A Comparative Study on Graft and Overall Survival Rates Between Diabetic and Nondiabetic Kidney Transplant Patients Through Survival Analysis.

Background: Patients with diabetes mellitus (DM) have worse graft and overall survival, but recent evidence suggests that the difference is no longer significant. Objective: To compare the outcomes between patients with end-stage kidney disease due to DM (ESKD-DM) and ESKD due to nondiabetic etiology (ESKD-non-DM) who underwent kidney transplantation (KT) up to 10 years of follow-up. Design: Survival analysis of a retrospective cohort. Setting and Patients: All patients who underwent KT at the Hospital Universitario San Ignacio, Colombia, between 2004 and 2022. Measurements: Overall and graft survival in ESKD-DM and ESKD-non-DM who received KT. Patients who died with functional graft were censored for the calculation of kidney graft survival. Methods: Log-rank test, Cox proportional hazards model, and competing risk analysis were used to compare overall and graft survival in patients with ESKD-DM and ESKD-non-DM who underwent KT. Results: A total of 375 patients were included: 60 (16%) with ESKD-DM and 315 (84%) with ESKD-non-DM. Median follow-up was 83.3 months. Overall survival was lower in patients with ESKD-DM at 5 (75.0% vs 90.8%, P < .001) and 10 years (55.0% vs 86.7%, P < .001). Cardiovascular death was higher in patients with diabetes (27.3% vs 8.2%, P = .021). Death-censored graft survival was similar in both groups (96.7% vs 93.3% at 5 years, P = .324). On multivariate analysis, the factors associated with global survival were DM (hazard ratio [HR] = 2.11, 95% confidence interval [CI] = 1.23-3.60, P = .006), recipient age (HR = 1.05, 95% CI = 1.02-1.08, P < .001), delayed graft function (HR = 2.07, 95% CI = 1.24-3.46, P = .005), and donor age (HR = 1.03, 95% CI = 1.01-1.05, P = .002). In the competing risk analysis, DM was associated with mortality only in the cardiovascular death group (sub-hazard ratio [SHR] = 6.06, 95% CI = 1.01-36.4, P = .049). Limitations: Change in diabetes treatment received over time and adherence to glycemic targets were not considered. The sample size is relatively small, which limits the precision of our estimates. The Kidney Donor Profile Index and the occurrence of treated acute rejection were not included in the regression models. Conclusion: Overall survival is lower in patients with diabetes, possibly due to older age and cardiovascular comorbidities. Therefore, patients with diabetes should be followed more closely to control cardiovascular risk factors. However, there is no difference in graft survival.

Contexte: Les patients diabétiques (DB) sont ceux qui présentent les pires résultats de greffe et de survie globale, mais des données récentes suggèrent que la différence n'est désormais plus significative. Objectif: Comparer les résultats des patients atteints d'insuffisance rénale terminale causée par le DB (IRT-DB) et ceux des patients non-diabétiques (IRT-nonDB) pour une période de 10 ans après une transplantation rénale (TR). Conception: Analyse de la survie d'une cohorte rétrospective. Sujets et cadre de l'étude: Tous les patients qui ont subi une TR à l'Hôpital Universitario San Ignacio (Colombie) entre 2004 et 2022. Mesures: La survie globale et la survie du greffon chez les patients IRT-DB et IRT-nonDB après une TR. Les patients décédés avec un greffon fonctionnel ont été censurés pour le calcul de la survie du greffon. Méthodologie: Le test logarithmique par rangs, un modèle de régression à effet proportionnel de Cox et une analyse des risques concurrents ont été utilisés pour comparer la survie globale et la survie du greffon des patients atteints d'IRT-DB et d'IRT-nonDB après une TR. Résultats: Au total, 375 patients ont été inclus à l'étude, soit 60 patients (16 %) atteints d'IRT-DB et 315 (84 %) atteints d'IRT-nonDB. La durée médiane du suivi était de 83,3 mois. La survie globale était plus faible chez les patients atteints d'IRT-DB à 5 ans (75,0 c. 90,8 %; p<0,001) et à 10 ans (55,0 % c. 86,7 %; p<0,001). Les décès de causes cardiovasculaires ont été plus nombreux chez les patients diabétiques (27,3 % c. 8,2 %; p=0,021). La survie du greffon censurée pour le décès était similaire pour les deux groupes (96,7 % c. 93,3 % à 5 ans, p=0,324). Dans l'analyse multivariée, les facteurs associés à la survie globale étaient le DB (RR=2,11; IC95 : 1,23-3,60; p=0,006), l'âge du receveur (RR=1,05; IC95 : 1,02-1,08; p<0,001), le retard de fonction du greffon (RR = 2,07; IC95 : 1,24-3,46; p = 0,005) et l'âge du donneur (RR = 1,03; IC95 : 1,01-1,05; p=0,002). Dans l'analyse des risques concurrents, le DB a été associé à la mortalité uniquement dans le groupe de patients décédés de causes cardiovasculaires (RRS=6,06; IC95 : 1,01-36,4; p=0,049). Limites: Les modifications dans le traitement du diabète au fil du temps et l'observance des cibles glycémiques n'ont pas été prises en compte. La taille de l'échantillon est relativement faible, ce qui limite la précision des estimations. L'indice de profil du donneur (Kidney Donor Profile Index­KDPI) et la survenue d'un rejet aigu traité n'ont pas été inclus dans les modèles de régression. Conclusion: La survie globale est plus faible chez les patients diabétiques, peut-être en raison de l'âge avancé et des comorbidités cardiovasculaires de ces patients. Les patients diabétiques devraient par conséquent faire l'objet d'un suivi plus rapproché afin de surveiller les facteurs de risque cardiovasculaire. Aucune différence n'a cependant été observée pour la survie du greffon.

