Urinary peptide biomarker panel associated with an improvement in estimated glomerular filtration rate in chronic kidney disease patients.

Background: An improvement in the glomerular filtration rate (GFR) of chronic kidney disease patients has been an underestimated clinical outcome. Although this may be considered as an unexpected disease course, it may provide some insights into possible mechanisms underlying disease remission and/or regression. Therefore, our aim was to identify urinary peptide biomarkers associated with an improvement in estimated GFR (eGFR) over time and to improve patient stratification. Methods: Capillary electrophoresis coupled with mass spectrometry (CE-MS) was employed to evaluate the urine peptidome of patients with different types of renal diseases. In total, 376 patients with a slope/year between -1.5% and +1.5% were designated as non-progressors or stable, while 177 patients with a > 5% slope/year were designated as patients with an improved eGFR for state-of-art biomarker discovery and validation. Results: We detected 384 significant peptide fragments by comparing the CE-MS data of the stable patients and those with improved renal function in our development cohort. Of these 384, a set of 141 peptides with available amino acid sequence information were used to generate a support vector machine-based classification panel. The biomarker panel was applied to our validation cohort, achieving a moderate area under the curve (AUC) value of 0.85 (81% sensitivity and 81% specificity). The majority of the peptides (78%) from the diagnostic panel arose from different types of collagen. Conclusions: We have developed a panel of urinary peptide markers able to discriminate those patients predisposed to improve their kidney function over time and possibly be treated with more specific or less aggressive therapy.

Diagnostic value of brush border enzymes of the proximal renal tubules in rheumatoid arthritis.

BACKGROUND: Proximal tubules of the kidney have a dominant function in the excretion of different enzymes in the urine. These enzymes can be used as markers for secondary renal damage under the action of different diseases, medicines, and toxins. The aim of this study was to evaluate the values of alanine aminopeptidase (AAP), gamma-glutamyl transferase (gamma-GT), and beta2 microglobulin (beta2m) in urine of patients with untreated rheumatoid arthritis (RA) and to define the possible association between untreated rheumatoid arthritis and tubular function at the brush border region. METHODS: We used a kinetic assay for AAP, standard methods by the International Federation for Clinical Chemistry (IFCC) for gamma-GT and Microparticle Enzyme Immunoassay (MEIA), (Abbott A(x)SYM System) for the determination of beta2m in urine of 70 participants (35 untreated RA patients and 35 healthy volunteers (HC)). RESULTS: From the total of 35 RA patients, AAP enzymuria was found in 24 patients with test sensitivity (68.57%), gamma-GT in 16 patients with test sensitivity (45.71%), while the presence of urinary beta2m was found in a very low percentage of cases. Out of 18 rheumatoid factor (RF) negative patients, 14 patients were AAP and 10 patients were gamma-GT positive, while the presence of beta2m in urine was not detected. Among 17 RF positive RA patients, the presence of AAP and gamma-GT was noticed in 10 and 6 patients, respectively, while the presence of beta2m in urine was not detected. CONCLUSIONS: In conclusion, AAP had a higher sensitivity than gamma-GT and beta2m in detection of asymptomatic renal lesions in untreated RA.

Successful treatment of severe secondary hyperparathyroidsm (Brown tumor) by kidney transplantation and pulses of oral calcitriol.

Brown tumor is an extreme form of severe hyperparathyroid bone disease in end-stage renal disease patients. The evolution of the tumor after renal transplantation and under conservative treatment is still unclear. Herein, we report a 22-yr-old girl with parathyroid glandular hyperplasia because of an inadequate compliance and control of the mineral metabolism and subsequently developed Brown tumor of the ribs. A gradual improvement in bone and parathyroid gland status was observed within three yr following successful kidney transplantation and treatment with pulses of oral calcitriol. To the best of our knowledge, this is the first case of such severe secondary hyperparathyroidism with successful conservative treatment in the setting of kidney transplantation with no evidence of vascular calcifications and graft failure.

