Successful Transcatheter Aortic Valve Replacement in an Elderly Patient with Calcified Bicuspid Aortic Valve with Calcified Raphe: A Case Report.

At present, transcatheter aortic valve replacement (TAVR) is not only used in high-surgical-risk patients with aortic stenosis (AS), but its use has also been extended to low-risk patients, resulting in its increasing utilization in patients with bicuspid aortic valve (BAV). BAV however presents unique challenges for TAVR due to its distinct valvular anatomy, and surgical aortic valve replacement (SAVR) remains the primary recommended method of aortic valve replacement in patients with BAV. Nonetheless, observational data have been quickly accumulating regarding the successful use of TAVR in BAV. Here, we present a case of a 73-year-old female who presented with heart failure symptoms and was found to have severe AS and BAV with calcified raphe (Sievers 1a). Due to her age and complicated medical history, including coronary artery disease and chronic kidney disease, she was considered to be at intermediate surgical risk (Society of Thoracic Surgeons (STS) score 5.4%) and underwent TAVR with the successful deployment of a 29 mm Edwards SAPIEN valve (Edwards Lifesciences, California, USA). A post-procedure echocardiogram confirmed the appropriate placement of the prosthesis without any valvular or paravalvular regurgitation. This case, therefore, adds to the growing body of evidence regarding the use of TAVR in patients with BAV despite anatomical challenges.

Sitagliptin Versus Placebo to Reduce the Incidence and Severity of Posttransplant Diabetes Mellitus After Kidney Transplantation-A Single-center, Randomized, Double-blind Controlled Trial.

BACKGROUND: Postkidney transplant diabetes mellitus (PTDM) affects cardiovascular, allograft, and recipient health. We tested whether early intervention with sitagliptin for hyperglycemia (blood glucose >200 mg/dL) within the first week of transplant and discontinued at 3 mo could prevent development of PTDM in patients without preexisting diabetes. METHODS: The primary efficacy objective was to improve 2-h oral glucose tolerance test (OGTT) by > 20 mg/dL at 3 mo posttransplant. The secondary efficacy objective was to prevent new onset PTDM, defined as a normal OGTT at 3 mo. RESULTS: Sixty-one patients consented, and 50 patients were analyzed. The 3-mo 2-h OGTT (end of treatment) was 141.00 ± 62.44 mg/dL in the sitagliptin arm and 165.22 ± 72.03 mg/dL ( P = 0.218) in the placebo arm. The 6-mo 2-h OGTT (end of follow-up) was 174.38 ± 77.93 mg/dL in the sitagliptin arm and 171.86 ± 83.69 ng/dL ( P = 0.918) in the placebo arm. Mean intrapatient difference between 3- and 6-mo 2-h OGTT in the 3-mo period off study drug was 27.56 + 52.74 mg/dL in the sitagliptin arm and -0.14 + 45.80 mg/dL in the placebo arm ( P = 0.0692). At 3 mo, 61.54% of sitagliptin and 43.48% of placebo patients had a normal 2-h OGTT ( P = 0.2062), with the absolute risk reduction 18.06%. There were no differences in HbA1c at 3 or 6 mo between sitagliptin and placebo groups. Participants tolerated sitagliptin well. CONCLUSIONS: Although this study did not show a significant difference between groups, it can inform future studies in the use of sitagliptin in the very early posttransplant period.

Posttransplant proteinuria due to Apolipoprotein E2 deposition in a kidney allograft.

Lipoprotein deposition disorders limited to the kidney and causing proteinuria are rare. We present a case of nephrotic range proteinuria presenting within 4 months after deceased donor renal transplantation in a patient with end-stage kidney disease presumed secondary to hypertension. Two transplant kidney biopsies were performed sixteen weeks after transplantation, and one year after the first biopsy, both showing lipoprotein deposits in the glomeruli, progressive focal segmental glomerulosclerosis, and effacement of visceral foot processes. The patient had a normal lipid profile. Based on previous case reports of Apolipoprotein E variants causing proteinuria in native kidneys, Apolipoprotein E genotyping was performed. Genotyping showed Apolipoprotein E2 homozygosity. This Apolipoprotein E variant has been associated with lipoprotein deposition, proteinuria, and progressive kidney disease in the native kidneys. However, this is the first case of Apolipoprotein E2 homozygosity-related kidney disease in a transplant recipient. The patient was treated with fenofibrate, angiotensin enzyme inhibition, and angiotensin receptor blockade with reduction in proteinuria, and he kept good stable kidney function.

Training the Public Physician: The Nephrology Social Media Collective Internship.

The significant growth of social media use by the medical community, including nephrology, has led to a need to equip health care professionals with the mentorship, knowledge, and tools to use these platforms both effectively and professionally. Social media is free and accessible to almost anyone with a computer or mobile device, which not only has revolutionized the dissemination of information, but also has created a venue for unprofessionalism and missteps. This article describes the Nephrology Social Media Collective internship, a 12-month, mentored training program during which selected interns participate in a curriculum of lectures, activities, and projects that aim to increase their knowledge, proficiency, and confidence in the use of social media. The goal of the internship is to train participants to acquire modern communication skills that are not taught in traditional medical training, and leverage these to become leaders in medicine. The structure of the internship, application process, and educational components, along with areas for improvement and future directions, are discussed.

