Duplex ultrasound-guided angioplasty of hemodialysis vascular access.

OBJECTIVE: Duplex ultrasound-guided angioplasty (DA) for hemodialysis vascular accesses remains questionable regarding its feasibility and safety. Minor complications (requiring no more treatment than nominal therapy) might be over-reported. Our hypothesis is that this procedure has no significant differences between observed rates and the recommended threshold of main outcomes of the procedure defined by the standards of arteriovenous fistulas (AVF) angioplasty. METHODS: In a single-center retrospective study, 298 DA performed on 141 patients from 2015 to 2019 were analyzed. Occluded AVF or concomitant use of radiographic guidance were excluded. Duplex ultrasound parameters were collected up to 1 month before, at the end of angioplasty, and on day 30 after the procedure. Complications were registered, and patency rates were studied at 24 months of follow-up. RESULTS: Anatomical success was achieved in 142 procedures (47.7%), clinical success in 284 (95.3%), and hemodynamic success in 283 (95.0%). Major complications-requiring at least a specific therapy-were reported in 8 procedures (2.7%) and minor complications-requiring no adjunctive therapy-in 157 (52.7%). At 24 months, overall postintervention primary patency was 34.0%, primary-assisted patency 87.4%, and secondary patency 92.5%. There were no significant differences of patency rates between groups with or without minor complications (P value for primary patency, 0.08; primary-assisted patency, 0.08; secondary patency, 0.23) or 30% residual stenosis (P value for primary patency, 0.82; primary-assisted patency, 0.46; secondary patency: 0.63). Duplex parameters further improved at postoperative day 30 after angioplasty. CONCLUSIONS: DA of AVF is feasible, safe-despite over-reported minor complications having no impact on postintervention patency rates-and efficient. A minor complication can be seen as an event without bad or good consequences. Anatomical definition of success does not fit on DA for hemodialysis vascular access. Further studies are required to define the duplex parameter threshold for efficacy.

Extracorporeal photopheresis for the treatment of graft rejection in 33 adult kidney transplant recipients.

Background - Extracorporeal photopheresis (ECP) has shown encouraging results in the prevention of allograft rejection in heart transplantation. However, the role of ECP in kidney transplant (KT) rejection needs to be determined. Methods - This multicentre retrospective study included 33 KT recipients who were treated with ECP for allograft rejection (23 acute antibody-mediated rejections (AMRs), 2 chronic AMRs and 8 acute cellular rejections (ACRs)). The ECP indications were KT rejection in patients who were resistant to standard therapies (n = 18) or in patients for whom standard therapies were contraindicated because of concomitant infections or cancers (n = 15). Results - At 12 months (M12) post-ECP, 11 patients (33%) had a stabilization of kidney function with a graft survival rate of 61%. The Banff AMR score (g + ptc + v) was a risk factor for graft loss at M12 (HR 1.44 [1.01-2.05], p < 0.05). The factorial mixed data analysis identified 2 clusters. Patients with a functional graft at M12 tended to have cellular and/or chronic rejections. Patients with graft loss at M12 tended to have acute rejections and/or AMR; higher serum creatinine levels; DSA levels and histologic scores of AMR; and a longer delay between the rejection and ECP start than those of patients with functional grafts. Conclusions - ECP may be helpful to control ACR or moderate AMR in KT recipients presenting concomitant opportunistic infections or malignancies when it is initiated early.

Evidence for anti-inflammatory effects of exercise in CKD.

CKD is associated with a complex state of immune dysfunction characterized by immune depression, predisposing patients to infections, and immune activation, resulting in inflammation that associates with higher risk of cardiovascular disease. Physical exercise may enhance immune function and exert anti-inflammatory effects, but such effects are unclear in CKD. We investigated the separate effects of acute and regular moderate-intensity aerobic exercise on neutrophil degranulation (elastase release), activation of T lymphocytes (CD69 expression) and monocytes (CD86 and HLA-DR expression), and plasma inflammatory markers (IL-6, IL-10, soluble TNF-receptors, and C-reactive protein) in patients with predialysis CKD. A single 30-minute (acute) bout of walking induced a normal pattern of leukocyte mobilization and had no effect on T-lymphocyte and monocyte activation but improved neutrophil responsiveness to a bacterial challenge in the postexercise period. Furthermore, acute exercise induced a systemic anti-inflammatory environment, evidenced by a marked increase in plasma IL-10 levels (peaked at 1 hour postexercise), that was most likely mediated by increased plasma IL-6 levels (peaked immediately postexercise). Six months of regular walking exercise (30 min/d for 5 times/wk) exerted anti-inflammatory effects (reduction in the ratio of plasma IL-6 to IL-10 levels) and a downregulation of T-lymphocyte and monocyte activation, but it had no effect on circulating immune cell numbers or neutrophil degranulation responses. Renal function, proteinuria, and BP were also unaffected. These findings provide compelling evidence that walking exercise is safe with regard to immune and inflammatory responses and has the potential to be an effective anti-inflammatory therapy in predialysis CKD.

