Biochemical Clusters as Substitutes of Bone Biopsies in Kidney Transplant Patients.

Bone and mineral metabolism abnormalities are frequent in kidney transplant recipients and have been associated with cardiovascular morbidity. The primary aim of this study was to analyse the association between routine clinically available biochemical evaluation, non-routine histomorphometric bone evaluation, and vascular disease in kidney transplanted patients. A cross-sectional analysis was performed on 69 patients, 1-year after kidney transplantation. Laboratory analysis, radiography of hands and pelvis, bone biopsy, bone densitometry, and coronary CT were performed. One-year post-transplantation, nearly one-third of the patients presented with hypercalcemia, 16% had hypophosphatemia, 39.3% had iPTH levels > 150 pg/mL, 20.3% had BALP levels > 40 U/L, and 26.1% had hypovitaminosis D. Evaluation of extraosseous calcifications revealed low Adragão and Agatston scores. We divided patients into three clusters, according to laboratory results routinely used in clinical practice: hypercalcemia and hyperparathyroidism (Cluster1); hypercalcemia and high BALP levels (Cluster2); hypophosphatemia and vitamin D deficiency (Cluster 3). Patients in clusters 1 and 2 had higher cortical porosity (p = 0.001) and osteoid measurements, although there was no difference in the presence of abnormal mineralization, or low volume. Patients in cluster 2 had a higher BFR/BS (half of the patients in cluster 2 had high bone turnover), and most patients in cluster 1 had low or normal bone turnover. Cluster 3 has no differences in volume, or turnover, but 60% of the patients presented with pre-osteomalacia. All three clusters were associated with high vascular calcifications scores. Vascular calcifications scores were not related to higher bone mineral density. Instead, an association was found between a higher Adragão score and the presence of osteoporosis at the femoral neck (p = 0.008). In conclusion, inferring bone TMV by daily clinical biochemical analysis can be misleading, and bone biopsy is important for assessing both bone turnover and mineralization after kidney transplantation, although hypophosphatemia combined with vitamin D deficiency is associated with abnormal mineralization. The presence of hypercalcemia with high levels of PTH or high levels of BALP, or hypophosphatemia and vitamin D deficiency should remind us to screen vascular calcification status of patients.Clinical Research: ClinicalTrials.gov ID NCT02751099.

Adenovirus Infection in a Kidney-Pancreatic Transplant Recipient: Case Report.

Adenovirus infection in transplant recipients may present from asymptomatic viremia to multisystemic involvement. Most frequently, it occurs in the first year after a kidney transplant, and it is secondary to the reactivation of latent disease. However, primary infection may occur, and disseminated disease is more common when related to primary infection. Kidney involvement may be confirmed by biopsy, although diagnosis may be presumptive. Reduction of immunosuppression and supportive care are important components of therapy. CASE DESCRIPTION: A 41-year-old female renal-pancreatic recipient 12 years before with chronic renal graft dysfunction and a functional pancreatic graft had a history of cytomegalovirus and polyoma virus infection 2 years after transplantation. She was taking tacrolimus, mycophenolate mofetil, and prednisolone. The patient was admitted after persistent uncharacteristic diarrhea 3 weeks before hospitalization without any relevant epidemiologic context. She was dehydrated, and the lab results showed worsened kidney function and leucocytosis. The viral culture revealed adenovirus. Vigorous hydration was implemented, and the mycophenolate mofetil dose was reduced. The patient was discharged, and renal function returned to previous values. DISCUSSION AND CONCLUSION: Adenovirus infection has a wide clinical presentation, and multisystemic involvement may occur in transplant recipients. Supportive care is paramount. The clinical features and viral culture confirm the diagnosis, although tissue samples and quantitative polymerase chain reaction may be required in more severe cases.

Improvement of Mineral and Bone Disorders After Renal Transplantation.

