Evolution of laparoscopic ileal pouch-anal anastomosis: impact of enhanced recovery program, medication changes, and staged approaches on outcomes.

BACKGROUND: Although laparoscopic Ileal pouch-anal anastomosis (IPAA) has become the gold standard in restorative proctocolectomy, surgical techniques have experienced minimal changes. In contrast, substantial shifts in perioperative care, marked by the enhanced recovery program (ERP), modifications in steroid use, and a shift to a 3-staged approach, have taken center stage. METHODS: Data extracted from our prospective IPAA database focused on the first 100 laparoscopic IPAA cases (historic group) and the latest 100 cases (modern group), aiming to measure the effect of these evolutions on postoperative outcomes. RESULTS: The historic IPAA group had more 2-staged procedures (92% proctocolectomy), whereas the modern group had a higher number of 3-staged procedures (86% proctectomy) (P < .001). Compared with patients in the modern group, patients in the historic group were more likely to be on steroids (5% vs 67%, respectively; P < .001) or immunomodulators (0% vs 31%, respectively; P < .001) at surgery. Compared with the historic group, the modern group had a shorter operative time (335.5 ± 78.4 vs 233.8 ± 81.6, respectively; P < .001) and length of stay (LOS; 5.4 ± 3.1 vs 4.2 ± 1.6 days, respectively; P < .001). Compared with the modern group, the historic group exhibited a higher 30-day morbidity rate (20% vs 33%, respectively; P = .04) and an elevated 30-day readmission rate (9% vs 21%, respectively; P = .02). Preoperative steroids use increased complications (odds ratio [OR], 3.4; P = .01), whereas 3-staged IPAA reduced complications (OR, 0.3; P = .03). ERP was identified as a factor that predicted shorter stays. CONCLUSION: Although ERP effectively reduced the LOS in IPAA surgery, it failed to reduce complications. Conversely, adopting a 3-staged IPAA approach proved beneficial in reducing morbidity, whereas preoperative steroid use increased complications.

[Pouchitis showed complete response to ustekinumab].

Pouchitis is the most common long-term complication following ileal pouch-anal anastomosis (IPAA) in patients with ulcerative colitis. Although several agents, including probiotics, steroids, and immunomodulators, have been used, the treatment of pouchitis remains challenging. Owing to the proven efficacy of biological therapy in inflammatory bowel disease, there is now growing evidence suggesting the potential benefits of biological therapy in refractory pouchitis. Here, we report the case of a 64-year-old woman with pouchitis due to ulcerative colitis who was successfully treated with ustekinumab (UST). The patient developed ulcerative pancolitis at the age of 35. Total colectomy and IPAA with J-pouch anastomosis were performed when the patient was 47 years old. Ileotomy closure was performed 6 months later. Postoperatively, the patient developed steroid-dependent pouchitis. Three years later, she developed steroid-induced diabetes. The patient has been taking 3mg of steroid for 20 years;therefore, her lifetime total steroid dose was 21g. The patient had over 20 episodes of bloody diarrhea a day. The last pouchoscopy in 20XX-9 revealed inflammatory stenosis with deep ulcerations of the afferent limb just before the ileoanal pouch junction. In July 20XX, when we took over her treatment, the policy of treatment was to withdraw her from steroids. Pouchoscopy revealed a widened but still tight afferent limb through which the scope could easily pass, and the ileoanal pouch still showed erosive ileitis without ulcers. Thiopurine administration and steroid tapering were initiated. Steroid tapering increased the erythrocyte sedimentation rate (ESR). As ESR increased, her arthritis exacerbated. Six months after the end of steroid administration, the patient consented to UST treatment. On April 20XX+1, the patient received her first 260-mg UST infusion. At this point, she experienced 14-15 episodes of muddy bloody stools. She had no abdominal pain;however, she experienced shoulder pain. Gradually, UST affected both pouchitis and arthritis. UST treatment was continued at 90mg subcutaneously every 12 weeks without abdominal pain recurrence. Eight months after the first UST infusion, nonsteroidal anti-inflammatory drugs were no longer necessary for shoulder pain. Follow-up pouchoscopy performed 14 months after UST optimization revealed a normal afferent limb without ulcerations in either segment. Pouchitis remission was maintained for over 2 years.

