Polyphenols: immunonutrients tipping the balance of immunometabolism in chronic diseases

Mounting evidence progressively appreciates the vital interplay between immunity and metabolism in a wide array of immunometabolic chronic disorders, both autoimmune and non-autoimmune mediated. The immune system regulates the functioning of cellular metabolism within organs like the brain, pancreas and/or adipose tissue by sensing and adapting to fluctuations in the microenvironment's nutrients, thereby reshaping metabolic pathways that greatly impact a pro- or anti-inflammatory immunophenotype. While it is agreed that the immune system relies on an adequate nutritional status to function properly, we are only just starting to understand how the supply of single or combined nutrients, all of them termed immunonutrients, can steer immune cells towards a less inflamed, tolerogenic immunophenotype. Polyphenols, a class of secondary metabolites abundant in Mediterranean foods, are pharmacologically active natural products with outstanding immunomodulatory actions. Upon binding to a range of receptors highly expressed in immune cells (e.g. AhR, RAR, RLR), they act in immunometabolic pathways through a mitochondria-centered multi-modal approach. First, polyphenols activate nutrient sensing via stress-response pathways, essential for immune responses. Second, they regulate mammalian target of rapamycin (mTOR)/AMP-activated protein kinase (AMPK) balance in immune cells and are well-tolerated caloric restriction mimetics. Third, polyphenols interfere with the assembly of NLR family pyrin domain containing 3 (NLRP3) in endoplasmic reticulum-mitochondria contact sites, inhibiting its activation while improving mitochondrial biogenesis and autophagosome-lysosome fusion. Finally, polyphenols impact chromatin remodeling and coordinates both epigenetic and metabolic reprogramming. This work moves beyond the well-documented antioxidant properties of polyphenols, offering new insights into the multifaceted nature of these compounds. It proposes a mechanistical appraisal on the regulatory pathways through which polyphenols modulate the immune response, thereby alleviating chronic low-grade inflammation. Furthermore, it draws parallels between pharmacological interventions and polyphenol-based immunonutrition in their modes of immunomodulation across a wide spectrum of socioeconomically impactful immunometabolic diseases such as Multiple Sclerosis, Diabetes (type 1 and 2) or even Alzheimer's disease. Lastly, it discusses the existing challenges that thwart the translation of polyphenols-based immunonutritional interventions into long-term clinical studies. Overcoming these limitations will undoubtedly pave the way for improving precision nutrition protocols and provide personalized guidance on tailored polyphenol-based immunonutrition plans.

The type of SARS-CoV-2 vaccine influences serological response in kidney transplant recipients

Vaccination is a promising strategy to control the ongoing pandemic; however, solid organ recipients tend to develop a weaker immune response to vaccination. Anti-spike SARS-CoV-2 antibodies titers were measured 2-4 weeks post-vaccination completion in 131 KT patients without previous infection. Demographic, clinical, and laboratorial parameters were analyzed to identify which factors contributed to seroconversion. Factors that influenced seroconversion, that occurred in 76 patients (58%), were longer time post-transplant, immunosuppression without an antiproliferative drug and vaccination with mRNA vaccines. Patients who received mRNA vaccines had significantly higher rates of seroconversion compared with adenovirus vector vaccines (67% vs 33%, P < .001) and higher anti-spike IgG titers. These findings reinforce the need to discuss the vaccination strategy in this population, including a third dose with a mRNA vaccine.

MO940ACUTE REJECTION IN KIDNEY RETRANSPLANTATION: RISK FACTORS AND IMPACT IN GRAFT SURVIVAL

Background and Aims

Kidney retransplantation confers a robust survival benefit over dialysis in selected patients and recent data has shown second graft outcomes similar to those of a first graft. However, the management of these patients is challenging, particularly due to allosensitization and an increased risk of acute rejection, which are related with poorer graft survival. The recognition of risk factors to acute rejection, dependent on the first and second graft, might help us to personalize standard care and achieve similar graft survival rates to patients with a first transplant. Our aim was to identify risk factors to second graft acute rejection, and the impact of acute rejection in graft failure.