BACKGROUND: Posttransplant mineral and bone diseases are causes of fractures, and their association with cardiovascular events is being studied. METHODS: We analyzed the evolution of biochemical, histological, and imaging parameters pre- and 1 y post-renal transplantation in 69 patients and correlated mineral and bone findings with coronary calcifications. At inclusion and after 12 mo, clinical data and echocardiographic findings were recorded, and laboratory evaluations, radiography of the pelvis and hands, and bone biopsy were performed. Noncontrast cardiac computed tomography was performed during the second evaluation. RESULTS: Serum levels of fibroblast growth factor 23 and sclerostin decreased in all patients, parathyroid hormone levels decreased in 89.8% of patients, bone alkaline phosphatase levels decreased in 68.1% of patients, and alpha-Klotho levels increased in 65.2% of patients. More than half of the patients presented with renal osteodystrophy at both biopsies, but histological findings improved: a significant transition from high to normal or low turnover and no significant differences in volume, mineralization defect, or cortical porosity at the 2 evaluations. Alpha-Klotho, sclerostin, and bone alkaline phosphatase shifts affect bone changes. Neither echocardiographic findings nor vascular calcification scores differed between the 2 points. Both the pretransplant period (dialysis vintage, sclerostin, and low bone volume at baseline) and the maintenance of abnormalities in the posttransplant period (high turnover posttransplant) were the most reliable predictors of the severity of the coronary calcification percentile. CONCLUSIONS: Renal transplantation improved bone and mineral abnormalities. The pretransplant period determines the severity of calcification.

Validation of blood gas analysis in arteriovenous fistula for hemodialysis.

INTRODUCTION: Arterial blood gas analysis is a minimally invasive technique used in our daily practice but is not a complication free technique. The aim of this study was to validate results from blood gas analysis obtained from the arteriovenous fistula (AVF)/graft as a surrogate marker of the arterial blood gas analysis. METHODS: A prospective observational study was made in 45 patients. We performed arterial and AVF/graft blood gas analysis and results were compared by a paired sample t Student test. RESULTS: Most of our subjects was male (68.9%) and the mean age was 67 years (±14). Hemodialysis vintage was 63 months (±66), and vascular access age was 62 months (±56). The more prevalent vascular access was left radiocephalic AVF (n = 16; 35.6%) and the main puncture artery was right radial artery (n = 27; 60.0%). There were no statistically significant differences between the samples collected. CONCLUSIONS: Our results suggest a possible alternative of arterial blood gas analysis in AVF/graft for hemodialysis patients. This could result in making an uncomfortable procedure almost painless and reducing complications. Future research should take place to include anatomical characteristics of the AVF or the circulation of recirculation.

The Role of Bone Volume, FGF23 and Sclerostin in Calcifications and Mortality; a Cohort Study in CKD Stage 5 Patients.

Chronic kidney disease-mineral and bone disorder has been associated with increasing morbid-mortality. The aim of this study was to determine the prevalence and phenotype of bone disease before transplantation and to correlate FGF23 and sclerostin levels with bone histomorphometry, and study possible associations between FGF23, sclerostin, and bone histomorphometry with cardiovascular disease and mortality. We performed a cross-sectional cohort study of a sample of 84 patients submitted to renal transplant, which were prospectively followed for 12 months. Demographic, clinical, and echocardiographic data were collected, laboratory evaluation, bone biopsy, and X-ray of the pelvis and hands were performed. Patient and graft survival were recorded. We diagnosed low bone turnover in 16 patients (19.5%); high bone turnover in 22 patients (26.8%); osteomalacia in 1 patient (1.2%), and mixed renal osteodystrophy in 3 patients (3.7%). At the end of 12 months, 5 patients had graft failure (5.9%), 4 had a cardiovascular event (4.8%), and 4 died. Age was associated with low remodeling disease, whereas high BALP and phosphorus and low sclerostin with high turnover disease. Sclerostin was a risk factor for isolated low bone volume. High BALP, low phosphorus, and low FGF23 were risk factors for abnormal mineralization. FGF23 appears as an independent factor for severity of vascular calcifications and for cardiovascular events, whereas the presence of valve calcifications was associated with low volume and with turnover deviations. Sclerostin was associated a higher HR for death. Sclerostin and FGF23 seemed to provide higher cardiovascular risk, as well as low bone volume, which associated with extra-osseous calcifications.