Risk factors associated with acute kidney injury in a cohort of hospitalized patients with COVID-19.

BACKGROUND: Patients with COVID-19 have a high incidence of acute kidney injury (AKI), which is associated with mortality. The objective of the study was to determine the factors associated with AKI in patients with COVID-19. METHODOLOGY: A retrospective cohort was established in two university hospitals in Bogotá, Colombia. Adults hospitalized for more than 48 h from March 6, 2020, to March 31, 2021, with confirmed COVID-19 were included. The main outcome was to determine the factors associated with AKI in patients with COVID-19 and the secondary outcome was estimate the incidence of AKI during the 28 days following hospital admission. RESULTS: A total of 1584 patients were included: 60.4% were men, 738 (46.5%) developed AKI, 23.6% were classified as KDIGO 3, and 11.1% had renal replacement therapy. The risk factors for developing AKI during hospitalization were male sex (OR 2.28, 95% CI 1.73-2.99), age (OR 1.02, 95% CI 1.01-1.03), history of chronic kidney disease (CKD) (OR 3.61, 95% CI 2.03-6.42), High Blood Pressure (HBP) (OR 6.51, 95% CI 2.10-20.2), higher qSOFA score to the admission (OR 1.4, 95% CI 1.14-1.71), the use of vancomycin (OR 1.57, 95% CI 1.05-2.37), piperacillin/tazobactam (OR 1.67, 95% CI 1.2-2.31), and vasopressor support (CI 2.39, 95% CI 1.53-3.74). The gross hospital mortality for AKI was 45.5% versus 11.7% without AKI. CONCLUSIONS: This cohort showed that male sex, age, history of HBP and CKD, presentation with elevated qSOFA, in-hospital use of nephrotoxic drugs and the requirement for vasopressor support were the main risk factors for developing AKI in patients hospitalized for COVID-19.

Mycobacterium tuberculosis and Cytomegalovirus Colitis in a Renal Transplant Patient: A Case Report.

Chronic diarrhea is a common reason for consultation in renal transplant patients. Cytomegalovirus infection is the cause of chronic diarrhea of infectious origin in 50% of cases, but coinfection with tuberculosis is rare. We present the case of a renal transplant patient with chronic diarrhea, with a finding of left colon colitis and positive microbiological studies in biopsy for tuberculosis and cytomegalovirus. The patient received valganciclovir and anti-tubercular treatment with adequate evolution. Immunosuppressed patients may have diarrhea secondary to opportunistic infections; therefore, an algorithm for early diagnosis and treatment is recommended.

Methotrexate nephrotoxicity in a patient with preserved renal function. case report

ABSTRACT Introduction: Methotrexate is a drug with chemotherapeutic properties frequently used for the treatment of certain types of cancer. The following is a clinical case which, to the best of the authors' knowledge, is the first report in Colombia on nephrotoxicity caused by this drug and describes the consequences as well as the treatment provided at a quaternary care hospital. Case report: A 71-year-old patient with a diagnosis of non-Hodgkin's lymphoma with normal renal function underwent chemotherapy (high-dose methotrexate intravenously) and developed stage 3 acute renal failure according to the KDIGO guidelines, which was most likely related to methotrexate intake. The patient received treatment with intravenous fluids and sodium bicarbonate as promoters of urine excretion of the toxin, and oral calcium folinate following the institutional protocol. The patient was discharged with recovery of kidney function and improved creatinine and urea nitrogen levels. Conclusion: The treatment given to the patient in this case report shows that although methotrexate nephrotoxicity is a potentially serious entity, it can have a good prognosis if treated promptly.

