IgA Nephropathy with Crescents: A Single-Center Experience.

INTRODUCTION: The presence of crescents in IgA nephropathy (IgAN) has been associated with a poor prognosis. We assess the prognosis of crescents in our patients with IgAN. METHODS: IgAN was diagnosed in 73 patients biopsied at Rush University Medical Center from 1992 to 2020, and crescents were seen in 26 (36%). Clinical, laboratory and histologic features at biopsy, and treatment and outcome (end-stage kidney disease, ESKD) were collected retrospectively. Data are presented as mean ± SD and a p value of <0.05 was significant. RESULTS: There was no difference in hypertension, SCr, or eGFR in patients with crescents compared to those without crescents but patients with crescents had higher UPro/Cr ratio (2.8 ± 2.7 vs. 1.7 ± 1.7 g/g, p 0.04). The percentage of glomeruli with global and segmental sclerosis (32 ± 25% vs. 38 ± 28%, p 0.35) and the proportion of interstitial fibrosis and tubular atrophy (22 ± 20% vs. 22 ± 22%, p 0.76) were similar. Only 19% of patients with crescents had lesions involving ≥25% of glomeruli. A larger proportion of patients with crescents were treated with immunosuppressive agents (70% vs. 21%, p 0.0005). After 8.4 ± 7 years of follow-up, ESKD (19% vs. 23%, p 0.77) and renal survival at 10 years (80% vs. 74%, p 0.99) were similar in patients with and without crescents. CONCLUSION: The presence of crescents in IgAN was not associated with an increased risk of progression to ESKD. This may be a result of the fact that the majority of our patients had crescents involving <25% of glomeruli and received aggressive treatment with immunosuppressive agents.

Percutaneous Renal Biopsy Using an 18-Gauge Automated Needle Is Not Optimal.

BACKGROUND: As percutaneous renal biopsies (PRBs) are increasingly performed by radiologists, an increase in the use of 18-gauge automated needle stands to compromise adequacy. We compare the adequacy and safety of PRB with 14-, 16-, and 18-gauge automated needles. METHODS: PRB of native (N-592) and transplant (T-1,023) kidneys was performed from January 2002 to December 2019 using real-time ultrasound. Baseline clinical and laboratory data, biopsy data (number of cores, total glomeruli, and total glomeruli per core), and outcome (hematoma on renal US at 1-h, complications, and transfusion) were collected prospectively. PRB with N14g (337) versus N16g (255) and T16g (892) versus T18g (131) needles were compared. A p value of <0.05 was significant. RESULTS: PRB with an 18-g needle yielded the lowest number of total glomeruli per biopsy (N14g vs. N16g: 33 ± 13 vs. 29 ± 12, p < 0.01 and T16g vs. T18g: 34 ± 16 vs. 21 ± 11, p < 0.0001), significantly fewer total glomeruli per core (T16g vs. T18g: 12.7 ± 6.4 vs. 9.6 ± 5.0, p < 0.001 and N16g vs. T18g: 14.2 ± 6.3 vs. 9.6 ± 5.0, p < 0.001). A hematoma by renal US 1-h post-PRB was similar for native (14g-35% vs. 16g-29%, p = 0.2), and transplant biopsies (16g-10% vs. 18g-9%, p = 0.9) and the complication rate for native (14g-8.9% vs. 16g-7.1%, p = 0.5), transplant biopsies (16g-4.6% vs. 18g-1.5%, p = 0.2) and transfusion rate for native (14g-7.7% vs. 16g-5.8%, p = 0.4), and transplant biopsies (16g-3.8% vs. 18g-0.8%, p = 0.1) were similar irrespective of needle size. CONCLUSIONS: PRB of native and transplant kidneys with the use of a 16-gauge needle provides an optimal sample. However, our experience in transplant biopsies suggests the use of an 18-gauge needle stands to jeopardize the diagnostic accuracy of the PRB while not improving safety.

Establishing Surrogate Kidney End Points for Lupus Nephritis Clinical Trials: Development and Validation of a Novel Approach to Predict Future Kidney Outcomes.

