An Integrated Approach Using HLAMatchmaker and Pirche II for Epitopic Matching in Pediatric Kidney Transplant-A Romanian Single-Center Study

(1) Background: Renal transplantation (KT) is the most efficient treatment for chronic kidney disease among pediatric patients. Antigenic matching and epitopic load should be the main criteria for choosing a renal graft in pediatric transplantation. Our study aims to compare the integration of new histocompatibility predictive algorithms with classical human leukocyte antigen (HLA) matching regarding different types of pediatric renal transplants. (2) Methods: We categorized our cohort of pediatric patients depending on their risk level, type of donor and type of transplantation, delving into discussions surrounding their mismatching values in relation to both the human leukocyte antigen Matchmaker software (versions 4.0. and 3.1.) and the most recent version of the predicted indirectly identifiable HLA epitopes (PIRCHE) II score. (3) Results: We determined that the higher the antigen mismatch, the higher the epitopic load for both algorithms. The HLAMatchmaker algorithm reveals a noticeable difference in eplet load between living and deceased donors, whereas PIRCHE II does not show the same distinction. Dialysis recipients have a higher count of eplet mismatches, which demonstrates a significant difference according to the transplantation type. Our results are similar to those of four similar studies available in the current literature. (4) Conclusions: We suggest that an integrated data approach employing PIRCHE II and HLAMatchmaker algorithms better predicts histocompatibility in KT than classical HLA matching.

The immunologically high-risk kidney recipient in the early post-COVID-19 period. To do or not to do? A case report

Kidney transplantation is nowadays the treatment of choice for end-stage kidney disease (ESKD), and it is the most performed organ transplantation. During the COVID-19 pandemic, kidney-transplant recipients appeared to be at higher risk of morbidity and mortality due to severe forms of illness. The result was a decrease in the number of solid organs transplants worldwide, with patients' reduced chance of receiving transplants. The best timing for surgery after COVID-19 infection is still controversial since most of the available data come from study periods with zero or low prevalence of vaccination and COVID-19 variants with high mortality rates. The American Society of Anesthesiologists (ASA) and the Anesthesia Patient Safety Foundation (APSF) Joint Statement on Elective Surgery/Procedures and Anesthesia for Patients after COVID-19 Infection states that elective surgery should be delayed for 7 weeks after a SARS-CoV-2 infection in unvaccinated patients while making no clear statement for vaccinated ones, or those which have already been infected with the virus. Kidney transplant, as opposed to tissue transplant, is not an elective surgery, so the question raised is whether to do it or not. We present the case of a hyper-immunized 47-year-old male patient with end-stage chronic kidney disease who received a second kidney transplant, despite having a mild SARS-COV 2 infection just 2 weeks before his transplantation surgery.

The Use of Machine Learning Algorithms and the Mass Spectrometry Lipidomic Profile of Serum for the Evaluation of Tacrolimus Exposure and Toxicity in Kidney Transplant Recipients

Tacrolimus has a narrow therapeutic window; a whole-blood trough target concentration of between 5 and 8 ng/mL is considered a safe level for stable kidney transplant recipients. Tacrolimus serum levels must be closely monitored to obtain a balance between maximizing efficacy and minimizing dose-related toxic effects. Currently, there is no specific tacrolimus toxicity biomarker except a graft biopsy. Our study aimed to identify specific serum metabolites correlated with tacrolinemia levels using serum high-precision liquid chromatography–mass spectrometry and standard laboratory evaluation. Three machine learning algorithms were used (Naïve Bayes, logistic regression, and Random Forest) in 19 patients with high tacrolinemia (8 ng/mL) and 23 patients with low tacrolinemia (5 ng/mL). Using a selected panel of five lipid metabolites (phosphatidylserine, phosphatidylglycerol, phosphatidylethanolamine, arachidyl palmitoleate, and ceramide), Mg2+, and uric acid, all three machine learning algorithms yielded excellent classification accuracies between the two groups. The highest classification accuracy was obtained by Naïve Bayes, with an area under the curve of 0.799 and a classification accuracy of 0.756. Our results show that using our identified five lipid metabolites combined with Mg2+ and uric acid serum levels may provide a novel tool for diagnosing tacrolimus toxicity in kidney transplant recipients. Further validation with targeted MS and biopsy-proven TAC toxicity is needed.

