Outcomes of patients with end-stage kidney disease hospitalized with COVID-19.

Given the high risk of infection-related mortality, patients with end-stage kidney disease (ESKD) may be at increased risk with COVID-19. To assess this, we compared outcomes of patients with and without ESKD, hospitalized with COVID-19. This was a retrospective study of patients admitted with COVID-19 from 13 New York hospitals from March 1, 2020, to April 27, 2020, and followed through May 27, 2020. We measured primary outcome (in-hospital death), and secondary outcomes (mechanical ventilation and length of stay). Of 10,482 patients with COVID-19, 419 had ESKD. Patients with ESKD were older, had a greater percentage self-identified as Black, and more comorbid conditions. Patients with ESKD had a higher rate of in-hospital death than those without (31.7% vs 25.4%, odds ratio 1.38, 95% confidence interval 1.12 - 1.70). This increase rate remained after adjusting for demographic and comorbid conditions (adjusted odds ratio 1.37, 1.09 - 1.73). The odds of length of stay of seven or more days was higher in the group with compared to the group without ESKD in both the crude and adjusted analysis (1.62, 1.27 - 2.06; vs 1.57, 1.22 - 2.02, respectively). There was no difference in the odds of mechanical ventilation between the groups. Independent risk factors for in-hospital death for patients with ESKD were increased age, being on a ventilator, lymphopenia, blood urea nitrogen and serum ferritin. Black race was associated with a lower risk of death. Thus, among patients hospitalized with COVID-19, those with ESKD had a higher rate of in-hospital death compared to those without ESKD.

Phospholipase A2 Receptor Antibody-Positive Pregnancy: A Case Report.

Renal course and clinical outcomes in pregnant women with primary membranous nephropathy are not completely understood. In addition, the use of autoantibodies to M-type phospholipase A2 receptor (PLA2R) as a serologic marker throughout pregnancy and postpartum in the mother and baby is not yet fully elucidated. We followed up a pregnant woman with primary membranous nephropathy during pregnancy and postpartum and describe the clinical course and outcomes of mother and baby and the course of PLA2R antibody titers. We show evidence of transplacental transfer of PLA2R antibody from mother to fetus. In addition, we observe the effect of breastfeeding in a PLA2R antibody-positive pregnancy and describe the transfer of this antibody into breast milk. Although pregnancy in women with underlying PLA2R antibody-positive membranous nephropathy is possible, there is an increase in risk to both mother and fetus, requiring a multidisciplinary team approach and careful monitoring of both neonate and mother during pregnancy and postpartum.

COVID-19 in Hospitalized Patients on Chronic Peritoneal Dialysis: A Case Series.

BACKGROUND: The COVID-19 pandemic has affected the end-stage kidney disease (ESKD) population, with high mortality rates reported among patients on hemodialysis. However, the degree to which it has affected the peritoneal dialysis (PD) population in the United States has not yet been elucidated. In this report, we describe the clinical characteristics, presentations, clinical course, and outcomes of ESKD patients on PD hospitalized with COVID-19. METHODS: We describe the characteristics, presentation, and outcomes of adult ESKD patients on chronic PD hospitalized with CO-VID-19 in our 13 major hospitals in the NY health system using descriptive statistical analysis. RESULTS: Of 419 hospitalized patients with ESKD, 11 were on chronic PD therapy (2.6%). Among those 11, 3 patients required mechanical ventilation, 2 of whom died. Of the entire cohort, 9 of the 11 patients (82%) were discharged alive. While fever was a common presentation, more than half of our patients also presented with diarrhea. Interestingly, 3 patients were diagnosed with culture-negative peritonitis during their hospitalization. Seven patients reported positive SARS-CoV-2 exposure from a member of their household. CONCLUSION: Hospitalized patients on PD with COVID-19 had a relatively mild course, and majority of them were discharged home.

Should obesity affect suitability for kidney donation?

As with the suitability for kidney transplantation for obese recipients, there is no universally accepted guideline for clinicians for obese donors; criteria for acceptance are variable among transplant centers. Obesity is on the rise in the United States and the number of living kidney donors who are obese parallel this national trend. Careful risk assessment and informed consent must be undertaken predonation prior to accepting an obese kidney donor in order to minimize long- and short-term complications. Likewise, close postdonation follow-up for this higher risk group should be implemented.

Renal Ultrasound, Dialysis Catheter Placement, and Kidney Biopsy Experience of US Nephrology Fellows.

