A case of relapsing anti-GBM disease secondary to alemtuzumab therapy.

We report the first case of relapsing anti-GBM disease secondary to alemtuzumab in a 24-year-old female with relapsing-remitting multiple sclerosis. Initial anti-GBM disease was detected 10 months after alemtuzumab was given and was diagnosed by demonstrating high anti-GBM antibody titers and with a confirmatory kidney biopsy. The patient presented with a rapidly progressive glomerulonephritis with no pulmonary involvement. After appropriate treatment, the patient went into remission with undetectable anti-GBM antibodies. However, 20 months later, the patient re-presented with relapsing anti-GBM disease. Despite aggressive treatment, the patient became dialysis-dependent.

Hospitalizations Among Adults With CKD in Public Renal Specialty Practices: A Retrospective Study From Queensland, Australia.

Rationale & Objective: Little is known about hospital admissions in nondialysis patients with chronic kidney disease (CKD) before death or starting kidney replacement therapy (KRT). Study Design: Retrospective observational cohort study. Setting & Participants: Hospitalizations among 7,201 patients with CKD from 10 public renal clinics in Queensland (QLD), enrolled in the CKD.QLD registry starting in May 2011, were followed for 25,496.34 person-years until they started receiving KRT or died, or until June 30, 2018. Predictors: Demographic and clinical characteristics of patients with CKD. Outcomes: Hospital admissions. Analytical Approach: We evaluated the association of demographic and clinical features with hospitalizations, length of hospital stay, and cost. Results: Approximately 81.5% of the patients were admitted at least once, with 42,283 admissions, costing Australian dollars (AUD) 231 million. The average number of admissions per person-year was 1.7, and the cost was AUD 9,060, 10 times and 2 times their Australian averages, respectively. Single (1-day) admissions constituted 59.2% of all the hospital episodes, led by neoplasms (largely chemotherapy), anemia, CKD-related conditions and eye conditions (largely cataract extractions), but only 14.8% of the total costs. Approximately 41% of admissions were >1-day admissions, constituting 85.2% of the total costs, with cardiovascular conditions, respiratory conditions, CKD-related conditions, and injuries, fractures, or poisoning being the dominant causes. Readmission within 30 days of discharge constituted >42% of the admissions and 46.8% costs. Admissions not directly related to CKD constituted 90% of the admissions and costs. More than 40% of the admissions and costs were through the emergency department. Approximately 19% of the hospitalized patients and 27% of the admissions did not have kidney disease mentioned as either principal or associate causes. Limitations: Variable follow-up times because of different dates of consent. Conclusions: The hospital burden of patients with CKD is mainly driven by complex multiday admissions and readmissions involving comorbid conditions, which may not be directly related to their CKD. Strategies to prevent these complex admissions and readmissions should minimize hospital costs and outcomes. Plain-Language Summary: We analyzed primary causes, types, and costs of hospitalizations among 7,201 patients with chronic kidney disease (CKD) from renal speciality clinics across Queensland, Australia, over an average follow-up of 3.54 years. The average annual cost per person was $9,060, and was the highest in those with more advanced CKD, higher age, and with diabetes. More than 85% of costs were driven by more complex hospitalizations with longer length of stay. Cardiovascular disease was the single largest contributor for hospitalizations, length of hospital stay, and total costs. Readmission within 30 days of discharge, particularly for the same disorder, and multiday admissions should be the main targets for mitigation of hospital costs in this population.

Chronic kidney disease in public renal practices in Queensland, Australia, 2011-2018.

AIM: To describe adults with (non-dialysis) chronic kidney disease (CKD) in nine public renal practice sites in the Australian state of Queensland. METHODS: 7,060 persons were recruited to a CKD Registry in May 2011 and until start of kidney replacement therapy (KRT), death without KRT or June 2018, for a median period of 3.4 years. RESULTS: The cohort comprised 7,060 persons, 52% males, with a median age of 68 yr; 85% had CKD stages 3A to 5, 45.4% were diabetic, 24.6% had diabetic nephropathy, and 51.7% were obese. Younger persons mostly had glomerulonephritis or genetic renal disease, while older persons mostly had diabetic nephropathy, renovascular disease and multiple diagnoses. Proportions of specific renal diagnoses varied >2-fold across sites. Over the first year, eGFR fell in 24% but was stable or improved in 76%. Over follow up, 10% started KRT, at a median age of 62 yr, most with CKD stages 4 and 5 at consent, while 18.8% died without KRT, at a median age of 80 yr. Indigenous people were younger at consent and more often had diabetes and diabetic kidney disease and had higher incidence rates of KRT. CONCLUSION: The spectrum of characteristics in CKD patients in renal practices is much broader than represented by the minority who ultimately start KRT. Variation in CKD by causes, age, site and Indigenous status, the prevalence of obesity, relative stability of kidney function in many persons over the short term, and differences between those who KRT and die without KRT are all important to explore.

