Massive Ascites of Unknown Origin: A Case Report

Ascites is the excessive accumulation of fluid in the peritoneal cavity and predominantly caused by liver cirrhosis, cancers, or heart failure. In this study, a 31-year-old woman with chronic renal failure of unknown etiology treated with hemodialysis and peritoneal dialysis was often hospitalized because of ascites, which appeared 4 years after the second kidney transplantation. The patient was regularly (every 2-3 weeks) treated with paracentesis. Peritoneal fluid tested negative for bacterial (including atypical) and fungal infections and tuberculosis. Doppler ultrasound and liver FibroScan did not show any irregularities. Computed tomography (CT) revealed an enlarged left ovary. A high level of CA 125 was found. The second diagnostic laparoscopy revealed no changes in the ovaries, and there were no tumor cells. Diagnostics were extended, but no deviations were revealed. Suspecting drug etiology, mycophenolic acid was discontinued, bringing no improvement. Diagnostic tests caused suspicion of Meigs' syndrome; therefore, oophorectomy of left ovary was conducted, revealing numerous small cysts filled with serous fluid, without tumor cells in the ovary or peritoneal fluid. Despite the procedure performed, ascites was recurrent. Five month later, ascites spontaneously stopped growing. Paracentesis to decompress ascites was no longer required. There were 9 paracenteses performed from oophorectomy (the latest on May 23, 2019). The need for repetitive paracentesis, significantly reducing the patient's quality of life, required diagnosis for casuistic diseases. The described case is atypical because of the confusing etiology of ascites and its spontaneous cessation. Despite numerous examinations and recession of ascites, the cause of the problem is not entirely clear.

FRAX prognostic and intervention thresholds in the management of major bone fractures in hemodialysis patients: A two-year prospective multicenter cohort study

PURPOSE

The usefulness of FRAX in predicting major bone fractures in patients with end-stage kidney disease on maintenance hemodialysis treatment has been confirmed in previous studies. For meaningful clinical use, the prognostic and intervention FRAX thresholds need to be established.

METHODS

The primary aim of our study was to calculate the optimal cut-off point of FRAX for the best prediction of an increased bone fracture risk in dialysis patients and additionally, to propose its intervention threshold, indicating the need for antifracture pharmacological treatment. The study included 718 hemodialysis patients, who were followed up for two years. Thirty low-energy major bone fractures were diagnosed during the study period. We used the Polish version of FRAX (without the DXA examination) and some particular variables of the FRAX calculator. The optimal cut-off point for prediction of an increased major bone fracture risk was based on the analysis of the sensitivity and specificity curves of FRAX.

RESULTS

The analysis revealed FRAX >5% (sensitivity of 70.0%, specificity of 69.8%) as the prognostic threshold for major bone fractures. Its sensitivity for bone fracture prediction was significantly higher, but specificity lower than those of FRAX ≥10%, used in general Polish population. The reason for this can be an underestimation of bone fracture risk with FRAX in dialysis patients.

CONCLUSIONS

We conclude that the FRAX prognostic threshold for identification of an increased risk of major bone fractures in hemodialysis patients is >5%. We propose to use this specific value of FRAX as an intervention threshold for pharmacological antifracture treatment in hemodialysis patients.

Differences in the Incidence of Pathologic Lesions on the Oral Mucosa in Patients Undergoing Hemodialysis vs Renal Organ Transplant Recipients Subjected to Long-term Pharmacologic Immunosuppressive Therapy

Disorders of homeostasis and an increased incidence of infection in patients undergoing hemodialysis causes frequent appearance of pathologic changes in the oral mucosa. The organ transplant and subsequent pharmacologic immunosuppression may result in systemic disorders manifesting by pathologic oral lesions.

METHODS

The study was conducted on 18 patients undergoing hemodialysis and 18 patients after renal transplant. The study comprised case taking and physical examination, including detailed intraoral and extraoral examination.

RESULTS

The intraoral examination revealed gingivitis in 61.1% of patients in both groups. In the renal transplant group compared with the hemodialysis group 55.6% vs 38.9% of patients had gingival recession, 55.6% vs 44.4% had periodontitis, 27.8% vs 22.2% had macroglossia, and 11.1% vs 5.6% had geographic tongue, respectively. In the patients on hemodialysis leukoplakia and pallor or pathologic pigmentation of oral mucosa were more frequently observed lesions. Other significant findings in the renal transplant group were lingual papillary atrophy, aphthae, and erythroplakia. Patients of both group reported xerostomia, halitosis, gum bleeding, dysgeusia in their history.