OBJECTIVE: End points currently used in lupus nephritis (LN) clinical trials lack uniformity and questionably reflect long-term kidney survival. This study was undertaken to identify short-term end points that predict long-term kidney outcomes for use in clinical trials. METHODS: A database of 944 patients with LN was assembled from 3 clinical trials and 12 longitudinal cohorts. Variables from the first 12 months of treatment after diagnosis of active LN (prediction period) were assessed as potential predictors of long-term outcomes in a 36-month follow-up period. The long-term outcomes examined were new or progressive chronic kidney disease (CKD), severe kidney injury (SKI), and the need for permanent renal replacement therapy (RRT). To predict the risk for each outcome, hazard index tools (HITs) were derived using multivariable analysis with Cox proportional hazards regression. RESULTS: Among 550 eligible subjects, 54 CKD, 55 SKI, and 22 RRT events occurred. Variables in the final CKD HIT were prediction-period CKD status, 12-month proteinuria, and 12-month serum creatinine level. The SKI HIT variables included prediction-period CKD status, International Society of Nephrology (ISN)/Renal Pathology Society (RPS) class, 12-month proteinuria, 12-month serum creatinine level, race, and an interaction between ISN/RPS class and 12-month proteinuria. The RRT HIT included age at diagnosis, 12-month proteinuria, and 12-month serum creatinine level. Each HIT validated well internally (c-indices 0.84-0.92) and in an independent LN cohort (c-indices 0.89-0.92). CONCLUSION: HITs, derived from short-term kidney responses to treatment, correlate with long-term kidney outcomes, and now must be validated as surrogate end points for LN clinical trials.

Changing Trends in the Performance of Percutaneous Renal Biopsy from Nephrologist to Interventional Radiologist: A Single-Center Experience.

BACKGROUND: Percutaneous renal biopsy of native kidneys (PRB) has been an integral part of the practice of nephrology. However, over the past 30 years, PRB has transitioned from a procedure performed only by nephrologists to interventional radiologists (IRs). We surveyed practicing nephrologists completing training in our program to determine the clinical practice patterns of PRB. METHODS: The 78 fellows completing the nephrology program at Rush University Medical Center from June 1984 through June 2017 were successfully contacted and surveyed regarding their opinion on adequacy of their training and whether they performed PRB in practice and if not or no longer, why. To evaluate for differences in the performance of PRB over time, a comparison of 4 periods of fellowship completion (i.e., 1984-1990, 1991-2000, 2001-2010, 2011-2017) was performed. RESULTS: All 78 nephrologists felt they had been adequately trained to perform PRB. PRB was performed by 45 (58%) nephrologists post-fellowship, but a significant decline was observed over the 4 periods of time from 1984 to 2017 (100 vs. 86 vs. 52 vs. 20%, p < 0.0001). The primary reason that 33 nephrologists did not perform PRB was that it was too time consuming and IR was available to perform PRB. Of the 71 nephrologists still in practice only 12 (17%) continue to perform PRB. A greater proportion of nephrologists completing training from 1984-1990 continue to perform PRB relative to those trained after 1990. The universal reason that nephrologists were no longer performing PRB was again an issue of time and the fact that IRs were available to perform PRB. CONCLUSION: We find that there has been a significant transition over time in the performance of PRB by a nephrologist to IR. The major reason for this is the time burden associated with PRB and the availability of IRs.

Risk of percutaneous renal biopsy of native kidneys in the evaluation of acute kidney injury.

BACKGROUND: Percutaneous renal biopsy (PRB) of native kidneys (NKs) to better understand and treat acute kidney injury (AKI) is being advocated, but little is known about the risk of complications. METHODS: We performed a retrospective study of PRB of NKs in 955 adults from 1991 to 2015 at an academic medical center with real-time ultrasound and automated biopsy needles. Patients undergoing PRB for evaluation of AKI (n = 160) were compared with 795 patients biopsied for other reasons (not-AKI) for postbiopsy complications [need for transfusion of packed red blood cells (PRBCs), an interventional radiologic or surgical procedure, readmission or death]. RESULTS: Patients biopsied for AKI were older (58 ± 16 versus 44 ± 16 years; P < 0.0001), with a higher serum creatinine (SCr) (4.5 ± 2.7 versus 1.8 ± 1.6 mg/dL; P < 0.0001) and lower hemoglobin (Hgb) (10.4 ± 1.7 versus 12.1 ± 2.1; P < 0.0001) and a greater proportion had an abnormal bleeding time (12.5% versus 7.4%, P 0.04), partial thromboplastin time (15.2% versus 5.3%, P < 0.0001) and/or prothrombin time (27.0% versus 12.8%; P < 0.0001) compared with not-AKI patients. Complications post-PRB were significantly greater in patients biopsied for AKI {11.3% versus 6.7%; P=0.04; odds ratio [OR] 1.78 [95% confidence interval (CI) 1.01-3.12]} with patients biopsied for AKI requiring more blood transfusions (10.0% versus 5.3%; P 0.02; OR 2.04 (95% CI 1.12-3.74)]. By multivariate analysis, baseline features predictive of a complication were increased SCr and decreased Hgb level, as well as female gender and increased systolic blood pressure. CONCLUSION: Patients biopsied for evaluation of AKI are at greater risk of complications due to increased risk factors.