Convolutional neural network algorithm trained on lumbar spine radiographs to predict outcomes of transforaminal epidural steroid injection for lumbosacral radicular pain from spinal stenosis.

Little is known about the therapeutic outcomes of transforaminal epidural steroid injection (TFESI) in patients with lumbosacral radicular pain due to lumbar spinal stenosis (LSS). Using lumbar spine radiographs as input data, we trained a convolutional neural network (CNN) to predict therapeutic outcomes after lumbar TFESI in patients with lumbosacral radicular pain caused by LSS. We retrospectively recruited 193 patients for this study. The lumbar spine radiographs included anteroposterior, lateral, and bilateral (left and right) oblique views. We cut each lumbar spine radiograph image into a square shape that included the vertebra corresponding to the level at which the TFESI was performed and the vertebrae juxta below and above that level. Output data were divided into "favorable outcome" (≥ 50% reduction in the numeric rating scale [NRS] score at 2 months post-TFESI) and "poor outcome" (< 50% reduction in the NRS score at 2 months post-TFESI). Using these input and output data, we developed a CNN model for predicting TFESI outcomes. The area under the curve of our model was 0.920. Its accuracy was 87.2%. Our CNN model has an excellent capacity for predicting therapeutic outcomes after lumbar TFESI in patients with lumbosacral radicular pain induced by LSS.

Clinicoradiological features of probable chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) syndrome.

Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) is a recently described chronic inflammatory central nervous system disease. This case report describes a young female patient presenting with weakness in bilateral upper and lower limbs and tinnitus for 2 months. A neurological examination revealed signs of brainstem and cerebellar involvement. MRI brain showed characteristic features of CLIPPERS, with punctate and nodular enhancement in the pons and cerebellum. Differential diagnoses were systematically considered and excluded. The patient showed significant clinical and radiological improvement with steroid therapy. No clinical or radiological red flags occurred during the follow-up. This case underscores the critical role of integrating clinical and radiological findings to effectively diagnose and manage CLIPPERS. It emphasises the importance of ruling out alternative diagnoses through a thorough evaluation.

Management after cataract surgery for patients with diabetic retinopathy: a systematic review and meta-analysis.

PURPOSE: To evaluate the safety and effectiveness of various treatment modalities in patients with diabetic retinopathy (DR) who underwent cataract surgery. METHODS: A comprehensive search for randomized controlled trials (RCTs) was conducted using the PubMed, Embase, Cochrane Library, and CNKI databases up to December 22, 2021. The safety and efficacy of treatment modalities were assessed using the risk ratio (RR) to compare the progression of DR and the mean difference to evaluate the best corrected visual acuity (BCVA) and macular thickness (MT). RESULTS: The meta-analysis of the RCTs revealed that anti-VEGF (anti-vascular endothelial growth factor) drugs significantly reduced the progression of DR [RR: 0.37 (95%CI 0.19, 0.70), P = 0.002] and improved BCVA [mean difference = - 0.06 (- 0.12, - 0.01), P = 0.03] in patients with pre-existing DR who underwent cataract surgery. Steroid drugs also showed a significant reduction in macular thickness [mean difference = - 55.63 (- 90.73, - 20.53), I2 = 56%, P = 0.002] in DR patients two weeks after cataract surgery compared to the control group. The safety profiles of different management options did not differ significantly. CONCLUSION: The present meta-analysis suggests that anti-VEGF drugs can effectively slow down the progression of diabetic retinopathy, improve BCVA, and reduce MT in DR patients who underwent cataract surgery. Steroid drugs also show promise in reducing MT. However, further studies with larger sample sizes are required to compare the efficacy and safety of different management options in a multi-center clinical setting.

Dysregulation of CD4+ and CD8+ resident memory T, myeloid, and stromal cells in steroid-experienced, checkpoint inhibitor colitis.

