Transitional immature regulatory B cells and regulatory cytokines can discriminate chronic antibody-mediated rejection from stable graft function

BACKGROUND

The balance between inflammatory and anti-inflammatory responses of the immune system has been demonstrated to determine the fate of transplanted allografts. Here we analyzed CD19⁺CD24^hiCD38^hi immature transitional regulatory B (TRB) cells, as well as the gene and protein levels of interleukin (IL)-10 and transforming growth factor (TGF)-β in the three separate groups, include of stable transplanted subjects, chronic antibody-mediated rejection (cAMR) patients, and healthy individuals.

METHOD

Peripheral blood mononuclear cells (PBMCs) from stable subjects (n = 36), cAMR patients (n = 36) and healthy controls (n = 18) were isolated. Flowcytometry was performed for CD19, CD24, and CD38 surface markers. ELISA and quantitative real-time PCR were performed for IL-10 and TGF-β cytokines.

RESULT

The percentages of immature TRB cells were significantly decrease in cAMR patients (0.98%) versus stable recipients (2.81%) and healthy subjects (4.03%) (P = 0.001 and P < 0.001, respectively). Total lymphocytes, circulating B cells, memory and mature subsets of B cells did not show any significant difference between the groups. TGF-β mRNA was 3-fold upregulated in the cAMR group compared to stable patients (P < 0.001.), but without significant alteration at the protein level. Also, long-term survival renal transplant recipients had a higher protein but not mRNA levels of IL-10 than short-term survival renal transplant recipients.

CONCLUSION

It seems that immature TRB cell subpopulation might be a crucial regulator of immune system response and plays an important role in determining the transplantation outcome. Furthermore, immunosuppressive IL-10 and TGF-β cytokines might act as a double sword and can exhibit either pathogenic or protective effects against allograft.

Successful non-surgical management of bilateral emphysematous pyelonephritis despite adverse prognostic factors; report of a case and review of the literature

Emphysematous pyelonephritis (EPN) is a rare and ominous necrotizing kidney infection mainly involving diabetic patients. While prompt medical therapy with antibiotic and percutaneous catheter drainage is mainstay of management, nephrectomy should remain for unresponsiveness situations with poor prognostic factors. We introduced the clinical course of an old male presented with bilateral EPN which was successfully treated without nephrectomy regardless of various risk factors such as thrombocytopenia, impaired consciousness, and acute renal failure.

Subacute bacterial endocarditis with vasculitis-like presentation; report of a case and literature review

Infective endocarditis is a diagnostic challenge since it could manifest as a systemic disease mimicking rheumatologic disorders by immunological mechanisms. We introduced a case of infective endocarditis which was a 62-year-old man who presented with weakness, weight loss, myalgia, arthritis, petechiae, hematuria and proteinuria and was admitted by a rheumatologist for evaluation of possible vasculitis.

Predictors of Clinical Outcomes in Hemodialysis Patients: a Multicenter Observational Study

INTRODUCTION

Cardiovascular and noncardiovascular mortality and morbidity rates of hemodialysis patients are high despite improvement in dialysis delivery.

MATERIALS AND METHODS

Hemodialysis patients (n = 532) from 9 hemodialysis facilities were enrolled in this cohort study in September 2012. Causes of death, hospitalization, and hemodialysis exit were recorded during a 28-month follow-up period. A Cox proportional hazard model was used to predict death adjusting for case-mix variables, nutrition variables, bone mineral variables, Kt/V, vascular access, and Charlson comorbidities index.

RESULTS

Patients were 56.0 ± 15.4 years old (57% men). A total of 161 patients (30%) died (17 per 100 patient years), and the most common causes of death were cardiovascular diseases (42%) and infections (25%). Transplantation rate was 7 per 100 patient years and hospitalization frequency was 0.76 per patient year. Based on the multivariable Cox proportional hazard model, the mortality hazard ratio was 1.03 (95% confidence interval [CI], 1.01 to 1.05; P = .007) for age (years), 0.21 (95% CI, 0.11 to 0.40; P < .001) for serum albumin (g/dL), 1.21 (95% CI, 1.03 to 1.42; P = .02) for serum phosphorus (mg/dL), 1.001 (95% CI, 1.0005 to 1.002; P = .001) for serum intact parathyroid hormone (pg/mL), 1.58 (95% CI, 1.01 to 2.51; P = .047) for hemodialysis catheter (compared to arteriovenous fistula), and 1.75 (95% CI, 1.59 to 1.94; P < .001) for the Charlson score.