RESUMEN Introducción. El metotrexato es un fármaco con propiedades quimioterapéuticas usado de forma frecuente para el tratamiento de ciertos tipos de cáncer. A continuación, se presenta un caso clínico que, a conocimiento de los autores, es el primer reporte en Colombia sobre nefrotoxicidad por este medicamento, así como sus consecuencias y el manejo que se le dio en un hospital de cuarto nivel. Presentación del caso. Hombre de 71 años con diagnóstico de linfoma no Hodgkin y función renal normal, quien se sometió a tratamiento quimioterapéutico (metotrexato a altas dosis por vía endovenosa) y desarrolló insuficiencia renal aguda estadio 3 según las guías KDIGO, la cual muy probablemente se relacionaba al consumo de metotrexato. El paciente recibió manejo con líquidos endovenosos y bicarbonato de sodio como promotores de la eliminación renal del tóxico, así como folinato cálcico oral, según el protocolo institucional, con lo cual se logró la recuperación de su función renal y que los niveles de niveles de creatinina y nitrógeno ureico mejoraran. Conclusiones. El manejo del paciente reportado demuestra que aunque la nefrotoxicidad por metotrexato es una entidad potencialmente grave, puede tener un buen pronóstico si se maneja oportunamente.

Cost-Effectiveness of Rituximab (Fixed Schedule vs Tailored Dose) Compared With Azathioprine Maintenance Therapy in Adults With Generalized Antineutrophil Cytoplasm Antibody-Associated Vasculitis in Colombia.

OBJECTIVES: Azathioprine has been the therapy of choice for the maintenance of remission in patients with antineutrophil cytoplasm antibody (ANCA)-associated systemic vasculitis, but recent studies show that rituximab could be more effective. To evaluate the cost-effectiveness of azathioprine, fixed-schedule rituximab, and tailored-dose rituximab for ANCA-associated systemic vasculitis. METHODS: A Markov model from the perspective of the Colombian healthcare system was designed with annual cycles and a 5-year time horizon, charting the following states: remission, minor relapse, major relapse, and death. The discount rate was 5%. Transition probabilities were obtained from a systematic literature review. The costs (1 US dollar = 2956 Colombian pesos in 2018) were estimated based on national drug registries and official fee manuals for procedures, along with other resources. The main outcomes were quality-adjusted life-years (QALYs) taken from the Tufts registry. Univariate and multivariate sensitivity analyses were performed. RESULTS: Final costs were $1446 for azathioprine, $4898 for tailored-dose rituximab, and $6311 for fixed-schedule rituximab. QALYs gained were 3.18, 4.08, and 3.98, respectively. Rituximab was cost-effective (cost per incremental QALY gained: $4919, and $6865), and tailored-dose administration had a lower cost. Sensitivity analyses did not affect the results. CONCLUSIONS: Tailored-dose rituximab was the most cost-effective treatment for ANCA-associated vasculitis. Azathioprine presented worse effectiveness and lower cost, and fixed-schedule rituximab was dominated by tailored-dose rituximab.

Recomendaciones de la Asociación Colombiana de Nefrología en casos de trasplante renal durante la pandemia por COVID-19 / Recommendations of the Colombian Association of Nephrology in renal transplantation during the coronavirus pandemic (COVID-19)