DISCUSSION

Both groups of patients after renal transplant and patients undergoing hemodialysis presented pathologic lesions in the oral cavity. The study revealed the differences between type and frequency of these pathologic changes, which shows different effect of the above methods of treatment of end-stage renal failure on the oral cavity.

Diffusion Weighted Magnetic Resonance Imaging in the Assessment of Renal Function and Parenchymal Changes in Chronic Kidney Disease: A Preliminary Study

Background

The aim of this study was to evaluate the feasibility of using intravoxel incoherent motion (IVIM) imaging for noninvasive assessment of pathologic changes in chronic kidney disease (CKD).

Material/Methods

Thirty-four patients with CKD and 20 healthy volunteers were examined on a 1.5 T magnetic resonance imaging (MRI) unit. The examination consisted of morphologic sequences and diffusion-weighted echo-planar sequence with 10 b values. Diffusion parameters were calculated with the use of mono- (apparent diffusion coefficient, ADC) and bi-exponential model: pure diffusion coefficient (D) and perfusion fraction (Fp). Blood samples to assess the serum creatinine level were taken immediately before examination. Ultrasound guided biopsies were performed in less than 30 days from MRI and were scored by an experienced nephropathologist. Parametrical unpaired t-test and ROC curve analysis were used to investigate differences in diffusion parameters in relation to estimated glomerular filtration rate (eGFR). Pearson’s correlation coefficients were calculated to assess relationship between diffusion parameters and laboratory and histopathological markers of renal damage. P-value <0.05 indicated statistical significance.

Results

Both ADC and D correlated positively with eGFR (respective r 0.74 and 0.72), however D showed a more significant correlation with histopathology: while D correlated negatively with parameters reflecting chronic glomerular (r −0.48) and tubulo-interstitial changes (r −0.47), ADC correlated only with interstitial infiltrations (r −0.44). Flow-related diffusion parameters showed high standard deviation.

Conclusions

IVIM imaging is sensitive to functional and morphologic changes in CKD. The separation of influence of Fp from true diffusion improves the assessment of chronic changes in renal parenchyma.

Defective gene expression of the membrane complement inhibitor CD46 in patients with progressive immunoglobulin A nephropathy

BACKGROUND

Complement is thought to play a role in immunoglobulin A nephropathy (IgAN), though the activating mechanisms are unknown. This study focused on the gene expression of CD46 and CD55, two key molecules for regulating C3 convertase activity of lectin and alternative complement pathways at a cellular level.

METHODS

The transcriptional expression in peripheral white blood cells (WBCs) of CD46 and CD55 was investigated in 157 patients enrolled by the Validation of the Oxford Classification of IgAN group, looking for correlations with clinical and pathology features and estimated glomerular filtration rate (eGFR) modifications from renal biopsy to sampling. Patients had a previous median follow-up of 6.4 (interquartile range 2.8-10.7) years and were divided into progressors and non-progressors according to the median value of their velocity of loss of renal function per year (-0.41 mL/min/1.73 m2/year).

RESULTS

CD46 and CD55 messenger RNA (mRNA) expression in WBCs was not correlated with eGFR values or proteinuria at sampling. CD46 mRNA was significantly correlated with eGFR decline rate as a continuous outcome variable (P = 0.014). A significant difference was found in CD46 gene expression between progressors and non-progressors (P = 0.013). CD46 and CD55 mRNA levels were significantly correlated (P < 0.01), although no difference between progressors and non-progressors was found for CD55 mRNA values. The prediction of progression was increased when CD46 and CD55 mRNA expressions were added to clinical data at renal biopsy (eGFR, proteinuria and mean arterial blood pressure) and Oxford MEST-C (mesangial hypercellularity, endocapillary hypercellularity, segmental glomerulosclerosis, tubular atrophy/interstitial fibrosis, presence of any crescents) score.

CONCLUSIONS

Patients with progressive IgAN showed lower expression of mRNA encoding for the complement inhibitory protein CD46, which may implicate a defective regulation of C3 convertase with uncontrolled complement activation.