External Intensivists Versus In-House Intensivists: Analysis of Outcomes of Nighttime Coverage of ICUs by External On-Call and In-House On-Call Intensivists.

A 24/7 intensivist model may improve important outcomes such as mortality, length of stay, and number of ventilator days. In this retrospective, single-center study at Saint Luke's Hospital in Kansas City, Missouri, we examined patient outcomes before and after adopting a 24/7 model from 2014 to 2016. The addition of a nighttime intensivist did not lead to a statistically significant improvement in mortality (hospital and ICU) and LOS (hospital and ICU).

Comparison of the Frequency of Acute Kidney Injury in Patients With Renal Transplant Who Underwent Percutaneous Coronary Intervention Versus Coronary Artery Bypass Graft Surgery.

Percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) are established modalities of coronary revascularization. Choosing between the two requires taking into consideration not only disease severity, patient characteristics, and expected outcomes but also adverse effects. One such adverse effect is acute kidney injury (AKI), especially when considering coronary revascularization in patients with renal transplant (RT). We searched the National Inpatient Sample from 2008 to 2014 using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for patients with RT (V42.0) who underwent PCI (00.66, 36.06, and 36.07) and CABG (36.1×, 36.2, and 36.3×). We further identified patients with AKI (584.5, 584.6, 584.7, 584.8, and 584.9) and those on dialysis (39.95). The propensity score model/method was used to form matched cohorts for PCI and CABG. We compared the incidence of AKI and AKI requiring dialysis in CABG and PCI groups. We identified 1,871 patients who underwent PCI and 1,878 patients who underwent CABG after propensity score matching. We found the incidence of both AKI (22% vs 38%, odds ratio 2.20, 95% confidence interval 1.91 to 2.54, p <0.0001) and AKI requiring dialysis (1% vs 3%, odds ratio 2.50, 95% confidence interval 1.49 to 4.19, p = 0.001) to be significantly higher in the CABG compared with the PCI cohort. In conclusion, the results of the study reflect the importance of accounting for the RT status before choosing between PCI and CABG for coronary revascularization.

Perforated Bladder as a Cause of Abdominal Ascites in a Patient Presenting with Acute Onset Abdominal Pain.

Bladder perforation, especially when atraumatic, is a rare cause of ascites and is often difficult to differentiate from other causes of abdominal pain and ascites in the acute setting.  A 43-year-old Caucasian woman with a history of multiple sclerosis presented with acute abdominal pain. A computed tomography (CT) scan of her abdomen and pelvis without contrast revealed ascites, acute kidney injury (AKI) was noted on laboratory workup, and very little urine was drained by Foley catheter. Over the next several days, the patient's clinical condition deteriorated with no definitive diagnosis. A repeat CT of her abdomen and pelvis without contrast showed worsening ascites. She underwent paracentesis, which revealed a markedly elevated ascitic fluid creatinine consistent with bladder rupture. She then underwent an urgent cystogram to confirm the diagnosis, and the urologic consultant recommended conservative management with a Foley catheter to allow for bladder healing. Conservative treatment failed however, and she underwent a surgical repair with drain placement which was followed by an improvement in her clinical condition. This case illustrates a unique presentation of a young woman with multiple sclerosis whose bladder perforation presented as abdominal pain and ascites. The multidisciplinary approach required here highlights the difficulty in reaching this diagnosis which is often undermined in patients who lack a history of traumatic injury. Such delays led to a complicated hospital course for our patient. Maintaining a broad differential for abdominal pain and ascites is essential.

Henoch-Schönlein Purpura Presenting as Severe Gastrointestinal and Renal Involvement with Mixed Outcomes in an Adult Patient.

Henoch-Schönlein purpura (HSP) is typically seen as a self-limiting disease in children, but can present more severely in adults, especially when there is renal involvement. Management of HSP in adults also remains a controversial topic with very few studies evaluating available therapies. In this case, HSP presenting as a combination of severe gastrointestinal involvement and a rapid decline in renal function in an adult patient directed our therapy. The patient was a 48-year-old Caucasian male with no known past medical history, who presented with a combination of purpuric rash over the lower extremities, severe abdominal pain with upper gastrointestinal bleeding and a rapidly increasing serum creatinine, with hematuria. He initially underwent a skin biopsy, along with investigation for other possible causes, including autoimmune and infectious etiologies, which were negative. He was started on therapy for presumed HSP with intravenous methylprednisolone. The skin biopsy, however, was not conclusive, and the patient had no improvement in his clinical status. He then underwent a kidney biopsy that was consistent with HSP nephritis (immunoglobulin A (IgA) predominant glomerulonephritis with crescents), and esophagogastroduodenoscopy (EGD) that showed mucosal inflammation, ulcerations, and stigmata of bleeding-findings that were consistent with ischemia. Cyclophosphamide was added to the regimen at this time. However, he had worsening abdominal pain, continued gastrointestinal bleeding, now with hematochezia, and also worsening renal function that required dialysis. Plasmapheresis was then initiated on days alternating with dialysis. This resulted in the improvement of his gastrointestinal symptoms, but no recovery was seen of his renal function, and the patient required outpatient dialysis. This case report exhibits the unique presentation of severe gastrointestinal (GI) manifestations and rapid progression to renal failure in an adult patient with partial resolution of his severe manifestation after therapy was escalated as above. There was no established protocol that guided this therapy, which reflects the need for more studies on adult HSP.