Pyelo-ureteral necrosis after renal transplantation.

Because of the limited chance of receiving a kidney transplant (for several well-known reasons), a lot of desperate dialysis patients procure an unrelated donor kidney transplant against all medical advice. This type of renal paid transplantation is associated with many surgical complications and invasive opportunistic infections that increase the morbidity and mortality in this group of transplant recipients. In this report, we describe a case of a 22-year-old girl with a segmental infarction of the graft lower pole and a complete pyelo-ureteral necrosis as a consequence of some vascular damage, complicated by a pathohistological finding of an invasive candidiasis. Despite the successful surgical pyelovesical anastomosis and the good recovery of the patient and the kidney, long-term prognosis remains poor. The lack of information from the transplanting center regarding both donor and recipient and the associated, unacceptable risks on the graft and patient survival in unrelated, paid transplant recipients reinforce the standpoint that this practice should be abandoned.

Improvement of bone and mineral parameters related to adynamic bone disease by diminishing dialysate calcium.

BACKGROUND: The existence of adynamic bone disease (ABD) as most prevalent form of renal osteodystrophy in recent years and its reduced ability to handle an exogenous calcium load has implied a higher risk for vascular and soft-tissue calcifications. The effect of low dialysate calcium (LCD) on parathyroid hormone (PTH) secretion in ABD patients has not yet sufficiently been clarified. This randomized, prospective study aimed to compare the effects of LCD and high calcium dialysate (HCD) on the evolution of bone and mineral parameters related to ABD in dialysis patients. METHODS: 52 out of 60 patients with predialysis intact PTH<100 pg/ml completed this study and were equally distributed over LCD (1.25 mmol/l) or HCD (1.75 mmol/l) treatment. The duration of the study was 6 months and the only peroral phosphate binder administered was calcium carbonate. Total and ionised calcium were measured monthly in serum before and after dialysis while serum parameters relevant to bone were measured at the enrollment and at 3-month intervals. RESULTS: There were no differences in predialysis mean phosphate or calcium x phosphorus product (Ca x P). The most common side effects of both treatments were comparable. Hypotension occurred in 16% and 17% and cramps in 6% and 8% of the dialysis sessions, in the HCD and LCD group, respectively. The groups did not differ in the mean tCa before dialysis, but this parameter was significantly higher in the HCD group vs. LCD at the end of dialysis (2.59+/-0.18 vs. 2.44+/-0.19 mmol/l; p<0.01). The patients of the HCD group also had a significantly higher mean iCa both before (1.08+/-0.05 vs. 1.04+/-0.06 mmol/l; p=0.02) and at the end of dialysis (1.18+/-0.04 vs. 1.48+/-0.04 mmol/l; p<0.01). There were no differences within the LCD group between baseline and end of dialysis treatment values of tCa and iCa. However, the mean tCa and iCa were markedly increased at the end of dialysis in the HDC group [2.40+/-0.21 vs. 2.59+/-0.18 mmol/l (p<0.01); 1.08+/-0.05 vs. 1.18+/-0.04 mmol/l (p<0.01)]. Mean serum levels of iPTH and total alkaline phosphatase in the LCD group were increased at 3 months and at the end of the study compared with the baseline levels [(38.6+/-22.9 vs. 63.3+/-46.0 vs. 78.6+/-44.7 pg/ml); (59.5+/-18.7 vs. 75.9+/-26.7 vs. 84.0+/-35.4 U/l)], respectively, and bone alkaline phosphatase increased also only after 6 months of treatment (23.4+/-7.3 U/l vs. 35.6+/-22.3). The bone markers in the HCD group did not change. At the end of the study all bone parameters in the LCD group were significantly higher than in the HCD group. CONCLUSION: There was an evolution towards parameters reflecting higher bone turnover in patients treated with dialysate calcium of 1.25 mmol/l, probably by prevention of a positive calcium balance and enabling sustained stimulation of PTH secretion. Hence, LCD might be considered a valuable therapeutic option for ABD patients.