Viruses in transplantology

The 3 leading causes of death in patients after solid organ transplantation (SOT) include cardiovascular diseases, malignancies, and infections. According to our current understanding, the latter play the key role in the pathogenesis of atherosclerosis. Similarly, infections (mainly viral) are implicated in the pathogenesis of at least 20% of known neoplasms. In other words, the implications of acute and chronic infectious diseases in modern medicine, not only transplantology, are significant and ever‑increasing. Immunosuppressive treatment impairs the immune function, which renders the patient more susceptible to infections. Furthermore, treatment of infections in immunocompromised patients poses a challenge and SOT. The current publication provides a brief summary of the key information provided in 20 lectures on viral infections in patients after SOT delivered during the 9th Practical Transplantology Course in Warsaw, Poland on September 15-16, 2017.

Should Immunosuppression After Kidney Transplant Be Adjusted Based on Renal Resistance During Pretransplant Hypothermic Machine Perfusion?

BACKGROUND

The hypothermic machine perfusion reduces delayed graft function after kidney transplant and allows, to some extent, predicting early graft function. However, it is difficult to identify exact perfusion criteria with which to exclude kidneys from transplant or modify post-transplant care. The aim of this study was to analyze whether renal resistance during the fourth hour of hypothermic machine perfusion is useful in the prediction of graft survival and acute rejection.

PATIENTS AND METHODS

Data on pretransplant hypothermic machine perfusion parameters of 407 transplanted kidneys were available. Receiver operating characteristic curve analysis was performed to find an optimal cutoff value of ratio for predicting a higher risk class of considered group of patients. According to this, patients were divided into 2 groups: those who received kidneys with renal resistance lower than 0.19 mm Hg/mL/min (R1; n = 187) and those who received kidneys with renal resistance equal to or higher than 0.19 mm Hg/mL/min (R2; n = 220). Within R2, we additionally analyzed 2 subgroups: patients who received induction therapy (R2-Ind+; n = 124) and those who did not received induction therapy (R2-Ind-; n = 96).

RESULTS

Acute rejection in R1 within 1 month post transplant was 2-fold lower compared with R2 and was 6.4% vs 13.1% (P = .03), respectively. One-year graft survival was higher in R1 compared with R2 and was 94.6% vs 88.5% (P = .03), respectively. Acute rejection in the R2-Ind+ subgroup within 1 month post transplant was 2.46-fold lower compared with the R2-Ind- subgroup and was 8% vs 19.7% (P = .01), respectively.

CONCLUSION

Immunosuppression treatment after transplant should be adjusted to perfusion parameters.

Predictors of Acute Kidney Injury in Deceased Kidney Donors After Brain Death

BACKGROUND

Donors with acute kidney injury (AKI) are generally accepted as a valuable source of kidneys for transplant. The aim of this study was to assess the risk of developing AKI based on deceased kidney donor parameters.

MATERIALS AND METHODS

The data of 162 kidneys procured from deceased donors after brain death were collected. These included clinical characteristics of donors and histologic assessment in organ biopsy specimens. The donors' kidney terminal function was classified according to the Acute Kidney Injury Network criteria. All biopsies were performed with the use of a 16G automatic needle, and the 20-mm tissue specimen was available in all cases. Biopsy specimens were secured and prepared in a routine way with hematoxylin and eosin. The presence of chronic changes was analyzed according to the Banff 2009 classification by 1 experienced nephropathologist. The logistic regression model was used to assess the risk of AKI regarding donor characteristics and histologic findings.

RESULTS

There were 50 kidneys (30.9%) with AKI identified. The risk of AKI increased with donor age (P = .002; odds ratio [OR], 1.02; 95% CI, 1.01-1.03), body mass index (P = .003; OR, 1.05; 95% CI, 1.01-1.09), and male sex (P = .001; OR, 1.79; 95% CI, 1.31-2.27). Regarding the histologic findings, the interstitial fibrosis presence was a risk factor of AKI (P = .004; OR, 1.04; 95% CI, 1.01-1.06).

CONCLUSIONS

Older donor age, male sex, higher body mass index, and presence of interstitial fibrosis in kidney graft biopsy specimen are risk factors of AKI.

Time of Cold Storage Prior to Start of Hypothermic Machine Perfusion and Its Influence on Graft Survival

BACKGROUND

Hypothermic machine perfusion (HMP) has become a standard method of preservation for kidneys procured from expanded-criteria donors and donors after cardiac death. There are different systems and approaches to the HMP preservation period, with cold storage prior to HMP sometimes taking several hours. This study evaluated whether the time at which kidneys receive HMP had any influence on the outcomes of kidney transplantation.