BACKGROUND: Colitis caused by checkpoint inhibitors (CPI) is frequent and is treated with empiric steroids, but CPI colitis mechanisms in steroid-experienced or refractory disease are unclear. METHODS: Using colon biopsies and blood from predominantly steroid-experienced CPI colitis patients, we performed multiplexed single-cell transcriptomics and proteomics to nominate contributing populations. RESULTS: CPI colitis biopsies showed enrichment of CD4+resident memory (RM) T cells in addition to CD8+ RM and cytotoxic CD8+ T cells. Matching T cell receptor (TCR) clonotypes suggested that both RMs are progenitors that yield cytotoxic effectors. Activated, CD38+ HLA-DR+ CD4+ RM and cytotoxic CD8+ T cells were enriched in steroid-experienced and a validation data set of steroid-naïve CPI colitis, underscoring their pathogenic potential across steroid exposure. Distinct from ulcerative colitis, CPI colitis exhibited perturbed stromal metabolism (NAD+, tryptophan) impacting epithelial survival and inflammation. Endothelial cells in CPI colitis after anti-TNF and anti-cytotoxic T-lymphocyte-associated antigen 4 (anti-CTLA-4) upregulated the integrin α4ß7 ligand molecular vascular addressin cell adhesion molecule 1 (MAdCAM-1), which may preferentially respond to vedolizumab (anti-α4ß7). CONCLUSIONS: These findings nominate CD4+ RM and MAdCAM-1+ endothelial cells for targeting in specific subsets of CPI colitis patients.

Clinicopathological features and outcome of secondary steroid resistant nephrotic syndrome: A retrospective analysis.

Objective: To determine the clinico-pathological features and long-term outcome of secondary steroid-resistant nephrotic syndrome treated with steroids and calcineurin inhibitors. METHODS: The retrospective cohort study was conducted at the Sindh Institute of Urology and Transplant, Karachi, in June and July 2023, and comprised data from January 1, 2008, to December 31, 2020, of children aged 1-18 years who developed steroid resistance after initial sensitivity to steroids with at least 1-year of follow-up. Demographics as well as time taken to secondary steroid response were documented. Renal biopsy of all patients with secondary steroid resistance had been performed. Eventual outcomes after treatment with calcineurin inhibitors based on the degree of proteinuria and serum albumin levels were used to categorise complete remission, partial remission and no response. Kidney function, as determined by estimated glomerular filtration rate, was recorded. Data was analysed using SPSS 22. RESULTS: Of the 1,000 patients who underwent renal biopsy for steroid resistance, 48(4.8%) had idiopathic steroid-resistant nephrotic syndrome; 32(66.7%) males, 16(33.3%) females and median age of 5 years (interquartile range: 4-7.3 years). Median age at diagnosis of nephrotic syndrome was 5 years (interquartile range: 3.6-7.3 years). The median time from nephrotic syndrome to secondary steroid-resistant nephrotic syndrome was 23 months (interquartile range: 8.75-44.5 months). Biopsy results at diagnosis showed that 27(56.3%) had minimal change disease. The mean follow-up time was 6.1±3.2 years. Of the 43(89.5%) patients who received cyclosporin for 1 year, 29(67%) obtained complete remission, 5(12%) attained partial remission and no response was seen in 9(21%) patients. Conclusion: Majority of the children had minimal change disease at the time of diagnosis of secondary steroid-resistant nephrotic syndrome. The long-term response with calcineurin inhibitors was favourable at 1 year.

Transforaminal pulsed radiofrequency and epidural steroid injection on chronic lumbar radiculopathy: A prospective observational study from a tertiary care hospital in Vietnam.

BACKGROUND: Lumbosacral radicular syndrome (LRS) is probably the most frequent neuropathic pain syndrome, exaggerating medical and economy burden on developing countries, such as Vietnam. As a result, the urgence to find an approach which is both affordable and effective always puts great demand on medical researchers. OBJECTIVES: Evaluate the effectiveness of transforaminal pulsed radiofrequency (PRF) stimulation on the dorsal root ganglion (DRG) and epidural steroid injection (ESI) in management of chronic lumbosacral radiculopathy. METHODS: Seventy-six patients with chronic radicular pain were performed transforaminal PRF + ESI by neurosurgeons. Demographic characteristics and surgical outcomes were recorded on admission, pre-procedural and post-procedural for 1-month, 3-month, 6-month and 12-month follow-up. Primary outcome was measured by using Visual Analogue Scale (VAS), Oswestry disability index (ODI) and Straight Leg Raising Test (SLRT). Secondary outcome was subjectively collected based on short assessment of patients' satisfaction (SAPS). RESULTS: Patients who received transforaminal PRF and ESI showed significant improvements on all three evaluation tools (VAS, ODI, SLRT), compared to that before treatment (p<0.001). Pain relief was achievable and long-lasting, which met patients' expectation. No significant complications were observed for 12 months follow-up. CONCLUSION: Transforaminal PRF combined with ESI in management of lumbosacral radiculopathy should be a good method of choice for its effectiveness and safety in management of pain.

