Safe and Successful Treatment With Pcsk9 Inhibitors in Hypercholesterolemia and Renal Transplantation: A Case Report

BACKGROUND

Patients with chronic kidney disease (CKD) are more prone to cardiovascular disease (CVD) risks, including CVD-derived sudden death. Additionally, patients with CKD also develop lipid metabolism abnormalities. Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors (PCSK9i) are drugs capable of reducing CVD risk in patients with CKD, but their efficacy is scarcely assessed in transplant patients.

CASE PRESENTATION

Here, we report a case of a 74-year-old man undergoing nephrology follow-up for a cadaver donor kidney transplant. The patient described an atorvastatin allergic reaction after an acute coronary syndrome. Because the patient had a very high risk for CVD, alirocumab was substituted for atorvastatin. The patient showed a well-tolerated and effective response and stable everolimus levels.

CONCLUSION

PCSK9i may be considered a pharmacologic option for treating lipid metabolism disorder and reducing low-density lipoprotein cholesterol in transplant recipients.

COVID-19 in Patients with Glomerular Disease: Follow-Up Results from the IRoc-GN International Registry

Background

The acute and long-term effects of severe acute respiratory syndrome coronavirus 2 infection in individuals with GN are still unclear. To address this relevant issue, we created the International Registry of COVID-19 infection in GN.

Methods

We collected serial information on kidney-related and -unrelated outcomes from 125 GN patients (63 hospitalized and 62 outpatients) and 83 non-GN hospitalized patients with coronavirus disease 2019 (COVID-19) and a median follow-up period of 6.4 (interquartile range 2.3-9.6) months after diagnosis. We used logistic regression for the analyses of clinical outcomes and linear mixed models for the longitudinal analyses of eGFR. All multiple regression models were adjusted for age, sex, ethnicity, and renin-angiotensin-aldosterone system inhibitor use.

Results

After adjustment for pre-COVID-19 eGFR and other confounders, mortality and AKI did not differ between GN patients and controls (adjusted odds ratio for AKI=1.28; 95% confidence interval [CI], 0.46 to 3.60; P=0.64). The main predictor of AKI was pre-COVID-19 eGFR (adjusted odds ratio per 1 SD unit decrease in eGFR=3.04; 95% CI, 1.76 to 5.28; P<0.001). GN patients developing AKI were less likely to recover pre-COVID-19 eGFR compared with controls (adjusted 6-month post-COVID-19 eGFR=0.41; 95% CI, 0.25 to 0.56; times pre-COVID-19 eGFR). Shorter duration of GN diagnosis, higher pre-COVID-19 proteinuria, and diagnosis of focal segmental glomerulosclerosis or minimal change disease were associated with a lower post-COVID-19 eGFR.

Conclusions

Pre-COVID-19 eGFR is the main risk factor for AKI regardless of GN diagnosis. However, GN patients are at higher risk of impaired eGFR recovery after COVID-19-associated AKI. These patients (especially those with high baseline proteinuria or a diagnosis of focal segmental glomerulosclerosis or minimal change disease) should be closely monitored not only during the acute phases of COVID-19 but also after its resolution.

'Real-life' experience with direct-acting antiviral agents for hepatitis C virus in end-stage renal disease

BACKGROUND AND AIMS

The advent of direct-acting antiviral agents promises to change the management of hepatitis C in patients with end-stage renal disease, a patient group where the treatment of hepatitis C was historically challenging. We investigated the safety and efficacy of all-oral, interferon-free direct-acting antiviral agents for the treatment of hepatitis C in a 'real-world' group of patients with end-stage renal disease.

METHODS

We performed a single-arm, multi-centre study in a cohort (n=30) of patients with advanced chronic kidney disease (mostly on dialysis) who underwent antiviral therapy with direct-acting antiviral agents. The primary end-point was sustained virologic response (serum hepatitis C virus RNA < 15 mIU/mL, 12 weeks after treatment ended). We collected data on on-treatment adverse events, serious adverse events and laboratory abnormalities.