CONCLUSIONS

Nutritional factors, comorbidities, vascular access, and abnormal mineral metabolism are the main determinants of mortality and morbidity in hemodialysis patients.

Clinical outcomes and quality of life in hemodialysis diabetic patients versus non-diabetics

Background

Diabetes is the leading cause of end stage renal disease (ESRD) worldwide.

Objectives

We compared the clinical outcomes in diabetic patients on hemodialysis (HD) with non-diabetics.

Patients and Methods

Adult maintenance HD patients (N= 532) from 9 HD facilities were enrolled to this prospective cohort study in September 2012. Causes of death, hospitalization, and HD exit were recorded in a median 28 months follow up period.

Results

Forty-one percent of patients were diabetic. Diabetic patients compared to non-diabetics had significantly higher age (62.2 ± 11.2 versus 53.1 ± 16.7 years), lower dialysis duration (median: 23 versus 30 months), more cardiovascular comorbidities (64% versus 28%) , higher C-reactive protein (CRP) levels (median: 3.80 versus 2.25 mg/L), lower serum albumin (3.86 ± 0.35 versus 3.93 ± 0.35 g/dL), lower intact parathyroid hormone (iPTH) (median: 272 versus 374 ρg/mL), higher serum triglyceride (167 ± 91 versus 139 ± 67 mg/dL) and low density lipoprotein (LDL) (82.5 ± 24.5 versus 77.5 ± 23.8 mg/dL), and worse short form health survey (SF36) score (45.7 ± 20.9 versus 52.7 ± 20.5). Annual admission rate was higher in diabetics (median: 0.86 versus 0.43) and diabetic foot involved 16% of their admissions. Transplantation rate was 4 and 9 per 100 patient years in diabetics and non-diabetics, respectively. Death rate was two folds higher in diabetics (24 versus 12 per 100 patient years). Cardiovascular diseases ( ± infections/other causes) comprised 80.5% of death in diabetics and 54.5% in non-diabetics. In Cox regression proportional hazard multivariate analysis, hazard risk of death in diabetics was 1.9 times higher than non-diabetics.

Conclusions

Clinical outcomes and health related quality of life (HRQOL) are much worse in diabetic compared to non-diabetic HD patients mainly due to more frequent of cardiovascular diseases (CVDs).

Outcome of patients with multiple myeloma and renal failure on novel regimens

Renal involvement occurs in 20-40% of newly diagnosed multiple myeloma (MM) patients, and diagnosis of myeloma is frequently made after investigation for unexplained renal disease. This is a retrospective study between 2006 and 2013 in which 57 consecutive patients seen at the Nephrology Unit with diagnosis of MM were enrolled. MM was diagnosed for the first time because of renal dysfunction and/or proteinuria in these patients. The mean age of the patients (65% male) was 58.3 ± 12.7 years. The median baseline serum creatinine was 3.5 mg/dL (1.4-14.5). Anemia (hemoglobin <12 g/dL) was noted in 88% and hypercalcemia (calcium >10.5 mg/dL) in 35% of patients. Early hemodialysis was started in 28 patients (49%). Thalidomide plus dexamethasone (16% on bortezomib) were the main therapeutic regimens. Three patients (5%) underwent autologous stem cell transplantation. Twenty-six patients (45.6%) died during a median follow-up of 25 months (1-90). The mean age of patients who died was significantly higher than the age in patients who were alive (62.2 ± 12.7 vs. 55.2 ± 11.9 years, respectively; P = 0.037). Early hemodialysis had no significant effect on mortality rate. The one-, three and five year patient survival was 71%, 54%, and 41%, respectively. The median overall survival of patients was 50 months. Prolonged patient survival can be expected in myeloma patients with renal failure or on dialysis by applying novel therapeutic agents.

Impact of Kidney Transplantation on Biomarkers of Oxidative Stress and Inflammation

INTRODUCTION

Hemodialysis patients face oxidative stress and inflammation induced by both kidney dysfunction and hemodialysis procedure. These are supposed to be partly responsible for the excessive cardiovascular morbidity and mortality in hemodialysis patients. We investigated the impact of kidney transplantation on the biomarkers of oxidative stress and inflammation.

