Prevalence and Risk Factors of Abnormal Glucose Metabolism and New-Onset Diabetes Mellitus after Kidney Transplantation: A Single-Center Retrospective Observational Cohort Study.

Background and objectives: New-onset diabetes after transplantation (NODAT) represents a primary cause of morbidity and allograft loss. We assessed prevalence and risk factors for NODAT in a population of Italian kidney transplant (KT) recipients. Methods: Data from 522 KT performed between January 2004 and December 2014 were analyzed. Participants underwent clinical examination; blood and urine laboratory tests were obtained at baseline, one, six, and 12-month of follow-up to detect glucose homeostasis abnormalities and associated metabolic disorders. An oral glucose tolerance test (OGTT) was performed at six months in 303 subjects. Results: Most patients were Caucasian (82.4%) with a mean age of 48 ± 12 years. The prevalence of abnormal glucose metabolism (AGM) and NODAT was 12.6% and 10.7%, respectively. Comparing characteristics of patients with normal glucose metabolism (NGM) to those with NODAT, we found a significant difference in living donation (16.6% vs. 6.1%; p = 0.03) and age at transplant (46 ± 12 vs. 56 ± 9 years; p = 0.0001). Also, we observed that patients developing NODAT had received higher cumulative steroid doses (1-month: 1165 ± 593 mg vs. 904 ± 427 mg; p = 0.002; 6-month:2194 ± 1159 mg vs. 1940 ± 744 mg; p = 0.002). The NODAT group showed inferior allograft function compared to patients with NGM (1-year eGFR: 50.1 ± 16.5 vs. 57 ± 20 mL/min/1.73 m2; p = 0.02). NODAT patients were more likely to exhibit elevated systolic blood pressure and higher total cholesterol and triglyceride levels than controls. Conclusions: The prevalence of NODAT in our cohort was relatively high. Patient age and early post-transplant events such as steroid abuse are associated with NODAT development.

COVID-19 in chronic hemodialysis patients: A report of 9 cases in Madrid, Spain.

INTRODUCTION: In December 2019, a new respiratory disease, named COVID-19, caused by a novel coronavirus, emerged in Wuhan and since then spread rapidly throughout China and worldwide. Hemodialysis patients are an especially vulnerable subgroup of the general population. However, there are only a few reports on the course of COVID-19 in maintenance hemodialysis patients. CASE REPORT: We describe in depth the clinical, analytical, and radiological details of 9 hemodialysis patients from a single center in Madrid (Spain) diagnosed with COVID-19. Furthermore, we describe and discuss the therapeutic aspects and the patients' outcomes. DISCUSSION: We present one of the first case series of chronic hemodialysis patients with COVID-19. Between March 14 and April 8, 2020, out of 76 prevalent patients in our hemodialysis unit, 9 (11.8%) patients were diagnosed with COVID-19. The most common symptoms were fever (77.8%), asthenia (77.8%), cough (55.6%), and dyspnea (33.3%). A total of 3 patients developed severe pneumonia, whereas 4 patients developed mild pneumonia. In 2 patients, no pathologic changes were found on chest radiography. All patients presented lymphopenia. While 6 (66.7%) patients required hospitalization, none of them was admitted to intensive care unit. The most common treatments used were azithromycin (100%), hydroxychloroquine (66.7%), lopinavir/ritonavir (55.6%) and ß-interferon (22.2%). In general, we observed a mild to moderate severity of disease in our case series. One patient died, however due to a cause not related to COVID-19.

Relationship between number of daily exchanges at CAPD start with clinical outcomes.

BACKGROUND: Peritoneal dialysis (PD) continues to be demanding for patients affected by kidney failure. In kidney failure patients with residual kidney function, the employment of incremental PD, a less onerous dialytic prescription, could translate into a decrease burden on both health systems and patients. METHODS: Between 1st January 2009 and 31st December 2021, 182 patients who started continuous ambulatory peritoneal dialysis (CAPD) at our institution were included in the study. The CAPD population was divided into three groups according to the initial number of daily CAPD exchanges prescribed: one or two (50 patients, CAPD-1/2 group), three (97 patients, CAPD-3 group) and four (35 patients, CAPD-4 group), respectively. RESULTS: Multivariate analysis showed a difference in term of peritonitis free survival in CAPD-1/2 in comparison to CAPD-3 (hazard ratio (HR): 2.20, p = 0.014) and CAPD-4 (HR: 2.98, p < 0.01). A tendency towards a lower hospitalisation rate (CAPD-3 and CAPD-4 vs. CAPD-1/2, p = 0.11 and 0.13, respectively) and decreased mortality (CAPD-3 and CAPD-4 vs. CAPD-1/2, p = 0.13 and 0.22, respectively) in patients who started PD with less than three daily exchanges was detected. No discrepancy of the difference of the mean values between baseline and 24 months residual kidney function was observed among the three groups (p = 0.33). CONCLUSIONS: One- or two-exchange CAPD start was associated with a lower risk of peritonitis in comparison to three- or four-exchange start. Furthermore, an initial PD prescription with less than three exchanges may be associated with an advantage in term of hospitalisation rate and patient survival.