The Impact of Baseline Serum Creatinine on Complete Remission Rate and Long-Term Outcome in Patients with Severe Lupus Nephritis.

BACKGROUND/AIM: We assess the impact of serum creatinine at baseline on complete remission rate and long-term outcome in severe lupus nephritis (SLN). METHODS: A total of 86 adult patients with SLN [International Society of Nephrology/Renal Pathology Society (ISN/RPS) class IV lesions] were evaluated based on baseline serum creatinine levels (≤1.0, 1.01-1.5, 1.51-2.0, 2.01-3.0, and >3.0 mg/dl; n = 22, 23, 16, 12, and 13, respectively). The complete remission rates (serum creatinine level of ≤1.4 mg/dl and proteinuria of ≤0.33 g/day) and long-term outcomes (stable renal function, dialysis, and death) were compared. The patients were followed for 121 ± 64 months. RESULTS: The baseline clinical features were similar, but the chronicity index was significantly higher with increasing levels of serum creatinine. Complete remission rates were significantly higher in patients with lower levels of serum creatinine (86 vs. 52 vs. 19 vs. 25 vs. 0%, p < 0.0001). Patients with a baseline serum creatinine level of ≤1.0 mg/dl were >16 times as likely (OR 16.2; 95% CI: 4.2-61.5) to attain a complete remission and >6 times as likely (OR 6.1; 95% CI: 1.9-18.6) to have stable renal function at the last follow-up as compared to patients with a serum creatinine level of >1.0 mg/dl. The 15-year renal survival rate was greatest among those patients with a baseline serum creatinine level of ≤1.0 mg/dl (76 vs. 57 vs. 48 vs. 25 vs. 10%, p < 0.0001). CONCLUSION: The prognosis of SLN is significantly affected by the serum creatinine level at baseline. The complete remission rate is highest, and the long-term prognosis most favorable, in patients with a baseline serum creatinine level of ≤1.0 mg/dl. This emphasizes the importance of early diagnosis and treatment.

Clinical factors influencing the decision to transfuse after percutaneous native kidney biopsy.

BACKGROUND: Transfusion of erythrocytes is the most common intervention after a complicated percutaneous renal biopsy (PRB). Anemia is considered to be a leading risk factor for bleeding following a PRB, and based on recent studies of transfusions in hospitalized patients, many institutions are restricting the threshold for erythrocyte transfusion to a lower hemoglobin concentration (Hgb). The purpose of this study is to analyze factors that influence the transfusion decision after a PRB, and to determine whether anemia is truly a risk factor for bleeding or anemic patients are simply more likely to receive a transfusion because of their already lower pre-PRB Hgb. METHODS: PRB of native kidneys was performed using real-time ultrasound with automated biopsy needles from January 1990 to April 2014. All patients were prospectively followed for bleeding with a 24-h inpatient observation. An intervention for a bleeding complication (BL-I) was defined by undergoing a procedure (cystoscopy, embolization), receiving a blood transfusion (BL-T), death and/or readmission related to the biopsy. To further define the effect of anemia, patients were divided into three pre-PRB Hgb groups: <9.0 g/dL (n = 79), 9.0-11.0 g/dL (n = 266) and >11.0 g/dL (n = 565). RESULTS: BL-I occurred in 71/910 (7.8%) of PRBs. The majority of these were BL-T (57/71, 80%; 57/910, 6.3% overall). Patients with BL-I had lower pre-PRB Hgb than those without BL-I (mean ± SD; 10.3 ± 2.0 versus 12.0 ± 2.1 g/dL, P < 0.0001) and a greater change (Δ) in Hgb (2.1 ± 1.6 versus 1.0 ± 0.8 g/dL, P < 0.0001). When compared with higher Hgb, patients with Hgb <9.0 g/dL had more traditional risk factors for bleeding (older age: 49 ± 18 versus 48 ± 18 versus 45 ± 16 years, P = 0.02; female: 72 versus 70 versus 56%, P < 0.0001; higher serum creatinine: 4.0 ± 2.9 versus 2.9 ± 2.6 versus 1.7 ± 1.4 mg/dL, P < 0.0001; higher systolic blood pressure: 138 ± 18 versus 133 ± 19 versus 133 ± 18 mmHg, P = 0.06; higher bleeding time: 7.6 ± 1.8 versus 7.4 ± 2.0 versus 6.7 ± 1.8 min, P < 0.0001). When BL-T was stratified by pre-PRB Hgb, there were more transfusions in those with lower pre-PRB Hgb (24 versus 9 versus 3%, P < 0.0001). However, these patients not only had fewer hematomas (58 versus 83 versus 87%, P = 0.04) but also demonstrated a smaller ΔHgb post-PRB (1.3 ± 1.0 versus 1.8 ± 0.8 versus 3.2 ± 1.6, P < 0.0001) compared with patients with higher pre-PRB Hgb, yet still received a transfusion. CONCLUSIONS: While patients with lower pre-PRB Hgb have more of the traditional risk factors for a complication after PRB, there was actually less clinically evident bleeding in these patients who were transfused. Although anemia itself has been considered to be a risk factor for a complication in the past, it more accurately represents only a predictor of receiving an erythrocyte transfusion. In the setting of the PRB, the decision for transfusion is influenced more by the severity of anemia at baseline as opposed to clinically evident bleeding.