Method

We performed a retrospective, longitudinal study including all patients submitted to a second kidney transplant between January 2008 and December 2019, excluding patients with more than 2 grafts or multi-organ transplant. Demographic, clinical and histocompatibility data from the donor and receptor were collected from our unit database. Delayed graft function was defined as the need of dialysis in the first week post-transplant. All acute rejection episodes were biopsy proven, according to Banff 2017 criteria. Follow-up was defined at 1st June 2020 for functioning grafts or at graft failure, with a mean time of 94±42 months.

Results

We included 109 patients of which 70 males (64%), mostly Caucasian (97%), with a mean age of 43±12 years at second kidney transplant. The main causes of end stage renal disease were glomerular disease (37%), undetermined cause (34%), and urological pathology (15%). First kidney transplant was performed before the year 2010 in 95 patients (87%). The median time of first graft survival was 75 months (IQR 58.5-91.4) and the main causes of first graft loss were chronic allograft nephropathy (N=62, 70.5%) and 11 patients (12.5%) presented primary disfunction due to surgical/vascular complications. During follow-up, 20 patients (18%) presented biopsy proven acute rejection: 3 patients borderline changes, 10 patients T cell mediated and 7 patients antibody mediated, the majority during the first-year post-transplant (N=17, 85%). The risk factors for second graft rejection are summarized in table 1. First year graft survival of the second transplant was 90% and survival at follow up was 72.5% (N=79). Acute rejection was an important risk factor for graft loss (OR 6.548 (95%CI[2.292 - 18.703]), p&lt;0.01).

Conclusion

Worst outcomes in first kidney transplant, such as acute rejection, primary dysfunction and lower graft survival were related with an increased risk of acute rejection in second graft outcomes, and consequently a higher risk of graft failure.

MO942PREDICTORS OF DELAYED GRAFT FUNCTION IN KIDNEY TRANSPLANT RECIPIENTS THROUGHOUT 3 DECADES: A SINGLE-CENTER EXPERIENCE

Background and Aims

Delayed graft function (DGF), defined as the need for dialysis within one week post-transplantation, is associated with poorer kidney graft survival. We aimed to identify risk factors for DGF throughout 3 decades and evaluate their effect on graft survival.

Method

Retrospective study including 3081 kidney transplants performed at our transplantation unit between January 1st, 1989 and December 31st, 2018, split in 3 decades (1: 1989-1998; 2: 1999-2008; 3: 2009-2018). Data regarding donor and recipient demographics, time on dialysis, immunization, cold ischemia time, hemodynamic parameters and immunosuppression were collected from our prospectively maintained data base.

Results

Main donor, recipient and perioperative characteristics are summarized in table 1. There were clear differences in these characteristics between the decades, standing out more adverse features from both recipients and donors.

Overall incidence rate of DGF was 16% (n=493): 14% in decade 1; 19.3% in decade 2 and 15% in decade 3.

On univariate analysis, most studied variables included in table 1 were statistically significant as predictors of DGF. However, on multivariate analysis, we found that in the first decade the predominant risk factors for DGF were pre-transplant dialysis time and cold-ischemia time, whilst in the following decades donor characteristics, as well as recipient’s weight became more relevant (table 2).

Conclusion

The observed shift from donor-unrelated variables in the first decade into donor-related variables in the second and third decades as the main determinants of DGF highlights the impact of expanding donor’s acceptance criteria. Nevertheless, the increase in expanded criteria donors did not translate into poorer overall results, probable contributors being shorter cold-ischemia times and stronger immunosuppression.

Incidence, prevalence and crude survival of patients starting dialysis in Portugal (2010-16): analysis of the National Health System individual registry

Background

The Portuguese Society of Nephrology (PSN) reported that Portugal has one of the highest incidences of dialysis in Europe. However, this claim was based on aggregated data supplied by dialysis providers, hampering comparisons between countries. In 2009, an individual registry of patients starting dialysis was set up by the Portuguese Ministry of Health. We analysed individual data of patients starting dialysis from January 2010 until December 2016.

