Ann Bugeja

Gout After Living Kidney Donation: A Matched Cohort Study

BACKGROUND In the general population, high serum uric acid concentration is a risk factor for gout. It is unknown whether donating a kidney increases a living donors risk of gout as serum uric acid concentration increases in donors after nephrectomy. STUDY DESIGN Retrospective matched cohort study using large health care databases. SETTING & PARTICIPANTS We studied living kidney donors who donated in 1992 to 2010 in Ontario, Canada. Matched nondonors were selected from the healthiest segment of the general population. 1,988 donors and 19,880 matched nondonors were followed up for a median of 8.4 (maximum, 20.8) years. PREDICTOR Living kidney donor nephrectomy. OUTCOMES The primary outcome was time to a diagnosis of gout. The secondary outcome in a subpopulation was receipt of medications typically used to treat gout (allopurinol or colchicine). MEASUREMENTS We assessed the primary outcome with health care diagnostic codes. RESULTS Donors compared with nondonors were more likely to be given a diagnosis of gout (3.4% vs 2.0%; 3.5 vs 2.1 events/1,000 person-years; HR, 1.6; 95% CI, 1.2-2.1; P<0.001). Similarly, donors compared with nondonors were more likely to receive a prescription for allopurinol or colchicine (3.8% vs 1.3%; OR, 3.2; 95% CI, 1.5-6.7; P=0.002). Results were consistent in multiple additional analyses. LIMITATIONS The primary outcome was assessed using diagnostic codes in health care databases. Laboratory values for serum uric acid and creatinine in follow-up were not available in our data sources. CONCLUSIONS The findings suggest that donating a kidney modestly increases an individuals absolute long-term incidence of gout. This unique observation should be corroborated in future studies.

Lupus after kidney donation to an affected male relative.

We report a case of lupus occurring in a 52 year-old woman approximately 2 years after donating a kidney to her brother who had end-stage-renal-disease on the basis of lupus nephritis (LN). At the time of donation, the patient had been asymptomatic with a normal physical examination, laboratory and imaging studies. At the time of her diagnosis of lupus she was found to be ANA negative but positive for anti-double stranded DNA. Testing for markers of autoimmune disease was not performed prior to donation. There is little guidance in the literature on risk stratification for potential living kidney donors with a family history of systemic lupus erythematosus (SLE) and LN. The utility of routine ANA testing for all potential kidney donors is limited however it may help inform the risk-assessment of possible donors with a family history of SLE. We suggest that ANA screening be done for all potential kidney donors with first-degree relatives who have SLE. More complete screening for autoimmune markers and greater caution should be used when assessing potential kidney donors with SLE-affected first-degree male relatives.

As in Real Estate, Location Is What Matters: A Case Report of Transplant Ureteral Obstruction Due to an Inguinal Hernia:

Background: Kidney allograft dysfunction is common and often reversible but can lead to allograft loss if not promptly evaluated. Transplant ureteral obstruction in an inguinal hernia is a rare cause of allograft dysfunction, but early recognition may prevent allograft loss. Case Presentation: We present a case of a man with acute kidney allograft dysfunction who received a deceased donor kidney transplant 6 years earlier for end-stage kidney disease secondary to polycystic kidney disease. Abdominal ultrasounds revealed hydronephrosis without full visualization of the transplant ureter. Abdominal computed tomography revealed moderate hydronephrosis of the transplant kidney due to obstructed herniation of the transplant ureter in a right inguinal hernia. A stent was inserted into the transplant ureter to prevent further allograft dysfunction and facilitate hernia repair. Conclusions: Transplant ureteral obstruction is a rare cause of acute kidney allograft dysfunction, and its detection can be challenging. The recognition of transplant ureteral obstruction is vital to timely management for preventing allograft loss.

Sickle cell disease: a case report of renal amyloidosis

BackgroundThe development of proteinuria and reduced glomerular filtration rate is associated with higher mortality among patients with sickle cell disease (SCD). AA amyloidosis, also associated with increased mortality, in SCD is rare. We present a case of a woman with homozygous sickle cell disease with nephrotic syndrome and antibodies to double stranded DNA without clinical features of systemic lupus erythematosus. Kidney biopsy reveals AA amyloidosis and is the first report of concomitant AA amyloidosis with antibodies to double stranded DNA in SCD.Case presentationA 40-year-old Central African woman with homozygous sickle cell disease and history of vaso-occlusive pain crises undergoes kidney biopsy for nephrotic-range proteinuria. Kidney biopsy reveals AA type amyloidosis, which is a rare manifestation of SCD in the kidney. Her anemia worsens with an ACE inhibitor, initiated to reduce proteinuria and limit GFR decline, so it was discontinued. Hydroxyurea, shown to decrease the frequency of vaso-occlusive crises and lower proteinuria, was subsequently initiated but then discontinued due to worsening anemia. Unfortunately, her glomerular filtration rate worsens.ConclusionsAA amyloidosis and antibodies to double stranded DNA can occur in sickle cell disease. ACE inhibition and hydroxyurea decrease proteinuria so they may limit progression of chronic kidney disease. Hydroxyurea also decreases frequency of vaso-occlusive pain crises so it might be helpful in limiting progression of renal AA amyloidosis. However, further studies are needed to determine optimal treatment strategies for AA amyloidosis in sickle cell disease.

Hemodialysis Access Choice: Impact of Health Literacy

Background: Hemodialysis patients need to make decisions about vascular access and diet that they may not fully understand. In this study, we hypothesized that patients with low health literacy are likely to choose a central venous catheter (CVC) and have higher serum potassium (K), serum phosphate (P), and inter-dialysis weight gains (IDWG). Objective: Primarily, the study sought to describe the health literacy of patients treated with hemodialysis in a Canadian tertiary care center. The secondary objective was to describe the association between health literacy and permanent vascular access choice, hyperkalemia, hyperphosphatemia, and IDWG. Methods: Adult patients receiving hemodialysis for more than 6 months were included. Health literacy was assessed with the Newest Vital Sign (NVS) test. Vascular access type and reasons for CVC use were determined. Serum K, P, and IDWG were collected retrospectively for 6 months. Students t test and logistic regression were used to determine the association between health literacy (NVS score < 4 versus ≥ 4) and CVC choice, hyperkalemia, hyperphosphatemia, and high IDWG. Key Results: Fifty-six patients were involved. The average NVS score was 2.9. Overall, 66% of the patients had a CVC; one-third had chosen this access themselves. Poor control of K, P, and IDWG was experienced by 27%, 55%, and 36% of patients, respectively. The average NVS score was lower for patients choosing a CVC (p = .001), but not different for those with higher K, P, or IDWG. None of the patients who chose a CVC had adequate health literacy (NVS ≥ 4). Conclusions: Patients with low health literacy, who are eligible for both surgically created vascular access (fistula or graft) and CVC, are more likely to refuse fistula/graft creation compared to patients with adequate health literacy. Different educational strategies for such patients may help in appropriate decision-making. [Health Literacy Research and Practice. 2017;1(3):e136–e144.] Plain Language Summary: This study suggests that more than one-half of patients who receive hemodialysis may not understand all the information provided by their health care team. Despite a higher risk of complications with a central venous catheter, patients with lower health literacy prefer the catheter over fistula as their blood access for hemodialysis. We need to explore patient education to ensure that information is easy to understand.

Living kidney donation

Kidney transplantation from living donors has improved survival rates, better quality of life and lower costs for health care for eligible patients with end-stage kidney disease than dialysis.[1][1],[2][2] Kidney transplants from living donors also last about 25% longer (typically 20–25 years) and