Resumen Introducción: los pacientes con trasplante renal y COVID-19 tienen alto riesgo de complicaciones y mortalidad dado que con mayor frecuencia presentan compromiso respiratorio. Hasta el momento, en Colombia no existen protocolos establecidos sobre el manejo de la inmunosupresión de base ni sobre estrategias de tratamiento en esta población, por lo que es necesario establecer recomendaciones basadas en la evidencia disponible y en el consenso de expertos para que sean aplicadas a nivel local. Objetivo: desarrollar mediante un consenso de expertos y una revisión de la literatura una serie de recomendaciones para diagnosticar y prevenir el contagio de SARS-CoV-2 en pacientes con trasplante renal, así como para darles un manejo adecuado. Materiales y métodos: se formularon una serie de preguntas sobre infección por SARS-CoV-2 en trasplante renal con énfasis en comportamiento clínico, frecuencia de la infección, prevención, diagnóstico, manejo de la inmunosupresión y tratamiento, a partir de las cuales se realizó una búsqueda de la literatura en las bases de datos PubMed y EMBASE y en los portales web de algunas sociedades científicas y se consultó a un grupo de especialistas en nefrología y cirugía. La discusión de las preguntas, las respuestas y lo encontrado en la literatura se realizó entre el 23 de abril y el 10 de mayo de 2020. Resultados: se realizó un panel de discusión donde los expertos discutieron y evaluaron la calidad de la evidencia para emitir una recomendación final sobre cada punto evaluado. Asimismo, se realizó un consolidado de las principales series de casos de infección por SARS-CoV2 en población con trasplante renal y sus desenlaces clínicos publicados hasta el momento. Conclusiones: se establecieron unas recomendaciones para la prevención, el diagnóstico y el manejo de pacientes con trasplante renal y COVID-19, las cuales hacen énfasis en el manejo inmunosupresor de base y resaltan la importancia de las interacciones farmacológicas de los tratamientos disponibles para el SARS-CoV-2 con la terapia inmunosupresora. Igualmente se dan recomendaciones para realizar trasplantes de forma segura durante la pandemia.

Abstract Introduction: Kidney transplant patients are a high-risk population for complications and mortality associated with SARS CoV2 infection. Different reports in the literature have shown a higher frequency of respiratory compromise and mortality, currently don't exist recommendations with an adequate level of evidence regarding the management of base immunosuppression and treatment strategies in this population, for which reason it is necessary from the national scene, build recommendations based on the available evidence and consensus of experts, to be applied at the local level. Objective: To develop, by means of an expert consensus and a review of the available literature, recommendations for the prevention, diagnosis and management of transplant patients with SARS Cov2 infection. And give recommendations to continue with the organ procurement and transplant activity in the scenario of the COVID-19 pandemic. Materials and methods: Questions were asked about SARS Cov2 infection in kidney transplantation, with emphasis on clinical behavior, frequency of infection, prevention, diagnosis, management of immunosuppression and treatment. A search of the literature in Pubmed, Embase and scientific societies was performed to answer each of the questions. The discussion of the answers to each of the questions according to the available evidence and the possibility of adapting them to local practice was carried out by consensus method and panel of experts. Nephrology and transplant surgery specialists from transplant groups in the country participated in the consensus. Results: A panel of experts was held to discuss the questions and answers found in the literature between April 23, 2020 and May 10, 2020, for each question a panel discussion was held where the total of experts discussed and Evaluates the quality of the evidence to issue a final recommendation on each evaluated point. A consolidation of the main series of cases of SARS-CoV2 infection in the kidney transplant population and the clinical outcomes was carried out up to the moment of publication. Conclusions: According to what is found in the literature, recommendations are made for the prevention, diagnosis and management of patients with kidney transplantation and SARS-CoV2 infection, emphasizing behavior with respect to basic immunosuppressive management, and highlighting the importance of the pharmacological interactions of the available treatments for SARS-CoV2 with immunosuppressive therapy, recommendations are also given to implement the procupara and transplant activity safely during the pandemic.

Behavior of Bone Mineral Metabolism in Renal Posttransplantation Patients with Severe Hyperparathyroidism.

BACKGROUND: Secondary hyperparathyroidism usually improves after renal transplantation. When it becomes persistent, it is associated with deleterious effects on the graft, bone demineralization, fractures, calcifications, and cardiovascular events. In this study we describe the development of cases of severe hyperparathyroidism occurring after renal transplantation. OBJECTIVE: To describe the behavior of the indicators of bone mineral metabolism in the renal transplantation patient with severe secondary hyperparathyroidism before transplantation, treated with or without parathyroidectomy. METHODS: This is a case series study conducted between 2004 and 2017 on renal transplantation patients presenting with PTH > 800 pg/mL or who required pretransplantation parathyroidectomy. RESULTS: We found 36 patients with severe hyperparathyroidism, corresponding to 10.8% of transplantation recipients, with an average age of 54.5 years (±12.35). The median follow-up after transplantation was 128 months (16-159). Fourteen patients underwent parathyroidectomy before transplantation, with a median intact parathyroid hormone at the time of transplantation of 56 (3-382) pg/mL, with more episodes of hypocalcaemia and oral calcium requirement. The other patients were transplanted with a median intact parathyroid hormone of 1010 (range, 802-1919) pg/mL, reaching a median intact parathyroid hormone of 98.8 (43.8-203) at 3 years of follow-up. Only 2 patients underwent parathyroidectomy for tertiary hyperparathyroidism. CONCLUSIONS: Renal transplantation improves secondary hyperparathyroidism. Sixty-eight percent of patients presented PTH of less than 130 pg/mL after renal transplantation. Only 2 patients underwent posttransplantation parathyroidectomy.

