What Is Wrong with the Blood Pressure Target Recommendation of KDIGO 2021 for Hypertension in Chronic Kidney Disease?

CONTEXT: Eighty-five percent of patients with chronic kidney disease (CKD) have hypertension, and blood pressure (BP) control is the cornerstone in the management of CKD. Although it is widely accepted that BP should be optimized, BP targets in CKD are not known. Subject of Review: Kidney Disease Improving Global Outcomes (KDIGO) clinical practice guideline for the management of BP in CKD (Kidney Int. 2021 Mar 1;99(3S):S1-87) recommends targeting BP to less than 120 mm Hg systolic for patients with CKD. Second Opinion: KDIGO BP target differs from all other hypertension guidelines. This is also a major change from the previous recommendation which was <140 systolic to all patients with CKD and <130 systolic for those with proteinuria. Targeting systolic BP to less than 120 mm Hg is hard to substantiate based on available data and is based primarily on subgroup analysis of a randomized control trial. Intensive BP lowering as suggested by the guidelines may lead to polypharmacy, added cost burden, and risk of serious harms.

Clinical Course and Outcomes of COVID-19 in Kidney Transplant Recipients.

Introduction: Kidney transplant recipients (KTR) are at increased risk of morbidity and mortality due to coronavirus disease 2019 (COVID-19). This study aimed to explore the clinical characteristics and outcomes of COVID-19 in KTR. Methods: We reviewed the clinical profile, outcomes, and immunological responses of recipients admitted with COVID-19. We determined the risk factors for mortality and severe COVID-19. Results: Out of 452 recipients on follow-up, 60 were admitted with COVID-19. Prevalent comorbidities were hypertension (71%), diabetes (40%), lung disease (17%). About 27% had tuberculosis. The median Sequential Organ Failure Assessment score at presentation was 3 (interquartile range [IQR] 1-5). There was a high incidence of diarrhea (52%) and anemia (82%). Treatment strategies included antimetabolite withdrawal (85%), calcineurin inhibitor decrease or withdrawal (64%), increased steroids (53%), hydroxychloroquine (21%), remdesivir (28.3%), and tocilizumab (3.3%). Severe COVID-19 occurred in 34 (56.4%) patients. During a median follow-up of 42.5 days (IQR 21-81 days), 83% developed acute kidney injury (AKI) and eight (13%) died. Mortality was associated with the baseline graft dysfunction, hypoxia at admission, lower hemoglobin and platelets, higher transaminases, higher C reactive protein, diffuse radiological lung involvement, hypotension requiring inotropes, and Kidney Diseases Improving Global Outcomes (KDIGO) stage 3 AKI (univariate analysis). Around 57% of patients remained RT-PCR positive at the time of discharge. By the last follow-up, 66.6% of patients developed IgM (immunoglobulin M) antibodies and 82.3% of patients developed IgG antibodies. Conclusion: COVID-19 in kidney transplant recipients is associated with a high risk of AKI and significant mortality.

Prevalence and subtypes of hypertension in normal-weight and obese Indian adolescents: a cross-sectional study.

This cross-sectional study examined the prevalence, stages, subtypes of hypertension, and the associated risk factors in adolescent school children in Western India. We screened 2,644 adolescents, from 10 different private and government schools in urban and rural areas for hypertension, as defined by the 2017 Clinical Practice Guidelines. The association of stages and subtypes with age, gender, body mass index, type of school, and place of residence was analysed. 197 children (7.5%) had hypertension; 170 (6.4%) had stage I, 27 (1%) had stage II and 76 (2.9%) had elevated blood pressure (EBP). The risk of EBP was higher in children > 15 years of age (p = 0.006). Compared with normal-weight children, obese, and overweight children had a higher risk of hypertension [odds ratio (OR) 9 (5.84, 13.88) and 3.77 (2.59, 5.48) respectively], whereas underweight children had a lower risk [OR 0.39 (0.16, 0.98)]. Normal-weight hypertension was seen in 5.2% and was higher in children from government schools (9.4%). Systolic-diastolic hypertension (SDH) was the most common subtype, seen in 136 (5.1%). SDH was more common in girls, in rural children, and in those with stage II hypertension. Isolated diastolic hypertension, seen in 51 (1.9%), was more common in boys, in urban children, and in those with EBP.

Recovery of kidney function after AKI because of COVID-19 in kidney transplant recipients.

