A Preemptive Living Donor Renal Transplant in an HIV Positive Patient from an HIV Positive Donor.

With recent advances in the treatment of human immunodeficiency virus (HIV), renal transplantation is no longer considered a contraindication in properly selected HIV-positive patients. Several studies have demonstrated comparable patient and graft outcomes between HIV-negative and HIV-positive renal transplant recipients. Most of the information on outcomes of HIV-positive to HIV-positive transplantation is based on data from deceased donors. There are only a handful of case reports about living donor renal transplantation in an HIV-positive patient from an HIV-positive donor. Furthermore, there is no report in the world of preemptive living donor renal transplantation in this setting. Here, we report a case of successful preemptive renal transplantation in an HIV-positive recipient from an HIV-positive living donor performed at our center.

An Unusual Presentation of Multiple Myeloma.

Multiple myeloma commonly presents as anemia, renal failure, bone pain, and infections. Presentation with epistaxis is extremely rare, and hence myeloma as the etiologic factor is seldom considered. We report the case of a patient who initially presented with recurrent epistaxis and then with myasthenia. It was only when he developed acute kidney injury 4 months after the initial presentation with epistaxis that a diagnosis of multiple myeloma was made.

Outcomes of symptomatic coronavirus disease 19 in maintenance hemodialysis patient in India.

BACKGROUND: Maintenance hemodialysis (MHD) patients face disadvantages with higher risk of acquiring SARS-CoV-2 infection, atypical manifestations, and associated multiple comorbidities. We describe patients' outcomes with symptomatic COVID-19 on MHD in a large cohort of patients from India. METHODS: Data were collected prospectively from hemodialysis units in 11 public and private hospitals between March 15, 2020, and July 31, 2020. The survival determinants were analyzed using stepwise backward elimination cox-regression analysis. RESULTS: Of the 263 total patients (mean age 51.76 ± 13.63 years and males 173) on MHD with symptomatic COVID-19, 35 (13.3%) died. Those who died were older (p = 0.01), had higher frequency of diabetic kidney disease (p = 0.001), comorbidities (p = 0.04), and severe COVID-19 (p = 0.001). Mortality was higher among patients on twice-weekly MHD than thrice-weekly (p = 0.001) and dialysis through central venous catheter (CVC) as compared to arteriovenous fistula (p = 0.001). On multivariate analysis, CVC use (HR 2.53, 95% CI 1.26-5.07, p = 0.009), disease severity (HR = 3.54, 95% CI 1.52-8.26, p = 0.003), and noninvasive ventilatory support (HR 0.59, 95% CI 0.25-0.99, p = 0.049) had significant effect on mortality. CONCLUSION: The adjusted mortality risk of COVID-19 in MHD patients is high in patients associated with severe COVID-19 and patients having CVC as vascular access.

Glucoregulatory hormones and choice of osmotic agent in peritoneal dialysis.

OBJECTIVE: The present study was performed to explore the range of effects of amino acid-based peritoneal dialysis (PD) solutions on glucoregulatory hormones in comparison with an osmotically equivalent glucose-based solution. ♢ METHODS: 13 adult nondiabetic patients on PD underwent 2 peritoneal dwells of 2 hours' duration with either 1.5% dextrose solution or 1.1% amino acid solution. Serial sampling for glucoregulatory hormones was done throughout the duration of the dwell. ♢ RESULTS: Instillation of the 1.5% dextrose solution resulted in a modest change in plasma glucose, paralleled by a small increase in plasma insulin levels and plasma insulin-like growth factor (IGF-1). Plasma glucagon was not changed and plasma growth hormone level declined. Instillation of the 1.1% amino acid solution resulted in an increase in plasma glucose, plasma insulin, plasma glucagon, and plasma IGF-1. Plasma growth hormone level declined. Both solutions led to an increase in plasma norepinephrine but no changes were observed in epinephrine or dopamine. ♢ CONCLUSIONS: Our observations suggest that the mere replacement of glucose by amino acids in PD solutions does not necessarily imply "glucose sparing" from the perspective of induction of a glucoregulatory hormonal response because of the aminogenic stimulation of secretion of multiple hormones.