Methods

Demography, starting treatment day, modality, regional distribution and outcomes, such as death, recovery of renal function, transfer to renal transplantation, peritoneal dialysis or conservative management, were extracted. Incidence, prevalence and survival analysis were calculated and compared with the PSN registry.

Results

Out of 19 190 registrations, 16 775 were incident patients (61.8% men). Yearly incidence of renal replacement therapy was 250, 248, 229, 239, 230, 231 and 244 per million population (p.m.p.) for 2010 to 2016, compared with 235, 224, 218, 230, 234, 225 and 239 p.m.p. reported by the PSN registry. On the other hand, prevalence increased from 998 p.m.p. in 2010 to 1286 p.m.p. in 2016, compared with 1010 p.m.p. in 2010 increasing to 1203 p.m.p. in 2016 from the PSN registry. The regions of Alentejo (122.9 p.m.p.) and the the Centre (160.8 p.m.p.) had the lowest regional incidence, while Lisbon had the highest (386 p.m.p. in 2016). Unadjusted survival analysis revealed that 93.5% of the patients were alive on the 91st day, whereas 85.2 and 78.3% were alive at 1 and 2 years, respectively. Crude survival at 7 years was 40%.

Conclusions

For the first time, an individual registry of patients starting dialysis in Portugal was subject to analysis and added new information about long-term survival and regional differences in the incidence and prevalence of renal replacement therapy. We were able to confirm that Portugal has one of the world's highest incidences and prevalences of dialysis. We also demonstrate, for the first time, a striking regional difference in the incidence of dialysis and an excellent early and long-term survival of patients on dialysis. These results compare well with other European countries in terms of the dialysis efficiency.

P1501KIDNEY FAILURE AND BRAIN FUNCTION DECLINE

Background and Aims: Chronic kidney disease (CKD) and cognitive impairment (CI) are two major health problems in an aging population, and both carry out negative prognostic implications. Prevalence in general population appears to be around 22.2% and recent analysis indicates that CI and frailty can be more prevalent in individuals undergoing hemodialysis (HD). Many causes can contribute to this higher prevalence, from vascular calcification to cerebral hypoperfusion, oxidative damage and uremic toxins. Both frailty and CI can lead to an increase morbimortality. Montreal Cognitive Assessment (MoCA) and Mini Mental State Examination (MMSE) are two screening instruments with a good application profile for cognitive evaluation, as well as the Frailty Clinical Scale (FCS). However, there are few studies using these scales on HD patients and demonstrating association between frailty, cognitive impairment and their clinical characteristics. The aim of this study is to investigate the prevalence of coexisting cognitive impairment and frailty in our center hemodialysis patients and its association with clinical characteristics and outcomes. Method: Thirty-two patients undergoing hospital hemodialysis program were assessed. The MoCA scale, MMSE and FCS were applied. Data were analyzed using appropriate statistical methods, using SPSS ® version 22.0. The significance level considered was 5%. Results: Thirty-two patients aged between 30 and 90 years were evaluated, with a mean of 61.63 years (SD ± 18.26), without gender predominance. The prevalence of deficits was 78.1% and 37,5% in MoCA and MMSE, respectively, without differences between gender. The prevalence of frailty (≥3) was 43.8%. Patients with deficit assessed by MoCA and MMSE were on average 15 years and 20 years older, respectively, than patients without deficit (p = 0.002). We found a statistically significant association between deficit measured by MMSE and frailty (p &lt;.001), with higher prevalence of frailty (83.3%) in individuals with deficit compared to individuals without deficit, where the prevalence of frailty was 20.0%. The deficit assessed by MMSE was also associated with time on dialysis (p = .029). No statistically significant associations were detected between MoCA and frailty over time on dialysis or between deficit measured by MoCA and frailty. Regarding patients’ comorbidities, there were no statistically significant differences between deficit assessed by MoCA and MMSE and presence of diabetes mellitus, hypertension and dyslipidemia. Deficits assessed by MoCA, MMSE, and Frailty were not associated with phosphoremia and also there was no association between presence of significative hypotension episodes during HD and these scales. Dialysis efficacy (kt/v) was not statistically associated with MoCA and MMSE deficits. Similarly, no association was found between Kt / v and frailty. Conclusion: In our study, prevalence of CI and frailty in hemodialysis patients was high. Time on dialysis program was related in a statistically significant way with CI and there was higher prevalence of frailty in individuals with deficit measured by MMSE. However, we did not find a correlation between dialysis efficacy, comorbidities and vascular risk factors and cognitive deficit or frailty score. The epidemiology and natural history of cognitive impairment and its association with frailty are important to understand among patients on HD for early intervention and management.

