Renal AA amyloidosis revealing extramedullary plasmocytoma

Introduction

Solitary plasmacytoma is a rare, localized malignancy. Bone localizations are the most common. Extramedullary plasmacytomas are much rarer. They are most often in the upper respiratory tract and can be complicated by amyloidosis. Here is an original report of a mediastinal extramedullary plasmacytoma revealed by type AA renal amyloidosis.

Case presentation

We present the case of a 52-year-old patient with mediastinal extramedullary plasmocytoma diagnosed by renal failure due to type AA renal amyloidosis. Treatment was based on surgery with chemotherapy based on prednisone and melphalan. The patient presented end-stage renal failure that required hemodialysis at discharge.

Conclusion

Extramedullary plasmacytoma is a rare tumour that may be associated with amyloidosis, usually type AL. To our knowledge, its association with AA amyloidosis has not been reported in the literature. Treatment is based on surgery combined with radiotherapy or chemotherapy.

Predicting long-term outcomes of kidney transplantation in the era of artificial intelligence

The ability to accurately predict long-term kidney transplant survival can assist nephrologists in making therapeutic decisions. However, predicting kidney transplantation (KT) outcomes is challenging due to the complexity of the factors involved. Artificial intelligence (AI) has become an increasingly important tool in the prediction of medical outcomes. Our goal was to utilize both conventional and AI-based methods to predict long-term kidney transplant survival. Our study included 407 KTs divided into two groups (group A: with a graft lifespan greater than 5 years and group B: with poor graft survival). We first performed a traditional statistical analysis and then developed predictive models using machine learning (ML) techniques. Donors in group A were significantly younger. The use of Mycophenolate Mofetil (MMF) was the only immunosuppressive drug that was significantly associated with improved graft survival. The average estimated glomerular filtration rate (eGFR) in the 3rd month post-KT was significantly higher in group A. The number of hospital readmissions during the 1st year post-KT was a predictor of graft survival. In terms of early post-transplant complications, delayed graft function (DGF), acute kidney injury (AKI), and acute rejection (AR) were significantly associated with poor graft survival. Among the 35 AI models developed, the best model had an AUC of 89.7% (Se: 91.9%; Sp: 87.5%). It was based on ten variables selected by an ML algorithm, with the most important being hypertension and a history of red-blood-cell transfusion. The use of AI provided us with a robust model enabling fast and precise prediction of 5-year graft survival using early and easily collectible variables. Our model can be used as a decision-support tool to early detect graft status.

Fulminant lupus pneumonitis complicating systemic lupus erythematosus in the elderly

Fulminant lupus pneumonitis is a rare complication of SLE. We report a case of 75 years-old male patient with SLE who developed pneumonia and severe respiratory failure requiring mechanical ventilation. Refractory respiratory distress complicating noninfectious fulminant lupus pneumonitis did not respond to methylprednisolone and intravenous immunoglobulin treatment.

Toward generalizing the use of artificial intelligence in nephrology and kidney transplantation

With its robust ability to integrate and learn from large sets of clinical data, artificial intelligence (AI) can now play a role in diagnosis, clinical decision making, and personalized medicine. It is probably the natural progression of traditional statistical techniques. Currently, there are many unmet needs in nephrology and, more particularly, in the kidney transplantation (KT) field. The complexity and increase in the amount of data, and the multitude of nephrology registries worldwide have enabled the explosive use of AI within the field. Nephrologists in many countries are already at the center of experiments and advances in this cutting-edge technology and our aim is to generalize the use of AI among nephrologists worldwide. In this paper, we provide an overview of AI from a medical perspective. We cover the core concepts of AI relevant to the practicing nephrologist in a consistent and simple way to help them get started, and we discuss the technical challenges. Finally, we focus on the KT field: the unmet needs and the potential role that AI can play to fill these gaps, then we summarize the published KT-related studies, including predictive factors used in each study, which will allow researchers to quickly focus on the most relevant issues.

