Peritoneal Dialysis in Austere Environments: An Emergent Approach to Renal Failure Management.

Peritoneal dialysis (PD) is a means of renal replacement therapy (RRT) that can be performed in remote settings with limited resources, including regions that lack electrical power. PD is a mainstay of end-stage renal disease (ESRD) therapy worldwide, and the ease of initiation and maintenance has enabled it to flourish in both resource-limited and resource-abundant settings. In natural disaster scenarios, military conflicts, and other austere areas, PD may be the only available life-saving measure for acute kidney injury (AKI) or ESRD. PD in austere environments is not without challenges, including catheter placement, availability of dialysate, and medical complications related to the procedure itself. However, when hemodialysis is unavailable, PD can be performed using generally available medical supplies including sterile tubing and intravenous fluids. Amidst the ever-increasing global burden of ESRD and AKI, the ability to perform PD is essential for many medical facilities.

Incorporating Geriatric Assessment into a Nephrology Clinic: Preliminary Data from Two Models of Care.

Older adults with advanced chronic kidney disease (CKD) experience functional impairment that can complicate CKD management. Failure to recognize functional impairment may put these individuals at risk of further functional decline, nursing home placement, and missed opportunities for timely goals-of-care conversations. Routine geriatric assessment could be a useful tool for identifying older adults with CKD who are at risk of functional decline and provide contextual information to guide clinical decision-making. Two innovative programs were implemented in the Veterans Health Administration that incorporate geriatric assessment into a nephrology visit. In one program, a geriatrician embedded in a nephrology clinic used standardized geriatric assessment tools with individuals with CKD aged 70 and older (Comprehensive Geriatric Assessment for CKD) (CGA-4-CKD). In the second program, a nephrology clinic used comprehensive appointments for individuals aged 75 and older to conduct geriatric assessments and CKD care (Renal Silver). Data on 68 veterans who had geriatric assessments through these programs between November 2013 and May 2015 are reported. In CGA-4-CKD, difficulty with one or more activities of daily living (ADLs), history of falls, and cognitive impairment were each found in 27.3% of participants. ADL difficulty was found in 65.7%, falls in 28.6%, and cognitive impairment in 51.6% of participants in Renal Silver. Geriatric assessment guided care processes in 45.4% (n = 15) of veterans in the CGA-4-CKD program and 37.1% (n = 13) of those in Renal Silver. Findings suggest there is a significant burden of functional impairment in older adults with CKD. Knowledge of this impairment is applicable to CKD management.

Proliferative C4 Dense Deposit Disease, Acute Thrombotic Microangiopathy, a Monoclonal Gammopathy, and Acute Kidney Failure.

Dense deposit disease (DDD) is a rare form of glomerulonephritis that has recently been reclassified under the broad group of C3 glomerulopathy, which also includes C3 glomerulonephritis. C3 glomerulopathy is characterized by predominant C3 staining on immunofluorescence microscopy and dysregulation of the alternative complement pathway. We present a case of DDD concurrent with acute thrombotic microangiopathy (TMA) in a 54-year-old white man. The patient presented with acute kidney injury, and a kidney biopsy showed segmental highly electron-dense intramembranous deposits and large rounded mesangial electron-dense deposits consistent with DDD and coexisting glomerular and vascular thrombosis consistent with concurrent acute TMA. However, immunofluorescence microscopy did not show C3 staining in nonsclerotic glomeruli, excluding C3 DDD. Rather, there was dense staining for C4d along the glomerular capillaries, suggesting C4 DDD. Activity of the alternative complement pathway was normal. To our knowledge, this is the first reported case of C4 DDD concurrent with TMA. One previous case report of C4 DDD had been reported, though in a teenage girl. These 2 cases suggest that C4 DDD is a rare entity and should be distinguished from the C3 glomerulopathies.