P1212PREDICTORS OF QUALITY OF LIFE IN PERITONEAL DIALYSIS: A SINGLE-CENTER EXPERIENCE

Background and Aims

Quality of life (QoL) is an important indicator of quality of healthcare. Measuring QoL and its correlates for peritoneal dialysis (PD) patients is very important for intervention and clinical decision-making. Being a technique performed by the patients themselves, their perspective of health related QoL is extremely important. The EuroQol questionnaire evaluates 5 QoL dimensions (mobility, self-care, usual activities, pain/ discomfort and anxiety/ depression) and includes a visual analogue scale (VAS) rated 0-100% that provides a quantitative measure of the patients’ perception of their overall health.

Method

Data from 69 patients on peritoneal dialysis at our center were collected using EQ-5D-5L EuroQol questionnaire. Health state index (HSI) scores were calculated from individual health profiles using the Spanish value set (maximum score 1). Additional clinical and laboratory data was collected from the patient’s medical files.

Results

Mean age of the population studied was 55,2 ± 14,0 years, and 66,7% (n=46) were male. Most patients were on PD &gt; 1 year (62,3%, n=43) and performing automated peritoneal dialysis (APD) (52,2%, n=36). Mean HSI was 0,88 ± 0,15 and mean VAS score was 75,1 ± 18,7.

Patients with weekly Kt/V ≥ 1,7 scored on average 0,09 points higher on the HSI (p=0,070) and 13,34 points higher in VAS (p=0,019), compared to patients with weekly Kt/V &lt; 1,7. Patients on PD &gt; 1 year scored on average 0,09 points lower on the HSI (p=0,017), mainly due to higher levels of anxiety/depression, and 11,9 points lower in VAS (p=0,005) than those &lt; 1 year.

Age did not significantly influence QoL, even when comparing patients &gt; 70 years with those &lt; 70 years old (HSI 73.0 ± 15.5 vs 75.4 ± 19.3, p=0.710 / VAS 0.82 ± 0.3 vs 0.89 ± 0.1, p=0.175). Likewise, when comparing continuous ambulatory peritoneal dialysis (CAPD) to APD, there was no significant difference in the scores of QoL. Gender, diabetes mellitus, arterial hypertension, cancer and infectious events related to PD in the last year did not influence QoL. Residual diuresis as an isolated factor did not significantly influence QoL scores. However, as it is a fundamental contributor to Kt/V, it may be indirectly associated with better QoL. A more detailed analysis was not possible as the number of patients with Kt/V ≥ 1.7 and no residual diuresis was, as expected, very low (n=4).

Conclusion

Perceived QoL in the elderly when compared to younger patients in PD was not inferior in our study, showing this option should be discussed individually with each patient.

Our results revealed time in PD negatively influences patients’ perception of their own health, which may be due to patient’s burden and exhaustion, and eventually lead to technique related complications.

Kt/V ≥ 1,7 was related to better QoL, either because higher dialysis adequacy leads to better QoL, or because patients who feel better have less tendency to neglect the technique.

Finally, we also found type of PD (CAPD vs APD) to have no significant influence on QoL, reinforcing the idea that it should be discussed and adapted to each individual patient.