Procedures are a key component to the practice of nephrology. The Accreditation Council for Graduate Medical Education (ACGME) requires nephrology fellows to acquire skills and demonstrate competency in the performance of several procedures during fellowship training, including temporary hemodialysis catheter placement, biopsy of native and transplanted kidneys, and various dialytic therapies. It is also required that fellows acquire competency in the interpretation of renal imaging, including renal ultrasound, during their training. To gain a more recent perspective of nephrology fellows' experiences regarding renal ultrasonography, dialysis catheter placement, and kidney biopsies, we carried out a national survey of nephrology fellows in May 2014. A majority of the programs did not offer formal clinical training in renal ultrasonography. In addition, a significant percentage of fellows in adult nephrology may not be acquiring the required procedural skills and competency during fellowship training. In this perspective, we explore some of the reasons for this occurrence and propose some measures that the nephrology training community can take to enhance procedural skills and competency of fellows.

Outcomes following Kidney transplantation in IgA nephropathy: a UNOS/OPTN analysis.

This study updates assessment of post-transplant outcomes in IgAN patients in the modern era of immunosuppression. Using UNOS/OPTN data, patients ≥18 yr of age with first kidney transplant (1/1/1999 to 12/31/2008) were analyzed. Multivariable Cox regression models and propensity score-based matching techniques were used to estimate hazard ratios (HRs) for death-censored allograft survival (DCGS) and patient survival in IgAN compared to non-IgAN. Results of multivariable regression were stratified by donor type (living vs. deceased). A total of 107, 747 recipients were included (4589 with IgAN and 103 158 with non-IgAN). Adjusted HR for DCGS showed no significant difference between IgAN and non-IgAN. IgAN had higher patient survival compared to non-IgAN (HR 0.54, 95% CI 0.47-0.62, p < 0.0001 for deceased donors; HR 0.42, 95% CI 0.33-0.54, p < 0.0001 for living donors). Propensity score-matched analysis was similar, with no significant difference in DCGS between matched groups and higher patient survival in IgAN patients compared to non-IgAN group (HR 0.54, 95% CI 0.47, 0.63; p-value <0.0001). IgAN patients with first kidney transplant have superior patient survival and similar graft survival compared to non-IgAN recipients. Results can be used in prognostication and informed decision-making about kidney transplantation in patients with IgAN.

Obesity as a barrier to living kidney donation: a center-based analysis.

BACKGROUND: Obesity is a major epidemic and may present a significant barrier to living kidney donation. The purpose of our study was to determine the frequency of obesity as an exclusion factor and assess how often these donors lose weight and donate. METHODS: A single center, retrospective analysis of 104 potential living kidney donors between 2008 and 2012. RESULTS: Of the 104 donors, 19 (18%) had a normal body mass index (BMI) of <25. Eighty-five of the 104 (82%) donors spanned the overweight to morbidly obese classifications. Thirty-eight (37%) were overweight (BMI 25-29.9). Twenty-four (23%) were categorized as class I obesity (BMI 30-34.9), 17 (16%) as class II obesity (BMI 35-39.9), and six (6%) as class III obesity (BMI >40). There were a total of 23 donors (22%) who were considered moderately and morbidly obese (BMI >35). Of these, only three (13%) succeeded at losing weight and donating. CONCLUSIONS: Obesity may be a frequent barrier to living kidney donation, directly leading to exclusion as a potential kidney donor in about one in five instances. Successful weight loss leading to donation appears to be infrequent, suggesting need to address obesity in the donor population.

Significance of elevated transplant renal artery velocities in the postoperative renal transplant patient.

INTRODUCTION: Non-invasive imaging studies can provide visualization of allograft perfusion in the postoperative evaluation of newly transplanted renal allografts. AIM: The purpose of our study was to evaluate the significance of elevated renal artery velocities in the immediate postoperative period. METHODS: Peak systolic velocities (PSVs) were obtained in the transplanted renal artery of 128 patients immediately after transplantation. Repeat allograft Doppler ultrasonography was performed on patients with elevated values. RESULTS: Of the 128 patients, 57 (44.5%) had severely elevated Doppler velocities >400 cm/s on the initial studies. Three patients within this category had persistently elevated values of >400 cm/s, warranting angiographic visualization of the renal vessels. Stent placement within the transplanted renal artery was required in two of these patients. There was normalization of the PSV in the remaining patients. CONCLUSIONS: Routine allograft Doppler ultrasonography in the immediate postoperative period allows for visualization of allograft perfusion. Elevated renal artery velocities in the immediate postoperative period do not necessarily represent stenosis requiring intervention. Failure of the PSV to normalize may require further intervention, and angiography continues to be the gold standard.