Evidence on the evolution of graft function in kidney transplant recipients recovering from coronavirus disease-2019 (COVID-19) is lacking. This multicenter observational study evaluated the short-term clinical outcomes in recipients with acute kidney injury (AKI) secondary to COVID-19. Out of 452 recipients following up at five centers, 50 had AKI secondary to COVID-19. 42 recipients with at least 3-month follow-up were included. Median follow-up was 5.23 months [IQR 4.09-6.99]. Severe COVID-19 was seen in 21 (50%), and 12 (28.6%) had KDIGO stage 3 AKI. Complete recovery of graft function at 3 months was seen in 17 (40.5%) patients. Worsening of proteinuria was seen in 15 (37.5%) patients, and 4 (9.5%) patients had new onset proteinuria. Graft failure was seen in 6 (14.3%) patients. Kidney biopsy revealed acute tubular injury (9/11 patients), thrombotic microangiopathy (2/11), acute cellular rejection (2/11), and chronic active antibody-mediated rejection (3/11). Patients with incomplete recovery were likely to have lower eGFR and proteinuria at baseline, historical allograft rejection, higher admission SOFA score, orthostatic hypotension, and KDIGO stage 3 AKI. Baseline proteinuria and the presence of orthostatic hypotension independently predicted incomplete graft recovery. This shows that graft recovery may remain incomplete after AKI secondary to COVID-19.

Characteristics and Outcomes of Exit Sites of Buried Peritoneal Dialysis Catheters: A Cohort Study.

Buried peritoneal dialysis (PD) catheters are placed months before dialysis is needed and the exit site is created when the catheter is dissected out at the initiation of dialysis. In contrast, the exit site of an unburied catheter is created by the surgeon at the time of insertion. We reviewed all patients who initiated PD at our center over a 2-year period. At each clinic visit, exit sites were subjectively classified into standard predefined groups. Outcomes of interest were the frequency of perfect exit sites at 2, 6, and 12 months and rate of exit-site infections (ESIs) at 90 days. One hundred and seventy-seven patients initiated PD during the period of interest, and 169, 157, and 144 remained on PD at 2, 6, and 12 months, respectively. Ninety-three patients had buried catheters, and 76 patients had unburied catheters. Both groups had similar frequency of perfect appearance of exit sites at 2, 6, and 12 months (37/93 vs 41/76 at 2 months; 54/87 vs 43/70 at 6 months; 50/ 81 vs 35/ 63 at 12 months in buried and unburied groups, respectively). More patients with buried catheters had ESIs in the first 3 months (7/93 vs 1/76, p = 0.059). We conclude that exit sites of buried PD catheters do not differ qualitatively from those of unburied catheters. The trend towards more ESIs with buried catheters suggests that there may be clinical consequences of the tissue trauma at time of exteriorization.

Peritonitis as the First Presentation of Disseminated Listeriosis in a Patient on Peritoneal Dialysis-a Case Report.

Infections with Listeria monocytogenes are uncommon but serious, with mortality rate approaching 30% in cases of systemic involvement despite first-line therapy. They are usually caused by ingestion of contaminated foods, but spontaneous infections have also been described. Listeria monocytogenes is a rare cause of peritonitis, and most of the published cases are in patients with cirrhosis and ascites. There are a few reported cases of Listeria peritonitis associated with peritoneal dialysis (PD), primarily isolated peritonitis.If detected early, Listeria peritonitis can be successfully treated with ampicillin, alone or in combination with gentamicin. Vancomycin has been listed as a second-line agent. However, it has been associated with treatment failure.In this case report, we present a patient who developed disseminated listeriosis, with peritonitis as the first manifestation of disseminated infection. This case illustrates the importance of having a high index of suspicion for L. monocytogenes if patients deteriorate despite empiric therapy for PD-associated peritonitis and serves as a further example demonstrating the inadequate coverage of vancomycin for L. monocytogenes.

Successful Treatment of PD Peritonitis Due to Morganella morganii Resistant to Third-Generation Cephalosporins - A Case Report.

Morganella morganii is a rare cause of peritonitis in patients on peritoneal dialysis (PD). Most of the reported cases have resorted to a switch to hemodialysis. We herein report a case of peritonitis due to M. morganii resistant to third-generation cephalosporins, which was treated successfully with intraperitoneal (IP) tobramycin followed by oral ciprofloxacin. Early microbiologic diagnosis is essential in the treatment of peritonitis from rare microorganisms such as Morganella morganii, and appropriate antibiotic therapy is the key to avoiding catheter loss and subsequent switch to hemodialysis.

Subcutaneous Phaeohyphomycosis Caused By Pyrenochaeta Romeroi in a Kidney Transplant Recipient: A Case Report.

Infections are Achilles heel of kidney transplant recipients. Opportunistic fungal infections are increasingly recognized in these patients. We report a case of kidney transplant recipient with skin and soft tissue infection caused by Pyrenochaeta romeroi, a dematiaceous fungi. Infection by this organism is rare.

The association of anticoagulation, ischemic stroke, and hemorrhage in elderly adults with chronic kidney disease and atrial fibrillation.