Bone densitometry versus bone histomorphometry in renal transplanted patients: a cross-sectional study.

Bone loss leads to increase risk of fractures in renal transplantation. The aim of this study was to analyse the relationship between bone densitometry (DXA) findings, bone histomorphometry and bone-related molecules 1-year after renal transplantation. We performed a cross-sectional study of de novo renal transplanted patients that agreed to perform a bone biopsy and a DXA examination 1 year after transplantation. All patients underwent a laboratory evaluation, bone biopsy, DXA examination and cardiac CT 1 year after transplantation. 67 patients were included, 16 had a normal examination, and 18 patients were classified as having osteoporosis by DXA. Correlations between bone mineral density and T-scores of total femur and femoral neck were the ones that best correlated with bone volume assessed by a bone biopsy. The sensitivity of DXA for osteoporosis diagnosis was 47.0%, and the specificity was 81.2%. The positive predictive value was 50.0%, and the negative predictive value (NPV) was 80.0%. DXA parameters also correlated with klotho and sclerostin serum levels. In this population, a normal examination excluded the presence of osteoporosis, helping in identifying patients that would not benefit from therapy. Overall, densitometry in total femur and femoral neck correlated well with bone volume measured by bone biopsy.

A rare diarrheic parasite in a kidney transplant patient: Cystoisospora belli.

Cystoisospora belli colitis is a rare complication of immunosuppression in solid organ transplant recipients. We describe a case of Cystoisospora belli infection with colitis following renal transplantation.

Porphyria Cutanea Tarda in a Patient with End-Stage Renal Disease: A Case of Successful Treatment with Deferoxamine and Ferric Carboxymaltose.

Porphyria cutanea tarda (PCT) is a rare disease, with a strong association with hepatitis C virus. PCT is particularly problematic in end-stage renal disease patients as they have no renal excretion of porphyrins and these are poorly dialyzed. Also, conventional treatment of PCT is compromised in these patients as hydroxychloroquine is contraindicated, phlebotomies with the stipulated frequency are poorly tolerated in already anaemia-prone patients, and iron-chelating agents are less efficient in removing iron and contribute to worsening anaemia. The authors report a patient on haemodialysis, with hepatitis C infection, that is diagnosed with PCT. Despite the good clinical results with deferoxamine, she became dependent on blood transfusions because of her ferropenic state. Every time oxide iron was started, the patient developed clinical features of the disease, resolving after the suspension of the drug. A decision was made to start the patient on ferric carboxymaltose, which was well tolerated without disease symptoms and need of further blood transfusions. This case suggests that deferoxamine is efficient in treatment of porphyria cutanea tarda. Also, ferric carboxymaltose may be a valuable option for refractory anaemia in patients with this disease and end-stage renal disease, as it seems to provide iron without clinical relapse of the disease.

Morphologic patterns and treatment of transplant glomerulopathy: A retrospective analysis.

Transplant glomerulopathy is mainly due to chronic antibody-mediated rejection and actually represents a major cause of long-term allograft failure. The lack of effective treatment remains a serious problem in transplantation. A retrospective and uni-center study was performed in 48 kidney allograft recipients with transplant glomerulopathy between January 2010 and December 2015. Median time for diagnosis was 7.1 (3.6-11.8) years post-transplant. Light microscopy showed severity of transplant glomerulopathy in the majority of patients (cg1=10.4%; cg2=20.8%; cg3=68.8%). Moderate microvascular inflammation was present in 56.3% (g+ptc≥2), and almost half of recipients (51.1%) were C4d positive in immunofluorescence. Female gender (P=.001), age (P=.043), renal dysfunction (P=.002), acute rejection episodes (P=.026), and anti-HLA class II antibodies (P=.004) were associated with kidney allograft failure. Treatment of transplant glomerulopathy was performed in 67.6% of patients. The histologic and laboratory features that led to a therapeutic intervention were score ptc (P=.021), C4d (P=.03), and the presence of anti-HLA antibodies (P=.029), whereas score ah (P=.005) was associated with conservative measure. The overall cumulative kidney allograft survival at 10 years was 75%. Treatment of transplant glomerulopathy was ineffective to improve long-term kidney allograft survival.

