The eutrophic Lake Eichbaumsee, a ~1 km long and 280 m wide (maximum water depth 16 m) dredging lake southeast of Hamburg (Germany), has been treated for water quality improvements using various ...techniques (i.e., aeration plants, removal of dissolved phosphorous by aluminum phosphorous precipitation, and by Bentophos® (Phoslock Environmental Technologies, Sydney, Australia), adsorption) during the past ~15 years. Despite these treatments, no long-term improvement of the water quality has been observed and the lake water phosphorous content has continued to increase by e.g., ~670 kg phosphorous between autumn 2014 and autumn 2019. As no creeks or rivers drain into the lake and hydrological groundwater models do not suggest any major groundwater discharge into the lake, sources of phosphorous (and other nutrients) are unknown. We investigated the phosphorous fluxes from sediment pore water and from groundwater in the water body of the lake. Sediment pore water was extracted from sediment cores recovered by divers in August 2018 and February 2019. Diffusive phosphorous fluxes from pore water were calculated based on phosphorus gradients. Stable water isotopes (δ2H, δ18O) were measured in the lake water, in interstitial waters in the banks surrounding the lake, in the Elbe River, and in three groundwater wells close to the lake. Stable isotope (δ2H, δ18O) water mass balance models were used to compute water inflow/outflow to/from the lake. Our results revealed pore-water borne phosphorous fluxes between 0.2 mg/m2/d and 1.9 mg/m2/d. Assuming that the measured phosphorous fluxes are temporarily and spatially representative for the whole lake, about 11 kg/a to 110 kg/a of phosphorous is released from sediments. This amount is lower than the observed lake water phosphorous increase of ~344 kg between April 2018 and November 2018. Water stable isotope (δ2H, δ18O) compositions indicate a water exchange between an aquifer and the lake water. Based on stable isotope mass balances we estimated an inflow of phosphorous from the aquifer to the lake of between ~150 kg/a and ~390 kg/a. This result suggests that groundwater-borne phosphorous is a significant phosphorous source for the Eichbaumsee and highlights the importance of groundwater for lake water phosphorous balances.
Abstract
In January 2019, the ERA-EDTA surveyed nephrologists with questions on kidney care and kidney research designed to explore comprehension of the impact of alterations to organization of renal ...care and of advancements in technology and knowledge of kidney disease. Eight hundred and twenty-five ERA-EDTA members, ∼13% of the whole ERA-EDTA membership, replied to an ad hoc questionnaire. More than half of the respondents argued that kidney centres will be increasingly owned by large dialysis providers, nearly a quarter of respondents felt that many medical aspects of dialysis will be increasingly overseen by non-nephrologists and a quarter (24%) also believed that the care and long-term follow-up of kidney transplant patients will be increasingly under the responsibility of transplant physicians caring for patients with any organ transplant. Nearly half of the participants (45%, n = 367) use fully electronic clinical files integrating the clinical ward, the outpatient clinics, the haemodialysis and peritoneal dialysis units, as well as transplantation. Smartphone-based self-management programmes for the care of chronic kidney disease (CKD) patients are scarcely applied (only 11% of surveyed nephrologists), but a substantial proportion of respondents (74%) are eager to know more about the potential usefulness of these apps. Finally, European nephrologists expressed a cautious optimism about the application of omic sciences to nephrology and on wearable and implantable kidneys, but their expectations for the medium term are limited.
In recent years, increased efforts have been undertaken to address the needs of patients with rare diseases by international initiatives and consortia devoted to rare disease research and management. ...However, information on the overall prevalence of rare diseases within the end-stage renal disease (ESRD) population is limited. The aims of this study were (i) to identify those rare diseases within the ERA-EDTA Registry for which renal replacement therapy (RRT) is being provided and (ii) to determine the prevalence and incidence of RRT for ESRD due to rare diseases, both overall and separately for children and adults.
The Orphanet classification of rare disease was searched for rare diseases potentially causing ESRD, and these diagnosis codes were mapped to the corresponding ERA-EDTA primary renal disease codes. Thirty-one diagnoses were defined as rare diseases causing ESRD.
From 1 January 2007 to 31 December 2011, 7194 patients started RRT for a rare disease (10.6% children). While some diseases were exclusively found in adults (e.g. Fabry disease), primary oxalosis, cystinosis, congenital anomalies of the kidney and urinary tract (CAKUT) and medullary cystic kidney disease affected young patients in up to 46%. On 31 December 2011, 20 595 patients (12.4% of the total RRT population) were on RRT for ESRD caused by a rare disease. The point prevalence was 32.5 per million age-related population in children and 152.0 in adults. Only 5.8% of these patients were younger than 20 years; however, 57.7% of all children on RRT had a rare disease, compared with only 11.9% in adults. CAKUT and focal segmental glomerulosclerosis were the most prevalent rare disease entities among patients on RRT.
More than half of all children and one of nine adults on RRT in the ERA-EDTA Registry suffer from kidney failure due to a rare disease, potentially with a large number of additional undiagnosed or miscoded cases. Comprehensive diagnostic assessment and the application of accurate disease classification systems are essential for improving the identification and management of patients with rare kidney diseases.