Relationships between the Spinal Dural Pulsations and the Short-Term Efficacy of Lumbar Epidural Steroid Injection.

Background: Lumbar spinal stenosis (LSS) causes low back pain, leg pain, numbness in the leg, and neurogenic intermittent claudication. Epidural steroid injection (ESI) has been used for treating spinal stenosis symptoms. We hypothesized that dural pulsation was variable for lumbar spinal stenosis. In cases of the presence of dural pulsation, the pain relief after the ESI was better than in the absence of dural pulsation. This study aimed at investigating the relationships between the presence or absence of spinal dural pulsations and the efficacy of ESI. Methods: A total of 71 patients were enrolled in this prospective study. Prior to the ESI, the dural pulsation was measured using a 5-1 MHz array ultrasound transducer. The visual analogue scale (VAS) score was measured pre-ESI and 2 weeks post-ESI and 4 weeks post-ESI. At 4 weeks post-ESI, dural pulsation was rechecked. Results: The VAS scores improved after the ESI procedure regardless of the presence or absence of dural pulsation. There was a correlation between the pulsation of the dura and post-ESI VAS scores. However, VAS was not significantly different for different grades of stenosis. Conclusion: The ESI was effective in patients with spinal stenosis in short-term follow-up. Dural pulsation of the spinal cord was a positive predictive factor for the ESI effect, but the grade of spinal stenosis severity had no effect on the effectiveness of ESI.

Do Patients Accurately Recall Pain Levels Following Sacroiliac Joint Steroid Injection? A Cohort Study of Recall Bias in Patient-reported Outcomes.

BACKGROUND: Sacroiliac joint (SIJ) injections are crucial in the diagnostic toolkit for evaluating SIJ pathology. Recall bias is an important component in patient-reported outcomes that has not been well studied in SIJ injection. OBJECTIVE: The purpose of this study was to characterize the accuracy, direction, and magnitude of pain level recall bias following SIJ steroid injection and study the factors that affect patient recollection. STUDY DESIGN: Prospective cohort study. SETTING: Level 1 academic medical center. METHODS: Using standardized questionnaires, baseline Numeric Rating Scale (NRS-11) scores were recorded for patients undergoing SIJ steroid injections at preinjection, at 4 hours postinjection, and at 24 hours postinjection. At a minimum of 2 weeks postinjection, patients were asked to recall their preinjection, 4-hour, and 24-hour postinjection NRS-11 scores. Actual and recalled NRS-11 scores were compared using paired t tests for each time interval. Multivariable linear regression was used to identify factors that correlated with consistent recall. RESULTS: Sixty patients with a mean age of 66 years (65% women) were included. Compared to their preinjection pain score, patients showed considerable improvement at both 4 hours (mean difference [MD] = 3.28; 95% CI, 2.68 - 3.89), and 24 hours (MD = 3.23; 95% CI, 2.44 - 4.03) postinjection. Patient recollection of preinjection symptoms was more severe than actual (MD = 0.65; 95% CI, 0.31 - 0.99). Patient recollection of symptoms was also more severe than actual at 4 hours (MD = 0.50; 95% CI .04 - 1.04) as well as at 24 hours postinjection (MD = 0.80; 95% CI, 0.16 - 1.44). The magnitude of recall bias was mild and did not exceed the minimal clinically important difference. There was a moderate correlation between actual and recalled pain levels when comparing preinjection with the 4-hour postinjection NRS-11 score (correlation coefficient [r] =0.64; P < 0.001) and moderate correlation when comparing preinjection with the 24-hour postinjection NRS-11 score (r = 0.62; P < 0.001). Linear regression models showed that at preinjection, patients with a lower body mass index and the presence of coexisting psychiatric diagnoses were better at recalling their pain (P < 0.05). Patients with a higher body mass index also experienced less pain relief when comparing preinjection with the 4-hour postinjection NRS-11 score (P < 0.05). LIMITATIONS: Recall pain scores were obtained via telephone surveys, which can lead to interview bias. One patient died, and 3 were lost to follow-up. We did not control for patient use of adjunctive pain relief modalities, which may modulate the overall response to injection. SIJ injections can also be diagnostic, so some patients may not have shared the same indication for injection or pain-generating diagnosis. CONCLUSIONS: Patients had favorable pain level responses to their SIJ steroid injection for both actual and recall surveys. Although patients demonstrated poor recall of absolute pain scores at preinjection, 4-hour postinjection, and 24-hour postinjection, they demonstrated robust recall of their net pain score improvement at both 4- and 24-hours postinjection. These findings suggest that there is utility in using patient recollection to describe the magnitude of pain relief following treatment for sacroiliac joint dysfunction.

