Recently, a new class of dialyzers, medium cut-off membranes (MCO), designed to improve the permeability, which could provide an efficacy similar to hemodiafiltration, have been incorporated into our ...therapeutic possibilities. To increase the knowledge about its use, the objective of the study was to evaluate the effect of the surface and blood flow (Qb) on the depurative efficacy in the MCO membranes.
We included 19 patients in the hemodialysis. Each patient received 6 sessions, in which the membrane surface was varied, 1.7 or 2.0 m2, and/or the Qb (300, 350, 400 or 450 mL/min). In each session, different solutes were determined at the beginning and end of dialysis.
The surface change of the dialyzer did not show significant differences in the removal of small or large molecules, without changes in albumin loss. The increase in Qb was accompanied by an increase in clearance of small molecules, without showing differences in the percentage reduction of β2-microglobulin, myoglobin, prolactin, α1-microglobulin and α1-acid glycoprotein, except for some comparison with Qb 450 mL/min. There were also no differences in the loss of albumin in the dialysis fluid, less than 2.5 grams in all situations.
The increase of the surface area of 1.7–2.0 m2 in the MCO dialyzer has not meant a greater depurative effectiveness. In these dialyzers the increase of Qb does not seem to be as determinant as in hemodiafiltration except for the clearance of small molecules.
Recientemente, se han incorporado en nuestras posibilidades terapéuticas, una nueva clase de dializadores, membranas de medio cut-off (MCO), diseñados para mejorar la permeabilidad y podrían alcanzar una eficacia similar a la hemodiafiltración. Para aumentar el conocimiento sobre su utilización, el objetivo del estudio fue valorar en las membranas de MCO el efecto de la superficie y del flujo sanguíneo (Qb) sobre la eficacia depurativa.
Se incluyeron 19 pacientes en programa de hemodiálisis. Cada paciente recibió 6 sesiones, en las que se varió la superficie de membrana, 1.7 o 2.0 m2, y el Qb (300, 350, 400 o 450 mL/min). En cada sesión se determinaron diferentes solutos al inicio y al final de diálisis.
El cambio de superficie del dializador no mostró diferencias significativas en la depuración de pequeñas o grandes moléculas, sin cambios en la pérdida de albúmina. El aumento del Qb se acompaño de un aumento de depuración de pequeñas moléculas, sin mostrar diferencias en el porcentaje de reducción de β2-microglobulina, mioglobina, prolactina, α1-microglobulina y α1-glicoproteína ácida, a excepción de alguna comparación con Qb 450 mL/min. Tampoco se observaron diferencias en la pérdida de albúmina en el líquido de diálisis, inferior a 2.5 gramos en todas las situaciones.
El incremento de la superficie de 1.7 a 2.0 m2 en el dializador de MCO no ha significado una mayor eficacia depurativa. En estos dializadores el aumento del Qb no parece ser tan determinante como en la hemodiafiltración a excepción de la depuración de pequeñas moléculas.
Recientemente, se ha incorporado a nuestras posibilidades terapéuticas una nueva clase de dializadores, las membranas de medio cut-off (MCO), diseñadas para mejorar la permeabilidad y que podrían ...alcanzar una eficacia similar a la hemodiafiltración. Para aumentar el conocimiento sobre su uso, el objetivo del estudio fue valorar en las membranas de MCO el efecto de la superficie y del flujo sanguíneo (Qb) sobre la eficacia depurativa.
Se incluyó a 19 pacientes en programa de hemodiálisis. Cada paciente recibió 6 sesiones, en las que se varió la superficie de membrana, de 1,7 o 2,0 m2, y el Qb (300, 350, 400 o 450mL/min). En cada sesión se determinaron diferentes solutos al inicio y al final de la diálisis.
El cambio de superficie del dializador no mostró diferencias significativas en la depuración de pequeñas o grandes moléculas, sin cambios en la pérdida de albúmina. El aumento del Qb se acompañó de un aumento de depuración de pequeñas moléculas, sin mostrar diferencias en el porcentaje de reducción de β2-microglobulina, mioglobina, prolactina, α1-microglobulina y α1-glicoproteína ácida, a excepción de alguna comparación con Qb 450mL/min. Tampoco se observaron diferencias en la pérdida de albúmina en el líquido de diálisis, inferior a 2,5 g en todas las situaciones.