Renal Graft Embolization as a Treatment for Graft Intolerance Syndrome.

BACKGROUND: Renal graft intolerance syndrome is an inflammatory process that occurs in up to 40% of patients with graft loss. It is characterized by fever, graft pain, hematuria, and anemia. Traditionally, the treatment has been nephrectomy; however, this procedure is associated with high morbidity and mortality rates. As an alternative, graft embolization is associated with success rates of up to 92%. In this study, we describe the graft embolization experience of 1 center, its clinical outcomes and complications. METHODS: An observational, retrospective study was conducted. It included all patients with graft intolerance syndrome undergoing graft embolization between 2012 and 2018. The success of the procedure was defined by the resolution of the symptoms that motivated the embolization. RESULTS: We found 12 cases of patients undergoing embolization. The time of presentation of the graft intolerance syndrome after admission to dialysis was 6 months (range, 0.6-13). The main clinical manifestation was pain in the area of the graft and macroscopic hematuria. Except for 1 patient, all continued with the immunosuppressive treatment regimen after graft loss for 4 months (range, 0.6-9), received antibiotics for 5.5 days (range, 2-14), and 10 patients received steroid treatment for 6.5 days (range, 5-10). The main complication, secondary to the procedure, was hematoma at the puncture site in 3 patients. Only 1 patient had postembolization syndrome, which resolved with steroid administration. Two patients required postembolization nephrectomy due to persistent renal blood flow and symptoms such as pain and hematuria. The average hospital stay was 5.5 days (range, 1-24). CONCLUSIONS: Renal graft embolization is an effective technique as a treatment strategy in patients with clinical signs of intolerance syndrome, with a success rate ≥83.3%, low morbidity, and short hospital stay; furthermore, it avoids the potential complications of a surgical nephrectomy. Graft infection should be ruled out before embolization, and the use of prophylactic antibiotics and steroid therapy is recommended to reduce the risk of postembolization syndrome and infectious complications.

Impact of Complicated Urinary Tract Infection on Renal Graft Function.

BACKGROUND: Urinary tract infection (UTI) is the most common infectious complication after renal transplantation. It is uncertain whether the development of UTI has an impact on renal graft function. The objective of this study was to evaluate the effects of complicated and recurrent UTI on 2-year renal graft function. METHODS: This was a historical cohort study in renal transplantation patients in a kidney transplant center. All renal transplant recipients from June 2004 to September 2016 were included. A linear regression analysis was performed to study the association between the outcome (variation in estimated glomerular filtration rate [eGFR] by the Chronic Kidney Disease Epidemiology Collaboration [CKD-EPI] equation between month 1 and month 24 post-transplant) and the UTI. The approval of the Ethics and Research Committee to carry out this study was obtained. RESULTS: In total, 276 kidney transplants were performed during the observation period. Of the transplant patients, 193 (69.9%) did not develop a UTI and 83 (30.1%) presented at least 1 complicated UTI. Patients who presented at least 1 UTI had a variation in eGFR during the observation period of -12.6 mL/min/1.73 m2 (95% confidence interval [CI] -4.5 to -20.7 mL/min/1.73 m2; P = .02), compared with those without a UTI. Said difference persisted in the adjusted model controlling for variables that have an impact on the eGFR. This difference was -10.7 mL/min/1.73 m2 (95% CI -3.1 to -18.2 mL/min/1.73 m2; P = .006). CONCLUSION: The findings suggest that the occurrence of complicated UTI has a negative impact on graft function and that prevention and monitoring of UTIs should be stepped up to avoid their deleterious effects on graft function.