SERS liquid biopsy in breast cancer. What can we learn from SERS on serum and urine?

SERS analysis of biofluids, coupled with classification algorithms, has recently emerged as a candidate for point-of-care medical diagnosis. Nonetheless, despite the impressive results reported in the literature, there are still gaps in our knowledge of the biochemical information provided by the SERS analysis of biofluids. Therefore, by a critical assignment of the SERS bands, our work aims to provide a systematic analysis of the molecular information that can be achieved from the SERS analysis of serum and urine obtained from breast cancer patients and controls. Further, we compared the relative performance of five different machine learning algorithms for breast cancer and control samples classification based on the serum and urine SERS datasets, and found comparable classification accuracies in the range of 61-89%. This result is not surprising since both biofluids show striking similarities in their SERS spectra providing similar metabolic information, related to purine metabolites. Lastly, by carefully comparing the two datasets (i.e., serum and urine) we show that it is possible to link the misclassified samples to specific metabolic imbalances, such as carotenoid levels, or variations in the creatinine concentration.

Combined miRNA and SERS urine liquid biopsy for the point-of-care diagnosis and molecular stratification of bladder cancer

BACKGROUND

Bladder cancer (BC) has the highest per-patient cost of all cancer types. Hence, we aim to develop a non-invasive, point-of-care tool for the diagnostic and molecular stratification of patients with BC based on combined microRNAs (miRNAs) and surface-enhanced Raman spectroscopy (SERS) profiling of urine.

METHODS

Next-generation sequencing of the whole miRNome and SERS profiling were performed on urine samples collected from 15 patients with BC and 16 control subjects (CTRLs). A retrospective cohort (BC = 66 and CTRL = 50) and RT-qPCR were used to confirm the selected differently expressed miRNAs. Diagnostic accuracy was assessed using machine learning algorithms (logistic regression, naïve Bayes, and random forest), which were trained to discriminate between BC and CTRL, using as input either miRNAs, SERS, or both. The molecular stratification of BC based on miRNA and SERS profiling was performed to discriminate between high-grade and low-grade tumors and between luminal and basal types.

RESULTS

Combining SERS data with three differentially expressed miRNAs (miR-34a-5p, miR-205-3p, miR-210-3p) yielded an Area Under the Curve (AUC) of 0.92 ± 0.06 in discriminating between BC and CTRL, an accuracy which was superior either to miRNAs (AUC = 0.84 ± 0.03) or SERS data (AUC = 0.84 ± 0.05) individually. When evaluating the classification accuracy for luminal and basal BC, the combination of miRNAs and SERS profiling averaged an AUC of 0.95 ± 0.03 across the three machine learning algorithms, again better than miRNA (AUC = 0.89 ± 0.04) or SERS (AUC = 0.92 ± 0.05) individually, although SERS alone performed better in terms of classification accuracy.

CONCLUSION

miRNA profiling synergizes with SERS profiling for point-of-care diagnostic and molecular stratification of BC. By combining the two liquid biopsy methods, a clinically relevant tool that can aid BC patients is envisaged.

COVID-19 AND KIDNEY TRANSPLANTATION: THE IMPACT OF REMDESIVIR ON RENAL FUNCTION AND OUTCOME- A RETROSPECTIVE COHORT STUDY

OBJECTIVES

The aim of the study is to evaluate the impact of remdesivir on overall mortality, ICU mortality and renal functional outcome in hospitalized Covid 19 kidney transplant patients.

METHODS

We reviewed 165 KTx hospitalized due to COVID-19 between March 1, 2020, and May 31, 2021. Thirty-eight KTx received a five-day RDV treatment while 127 received standard of care (SOC). Overall and ICU mortality along with functional outcome were assessed.