Delayed graft function and the risk for death with a functioning graft.

Delayed graft function (DGF) associates with an increased risk for graft failure, but its link with death with graft function (DWGF) is unknown. We used the US Renal Data System to assemble a cohort of all first, adult, deceased-donor kidney transplant recipients from January 1, 1998, through December 31, 2004. In total, 11,542 (23%) of 50,246 recipients required at least one dialysis session in the first week after transplantation. Compared with patients without DGF, patients with DGF were significantly more likely to die with a functioning graft (relative hazard 1.83 [95% confidence interval 1.73 to 1.93] and 1.53 [95% CI 1.45 to 1.63] for unadjusted and fully adjusted models, respectively). The risk for DWGF was slightly higher among women with DGF than among men. There was no significant heterogeneity among other subgroups, and the results were robust to sensitivity analyses. Acute rejection within the first year attenuated the DGF-DWGF association. Cardiovascular and infectious deaths were slightly more prevalent in the DGF group, but the relative hazards of cause-specific death were similar between DWGF and deaths during total follow-up. In summary, DGF associates with an increased risk for DWGF; the mechanisms underlying the negative impact of DGF require further study.

Prolonged use of the tyrosine kinase inhibitor in a peritoneal dialysis patient with metastatic renal cell carcinoma: possible beneficial effects on peritoneal membrane and peritonitis rates.

Increased submesothelial collagen deposition, loss of mesothelial cells and increased peritoneal vascularization of peritoneal membrane with vasculopathy leads to peritoneal fibrosis in a patient on long-term peritoneal dialysis (PD). This vascular proliferation within the peritoneum is associated with an increased expression of vascular endothelial growth factor (VEGF), which in turn leads to functional loss or deterioration of the peritoneal membrane over time. Vascular endothelial growth factor inhibitors may slow or even prevent vascular proliferation and subsequent loss of membrane function in peritoneal dialysis patient. We have observed the anti-VGEF effects of a tyrosine kinase inhibitor, sunitinib maleate, in a patient who was on this medication for renal cell carcinoma with extensive abdominal metastasis. The patient had also been on PD for 26 months at the time of the study. In this patient, the tyrosine kinase inhibitor helped to stabilize the abdominal metastasis as well as the thickness of the peritoneal membrane. The D/P creatinine ratio also remained stable. These observations suggest that this tyrosine kinase inhibitor may have prevented peritoneal membrane angiogenesis. We also observed that the patient did not have any further episode of peritonitis from gut-derived organisms, suggesting that stabilization of the intestinal metastasis prevented the transmural migration of bacteria from the gut, thereby preventing peritonitis.

Is survival enough for quality of life in Sagliker Syndrome-uglifying human face appearances in chronic kidney disease?

BACKGROUND: It is known that secondary hyperparathyroidism (SH) and particularly skeletal changes is a severe condition in chronic kidney disease (CKD). Sagliker syndrome (SS) is a very prominent feature in CKD including uglifying human face appearances, short stature, extremely severe maxillary and mandibulary changes, soft tissues in the mouth, teeth-dental abnormalities, finger tip changes and severe psychological problems. METHODS: In the last 8 years we have confronted 36 extremely incredible SS cases in CKD by performing an international study in Turkey, India, Malaysia, Romania and Egypt. RESULTS: In addition to the uglifying human face appearance, we found extremely severe X-ray and tomographical, pantomographical, histo-pathological changes in the head and whole body. Finally, we compared previous face pictures with recent ones. Just a few years earlier they had been pretty and good-looking young boys and girls. By investigating their history, we understood they had not received proper therapy and were in the late-irreversible period. CONCLUSION: SS is a serious and severe complication of CKD. Late and improper treatment leads to abnormalities throughout skeleton particularly in the skull and face. Changes particularly in children and teens become irreversible-disastrous for appearance and psychological health. Appropriate treatment must begin as early as possible in specialized centers. It is possible that SS patients may survive long-term with dialysis, but with all those particular changes could anyone claim this type of life would continue in an acceptable way without extending their height, correcting all the changes in the skull and face, remodeling new faces and most particularly convincing the patients to deal with all those tragi-dramatic psychological problems?