Non-traumatic lower limb amputation in patients with end-stage renal failure on dialysis: an Australian perspective.

BACKGROUND: End-stage renal failure (ESRF) and dialysis have been identified as a risk factor for lower limb amputations (LLAs). High rate of ESRF amongst the Australian population has been reported, however till date no study has been published identifying magnitude and risk factors of LLA in subjects on renal dialysis. OBJECTIVE: The study aims to document trends in the prevalence and identify risk factors of non-traumatic LLA in Australian patients on dialysis. METHODS: A retrospective review of all patients (218) who attended the regional dialysis center between 1st January 2009 and 31st December 2013 was conducted. Demographic, clinical and biochemical data were analyzed. RESULTS: We identified a high prevalence of 13.3% of LLAs amongst Australian patients with ESRF on dialysis at our center. The associated risk factors were the presence of diabetes (OR 1.67 [1.49-1.88] p < 0.001), history of foot ulceration (OR 81 [18.20-360.48] p < 0.001), peripheral arterial disease (OR 31.29 [9.02-108.56] p < 0.001), peripheral neuropathy (OR 31.29 [9.02-108.56] p < 0.001), foot deformity (OR 23.62 [5.82-95.93] p < 0.001), retinopathy (OR 6.08 [2.64-14.02] p < 0.001), dyslipidemia (OR 4.6 [1.05-20.05] p= 0.049) and indigenous background (OR 3.39 [1.38-8.33] p= 0.01). 75% of the amputees had aboriginal heritage. We also identified higher HbA1c and CRP levels as well as low serum albumin, hemoglobin and vitamin D levels to have a strong association with LLAs (p < 0.05). CONCLUSION: There is high prevalence of LLAs amongst Australian indigenous patients with diabetes on dialysis in North Queensland. Other strongly associated risk factors include history of foot ulceration, foot deformity and peripheral neuropathy as well as high HbA1c levels and low serum albumin levels.

Calcific uremic arteriolopathy on multimodal combination therapy: still unmet goal.

Background. Calcific uremic arteriolopathy (CUA) or calciphylaxis though generally noted for its high mortality, recent case reports have shown promising results using single agent therapies. However, it is not clear whether combination therapeutic agents will improve course of the disease. Objective. To determine clinical outcome in subjects with CUA on multimodal treatment. Methods. All patients with end-stage renal failure (ESRF) at The Townsville Hospital, Australia, from April 1, 2006, to March 31, 2011, with diagnosis of CUA were retrospectively studied. Results. Six subjects with CUA (4 females and 2 males) were on various combination therapeutic agents comprising sodium thiosulphate, hyperbaric oxygen, prednisolone, cinacalcet, and parathyroidectomy in addition to intensified haemodialysis, specialist local wound care, and antibiotics. The wounds failed to heal in 3 patients while 5 of the 6 subjects died; cause of death being sepsis in 3 and myocardial infarction in 2. Conclusion. Prognosis of CUA remains poor in spite of multimodal combination therapy. Further prospective studies on a larger population are needed to verify our findings.

Seroreactivity against streptococcal DRS (distantly related to SIC) protein is a predictor for end-stage renal failure.

We hypothesized that immunoreactivity against antigens from nephritic strains of Streptococcus pyogenes may be elevated in patients with end-stage renal failure (ESRF). Additionally, we investigated whether a difference in seroreactivity exists between nonindigenous and indigenous (Aboriginal/Torres Strait Islander) patients. To examine these possibilities, antibodies against potentially nephritogenic proteins, streptokinase (Ska1) (from M1), streptococcal pyrogenic exotoxin type B (SpeB) (from M1), the streptococcal inhibitor of complement-mediated cell lysis (SIC) (from M1) and its two variants, closely related to SIC (CRS) (from M57) and distantly related to SIC (DRS) (from M12) were determined in 66 patients and 31 healthy controls by enzyme-linked immunosorbent assays. A significantly higher proportion of patients compared to controls were seropositive to Ska1 (P = 0.004), DRS (P = 0.0003), CRS (P = 0.001), and SIC (P = 0.018). Regression analysis showed that seroreactivity to DRS (r(2) = 0.85, P = 0.001) predicted the development of ESRF and that being diabetic was positively associated with being an ESRF patient (r(2) = 0.37, P < 0.0001) and being indigenous (r(2) = 0.47, P < 0.0001). These results suggest that these ESRF patients were exposed to strains of S. pyogenes that secrete Ska1, DRS, CRS, and SIC and may have pathological significance. No significant difference was observed between the indigenous patients and nonindigenous patients.

