Primary brain lymphomas after kidney transplantation: an under-recognized problem?

UNLABELLED: Primary central nervous system post-transplant lymphoproliferative disease (CNS PTLD) is a serious complication after solid organ transplantation that has not received much attention so far. However, it could become a more frequent problem with the introduction of new biological agents. METHODS: We identified five cases with CNS PTLD in our center who were transplanted between 1986 and 2007, three men and two women, with a mean age of 55.9 years (range 42-74). Three patients had received only kidney transplant and two patients had received a kidney-pancreas transplant. RESULTS: The mean time from first symptoms until diagnosis was 3.5 months (2-6). One patient was diagnosed post-mortem in autopsy. The mean time from transplantation to onset of neurological symptoms was 73.8 months (31-144). The initial clinical manifestation was heterogeneous: all five cases showed headache, four cases presented with gait disturbance, one with dysarthria and two with a confusional state. Epstein-Barr virus (EBV) immunoglobulin (Ig)G serology was positive in four out of five cases; in situ hybridization for EBV in brain biopsy samples was positive in three cases, negative in one and not available in one. In four patients, EBV polymerase chain reaction (PCR) was positive in cerebrospinal fluid (CSF). After diagnosis, overall immunosuppressive load was lowered in all patients (n = 4). Three patients died at 8-104 weeks (mean 40 weeks) after diagnosis and one patient is still alive 20 months after diagnosis. CONCLUSIONS: CNS PTLD is a complication difficult to diagnose, frequently diagnosed too late and often refractory to treatment. A more aggressive screening might be necessary in patients even with mild CNS symptoms.

Individualización del calcio en el baño de diálisis: una asignatura pendiente / Dialysate calcium individualisation: a pending issue

Introducción: El calcio (Ca) es uno de los elementos fundamentales a tener en cuenta en los pacientes en diálisis, dada su relación con el riesgo cardiovascular. Con la introducción de los modernos quelantes del fósforo no cálcicos y de los calcimiméticos, hemos visto variar la calcemia prehemodiálisis, en los últimos años, de 9,5-10,5 a 8,4-9,5 mg/dl. Para valorar de una forma más precisa las variaciones del Ca durante la sesión de hemodiálisis e individualizar su prescripción, el objetivo del estudio fue comparar diferentes concentraciones de Ca en el baño de diálisis, valorando el balance pre y poshemodiálisis y sus implicaciones en el control del metabolismo fosfocálcico. Pacientes y métodos: Se incluyeron 98 pacientes con una edad media de 59,3 ± 15 años, 68 hombres y 30 mujeres. Cada paciente se sometió a dos sesiones de hemodiálisis variando únicamente la concentración de Ca del baño, una sesión con Ca 2,5 mEq/L (grupo Ca25) y otra con Ca 3,0 mEq/L (grupo Ca30). Se determinaron los niveles de Ca, fósforo (P) y paratohormona (PTH) pre y poshemodiálisis, registrando la medicación relacionada. Además se dividieron los pacientes en cuatro subgrupos según los niveles de calcemia prediálisis en Ca < 8,5, 8,5-9,0, 9,0-9,5 y > 9,5 mg/dl para realizar un análisis más individualizado. Resultados: No se observaron diferencias en los valores prediálisis de Ca, 8,81 ± 0,65 (Ca25) y 8,88 ± 0,61 (Ca30); P, 4,01 ± 1,3 (Ca25) y 4,19 ± 1,2 (Ca30); y PTH, 352 ± 288 (Ca25) y 369 ± 310 (Ca30). Con el baño Ca25, el Ca y la PTH posdiálisis no se modificaron significativamente, mientras que con el Ca30 se observó un incremento significativo del Ca a 10,2 ± 0,6 (p < 0,001) acompañado de un descenso de la PTH (181 ± 227, p < 0,001). No obstante, cuando se analizaba el baño Ca25 por subgrupos de Ca prediálisis (< 8,5 mg/dl [30,6%], 8,5-9,0 [31,6%], 9,1-9,5 [23,5%] y > 9,5 mg/dl [14,3%]), se apreció un aumento del Ca posdiálisis en los (AU)

Calcium is one of the key elements to consider in patients on dialysis due to its relationship with cardiovascular risk. The introduction of non-calcium-based phosphate binders and calcimimetics has changed the setting for pre-dialysis serum calcium in recent years from 9.5-10.5mg/dl to 8.5-9.5mg/dl. To assess more accurately the changes in calcium (Ca) during haemodialysis sessions and to individualise prescriptions, the aim of this study was to assess the intradialytic changes of two different dialysate Ca concentrations before and after hemodialysis and their implications in controlling calcium-phosphate metabolism. Patients and method: We analysed 98 patients with a mean age of 59.3±15 years, 68 of which were men and 30 women. Each patient received two HD sessions with two different dialysate Ca concentrations: 2.5mEq/l (Ca25 group) or 3.0mEq/l (Ca30 group). Pre- and post-dialysis Ca, phosphorus (P) and PTH were determined, and associated medications were recorded. For a more individualised analysis, patients were divided into four subgroups of Ca<8.5mg/dl, 8.5-9.0mg/dl, 9.0-9.5mg/dl, and >9.5mg/dl, according to pre-dialysis serum calcium levels. Results: There were no differences in pre-dialysis values of Ca: 8.81±0.65 (CA25) and 8.88±0.61 (CA30), P: 4.01±1.3 (CA25) and 4.19±1.2 (CA30), or PTH: 352±288 (CA25) and 369±310 (CA30). Post-dialysis Ca and PTH did not change significantly with CA25 dialysate, although there was a significant post-dialysis Ca increase to (AU)

Dialysate calcium individualisation: a pending issue.