Incidence and challenges in management of hemodialysis catheter-related infections

Catheter-related infections (CRI) are a major cause of morbidity and mortality in chronic hemodialysis (HD) patients. In this paper, we share our experience with CRI in HD patients. We recorded 49 cases of CRI among 167 patients during a period of 40 months (January 2018-April 2021). The incidence of CRI was 3.7 per 1000 catheter-days. The revealing symptoms were dominated by fever or chills (90%). Inflammatory signs were observed in 74% of cases with respectively concurrent exit-site (51%) and tunnel infection (6%). The biological inflammatory syndrome was found in 74% of patients (average CRP level = 198.9 mg/l). Blood cultures were performed in all cases and were positive in 65% of cases. Thirteen patients have been diagnosed with Infection complications, which were respectively infective endocarditis in 7 cases, septic arthritis in 3 cases, infective myositis in one case, cerebral thrombophlebitis in 1 case and mediastinitis in 1 case. The death occurred in eleven patients, it was due to septic shock in 9 cases, pulmonary embolism in one case and neurologic alterations related to cerebral thrombophlebitis. The mean seniority in HD was 16.5 months in the group with CRI and 3.7 months in the group without CRI (p < 0.04). We did not notice significant difference in mortality between tunnelled and non-tunnelled catheters. CRI does not seem to be more severe in patients with diabetes. Duration of use of the HD catheter (p < 0.007) and ferritin level (p < 0.0001) were independent factors that predispose to CRI in our population.

Vascularite à anticorps anti-membrane basale glomérulaire secondaire au Covid-19 : observation inédite !

Introduction

La maladie des anticorps anti-membrane basale glomérulaire (Ac anti-MBG) est une affection auto-immune médiée par des anticorps dirigés conte la MBG et alvéolaire définissant le syndrome pneumo rénal. Plusieurs facteurs environnementaux ont été incriminés dans la genèse de cette maladie notamment les infections virales des voies respiratoires. Nous rapportons le cas d’une maladie à Ac anti-MBG survenue suite à une infection par le Sars Cov2.

Observation

Patiente âgée de 56 ans, non tabagique, suivie pour une insuffisance antéhypophysaire sous traitement substitutif, qui a consulté aux urgences pour fièvre, rhinorrhée, toux, diarrhée avec douleurs abdominales diffuses et oligurie évoluant depuis 02 semaines. L’examen objectivait une fièvre à 39 °C, un état hémodynamique stable, une pression artérielle à 11/06 mmHg et une tachycardie à 110 bpm. La saturation pulsée de l’oxygène était à 95 % à l’air ambiant. Elle présentait des œdèmes des 2 membres inférieurs de type rénal. Les bandelettes urinaires ont objectivé une hématurie à 2 croix associée à une protéinurie à 2 croix. Le reste de l’examen était sans anomalies. La patiente présentait à la biologie une créatinine à 1295 μmol/L, une protéinurie de 24 heures à 1 g, un syndrome inflammatoire et une anémie hypochrome microcytaire. L’échographie rénale a objectivé des reins de taille normale avec une bonne différenciation cortico-médullaire.

Devant les signes respiratoires et la fièvre, une infection par le Sars-Cov2, fortement suspectée vue le contexte pandémique, était confirmée par un test PCR. Par ailleurs, devant l’insuffisance rénale aiguë, la patiente a eu des séances d’hémodialyse et une ponction biopsie rénale avec étude en immunofluorescence montrant une glomérulonéphrite extra-capillaire associée à des dépôts linéaires d’IgG et une nécrose fibrinoïde. Les étiologies toxiques, iatrogènes, infectieuses (hormis la Covid) et néoplasiques étaient éliminées. Devant ce tableau clinico-biologique, histologique et la positivité du bilan immunologique montrant des Ac anti-MBG positif à 3+ des anticorps antimyéloperoxydase positif à 2+ associés à une cryoglobulinémie positive, le diagnostic de maladie des Ac anti-MBG était retenu. Un complément d’exploration par fibroscopie bronchique avec lavage broncho-alvéolaire était en faveur d’une hémorragie intra-alvéolaire avec un score de Golde à 102. La patiente a reçu donc des boli de méthylprednisolone à la dose de 800 mg/j durant 3 jours, relayés par une corticothérapie orale à la dose de 1 mg/kg/j associés aux échanges plasmatiques et à l’hémodialyse. Après guérison de l’infection COVID-19, des cures de cyclophosphamide ont été initiées. L’évolution sur le plan rénal était marquée par le passage au stade terminal de l’insuffisance rénale chronique nécessitant l’épuration extrarénale régulière.

Conclusion

Plusieurs cas de vascularite post infection Covid-19 ont été rapportés dans la littérature. Les mécanismes physiopathologiques responsables de cette association restent jusque-là mal élucidés. Ainsi, devant toute anomalie du sédiment urinaire et/ou de la fonction rénale survenant au cours ou au décours de la maladie Covid-19, une vascularite doit impérativement être évoquée afin d’instaurer un traitement adapté le plutôt possible, seul garant d’un meilleur pronostic.

