the other patient survived after colectomy. CDC should be considered as a diagnosis in transplant patients with history of diarrhea after antibiotic use, and should be treated aggressively before the infection becomes complicated. KeywordsClostridium difficile; kidney; pancreas; kidney; transplantation Infections are the leading cause of morbidity and mortality in the early post-transplant period. More than 80% of recipients suffer at least one episode of infection in the first year (1,2). The occurrence of infectious complications is closely related to immunosuppressive treatment, including induction, maintenance, and the treatment of acute rejection.Although, many viral and bacterial opportunistic infections are well known in kidney and pancreas-kidney allograft recipients, Clostridium difficile colitis (CDC) is a less frequently described gastrointestinal infection in these patients. Clostridium difficile (CD) is one of the most common hospital-acquired (nosocomial) infections causing antibiotic-associated colitis (3). CDC has been defined as the existence of diarrhea and CD toxin in the stool.In this study, we identified our patients with CDC after kidney and pancreas-kidney transplantation and report the clinical presentation, timing of infection, risk factors, recurrence, and treatment. We also report two patients with fulminant CDC (FCDC) after kidney transplantation.

With this approach to immunosuppression, it has been possible to avoid early posttransplant overimmunosuppression and thereby to promote the evolution of a degree of partial tolerance sufficient to undertake substantial dose reduction. The strategy, which is applicable for all organ grafts, constitutes a paradigm shift in transplant management at our center.

Alemtuzumab was used as an induction agent in 205 renal transplant recipients undergoing 207 living donor renal transplants. All donor kidneys were recovered laparoscopically. Postoperatively, patients were treated with tacrolimus monotherapy, and immunosuppression was weaned when possible. Forty-seven recipients of living donor renal transplants prior to the induction era who received conventional triple drug immunosuppression without antibody induction served as historic controls. The mean follow-up was 493 days in the alemtuzumab group and 2101 days in the historic control group. Actuarial 1-year patient and graft survival were 98.6% and 98.1% in the alemtuzumab group, compared to 93.6% and 91.5% in the control group, respectively. The incidence of acute cellular rejection (ACR) at 1 year was 6.8% in the alemtuzumab group and 17.0% (p < 0.05) in the historic control group. Most (81.3%) episodes of ACR in the alemtuzumab group were Banff 1 (a or b) and were sensitive to steroid pulses for the treatment of rejection. There was no cytomegalovirus disease or infection. The incidence of delayed graft function was 0%, and the incidence of posttransplant insulin-dependent diabetes mellitus was 0.5%. This study represents the largest series to date of live donor renal transplant recipients undergoing alemtuzumab induction, and confirms the shortterm safety and efficacy of this approach.

Chronic allograft nephropathy (CAN) is a major indication for initiation of sirolimus (SRL) in renal transplantation (TX) to prevent deterioration of renal function. We evaluated whether the CAN score at time of sirolimus rescue (SRL-R) predicts renal allograft function. CAN score is the sum of the following 4 categories: glomerulopathy (cg, 0-3), interstitial fibrosis (ci, 0-3), tubular atrophy (ct, 0-3), and vasculopathy (cv, 0-3).

2 7 7 THURSDAY Supplement to Transplantation July 27, 2008, Volume 86 Number 2S corticosteroids, antithymocyte globulin and/or daclizubab. From Jan. 2004 to Dec. 2007 received rituximab in addition to the "standard" immunosuppression. Posttransplant proteinuria was treated with plasmapheresis (PP) and maintenance angiotensin blockade (AB). Results: There was no adverse event related to rituximab infusion. The overall incidence of posttransplant proteinuria was signifi cantly lower in recipients with rituximab induction (p < 0.05). Four recipients treated with "standard" immunosuppression developed massive proteinuria (u-protein/creat. > 10) immediately following transplantation; they responded poorly to PP and AB. Four other recipients had moderate proteinuria. In contrast to this, of the 18 patients induced with rituximab, only 2 had massive proteinuria and 4 had mild to moderate proteinuria which responded well to PP and AB. With a median follow-up of 26 months, there was no signifi cant difference of graft survival between 2 groups (2-year survival: 81% without rituximab vs. 84% with rituximab). A half of the graft loss was related to noncompliance. Conclusion: While the mechanism of action is unclear, our observation indicates that rituximab induction may decrease the incidence and severity of recurrence of FSGS following kidney transplantation. A larger-scale study is desirable to confi rm this observation. Alemtuzumab has been used in off-label studies of solid organ transplantation. We extend our report of the fi rst 200 consecutive living donor solitary kidney transplantations under alemtuzumab pretreatment with tacrolimus monotherapy and subsequent spaced weaning to 3 years of follow up. We focused especially on the causes of recipient death and graft loss, and the characteristics of rejection. The actuarial 1, 2, and 3 year patient and graft survivals were 99.0% and 98.0%, 96.4% and 90.8%, and 93.3% and 86.3%, respectively. The incidence of acute cellular rejection (ACR) at the following months was 2% <6, 9.0% <12, 16.5% <18, 19.5% <24, 23.5% <30, 24.0% <36, and 25% <42. The mean serum creatinine (mg/dL) and glomerular fi ltration rate (mL/min/1.73m2) at 1 and 3 years were 1.43+0.55 and 58.7+21.6, and 1.50+0.71 and 54.5+21.3, respectively. 50 (25%) recipients had a total of 89 episodes of ACR. 88.7% of ACR episodes were Banff 1, and of those, 82% were steroid-sensitive. Nine (4.5%) recipients had antibody mediated rejection (AMR). 76.5% were weaned to spaced dose (qod or less) tacrolimus monotherapy, and 94.4% were still steroid-free from the time of transplantation. Infectious complications was low. This experience confi rms the 3-year effi cacy of this approach. Introduction: We evaluated early and long-term (two year) immunophenotypic peripheral blood profi les in renal transplant patients receiving single agent induction therapy with Thymoglobulin (T), Campath-1H (alemtuzumab) (C) or Daclizumab (D) versus combined T and D (T-D) or T and C (T-C) with steroid avoidance. The focus was to identify spec...

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