Characterization of kidney transplant patients with expanded criteria donors / Caracterización de trasplantados renales con donantes de criterios expandidos

Abstract Introduction: Kidney transplantation is the treatment of choice for patients with chronic kidney disease; however, the number of donors is insufficient, and waiting lists grow exponentially each year. Transplantation from expanded criteria donors benefits a significant number of patients, improving their survival when compared to those who remain on dialysis. The objective of this study is to describe the characteristics of patients who have received transplants from expanded criteria donors and their renal function at the first and third years after transplantation. Methods: A descriptive observational study was conducted. Patients older than 18 years who received transplants from an expanded criteria donor were chosen between 2007 and 2015. Results: Of a total of 227 patients analyzed, 18 received transplants from an expanded criteria donor. The recipients were 59.5 years old (37-79) and had spent 22.4 months on the waiting list (2.6-77.8) and 4.5 years on dialysis (0.5-18.4). The donors' age was 61 years (50-73). Graft survival at one year was 88.9%; at three years, it was 80%. A total of 11.1% of the patients presented acute cellular rejection at one year, and the average glomerular filtration rate at the first and third years was 58.4 mL/min/1.73 m2. Conclusion: Patients who received transplants from expanded criteria donors have good kidney graft function at three years, with graft and patient survival, similar to that reported for patients who received transplants from standard criteria donors (Acta Med Colomb 2019; 44. DOI: https://doi.org/ 10.36104/amc.2019.1185).

Resumen Introducción: el trasplante renal es el tratamiento de elección para pacientes con enfermedad renal crónica, sin embargo, el número de donantes es insuficiente y las listas de espera crecen exponencialmente cada año. El trasplante con donante de criterios expandidos beneficia a un número importante de pacientes, mejorando su supervivencia al compararlos con los que permanecen en diálisis. El objetivo de este estudio es describir las características de pacientes trasplantados con donantes de criterios expandidos y su función renal al primer y tercer año del trasplante. Métodos: se realizó un estudio descriptivo observacional. Se eligieron pacientes mayores de 18 años trasplantados con donante de criterios expandidos entre 2007 y 2015. Resultados: de un total de 227 pacientes analizados, 18 fueron trasplantados con donante de criterios expandidos. Los receptores tenían 59.5 años (37-79), tiempo en lista de espera de 22.4 meses (2.6-77.8), tiempo en diálisis de 4.5 años (0.5-18.4). La edad del donante fue 61 años (50-73). La supervivencia del injerto al año fue 88.9% y a los tres años de 80%. El 11.1% de los pacientes presentaron rechazo celular agudo al año y el promedio de la tasa de filtración glomerular al primer y tercer año fue de 58.4 mL/min/1.73m2 Conclusión: los pacientes trasplantados con donante de criterios expandidos tienen una buena función del injerto renal a tres años, con supervivencia del injerto y del paciente, similar a la reportada con donante con criterio estándar. (Acta Med Colomb 2019; 44. DOI: https://doi.org/10.36104/amc.2019.n85).

Hemorragia alveolar difusa secundaria a vasculitis asociada a ANCA. Recaída durante hemodiálisis / Diffuse alveolar hemorrhage secondary to ANCA-associated vasculitis. Relapse during hemodialysis

Resumen La hemorragia alveolar difusa (HAD) masiva es una complicación inusual de los pacientes con vasculitis ANCA, frecuentemente amenaza la vida y está asociada con una mortalidad de hasta el 100%. La información en la literatura acerca del tratamiento en casos refractarios y cuando el paciente se encuentra en diálisis es escasa. Se presenta el caso de un paciente con vasculitis p-ANCA con compromiso renal y pulmonar en el escenario de síndrome pulmón-riñón, con múltiples recaídas de hemorragia alveolar a pesar de tratamiento con corticoide, azatioprina, ciclofosfamida y terapia de recambio plasmático. Se instauró manejo con anticuerpo monoclonal anti CD20 e inmunoglobulina, logrando resolución del episodio de hemorragia alveolar y permaneciendo sin actividad. Se resalta la utilidad del rituximab como estrategia terapéutica en casos refractarios. (Acta Med Colomb 2019; 44: 111-114).

Abstract Massive diffuse alveolar hemorrhage (DAH) is an unusual complication of patients with ANCA vasculitis that frequently threatens life and is associated with mortality up to 100%. In formation in the literature about treatment in refractory cases and when the patient is on dialysis is scarce. The case of a patient with p-ANCA vasculitis with renal and pulmonary involvement in the lung-kidney syndrome scenario, with multiple relapses of alveolar hemorrhage despite treatment with corticosteroid, azathioprine, cyclophosphamide and plasma exchange therapy is presented. Management with anti-CD20 monoclonal antibody and immunoglobulin was estab lished, achieving resolution of the episode of alveolar hemorrhage and remaining without activity. The usefulness of rituximab as a therapeutic strategy in refractory cases is highlighted. (Acta Med Colomb 2019; 44: 111-114).

Gastric sleeve surgery in hemodialysis: A case report.