MO054: Histological Findings in Drug-Induced Acute Interstitial Nephritis

BACKGROUND AND AIMS

Acute interstitial nephritis (AIN) represents an important cause of acute kidney injury. The most common etiology of AIN is drug-induced disease. Definitive diagnosis of AIN requires renal biopsy. Despite this, there is a lack of consensus regarding precise histological diagnostic criteria, and the clinical significance of common histological findings is uncertain. The aim of this study was to explore the histological characteristics of drug-induced AIN and to evaluate their impact on the renal outcome.

METHOD

We conducted a retrospective study that included patients with biopsy proven drug-induced AIN, followed in the department of nephrology of Charles Nicolle hospital in Tunis during the period between 1990 and 2019. Histological diagnosis of AIN was based on the presence of an interstitial inflammatory cell infiltrate with or without fibrosis.

RESULTS

During the period of the study, we collected 69 cases of biopsy proven AIN. The diagnosis of drug-induced AIN was performed in 23 patients (33%), with a medium age of 35 years. In eight patients (35%), nonsteroidal anti-inflammatory drugs were the culprit, followed by antibiotics in six patients (26%) and other drugs in three cases (13%). In six patients (26%), no single drug could be identified as the culprit, and these were classified as multidrug causes. The presence of acute kidney disease was the main indication for the kidney biopsy. All cases were characterized by a prominent tubulointerstitial inflammatory cell infiltrate. Interstitial infiltration was mild in three cases (13%), moderate in five cases (17%) and severe in 15 cases (65%). The interstitial infiltrate consisted predominantly of lymphocytes. The presence of eosinophils has been noted in 10 cases (43%). Interstitial granulomas were noted in two patients (8%). Interstitial edema and tubulitis were observed in 13 (56%) and 6 cases (26%), respectively. In seven patients (30%) interstitial fibrosis was present, and four patients (17%) had mild-to-moderate tubular atrophy, whereas tubular necrosis was present in seven cases (30%). After a mean follow up of 24 months, eight patients (35%) progressed to chronic kidney disease. Histological factors associated with poor renal outcome, were interstitial fibrosis (P ˂ 0.001) and tubular atrophy (P = 0.01). Patients with interstitial edema (P ˂ 0.001) or tubulitis (P = 0.005) had a better renal prognosis.

CONCLUSION

Renal biopsy is required to establish a definitive diagnosis of drug-induced AIN. Nevertheless, it is not carried out in a systematic way. The composition of cells in the interstitial infiltrate may at times be helpful in determining the etiology of AIN. In particular, the presence of a considerable proportion of eosinophils favors a diagnosis of drug-induced AIN. Moreover, during drug-induced AIN, histological data have a great prognostic value. In our study, the main histological prognostic factors were interstitial fibrosis, tubular atrophy, interstitial edema and tubulits. Further studies are needed to validate these results and establish a score based on histological data in order to predict renal outcome during drug-induced AIN.

Hospitalization patterns in HD patients in the Kingdom of Saudi Arabia: A comprehensive cohort study

INTRODUCTION

The rate of hospitalization represents a morbidity indicator in HD patients. The study aimed to evaluate hospitalization patterns in a large HD cohort.

METHODS

All DaVita-KSA HD patients from October 2014 to December 2019 were included. Demographical and clinical characteristics and hospitalization data were recorded. Less than 24 h admission was excluded. Overall and cause-specific hospitalization rates were calculated.

RESULTS

During the follow-up period, 3982 patients with a mean age of 52.5 ± 16.8 years, 2667 hospitalizations were recorded in 34.1% of the patients and 45.6% had repeated admissions. Infectious causes accounted for 26.6% of all recorded causes vs. 15.6% for cardiovascular complications. The median hospital stay length was 11 days, while the overall annual hospitalization rate of 34.9% and the annual duration of 3.7 days per patient. Hospitalized patients had a higher risk of mortality (p < 0.001).

CONCLUSION

Infectious complications were the leading cause of hospitalization and had the longest hospital stay.

La pandémie COVID-19 a-t-elle changé mon médecin ? Point de vue du patient de médecine interne

Introduction

Patients et méthodes

Résultats

Conclusion

MO970GRAFT OUTCOME AFTER ACUTE REJECTION: A CASE CONTROL STUDY

Background and Aims

Although Acute rejection (AR) is a complication associated with the early period after kidney transplantation (KT), its complications are mostly seen after a long term. The aim of this study was to evaluate graft outcome after AR.