UNLABELLED: Calcium is one of the key elements to consider in patients on dialysis due to its relationship with cardiovascular risk. The introduction of non-calcium-based phosphate binders and calcimimetics has changed the setting for pre-dialysis serum calcium in recent years from 9.5-10.5mg/dl to 8.5-9.5mg/dl. To assess more accurately the changes in calcium (Ca) during haemodialysis sessions and to individualise prescriptions, the aim of this study was to assess the intradialytic changes of two different dialysate Ca concentrations before and after hemodialysis and their implications in controlling calcium-phosphate metabolism. PATIENTS AND METHOD: We analysed 98 patients with a mean age of 59.3 ± 15 years, 68 of which were men and 30 women. Each patient received two HD sessions with two different dialysate Ca concentrations: 2.5 mEq/l (Ca25 group) or 3.0 mEq/l (Ca30 group). Pre- and post-dialysis Ca, phosphorus (P) and PTH were determined, and associated medications were recorded. For a more individualised analysis, patients were divided into four subgroups of Ca<8.5mg/dl, 8.5-9.0mg/dl, 9.0-9.5mg/dl, and >9.5mg/dl, according to pre-dialysis serum calcium levels. RESULTS: There were no differences in pre-dialysis values of Ca: 8.81 ± 0.65 (CA25) and 8.88 ± 0.61 (CA30), P: 4.01 ± 1.3 (CA25) and 4.19 ± 1.2 (CA30), or PTH: 352 ± 288 (CA25) and 369 ± 310 (CA30). Post-dialysis Ca and PTH did not change significantly with CA25 dialysate, although there was a significant post-dialysis Ca increase to 10.2 ± 0.6 (P<.001) accompanied by a decrease in post-dialysis PTH (181 ± 227, P<.001) with CA30. However, with CA25 dialysate, when different subgroups of pre-dialysis Ca were analysed: <8.5mg/dl (30.6%), 8.5-9.0mg/dl (31.6%), 9.1-9.5mg/dl (23.5%) and >9.5mg/dl (14.3%) we observed a Ca increase during the session in the <8.5 (P<.001) and 8.5-9.0 (P<.01) subgroups. Ca was unchanged in the 9.1-9.5 group and Ca decreased when the initial Ca values were >9.5mg/dL (P<.01). A Ca increase (P<.001) and a decrease in PTH (P<.01) were observed in all subgroups with CA30 dialysate. A total of 42% of patients were taking calcimimetics, 47% paricalcitol, and 32% calcium-based phosphate binders, although these drugs were not linked with pre- or post-dialysis Ca levels in or dialysate treatment. CONCLUSION: We concluded that the prescription of Ca dialysate needs to be individualised based on pre- and post-dialysis Ca values and the need for an increase, decrease, or no changes in post-dialysis calcium in relation to the clinical condition of the patient's phosphorous-calcium metabolism.

Nocturnal, every-other-day, online haemodiafiltration: an effective therapeutic alternative.

BACKGROUND: Longer and more frequent dialysis sessions have demonstrated excellent survival and clinical advantages, while online haemodiafiltration (OL-HDF) provides the most efficient form of dialysis treatment. The aim of this study was to evaluate the beneficial effects of a longer (nocturnal) and more frequent (every-other-day) dialysis schedule with OL-HDF at the same or the highest convective volume. METHODS: This prospective, in-centre crossover study was carried out in 26 patients, 18 males and 8 females, 49.2±14 years old, on 4-5 h thrice-weekly post-dilution OL-HDF, switched to nocturnal every-other-day OL-HDF. Patient inclusion criteria consisted of stable patients with good vascular access and with good prospects for improved occupational, psychological and social rehabilitation. Patients were randomly assigned into two groups: Group A received the same convective volume as previously for 6 months followed by a higher convective volume for a further 6 months, while Group B received the same schedule in reverse order. RESULTS: Nocturnal every-other-day OL-HDF was well tolerated and 56% of patients who were working during the baseline period continued to work throughout the study with practically no absenteeism. The convective volume was 26.7±2 L at baseline, 27.5±2 with the unchanged volume and 42.9±4 L with the higher volume. eKt/V increased from 1.75±0.4 to 3.37±0.9. Bicarbonate, blood urea nitrogen (BUN) and creatinine values decreased, while phosphate levels fell markedly with a 90% reduction in phosphate binders. Blood pressure and left ventricular hypertrophy (LVH) improved and the use of anti-hypertensive drugs decreased. In both groups, BUN, creatinine and ß2-microglobulin reduction ratios improved. Different removal patterns were observed for myoglobin, prolactin and α1-acid glycoprotein. CONCLUSIONS: Nocturnal every-other-day OL-HDF could be an excellent therapeutic alternative since good tolerance and occupational rehabilitation, marked improvement in dialysis dose, nutritional status, LVH, phosphate and hypertension control and a substantial reduction in drug requirements were observed. In this crossover study, different removal patterns of large solutes were identified.