INTRODUCTION: Morbid obesity in chronic kidney disease patients on hemodialysis limits access to renal transplantation. We report here a case of a surgical procedure for weight reduction in a hemodialysis patient and adjustment of dry weight through bioelectrical impedance. CASE PRESENTATION: A 44-year-old male with CKD on hemodialysis for 26 years. After 3 years on dialysis, he underwent a cadaveric kidney transplant. However, after 8 years of transplant, he loses the kidney graft and returns to dialysis treatment. The patient's BMI increased to 42 kg/m2 and he had difficult-to-control hypertension and severe sleep apnea. Behavioral, nutritional and pharmacologic measures were not sufficient to achieve an adequate weight control. Thus, a surgical procedure for weight reduction was considered. The patient underwent a laparoscopic gastric sleeve without any complications. Dry weight was adjusted through bioelectrical impedance before each hemodialysis session. The patient did not display hypotension, cramps, or fluid overload. After a 30 kg weight loss, the patient's BMI was 28.3 kg/m2, allowing registration on the kidney transplant waitlist. DISCUSSION: Obesity in CKD restricts access to kidney transplant waitlist. Bariatric surgery has proven to be safe and effective for sustained weight loss and it seems that the fact that a patient is dialysis dependent does not independently increase post-operatory complications. CONCLUSION: Surgical procedures for weight reduction in dialysis patients does not independently increase the risk for adverse outcomes after bariatric surgery. The estimation of DW through BIA is an effective method for avoiding complications generated by excessive or deficient ultrafiltration.

PTLD in a kidney receptor: case report / Enfermedad linfoproliferativa en el injerto renal. Reporte de un caso y revisión de la literatura

Abstract Posttransplant Lymphoproliferative Disorders (PTLDs) occur in 3 to 10% of adults with solid organ transplant (SOT). It has been associated with Epstein Barr Virus (EBV) infection. Differential diagnostics of PTLD from rejection or viral infection is difficult when the tumor infiltrates the graft, because the clinical and histopathological findings are similar. We report a case of patient with chronic kidney disease due to Ig M glomerulonephritis with cadaveric donor kidney transplantation who presented proteinuria and decreased glomerular filtration rate, with a solid mass at renal graft and confirmatory histology of polymorphic renal transplant lymphoproliferative disorder (PTLD), VEB positive, and CD 20 positive. The patient was treated with rituximab 375 mg / m2 weekly, four doses, followed by chemotherapy with ciclophosphamide, vincristine and doxorubicin. He didn't need radiotherapy or graft nephrectomy, with complete remission at one year of follow-up and optimal graft function.

Resumen Los desórdenes linfoproliferativos postrasplante (PTLD por sus siglas en inglés: Posttransplant Lymphoproliferative disorders) se presentan en 3 a 10% de adultos con trasplante de órgano sólido (TOS). Se ha asociado a infección por Virus Epstein Barr (VEB). Es difícil diferenciar PTLD de rechazo o infección viral, porque los hallazgos clínicos e histopatológicos son muy similares. Presentamos el caso de un paciente con enfermedad renal crónica (ERC) secundaria a glomerulonefritis IgM, con trasplante renal de donante cadavérico, quien presentó proteinuria y disminución de la función renal, se le documentó una masa en el injerto renal compatible con desorden linfoproliferativo pos-trasplante renal de tipo polimórfico (PTLD), VEB positivo y CD 20 positivo. El tratamiento consistió en rituximab 375 mg/m2 semanales, cuatro dosis, se realizó control con imágenes y se adicionó el esquema CHOP (ciclofosfamida, vincristina, doxorubicina). El paciente toleró de manera adecuada la quimioterapia, no requirió radioterapia, ni trasplantectomía y después del R-CHOP la masa disminuyó de manera significativa hasta desaparecer al año de seguimiento manteniendo función óptima del injerto renal.

Methicillin-Resistant Staphylococcus aureus USA300 Latin American Variant in Patients Undergoing Hemodialysis and HIV Infected in a Hospital in Bogotá, Colombia.