RESULTS

The two groups had similar baseline characteristics. RDV treatment was completed in all patients without any adverse effects attributable to RDV. In terms of overall mortality, there was no difference between the RDV and SOC groups (18% vs 23%, p>0.05), but the ICU mortality was significantly reduced in the RDV group (38% vs 29%, p<0.05). RDV seems to have no nephrotoxic effect on TxR patients, as there was no difference in the incidence of AKI between RDV and SOC groups (50% vs 43%, p<0.05), and the discharge eGFR values significantly improved in the RDV group compared with the admission values (57±23 vs 44±22, p<0.05).

CONCLUSION

Five-day RDV treatment appears safe in KTx recipients and may decrease ICU mortality attributed to COVID-19 and has no nephrotoxic effect.

Favipiravir in Kidney Transplant Recipients With COVID-19: A Romanian Case Series

Background

Favipiravir (FPV) is an orally administrable antiviral drug that selectively inhibits RNA-dependent RNA polymerase and has been repurposed for COVID-19 treatment. There is limited information on the use of FPV in kidney transplant recipients (KTx), who often have multiple comorbidities and run a higher risk for death from COVID-19.

Methods

We retrospectively reviewed all KTx at our institution who got sick with COVID-19 between March 1, 2020, and May 31, 2021, and who received FPV (loading dose of 1800 mg × 2 on day 1, maintenance dose 2  ×  800 mg/d for 5-14 days) as part of their COVID treatment. We analyzed demographics, clinical course, laboratory data, management, and outcome.

Results

Nine KTx with COVID-19 received FPV; all were hospitalized. The median age was 52 years (range, 32-60 years), and women were predominant (77.7%). Eight KTx had pulmonary involvement on chest radiograph. On admission 1 patient had mild, 5 had moderate, 2 had severe, and 1 had critical disease. Leukopenia and increased creatinine were universally noted. Three patients had disease progression under treatment. Seven patients (77.7%) required additional oxygen, and 4 (57.1%) needed intensive care unit admission. Three KTx died, resulting in an overall mortality of 33.3%. Survivors did not show increased transaminases or creatinine during or after FPV treatment; leukocytes, neutrophils, and platelets improved on discharge compared with admission values.

Conclusions

FPV appears well tolerated by KTx with COVID-19, but its clinical benefit remains unclear. Larger analyses are needed.

SERS liquid biopsy: An emerging tool for medical diagnosis

Surface-enhanced Raman scattering (SERS) is emerging as a novel strategy for biofluid analysis. In this review, we delineate four experimental SERS protocols that are frequently used for the profiling of biofluids: 1) liquid SERS for the detection of purine metabolites; 2) iodide-modified liquid SERS for the detection of proteins; 3) dried SERS for the detection of both purine metabolites and proteins; 4) resonant Raman for the detection of carotenoids. To explain the selectivity of each experimental SERS protocol, we introduce a heuristic model for the chemisorption of analytes mediated by adsorbed ions (adions) onto the SERS substrate. Next, we show that the promising results of SERS liquid biopsy stem from the fact that the concentration levels of purine metabolites, proteins and carotenoids are informative of the cellular turnover rate, inflammation, and oxidative stress, respectively. These processes are perturbed in virtually every disease, from cancer to autoimmune maladies. Finally, we review recent SERS liquid biopsy studies and discuss future steps that are required for translating SERS in the clinical setting.

Difficulties in diagnosing HIV-associated nephropathy in kidney transplanted patients. The role of ultrasound and CEUS

A 62-year-old woman who underwent kidney transplantation in 2014 was diagnosed with HIV infection in 2018. Grey scale and Doppler ultrasound evaluation revealed a normal aspect of the allograft. Contrast-enhanced ultrasound detected a quick cortical contrast uptake followed by a rapid cortical wash-out. This behavior was interpreted as a sign of inflammation. Ten months after ultrasound evaluation the graft presented severe disfunction and the patient was reintroduced into the hemodialysis program.