Method

It was a longitudinal, retrospective, analytical study including kidney transplant patients followed up in our department between 1986 and 2019. Our population was divided in 2 groups: group A (129 KT complicated by at least one episode of AR) and group B (491 KT not complicated by AR).

Results

AR was responsible of immediate loss of 2 grafts. Chronic graft dyfonction was more frequent in group A (44,1% versus 17,4%, p&lt;0,0001). Creatininemia levels were significantly higher at 3, 6 months, 1 year and 2 years (respectively p =0,0113 ; &lt;0,0001 ; 0,0003 and 0,0172) after KT. The percentage of patients having creatinine levels &gt; 130 µmol/l was higher in group A at 3, 6 months, 1 year, 2 years, 3 years and 5 years (respectively p =0,0186 ; 0,001 ; &lt;0,0001 ; 0,0115 ; 0,0073 and 0,0255).

Graft survival was better in group B (p&lt;0,0001). In group A, AR recurrence was responsible of a worser survival (p&lt;0,0001). Over time, graft survival improved in the 2 groups. Complete functional recovery survival was similar to graft with no rejection but with impared graft function. The worst graft survival was noted if the functional recovery was absent.

Conclusion

Even if graft outcome after AR has improved over time, its deleterious effect is still inevitable. So AR must be prevented in order to enhance graft outcome.

P1463AMORTALITY AND HOSPITALIZATION PATTERNS IN ELDERLY HEMODIALYSIS PATIENTS. A LARGE SAUDI STUDY

Background and Aims

The aim of the study was to analyze hospitalization and mortality parameters in Saudi elderly patients undergoing hemodialysis for end stage renal disease.

Method

The study population included all patients admitted at Davita-KSA clinics to continue renal replacement by hemodialysis during the period October 2014-December 2018. Two groups were identified according to age at admission to Davita clinics: Group 1 (age&gt;=65 years), Group 2 (age&lt;65 years). Zero time data, including demographic and clinical characteristics were recorded at admission. Also, all deaths and morbid events necessitating hospital admission were regularly recorded during the follow-up period.

Annual mortality and hospitalization rates with the corresponding confident intervals were calculated as appropriate. Survival rates were calculated according to actuarial method logistic regression was used to identify factors influencing hospitalization and mortality.

Results

Elderly patients represented 23.84% of 3508 included patients (G1),). The sex ratio was of 1.07 Vs. 1.21 in control group (NS). ESRD was attributed to diabetes in 52.7% of elderly patients Vs. 36.3% in others (&lt;0.0001). The median duration of HD before joining Davita-clinics was of 6.5 months in G1 Vs. 11.5 months in G2 (p&lt;0.0001). There is no significant difference between the 2 groups regarding vascular access type, BMI and hemoglobin rate.

The proportion of patients who were hospitalized was of 30.8% in G1 Vs. 24.6% in G2 (p&lt;0.0006) corresponding to an annual rate of 37.33% (CI, 95%: [33.93-40.73]) in G1 Vs. 25.64 (CI, 95%: [24.14-27.15]) in G2. The annual rate of hospital stay was of 4.38 days per patient in G1 (CI, 95%: [4.26-4.49]) Vs. 3.11 in G2 (CI, 95%: [3.06-3.16]). The annual mortality rate was 13.36% in G1 (CI, 95%: [11.32-15.38]) Vs. 5.33% in G2 (CI, 95%: [4.64-6.01]). Survival rates in Group 2 were of 98.6, 95.4, 90.5 and 78.6% at 3, 12, 24 and 48 months respectively Vs. 96.1, 89.3, 78.8 and 55.8% in G1 (p&lt;0.0001).

Adjusted hospitalization and mortality risks were of 1.271 (CI, 95%: [1.065-1.516]; p&lt;0.008) and 2.257 (CI, 95%: [1.794-2.841]; p&lt;0.0001) in elderly patients compared to other patients.

Conclusion

Our study demonstrated that Saudi elderly hemodialysis patients remain a group at high risk for hospitalization and mortality.

Monoclonal gammopathy of renal significance with light-chain deposition disease in kidney transplantation

Light-chain deposition disease (LCDD) reoccurs almost invariably after renal transplantation, leading to early graft loss. We report a case of LCDD with monoclonal gammopathy of renal significance diagnosed in the post-transplant period in a 28-year-old male and we discuss the diagnostic and therapeutic challenges in the clinical course.