METHODS

In this analysis, patient and graft survival were evaluated over a 1-year post-transplantation period. Patients who received HMP kidneys (n = 379) were divided into 2 groups: those who received kidneys with a cold ischemia time (CIT) prior to HMP <295 minutes (group G1; n = 254) and those who received kidneys with CIT prior to HMP >295 minutes (group G2; n = 125).

RESULTS

Delayed graft function was observed in 31.8% (81/254) of patients in group G1 vs 46.4% (58/125) of patients in group G2 (P = .007). One-year graft survival was statistically higher in the group G1 (93.2%; 233/254) vs group G2 (86.5%; 105/125, P = .029). Mean 1-year estimated glomerular filtration rate was significantly better in the group G1.

CONCLUSIONS

In conclusion, introduction of HMP up to 295 minutes from procurement led to better early and 1-year graft results. Kidneys should receive HMP as soon as possible after retrieval, preferably during procurement.

Urinary levels of CCL2 and CXCL10 chemokines as potential biomarkers of ongoing pathological processes in kidney allograft: an association with BK virus nephropathy

INTRODUCTION

Early prognostic markers that identify high‑risk kidney transplant recipients may lead to optimization of immunosuppressive therapy and improved long‑term outcomes.

OBJECTIVES

The aim of this study was to assess whether the measurement of urinary concentrations of CCL2 and CXCL10 chemokines can be a valuable noninvasive tool for identifying ongoing pathological processes in a kidney allograft.

PATIENTS AND METHODS

The study included 40 patients who underwent a protocol biopsy within 1‑year post kidney transplant. The urinary concentrations of CCL2 and CXCL10 with reference to creatinine in urine were assayed in all patients. On the basis of biopsy results, a study group was selected (n = 25), including patients with a diagnosis of interstitial fibrosis and tubular atrophy grades II to III (n = 16), BK virus (BKV) nephropathy (n = 4), or mild inflammatory lesions fulfilling the criteria for mild rejection processes or borderline lesions (n = 11). Patients with normal biopsy results were included in a control group (n = 15).

RESULTS

The ratio of CCL2 to creatinine (CCL2:Cr) was a significant independent predictor of BKV ephropathy (odds ratio, 1.1; 95% CI, 1.0-1.2; P = 0.04). The CXCL10:Cr ratio was not found to be an independent predictor of BKV nephropathy (odds ratio, 1.3; 95% CI, 0.99-1.71; P = 0.06).

CONCLUSIONS

The CCL2:Cr and CXCL10:Cr ratios may predict BKV nephropathy. The diagnostic value of CCL2 and CXCL10 in BKV infection should be further evaluated.

Long-term outcome of renal transplantation: a 10-year follow-up of 765 recipients

INTRODUCTION

Renal transplantation is a treatment of choice for patients with end‑stage renal disease. The main goal of transplant care is to achieve the best long‑term patient survival (PS) and graft survival (GS).

OBJECTIVES

We aimed to assess the impact of various immunosuppression (IS) protocols on PS and GS following renal transplantation.

PATIENTS AND METHODS

This was a retrospective single‑center cohort study including a total of 765 consecutive adult renal transplant recipients (RTRs) who underwent transplantation between 1998 and 2003. The primary endpoints included PS and GS. The secondary endpoints were graft function determined by estimated glomerular filtration rate and hospitalization length per patient per year.

RESULTS

Ten‑year PS and GS rates were 88.6% and 78.7%, respectively. The intent‑to‑treat (ITT) group received IS that was later changed, whereas in the group on randomized therapy (ORT), the same IS protocol was maintained during follow‑up. The ITT group had significantly better PS and GS than the ORT group. In the ITT group, patients treated with a combination of tacrolimus (TAC) and azathioprine (AZA), cyclosporine (CSA) and AZA, or CSA and mycophenolic acid metabolites (MPAs) had significantly better PS than those treated with TAC and MPA. The ORT group receiving AZA in any combination also had significantly better PS than MPA‑treated individuals.

