André Weigert

JC polyomavirus nephropathy confirmed by using an in-house polymerase chain reaction method

We report the case of an isolated JC virus (JCV) infection, without co‐infection by polyoma BK virus (BKV), associated with nephropathy 4 years after kidney transplantation. Clinical suspicion followed the observation of a decrease in estimated glomerular filtration rate (eGFR) and a renal allograft biopsy revealing polyomavirus‐associated tubulointerstitial nephritis and positivity for SV40. An in‐house real‐time polymerase chain reaction assay, targeting the presence of JCV and the absence of BKV in biopsy tissue, confirmed diagnosis. Thirteen months after diagnosis, and following therapeutic measures, eGFR remains stable.

Gastrointestinal Bleeding and Diffuse Skin Thickening as Kaposi Sarcoma Clinical Presentation

A 56-year-old African patient received a kidney from a deceased donor with 4 HLA mismatches in April 2013. He received immunosuppression with basiliximab, tacrolimus, mycophenolate mofetil, and prednisone. Immediate diuresis and a good allograft function were soon observed. Six months later, the serum creatinine level increased to 2.6 mg/dL. A renal allograft biopsy revealed interstitial fibrosis and tubular atrophy grade II. Toxicity of calcineurin inhibitor was assumed and, after a switch for everolimus, renal function improved. However, since March 2014, renal function progressively deteriorated. A second allograft biopsy showed no new lesions. Two months later, the patient was admitted due to anuria, haematochezia with anaemia, requiring 5 units of packed red blood cells, and diffuse skin thickening. Colonoscopy showed haemorrhagic patches in the colon and the rectum; histology diagnosis was Kaposi sarcoma (KS). A skin biopsy revealed cutaneous involvement of KS. Rapid clinical deterioration culminated in death in June 2014. This case is unusual as less than 20 cases of KS with gross gastrointestinal bleeding have been reported and only 6 cases had the referred bleeding originating in the lower gastrointestinal tract. So, KS should be considered in differential diagnosis of gastrointestinal bleeding in some kidney transplant patients.

Ablação da atividade simpática renal para tratamento da hipertensão arterial resistente

Hypertension is an important cardiovascular risk factor and although there have been many improvements in pharmacological treatment, a significant percentage of patients are still considered resistant. The authors describe two cases of radiofrequency renal sympathetic denervation that illustrate the feasibility of this new technique for the treatment of resistant hypertension. The procedure consists of the application of radiofrequency energy inside the renal arteries to ablate afferent and efferent sympathetic renal activity, which has been implicated in the pathophysiology of hypertension.

Risk of Hepatitis B reactivation in kidney transplant recipients seronegative for the Hepatitis B surface antigen and seropositive for the Hepatitis B core antibody

Previous contact with Hepatitis B virus (HBV) is common in patients undergoing hemodialysis. Literature has shown conflicting results on the risk of HBV reactivation in kidney transplant (KT) recipients with serologic evidence of past HBV infection.

Multiple brown tumors – a rare presentation in the modern era

Chronic kidney disease (CKD) commonly evolves with disturbances in mineral and bone metabolism, currently defined as CKD-MBD. Management strategies have progressed over the years, but our knowledge regarding evaluation and treatment is still sparse. Herein, we describe a rare case of a hemodialysis patient with apparently fairly controlled hyperparathyroidism (HPTH), who developed multiple symptomatic brown tumors involving the scull, mandible, vertebrae, pelvis, and metacarpus. Parathyroidectomy allowed complete resolution of the bone lesions preventing disastrous consequences.
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Letter to the Editor. Use of Vitamin K Antagonists in Patients on Hemodialysis: Is Benefit Greater than the Risk?

Dear Editor, Recently, Salgado C et al described in this journal an uncommon condition in a 14-year-old female, which is cholestatic hepatitis caused by Epstein-Barr virus infection.1 Her jaundice was noticed in the third day of treatment with amoxicillin because of fever, odynophagia and lymphadenopathy, further associated with infectious mononucleosis.1 Blood tests and abdominal imaging revealed cholestatic hepatitis, hepatosplenomegaly with normal bile ducts, viral capsid antigen (IgM and IgG) positive, whereas the early antigen and Epstein-Barr nuclear antigen were negative.1 The diagnostic confirmation was based on serological controls showing reduction in the IgM and elevation in the IgG levels, and conversion of Epstein-Barr nuclear antigen.1 The authors emphasized the levels of direct bilirubin (6.3 mg/dL), γ-glutamyl transpeptidase (173 IU/L), alkaline phosphatase (488 IU/L), lactate dehydrogenase (872 IU/L) and aminotransferases (245 and 294 IU/L), indicative of mixed hepatic injury.1 Worthy of note, the total leukocyte count was 22100/μL, with 89.6% lymphocytes. With symptomatic management the evolution was favorable, and there

IGA nephropathy – Are intravenous steroid pulses more effective than oral steroids in relapse prevention?

INTRODUCTION It is recommended that IgA nephropathy (IgAN) is treated with steroids when the glomerular filtration rate (GFR) is >50ml/min and proteinuria >1g/day. Few studies have been performed comparing the two accepted steroid regimens (1g/day methylprednisolone pulses for 3 consecutive days at the beginning of months 1, 3 and 5, followed by 0.5mg/kg prednisolone on alternate days vs. 1mg/kg/day oral prednisolone). The aim of this study was to compare these two steroid regimens in IgAN treatment. METHODS We selected 39 patients with biopsy-proven IgAN treated with steroids. Mean age at diagnosis was 37.5 years, 23 males (59%), baseline proteinuria (Uprot) was 2.1 g/day and median serum creatinine (SCr) was 1.5mg/dl. The mean follow-up period was 56 months. Twenty-five patients (64%) were treated with methylprednisolone pulses and 14 (36%) with oral steroids. RESULTS Patients treated with steroid pulses presented lower relapse risk, defined as the reappearance of Uprot >1g/day and an Uprot increase of more than 50% (incidence rate ratio of 0.18, 95% CI 0.02-0.5). The Kaplan-Meier analysis showed longer relapse-free period (p=0.019). This result was confirmed in a multivariate analysis (p=0.026). However, we did not find other differences between the two steroid regimens. CONCLUSIONS In comparison to oral steroids, the intravenous pulse regimen was associated with a lower risk of relapse in IgAN, a known independent negative predictor of renal survival. No differences were found regarding the other renal outcomes.