El incremento de la superficie de 1,7 a 2,0 m2 en el dializador de MCO no ha significado una mayor eficacia depurativa. En estos dializadores el aumento del Qb no parece ser tan determinante como en la hemodiafiltración, a excepción de la depuración de pequeñas moléculas.
Recently, a new class of dialyzers, medium cut-off membranes (MCO), designed to improve the permeability, which could provide an efficacy similar to hemodiafiltration, have been incorporated into our therapeutic possibilities. To increase the knowledge about its use, the objective of the study was to evaluate the effect of the surface and blood flow (Qb) on the depurative efficacy in the MCO membranes.
We included 19 patients in the hemodialysis. Each patient received 6 sessions, in which the membrane surface was varied, from 1.7 to 2.0 m2, and/or the Qb (300, 350, 400 or 450mL/min). In each session, different solutes were determined at the beginning and end of dialysis.
The surface change of the dialyzer did not show significant differences in the removal of small or large molecules, without changes in albumin loss. The increase in Qb was accompanied by an increase in clearance of small molecules, without showing differences in the percentage reduction of β2-microglobulin, myoglobin, prolactin, α1-microglobulin and α1-acid glycoprotein, except for some comparison with Qb 450mL/min. There were also no differences in the loss of albumin in the dialysis fluid, less than 2.5 g in all situations.
The increase of the surface area from 1.7 to 2.0 m2 in the MCO dialyzer has not meant a greater depurative effectiveness. In these dialyzers the increase of Qb does not seem to be as determinant as in hemodiafiltration except for the clearance of small molecules.
Background:
Despite recent advances in immunosuppression treatment, antibody-mediated rejection (ABMR) remains the leading cause of kidney graft loss. Information about prognostic markers and the ...efficacy of treatment is scarce.
Methods:
Retrospective study with kidney recipients diagnosed an active ABMR from January 1, 2004 to December 31, 2019 to explore the influence of persistent inflammation in follow-up biopsies on graft survival after ABMR treatment.
Results:
About 116 patients were included. Active ABMR were treated with a combination of plasma exchange (PE), intravenous immunoglobulin (IVIg), rituximab, and steroids. At 6 months of treatment, 63 (54.3%) patients presented a stabilization or improvement in kidney-graft function. The effectiveness varied depending on the timepoint of the presentation between transplantation and rejection, which is lower for those with late ABMR (63 vs. 21% for early vs. late ABMR, respectively). Ninety patients (77%) underwent a control biopsy after ABMR treatment, from which 46 (51%) responded to the treatment. Microvascular inflammation (MVI) persisted in 64 (71%) biopsies, whereas tubulitis persisted in 17 (19%) biopsies. Death-censored graft survival at 1 year was significantly lower in patients with persistent MVI (86% vs. 95% without persistent MVI,
P
= 0.002), or with persistent tubulitis (44% vs. 66% without tubulitis,
P
= 0.02). In the Cox Regression analysis, the persistence of MVI hazard ratio (HR), 4.50 (95%CI, 1.35–14.96),
P
= 0.01 and tubulitis HR 2.88 95%CI (1.24–6.69),
P
= 0.01) in follow-up biopsies significantly increased the risk of graft failure.
Conclusion:
Persistent inflammation in follow-up biopsies after ABMR treatment was associated with an increased risk of graft loss, even without meeting Banff rejection criteria.
Study Registration:
Agencia Española de Medicamentos y Productos Sanitarios (AEMPS): 14566/RG 24161. Study code: UTRINM-2017-01.