MO014BORDERLINE T-CELL REJECTION IN RENAL TRANSPLANTATION: ARE WE AWARE OF THE REAL IMPACT IN GRAFT SURVIVAL?

Background and Aims

Histological findings that meet criteria for borderline changes “suspicious” for acute T cell mediated rejection (BR) as defined by the Banff Classification (2017) are frequently seen. However, its clinical significance, as well as the appropriate clinical management, are still controversial. Our goal was to compare clinical outcomes of kidney transplant recipients with biopsy proven BR versus acute T cell mediated rejection (aTCMR) and the influence of treating BR rejection in graft outcomes.

Method

A retrospective cohort study was performed in all kidney transplant recipients with biopsy proven BR and aTCMR between January 2012 and December 2018. Data related to donor and recipient demographics, treatment and subsequent evolution of serum creatinine, proteinuria and graft survival were collected. Mean time at follow up was 31.2 ± 29.1 months.

Results

We included 91 patients with biopsy proven T cell rejection of which 34 (37.4%) had a BR and 57 (62.6%) aTCMR: 39 (68.4%) IA, 9 (15.8%) IB, 7 (28.1%) IIA and 2 (3.5%) IIB. There was no difference between groups (BR vs aTCMR) regarding age (45,5 vs 48,1, p=0,38), sex (male 73% vs 60%, p=0,27) or race (Caucasian 100% vs 93%, p=0.114). For both groups, deceased donor was more frequent (82% vs 95%, p=0.074), and there was no difference in cytotoxic PRA (mean 4.5 ± 9.2 vs 3.7 ± 12.8, p=0.762) or number of compatibilities (mean 2.2 ± 1.2 vs 2.4 ± 1.3, p=0.539).

At the time of rejection diagnosis, the mean time of transplant was similar between groups (32.9 ± 43.6 vs 42.3 ± 67.4 months, p=0.467), but estimated glomerular filtration rate (GFR) was significantly higher in patients with BR when compared to aTCMR (32.0 ± 22.5 vs 19.9 ± 13.1 ml/min/1.73m2, p=0.009). We found no significant difference in proteinuria at the time of biopsy between the 2 groups.

Treatment with steroids was started in 20 (58.8%) patients with BR and all the patients with aTCMR were treated with steroids with or without thymoglobulin, depending on the Banff class. Fourteen (41.2%) patients with BR were followed closely with no acute interventions.

At 1-year post biopsy, graft survival was 70%, and we found no significantly statistical difference between the two groups (79.4% vs 64.3%, p=0.129). In patients with preserved graft, there was no difference in GFR (41.9 ± 17.7 vs 37.7 ± 19.8, p=0.401) at 12 months post biopsy for both groups. When performing Kaplan-Meyer survival curves at follow-up, we also found no difference between BR and aTCMR (57.6 ± 7.1 vs 43.6 ± 5.5 months, p=0.157) (Figure 1).

When analyzing the BR group (N=34) and comparing the patients that were treated (N=20) versus the patients with conservative approach (N=14), we found no difference in demographic features, sCr at biopsy (3.0 ± 1.1 vs 2.8 ± 2.1 mg/dl, p=0.696) and time post-transplant (28.1 ± 43.2 vs 39.7 ± 44.8 months, p=0.454). Graft survival at 1-year was 80% for treated patients and 79% for non-treated patients, p=0.919 and GFR for patients with preserved graft was not different between groups (43.9 ± 21.0 vs 39.7 ± 13.5 ml/min/1.73m2, p=0.572). When performing survival curves, we found that treated patients had almost the double time with functioning graft compared to non-treated patients (71.9 ± 8.5 vs 41.3 ± 6.2 months, p=0.104), although not statistically different probably due to the small sample size (figure 2).

Conclusion

Our study showed that despite having better GFR at time of biopsy, patients with BR (overall and treated) did not present better graft survival nor graft function at 1 year post biopsy or at follow up, compared with aTCMR. We also found a tendency to better graft survival in patients with BR treated with steroids compared with conservative approach. These results reinforce the importance of borderline rejection in graft outcomes and that the decision of whether to treat or not can influence long-term outcomes.