CONCLUSIONS

The effect of IS protocols on long‑term outcomes varies depending on patient subpopulations. Immunosuppressive therapy solves rejection‑related problems but does not address the increasing mortality of RTRs due to cardiovascular diseases, malignancies, or infections. Therefore, treatment recommendations should be individualized and posttransplant care, provided mainly by internists, should be carefully structured to improve long‑term outcomes of renal transplantation.

Successful transplantation of kidneys from deceased donors with terminal acute kidney injury

BACKGROUND

There are many doubts with regards to accepting deceased kidneys with acute kidney injury (AKI) for transplantation.

PURPOSE

The aim of this study was to present the 5-years outcome of kidney transplantation cases where deceased donors developed AKI before organ procurement.

METHODS

Two hundred twenty-six deceased renal transplants were analyzed. Data regarding donors and recipients were collected. Terminal AKI was defined as terminal serum creatinine concentration higher than 1.99 mg/dL and 66 such cases were diagnosed. All kidney transplant recipients were followed for 60 months.

RESULTS

AKI group presented more episodes of delayed graft function (DGF) compared to the non-AKI group (56% vs 35%, p < .05). No differences were observed between the groups in the rate of acute rejection episodes, kidney function as well as patient and graft survival.

CONCLUSIONS

Transplants with AKI present more often DGF and comparable graft survival to transplants without AKI. Kidneys with AKI can be a valuable source of organs provided attentive selection and appropriate care of deceased donors.

The use of anticoagulants in chronic kidney disease: Common point of view of cardiologists and nephrologists

In patients diagnosed with chronic kidney disease (CKD), atrial fibrillation (AF) is associated with an increased risk of thromboembolism and stroke. Moreover, patients with CKD - especially those in end-stage renal disease - also present an increased risk of bleeding. Oral anticoagulation is the most effective form of thromboprophylaxis in patients with AF and an increased risk of stroke. However, the underuse of these drugs was observed, mainly due to safety reasons and restricted evidence on efficacy. Much evidence suggests that non-vitamin K-dependent oral anticoagulant agents significantly reduce the risk of stroke, intracranial hemorrhage, and mortality, with lower to similar major bleeding rates compared with vitamin K antagonists, such as warfarin, in normal renal function subjects. Thus, they are currently recommended for that group of patients. However, their metabolism is largely dependent on the kidneys for elimination, and current knowledge in this area is limited due to patients with a decreased glomerular filtration rate are usually excluded from clinical trials. The present review article focuses on currently available data on oral anticoagulants in patients with moderate to advanced chronic kidney disease and those with end stage renal disease.

Therapeutic Problems and Pregnancy in a Patient With Infantile Nephropathic Cystinosis: A Case Report

BACKGROUND

Cystinosis is a rare genetic disorder characterized by the abnormal accumulation of cystine in the lysosomes of various tissues and organs leading to their dysfunction. The most common type is the infantile nephropathic cystinosis which without treatment leads to renal failure and before the introduction of cysteamine was the cause of death before puberty.

CASE PRESENTATION

A 27-year-old female patient with infantile cystinosis developed end-stage renal disease at the age of 10. The first kidney transplantation from patient's father was carried out at the age of 12. The recurrent urinary tract infections led to the graft failure after 6 years. Following the removal of right appendages due to the ovarian tumor, the patient underwent the second kidney transplantation from her mother at the age of 19. After the transplantation, the cysteamine treatment was irregular due to limited availability of the medicine. When it became regular in 2017 the patient did not tolerate full doses. Despite elevated blood levels of cystine and the removal of right appendages, the patient naturally became pregnant in August 2017. Except for recurrent urinary tract infections, the renal parameters remained normal throughout the entire pregnancy. However, in the 32nd week of gestation, due to preeclampsia a caesarean section was performed. A healthy daughter was born, 1400/41 and with a 9 point Apgar score.

CONCLUSIONS

Due to the possibility of treatment with cysteamine and kidney transplantations, patients with cystinosis live longer and their quality of life improves. These female patients can even naturally become pregnant and give birth to healthy children.

Successful Pediatric Kidney Transplantation Into an Adult Recipient: A Case Report

BACKGROUND

The constant shortage of kidney donors prompts exploration into new strategies of transplantation. One of these strategies is the use of pediatric donors aged up to 5 years whose kidneys can be transplanted into adult recipients, mainly en bloc. This involves retrieving kidneys en bloc with aorta and inferior vena cava and anastomosing them to the recipient's external iliac vessels.