A 12-month review of peritoneal dialysis-related peritonitis in Western Australia: is empiric vancomycin still indicated for some patients?

BACKGROUND: The International Society for Peritoneal Dialysis (ISPD) guidelines recommend empiric therapy with cefazolin and ceftazidime for peritoneal dialysis (PD)-related peritonitis. Empiric cefazolin therapy may have diminishing efficacy because of emerging methicillin resistance in gram-positive bacteria (GPB). Western Australia also has large numbers of Aboriginal and isolated regional patients, where giving these antimicrobials can be impractical. OBJECTIVES: To evaluate, based on local antimicrobial resistance patterns, the feasibility of following ISPD guidelines in Western Australia and to identify any subgroups of PD peritonitis patients that may benefit from alternative empiric intraperitoneal antibiotics (e.g., vancomycin). STUDY DESIGN: Retrospective study of all PD peritonitis episodes in Western Australia from 1 February 2000 to 31 January 2001. SETTING: Three adult tertiary referral university hospitals and their PD patients in metropolitan Perth and regional Western Australia. PATIENTS: All adults on PD in Western Australia. MAIN OUTCOME MEASURE: Isolates and antibiograms were analyzed versus patient characteristics, including race and patient demographics. RESULTS: 293 patients (28% Aborigines, 32% regional patients) received PD. 145 episodes of PD peritonitis occurred during the study. The overall PD peritonitis rate was 1 episode/16 patient months, with Aborigines having 1 episode/10.5 patient months versus non-Aborigines having 1 episode/17 patient months (p < 0.001). 36% of isolates from PD peritonitis episodes were resistant to cefazolin or ceftazidime. 22% were methicillin-resistant GPB (MR-GPB) [18% coagulase-negative staphylococci (CoNS), 1.6% MR Staphylococcus aureus]; 2.5% were multidrug-resistant gram-negative bacteria (MDR-GNB); 5.7% were polymicrobial (MR-GPB and/or MDR-GNB); and 5.7% were fungal. 63% of CoNS were methicillin resistant. Non-Aboriginal patients yielded MR-GPB in 22% of isolates versus 23% in Aborigines (p = 0.9). Six of seven cases of fungal peritonitis occurred in Aboriginal patients (p < 0.001). CONCLUSIONS: In our study population the ISPD guidelines were appropriate for 64% of patients with PD peritonitis. We could not identify specific patient subgroups where empiric cefazolin use could be more effective. High proportions of MR-GPB PD peritonitis episodes, along with local factors, make empiric cefazolin unsuitable for many regional PD patients in Western Australia.

Niveles de colesterol total LAD y triglicéridos plasmáticos en niños dominicanos de 0-15 años de edad / Total cholesterol, HDL and plasmatriglycerides levels in Dominican children from 0-15

Se estudió un total de 512 niños con edades de 0-15 años y estando compuesto por 32 grupos de niños para cada edad y dividido en dos grupos según su clase en alta y baya. Previo ayuno de 14 horas, se procedió a determinar el colesterol total, el LAD y los triglicéridos. El colesterol fue encontrado elevado en 51 niños (9.6%) estando dicha elevación distribuída en los niños de clase alta y más en los del sexo masculino. La elevación se inició a partir del 9no, año de edad, ocurriendo un pico hacia el 14 y 15 años. La diferencia estadísticamente significativa ocurrió a los 14 años, favoreciendo la clase alta P<0.005. Un 2,5% de los que mostraron el colesterol elevado presentaron además un LAD bajo, éstos constituirían el grupo de alto riesgo. El promedio de colesterol obtenido para el grupo total de niños de clase alta fue 164.94 ñ 32.61, y para los de clase baja fue de 147.76 ñ 30.40. El promedio de LAD de ambos grupos sobrepasó las cifras de la normalidad (V.N. = 55 fem., 45 masc.), siendo de 58.72 (clase alta) y de 58.1 para la clase baja. Este lípido fue encontrado elevado en un 56.7% de los niños y en un 31.3% de las niñas, obsevándose dichas alteraciones particularmente en las edades de 2 a 3 años. La diferencia estadísticamente significativa correspondió a las niñas de clase baja y para esa edad P<0.005. En los triglicéridos no hubo diferencia estadísticamente significativa ni en cuanto a clase o sexo, pero sí ocurrieron elevaciones importantes en 30 de los casos estudiados (5.8%). Las elevaciones más importantes ocurrieron en las edades de 13 y 15 años. Los promedios de triglicéridos obtenidos en ambos grupos estuvieron dentro de los límites de la normalidad (V.N. = 100-140), siendo éstos de 73.68ñ 26.18 (clase alta) y de 78.16 ñ 31.43 (clase baja)