Hypomagnesemia and cause-specific mortality in hemodialysis patients: 5-year follow-up analysis.

INTRODUCTION: The aim of this prospective study was to evaluate the association between serum magnesium (Mg) and mortality, in particular the cause-specific mortality of Mg and other risk factors in hemodialysis (HD) patients. METHODS: We studied a cohort of 185 HD patients receiving thrice-weekly HD treatment, on a dialysate Mg concentration of 0.5 mmol/L. We stratified 3 patient groups according to the level of Mg: lower (<1.1 mmol/L), intermediate-reference (1.1 to <1.3 mmol/L), and higher (Mg >1.3 mm/L). RESULTS: During the 5-year follow-up, 60 patients died, with cardiovascular (CV) disease as the predominant cause (73.3%). Hazard ratio (HR) for all-cause and CV mortality were 2.55 and 2.67 in the lower versus intermediate Mg group, but there was no significant association between the higher and intermediate Mg group. Univariate Cox regression analysis showed that Mg <1.1 versus 1.1-1.30 mml/L with HR 2.34, was a significant univariate predictor for increased mortality in addition to the Hb <110 g/L, Alb <40 g/L, C-reactive protein (CRP) ≥10 mg/L and brain natriuretic peptide >1,200 pg/mL. However, in the multivariate analysis only CRP ≥10 mg/L with HR 3.89 was a significant predictor of mortality. Subgroup analyses showed that among patients with CRP >10 mg/L, HR for all-cause and CV mortality of the lower versus intermediate Mg group were 1.96 and 2.39, respectively, not reaching significance for the higher versus intermediate Mg group. Conversely, there was no association between Mg level and all-cause and CV mortality within these 3 groups among patients with CRP <10 mg/L. CONCLUSIONS: Lower serum Mg level was significantly associated with an increased all-cause and cardiovascular mortality in HD patients, especially in inflamed patients.

How to improve the survival of the kidney transplant - is it only the pharmaceutical management?

Kidney transplantation is the best treatment option in chronic kidney disease patients. Despite the new potent immunosuppressants, the long-term graft survival has not significantly improved. This is a rather complex issue with interrelationship between pretransplant donor-recipient variables, recipient post-transplant perioperative non/immunological factors, the combination/dose of maintenance immunosuppression and the general noncompliance of the patient. The recipients with an increased immunological risk should be maintained on triple therapy with steroids, preferably tacrolimus (Tac) or cyclosporine (CsA) plus mycophenolate mofetil (MMF). Eventual calcineurin inhibitor (CNI) minimization should be coupled with either protocol biopsies or frequent biochemistry monitoring including periodical assessment of anti-human leukocyte antigen and donor-specific antibodies. Recipients with standard immunological risks may be considered for as low as possible triple immunosuppression (steroids, Tac/CsA, MMF) after a period of 6 - 12 months. In cases of CNI minimization, a modification with a higher dose of the other two drugs in the triple therapy combination might be considered. The nonadherence to the prescribed maintenance therapy should be regularly checked-up. In conclusion, antibody induction, MMF, steroids and low-dose Tac/CsA should be the mainstream therapy in majority of patients. The short- and mid-term encouraging results for CNI minimization/withdrawal seem to correspond to recent findings of chronic antibody-mediated rejection, and long-term results need further evaluation.

Cyclosporine nephrotoxicity and early posttransplant hyperkalemia in living-donor renal recipients: report of 4 cases.

