Background There is no consensus on the optimal perioperative antibiotic prophylaxis regimen for renal transplant recipients. Some studies have reported that irrigation of the wound at the time of ...closure without systemic antibiotics may suffice to minimize the risk for surgical site infection (SSI), but many centers still use long-term, multidose regimens in which antibiotics are administered until removal of foreign bodies occur, such as the urethral catheter, drain and central line. Methods We designed a prospective, randomized, multicenter, controlled trial to compare a single dose versus a multidose regimen of systemic antibiotic prophylaxis in adult, nondiabetic, non-morbidly obese patients undergoing renal transplantation. The primary endpoint was the incidence of SSI; the assessment of other infection in the first postoperative month was the secondary endpoint. Results Two hundred five patients were enrolled and randomized to receive either a single ( n = 103) or multidose antibiotic regimen ( n = 102) for prophylaxis. The incidences of SSI and urinary tract infection were similar in both groups. Conclusion As the dramatic increase in antibiotic resistance has mandated the implementation of global programs to optimize the use of antibiotic agents in humans, we believe that the single dose regimen is preferred, at least in nondiabetic, non-morbidly obese, adult renal transplant recipients.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Rationale:
Vaccines remain central to the management of COVID-19 pandemic, including the need for repeat doses of vaccines to boost immunity. There has been an accumulating case count of ...glomerulopathies temporally associated with COVID-19 vaccination. This case series presents 4 patients who developed double-positive anti–glomerular basement membrane antibody (anti-GBM) and myeloperoxidase (MPO) antineutrophil cytoplasmic autoantibody (ANCA)-associated glomerulonephritis after COVID-19 mRNA vaccination. This report contributes to our collective knowledge about the pathophysiology and clinical outcomes associated with this rare complication.
Presenting Concerns of the Patient:
Four patients developed nephritic syndrome within 1 to 6 weeks after receiving a COVID-19 mRNA vaccine (3 post Pfizer-BioNTech and 1 post Moderna vaccination). Three of the 4 patients also had hemoptysis.
Diagnosis:
Three of the 4 patients had double-positive serology, whereas the fourth patient had renal biopsy findings consistent with double-positive disease, although anti-GBM serology was negative. All patients had renal biopsy findings consistent with double-positive anti-GBM and ANCA-associated glomerulonephritis.
Interventions:
All 4 patients were treated with pulse steroids, cyclophosphamide, and plasmapheresis.
Outcomes:
Of the 4 patients, 1 demonstrated complete remission, 2 remained dialysis-dependent, and the fourth is deceased. Of the 2 patients who received repeat vaccination with COVID-19 mRNA vaccine, 1 patient had second serologic flare of anti-GBM in response to the vaccine.
Novel Findings:
This case series reinforces growing evidence that COVID-19 mRNA vaccine-induced glomerulonephritis is a rare but real phenomenon. Dual ANCA and anti-GBM nephritis can present after the first dose of COVID-19 mRNA vaccine or after several administrations of the vaccine. We are the first to report cases of double-positive MPO ANCA and anti-GBM nephritis after Pfizer-BioNTech vaccination. To our knowledge, we are also the first to report outcomes of repeat COVID-19 vaccination in patients with de novo flare of ANCA and anti-GBM nephritis temporally associated with COVID-19 vaccination.
Xanthogranulomatous pyelonephritis (XGPN) is a rare disorder affecting the kidney which can fistulise to the colon in exceptional cases. We herein report a case of XGPN with renocolic fistula and ...large vessel thrombosis presenting with sepsis and pulmonary embolism. Preoperative diagnosis and strategic planning resulted in successful management. A 64-year-old woman presented to the emergency department with abdominal pain and a septic condition, corroborated by venous thromboembolism. Workup diagnosed a left renal abscess with calicocolic fistula. Scintigraphy confirmed a nonfunctioning left kidney. The patient underwent inferior vena cava filter placement and staged surgery. The first, damage control procedure was a loop ileostomy. Ten days later, when the patient’s conditions improved, she underwent left nephrectomy and left colectomy with primary anastomosis. Finally, a year later, the ileostomy was closed. At follow-up, the patient was well, with unremarkable renal function. Scrupulous diagnostics, multidisciplinary decision making, and staged intervention have been key to optimal outcome.
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DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, UILJ, UKNU, UL, UM, UPUK
Successful transplantation should lead to improvements in sexual function and sex hormone disturbances in both men and women, but immunosuppressive drugs may interfere with hormone metabolism. In ...this regard, several studies have showed a potential negative effect of mTOR inhibitors (mTORi) on male gonadal function, while their role in the female patients is not well documented in the literature. Successful pregnancy is possible after solid organ transplantation. The fetal effects of mTORi are still poorly defined but they seem not to represent an absolute contraindication for pregnancy. The aim of our study would be to review the impact of mTORi on fertility and pregnancy in order to have a clearer picture about their possible use after organ transplantation.