RESULTS

In total, 23 (77%) and 7 (23%) patients underwent regular dialysis and had chronic kidney disease at pre-dialysis stage, respectively. Six regimens were adopted: elbasvir/grazoprevir ( n = 6), ledipasvir/sofosbuvir ± ribavirin ( n = 4), PrOD regimens ± ribavirin ( n = 10), simeprevir + daclatasvir ( n = 3), sofosbuvir + daclatasvir ± ribavirin ( n = 3), sofosbuvir + ribavirin ( n = 4). The SVR12 rate was 90% (95% confidence interval, 74%; 96%). A total of 27 (90%) patients achieved SVR12; there were three virologic failures - two were non-responders and one had a viral breakthrough while on therapy. Adverse events occurred in 53% (16/30) (95% confidence interval, 0.39; 0.73) of patients and were managed clinically without discontinuation of therapy or hospitalization. The most common adverse event was anaemia ( n = 12) that required blood transfusions in seven individuals; deterioration of kidney function occurred in one (14%).

CONCLUSION

All-oral, interferon-free therapy with direct-acting antiviral agents for chronic hepatitis C virus in advanced chronic kidney disease was effective and well tolerated in a 'real-life' clinical setting. Careful monitoring of haemoglobin and serum creatinine during therapy with direct-acting antiviral agents is suggested. Studies are under way to address whether sustained viral response translates into better survival in this population.

Treatment with adalimumab in amyloidosis secondary to rheumatoid arthritis: two case reports

Rheumatological diseases and, firstly, rheumatoid arthritis (RA) remain a major cause of secondary amyloidosis. The emergence of biological agents such as adalimumab in the early treatment of RA can be an effective alternative to stop the development and progression of secondary amyloidosis. Not all patients will respond the same way to treatment; we must consider associated comorbidity, the poor prognosis factors for predicting therapeutic response and possible adverse effects. In the adverse effects of biological therapies, there has been an increase in the rate of lethal infections and congestive heart failure. We present two cases with renal amyloidosis secondary to RA who had a different clinical course: our 1st case had a good response to Adalimumab while the 2nd case evolved unfavourably after treatment, and died from cardiovascular complications.

Fungemia por Kodamaea (Pichia) ohmeri asociada a cirugía

We report a case of fungemia caused by Kodamaea (Pichia) ohmeri associated with surgery in a patient with a history of diabetes and chronic renal failure. Kodamaea ohmeri is a yeast rarely involved in human infections. Since the first report of a case of fungemia in 1998, only thirteen cases of K. ohmeri infection have been so far described in the medical literature.

[An unusual cause of obstructive jaundice: giant gastroduodenal artery aneurysm]

Visceral artery aneurysms are rare vascular lesions. Hepatic aneurysms are the second most common type of visceral aneurysm after those of the splenic artery. These aneurysms often have a nonspecific clinical presentation and are difficult to diagnose before rupture. Because the natural course of hepatic aneurysms leads to rupture, with a high rate of morbidity and mortality, their early diagnosis is essential for surgical correction. We report a case of obstructive jaundice caused by a 7-cm gastroduodenal artery aneurysm in which the diagnosis was suggested by abdominal computed tomography and magnetic resonance cholangiography and was confirmed by angiography. The patient was surgically treated. In the following 48 h he presented ischemic-based acute hepatic failure and underwent left hepatic lobe resection. The patient finally died from a pulmonary thromboembolism.