We aimed to determine the prevalence of MRSA colonization and examine the molecular characteristics of colonizing isolates in patients receiving hemodialysis and HIV-infected in a Colombian hospital. Patients on hemodialysis and HIV-infected were prospectively followed between July 2011 and June 2012 in Bogota, Colombia. Nasal and axillary swabs were obtained and cultured. Colonizing S. aureus isolates were identified by standard and molecular techniques. Molecular typing was performed by using pulse-field gel electrophoresis and evaluating the presence of lukF-PV/lukS-PV by PCR. A total of 29% (n = 82) of HIV-infected and 45.5% (n = 15) of patients on hemodialysis exhibited S. aureus colonization. MSSA/MRSA colonization was observed in 28% and 3.6% of the HIV patients, respectively and in 42.4% and 13.3% of the hemodialysis patients, respectively. Staphylococcal cassette chromosome mec typing showed that four MRSA isolates harbored the type IV cassette, and one type I. In the hemodialysis group, two MRSA isolates were classified as belonging to the USA300-LV genetic lineage. Conversely, in the HIV infected group, no colonizing isolates belonging to the USA300-Latin American Variant (UDA300-LV) lineage were identified. Colonizing isolates recovered from the HIV-infected group belonged to the prevalent hospital-associated clones circulating in Latin America (Chilean [n = 1] and Pediatric [n = 2]). The prevalence of MRSA colonization in the study groups was 3.6% (HIV) and 13.3% (hemodialysis). Surveillance programs should be implemented in this group of patients in order to understand the dynamics of colonization and infection in high-risk patients.

Sarcoma de Kaposi en trasplante renal, respuesta a sirolimus: reporte de caso y revisión de la literatura científica / Kaposis sarcoma in renal transplant recipients, sirolimus utility: case report and literature revision

El cáncer en el paciente que ha recibido un trasplante es una enfermedad reconocida, con factores de riesgo demostrados e incidencia 3,12 mayor que en la población general. El sarcoma de Kaposi ocurre 400 a 500 veces más frecuentemente en el receptor de trasplante renal. Hicimos una revisión de la literatura científica a raíz del primer caso de sarcoma de Kaposi en nuestro grupo de trasplante renal del Hospital Universitario San Ignacio...

Cancer in transplant patients is a recognized disease, with risk factors demonstrated and an incidence of 3.12 times the general population.Kaposi’s sarcoma occurs 400-500 times more frequently in renal transplant recipients. We reviewthe literature of the first case of Kaposi’s sarcoma in our renal transplant group at the HospitalUniversitario San Ignacio...

Compromiso renal en un paciente con esclerosis tuberosa / Kidney Affection in a Patient with Tuberous Sclerosis

La esclerosis tuberosa es una enfermedad hereditaria, autosómica dominante y multisistémica, que cursa generalmente con crisis de epilepsia, retraso mental y tumores benignos en el cerebro y en otros órganos vitales como riñones, corazón, ojos, pulmones y piel. Objetivo. Describir las características clínicas y la evolución de un paciente con esclerosis tuberosa. Diseño. Reporte de caso. Materiales y métodos. Se revisó y describió la historia clínica de un paciente que fue hospitalizado en el Hospital Universitario San Ignacio para trasplante renal de donante cadavérico con enfermedad renal estado 5, con antecedentes de esclerosis tuberosa. Posteriormente, se revisó la literatura existente acerca de ®esclerosis tuberosa y trasplante renal” en PubMed, Ovid y Highwire. Conclusiones. La esclerosis tuberosa es una enfermedad poco común en nuestro medio, con compromiso renal dado por angiomiolipomas, con progresión a falla renal y estado terminal, que requiere soporte dialítico, a mediano plazo.

Hipertensión arterial: diagnóstico y manejo / Arterial hypertension: diagnosis and treatment

La hipertensión arterial es uno de los principales factores de riesgo de muerte en personas de edad media y ancianos. Se presentan en este artículo los elementos diagnósticos y terapéuticos de esta patología, que se puede presentar hasta en el 30% de la población mundial, y se trata del manejo de grupos especiales; todo lo anterior con base en diversas publicaciones de la literatura en los últimos años y en los informes publicados en el año 2003: el Séptimo Informe del Comité Conjunto en prevención, detección, evaluación y tratamiento de la hipertensión arterial y las guías de la Sociedad Europea de Hipertensión y la Sociedad Europea de Cardiología para el manejo de la hipertensión arterial.

Embolia pulmonar después de retirar catéter de hemodiálisis: informe de un caso / Pulmonary embolism after removing the catheter from hemodialysis: case report

Dentro de las complicaciones de los catéteres venosos centrales siempre se mencionan las de causa mecánica como neumotórax y hemotórax y las infecciosas. El caso descrito nos recuerda otras de las complicaciones como la trombosis y la embolia pulmonar, que se pueden presentar en 2 a 19% y 8 a 15% respectivamente. Se debe tener en cuenta este tipo de eventos adversos, que en algunos casos pueden llevar incluso hasta la muerte.