Forty-eight hour kidney transplant admissions.

Forty-eight hour kidney transplantation admissions are a feasible option in selected recipients of live-donor allografts through the use of standardized post-operative protocols, multidisciplinary team patient care, and intensive follow-up at outpatient centers. Age, gender, and pre-transplant dialysis status did not impact the ability to achieve 48-hour admissions. We did not identify any other pre-operative risk factors that contributed to increased length of stay. Although ABO and highly sensitized recipients had longer lengths of stay, the subgroup was too small to achieve statistical significance. We did not encounter any readmissions within the first seven post-operative days. Further improvements in clinical management will enhance the potential to shorten the length of hospital stay for all kidney transplant recipients.

Corrigendum to "Sarcoidosis presenting as Wallenberg syndrome and panuveitisË® Respir. Med. Case Rep. 24 (2018) 16-18.

[This corrects the article DOI: 10.1016/j.rmcr.2018.03.002.].

Contraception in Kidney Disease.

Unplanned pregnancies account for a large number of encountered pregnancies. One of the reasons for this is the lack of counseling surrounding contraception and subsequently lack of contraception use. A conversation during a regular CKD office visit of simply asking a woman what her plans are regarding pregnancy can lead to further discussion on timing of pregnancy and contraception and eventually safer outcomes for both the mother and fetus. Individual preference, as well as comorbid conditions, should be taken into account when deciding on optimal contraceptive methods. One must remember that contraception counseling and initiation of contraception should not be wrapped up in a single office visit, and there must be continued follow-up to ensure that the woman is using the contraceptive method correctly to prevent any future unplanned pregnancy.

Opportunities for Subspecialization in Nephrology.

The interface between nephrology and other fields of medicine continues to expand. With the advent of novel therapies in cancer, diagnostics and therapeutics in lithology, novel devices in cardiology, advances in women's health issues, novel diagnostics and therapies in glomerular diseases, and the national priority in home-based dialysis, several subspecialties in nephrology have emerged. This article will discuss the subspecialties of onconephrology, cardionephrology, obstetric nephrology, uronephrology, glomerular disease specialization, and home-based dialysis in nephrology. We discuss the current state of each subspecialty, recommended educational content, length of training, available training opportunities, and potential career pathways for each.

Vascular access type and changes in inflammatory markers in incident dialysis patients: a pilot study.

PURPOSE: To determine the association between the initial hemodialysis (HD) vascular access type and short-term changes in inflammation markers. METHODS: This is a prospective, observational study in incident chronic kidney disease (CKD) (stages 4 and 5) patients receiving their first HD vascular access. Serum samples were obtained pre-access placement, and 1 week, and 1 month post-access insertion. Samples were tested for high sensitivity C-reactive protein (hsCRP) and interleukin-6 (IL-6) using ELISA. Patients with known inflammatory states (infection, malignancy, connective tissue disorders, organ transplantation and those on immune modulating agents) were excluded. The hsCRP and IL-6 values were transformed into logarithmic scale. Chi-square analysis, independent and paired t-tests were performed where appropriate, and a two-way ANOVA with time as a repeated measure was also performed. Significance was determined at p=0.05. RESULTS: One-month follow-up data was obtained in 48 patients (arteriovenous fistula (AVF), n=10; tunneled catheter (TC), n=28; arteriovenous graft (AVG), n=10). A significant increase in both hsCRP (p <0.05) and IL-6 (p=0.02) occurring 1 week after TC insertion was observed. Elevation of the IL-6 levels appeared to be sustained 1 month after TC insertion, although this finding was not statistically significant (p=0.68), whereas the hsCRP levels returned to baseline within 1 month. After AVG insertion only the hsCRP levels rose significantly (p=0.01) after 1 week and returned to baseline within 1 month. In the AVF group, inflammatory markers did not change for any time period. CONCLUSIONS: In CKD patients, TC and AVG insertion result in a transient state of inflammation 1 week post-operatively, which is not observed after AVF surgery. Whether this is a persistent phenomenon after TC insertion requires a larger, longitudinal study.

Barriers to Peritoneal Dialysis in Aboriginal Patients.