Corrigendum: Impact of hyperparathyroidism and its different subtypes on long term graft outcome: a single Transplant Center cohort study.

[This corrects the article DOI: 10.3389/fmed.2023.1221086.].

Incremental peritoneal dialysis allows to reduce the time spent for dialysis, glucose exposure, economic cost, plastic waste and water consumption.

BACKGROUND: Incremental peritoneal dialysis (incPD) as the initial PD strategy represents a convenient and resource-sparing approach, but its impact on patient, healthcare and environment has not been thoroughly evaluated. METHODS: This study includes 147 patients who started incPD at our institution between 1st January, 2009 and 31st December, 2021. Adequacy measures, peritoneal permeability parameters, peritonitis episodes, hospitalizations and increase in CAPD dose prescriptions were recorded. The savings related to cost, patient glucose exposure, time needed to perform dialysis, plastic waste, and water usage were compared to full-dose PD treatment. RESULTS: During the study follow-up 11.9% of the patients transitioned from incremental to full dose PD. Patient cumulative probability of remaining on PD at 12, 24, 36, 48 and 60 months was 87.6, 65.4, 46.1, 30.1 and 17.5%, respectively. The median transition time from 1 to 2 exchanges, from 2 to 3 and 3 to 4 exchanges were 5, 9 and 11.8 months, respectively. Compared to full dose PD, 1, 2, and 3 exchanges per day led to reduction in glucose exposure of 20.4, 14.8 or 8.3 kg/patient-year, free lifetime gain of 18.1, 13.1 or 7.4 day/patient-year, a decrease in cost of 8700, 6300 or 3540 €/patient-year, a reduction in plastic waste of 139.2, 100.8 or 56.6 kg/patient-year, and a decline in water use of 25,056, 18,144 or 10,196 L/patient-year. CONCLUSIONS: In comparison with full-dose PD, incPD allows to reduce the time spent for managing dialysis, glucose exposure, economic cost, plastic waste, and water consumption.

Is there a role in acute kidney injury for FGF23 and Klotho?

Cardio-renal syndrome is a clinical condition that has recently been well defined. In acute kidney disease, this interaction might trigger chronic processes determining the onset of cardiovascular events and the progression of chronic kidney disease. Moreover, the high mortality rate of acute kidney injury (AKI) is also linked to the fact that this condition is often complicated by dysfunctions of other organs such as lungs or heart, or is associated with septic episodes. In this context the role and the potential link between bone, heart and kidney is becoming an important topic of research. The aim of this review is to describe the cardiac alterations in the presence of AKI (cardiorenal syndrome type 3) and explore how bone can interact with heart and kidney in determining and influencing the trend of AKI in the short and long term. The main anomalies of mineral metabolism in patients with AKI will be reported, with specific reference to the alterations of fibroblast growth factor 23 and Klotho as a link between the bone-kidney-heart axis.

Impact of hyperparathyroidism and its different subtypes on long term graft outcome: a single Transplant Center cohort study.

Purpose: We studied the association between parathormone (PTH) levels and long-term graft loss in RTx patients (RTx-p). Methods: We retrospectively evaluated 871 RTx-p, transplanted in our unit from Jan-2004 to Dec-2020 assessing renal function and mineral metabolism parameters at 1, 6, and 12 months after RTx. Graft loss and death with functioning graft during follow-up (FU, 8.3[5.4-11.4] years) were checked. Results: At month-1, 79% had HPT, of which 63% with secondary HPT (SHPT) and 16% tertiary HPT (THPT); at month-6, HPT prevalence was 80% of which SHPT 64% and THPT 16%; at month-12 HPT prevalence was 77% of which SHPT 62% and THPT 15%. A strong significant correlation was found between HPT type, PTH levels and graft loss at every time point. Mean PTH exposure remained strongly and independently associated to long term graft loss (OR 3.1 [1.4-7.1], p = 0.008). THPT was independently associated with graft loss at month-1 when compared to HPT absence and at every time point when compared to SHPT. No correlation was found with RTx-p death. Discriminatory analyses identified the best mean PTH cut-off to predict long-term graft loss to be between 88.6 and 89.9 pg/mL (AUC = 0.658). Cox regression analyses highlighted that THPT was strongly associated with shorter long-term graft survival at every time-point considered. Conclusion: High PTH levels during 1st year of RTx seem to be associated with long term graft loss.