Efficacy of percutaneous transluminal angioplasty on dysfunctional fistulae because of inflow stenosis.

PURPOSE: Autogenous fistulas are the preferential vascular access for hemodialysis. The aim of this retrospective study was to determine the efficacy of angioplasty for dysfunctional fistulas because of inflow dysfunction. 
 METHODS: We reviewed all the angiographic procedures performed on our institution between April 2007 and April 2009. Procedures performed in dysfunctional fistulas because of inflow stenoses were analyzed. Fistulas with stenoses out of these areas were excluded. The following data were collected: patient age and sex, fistula age at the time of intervention, location of fistula, number and location of stenosis, angiography referral criteria, clinical findings (presence or absence of thrills, bruits and pulsatility) and date of reintervention or failure. 
 RESULTS: During the study period 215 fistulas were submitted to angiography of which, seventy-one presented inflow stenosis (33%). Mean follow-up was 21.72±9.26 months, and average age was 7.03 months. Two groups were considered: 31 fistulas comprising ≤6 months old, and 40 fistulas >6 months old. Primary patency rates±SE for older fistulas at 6, 12, 18 and 24 months, respectively, was 91.3%± 0.04%, 80.7%± 0.07%, 53.8% ±0.10% and 34.2±0.1% versus 91.7±0.08%, 57.1±0.14%, 23±0.14%, 11.4%± 0.1% for younger fistulas (P=0.04). Fistulas ≤6 months old and multiple stenosis were associated with a poorer primary patency rate (P=0.005).
 CONCLUSIONS: Inflow stenosis is frequently associated with fistula dysfunction. In this study we only analyzed AVF with inflow stenosis and we have shown that angioplasty can have great patency results, particularly for single lesions in matured fistulas.

Aortic and tricuspid endocarditis due to Streptococcus gallolyticus in an immunocompetent patient with a normal heart.

Endocarditis due to Streptococcus gallolyticus, an agent previously included in the Streptococcus bovis denomination is a serious disease, often associated with lesions of the colon mucosa. Aortic valve is more often affected and tricuspid involvement is quite rare. We present a case of a 56-year-old man who was admitted with a 2-month history of fever. Echocardiogram revealed vegetations on the aortic and tricuspid valve and blood cultures grew S. gallolyticus. Thoracic X-ray and computed tomography were consistent with septic pulmonary embolism. Despite optimal antibiotic therapy he developed an ischemic stroke and acute aortic regurgitation, which led to emergent surgery. Colonoscopy found a benign adenoma which was excised, and the patient had a full recovery.

Direction general de los cuidados de salud primarios / Enfermedad de Hansen en Portugal Continental: situación en 1984

De un total de 2.234 enfermos de Hansen existentes en Portugal Continental en 1984, el 55,6 por ciento son hombres y el 44,4 por ciento son mujeres. Em ambos sexos hay un predominio de la forma lepromatosa. La edad media del total de los enfermos en 1984 es de 58, 9 años, mientras que fechas del inicio de la enfermedad era de mujeres son trabajadoras domésticas. Apenas el 4 por ciento de los enfermos no son portugueses. La tasa de prevalencia de la enfermedad de Hansen en Portugal Continental en 1984 es de 25,05 por 100.000 habitantes con una incidencia anual de 1975-1983 variaba entre 0,57 y 0,31 por 100.000 habitantes , lo que corresponde a una media de 38 nuevos casos por año. De estos 334 enfermos diagnosticados desde 1975 a 1983 hay que señalar: un mayor porcentaje - 16,6 por ciento de enfermos no son de nacionalidad portuguesa, la edad media del inicio de la enfermedad - 48,4 años y una mayor frecuencia de enfermos calsificados dentro del espectro borderline. Se considera que la endemia está en una fase regresiva y se hacen breves consideraciones sobre la evolución de la enfermedad de Hansen en Portugal.