Adequacy and complication rates with 14- vs. 16-gauge automated needles in percutaneous renal biopsy of native kidneys.

In performing percutaneous renal biopsy (PRB) of native kidneys, an increasing use of 16-gauge automated biopsy needles has been observed. We compare the adequacy and safety of PRBs in adults performed with a 14-gauge (n = 82) vs. 16-gauge (n = 55) automated needle using real-time ultrasound (US) from 1/2010 to 12/2013. Baseline clinical and laboratory data along with outcome data (renal US 1-hour postbiopsy, biopsy adequacy, and safety) were collected prospectively. There was no difference in age, gender, blood pressure, serum creatinine, or pre-PRB hemoglobin at baseline for PRBs performed with a 14- vs. 16-gauge needle. The number of glomeruli obtained per biopsy was similar (29 ± 11 vs. 31 ± 14, p = 0.6) and adequate tissue for diagnosis was obtained in 99% and 100% of biopsies. The clinical complication (8.5% vs. 9.1%, p = 1.0), transfusion (7.3% vs. 7.2%, p = 1.0), and embolization (3.7% vs. 1.8%, p = 0.6) rates were not significantly different for 14- vs. 16-gauge needles, but by routine renal US 1-hour post-PRB, a perinephric hematoma was demonstrated more often in biopsies done with the 14-gauge needle (39% vs. 22%, P 0.04). Thus, while the success of PRB of native kidneys is similar for both needle gauges, the potential for complication may be less using a 16-gauge automated needle.

Percutaneous renal biopsy of native kidneys: a single-center experience of 1,055 biopsies.

BACKGROUND: Percutaneous renal biopsy (PRB) of native kidneys is an essential tool in the diagnosis and management of renal disease. We report one of the largest single-center experiences on the success and safety of the procedure. METHODS: From June 1983 to March 2012, 1,055 adults underwent PRB using real-time ultrasound guidance and 14-gauge biopsy needles. Data were collected prospectively for 826 biopsies (78%). Statistical analysis was performed using the Mann-Whitney test, Wilcoxon matched pairs test and Kruskal-Wallis test for continuous data or the Fisher's exact test and χ(2) test for categorical data. Multivariate analysis using logistic regression was performed to determine which feature at baseline was predictive of a complication following renal biopsy. RESULTS: Patients were aged 46 ± 17 years; 38% were male, 40% were white and 43% were African-American. Serum creatinine (SCr) was 2.3 ± 2.3 mg/dl (>1.5 mg/dl in 47%). The pre-PRB hemoglobin was 12 ± 2 g/dl (<11.0 g/dl in 35%). Adequate tissue for diagnosis was obtained in 99% of biopsies. Minor complications occurred in 8.1% of biopsies (mainly gross hematuria, in 4.5%). Major complications occurred in 6.6% of biopsies, with transfusions required in 5.3%. Only 1 death (0.09%) resulted from post-PRB bleeding. By multivariate analysis, baseline features predictive of a complication were systolic blood pressure >170 mm Hg (OR 4.2, 95% CI 1.8-9.8), bleeding time >7.5 min (OR 1.7, CI 1.2-2.5) and SCr >3.5 mg/dl (OR 1.8, CI 1.2-2.9). CONCLUSIONS: PRB of native kidneys using real-time ultrasound with a 14-gauge automated needle remains a successful and safe procedure.