Analysis of mechanical complications in urgent-start peritoneal dialysis.

BACKGROUND: Peritoneal dialysis (PD) is an excellent, but underutilized dialysis technique. Thus, its implementation may depend also on the chance to offer this modality of treatment to patients referred late to the nephologists. This approach has recently been named "urgent-start peritoneal dialysis" (UPD). The main barrier to this practice is represented by the fear of early mechanical complications. METHODS: All prevalent patients needing urgent-start PD at our institution between 1 January, 2009 and 31 December, 2019 were included in the study. During this period, 242 peritoneal catheters were inserted in 222 patients. In all patients, an anti-leakage/dislocation suture was made. PD was started within 24 h from catheter placement. RESULTS: The early incidence of leakages, catheter dislocations, omental wrappings, bleedings, peritonitis and exit-site infections was 11/242 (4.5%), 5/242 (2%), 3/242 (1.2%), 2/242 (0.8%), 6/242 (2.5%) and 4/242 (1.6%), respectively. No bowel perforations were observed. Nearly one third of the late complications (13/45; 35.2%) resulted in discontinuation of PD, while one fourth (11/45; 24.4%) required surgical revision. The remaining episodes (21/45; 46.6%) were successfully managed by a conservative approach. The survival of the catheter at 3, 6, 12, 24, 36 and 48 months was 93.6, 91.2, 84.8, 77.4, 65.5 and 59.3%, respectively. The technique survival at 3, 6, 12, 24, 36 and 48 months was 97.2, 94.9, 87.6, 78.9, 66.6 and 60.0%, respectively. The main causes of PD drop-out included infectious complications (36.8%) followed by mechanical complications (17.5%). CONCLUSIONS: A tight seal between deep cuff and surrounding tissues (double purse-string technique) in association with a starting low-volume exchange scheme allows to minimize early and late mechanical complication in UPD.

Efficacy and Safety of Semaglutide, a Glucagon-Like Peptide-1 Receptor Agonist in Real-Life: A Case Series of Patients in Maintenance Incremental Hemodialysis.

The glucagon-like peptide-1 receptor agonists (GLP-1RA) are among the newest treatment options available for managing of type 2 diabetes mellitus and slowing the progression of diabetes kidney disease (DKD). Subcutaneous (SC) semaglutide (Ozempic®) is a GLP-1RA with an extended half-life of approximately 1 week. GLP-1RA are highly effective in improving glycemic control and also show other beneficial effects such as increased natriuresis; decreased blood pressure and albuminuria; reduction of oxidative stress and inflammation; delay of gastric emptying and suppress appetite; the latter may result in significant weight loss. GLP-1RA can be used in patients with advanced-stage CKD; the European Medicines Agency has approved the use of all commercially available human GLP-1 analogs up to a minimal eGFR of 15 mL/min/1.73 m2. However, studies of safety and use of these agents in renal replacement therapy are scarce. Therefore, herein we present 3 cases of patients with advanced DKD in maintenance incremental hemodialysis with 1 session per week to describe the efficacy and safety of the SC semaglutide treatment and the favorable effects on glycemic control, lowering HbA1c, albuminuria, weight, blood pressure control, and preservation of residual kidney function (RKF) during a 6-month follow-up in a hospital hemodialysis unit in Spain. These effects could produce an improvement in morbidity and mortality and could also prevent albuminuria and preserve the RKF. This may allow our patients to maintain a weekly hemodialysis session and could facilitate their inclusion in the kidney transplant waiting lists.

Frailty in kidney transplantation: a review on its evaluation, variation and long-term impact.

The problem of frailty in kidney transplantation is an increasingly discussed topic in the transplant field, partially also generated by the multiple comorbidities by which these patients are affected. The criteria currently used to establish the presence and degree of frailty can be rapidly assessed in clinical practice, even in patients with chronic kidney disease (CKD). The main objectives of this work are: (i) to describe the method of evaluation and the impact that frailty has in patients affected by CKD, (ii) to explore how frailty should be studied in the pre-transplant evaluation, (iii) how frailty changes after a transplant and (iv) the impact frailty has over the long term on the survival of renal transplant patients.