International study on Sagliker syndrome and uglifying human face appearance in severe and late secondary hyperparathyroidism in chronic kidney disease patients.

OBJECTIVE: It is known that skeletal changes due to secondary hyperparathyroidism (SH) can be severe in chronic kidney disease (CKD). Recently described Sagliker syndrome (SS) is a very striking and prominent feature of SH in CKD, including an uglifying appearance to the face, short stature, extremely severe maxillary and mandibulary changes, soft tissue in the mouth, teeth/dental abnormalities, fingertip changes, knee and scapula deformities, hearing abnormalities, and neurological and, more important, severe psychological problems. DESIGN, SETTING, PATIENTS: In the past 8 years, we have encountered 40 cases of SS in SH and CKD by performing an international study in Turkey, India, Romania, Egypt, Maleysia, Tunis, and China. RESULTS: The medical history of these patients showed that they did not receive proper therapy. Changes, particularly in children and teenagers, become irreversible, which was disastrous for the patients both aesthetically and psychologically. CONCLUSION: Treatment must begin early and be the appropriate treatment given in centers with sophisticated skills. Otherwise, the inability to correct all the changes in the skull and face, to remodel a new face, to extending the height, and, most important, to convince the patients to face the dramatic psychological problems can be catastrophic for those patients.

Icodextrin produces higher ultrafiltration in diabetic than in non-diabetic patients on continuous cyclic peritoneal dialysis.

A preliminary report from our unit previously suggested that diabetic patients on continuous cyclic peritoneal dialysis (CCPD) have higher ultrafiltration (UF) with icodextrin than non-diabetic patients. To confirm this observation, we did a retrospective analysis of our patients (17 diabetic and 23 non-diabetic) who were on stable CCPD prescription using a long-day dwell with icodextrin. We collected daily UF data from these patients' records for 30 days. The two groups showed no significant difference with respect to age, gender, hemoglobin, serum albumin, peritoneal dialysis and icodextrin vintage, peritoneal membrane characteristics, CCPD prescription, and peritoneal and residual renal clearance. The overnight net UF achieved with the cycler with standard glucose dialysate was similar in the two groups (850+/-379 in diabetic vs 713+/-484 ml/day in non-diabetic, P=0.34). However, UF with icodextrin during the day dwell (14.8+/-0.8 h) was significantly higher in diabetics than non-diabetics (348+/-198 vs 137+/-311 ml/day, P=0.02). Our results show that icodextrin produces significantly higher UF in long-day dwell in diabetic ESRD patients on CCPD than in non-diabetic patients. The reason for this difference is not clear.

Subjective global assessment of nutritional status of patients with chronic renal insufficiency and end stage renal disease on dialysis.

OBJECTIVES: (1)To assess the nutritional status of chronic renal insufficiency (CRI) and dialysis patients using the subjective global assessment (SGA) method. (2) To validate SGA in assessing the nutritional status of this group of patients. PARTICIPANTS: The nutritional status of 81 patients was evaluated using dietary recall, anthropometry, biochemical parameters and SGA. There were 51 males and 30 females. Their mean +/- SD age was 53.8 +/- 14.3 years. There were 27 patients with (CRI) on conservative management, 38 patients with end stage renal disease (ESRD) on maintenance hemodialysis (HD) and 16 patients with ESRD on continuous ambulatory peritoneal dialysis (CAPD). METHODS: SGA was done using seven variables derived from medical history and physical examination. Each variable was scored from 1-7 depending on the severity. The SGA scores were correlated with the standard methods. RESULTS: Thirteen (48%) patients with CRI, 22 (58%) patients on HD and 8 (50%) patients on CAPD were malnourished. It was seen that the dietary protein & calorie intake and serum albumin level did not correlate well with the SGA scores. The anthropometric measures correlated with the SGA scores (Skinfolds and SGA r = 0.2, MAC and SGA r = 0.5 and MAMC and SGA r = 0.5). CONCLUSION: Malnutrition is an important complication in CRI patients and ESRD patients on dialysis. SGA is a reliable method of assessing nutritional status. Most important is the fact that it can detect the changing trend of nutritional status, which may be missed by one-time anthropometry and biochemical methods.