Hemodialysis Reliable Outflow graft: A valid option in patients with central venous stenosis

INTRODUCTION

Central venous stenosis can be the main obstacle to the creation of an autologous vascular access in the upper limbs. The Hemodialysis Reliable Outflow graft was developed to provide an upper limb vascular access option to such patients, avoiding alternative, less advantageous options, such as lower limb vascular accesses or central venous catheters. Its advantages include catheter avoidance and, in case of lower limbs accesses, reduction of the ischemic risk and iliac vein thrombosis, potentially compromising a future kidney transplant.

PATIENTS AND METHODS

Revision of the clinical files of the four patients who were placed a Hemodialysis Reliable Outflow device in our Center, including demographic variables, implantation technique characteristics, surgical complications, episodes of infection and thrombosis of the access, and need to place a transitory central venous catheter to undergo hemodialysis treatment.

RESULTS

Four Hemodialysis Reliable Outflow grafts were placed, which resulted in a significant improvement in the dialysis efficacy in all patients, with a median raise in the Kt/V of 36.7%. Two cases needed thrombectomy, one of which was unsuccessful. The actual time of patency varies between 3 and 28 months.

CONCLUSION

Our experience with the Hemodialysis Reliable Outflow device showed that it was a safe option for patients with central venous stenosis and was associated with good clinical and analytic outcomes.

Arteriovenous graft in kidney transplant patients: Lookout for the rare but fearsome angiosarcoma

INTRODUCTION

Angiosarcomas are rare tumors, comprising less than 1% of all sarcomas. However, they portend a poor prognosis, as they tend to metastasize early, being of uttermost importance a prompt diagnosis and treatment.

CASE DESCRIPTION

We present the case of a 55-year-old female with history of kidney transplantation, immunosuppressed with tacrolimus, prednisolone, and mofetil mycophenolate. Fifteen years after the transplant, she developed an ulcerated lesion on the site of a nonfunctioning arteriovenous graft, which was excised. Histology was compatible with a high grade angiosarcoma that invaded the margins, and immunosuppression was switched to everolimus. Staging imaging exams revealed lymph node, muscle, and lung metastases. Shortly after, nodular lesions appeared compatible with local recurrence of the disease, and the patient showed severe deterioration of her clinical condition, being proposed for palliative chemotherapy. However, the disease showed an explosive progression and the patient died before starting the treatment.

CONCLUSION

This case emphasizes the importance of including inspection of the vascular access (functioning or not) in regular post-transplant consultation and value any alterations in the attempt of a timely diagnosis. Although rare, angiosarcoma is an important entity that should be considered in the differential diagnosis of soft tissue masses arising from a vascular access, especially in immunocompromised patients. Aggressive treatment should be offered whenever possible.

Renal transplant immunology in the last 20 years: A revolution towards graft and patient survival improvement

To deride the hope of progress is the ultimate fatuity, the last word in poverty of spirit and meanness of mind. There is no need to be dismayed by the fact that we cannot yet envisage a definitive solution of our problems, a resting-place beyond which we need not try to go. -P.B. Medawar, 1969 * Thomas E. Starlz, also known as the Father of Clinical Transplantation, once said that organ transplantation was the supreme exception to the rule that most major advances in medicine spring from discoveries in basic science [Starzl T. The mystique of organ transplantation. J Am Coll Surg 2005 Aug;201(2):160-170]. In fact, the first successful identical-twin kidney transplantation performed by Murray's team in December 1954 (Murray J et al. Renal homotransplantations in identical twins. Surg Forum 1955;6:432-436) was the example of an upside down translation medicine: Human clinical transplantation began and researchers tried to understand the underlying immune response and how to control the powerful rejection pathways through experimental models. In the last 20 years, we have witnessed an amazing progress in the knowledge of immunological mechanisms regarding alloimmune response and an outstanding evolution on the identification and characterization of major and minor histocompatibility antigens. This review presents an historical and clinical perspective of those important advances in kidney transplantation immunology in the last 20 years, which contributed to the improvement in patients' quality of life and the survival of end-stage renal patients. In spite of these significant progresses, some areas still need substantial progress, such as the definition of non-invasive biomarkers for acute rejection; the continuous reduction of immunosuppression; the extension of graft survival, and finally the achievement of real graft tolerance extended to HLA mismatch donor: recipient pairs.