The utility of anticoagulants for ischemic stroke prophylaxis in elderly patients with chronic kidney disease (CKD) and atrial fibrillation remains uncertain. In this population-based retrospective cohort study, we determined the association of anticoagulant use with ischemic stroke or hemorrhage in elderly patients (66 years and older) with advanced chronic kidney disease (eGFR under 45 ml/min/1.73m2) and atrial fibrillation. We followed 6,544 patients with CKD and new onset atrial fibrillation, of whom 1,475 filled a prescription for an anticoagulant. We used propensity-score matched Cox proportional hazards and competing risk models to determine the time to first event of ischemic stroke, hemorrhage or mortality. After matching to examine exposure to anticoagulants, 1,417 matched pairs were identified. The crude rate of ischemic stroke and hemorrhage were 41.3 and 61.3 with anticoagulants and 34.4 and 34.3 without anticoagulants per 100 person-years, respectively. The hazard ratios of ischemic stroke, hemorrhage, and mortality for receipt of an anticoagulation prescription were 1.10 (95% confidence interval, 0.78-1.56), 1.42 (1.04-1.93), and 0.74 (0.62-0.88) as compared to non-receipt of anticoagulation. After accounting for the competing risk of death, the hazard ratios for ischemic stroke and hemorrhage were 1.12 (0.90-1.39) and 1.60 (1.31-1.97), respectively. The findings were consistent in a sensitivity analysis accounting for time varying anticoagulant exposure. Thus, in older patients with CKD and atrial fibrillation, receipt of an anticoagulant was not associated with a lower risk of ischemic stroke, but a higher risk of hemorrhage and a lower risk of mortality.

Use of Oral Anticoagulation in the Management of Atrial Fibrillation in Patients with ESRD: Con.

Among patients with atrial fibrillation, prophylaxis for stroke prevention with the use of anticoagulation is well established in the general population. A number of randomized controlled trials and evidence-based risk prediction tools clearly delineate the benefit and risks of therapy. Despite the high incidence of atrial fibrillation in the late stage CKD and ESRD populations, little high quality evidence exists in these populations. Is it appropriate then to extrapolate findings from the general population to those with CKD/ESRD? In our view, too much uncertainty exists regarding proof of efficacy with clear signals of harm. Routine anticoagulation for stroke prevention in atrial fibrillation is not recommended for the majority of CKD and ESRD patients.

A cross-sectional study of dialysis practice-patterns in patients with chronic kidney disease on maintenance hemodialysis.

We studied the dialysis practice-patterns with regard to various aspects of chronic kidney disease (CKD) stage 5D, like anemia, mineral bone disease, vaccination, hospitalization, hypertension and cost of therapy. Four hundred and sixty-four adult hemodialysis (HD) patients from various dialysis centers of Mumbai were included in the study. The mean age of the study patients was 47.2 years. Temporary dialysis catheters were the most common initial vascular access. Thirteen percent of prevalent HD patients were on temporary catheters; 33% of patients had history of failure of arterio-venous fistula. The most common cause of failure was access thrombosis. About 75% of the patients had hemoglobin <11 g/dL and 35% had uncontrolled blood pressure. The prevalence of positive hepatitis B surface antigen and anti-hepatitis C virus antibody was 6% and 2%, respectively. The average cost of HD treatment was approximately 6100 Indian rupees (about US $100). HD is helpful in treating many of the clinical manifestations of CKD and postpones otherwise imminent death. However, dialysis treatment is no panacea to renal failure; HD patients have higher hospitalization rates and lower quality of life than the general population. The therapy itself brings with it a unique set of problems, such as vascular access-related complications, which cause significant mortality and morbidity. This study was a study of the current HD practices. The primary goal of this cross-sectional observational study is to understand dialysis practices and obtain data that can be used to improve care in the future.

Late-Onset Cytomegalovirus Gastritis in Low-Risk Renal Allograft Recipients.

OBJECTIVES: Skin grafting has been evolving as an important application in reconstructive surgery. Mixed reports about the survival of allogeneic and xenogeneic keratinocytes require further substantiation to determine the role of these cells in wound healing. MATERIALS AND METHODS: Rabbit and rat skins were recovered and cultured in vitro. Full-thickness wounds were created on the dorsum of rabbits (2 cm × 2 cm; n = 4). Cultured epithelial autograft, allograft, and xenograft cells were sprayed onto 3 freshly created wounds, with 1 wound acting as a control. The wounds were monitored every 2 days for 4 weeks. After 4 weeks, the rabbits were killed; skin biopsies were taken from each healed wound and stained with hematoxylin and eosin, and epidermal thickness was measured. RESULTS: All examined grafts showed favorable healing outcomes because the wounds appeared similar to normal skin upon healing. The only observed significant difference was the thickness of the epidermis layer, which was thinner in the xenograft (P = .002) than the autograft or allograft. Morphologic evaluation of the skin surface showed that the rat skin was thinner than the rabbit skin. The graft that achieved the best result was the autograft because the thickness was similar to and mimicked normal skin. CONCLUSIONS: All 3 grafts (autograft, allograft, and xenograft) have the potential to reconstitute epithelial defects. This approach can overcome the limitation of autologous skin donor sites, especially in burn cases.