Angle grinder as surgical tool for incarcerated penoscrotal steel ring

Penile strangulation with concomitant scrotal entrapment by a steel ring is an extremely rare urological emergency that requires immediate intervention. Any delay may lead to irreversible complications. Metal rings increase penile engorgement and are usually associated with an attempt to improve sexual pleasure or to maintain a prolonged erection. The removal of steel rings can be challenging and may require a multidisciplinary approach. We present a unique case report of an 18-year-old male with a penoscrotal steel ring retained for 24 hours that was safely removed using an angle grinder as a surgical tool.

Contrast-enhanced ultrasonography in the initial evaluation of the kidney graft function: a pilot study

AIM

Our study aimed to assess the usefulness of contrast-enhanced ultrasound (CEUS) in the initial evaluation of the graft function.

MATERIALS AND METHOD

A cross-sectional study was conducted in the early postoperative period on patients with kidney transplantation, between September 2017 to November 2018. Two groups of patients were investigated; delayed graft function (DGF) and early graft function (EGF). All patients were examined by grey scale, Doppler ultrasound and CEUS.

RESULTS

Nineteen patients, aged from 23 to 64 years (mean age 50 years), 7 in the DGF group and 12 in the EGF group were evaluated. The resistive index (RI) show significantly higher values in the DGF group at the level of upper interlobar artery (p=0.025) and medium interlobar artery (p=0.02). The CEUS investigation shows a greater region of interest (ROI) area (p=0.02) and lower values for wash-out area under the curve (WoAUC) (p=0.047) and respectively wash-in and wash-out area under the curve (WiWoAUC) (p=0.031) for the DGF group. The quality of fit (QoF) proved lower in the DGF group either for evaluation of global graft (p=0.012), cortex (p=0.025), or medulla (p=0.009).A significant relationship among all patients was found between the glomerular filtration rate (GFR) [ml/min] and the renal artery fall time (FT) [s] (p=0.012), WoAUC [a.u.] (p=0.03), and WiWoAUC [a.u.] (p=0.024). The arterial QoF [%] was associated with the arterial ROI area (p=0.048).

CONCLUSIONS

Intensity CEUS parameters WoAUC and WiWoAUC may be useful to diagnose and follow-up grafts with delayed function. Additional studies on larger cohorts are required for the recommendation of CEUS as a routine evaluation of the transplanted kidney.

First Reported Case in Romania of a Successfully Treated Severe COVID-19 in a Kidney Transplant Recipient: A Focus on Acute Kidney Injury

As coronavirus disease 2019 (COVID-19) caused by the novel virus SARS-CoV-2 is expanding worldwide, kidney involvement seems to be part of the spectrum of its effects. Moreover, the prognosis of the disease seems to be worse in immunocompromised patients when compared to the general population, with 4–5 times higher mortality rates. However, the overall impact on long-term function of the kidney graft is unknown. We report on a case of a 46-year-old kidney transplant recipient who was successfully treated for severe COVID-19 pneumonia. The clinical course was complicated by transient acute kidney injury, most likely due to tubulo-interstitial involvement, with return to the baseline of the creatinine level by the time of discharge. We discuss the characteristics and differential diagnosis of acute kidney injury, as well as management of immunosuppression in connection with overall clinical status and evolution of kidney function. The case is illustrative for dilemmas that transplant professionals may face in the absence of evidence-based, efficient COVID-19 therapy. The risk-benefit balance of the yet to be approved treatment strategies may be weighed differently in organ transplant recipients owing to their immunocompromised status and potential drug interactions with immunosuppressive therapy.

Renal Tumors in Young Adults: Is Preoperative Computer Tomography Imaging Suggestive for the Nature of the Tumors?