Inconsistency in steroid use as antiemetics in clinical trial protocols involving immune checkpoint inhibitors combined with chemotherapy.

OBJECTIVES: This study aims to investigate the use of steroids as antiemetics in clinical trials involving immune checkpoint inhibitors with chemotherapy. METHODS: Focusing on phase III trials registered before August 2023, it evaluated the consistency of steroid use guidelines. RESULTS: Out of 3452 trials screened, 44 were selected for in-depth review. The findings indicate a considerable variation: 13 trials did not specify the use of antiemetics, while 31 provided criteria for antiemetics, with 13 conforming to local standards, six to international guidelines, and five allowing either. Seven trials recommended effective antiemetics without detailed criteria. This inconsistency led to a range of steroid dosages, with only 11 trials advocating for minimizing or avoiding steroids for antiemetic purposes. CONCLUSION: The research highlights the lack of uniformity in antiemetic steroid use in trials, reflecting diverse clinical practices and underscoring the need for further research to understand the implications on treatment outcomes.

Recent advances in the treatment and delivery system of diabetic retinopathy.

Diabetic retinopathy (DR) is a highly tissue-specific neurovascular complication of type 1 and type 2 diabetes mellitus and is among the leading causes of blindness worldwide. Pathophysiological changes in DR encompass neurodegeneration, inflammation, and oxidative stress. Current treatments for DR, including anti-vascular endothelial growth factor, steroids, laser photocoagulation, and vitrectomy have limitations and adverse reactions, necessitating the exploration of novel treatment strategies. This review aims to summarize the current pathophysiology, therapeutic approaches, and available drug-delivery methods for treating DR, and discuss their respective development potentials. Recent research indicates the efficacy of novel receptor inhibitors and agonists, such as aldose reductase inhibitors, angiotensin-converting enzyme inhibitors, peroxisome proliferator-activated receptor alpha agonists, and novel drugs in delaying DR. Furthermore, with continuous advancements in nanotechnology, a new form of drug delivery has been developed that can address certain limitations of clinical drug therapy, such as low solubility and poor penetration. This review serves as a theoretical foundation for future research on DR treatment. While highlighting promising therapeutic targets, it underscores the need for continuous exploration to enhance our understanding of DR pathogenesis. The limitations of current treatments and the potential for future advancements emphasize the importance of ongoing research in this field.

Are monoclonals the only panacea for treatment of aquaporin-4 positive NMOSD? Experience from a low-&middle-income (LMIC) region.

OBJECTIVE: A plethora of monoclonals have ushered up for NMOSD treatment. However, their limited availability and cost concerns poses a challenge for usage in developing nations. We compared relapse rates and disabilities among aquaporin-4 positive(AQP4+ve) patients on conventional immunosuppressants and rituximab in a tertiary referral center in southern India. METHODS: This was a chart review of AQP4+ve patients registered under national demyelination registry maintained at institute. AQP4+ve patients were included if they were on azathioprine, MMF, methotrexate for six months; cyclophosphamide for three months and rituximab for one month. RESULTS: 207 records were screened, 154 fulfilled inclusion criteria. Drugs used were azathioprine (70), MMF (34) and rituximab (33). All three drugs were non-inferior to each other in terms of ARR reduction. Median EDSS at last follow-up was significantly lower for azathioprine(2;IQR:0-5) and rituximab(2;IQR:0.5-5) than MMF(3.5;IQR:2-5.6), however azathioprine was associated with highest switch rate(34.3%) and was the only drug which required change because of intolerance. Failure rate was least for rituximab(27.3%).Patients on azathioprine and MMF required higher mean duration of concurrent steroids(7.8±7.7 and 4.56±2.17 months respectively) when compared to rituximab(2.77±1.38) and had more relapses due to steroid withdrawal. CONCLUSION: Initial treatment with azathioprine, MMF and rituximab is comparable in terms of ARR reduction. Findings suggest that choice may be guided by adverse event profile of drug, rather than efficacy per se. Concurrent treatment duration with steroids should also guide clinical decision. Switch to second immunomodulation in event of initial failure adds to efficacy benefit, irrespective of the drug chosen.