CASE PRESENTATION

In our hospital, kidneys from a 3-year-old child were transplanted to a 30-year-old man. The recipient with end-stage renal failure, due to glomerular nephritis, was dialyzed for 12 years and had 1 failed transplantation with consequent graftectomy. In 2009, kidneys were transplanted to the external iliac artery and vein with reconstruction of the renal vessels. Shortly after transplantation the patient had normal renal measures. Three months later a critical stenosis of 1 renal artery was detected. Angioplasty was performed but technical reasons did not allow for effective dilatation of the vessel. Further, 6 months after kidney transplantation (KTx) nephrotic proteinuria appeared and features of membranous nephropathy were detected in a renal biopsy. The proteinuria subsided after administration of ramipril and losartan. Doppler ultrasound revealed that 1 artery remained 90% stenotic with a peak systolic velocity of 377 cm/sec. Despite reported complications, renal function appeared normal over 7 years of observation.

CONCLUSIONS

A transplantation of 2 pediatric kidneys into an adult recipient has very high efficacy. The survival of both graft and recipient is similar to the results obtained after living donor kidney transplantation.

Pharmacokinetics of free and total mycophenolic acid in adult lupus nephritis patients-implications for therapeutic drug monitoring

PURPOSE

To evaluate the relationship between total and free MPA pharmacokinetic (PK) parameters and renal outcome markers, and to verify whether conducting therapeutic drug monitoring (TDM) in lupus nephritis (LN) patients would be of value in routine clinical practice.

METHODS

Eighty-four samples were collected from sixteen LN patients. Total and free MPA concentrations were measured at predose, 0.5 and 2 h after mycophenolate mofetil (MMF) intake. Area under the concentration time curve from 0 to 2 h (AUC_0-2) and free fraction were calculated.

RESULTS

High between-patient variability was observed (CV% of 53.5% for dose-normalized total MPA AUC_0-2). A significant but weak correlation between dose-normalized total C₀ and AUC_0-2 was noted (r = 0.5699). Dose-normalized total C₀ above 2.76 μg/mL·g may indicate patients with eGFR < 81 mL/min with sensitivity of 83.3% and specificity of 75.0%. Hypoalbuminemic LN patients demonstrated significantly elevated MPA free fraction when compared with patients with serum albumin concentration ≥ 3.5 g/dL (1.49 ± 0.64% vs 1.08 ± 0.75%).

CONCLUSION

This study examined relationship between free and total pharmacokinetic MPA parameters as well as the effect of hypoalbuminemia on MPA plasma protein binding in adult LN patients. The study results suggest that TDM of MPA in LN seems to be a more reasonable approach than the fixed-dose protocol. Moreover, predose total MPA concentration may be a possible estimation of MPA exposure, while monitoring free rather than total MPA may be more beneficial in hypoalbuminemic patients.

Is there long-term value of pathology scoring in immunoglobulin A nephropathy? A validation study of the Oxford Classification for IgA Nephropathy (VALIGA) update

Background

It is unknown whether renal pathology lesions in immunoglobulin A nephropathy (IgAN) correlate with renal outcomes over decades of follow-up.

Methods

In 1130 patients of the original Validation Study of the Oxford Classification for IgA Nephropathy (VALIGA) cohort, we studied the relationship between the MEST score (mesangial hypercellularity, M; endocapillary hypercellularity, E; segmental glomerulosclerosis, S; tubular atrophy/interstitial fibrosis, T), crescents (C) and other histological lesions with both a combined renal endpoint [50% estimated glomerular filtration rate (eGFR) loss or kidney failure] and the rate of eGFR decline over a follow-up period extending to 35 years [median 7 years (interquartile range 4.1–10.8)].

Results

In this extended analysis, M1, S1 and T1–T2 lesions as well as the whole MEST score were independently related with the combined endpoint (P &lt; 0.01), and there was no effect modification by age for these associations, suggesting that they may be valid in children and in adults as well. Only T lesions were associated with the rate of eGFR loss in the whole cohort, whereas C showed this association only in patients not treated with immunosuppression. In separate prognostic analyses, the whole set of pathology lesions provided a gain in discrimination power over the clinical variables alone, which was similar at 5 years (+2.0%) and for the whole follow-up (+1.8%). A similar benefit was observed for risk reclassification analyses (+2.7% and +2.4%).