MATERIALS AND METHODS

In a prospective cohort study on 32 kidney transplant candidates on hemodialysis, biomarkers of oxidative stress and inflammation were compared before and 3 months after kidney transplantation and were compared with each other as well as their values in the kidney allograft donors as the controls. These biomarkers included total antioxidant capacity, total thiol molecules, lipid peroxidation, plasma catalase, superoxide dismutase, glutathione peroxidase, and C-reactive protein.

RESULTS

The mean age of the patients was 38.0 ± 15.5 years. The levels of total antioxidant capacity, total thiol molecules, and activity of glutathione peroxidase were significantly lower and the level of activity of plasma superoxide dismutase was significantly higher in the hemodialysis patients before transplantation as compared to the values for the controls and after transplantation. Lipid peroxidation was significantly higher in the patients before transplantation compared to the controls. A significantly higher level of C-reactive protein was noted in the hemodialysis patients as compared to their levels after transplantation and also C-reactive protein in the controls.

CONCLUSIONS

These results suggest that oxidative stress and inflammation are elevated in hemodialysis patients which could be improved partly and significantly by restoration of kidney function after kidney transplantation.

Non-diabetic renal disease with or without diabetic nephropathy in type 2 diabetes: clinical predictors and outcome

BACKGROUND

Renal involvement in type 2 diabetes is mostly due to diabetic nephropathy (DN), but a subset of diabetic patients could present with pure non-diabetic renal disease (NDRD) or NDRD superimposed on DN. We conducted a prospective cohort study to identify the underline renal pathology in type 2 diabetic patients with defined clinical criteria for renal biopsy.

METHODS

A total of 46 patients (27 female, mean age of 48.9 ± 11.9 years) with type 2 diabetes mellitus (DM) and atypical features of DN with unexpected proteinuria, hematuria, and/or renal impairment were enrolled in this study.

RESULTS

Of 46 patients with type 2 diabetes, 16 (34.8%) had DN, 20 (43.5%) had NDRD, and 10 (21.7%) had NDRD superimposed on DN. Membranous nephropathy (34%) was the most common NDRD. Patients with NDRD had a lower frequency of diabetic retinopathy (5%), shorter duration of diabetes, higher range of proteinuria, and better kidney survival. In multiple logistic regression analysis, only lack of diabetic retinopathy was independent predictor of NDRD. Positive and negative predictive value of diabetic retinopathy (DR) for diabetic nephropathy was 94 and 68%, respectively.

CONCLUSION

Kidney biopsy is strongly recommended for patients with type 2 diabetes and atypical renal presentation for DN, particularly in the absence of DR. This approach could lead to diagnosis of NDRD with better renal survival.

Prospective study of BK virus infection and nephropathy during the first year after kidney transplantation

INTRODUCTION

The aim of this study was to assess the prevalence and severity of BK virus infection, BK virus nephritis, and related risk factors among kidney transplant recipients.

MATERIALS AND METHODS

BK viremia during the first year of kidney transplantation was assessed prospectively in 32 successive recipients. BK virus DNA was extracted and determined in all samples by real-time polymerase reaction assay for 1 year after kidney transplantation.

RESULTS

The mean age of the patients was 33.3 ± 15.3 years. Sixteen patients (50%) received antithymocyte globulin for induction therapy. Living donor transplant consisted of 75% of the kidney donations. Maintenance immunosuppressive therapy included cyclosporine A in 27 patients (84.4%), plus tapering prednisolone and mycophenolate mofetil. BK viremia was detected in 8 patients (25%). The highest detected plasma viral load was less than 4000 copies per milliliter. BK virus was respectively positive in 5 (62.5%), 2 (25%), and 1 (12.5%) patients during the first 4, 8, and 12 months after transplantation. Biopsy-proven rejection and antirejection therapy by methylprednisolone pulses were 5 and 2.3 times more common in patients with BK virus infection (P = .01 and P = .01), respectively.

CONCLUSIONS

Despite occurrence of BK virus infection in 25% of our patients, BK nephropathy did not develop in any of them. Routine screening of BK virus infection, particularly in centers with low prevalence of BK virus nephritis, may not be cost effective for predicting this disease.

Patient outcome in primary peritoneal dialysis patients versus those transferred from hemodialysis and transplantation

BACKGROUND

According to the concept of integrated care, renal transplantation, peritoneal dialysis (PD), and hemodialysis (HD) should be considered three complementary methods of renal replacement therapy. This study tried to evaluate patient outcomes in three different groups of PD patients, namely primary PD patients, those transferred to PD with failing kidney transplant, and those transferred to PD from HD.