The variable course of women with X-linked Alport Syndrome.

X-linked Alport syndrome (XLAS) arises from mutations in the COL4A5 gene encoding the α5-chain of type IV collagen and is associated with hematuria, ocular abnormalities and high-tone sensorineural hearing loss. Nearly all affected males have decreased kidney function resulting in end-stage renal disease (ESRD) as early as the second decade of life. It was long thought that affected females had a benign outcome; however, in recent decades, it has become quite clear that they too are at risk for developing nephrotic syndrome, decreased kidney function and ESRD. We report two young females presenting with microscopic hematuria and proteinuria diagnosed with XLAS on renal biopsy. Both developed nephrotic-range proteinuria and progressive renal insufficiency. Additionally, both developed extra-renal manifestations of XLAS. The ultrastructural and immunofluorescence features on kidney biopsy were instrumental in making the diagnosis of heterozygous XLAS as neither patient had a family history of AS.

Severe lupus nephritis: the predictive value of a ≥ 50% reduction in proteinuria at 6 months.

BACKGROUND: A complete remission (CR) in severe lupus nephritis (SLN) is associated with a favorable long-term outcome. Initial therapy may be up to 6 months, but many patients do not achieve a CR until after 12 months. We assess the value of a ≥50% reduction in proteinuria (UPro) at 6 months in predicting the outcome in SLN patients. METHODS: We evaluated the 86 adult patients in the prospective, controlled trial of plasmapheresis (PP) in SLN (NEJM 1992). Patients with a CR (n = 12), end-stage renal disease (ESRD) or death (n = 13) at ≤6 months were excluded. The remaining 61 patients were categorized into two groups based on having attained a ≥50% reduction in UPro at 6 months: (yes) 34 patients and (no) 27 patients. The long-term outcomes were compared. A CR was defined by a serum creatinine (SCr) of ≤1.4 mg/dL and UPro of ≤0.33 g/day. RESULTS: Baseline features were similar, but the UPro was higher (7.1 ± 3.6 versus 4.6 ± 3.2, P 0.002) in the group with a ≥50% reduction in UPro at 6 months. At follow-up, a CR was attained in 56% of patients with a ≥50% reduction in UPro at 6 months compared with 22% (P = 0.009) in the group without. The 15-year renal survival (71 versus 25%, P = 0.005) and patient survival without ESRD (66 versus 18%, P = 0.004) was greatest in the patients with a ≥50% reduction in UPro at 6 months. CONCLUSION: A ≥50% reduction in UPro at 6 months predicts a favorable outcome in SLN.

Treatment of primary FSGS in adults.

Over the last 20 years, primary FSGS has emerged as one of the leading causes of idiopathic nephrotic syndrome in adults, particularly among African Americans. In nephrotic patients, progression to ESRD often occurs over the course of 5-10 years, whereas non-nephrotic patients and those entering a remission have an extremely favorable prognosis. As a result, it is in patients who remain persistently nephrotic despite conservative therapy that a more aggressive therapeutic approach is taken. Primary FSGS was once considered an entity nonresponsive to prednisone or immunosuppressive agents, but it has become apparent over the last 20 years that a substantial portion of nephrotic adults with primary FSGS do respond to treatment with a significantly improved prognosis. The recent histologic classification proposed for FSGS has provided additional insights into the prognosis and response to therapy. This article reviews the current knowledge regarding the presentation, prognosis, and therapeutic approach in adults with primary FSGS.

Complete remission in severe lupus nephritis: assessing the rate of loss in proteinuria.