Conclusion

Long-term follow-up analyses of the VALIGA cohort showed that the independent relationship between kidney biopsy findings and the risk of progression towards kidney failure in IgAN remains unchanged across all age groups and decades after the renal biopsy.

Resistance to Aminoglycosides of Methicillin-Resistant Strains of Staphylococcus aureus, Originating in the Surgical and Transplantation Wards of the Warsaw Clinical Center-A Retrospective Analysis

INTRODUCTION

Aminoglycoside resistance (AR) is common in health care-associated methicillin-resistant Staphylococcus aureus (HA-MRSA). AR is most often associated with the production of antibiotic modifying enzymes: bidomain AAC(6')-Ie/APH(2″)-Ia acetyltransferase and phosphotransferase, ANT(4')-Ia nucleotidyltransferase, and APH(3″)-IIIa phosphotransferase.

AIM

Determination of aminoglycoside sensitivity, presence of genes encoding enzymes, and molecular typing of HA-MRSA strains derived from patients hospitalized in surgical and transplantation wards.

MATERIALS AND METHODS

Fifty-four HA-MRSA strains, isolated from various materials from patients in the surgical and transplantation wards of Warsaw's clinical hospital, hospitalized between 1991 and 2007. The MIC values of gentamicin-GEN/tobramycin-TOB/amikacin-AK/netilmicin-NET were determined by the E-test (CLSI/EUCAST). Genes mecA/aacA-aphD/aadD/aph(3″)-IIIa were detected using PCR. SCCmec types were determined according to the Oliveira method and the sequence type (ST)/clonal complex (CC) by the MLST method.

RESULTS

Of the isolates tested, 36 (66.7%) showed resistance to at least one aminoglycoside: TOB (57.4%), GEN (53.7%), AK (55.6%), NET (24.1%). The aacA-aphD gene was present in 29 MRSA-GEN-R (most often in combination with aadD, 15/29 or aph(3″)-IIIa, 10/29); the aacA-aphD gene was the only determinant of resistance in 1 isolate. The AR variants mainly belonged to the CC8 clonal complex (ST239/247/241/254/8) and most frequently contained SCCmec type III (3A) cassettes.

CONCLUSIONS

Resistance to at least one aminoglycoside was present in 66.7% of HA-MRSA and in more than 22% to all of them. The presence of the aacA-aphD gene was sufficient to express the resistance phenotype to GEN/TOB/AK/NET. Resistant isolates were closely related to each other.

Reconstruction of Multiple Renal Arteries During Simultaneous Pancreas and Kidney Transplantation: A Case Report

We present a case of a multiple renal artery reconstruction during simultaneous pancreas and kidney transplantation. The kidney graft had 6 renal arteries, the aorta patch was 10 cm long, and there were two renal veins. To perform anastomoses to the left external iliac vessels we had to reconstruct the renal arterial and venal patches. The results of the transplantation were very good. Both grafts had satisfactory function, even though a control computed tomography performed a year after transplantation revealed infarction of a lower renal pole. Anatomical anomalies should not be a contraindication for transplantation, although transplants involving a multiplicity of vessels is a challenge for surgeons and requires both knowledge and microsurgical skills.

Long-term Outcomes in Simultaneous Pancreas-Kidney Transplant Recipients: Single-center Experience From Poland

BACKGROUND

Simultaneous pancreas-kidney transplantation (SPKT) is the treatment of choice for patients with end-stage renal disease (ESRD) due to type 1 diabetes mellitus (DM1). Since the 1980s, pancreas transplantation has become the most effective strategy to restore normoglycemia in patients with DM1. The aim of this study was to present long-term outcomes data for SPKT.

METHODS

We performed a retrospective analysis of 73 SPKT recipients followed in our outpatient center who underwent transplantation between 1988 and 2015.

RESULTS

A total of 50.7% of the patients were male. At the time of surgery, patients' mean age was 37.38 ± 7.44 years. Patients were diagnosed with DM1 at an average of 25 ± 6.08 years before SPKT. For 21.9% of patients, the transplant was done preemptively. Most (91.8%) had enteric drainage. All patients received induction of immunosuppression (either polyclonal immunoglobulins anti-thymocyte globulin or thymoglobulin [64.4%] or monoclonal globulins daclizumab or basiliximab [35.6%]). Patient survival at 1, 5, 10, 15 years was 99%, 97%, 89%, and 75%; kidney survival was 99%, 96%, 84%, and 67%; and pancreas survival was 95%, 92%, 84%, and 64%, respectively. There was a notable tendency toward increased creatinine level (from 1.18 at 1 year to 1.78 at 15 years) and decreased hemoglobin level (from 13.84 at 1 year to 12.65 at 15 years).