Current literature suggests a higher risk of pregnancy-related complications in patients with renal fibromuscular dysplasia (FMD). The aim of our study was to assess the nature and prevalence of ...pregnancy-related complications in patients subsequently diagnosed with FMD. A call for participation was sent to centers contributing to the European/International FMD Registry. Patients with at least 1 pregnancy were included. Data on pregnancy were collected through medical files and FMD characteristics through the European/International FMD Registry. Data from 534 pregnancies were obtained in 237 patients. Despite the fact that, in 96% of cases, FMD was not diagnosed before pregnancy, 40% of women (n=93) experienced pregnancy-related complications, mostly gestational hypertension (25%) and preterm birth (20%), while preeclampsia was reported in only 7.5%. Only 1 patient experienced arterial dissection and another patient an aneurysm rupture. When compared with patients without pregnancy-related complications, patients with complicated pregnancies were younger at FMD diagnosis (43 versus 51 years old; P<0.001) and had a lower prevalence of cerebrovascular FMD (30% versus 52%; P=0.003) but underwent more often renal revascularization (63% versus 40%, P<0.001). In conclusion, the prevalence of pregnancy-related complications such as gestational hypertension and preterm birth was high in patients with FMD, probably related to the severity of renal FMD. However, the prevalence of preeclampsia and arterial complications was low/moderate. These findings emphasize the need to screen hypertensive women for FMD to ensure revascularization before pregnancy if indicated and appropriate follow-up during pregnancy, without discouraging patients with FMD from considering pregnancy.
SARS-CoV-2 and influenza virus co-infection Cuadrado-Payán, Elena; Montagud-Marrahi, Enrique; Torres-Elorza, Manuel ...
The Lancet (British edition),
05/2020, Letnik:
395, Številka:
10236
Journal Article
Recenzirano
Odprti dostop
Since December, 2019, coronavirus disease 2019 (COVID-19) has been an international public health emergency.1–3 Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) mimics the influenza virus ...regarding clinical presentation, transmission mechanism, and seasonal coincidence.3 Thus, co-infection by both viruses is feasible. The clinical and analytical courses in these patients did not differ from those previously reported for COVID-19.5 However, more studies are needed to assess the effect of the SARS-CoV-2 and influenza co-infection in clinical outcomes. CRP (mg/dL <1 mg/dL) LDH (U/L <234 U/L) Ferritin (ng/mL 20–400) D-dimer (ng/mL <500) Lymphocyte count (×109 cells per L 0·9–4·5) Platelets count (×109 cells per L 130–400) Ultrasensitive troponin I (ng/L <45·2) 0 h 24 h 72 h 0 h 24 h 72 h 0 h 24 h 72 h 0 h 24 h 72 h 0 h 24 h 72 h 0 h 24 h 72 h 0 h 24 h 72 h Patient 1 (man, 53 years) 4·3 10 10 NA 191 209 NA 905 1203 NA 700 1300 0·6 0·4 0·3 125 101 86 191 168 300 Patient 2 (man, 78 years) 14·0 15·0 3·6 314 340 283 NA 162 235 NA NA 2100 0·3 0·3 0·5 60 60 81 NA NA NA Patient 3 (man, 56 years) 2·1 3·18 NA NA NA NA 280 305 NA 200 200 NA 1·2 1·8 NA 199 205 NA 2·8 2·9 NA Patient 4 (woman, 81 years) 1·3 6·1 9·7 247 231 250 NA NA NA 200 NA NA 0·5 0·5 0·7 99 78 78 1748 648 836 Table Analytical findings of four patients with severe acute respiratory syndrome coronavirus 2 and influenza virus co-infection
Despite the high incidence of posttransplant infections, postinfectious acute glomerulonephritis (PIAGN) in renal allograft is a rare entity, without effective treatment and a bad prognosis. We ...describe two cases of PIAGN: the first one was developed 2 years after kidney transplantation, secondary to Staphylococcus aureus bacteremia with presence of extracapillary proliferation in biopsy. The patient was treated with methylprednisolone and plasma exchanges without response, remaining dialysis dependent. The second case was reported 5 years after kidney transplantation, secondary to influenza A infection. Kidney biopsy showed an IgA-dominant PIAGN and methylprednisolone boluses were initiated without clinical response, suffering a progressive worsening and loss of kidney graft. Due to the aggressive clinical course of this entity, PIAGN should be considered in the differential diagnosis of acute kidney graft failure in the context of an infection. Elderly patients have a higher risk of more severe acute renal dysfunction, requiring dialysis in a great proportion of cases.