OBJECTIVES: Hyperkalemia is an electrolyte disorder that may occur during the first few months after a renal transplant, in patients undergoing cyclosporine immunosuppression. We present our experience with cyclosporine-associated hyperkalemia in living-donor renal transplant recipients, with isolated clinically relevant hyperkalemia soon after surgery. MATERIALS AND METHODS: We report 4 living-donor renal recipients with hyperkalemia soon after transplant. RESULTS: Severe unexpected hyperkalemia (7.5- 9.4 mmol/L) was noted in our patients 12, 20, 22, and 34 days after transplant. The C2 cyclosporine concentration was within recommended range or slightly greater than 1200 ng/mL. The hypertonic glucose/insulin treatment along with potassium diet was without results. A reduction in daily cyclosporine dosages, along with 1- to 2-week administration of fludrocortisone was effective. The patients became normokalemic taking a standard, triple-drug immunosuppression protocol, and were discharged home with normal renal function. There were no repeat episodes of hyperkalemia in any of the patients during 12 months of follow-up. CONCLUSIONS: Cyclosporine should be considered a cause of hyperkalemia in renal transplant recipients. Successful treatment with fludrocortisone confirms that transitional pseudohypoaldosteronism has a potential nephrotoxic effect of cyclosporine. We recommend close monitoring of the cyclosporine concentration and administering fludrocortisone when treating hyperkalemia in renal transplant recipients.

Protocol for performing nephrological activity in the Republic of Macedonia.

The fast development of nephrology in the world, especially in the second half of the 20 th century demanded protocol (guidelines) for nephrological activity for all levels of medical care, of doctors and specialists. The International Society of Nephrology, the European Renal Association and other national associations created their own protocol (guidelines) for nephrological activity. The Macedonian Society of Nephrology, Dialysis, Transplantation and Artificial Organs (MSNDTAO) proclaimed the First Protocol for Performing Nephrological Activity in the Republic of Macedonia at the First Congress of the MSNDTAO, held in Ohrid 1993, and it was published in the Macedonian Medical Review, 1994; Supplement 14: 397-406 [1]. The update of the Protocol for Performing Nephrological Activity in the Republic of Macedonia was proclaimed at the Fourth Congress of MSNDTAO, held in Ohrid 2012 and it presented in this text.

The improvement in kidney transplant program in R. Macedonia--what are the clues?

Kidney transplantation (KTx) is the best treatment option in patients with chronic kidney disease (CKD). Health-economics data favour the KTx in comparison with any type of dialysis procedure, but the multidisciplinary approach and required high level of organisational infrastructure are frequent impediments for its availability in the majority of developing countries. A living donor kidney transplant (LDKTx) programme has been developed in the Republic of Macedonia since 1977 but without a real continuum in the following years. There was a great success with 15 cadaveric kidneys transplanted (1987-1989) followed by an average of 13.5 KTx per year in the period 1996-2011. Because of the scarce organ donation and transplant activities in the majority of Balkan countries the question remains what could be done in order to enable organ transplantation as the basic human right for the best treatment option in patients with CKD. In addition to the possible increase in the number of LDKTx, prerequisites for a deceased donor (DD) programme would be the creation of an official waiting list of candidates for DD transplantation, organizational and infrastructural networking and raising public awareness on the number of potential deceased donors through permanent media presentation. Our involvement in the South-eastern Europe Health Network (SEEHN) initiative and the support from the newly created Regional Health Development Centre (RHDC) on Organ Donation and Transplant Medicine established in Croatia (Zagreb) was shown as successful for improvement of the KTx programme. At the very first professional meeting (27-28 May, 2011 in Skopje, Macedonia), the organ donation and transplantation needs of each country within the SEE geographical region were addressed and action plans for further steps on how to proceed were established. Hence, the number of professionals (including vascular surgeons) involved in KTx was increased along with the substantial increase in the reimbursement per transplant procedure at the Urology Department. Nowadays, we are pleased to report 24 successfully performed LDKTx in 2012, and in 2013 for 7 months 28 transplantations, awaiting 40 KTx at the end of the year. Prospectively, we should initiate the deceased donor programme, even in order to sustain the already established high number of transplantation per month/year, since the potential for LDKTx may be exhausted. We also hope to be supportive for regional collaboration and transplantation of CKD patients from the neighbouring countries (Albania and Kosovo), and eventually to establish regional networking in deceased donor procurement, exchange and allocation practice.