Aim
Protein‐bound uraemic toxin accumulation causes uraemia‐associated cardiovascular morbidity. Enhancing the plasma ionic strength releases toxins from protein binding and makes them available for ...removal during dialysis. This concept was implemented through high sodium concentrations (Na+) in the substituate of pre‐dilution haemodiafiltration at increased plasma ionic strength (HDF‐IPIS).
Methods
Ex vivo HDF‐IPIS with blood tested increasing Na+ to demonstrate efficacy and haemocompatibility. Haemocompatibility was further assessed in sheep using two different HDF‐IPIS set‐ups and Na+ between 350 and 600 mmol L−1. Safety and efficacy of para‐cresyl sulphate (pCS) and indoxyl sulphate (IS) removal was further investigated in a randomized clinical pilot trial comparing HDF‐IPIS to HD and HDF.
Results
Compared to Na+ of 150 mmol L−1, ex vivo HDF‐IPIS at 500 mmol L−1 demonstrated up to 50% higher IS removal. Haemolysis in sheep was low even at Na+ of 600 mmol L−1 (free Hb 0.016 ± 0.001 g dL−1). In patients, compared to HD, a Na+ of 240 mmol L−1 in HDF‐IPIS resulted in 40% greater reduction (48.7 ± 23.6 vs. 67.8 ± 7.9%; P = 0.013) in free IS. Compared to HD and HDF (23.0 ± 14.8 and 25.4 ± 10.5 mL min−1), the dialytic clearance of free IS was 31.6 ± 12.8 mL min−1 (P = 0.017) in HDF‐IPIS, but Na+ in arterial blood increased from 132 ± 2 to 136 ± 3 mmol L−1 (0 vs. 240 min; P < 0.001).
Conclusion
HDF‐IPIS is technically and clinically feasible. More effective HDF‐IPIS requires higher temporary plasma Na+, but dialysate Na+ has to be appropriately adapted to avoid sodium accumulation.
The incidence of cardiovascular disease (CVD) is very high in patients with chronic kidney (CKD) disease and in kidney transplant recipients. Indeed, available evidence for these patients suggests ...that the 10‐year cumulative risk of coronary heart disease is at least 20%, or roughly equivalent to the risk seen in patients with previous CVD. Recently, the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (K/DOQI) published guidelines for the diagnosis and treatment of dyslipidemias in patients with CKD, including transplant patients. It was the conclusion of this Work Group that the National Cholesterol Education Program Guidelines are generally applicable to patients with CKD, but that there are significant differences in the approach and treatment of dyslipidemias in patients with CKD compared with the general population. In the present document we present the guidelines generated by this workgroup as they apply to kidney transplant recipients. Evidence from the general population indicates that treatment of dyslipidemias reduces CVD, and evidence in kidney transplant patients suggests that judicious treatment can be safe and effective in improving dyslipidemias. Dyslipidemias are very common in CKD and in transplant patients. However, until recently there have been no adequately powered, randomized, controlled trials examining the effects of dyslipidemia treatment on CVD in patients with CKD. Since completion of the K/DOQI guidelines on dyslipidemia in CKD, the results of the Assessment of Lescol in Renal Transplantation (ALERT) Study have been presented and published. Based on information from randomized trials conducted in the general population and the single study conducted in kidney transplant patients, these guidelines, which are a modified version of the K/DOQI dyslipidemia guidelines, were developed to aid clinicians in the management of dyslipidemias in kidney transplant patients. These guidelines are divided into four sections. The first section (Introduction) provides the rationale for the guidelines, and describes the target population, scope, intended users, and methods. The second section presents guidelines on the assessment of dyslipidemias (guidelines 1–3), while the third section offers guidelines for the treatment of dyslipidemias (guidelines 4–5). The key guideline statements are supported mainly by data from studies in the general population, but there is an urgent need for additional studies in CKD and in transplant patients. Therefore, the last section outlines recommendations for research.
Abstract
The strengths and the limitations of research activities currently present in Europe are explored in order to outline how to proceed in the near future. Epidemiological and clinical research ...and public policy in Europe are generally considered to be comprehensive and successful, and the European Renal Association – European Dialysis and Transplant Association (ERA-EDTA) is playing a key role in the field of nephrology research. The Nephrology and Public Policy Committee (NPPC) aims to improve the current situation and translation into public policy by planning eight research topics to be supported in the coming 5 years by ERA-EDTA.
•Multicomponent geothermometry approach is coupled with numerical optimization.•Allows reconstruction the deep fluid composition using water analyses from multiple locations.•Application of this ...method to the Dixie Valley geothermal field suggests the presence of two separate reservoirs.•Impact of fluid re-equilibration on temperature estimations is investigated with reactive transport modeling.•Promising approach to evaluate geothermal reservoir temperatures in an integrated manner.