Abstract Background and Aims No data exists on humoral or cellular responses to mRNA vaccines in kidney transplant recipients (KTR) with HIV. We compared these responses in HIV-positive and negative ...KTR, as well as in people living with HIV (PLWH) without kidney transplantation. Method In a cross-sectional study of 33 patients receiving two (n=13) or three (n=20) doses of mRNA SARS-CoV-2 vaccination, we evaluated the humoral response to mRNA SARS-CoV-2 vaccination using a Luminex platform for IgG and IgM, and assessed cellular response with specific T cell response with S- and N- protein by ELISpot. We used logistic regression models to assess associated factors. Results The study comprised 11 HIV-negative KTRs (HIV-KTR+), 11 HIV-positive KTRs (HIV+KTR+), and 11 PLWH without kidney transplantation (HIV+KTR−). PLWH had suppressed viral load on ART. Seroconversion rates after two or three vaccine doses were 72.7% among KTRs, with no significant difference between HIV-KTR+ (81.8%) and HIV+KTR+ (63.6%) (P=0.338). In HIV+KTR−, seroconversion was 100%, higher than HIV+KTR+ (P=0.027). Cellular response against protein S occurred in 63.6% cases, irrespective of HIV or transplantation status or number of doses. Protein N reactivity was observed in 27.3% KTRs (HIV-KTR+ and HIV+KTR+), versus 9.1% HIV+KTR− (P=0.378). Higher age negatively influenced cellular response in PLWH (OR 0.77, 95% CI 0.60-0.99). Conclusion Although cellular immune response was similar across all groups, we found a reduced humoral response in HIV+KTR+. In PLWH, higher age reduced cellular response. These findings contribute to our understanding of vaccine response in immunosuppressed populations and provide valuable insights for optimizing vaccination strategies.
Abstract Background and Aims The use of mTOR inhibitors (mTORi) is not usually considered in high immunological risk kidney transplant recipients (KTR) for a perceived increased risk of rejection. ...However, in most of the studies that examined the combination of mTORi with calcineurin inhibitors (CNI), hypersensitized patients have been excluded from enrollment. The aim of the present study is to analyze our clinical experience with the use of mTORi in association with calcineurin inhibitors (CNI) in this subset of patients. Method Analysis of 212 consecutive kidney transplant recipients with a baseline calculated panel reactive antibody (cPRA) ≥50% who received a graft from June 2013 to December 2019. Immunosuppression was based on tacrolimus, steroids and, alternatively, mycophenolic acid (MPA; n = 96) or mTORi (either sirolimus or everolimus, target trough levels 3-8 ng/ml, n = 116) depending on the active Institution's protocol at the time of transplantation. The outcomes chosen included rejection-free, graft and patient survival and were analyzed by means of Cox-regression analysis. Results Demographic and immunological characteristics were similar between groups, apart from the higher number of living donors in the MPA group (42.7% vs 14.7%%, P < 0.001). Baseline cPRA was 92.5 76-98% for the MPA and 94 77.25-98% for the mTORi group, respectively (P = 0.882). Induction therapy with lymphocyte-depleting agents was employed in the majority of patients (91.7% in the MPA group and 88.8% in the mTORi group, P = 0.898). Median follow-up time was 2.6 1.45-4.05 years. Biopsy-proven rejection (either cellular or humoral) occurred in 33.3% of the MPA and in 19.8% of the mTORi group, respectively. Cox-regression analysis of rejection-free survival revealed better rejection-free survival with mTORi versus MPA (HR 95% CI, 0.54 0.32-0.98, P = 0.028). The only other baseline factor associated with rejection was previous transplantation (HR 95% CI 1.96 1.07-3.60, P = 0.030). When entered into a bivariable Cox-regression analysis, both mTORi and previous transplantation maintained a statistical significant association with rejection (mTORi versus MPA HR 95% CI 0.53 0.31-0.91, P = 0.023, and previous transplantation HR 95% CI 2.01 1.09-3.69, P = 0.024). No differences between mTORi and MPA were noted for graft (HR 95% CI 0.90 0.40-2.02, P = 0.807) and patient survival (HR 95% CI 1.23 0.60-2.50, P = 0.606). Median creatinine 1 year after transplantation was 1.45 1.11-1.98mg/dl for the MPA group and 1.51 1.09-2.06mg/dl for the mTORi group (P = 0.917). Conclusion This retrospective study suggests that hypersensitized KTRs can receive safely a maintenance immunosuppression based on a combination of CNI with mTORi, without an increased risk of rejection.
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