BACKGROUND: The prognosis of severe lupus nephritis (SLN) is improved in patients attaining a complete remission (CR). The time to remission ranges from 10 to 16 months with many patients not attaining a CR until after 12 months. We assessed whether the rate of loss in proteinuria (UPro) is predictive of a CR in SLN patients. METHODS: We studied 85 adult patients in the prospective controlled trial of plasmapheresis in SLN (New England Journal of Medicine 1992). All patients had International Society of Nephrology/Renal Pathology Society Class IV±Class V lesions. All patients received prednisone and oral cyclophosphamide and 39 patients received plasmapheresis. A CR was defined by a serum creatinine (SCr) of ≤1.4 mg/dL and UPro of ≤0.33 g/day. The change in UPro in gram per day per week was determined at 3 and 6 months from entry to the study. RESULTS: A CR was attained in 37 patients (44%) by 16±14 months. The level of UPro at baseline was similar in CR and no remission (NR) patients (5.5 versus 6.4 g/day), but CR patients had a lower SCr (1.2 versus 2.4, P<0.0001). At 6 months, the rate of change of UPro was higher at (-)0.224 g/day/week in CR patients and (-)0.107 g/day/week in NR patients (P=0.01) and a 50% reduction in UPro was seen in 78% of CR patients but only 42% of NR patients (P=0.009). The time to a CR was ≤12 months in 19 patients and >12 months in 18 patients. The baseline SCr was similar among the two groups. However, UPro at baseline was lower in patients with CR in ≤12 months (3.9±2.7 versus 7.2±3.0 g/day, P=0.001) but the proportion of patients with membranous glomerulonephritis was similar (16 versus 22%). The rate of change in UPro at 6 months was similar at (-)0.214 g/day/week in patients with CR ≤12 months and (-)0.235 g/day/week in those with CR>12 months (P=0.6). At 6 months, a 50% reduction in UPro was also similar in the two groups (84 versus 72%, P=0.4). Additionally, the rate of change in UPro at 3 and 6 months was similar within each group. CONCLUSIONS: The rate of change in proteinuria at 6 months is significantly greater in patients attaining a CR relative to NR patients but similar in patients with a CR in ≤12 months or >12 months. Thus, the rate of loss of UPro at 6 months may help in predicting which patients will attain a CR.

The Oxford classification of IgA nephropathy: a retrospective analysis.

BACKGROUND/AIMS: The Oxford classification of IgA nephropathy (IgAN) assesses the presence of mesangial hypercellularity ≥50% (M1 vs. 0), endocapillary proliferation (E1 vs. 0), segmental glomerulosclerosis (S1 vs. 0), tubular atrophy/interstitial fibrosis >25 or 50% (T1 or 2 vs. 0), and has been reported as having prognostic value. We studied the clinical significance of the classification in our adult patients with IgAN. METHODS: Retrospective study of 54 patients with biopsy-proven IgAN seen from 1983 to 2009. The correlation between the Oxford classification and baseline renal function was assessed. The primary endpoint was a 50% reduction in eGFR or end-stage renal disease. Predictors for progression to the endpoint were determined by multivariate analyses. RESULTS: Patients were 41 ± 15 years of age with a serum creatinine of 1.5 ± 0.8 mg/dl, eGFR of 61 ± 24 ml/min/1.73 m(2), and proteinuria of 2.0 ± 1.6 g/day. Oxford classifications were as follows: M1 = 72%, E1 = 20%, S1 = 81%, and T1 = 13%/T2 = 22%. During the follow-up of 5.8 ± 4.8 years, 19% of patients reached the primary endpoint. While the Oxford classification was associated with progressive renal disease, only the T score (T0, T1, T2) was predictive of outcome with 6, 29, and 50% of patients (p = 0.002) reaching the primary endpoint. The 10-year renal survival for T0, T1, and T2 was 100, 50, and 17%, respectively (p < 0.001). By multivariate analysis, the hazard ratio for reaching the primary endpoint was 32 for patients with T ≥1 versus T0 (p = 0.01). CONCLUSIONS: In our experience, the Oxford classification predicts progressive renal disease, but the degree of tubulointerstitial fibrosis was the only feature independently predictive of outcome.

Pruritic rash and eosinophilia in a patient receiving peritoneal dialysis.

A 28-year-old woman with end-stage renal disease maintained on peritoneal dialysis developed a hyperpigmented macular pruritic rash on multiple parts of her body associated with an eosinophilia of 22%. The consulting allergist suspected a silicone allergy from the peritoneal dialysis catheter. A patch test confirmed this diagnosis. Treatment with both topical and systemic steroids was ineffective. Following a living nonrelated renal transplant and removal of the catheter the rash and eosinophilia resolved.