Abstract To assess incidence and risk factors for de novo cancers (DNCs) after kidney transplant (KT), we carried out a cohort investigation in 15 Italian KT centres. Seven thousand two-hundred ...seventeen KT recipients (64.2% men), transplanted between 1997 and 2007 and followed-up until 2009, represented the study group. Person years (PY) were computed from 30 days after transplant to cancer diagnosis, death, return to dialysis or to study closure. The number of observed DNCs was compared to that expected in the general population of Italy through standardised incidence ratios (SIR) and 95% confidence intervals (CI). To identify risk factors, incidence rate ratios (IRR) were computed. Three-hundred ninety five DNCs were diagnosed during 39.598 PYs, with Kaposi’s sarcoma (KS), post-transplant lymphoproliferative disorders (PTLD), particularly non-Hodgkin’ lymphoma (NHL), lung, kidney and prostate as the most common types. The overall IR was 9.98/1.000 PY, with a 1.7-fold augmented SIR (95% CI: 1.6-1.9). SIRs were particularly elevated for KS (135), lip (9.4), kidney carcinoma (4.9), NHL (4.5) and mesothelioma (4.2). KT recipients born in Southern Italy were at reduced risk of kidney cancer and solid tumors, though at a higher KS risk, than those born in Northern Italy. Use of mTOR inhibitors (mTORi) exerted, for all cancers combined, a 46% significantly reduced risk (95% CI: 0.4–0.7). Our study findings confirmed, in Italy, the increased risks for cancer following KT, and they also suggested a possible protective effect of mTORi in reducing the frequency of post transplant cancers.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Tumor necrosis factor (TNF) activates transcription of endothelial leukocyte adhesion molecule-1 (CD62E) in endothelial cells (ECs) through the binding to the gene promoter of the p50/p65 ...heterodimeric form of nuclear factor-kappa B (NF-kappa B) and of the N-terminal phosphorylated form of the ATF2/c-Jun transcription factor, which is phosphorylated by Jun N-terminal kinase (JNK). However, the intracellular signaling pathways that activate endothelial NF-kappa B and JNK in TNF-induced responses are unknown. In this study we have examined the role of a recently described TNF signaling pathway involving sphingomyelin activation to generate ceramide, a potential intracellular mediator. We find that concentrations of TNF that strongly activate NF-kappa B and JNK within 15 minutes do not produce either a measurable decline in sphingomyelin or a measurable generation of ceramide in cultured human umbilical vein ECs at any time examined. Stimulation of ECs with purified sphingomyelinase (SMase) enzyme causes a rapid 60% to 80% decrease in cellular sphingomyelin content and a large increase in ceramide. However, SMase treatment only minimally activates NF-kappa B, achieving levels that are insufficient to initiate gene transcription. Extracellular SMase does not have access to intracellular sphingomyelin, but treatment of ECs with membrane-permeant ceramide analogues still completely fails to activate NF-kappa B and only activates JNK at late times. Neither SMase nor ceramide analogues induce gene transcription or surface expression of endothelial leukocyte adhesion molecules that are readily induced by TNF. Strikingly, low concentrations of membrane-permeant ceramide cause programmed cell death in ECs, a finding not observed at any concentrations of TNF tested. We conclude that ceramide is not an important second messenger for TNF signaling of gene transcription in ECs but may be a second messenger for cell death in response to as-yet-unidentified signals.(Circ Res. 1996;79:736-747.)
Coupled plasma filtration adsorption (CPFA) is an extracorporeal treatment based on plasma filtration associated with an adsorbent cartridge and hemofiltration. CPFA is able to remove inflammatory ...mediators and it has been used to treat severe sepsis, septic shock and multiple organ dysfunction syndrome. Limited experience exists on the use of CPFA after solid organ transplantation. We report our experience with CPFA in 2 kidney transplant recipients with post-nephrolithotomy septic shock and severe unexplained rhabdomyolysis. In both the cases, excellent results were observed. In selected cases, CPFA can be safely and effectively used in patients with a solid organ transplant. However, additional studies are needed in this particular setting, to further investigate the potential role of CPFA for the treatment of other conditions associated with excessive inflammation, such as in rheumatologic disorders and delayed graft function.
Abdominal aortic aneurysms after a kidney transplant are becoming treated more frequently owing to the extension of renal transplant in severely arteriosclerotic older patients. Renal transplant ...recipients with autosomal dominant polycystic kidney disease are prone to develop abdominal aortic aneurysms. We present the case of a ruptured abdominal aortic aneurysm that occurred in a renal transplant patient with autosomal dominant polycystic kidney disease. The patient was treated with emergency endovascular repair because open surgery could not be performed successfully owing to the presence of massive polycystic native kidneys and a liver that was occupying the entire peritoneal cavity. His postoperative course was uneventful without complications. The important lessons to be learned from our case are 2-fold: (1) Autosomal dominant polycystic kidney disease renal transplant recipients should be screened annually for abdominal aortic aneurysms to prevent ruptures and (2), emergency endovascular repair may be a preferred treatment in renal transplant recipients owing to its low surgical risk and success.
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