Acute liver failure due to primary amyloidosis in a nephrotic syndrome: a swiftly progressive course

AL amyloidosis is a clonal plasma cell proliferative disorder characterised by extracellular tissue deposits of insoluble fibrils derived from κ or λ immunoglobulin light chains. The most common organs affected by AL amyloidosis are the kidney, presenting with nephrotic syndrome and/or progressive renal dysfunction, and the heart, with restrictive cardiomyopathy. Hepatic deposition of fibrils occurs in half the cases but the liver is rarely the predominantly affected organ. The most common presentation of hepatic amyloidosis is hepatomegaly with elevated alkaline phosphatase. Acute liver failure with cholestasis and jaundice is a rare complication, with a prevalence of approximately 5%, and is usually associated with a worse prognosis. We report a case of a 39-year-old man admitted to our nephrology department with an unusual presentation of primary amyloidosis with nephrotic syndrome and acute liver failure, complicated by obstructive cholestasis resulting in death 2 months after diagnosis.

Severe acute kidney injury and multiple myeloma: evaluation of kidney and patient prognostic factors

BACKGROUND

Patients with multiple myeloma (MM) manifesting acute kidney injury (AKI) and who later recover renal function and independence from renal replacement therapy (RRT) are considered to have a better outcome. The aim of this work was to study the factors associated with renal function recovery (independence of hemodialysis) and longer survival in these patients.

METHODS

A retrospective single center study including patients with a diagnosis of MM and severe AKI, defined as stage 3 of the Kidney Disease: Improving Global Outcomes (KDIGO) criteria: 3.0 times baseline increase in serum creatinine (sCr) or increase in sCr to ≥4.0mg/dL or initiation of RRT, was conducted. Data was registry-based and collected between January 2000 and December 2011. We examined demographic and laboratorial data, presenting clinical features, precipitating factors, need for RRT and chemotherapy. Death was considered the primary endpoint.

RESULTS

Lower serum β2-microglobulin was the only independent factor associated with recovery of renal function and independence of RRT (OR 0.95, 95% CI: 0.91-0.99, P=0.02). The median survival after AKI was 10.7±12.1months. The factors associated with longer survival were independence of RRT (HR 2.21; 95% CI: 1.08-4.49; P=0.02), lower CRP (HR 1.07; 95% CI: 1.03-1.12; P=0.001) and younger age (HR 1.03; 95% CI: 1.01-1.06; P=0.005).

CONCLUSIONS

Our study suggests that MM patients with lower serum β2-microglobulin have a higher likelihood of recovering renal function after severe AKI. Independence of RRT, lower CRP and younger age are associated with longer survival.

Uncommon cause of chest pain in a renal transplantation patient with autosomal dominant polycystic kidney disease: a case report

Autosomal dominant polycystic kidney disease (ADPKD) is a common cause of end-stage renal disease (ESRD) and, because of its intrinsic systemic involvement, its treatment can be a medical and surgical challenge. This condition is often associated with the presence of hepatic cysts and their prevalence generally increases with age. Most patients remain asymptomatic, but some of these will develop complications associated with enlargement and infection of their cysts. Chest pain is a rare manifestation of these complications and, after exclusion of more common cardiovascular and pulmonary causes, should raise the suspicion of an infected hepatic cyst in these patients. We report the case of a 62-year-old male who underwent a kidney transplantation from a cadaveric donor in 1997 (etiology of the ESRD was ADPKD), and was admitted to the emergency department with complaints of chest pain radiating to both shoulders and the interscapular region. An echocardiogram was showed compression of the right atrium by a large liver cyst without associated ventricular dysfunction. Computer tomography-guided drainage of the cyst was performed and an Enterobacter aerogenes sensitive to carbamapenemes was isolated from respective cultures. The patient presented a favorable clinical outcome with prolonged administration of antibiotic therapy according to the antibiotic susceptibility testing. There was no need for surgical intervention.