A new geothermometry approach is explored, incorporating multicomponent geothermometry coupled with numerical optimization to provide more confident estimates of geothermal reservoir temperatures when results of classical geothermometers are inconsistent. This approach is applied to geothermal well and spring waters from the Dixie Valley geothermal area (Nevada), to evaluate the influence of salt brines mixing and dilution of geothermal fluids on calculated temperatures. The main advantage of the optimized multicomponent method over classical geothermometers is its ability to quantify the extent of dilution and gas loss experienced by a geothermal fluid, and to optimize other poorly constrained or unknown parameters (such as Al and Mg concentrations), allowing the reconstruction of the deep reservoir fluid composition and therefore gaining confidence in reservoir temperatures estimations. Because the chemical evolution of deep geothermal fluids is a combination of multiple time-dependent processes that take place when these fluids ascend to the surface, reactive transport modeling is used to assess constraints on the application of solute geothermometers. Simulation results reveal that Al and Mg concentrations of ascending fluids are sensitive to mineral precipitation–dissolution affecting reservoir temperatures inferred with multicomponent geothermometry. In contrast, simulations show that the concentrations of major elements such as Na, K, and SiO2 are less sensitive to re-equilibration. Geothermometers based on these elements give reasonable reservoir temperatures in many cases, except when dilution or mixing with saline waters has taken place. Optimized multicomponent geothermometry yields more representative temperatures for such cases. Taking into account differences in estimated temperatures, and chemical compositions of the Dixie Valley thermal waters, a conceptual model of two main geothermal reservoirs is proposed. The first reservoir is located along the Stillwater range normal fault system and has an estimated temperature of 240–260°C. It covers the area corresponding to the geothermal field but could extend towards the south-west where deep temperatures of 200–225°C are estimated. The second reservoir has an estimated temperature of 175–190°C and extends from well 62-21 to northeastern Hyder, Lower Ranch, Fault Line, and Jersey springs.
Abstract Background Nocardia is a genus of gram-positive Actinomycetes that are ubiquitous in decaying organic material, soil, and water. Some Nocardia species can infect humans, mainly by airborne ...transmission. Several reports describe disseminated infections, which are rare and mostly affect strongly immunocompromised patients because intact T-cell–mediated immunity is the major protective mechanism. Case Report We report a case of disseminated pulmonary, cerebral, and cutaneous infection with Nocardia farcinica in a 66-year-old kidney transplant recipient treated with low-dose triple immunosuppression. The patient was initially admitted because of severe hyponatremia and pneumonia with radiologic signs of pleural effusion. The infectious agent was isolated when cutaneous lesions developed. Oral trimethoprim/sulfamethoxazole treatment led to severe hyponatremia; therefore, long-term treatment with parenteral amikacin and minocycline was initiated. After 7 months of consistent intravenous treatment, the lesions completely resolved and treatment was stopped, against some expert suggestions. The patient had remained free of relapse at the time of writing. Conclusions Disseminated Nocardia infection in immunocompromised patients is a rare but life-threatening disease. Owing to its infrequency, the variety of clinical patterns, antimicrobial resistance, and often fatal complications of standardized therapy, the diagnosis and treatment of this infection remain challenging and protracted.
Data suggest an additional role of T cells in antibody-mediated rejections. In 2001 a protocol for AB0-incompatible kidney transplantation based on B-cell–depleting anti–CD20 antibody rituximab, ...antigen-specific blood group IgG immunoadsorption, intravenous immunoglobulins, and triple immunosuppression was introduced in Europe, which used induction therapy with the use of interleukin-2 receptor antibody (IL2-RA) basiliximab. We used thymoglobulin in AB0-incompatible patients as induction in the face of high immunologic risk.
We retrospectively evaluated a cohort of 9 AB0i living donation (LD) recipients from 2011 to 2014. Desensitization included blood group–specific immunoadsorption. Eighteen AB0-compatible LD recipients receiving induction therapy with thymoglobulin served as control subjects. Another control group consisted of 18 AB0-compatible LD recipients receiving basiliximab. Follow-up was 24 months. We captured graft function by estimating glomerular filtration rate (eGFR by Modification of Diet in Renal Disease formula), rejection episodes, and bacterial and viral infections.
All patients experienced immediate graft function. No significant or clinical differences were observed regarding graft function, rejection rates, or infections between the groups, although there seemed to be slightly higher cytomegalovirus infection rates due to preemptive therapy strategy.
Thymoglobulin appears to be similar in safety and efficacy to IL-2-antagonists in AB0i kidney transplantation.
•In AB0-incompatible kidney transplantation, immunologic risk is high and T-cell involvement in antibody-mediated rejection is described.•Because of the high immunologic risk, we use T-cell–depleting antibody thymoglobulin instead of the more common interleukin-2 receptor antagonist basiliximab.•We share the concerns about higher risk of severe infections or opportunistic pathogens. Most centers use basiliximab even in high-risk patients owing to these apprehensions.•We still believe that most rejection episodes are triggered by T cells, and we see that thymoglobulin in a low-dose regimen is safe and effective.•We compared 9 AB0-incompatible kidney transplantations with 36 matched AB-compatible control cases who received either thymoglobulin or basiliximab.•In our cohort we did not see a significantly higher risk for complications.
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