BACKGROUND: Aboriginal people in Canada have an unduly high burden of end-stage kidney disease (ESKD) and many live in rural settings. Peritoneal dialysis (PD) is a home-based dialysis modality that may provide a valuable alternative to in-center hemodialysis which is relatively underutilized by the Aboriginal population. OBJECTIVE: We aim to assess the barriers to PD utilization in Aboriginal patients with ESKD. DESIGN: This article is a prospective observational cohort study. SETTING: The setting involves 3 predialysis clinics in Winnipeg, Kingston, and Moose Factory. PATIENTS: The patients were 99 individuals (67 non-Aboriginal and 32 Aboriginal) who were at least 18 years of age with an estimated glomerular filtration rate of less than 30 mL/min/1.73m2, and were enrolled in one of the 3 study sites from April 2011 to October 2013. MEASUREMENTS: Patient demographics and comorbidities were documented. Barriers to PD, PD as modality choice, and Aboriginal status were assessed via patient survey upon study enrollment. PD use as the initial dialysis modality was assessed via monthly patient follow-up for 1 year after enrollment in the study. METHODS: The patient survey was created based on literature review of known barriers to PD, repaired based on direct patient feedback, and tested for reliability via the test-retest method. Differences in PD choice, barriers to PD, and PD use between Aboriginal and non-Aboriginal patients were determined by chi-square test and logistic regression. RESULTS: All patients enrolled in the study completed the survey. Mean age was 65.5 versus 54.6 years for non-Aboriginals and Aboriginals, respectively. Barriers to PD significantly associated with Aboriginal status were lack of money (odds ratio [OR]: 21.3; 95% confidence interval [CI]: 5.3-86.4; P < .0001) and anxiety (OR: 2.8; 95% CI: 1.1-7.1; P = .03). There was no difference in PD choice between non-Aboriginals and Aboriginals (66.7% vs 68.8%, respectively; P = .83). One of 67 non-Aboriginals (1.5%) and 5 of 32 Aboriginals (15.6%) died prior to initiating dialysis (P = .013). No significant difference was observed between non-Aboriginals (33%) and Aboriginals (28%) in use of PD (P = .81). LIMITATIONS: Small sample size was a limitation of this study. CONCLUSIONS: Aboriginal people in Canada have a disproportionately large burden of ESKD, and PD could provide an alternative to in-center hemodialysis for those living in rural areas. Our study identified anxiety and lack of money as barriers to PD significantly associated with Aboriginal status. When choosing dialysis modality, shared decision making between physicians and patient is of key importance to weigh all potential benefits and risks and emphasize the Aboriginal patient's values and preferences. These results can be used to guide future research and to help devise interventions targeting barriers to PD in Aboriginals.