Subcutaneous hyalohyphomycosis caused by Fusarium in a kidney transplant recipient.

Fusarium is a filamentous opportunistic pathogenic fungus responsible for superficial as well as invasive infection in immunocompromized hosts. Net state of immunosuppression and cytomegalovirus (CMV) infection appear to predispose to this disease which is life-threatening when disseminated. Though infections with Fusarium have been widely described in hematological malignancies and hematopoietic stem cell transplant cases, they have been reported to be rare in solid organ transplant recipients, are often localized and carry a favorable prognosis. We here describe a rare case of subcutaneous non-invasive infection with Fusarium in a renal allograft recipient two and half years after transplantation. Patient had a previous history of CMV infection along with multiple other recurrent co-infections. Diagnosis was based on culture of tissue specimens yielding Fusarium species. The infection had a protracted course with persistence of lesions after treatment with voriconazole alone, requiring a combination of complete surgical excision and therapy with the anti-fungal drug.

Earlier-start versus usual-start dialysis in patients with community-acquired acute kidney injury: a randomized controlled trial.

BACKGROUND: Optimum timing of the initiation of dialysis therapy in acute kidney injury is not clear. STUDY DESIGN: Prospective, open label, 2-arm, randomized, controlled trial. SETTING & PARTICIPANTS: 208 adults with acute kidney injury with progressively worsening azotemia at the artificial kidney dialysis unit of a tertiary-care referral center in western India. INTERVENTION: Earlier-start dialysis was initiated when serum urea nitrogen and/or creatinine levels increased to 70 and 7 mg/dL, respectively, whereas the usual-start dialysis patients (control group) received dialysis when clinically indicated as judged by treating nephrologists. OUTCOMES: Primary outcome was in-hospital mortality and dialysis dependence at 3 months. Secondary outcome in patients receiving dialysis was time to recovery of kidney function, computed from time of enrollment to the last dialysis session. RESULTS: Of 585 screened patients, 102 were assigned to earlier-start dialysis, and 106 to usual-start dialysis. Baseline characteristics were similar between randomized groups. 93 (91.1%) and 88 (83.1%) participants received dialysis in the intervention and control groups, respectively. Mean serum urea nitrogen and serum creatinine levels at dialysis therapy initiation were 71.7 ± 21.7 (SD) and 7.4 ± 5.3 mg/dL, respectively, in the intervention group versus 100.9 ± 32.6 and 10.41 ± 3.3 mg/dL in the control group. Data on primary outcome were available for all patients. In-hospital mortality was 20.5% and 12.2% in the intervention and control groups, respectively (relative risk, 1.67; 95% CI, 0.88-3.17; P = 0.2). 4.9% and 4.7% of patients in the intervention and control groups, respectively, were dialysis dependent at 3 months (relative risk, 1.04; 95% CI, 0.29-3.7; P = 0.9). LIMITATIONS: Study was not double blind, event rate (ie, mortality) was less than predicted, wide CIs preclude definitive findings. CONCLUSIONS: Our data do not support the earlier initiation of dialysis therapy in community-acquired acute kidney injury.

Minimal-change disease in adolescents and adults: epidemiology and therapeutic response.

BACKGROUND: Epidemiology of minimal-change disease (MCD) in adults differs from that in children and is not studied well in Indian population. METHODS: We retrospectively studied the records of 61 adult patients with MCD to assess clinical, laboratory and histopathological features, and to evaluate the response to treatment, course and complications of the disease and therapy. RESULTS: The male to female ratio was 1.17:1. Mean age was 30.46 years. Of the total, 6.55% had hypertension; 13.11% had microhaematuria. After initial treatment with steroids, 68.85% had complete remission (CR) and 13.1% had partial remission (PR). Twelve of 14 (85.71%) steroid-resistant cases had CR or PR after alternative immunosuppression with cyclophosphamide, or mycophenolate mofetil. Of all patients, 44.2% had at least one relapse; 8.19% were frequently relapsing and 26.22% were steroid dependent. After a mean follow-up of 149.9 weeks, 38 (61.29%) patients were in CR and 16 (26.22%) in PR with a mean proteinuria of 1.28 g/day, 3 being treated for relapse. Mean serum creatinine was 89.28 µmol/L (1.01 mg/dL). Fourteen (22.95%) had acute kidney injury (AKI). All but two recovered completely. CONCLUSIONS: This single-centre study with a medium-term follow-up shows that majority of patients respond to steroids or alternative immunosuppressants. AKI is common and may not be completely reversible in some cases.