Clinical challenges of an oligosecretory plasma cell dyscrasia

Light chain deposition disease (LCDD) and immunoglobulin light chain (AL) amyloidosis are uncommon, and heterogeneous clonal plasma cell (PC) proliferative disorders defined by the different biochemical characteristics of the underlying anomalous immunoglobulin. The deposits are usually multisystemic and the two diseases can coexist. The diagnosis is sometimes made difficult by the absence of a detectable paraprotein by routine immunofixation techniques, and the use of serum-free light chain (FLC) immunoassay brought new value in terms of their diagnosis, prognosis and assessment of treatment response. Association of LCDD and AL amyloidosis with multiple myeloma (MM) at the time of diagnosis is common, but further progression to this condition is considered rare. We present a case of a patient diagnosed with systemic LCDD and AL amyloidosis of atypical biochemical characteristics, with no paraprotein detected in immunoelectrophoresis and immunofixation techniques, who progressed to MM in the later course of her disease.

Kidney transplantation with corticosteroid-free maintenance immunosuppression: a single center analysis of graft and patient survivals

The purpose of this study was to assess the impact of a corticosteroid-free maintenance immunosuppression on graft survival in kidney transplantation. We analyzed 79 patients who were transplanted between June 1, 2006 and May 31, 2007. We excluded hyperimmunized patients, second transplantations, living donors, and black recipients. Patients underwent induction with thymoglobulin or basiliximab, followed by treatment with mycophenolate mofetil (MMF), tacrolimus, and methylprednisolone. On the 5th day, the patients were divided into 2 groups: group A (n = 45) discontinued steroid therapy; group B (n = 34) continued prednisone therapy. We performed a comparative analysis of incidence of delayed graft function (DGF), acute rejection episodes (ARE), renal function at 6 and 12 months, graft and patient survivals, causes of graft loss, and mortality. The 2 groups were similar for donor, recipient, and graft characteristics. The incidences of DGF were 8.9% in group A and 14.7% in group B; those for ARE were 2.3% in group A and 13.8% in group B (P = .077). The mean serum creatinine levels at 6 and 12 months were similar. There were 8 graft losses: 3 in group A (3 deaths with functioning grafts) and 5 in group B (1 death, 3 vascular causes, 1 kidney nonfunction). The 4 deaths were due to infection (n = 3) or neoplasia (n = 1). Graft survivals at 1 year were 98% in group A and 85% in group B, and patient survivals were 98% and 97%, respectively. An immunosuppressive regimen using antibody induction and steroid-free treatment proved to be effective in low-risk patients.

Primary antiphospholipid syndrome presented by total infarction of right kidney with nephrotic syndrome

We report the case of a young woman with primary antiphospholipid syndrome (APS), which presented with acute renal failure, hypoproteinemia, hypoalbuminemia and nephrotic proteinuria. Investigations showed total infarction of right kidney by extensive arterial and vein thrombosis and presence of anticardiolipin antibodies IgG isotype (anti-beta2-glycoprotein I-positive). She was submitted to right nefrectomy and initiated anticoagulant therapy. After nefrectomy, the postoperative period was marked by the development of arterial hypertension and persistence of nephrotic syndrome. Hypertension was treated with antihypertensive drugs (IECA, beta-blocker and calcium antagonist). As the nephrotic syndrome persisted despite anticoagulant and antihypertensive therapy, the patient was treated with oral corticosteroids. Her renal function improved, hypoproteinemia and hypoalbuminemia corrected to normal values and proteinuria decreased to subnephrotic value. We discuss the unusual presentation of this case of primary antiphospholipid syndrome with total unilateral renal thrombosis and nephrotic syndrome that respond to anticoagulant, antihypertensive and corticosteroid therapy.