CONTEXTE: Au Canada, un nombre important de personnes autochtones habitent en région rurale, et cette population présente un taux exagérément élevé d'insuffisance rénale terminale (IRT) par rapport à la population générale. La dialyse péritonéale (DP) est une modalité de dialyse que le patient reçoit à domicile et qui pourrait s'avérer une solution de remplacement intéressante à l'hémodialyse en centre, laquelle est relativement sous-utilisée par les patients autochtones. OBJECTIF DE L'ÉTUDE: Nous voulions recenser les facteurs qui restreignent l'utilisation de la DP chez les patients autochtones souffrant d'IRT. TYPE D'ÉTUDE: Il s'agit d'une étude de cohorte observationnelle et prospective. CADRE DE L'ÉTUDE: Trois cliniques de prédialyse situées à Winnipeg, à Kingston et à Moose Factory ont pris part à l'étude. PATIENTS: La cohorte était constituée de 99 patients adultes (67 allochtones et 32 autochtones) dont le débit de filtration glomérulaire estimé (DFGe) était de moins de 30 ml/min/1,73 m2. Les participants à l'étude ont été recrutés parmi les patients des trois centres de prédialyse mentionnés ci-haut entre avril 2011 et octobre 2013. MESURES: On a d'abord noté les données démographiques et les comorbidités des patients. Ensuite, un sondage réalisé auprès des patients au moment du recrutement a permis d'établir leur statut autochtone ou allochtone, de déterminer les facteurs qui constituaient un frein à leur utilisation de la DP, de même que des données sur l'usage de la DP comme modalité de dialyse. Le choix de la DP comme modalité initiale a été déterminé par un suivi mensuel sur une période d'un an post-recrutement. MÉTHODOLOGIE: Les obstacles à l'utilisation de la DP comme modalité de dialyse figurant dans le sondage étaient basés sur une revue de la littérature recensant ces facteurs. Le sondage a ensuite été modifié en fonction de la rétroaction offerte par les patients, et sa fiabilité a été évaluée par la méthode du test-retest. Les divergences observées entre le choix ou non de la DP comme modalité de dialyse, les facteurs freinant son utilisation et les variations relevées en regard de l'origine ethnique des patients (autochtones ou allochtones) ont été établies par le test du chi carré et par régression logistique. RÉSULTATS: Tous les patients inclus dans l'étude ont répondu au sondage. L'âge moyen des patients allochtones était de 65,5 ans alors qu'il était de 54,6 ans pour les patients autochtones. Les entraves à l'utilisation de la DP associées de façon significative avec le statut d'autochtone étaient le manque d'argent (RC=21,3; IC 95% 5,3-86,4; p<0,0001) et l'anxiété (RC=2,8; IC 95 1,1-7,1; p=0,03). Aucune différence n'a été observée entre allochtones et autochtones (66,7 % contre 68,8 % respectivement; p=0,83) en ce qui concerne le choix de la DP comme modalité de dialyse. Un patient allochtone (1,5 %) et 5 patients autochtones (15,6 %) sont décédés au cours de la période couverte par l'étude. Enfin, aucune variation significative n'a été observée entre les patients autochtones et allochtones (28 % et 33 % respectivement; p=0,81) en regard de l'utilisation de la DP comme modalité de dialyse. LIMITES DE L'ÉTUDE: La taille restreinte de l'échantillon limite la portée de cette étude. CONCLUSION: Au Canada, l'insuffisance rénale terminale affecte les patients autochtones de façon disproportionnelle. Pour ceux d'entre eux qui habitent en région rurale, la dialyse péritonéale, qui se pratique à domicile, pourrait s'avérer une solution de remplacement intéressante à l'hémodialyse conventionnelle qui elle, se pratique en centre hospitalier. Notre étude a révélé que l'anxiété et le manque d'argent constituaient des facteurs restreignant l'utilisation de la DP chez la population autochtone. Dans le choix d'une modalité de dialyse, la prise de décision conjointe du patient avec les médecins revêt une importance majeure : d'abord pour bien mesurer les bienfaits et les risques potentiels, mais également pour tenir compte des valeurs et des préférences du patient autochtone. Ces résultats pourront servir à orienter les recherches futures et à concevoir des interventions ciblant les facteurs qui freinent l'utilisation de la DP chez les patients autochtones atteints d'IRT.

Sarcoidosis presenting as Wallenberg syndrome and panuveitis.

Sarcoidosis is a multi-system disease with neurological involvement being one of the more rare manifestations. We report a case of a patient who presented with the lateral medullary syndrome and panuveitis as her initial manifestation of sarcoidosis. The patient's course was further complicated by renal involvement. Lacrimal gland and renal biopsies showed noncaseating granulomas without evidence of infection, establishing the diagnosis. Intracranial vertebral artery involvement was confirmed by brain imaging. Bilateral hilar lymphadenopathy with upper lobe predominant nodules on chest imaging was consistent with asymptomatic pulmonary involvement. Systemic steroid therapy is indicated for treatment of ocular sarcoidosis, with standard stroke management indicated for the treatment of lateral medullary syndrome.

Lung ultrasonography in end-stage renal disease: moving from evidence to practice-a narrative review.

Traditionally, point of care ultrasonography in nephrology has been used for renal biopsies and dialysis line placement. However, there is an emerging literature supporting the value of point of care lung ultrasonography in the assessment of volume status for dialysis patients. We conducted a review and identified 12 studies that examined the utility of lung ultrasonography in assessing volume status in patients with end-stage renal disease. We conclude that lung ultrasonography can be used to determine volume status in chronic dialysis patients by identifying lung congestion using the B-line score. Incorporating this technique into practice may have significant diagnostic and prognostic value for this high-risk population, as it provides the nephrologist with a useful bedside technique to assess extravascular lung water. Developing competence in lung ultrasonography is straightforward. The nephrology community should consider adding this useful tool into fellowship training, paralleling its broader use in other internal medicine specialties.

Primary Cytomegalovirus Infection Causing Guillain-Barré Syndrome in a Living Renal Allograft Recipient.

Guillain-Barré Syndrome (GBS) is a common acute autoimmune polyneuropathy in adults. There have been few reported cases of Guillain-Barré Syndrome associated with active cytomegalovirus (CMV) infection in renal transplant recipients. Here we present a case of active CMV viremia inducing Guillain-Barré Syndrome in a renal transplant recipient. We discuss the treatment regimen utilized. Furthermore, we performed a review of the literature and discuss the cases of CMV induced GBS in renal transplant recipients.