[Study of the susceptibility of black yeasts of the Exophiala genus to antifungals using the Sensititre System]

Black yeasts belong to a group of dematiaceous fungi which are difficult to classify and identify. One of the genera that cause human infection, mainly phaeohyphomycosis, is Exophiala, which includes the species E. berger, E. castellanii, E. dermatitidis, E. jeanselmei, E. lecanii-corni, E. moniliae, E. pisciphila, E. salmonis and E. spinifera. We carried out a susceptibility study of five of these species (E. castellanii, E.dermatitidis, E, jeanselmei, E. lecanii-corni and E. moniliae), isolated from cutaneous exudates, to the usual antimycotic agents. Strains were cultured on Sabouraud agar and potato-dextrose agar. Species identification was made by conidiogenous microscopic observation and the following characteristics: maximum growth temperature, tolerance to cicloheximide and carbohydrate assimilation. Susceptibility to antimycotic agents (amphotericin B, fluconazole, itraconazole, ketoconazole and 5-fluorocytosine) was determined by the Sensititre YeastOne (Aamar Blue) commercial method. Amphotericin B activity was good for the five tested species, although the MIC for E. jeanselmei was high (1 mg/l. MICs for fluconazole were high for all the species, but only E. moniliae and E. lecanii-corni c be considered resistant. Activity of itraconazole, ketoconazole and 5-fluorocytosine was good.

[Antifungal susceptibility of emerging yeast pathogens]

BACKGROUND

To study the antifungal susceptibility of emerging yeast pathogens to know their possible resistance under the need of applying a treatment.

MATERIAL AND METHODS

We investigated the in vitro susceptibility of 69 yeast strains isolates of clinical samples, belonging to 24 different species, to amphotericin B, fluconazole, itraconazole, ketoconazole and 5-fluorocytosine.

RESULTS

Only 9 species showed susceptibility to all antifungal agents: Candida famata, C. guillermondii, C. holmii, C. kefyr, C. pelliculosa, C. rugosa, C. utilis, C. zeylanoides y Trichosporon cutaneum; the rest of them presented resistance to some antifungal agent. C. haemulonii, Pichia farinosa and Trichosporon mucoides were resistant to amphotericin B; C. haemulonii, C. inconspicua, C. lusitaniae, C. norvegensis, C. pintolepesii, C. valida, P. ohmeri, Rhodotorula glutinis, R. minuta, R. mucilaginosa and Saccharomyces cerevisiae were resistant to azoles; Blastoschizomyces capitatus and C. lipolytica were resistant to 5-fluorocytosine.

CONCLUSIONS

The resistance of emerging yeast pathogens to amphotericin B and 5-fluorocytosine is low, while resistance to azoles is significative, especially to fluconazole (36%). Many of this yeasts present problems of intrinsic resistance. In yeast infections, the correct identification of species and the study of the in vitro susceptibility is important in order to choose the most adequate antifungal treatment.

Isolation of Hanseniaspora uvarum (Kloeckera apiculata) in humans

Isolation of Hanseniaspora uvarum, a yeast of the ascomycetes group, whose anamorph corresponds to Kloeckera apiculata, obtained from stool and two ungual specimens from three patients, is reported. This yeast has been found in soil, water, various fruits, bivalve molluscs, crabs, prawns and fruit flies; in Spain, it has been described in the fermentation processes of some wines. In our region, it has also been found in the intestine of mackerel (Scomber scombrus). Its finding in humans constitutes a clinical rarity.

[Identification of yeasts of clinical interest on CHROMagar Candida culture medium.]

The efficiency of CHROMagar Candida was evaluated as a medium for the presumptive identification of yeasts. We tested 36 different yeast species, pertaining to 9 genera: one Blastoschizomyces, 20 Candida, five Cryptococcus, two Geotrichum, one Kloeckera, two Pichia, three Rhodotorula, one Saccharomyces and one Trichosporon, to determine the colony colors and characteristics on this medium. Afterwards, we identified 2,230 strains isolated directly on CHROMagar Candida from clinical samples by specific colouration and morphology of the colonies after 72 hours. Their results were compared with standard methods for the identification of yeasts. The sensitivity and specificity were both superior to 97% for all strains, 100% and 100% for Candida albicans, 97.3% and 99.9% for Candida glabrata, 92.3% and 99.6% for Candida krusei, 90.3% and 99.6% for Candida parapsilosis, and 100% and 100% for Candida tropicalis. CHROMagar Candida is a very useful medium for the culture of clinical samples; its use for identification of yeasts has an accuracy of 97.5%, close to 100% of conventional methods.