Combined walking exercise and alkali therapy in patients with CKD4-5 regulates intramuscular free amino acid pools and ubiquitin E3 ligase expression.

Muscle-wasting in chronic kidney disease (CKD) arises from several factors including sedentary behaviour and metabolic acidosis. Exercise is potentially beneficial but might worsen acidosis through exercise-induced lactic acidosis. We studied the chronic effects of exercise in CKD stage 4-5 patients (brisk walking, 30 min, 5 times/week), and non-exercising controls; each group receiving standard oral bicarbonate (STD), or additional bicarbonate (XS) (Total n = 26; Exercising + STD n = 9; Exercising +XS n = 6; Control + STD n = 8; Control + XS n = 3). Blood and vastus lateralis biopsies were drawn at baseline and 6 months. The rise in blood lactate in submaximal treadmill tests was suppressed in the Exercising + XS group. After 6 months, intramuscular free amino acids (including the branched chain amino acids) in the Exercising + STD group showed a striking chronic depletion. This did not occur in the Exercising + XS group. The effect in Exercising + XS patients was accompanied by reduced transcription of ubiquitin E3-ligase MuRF1 which activates proteolysis via the ubiquitin-proteasome pathway. Other anabolic indicators (Akt activation and suppression of the 14 kDa actin catabolic marker) were unaffected in Exercising + XS patients. Possibly because of this, overall suppression of myofibrillar proteolysis (3-methylhistidine output) was not observed. It is suggested that alkali effects in exercisers arose by countering exercise-induced acidosis. Whether further anabolic effects are attainable on combining alkali with enhanced exercise (e.g. resistance exercise) merits further investigation.

Hemodialysis treatment on an adult patient with Down syndrome associated with ectopic right kidney chronic obstructive nephropathy and secondary amyloidosis.

In the present report, we describe an unusual case of an adult patient with Down syndrome and ectopic right kidney, who developed end-stage renal disease due to chronic obstructive nephropathy and secondary amyloidosis and was successfully treated with hemodialysis.

End-stage renal disease due to hydronephrosis in a patient with artificial urinary sphincter.

In this report we describe the case of a 65-year-old diabetic patient who developed hydronephrosis and irreversible end-stage renal disease nine years after the placement of an AMS 800™ artificial urinary sphincter. This was due to non-compliance with the voiding regime and lack of follow-up after the placement of the urinary sphincter.

Acute kidney injury due to rhabdomyolysis in narcotic drug users.

BACKGROUND: Regular or illegal drugs and toxins are the most frequent non-physical causes of rhabdomyolysis (RM) in peacetime. Acute kidney injury (AKI) is a serious and, sometimes, fatal complication of RM. It occurs in 8-20% of RM incidents. METHODS: In this prospective study we evaluated the severity of RM and AKI in narcotic drug users. From January 2001 to December 2007, 21 patients (17 males, mean age 27.8±4.8 years) with RM associated with AKI were classified into two groups: 11 heroin users (HU) and 10 non-heroin users (NHU). The severity of RM was evaluated by estimation, on admission, of serum creatine phosphokinase (CPK), serum glutamic oxaloacetic transaminase (SGOT), lactate dehydrogenase (LDH), phosphate (PO4 ) and calcium (Ca) and by the presence of paraplegia (PPL). The severity of AKI during hospitalization was evaluated by estimation of serum creatinine (CR), the presence of oligoanuria (OA), the days of hospitalization (DH), the total of hemodialysis treatments (THD) and the number of patients who received blood transfusions (BT). RESULTS: RM was much more severe in HU than in NHU. Mean SGOT, CPK, LDH, and P values on admission were higher in HU. Hypocalcemia was statistically more severe in HU. Nine HU were admitted with PPL vs. 1 NHU. Serum CR levels were higher and oligoanuria was much more common in HU. HU had a longer hospitalization period and underwent a bigger number of HT. More HU took BT. CONCLUSIONS: The results of this study suggest that both RM and ARF are more severe in HU than in NHU possibly due to an additional myotoxic effect of heroin.