Renal cell carcinoma (RCC) accounts for 2–3% of all adult malignant neoplasms and is even rarer in patients under 45 years old. Clear-cell carcinoma represents most of the pathological subtypes. Our study aimed to investigate the association between preoperative computer tomography imagistic evaluation and histopathological diagnosis of renal tumors in young adults. Patients younger than 45 years old with renal tumors who were referred for medical treatment at the Clinical Institute of Urology and Renal Transplantation Cluj-Napoca from 2012 to 2019 were considered eligible for the study. Medical charts were retrospectively reviewed, and patients with complete data regarding preoperative diagnostic, histopathological evaluation, and follow-up data, regardless of gender, were included in the study. Sixteen patients younger than 45 years fulfilled all the inclusion criteria and were evaluated. With two exceptions, the evaluated patients were in a T1 and T2 stage, with no vascular invasion or of the adjacent organs. Two-thirds of our patients had a clear-cell renal cell carcinoma. None of our patients fitted in the low complexity surgery category of the R.E.N.A.L. Nephrometry Score and 37.5% of them benefited from partial nephrectomy. Half of the suppositions made based on imaging were concordant with the histopathology report. Fifteen of the patients showed no recurrence during the respective follow-up interval. Computer tomography imaging reports showed on our sample a higher concordance with the histopathological report in the more common subtypes (namely Renal Clear Cell RCC), with typical appearances.

Current status of imaging diagnosis in the transplanted kidney. A review of the literature with a special focus on contrast-enhanced ultrasonography

Objectives

Ultrasonographic scanning is currently the most widespread imaging diagnostic procedure. The method provides real-time morphological, vascular and elastographic information in a non-invasive manner. In recent years, harmonic vascular examination has become accessible using intravenous contrast agents. In urological pathology, this procedure is used in the detection and evaluation of vascular and ischemic complications, in the classification of complex cysts according to the Bosniak system, also in the renal lesions with uncertain etiology and in acute pyelonephritis for the detection of abscesses. The contrast agent (SonoVue) is angiospecific and can be used in patients transplanted immediately after surgery without adverse effects or impaired renal function. Thus, it is desirable to be used in the nephrological pathology of the renal graft and to develop diagnostic models based on the evaluation of renal microvascularization, as well as the quantitative data resulting from the graphical representation of the specific parameters. The purpose of this review is to evaluate the current state of the literature regarding the place and role of contrast substance ultrasound in the early diagnosis of acute renal graft dysfunction and to make a differential diagnosis of this pathological entity.

Method

This review quantifies the role of contrast ultrasound in the diagnosis of acute complications of the renal graft. The research was conducted based on the databases PubMed, MedScape, Cochrane, according to the search criteria such as contrast-enhanced ultrasound + kidney transplant, “time intensity curves” + “kidney transplant”, filtered for the period 2004–2018.

Results

In the nephrological pathology of the renal graft, contrast-enhanced ultrasound is a valuable tool, superior to Doppler ultrasound in predicting the evolution of the renal graft, identifying very small early defects in renal microvascularization. A number of studies succeeded in identifying acute graft dysfunction, some of which establish its etiology - humoral rejection versus acute tubular necrosis. On the other hand, the contrast-enhanced ultrasound parameters do not have the ability to distinguish between cellular and humoral rejection.

Conclusions

If, at present, the histopathological examination is the only one that can differentiate with certainty the cause of acute renal graft dysfunction, we consider that contrast-enhanced ultrasound, as a non-invasive imaging technique, opens a favorable perspective for increasing the survival of the renal graft and decreasing the complications in the renal transplant. The combination of other ultrasound techniques, together with contrast-enhanced ultrasound, could lead to the development of new diagnostic models.

Imaging appearance and role of CEUS of high flow priapism. A case report

High flow priapism caused by perineal trauma is a relatively rare disorder. Early diagnosis represents a mandatory condition for the therapeutic resolution. Ultrasound examination is affordable and a within reach method for diagnosis also in an emergency context. We present the case of a 56-year-old male patient with traumatic priapism which was subsequently investigated by contrast-enhanced ultrasound and shear wave elastography. This may be one of the first cases presented in the literature.