Malignant metastatic deposits in an immunocompromised patient-could this be tuberculosis?

We report the case of a 50-year-old female renal transplant patient who developed disseminated deposits initially diagnosed as metastatic malignancy of unknown primary. She declined a tissue diagnosis but subsequently developed recurrent sepsis and symptomatic unilateral pleural effusion. Mycobacterium tuberculosis was cultured from pleural fluid. Following introduction of anti-tuberculous medications, her symptoms improved rapidly and the progression of her disseminated deposits stabilized. Tuberculosis is well-known to be associated with immunocompromised patients. It is a curable disease and should remain an important differential diagnosis for transplant patients who develop suspicious malignant metastatic lesions.

Variation between centres in access to renal transplantation in UK: longitudinal cohort study.

OBJECTIVE: To assess whether equity exists in access to renal transplantation in the UK after adjustment for case mix in incident patients with end stage renal disease. DESIGN: Longitudinal cohort study. SETTING: UK Renal Registry and UK Transplant Registry. PARTICIPANTS: All incident renal replacement treatment patients (n=16 202) from 65 renal centres submitting data to the UK Renal Registry between 1 January 2003 and 31 December 2005, followed until 31 December 2008 (or until transplantation or death, whichever was earliest). OUTCOME MEASURES: Proportion of incident dialysis patients at each renal centre who were registered on the national transplant list; time taken to achieve registration; and proportion of patients subsequently transplanted. RESULTS: We found that recipients' age, ethnicity, and primary renal diagnosis were associated with the likelihood of accessing the waiting list or receiving a transplant. After adjustment for case mix, significant inter-centre variability existed in access to the transplant list (change in -2LogL=89.9, df=1, P<0.001), in the time taken to register patients on the waiting list (change in -2LogL=247.4, df=64, P<0.001), in receipt of a renal transplant from a donor after brain stem death (change in -2LogL=15.1, df=1, P=0.001), and in receipt of a renal transplant from a living donor or a donor after cardiac death (change in -2LogL=46.1, df=1, P<0.001). CONCLUSIONS: Significant variation in access to renal transplantation exists between centres within the UK that cannot be explained by differences in case mix.

Inhalation of glutamic acid decarboxylase 65-derived peptides can protect against recurrent autoimmune but not alloimmune responses in the non-obese diabetic mouse.

Systemic administration of islet-derived antigens has been shown to protect against diabetes in the non-obese diabetic (NOD) mouse by the induction of antigen-specific regulatory T cells. Bystander regulation to related and unrelated islet-derived antigens (intramolecular and intermolecular recognition) in this context is recognized. We tested if intranasal administration of glutamic acid decarboxylase 65 (GAD 65)-derived peptides could protect against both autoimmune and, through bystander regulation, alloimmune responses in a NOD mouse model. Spontaneously diabetic female NOD mice underwent islet transplantation from either C57Bl/6 or NOD islet donors. Islet recipients were treated with intranasal GAD 65-derived peptides or control (ovalbumin) peptide pre- and post-transplantation. In-vitro analysis of the effect of inhalation was defined using lymph node proliferation assays and supernatant analysis for cytokines. GAD 65-derived peptide inhalation resulted in significant protection against recurrent autoimmune disease, with the generation of an interleukin (IL)-10-producing immune phenotype in a syngeneic islet transplant model. This phenotype, however, was not robust enough to protect against alloimmune responses. Inhalation of GAD-derived peptides induces an immunoregulatory response that protects against recurrent autoimmune, but not alloimmune responses in the NOD mouse.

Impact of diabetes on haemoglobin levels in renal disease.

AIMS/HYPOTHESIS: Anaemia is a common complication of renal impairment. It has been suggested that renal failure secondary to diabetes is associated with more severe anaemia, but this has not been clearly substantiated in the published literature. To clarify this, we undertook a single centre, retrospective study to identify the impact of diabetes on anaemia associated with renal impairment. MATERIALS AND METHODS: Information on clinical, biochemical and haematological parameters of 2,052 stable ambulatory patients attending a single tertiary referral renal unit was collected. The impact of diabetic kidney disease on haemoglobin levels at all degrees of renal impairment was studied by comparison with patients with non-diabetic kidney disease after correcting for other commonly associated variables that influence anaemia in patients with renal impairment. RESULTS: Linear regression analysis showed lower haemoglobin in patients with diabetic kidney disease (p < 0.01). At chronic kidney disease (CKD) stages 3, 4 and 5, mean haemoglobin levels in patients with diabetic kidney disease compared with those in patients with non-diabetic kidney disease were 129.5 vs 136.9 g/l (p < 0.001), 120.5 vs 126.9 g/l (p < 0.001) and 107.1 vs 115.9 g/l (p < 0.01), respectively. At CKD stage 4 and 5 the two groups were comparable for ferritin, plasma intact parathyroid hormone levels, ACE inhibitor use and length of follow-up by a nephrologist. CONCLUSIONS/INTERPRETATION: Diabetic kidney disease is associated with lower haemoglobin in comparison with non-diabetic kidney disease, especially at GFR <60 ml/min.

Restoration of acutely thrombosed arterio-venous fistulae by rTPA and percutaneous angioplasty.

Acute thrombosis in native arterio-venous fistulae (AVF) results in considerable patient morbidity. Interventional radiology (IR) comprising thrombolysis and percutaneous transluminal angioplasty (PTA) is well established in the management of thrombosed polytetrafluoroethylene (PTFE) grafts. However its role in thrombosed AVF is uncertain. We looked retrospectively at the role of IR in re-establishing blood flow in acutely throm-bosed AVF. Between 1992-2000, 21 episodes of acutely thrombosed AVF in 15 patients (9 females; age range 29-80yrs) were referred for intervention. All fistulae were being used for haemodialysis at the time. Diagnosis was established by angiography and thrombolysis with recombinant tissue plasminogen activator (rTPA) was attempted in all patients. Discrete stenoses when present (n=12) were then treated with PTA and resistant or recurrent stenoses were managed by stent insertion (n=3). Patients were then heparinised for 24 hours. Technical success as defined by radiological patency was achieved in 86% cases. Clinical success i.e. the ability to reuse of the fistula for haemodialysis was achieved in 62% of the interventions, where patency rates at 3 and 6 months were 92% and 69% respectively. Five patients had recurrence of thrombosis >3 months after the primary procedure, 3 had successful reintervention. Minor local bleeding was the only complication. Our retrospective study shows rTPA and PTA is successful in the management of acutely thrombosed AVF. We advocate the routine use of IR as a valuable technique for prolonging the life of native AVF in patients on maintenance haemodialysis.