CONCLUSION

Diabetic patients with ESRD have a poor prognosis without transplantation. SPKT provides marked prolongation of the patient's life and freedom from insulin injections. Enteric drainage is currently the surgical technique of choice. SPKT should remain as the treatment of choice in this patient population.

Analysis of Hospitalizations in Simultaneous Pancreas-Kidney Transplant Recipients: A Single-center Experience in Poland

BACKGROUND

End-stage renal disease due to type 1 diabetes mellitus appears to be a regular indication for simultaneous pancreas and kidney transplantation (SPKT). Although transplantation improves a patient's health condition, it does not mean that all complications will be eliminated.

METHODS

We performed a retrospective analysis of 73 patients who underwent SPKT and follow-up between 1988 and 2015 at our institute. The number, duration, and reasons for hospitalization at 1, 5, 10, and 15 years after SPKT were analyzed.

RESULTS

The average number of hospitalizations at 1, 5, 10, 15 years after SPKT were 1.66, 0.39, 0.36, and 0.33, respectively. The main reason for hospitalization over the 15-year period was infections, at 32.4% (SD, 6.8%). Within the first year after SPKT, 6.8% of hospital admissions were caused by cytomegalovirus (CMV) infection. Over time, the percentage of hospitalizations for cardiovascular complications increased from 0.6% at 1 year to 29% at 12-15 years. Incidence of hospitalization due to cardiovascular complications correlated with a longer period of dialysis and a diagnosis of ischemic heart disease before transplant (r = 0.56, P = .004; r = 0.54, P < .0001, respectively). At 12-15 years after transplantation, 18.2% of hospitalizations were caused by secondary complications of diabetes.

CONCLUSION

The most common reason for hospitalization after SPKT is infectious complications. In the first year posttransplant, there is a high percentage of CMV infections. Hospitalization associated with cardiovascular complications was found to be most common in the latter follow-up period and showed a correlation with longer dialysis period.

Significance of Screening Tests and the Incidence of New Delhi Metallo-beta-lactamase-Producing Gram-negative Bacilli in the Surgery and Transplantation Wards of a Warsaw Medical Center During the Period From April 2014 to May 2017

BACKGROUND

The first New Delhi metallo-beta-lactamase (NDM)-producing bacteria were isolated in 2008 in the world, and in 2011 in Poland. Due to the high clonal diversity (17 types) of their blaNDM gene, encoded on (Tn125-like) mobile genetic elements, these strains usually exhibit resistance to nearly all available antibiotics, which is particularly dangerous for organ transplant recipients.

PURPOSE

To assess of the prevalence of Gram-negative NDM-positive bacilli in surgery/transplantation wards of a teaching hospital in Warsaw and to ascertain the significance of screening tests on the rates and nature of colonization.

MATERIALS AND METHODS

The evaluated strains were isolated from 30 patients (between April 2014 and May 2017). The species were identified with VITEK-MS, antibiotic susceptibility was determined with VITEK 2, disk-diffusion, and/or E-test methods, according to EUCAST guidelines. The presence of the blaNDM-1 gene was confirmed using the polymerase chain reaction technique.

RESULTS AND CONCLUSIONS

There were 77 blaNDM-1-positive Klebsiella pneumoniae strains isolated from 30 patients. Cultures from individual patients, mainly from rectal swabs (53.9%) and urine samples (39.8%), yielded 1-11 isolates. Fifteen patients were already colonized on admission, and the other 15 developed a symptomatic infection. In total, 24 (80%) patients were carriers, and their colonizations persisted for <1-20 months. Most isolates were susceptible only to colistin, gentamicin, amikacin, tigecycline, and/or sulfamethoxazole/trimethoprim. Gastrointestinal-tract-colonizing K pneumoniae are the main reservoir of the blaNDM-1 gene. Following the introduction of on-admission mandatory screening for carbapenem-resistant strains, the rates of NDM-producing K pneumoniae isolation increased (7.5-fold), while the rates of isolation from patients with symptomatic infections considerably decreased (2.8-fold).