RESUMEN
We report a case of adenovirus nephritis (ADVN) in a kidney transplant recipient (KTR) occurring within 8 days post-transplantation. The patient, a 35-year-old male, displayed systemic symptoms, high-grade fever, and acute kidney injury (AKI) without signs of hemorrhagic cystitis (HC). Extensive diagnostic workup revealed widespread necrotizing granulomatous inflammation in the allograft, leading to the identification of adenovirus (ADV) via histopathology and polymerase chain reaction (PCR) testing. The source of ADV transmission remained uncertain, raising questions about the potential donor-derived infection. Unlike typical ADVN cases, the patient exhibited no hematuria or urinary symptoms. The case underscores the atypical presentation of ADVN in KTRs, challenging the conventional understanding of its timeline, transmission routes, and associated clinical features. We discuss the diagnostic challenges, histological findings, and management strategies for ADVN, emphasizing the importance of considering this entity in KTRs with unexplained fever and AKI, even in the absence of classical urinary symptoms or hematuria.
RESUMEN
Digital tools have revolutionized education in nephrology in India. All forms of in-person learning are moving online. Social media have taken over the world, with clinicians learning and promoting multidirectional education methods. E-learning is better equipped to keep up with the rapid pace of new knowledge generation and dissemination. The use of digital multimedia tools to enhance rapid learning is backed by science, viz., dual-coding theory. Digital tools such as Twitter, blogs, podcasts, YouTube, and Nephrology Simulator (NephSIM) have had an impact in facilitating nephrology education among medical professionals and the general public. Digital tools, such as NephMadness, have resulted in the gamification of nephrology learning. Social media usage by the nephrology community in India is growing at a rapid pace. Everyday Cases in Nephrology (#ECNeph), a monthly Twitter-based discussion focused on academically challenging clinical cases, has its origins in India. The Women in Nephrology, India (WIN-India) initiative is very active in facilitating digital education in India and has, in a short space of time, created phenomenal momentum. Furthermore, non-governmental organizations in India, such as the Kidney Warriors Foundation and the Multi Organ Harvesting Aid Network (MOHAN) Foundation, have successfully tapped into social media to educate and aid kidney disease patients. All technologies come with some drawbacks. Despite their acceptance and validation, digital tools have their own pitfalls. These relate to (1) accessibility and connectivity, (2) accuracy of the scientific information, (3) social media noise, and (4) patient privacy. All pitfalls of digital education can be addressed by avoiding excessive social media overload and adopting an appropriate peer-review process. It is advisable to seek written consent from patients whenever patient data are posted online, to avoid privacy issues.
RESUMEN
BACKGROUND: Nirmatrelvir/ritonavir has been shown to reduce the risk of COVID-19 related complications in patients at high risk for severe COVID-19. However, clinical experience of nirmatrelvir/ritonavir in the transplant recipient population is scattered due to the complex management of drug-drug interactions with calcineurin inhibitors. We describe the clinical experience with nirmatrelvir/ritonavir at The Ottawa Hospital kidney transplant program. METHODS: Patients who received nirmatrelvir/ritonavir between April and June 2022 were included and followed up 30 days after completion of treatment. Tacrolimus was withheld for 24 hours and resumed 72 hours after the last dose of nirmatrelvir/ritonavir (on Day 8) based on drug level the day before. The first 30 patients had their dose adjusted according to drug levels performed twice in the first week and as needed thereafter. Subsequently, a simplified algorithm with less frequent calcineurin inhibitor level monitoring was implemented. Outcomes including tacrolimus level changes, serum creatinine and acute kidney injury (AKI, defined as serum creatinine increase by 30%) and clinical outcomes were described globally and compared between algorithms. RESULTS: Fifty-one patients received nirmatrelvir/ritonavir. Tacrolimus levels drawn at the first timepoint, 7 days after withholding of calcineurin inhibitor and 2 days after discontinuing nirmatrelvir/ritonavir were within the therapeutic target in 17/44 (39%), subtherapeutic in 21/44(48%) and supratherapeutic in 6/44 (14%). Two weeks after, 55% were within the therapeutic range, 23% were below, and 23% were above it. The standard and simplified algorithms provided similar tacrolimus level (median 5.2 ug/L [4.0, 6.2] versus 4.8 ug/L [4.3, 5.7] p=0.70). There were no acute rejections or other complications. CONCLUSIONS: Withholding tacrolimus starting the day before initiation of nirmatrelvir/ritonavir with resumption 3 days after completion of therapy resulted in a low incidence of supratherapeutic levels but a short period of subtherapeutic levels for many patients. AKI was infrequent. The data are limited by the small sample size and short follow-up.
RESUMEN
In renal transplantation (RT), human leukocyte antigens (HLA) expressed on donor cells are the principal targets of the recipient's immune system. In addition to classical HLA-alloantibodies, the importance of non-HLA antibodies (Abs) in RT is being increasingly recognized. The majority of non-HLA Abs are considered as autoantibodies as they are directed against cryptic autoantigens of vascular endothelium, which express following tissue (graft) injury. The mechanisms by which these Abs are produced and induce rejection are not fully understood. This review discusses the spectrum of non-HLA Abs, their putative pathogenetic mechanisms, clinical relevance, and their relationship with graft survival and rejection in RT.