Japanese clinical practice patterns of rituximab treatment for minimal change disease in adults 2021: A web-based questionnaire survey of certified nephrologists.

BACKGROUND: In Japan, rituximab (RTX) for adult-onset frequently relapsing (FR)/steroid-dependent (SD) minimal change disease (MCD) is not explicitly reimbursed by insurance, and its standard regimen has not been established. METHODS: We conducted a cross-sectional web-based survey between November and December 2021. The participants were nephrologists certified by the Japanese Society of Nephrology and answered 7 items about RTX for adult MCD. Factors related to the experience of RTX administration at their facilities were estimated by generalized estimating equations. RESULTS: Of 380 respondents, 181 (47.6%) reported the experience of RTX use for adult MCD at their current facilities. Those who worked at university hospitals (vs. non-university hospitals, proportion difference 13.7%) and at facilities with frequent kidney biopsies (vs. 0 cases/year, 19.2% for 1-40 cases/year; 37.9% for 41-80 cases/year; 51.9% for ≥ 81 cases/year) used RTX more frequently. Of 181 respondents, 28 (15.5%) answered that there was no insurance coverage for RTX treatment. Of 327 respondents who had the opportunity to treat MCD, which was a possible indication for RTX, 178 (54.4%) indicated withholding of RTX administration. The most common reason was the cost due to lack of insurance coverage (141, 79.2%). Regarding RTX regimens for FR/SD MCD, introduction treatment with a single body surface area-based dose of 375 mg/m2 and maintenance treatment with a 6-month interval were the most common. CONCLUSION: This survey revealed the nephrologists' characteristics associated with RTX use, the barriers to RTX use, and the variation in the regimens for adult MCD in Japan.

Topical steroids or emollients: does order matter?

Topical corticosteroids, topical steroid-sparing agents, and emollients are all used to treat atopic dermatitis. However, there are no formal guidelines dictating the order and timing in which these topical modalities should be applied. Additionally, the order of application may change drug absorption, efficacy, and distribution. This is especially important for patients with atopic dermatitis. These patients have a dysfunctional skin barrier, which can lead to greater systemic absorption of drugs. Moreover, children already have an increased rate of systemic absorption due to a higher ratio of body surface area to body weight. Thus, the order of application of topical regimens is of the utmost importance in pediatric dermatology. This manuscript presents an updated review of the literature with a focus on guiding clinicians toward the best practices from the available resources.

Effect of steroid pulses in severe BK virus allograft nephropathy with extensive interstitial inflammation.

INTRODUCTION: As there is no specific antiviral treatment currently available for BK polyomavirus associated nephropathy (BKVAN), its management relies on immunosuppression reduction in kidney transplant patients. Data on efficacy of steroid pulses in this indication are lacking. METHODS: We performed a retrospective monocenter study on 64 patients diagnosed with biopsy-proven BKVAN. Patients within the "pulse group" (n = 37) received IV methylprednisolone 10 mg/kg 3 days consecutively. In the "low dose" steroid group (n = 27), patients were continued oral prednisone 5 mg daily. RESULTS: Mean follow up was 78 months in the steroid pulse group and 56 months in the low dose group (p = 0.15). Mean eGFR values at diagnosis were comparable, as well as other demographic characteristics. Mean BK plasma viral load was higher in "pulse" than in "low dose" steroid group. Pulse group had higher inflammation and tubulitis (p < 0.05). Graft loss reached 57% in the "pulse" group versus 41% in the "low dose" group, p = 0.20. Rejection events were similar. No major adverse event was statistically associated with steroid pulse, including infections, cancer, and de novo diabetes. CONCLUSION: No significant differences were found in the evolution of both groups of patients, despite patients receiving "pulse" steroids were identified as the most severe sharing higher BK viral load and more frequent active lesions on histology.