METHOD

From January 1, 1995, to end of 2006 from 26 PD centers, 1,355 patients including demographic, clinical and laboratory data, which were monthly collected through questionnaires, were enrolled in the study. We compared patients' characteristics, factors affecting patient survival, and patient outcomes between primary PD patients (group 1, n = 1,067), patients transferred from transplantation (group 2, n = 43) and those transferred from HD (group 3, n = 245), which had been on HD for at least 3 months before switching to PD.

RESULTS

There was no difference in the proportion of patients with diabetes in the three groups. Overall, 238 patients (17.5%) were transferred to HD but there was no significant difference in PD technique survival on between the three groups. Death occurred in 256 (24%), 3 (7%) and 65 (26.5%) subjects in groups 1, 2 and 3, respectively. Most patients (81.5%) in group 2 underwent re-transplantation. The Kaplan-Meier survival rates were not different between the three groups. In the Cox multiple regression model, age, presence of diabetes and serum albumin level significantly influenced patient survival.

CONCLUSION

We concluded that PD could be considered safe for patients experiencing complications on HD, as well as for those with renal transplantation.

The deleterious effect of metabolic acidosis on nutritional status of hemodialysis patients

One of the main causes of protein-energy malnutrition in patients on maintenance hemodialysis (MHD) is metabolic acidosis. The aim of this study was to evaluate the effect of metabolic acidosis on nutritional status in a group of MHD patients with adequately delivered dialysis treatment. Of 165 eligible anuric MHD outpatients with Kt/V ≥ 1 and no underlying inflammatory diseases, 47 subjects were enrolled. In order to evaluate the effect of different parameters on serum albumin, we measured the pre-dialysis serum albumin, blood pH, serum bicarbonate (HCO 3‾ ), Kt/V, normalized protein catabolic rate (nPCR) and body mass index (BMI) in these patients. The mean age of the study patients was 55 ± 13.8 years; there were 22 females and six diabetics. The average Kt/V was 1.22 ± 0.16, pH was 7.40 ± 0.15, serum HCO 3‾ was 23.18 ± 2.38 mEq/L, serum albumin was 4.03 ± 0.56 g/dL, nPCR was 1.00 ± 0.16 g/kg/day, post-dialysis body weight was 58.50 ± 11.50 kg and BMI was 23.47 ± 2.70 kg/m 2 . There was a statistically significant direct correlation between serum albumin and BMI (r = 0.415, P = 0.004), and between serum albumin and serum HCO 3 (r = 0.341, P = 0.019). On multiple regression analysis, the predictors of serum albumin were serum HCO3‾ and BMI (direct effect) and nPCR (inverse effect). In 17 patients on MHD with serum HCO3‾ <22 mEq/L, there was a significant inverse correlation between HCO 3 and nPCR (r = 0.492, P = 0.045), and these patients had significantly lower serum albumin compared with patients with serum HCO3‾ >22 mEq/L (P = 0.046). These data demonstrate that patients on MHD with metabolic acidosis had a lower serum albumin concentration despite adequate dialysis treatment. The inverse effect of nPCR on serum albumin concentration in acidotic MHD patients may be due to hypercatabolism in the setting of metabolic acidosis, leading to deleterious effects on the nutritional status of patients on MHD.

Low prevalence of BK virus nephropathy on nonprotocol renal biopsies in Iranian kidney transplant recipients: one center's experience and review of the literature

OBJECTIVES

BK virus-associated nephropathy in renal transplant recipients has been increasing in frequency in recent years. This rise is probably because of widespread use of highly potent immunosuppressive regimens, and increased immunosuppression load leads to inability of the recipients to increase a successful antiviral immune response. The incidence of BK virus-associated nephropathy in different reports is between 1% and 10%, with an allograft loss in significant numbers of patients, especially when timely diagnosis and treatment is not restored. We report our experience on BK virus nephropathy in our institute.

MATERIALS AND METHODS

All renal transplant biopsies performed at our center between 2001 and 2006 were immunohistochemically screened for the presence of PV-specific protein (SV40 Ag). The histologic diagnosis of BK virus-associated nephropathy was made upon the observation of morphologic changes in tubular epithelium and confirmation with immunohistochemical staining. We reviewed the clinical records of the subjects for demographic, clinical, and laboratory data.

