Management of mixed acute rejection driven by a de novo donor-specific complement-binding anti-DQB1*03:01 antibody and intraepithelial CD8 T-cells in a kidney recipient: a case report.

Mixed acute rejection is a clinicopathological entity that is difficult to accurately diagnose, and so may be under-reported. Allografts are lost more often than in either humoral or cellular rejection. The diagnosis requires both histological and immunological studies on renal biopsy and blood specimens from the transplant recipient to provide the required rescue therapy to abolish the allogeneic response against the graft. We present a clinical case report of an active mixed acute rejection driven by a de novo donor-specific complement-binding anti-DQB1*03:01 antibody and intraepithelial CD8 T-cells in a patient with a kidney transplant. The patient was diagnosed, treated, and followed up as per the local institution's procedure with a full recovery of graft function. Our case emphasises the challenge of a mixed acute rejection and supports the need to improve the post-transplant outcome of recipients and their grafts.

Adenopatía intramamaria metastásica como única manifestación de carcinoma mamario / Metastatic intramammary lymph node as the only manifestation of breast carcinoma

En el 5% de los estudios mamográficos de cribado se detectan adenopatías intramamarias. La ausencia de centro graso, la pérdida del hilio ganglionar, un tamaño superior al centímetro o un crecimiento con respecto a controles previos son motivos suficientes para realizar un estudio histológico de la adenopatía, con el objetivo de descartar enfermedad tumoral. A pesar del avance en los estudios radiológicos de cribado y el empleo generalizado de la técnica de biopsia selectiva del ganglio centinela en el tratamiento quirúrgico del carcinoma mamario precoz, el hallazgo de adenopatías intramamarias afectadas por tumor, en el carcinoma de mama infiltrante es generalmente un hallazgo casual durante la cirugía o en el subsiguiente exámen an atomopatológico. En la actualidad existe controversia en cuanto al manejo quirúrgico de la axila ante el hallazgo de una adenopatía intramamaria metastásica. Independientemente, tanto del manejo quirúrgico de la axila, como de la presencia o no de afectación tumoral ganglionar axilar, la afectación metastásica de una adenopatía intramamaria cambia no sólo el pronóstico de la paciente sino también la actitud en cuanto a terapia adyuvante (AU)

Abstract Intramammary lymph nodes are detected in 5% of screening mammographies. Suffi-cient grounds for histological examination to exclude malignancy are the absence of the hilarfatty radiolucent notch, a reduction in the volume of the central echogenic hilum, size greater than 1 cm or an increase in size compared with previous screens. Despite advances in radiological screening and the widespread use of sentinel lymph node biopsy in the surgical treatment of early breast carcinoma, breast cancer metastasis to intramammary lymph nodes is usually an incidental finding during surgery or in subsequent histological examination. The surgical treatment of the axilla in cases of metastatic intramammary lymph nodes is currently controversial. Independently of the surgical management of the axilla and the presence or absence of metastatic axillary lymph node, a finding of a metastatic intramammary lymph node changes not only the patient’s prognosis but also the approach to the use of adjuvant therapy (AU)

[Chronic renal failure secondary to hyperoxaluria following small bowel syndrome]. / Insuficiencia renal crónica secundaria a hiperoxaluria tras resección intestinal por trombosis mesentérica.

A 70-year-old woman was admitted in the Department of Nephrology because of renal insufficiency. Six years previously, as consequence of a venous mesenteric thrombosis, she underwent an extense intestinal resection with subsequent short intestine syndrome. Five years after the surgery an increase in the creatinine concentration was observed (1.4 mg/dl). One year later, it increased up to 3.1 mg/dl and the patient was remitted to our Department. The radiological study revealed calcifications on both kidney silhouettes. In the next year, renal function worsened and the calcifications increased. Coinciding with the beginning of the chronic hemodialysis treatment she suffered a renal colic with passage of a calcium oxalate stone.

Insuficiencia renal crónica secundaria a hiperoxaluria tras resección intestinal por trombosis mesentérica / Chronic renal failure secondary to hyperoxaluria following small bowel syndrome

Una enferma de 70 años de edad fue remitida al Servicio de Nefrología por insuficienciarenal (concentración de creatinina en plasma: 3,1 mg/dl). Seis añosantes había sido intervenida quirúrgicamente por abdomen agudo secundario atrombosis venosa mesentérica, y se le realizó una resección intestinal amplia conanastomosis entre yeyuno e íleon distal. A partir de la cirugía la enferma presentóun síndrome de intestino corto con estatorrea. La concentración plasmática decreatinina se mantuvo en el rango normal hasta el quinto año postoperatorio enque se detectó una cifra de 1,4 mg/dl. Al año siguiente la concentración de creatininaera de 3,1 mg/dl y la enferma fue enviada al Servicio de Nefrología. En elestudio inicial se comprobó la existencia de calcificaciones sobre ambas siluetasrenales sin objetivarse dilatación de la vía urinaria. La función renal se deterioróprogresivamente y un año más tarde (7 años después de la cirugía) comenzó tratamientocon hemodiálisis periódica. En ese momento se constató un aumento delas calcificaciones renales con nefrocalcinosis bilateral. Coincidiendo con el iniciodel tratamiento con hemodiálisis, la enferma tuvo un cólico renal expulsando uncálculo de oxalato cálcico

