Interleukin 6 Receptor Blockade to Treat Chronic Active Antibody-Mediated Rejection in Kidney Transplant: A Case Report With Review of Relevant Literature.

A 40-year-old male patient with a pretransplant calculated panel reactive antibody of 0 and no prior sensitizing events developed mixed active antibody-mediated rejection and acute cellular rejection (Banff grade 1A) 1.5 years posttransplant. Testing for donor-specific antibody or non-human leukocyte antigen antibody (major histocompatibility complex class I chain-related antigen A/angiotensin II type I receptor) was negative. Biopsy demonstrated diffuse C4d staining in peritubular capillaries. The patient was treated with standard of care, including plasma-pheresis and intravenous immunoglobulin along with steroids, with return of renal function to baseline. However, 1 year after treatment, he developed chronic active antibody-mediated rejection without any donor-specific antibodies. We believe he did have smoldering antibody-mediated rejection that had progressed to a more chronic state over time. He was then treated with tocilizumab and had a successful return of serum creatinine to baseline. One year after treatment, he still has stable renal function, suggesting a role of tocilizumab in stabilizing renal function in patients with chronic active antibody-mediated rejection for which there is no Food and Drug Administration-approved treatment.

Chylothorax and chylopericardial tamponade in a hemodialysis patient with catheter-induced superior vena cava stenosis.

Chylothorax and chylopericardium refer to the presence of milky, triglyceride-rich chylous fluid in the thoracic and pericardial spaces, respectively. Both conditions are extremely uncommon in end-stage renal disease patients on dialysis. We report the first known case of combined chylothorax and chylous pericardial tamponade in a dialysis patient associated with catheter-induced superior vena cava (SVC) stenosis. A successful outcome was achieved with drainage of both chylous effusions in combination with angioplasty of the SVC stenosis.

Antithymocyte globulin dosing effects on biopsy-proven acute rejection and infection risk.

BACKGROUND: Antithymocyte globulin (rATG) is a polyclonal antibody commonly used as induction therapy in kidney transplantation to reduce risk of allograft rejection. Currently there is no consensus on the optimal dosing. rATG is not FDA approved for induction therapy, so no dosing recommendations are provided by the manufacturer. Current kidney transplant guidelines do not provide dosing recommendations. The objective of this study was to evaluate effects of different cumulative doses of rATG on rejections and infection rates. MATERIAL AND METHODS: This was a retrospective, single-center chart review that included 142 renal transplant patients from January 2007 to October 2012 who received either 3 or 5 doses of rATG. RESULTS: The primary outcome of biopsy-proven acute rejection (BPAR) was not significantly different between the 3-dose and 5-dose groups, (6.1% versus 7.4%, p=NS). No significant difference was seen between the 3-dose and 5-dose groups in regards to bacterial infections (33.9% versus 40.7%, p>0.05) or BK viremia (24.3% versus 18.5%, p>0.05). However, in regards to CMV viremia there was a significantly higher incidence in the 5-dose group (37% versus 15.7%, p=0.47). CONCLUSIONS: Five doses of rATG versus 3 doses did not provide any additional benefit in preventing BPAR.

Improved use of thromboprophylaxis for deep vein thrombosis following an educational intervention.

BACKGROUND: We evaluated venous thromboembolism (VTE) prophylaxis rates in hospitalized medical patients in a teaching hospital, the State University of New York-Downstate Medical Center-University Hospital of Brooklyn, before and after implementation of a multifaceted VTE prophylaxis quality improvement intervention that combined regular education, dissemination of a decision support tool, and regular audit-and-feedback to resident physicians. METHODS: The charts of 312 hospitalized medical patients were retrospectively reviewed to assess baseline rates of appropriate VTE prophylaxis. Rates of appropriate VTE prophylaxis were then determined 12 and 18 months after implementation of the quality improvement intervention. Data collected included risk factors for VTE, contraindications to anticoagulant prophylaxis, type of VTE prophylaxis prescribed, and whether the prophylaxis was appropriate. RESULTS: Most of the hospitalized medically ill patients had 3 or more risk factors for VTE. At baseline, the proportion of patients receiving any form of VTE prophylaxis, primarily unfractionated heparin, was 47%. The proportion of patients for whom a physician provided appropriate prophylaxis was 43%. After the intervention, the proportion of patients receiving prophylaxis significantly increased, to 86% at 12 months, and this level was maintained at 18 months. The rate of appropriate prophylaxis increased to 68% and 85% after 12 and 18 months, respectively. CONCLUSIONS: The proportion of hospitalized medical patients receiving appropriate VTE prophylaxis as recommended by evidence-based guidelines can be increased significantly by combining regular education, a decision support tool, and regular audit-and-feedback.