RESULTS

BK virus nephropathy was found in 0.93% of all investigated allograft biopsies (1/108) and in 1.04% of all recipients (1/96; mean age of recipients, 36.48±14.10 years; age range, 13-74 years); 54 of them were male (57%). Type of kidney transplant was living-unrelated donor 76 (79%), living-related donor 13 (14%), and deceased donor 7. Seventeen patients (18%) were transplanted for a second time. Immunosuppressive drugs in 87 of recipients (90%) were cyclosporine, mycophenolate mofetil, and prednisolone. Our patient who developed BK virus-associated nephropathy 9 months after transplant was a 37-year-old man on prednisone, cyclosporine, and azathioprine immunosuppresion. He lost his graft 4 months after diagnosis.

CONCLUSIONS

Although BK virus nephropathy after renal transplant is uncommon, it is a serious complication causing loss of the allograft. It should be included in the clinical differential diagnosis of transplant dysfunction.

Description of an outbreak of acute sterile peritonitis in Iran

BACKGROUND

Outbreaks of sterile or chemical peritonitis are uncommon and often not well documented. It is therefore important to describe the characteristics of sterile peritonitis in continuous peritoneal dialysis (PD) patients.

METHODS

Characteristics of acute chemical peritonitis (ACP) are described in 20 patients (5 males, 15 females; mean age 50 +/- 15 years; range 29 - 72 years). Cultures and Gram stains were negative for micro-organisms. All patients with symptoms of peritonitis were using glucose bags with the same lot number and resolution of peritonitis occurred only after changing the suspicious bags. The first measurements of dialysate-to-plasma creatinine (D/P creat) and glomerular filtration rate (GFR) before and after ACP were compared in 14 patients with no separate episode of bacterial peritonitis during that time.

RESULTS

Cloudy dialysate was observed in 19 patients and 13 experienced abdominal pain. Mean dialysate white blood cell count and percentage neutrophils were 520/mm(3) (range 100 - 1600/mm(3)) and 65% (range 14% - 98%) respectively. Analysis of the unused PD solution showed that endotoxin (0.06 endotoxin unit/mL), 5-hydroxymethyl furaldehyde (8 microg/mL), and acetaldehyde (0.4 microg/mL) concentrations were within acceptable ranges. In 14 patients without episodes of bacterial peritonitis, D/P creat was significantly higher after than before ACP (0.77 +/- 0.07 vs 0.55 +/- 0.1, p = 0.036), whereas GFR was not (4.5 +/- 2.9 vs 4.9 +/- 2.53 mL/minute, p = 0.62).

CONCLUSION

Although chemical peritonitis in glucose-based PD solution is uncommon, it should be distinguished from bacterial peritonitis in outbreaks of peritonitis. Facilities to measure glucose degradation products are required, especially in developing countries. Acute chemical peritonitis increases small-molecule transport in the short term.

Survival and morbidity of HIV patients on hemodialysis and peritoneal dialysis: one center's experience and review of the literature

BACKGROUND

Controversy continues concerning the morbidity and mortality of HIV-infected ESRD patients on the two dialysis options. This article presents our experience with complications and survival rate among our HIV-infected ESRD patients on peritoneal dialysis and hemodialysis. We reviewed the literature on this subject.

METHODS

The charts of seven and eight HIV-infected ESRD patients on peritoneal dialysis and hemodialysis respectively, between January 1989 and November 2004, were reviewed retrospectively for specific clinical and demographic data. Their survival was calculated using the Kaplan-Meier method.

RESULTS

Total follow-up of HIV-infected PD and HD patients was 248.3 and 207 patient months, respectively. There was no significant difference in hospitalization rate between HIV-infected PD and HD patients (1.01 and 1.39 admission/year, respectively, P = NS). Survival of HIV-infected patients on PD at one, two and three years was 100, 83, and 50%, and for HD patients was 75, 33, and 33%, respectively. HIV-infected patients on HD had more prevalent advanced HIV disease. Two out of seven PD patients were on PD for more than five years and one of the HD patients was on that form of dialysis for more than nine years. Median survival of patients with advanced (Stage IV) AIDS (both HD and PD) was 15.1 months (range 1.6-17.3) while this value for non-advanced (Stage II, III) patients was 61.2 months (range 6.8-116.6).

CONCLUSION

Type of renal replacement therapy does not have a significant effect on the morbidity and mortality of HIV-infected ESRD patients. Survival is worse in patients with advanced HIV disease. Both dialysis options provide similar results in HIV patients; hence, the choice of dialysis modality should be based on patient's preference and social conditions.