A 70 years old woman was admitted in the Department of Nephrology becauseof renal insufficiency. Six years previously, as consequence of a venous mesentericthrombosis, she underwent an extense intestinal resection with subsequent short intestinesyndrome. Five years after the surgery an increase in the creatinine concentrationwas observed (1.4 mg/dl). One year later, it increased up to 3.1 mg/dl andthe patient was remitted to our Department. The radiological study revealed calcifications on both kidney silhouettes. In the next year, renal function worsened andthe calcifications increased. Coinciding with the beginning of the chronic hemodialysistreatment she suffered a renal colic with passage of a calcium oxalate stone

Lumbar bone mineral density after kidney transplantation: a three-year prospective study.

Osteopenia is a common complication after transplantation. However, prospective long-term studies are scarce and most were performed in patients on cyclosporine and high-dose steroids. In 65 patients with functioning grafts, 41 males and 24 females, 50 on tacrolimus-based immunosuppression and 15 on cyclosporine-based immunosuppression, bone mineral density (BMD) was measured in the lumbar spine (L2-L4) and femoral neck (FN) using dual X-ray absorptiometry (DEXA) in the first month after transplantation (baseline) and at 1, 2, and 3 years. At baseline, BMD was similar to the control population both in L2-L4 (z score = -0.421) and in FN (z score = -0.518). During the follow-up, 3 types of patterns were identified: BMD increased in L2-L4 in 25 patients (38.5%), remained stable in 20 patients (30.8%), and decreased in 20 patients (30.8%). BMD losses appeared mainly during the first year (0.964 +/- 0.162 baseline; 0.904 +/- 0.161 at 1 year, 0.886 +/- 0.140 at 3 years; analysis of variance [ANOVA] P < .001). However, the improvement was maintained throughout the follow-up (0.860 +/- 0.176 g/cm2 at baseline; 0.901 +/- 0.161 at 1 year; 0.954 +/- 0.178 at 3 years; ANOVA P < .001) and there was a parallel increase of BMD in FN (0.712 +/- 0.144 at baseline; 0.744 +/- 0.249 at 1 year; 0.826 +/- 0.184 at 3 years; ANOVA P < .01). There were no differences between both groups in graft function, intact parathyroid hormone (iPTH) levels, number of postmenopausal women, or steroid doses. About one third of patients had bone loss during the first year after transplantation. We were unable to identify any risk factor for this complication in patients on low-dose steroids.

Self-expanding metallic ureteral stents for treatment of ureteral stenosis after kidney transplantation.

The incidence of post-renal transplantation ureteral stenosis ranges from 2%-12%. Because the role of self-expanding ureteral metallic stents for its treatment has been scarcely reported, the aim of this study was to evaluate the efficacy of Nitinol stents. Eleven ureteral stenoses in patients with chronic graft dysfunction (8 cases) or high surgical risk (3 cases) were treated by antegrade percutaneous implantation of Nitinol stents through a nephrostomy tract. The mean follow-up period was 48 +/- 7 months (range, 3-85 months). The patency rate at the moment of return to dialysis, death, or last check-up was 73% (8/11). Three patients (27%) developed stent occlusion. Two patients were treated using a trans-stent double-J catheter and 1 patient using stent removal and pyeloureterostomy using the native ureter. The mean percentage decrease in serum creatinine (Cr) level after stent implantation was 41% (range, 14%-63%). Nitinol ureteral stent implantation is an effective alternative for the treatment of ureteral stenosis in patients with chronic graft dysfunction or high surgical risk.

[Colitis due to cytomegalovirus in a dialysis patient]. / Colitis por citomegalovirus asociada a insuficiencia renal crónica tratada con hemodiálisis.

Cytomegalovirus (CMV) is an ubiquitous agent and a pathogen in all age groups. Although CMV disease in normal adults is not very usual, the virus is well known to produce severe symptoms, mostly in immunocompromised patients. Chronic hemodialysed patients constitute a risk population for developing CMV infection, nevertheless, clinical manifestations are not usual. One chronic renal failure patient who developed acute and severe colitis due to CMV infection is presented. Of interest are, the rarity of this case, the favorable clinical course after the treatment and the differential diagnosis with other gastrointestinal disorders frequently found in renal patients.

Evolution of salmonella aortitis towards the formation of abdominal aneurysm.

We present a case of salmonella aortitis with necrosis of the arterial wall and its evolution to the formation of an abdominal aneurysm over a 6-day period. Computed tomography was performed before and after the development of a mycotic aneurysm. Presurgical aortography was also performed. The findings obtained give a dynamic concept to this pathology and show its rapid evolution in a short period of time.