Can an increased nitric oxide level be accepted as non-invasive marker for sub/acute rejection of the kidney allograft?

BACKGROUND: Subclinical and acute rejections (SAR/AR) continue to have a negative impact on graft survival. The aim of our study was to analyze allograft rejection and nitric oxide (NO) levels in patients with protocol- and clinically-indicated biopsies in relationship with other causes of allograft dysfunction, and to evaluate the clinical impact of NO measurement as non-invasive marker for early diagnosis of SAR/AR. METHODS: In 45 living-related kidney transplants, serum NO levels were measured at: 20 min after reperfusion (NO1); on days 1 (NO2), 5 (NO3), and 14 (NO4); and at the first (NO5) and sixth (NO6) months after transplantation (Tx). Protocol biopsies (Bx) were performed at the first and sixth months after Tx. RESULTS: 38 (42.2%) Bx showed histological features of (SAR), 4 (4.5%) Bx showed mild tubulointerstitial rejection, while 48 (53.3%) Bx had no histological signs of SAR/AR. Significantly higher (NO3) levels were found in patients with AR and (NO5)/(NO6) in SAR as compared to other causes of allograft dysfunction occurred within the first posttransplant month (delayed graft function, urinary tract infection, and cyclosporine toxicity). Sensitivity/specificity for cut-off NO level of 70 µmol/l were 69.2% and 88.4% in AR, and 78.9% and 75.4% for the level of 50 µmol/l in SAR patients, respectively. CONCLUSIONS: Our study reports significantly higher serum NO levels at day 5 and a gradual decrease at day 14 (prior to and at the time of clinically manifested AR), and at 1- and 6-month protocol biopsies in SAR patients as compared to all other causes of renal dysfunction. NO measurement may have a satisfactorily diagnostic performance as a useful non-invasive marker not only for AR, but also for SAR patients.

Acute fulminant hepatatis in kidney transplant recipient after repeated sevoflurane anesthesia--a case report and literature review.

INTRODUCTION: A liver dysfunction induced by halogenated volatile anaesthetics is considered as a significant diagnostic problem. The aim of our report was to describe the first case of lethal hepatic failure in a female patient undergoing kidney transplantation (KTx) from a living donor after repeated sevoflurane anaesthesia. CASE PRESENTATION: A 47-year-old hypertensive and diabetic female patient received kidney from her 70-year-old mother. There was an immediate graft function and around 800 ml of blood loss on the abdominal drains, which gradually decreased after the erythrocyte and fresh frozen plasma (FFP) substitution. On the first postoperative (p.o.) day she gradually became anuric and overweighed at the next day undergoing dialysis. Because of prolonged hypotension and somnolence she required reintubation. The second day transaminases increased (AST&ALT>700, LDH>1200 U/L). On the third p.o. day she was urgently reoperated because of a sudden excessive bleeding. However, there was a rather slow flow of tears from the whole operative field that was even more excessive after the operation with signs of a consumptive coagulopathy. She was adequately substituted until the bleeding stopped more than 24 hrs after its onset. The new laboratory results showed further increase in transaminazes (3300 U/L-ALT, 5100-AST, 8900-LDH) and ultrasound investigation confirmed an extensive toxic hepatic lesion. On the fourth p.o. night the patient was stable, diuresis rate was at 100 ml/hour, but in the morning she became hyposaturated because of an increased bronchial secretion. The dialysis could not improve the cardio-respiratory insufficiency and she died 30min later. CONCLUSIONS: This case report suggests that sevoflurane can lead to a severe hepatotoxicity in at-risk individuals with repeated sevoflurane anaesthesia, having renal failure, in those with a preoperative known history of cardiovascular disorders, as well as in those with excessive extracellular volume. A particular precaution should be considered in cases of an elective surgery including organ transplantation.

