Pure Red Cell Aplasia and Antibody-Mediated Rejection: Double Trouble in 1 Kidney Transplant Recipient Solved by Intravenous Immunoglobulin Infusion: A Case Report.

Acquired pure red cell aplasia (PRCA) is characterized by severe normocytic (rarely macrocytic) and normochromic anemia, a low reticulocytes count in peripheral blood, and near absence of erythroid precursors in the bone marrow, with a normal level of erythropoietin. We describe a case of the kidney transplant recipient, diagnosed with PRCA induced with parvovirus B19 infection. Our case demonstrates that although this complication is rare, it should be considered in a differential diagnosis of anemia diagnostics in immunocompromised patients. In our case reduced immune response resulted from post-transplant immunosuppressive therapy. In our patient, apart from infection by parvovirus B19, graft dysfunction due to polyomavirus BK virus infection was also detected together with histologic and serologic features of antibody-mediated renal graft rejection. Considering the entire clinical picture, intravenous immunoglobulin therapy (IVIg) was successfully introduced.

Relationship between serum asymmetric dimethylarginine and left ventricular structure and function in patients with end­stage renal disease treated with hemodialysis.

INTRODUCTION:  Asymmetric dimethylarginin (ADMA) is an endogenous inhibitor of endothelial nitric oxide synthase, considered an effector of endothelial dysfunction. Among multiple diseases associated with elevated ADMA, chronic renal disease is often mentioned. ADMA is thought to be related to certain adverse cardiovascular effects of chronic uremia. The association between left ventricular (LV) structure and function and ADMA has been studied in numerous papers, but only few of them addressed this issue in end­stage renal disease (ESRD). OBJECTIVES:  The aim of the study was to analyze associations between serum ADMA (sADMA) levels and LV geometry and function in patients with ESRD treated with hemodialysis (HD). PATIENTS AND METHODS:  The study group included 56 patients (31 women, 25 men) aged 59.0 ±13.1 years, treated with HD for 70 ±67 months. sADMA and biochemical parameters were measured and echocardiography was performed. sADMA levels were also measured in the control group of healthy individuals matched for age.  RESULTS:  Mean sADMA levels in patients were 2.39 ±1.0 µmol/ and were significantly higher compared with controls (0.55 ±0.12 µmol/l; P <0.01). Based on echocardiography, patients were classified into the following groups: normal LV geometry (17.8%), concentric remodeling (8.9%), concentric hypertrophy (35.7%), excentric hypertrophy (37.5%), impaired systolic function (10.7%), and impaired diastolic function (71.4%) (1 patient could be in 1 or more groups). sADMA correlated with mean (r = 0.78; P <0.05) and relative (r = 0.64; P <0.05) LV wall thickness and with the LV mass index (r = 0.65; P <0.05), but not with the indexes of systolic and diastolic function. sADMA was significantly higher in patients with excentric hypertrophy, concentric remodeling, and concentric hypertrophy compared with patients with normal LV geometry, and the highest was in patients with concentric hypertrophy. CONCLUSIONS:  Our study demonstrated an association between sADMA and disturbances in LV geometry in patients with ESRD treated with HD.

Renoprotective effects of benazepril: current perspective.

Cardiovascular (CV) disease, its associated risk factors and continued progression run in parallel with renal deterioration (cardio-renal syndrome). Most guidelines promote early treatment, including the use of ACE inhibitors to control CV risk in patients with chronic renal failure. The renoprotective effects of the ACE inhibitor, benazepril, independent of blood pressure control, have been demonstrated, as monotherapy or in combination with amlodipine or hydrochlorothiazide, in large clinical trials: Avoiding Cardiovascular Events through Combination Therapy in Patients Living with Systolic Hypertension (ACCOMPLISH) and Gauging Albuminuria Reduction with Lotrel in Diabetic Patients with Hypertension (GUARD) in patients with mild-to-severe chronic kidney disease. In the ACCOMPLISH trial, CV outcomes and renoprotective effects were greater in patients receiving benazepril in combination with amlodipine; the GUARD trial demonstrated that combined benazepril/hydrochlorothiazide was more effective than amlodipine combined with benazepril in reducing baseline urinary albumin:creatinine ratio and normalizing urinary albumin:creatinine ratio in patients with baseline microalbuminuria, although this effect was accompanied with a greater decrease in glomerular filtration rate than with benazepril/amlodipine. While this is not a study in patients with overt renal disease (patients had severe CV diseases), the ACCOMPLISH trial is the first large study to date to show the added benefit of combining ACE inhibitors and calcium-channel blockers in renal protection. Future large, well-controlled trials, designed to evaluate hard renal outcomes, are required to identify which patients will benefit most from particular combination treatment strategies in renoprotection.

Identifying chronic kidney disease in an emergency department: a chance for an early diagnosis.

INTRODUCTION: Chronic kidney disease (CKD) has relatively asymptomatic course, but even at its onset, it worsens the prognosis of patients, mainly because of the increased risk of cardiovascular diseases. Several population-based screening programs as well as initiatives focused on certain risk groups were undertaken to better diagnose early stages of CKD. It appears that an emergency department (ED) of a hospital may be the right place to screen for early CKD. OBJECTIVES: The aim of the study was to assess the accuracy of ED practices in the detection of CKD. PATIENTS AND METHODS: The study involved 176 subjects who presented at the ED over 1 month and were subsequently admitted to one of the wards at the general hospital. Blood pressure on admission was recorded in 61% of the patients; serum creatinine and estimated glomerular filtration rate (eGFR) were measured in 50% of the subjects, urea in 42.2%, potassium in 87.5%, and glucose in 82%. Patients with previously diagnosed CKD were excluded from the study. RESULTS: Sixty-three per cent of blood pressure values exceeded 140/90 mmHg, 27.3% of all creatinine samples exceeded the upper limit of 1.2 mg/dl, and 64.8% of eGFR results were below 90 ml/min/1.73 m² (mean 78 ± 36 ml/min/1.73 m²). Abnormal levels of urea (>50 mg/dl) were observed in 32% of the patients. Potassium levels were within the reference range in 81.5% of the patients (3.5-5.0 mmol/l; only 10.4% exceeding 5 mmol/l). Elevated glucose levels (>110 mg/dl) were observed in 60% of the patients. CONCLUSIONS: ED practices could be used to identify a significant number of patients with undiagnosed CKD. However, these simple, widely available, and cost-effective methods of early CKD detection are underused. Our results show that there is an urgent need for a structural screening program for CKD at the level of ED.