First two ABO-incompatible living renal transplantations using splenectomy, rituximab, plasmapheresis and IVIG as a preconditioning regimen: a single center experience in the Balkans.

BACKGROUND: Due to the growing organ shortage in the Balkans and still underdeveloped cadaver transplantation, we started accepting living expanded criteria renal donors including elderly, marginal and unrelated donors (spouses, etc). The ABO-incompatible renal transplantation was initiated last year. The first two successful cases are presented. METHODS: A 40-yr-old mother (blood group A1B) and a 57-yr-old husband (blood group B) were considered as suitable donors for an 18-yr-old daughter (blood group B) and a 52-yr-old wife (blood group O). Both the recipients had a relatively long dialysis treatment before the surgery. The anti-A1 and anti-B titer of isoaglutinins was 1 : 64 in both the recipients before the procedure. A routine laparoscopic splenectomy was performed 40 and 45 days before the transplantation, without any complications. In the 10 days pre-conditioning period, rituximab was administered in a single dose of 375 mg/m2. At the same time four to five plasmaphereses were performed to reduce the isoaglutinins to below 1 : 4. On the last night before the surgery intravenous immunoglobulin (IVIG) in a dose of 0.5 g/kg/bw was administered. Standard induction and maintenance therapy was introduced (Dacllizumab, CyA-Neoral, MMF and steroids) according to the accepted policy in our transplant center. The routine plasmaphereses were performed in the first 2 weeks after transplantation to keep the isoaglutinins titer below 1 : 8. RESULTS: Ten and 6 months after the surgery both recipients are doing well. Their graft function remains stable (actual serum creatinin 140 and 230 microm/L, respectively). In the 1 month protocol biopsy a subclinical cellular and mild vascular rejection occurred, and both recipients were treated by steroid pulse therapy. One to two additional plasmaphereses were performed. The regularly monitored anti-A1 and anti-B isoaglutinins titer was kept below 1 : 8 during a period of follow-up. CONCLUSION: The first short-term results fully justify the ABO-incompatible living renal transplantation. The authors consider ABO-incompatible transplantation as a safe and promising procedure which may, together with expanded criteria living donors, ameliorate the actual donor shortage in the region.

Evolution of bone and plasma concentration of lanthanum in dialysis patients before, during 1 year of treatment with lanthanum carbonate and after 2 years of follow-up.

BACKGROUND: Lanthanum carbonate (LC) has been proposed as a new phosphate binder. Presented here are the results from one centre that participated in a multicentre trial to assess the effect of treatment with LC and calcium carbonate (CC) on the evolution of renal osteodystrophy in dialysis patients. Bone biopsies were performed at baseline, after 1 year of treatment and after a further 2-year follow-up period to assess the lanthanum concentration in bone and plasma. METHODS: Twenty new dialysis patients were randomized to receive LC (median dose 1250 mg) for 1 year (n = 10), followed by 2 years of CC treatment or CC (n = 10) during the whole study period (3 years). RESULTS: After 36 weeks of treatment, steady state was reached with plasma lanthanum levels varying around 0.6 ng/ml. Six weeks after cessation of 1 year of treatment, the plasma lanthanum levels declined to a value of 0.17 +/- 0.12 ng/ml (P < 0.05) and after 2 years to 0.09 +/- 0.03 ng/ml. Plasma and bone lanthanum levels did not correlate with the average lanthanum dose at any time point. The mean bone concentration in patients receiving LC increased from 0.05 +/- 0.03 to 2.3 +/- 1.6 microg/g (P < 0.05) after 1 year and slightly decreased at the end of the study to 1.9 +/- 1.6 microg/g (P < 0.05). CONCLUSIONS: Bone deposition after 1 year of treatment with LC is low (highest concentration: 5.5 microg/g). There is a slow release of lanthanum from its bone deposits 2 years after the discontinuation of the treatment and no association with aluminium-like bone toxicity.