Hanna Augustyniak-Bartosik

The increased risk of post-transplant diabetes mellitus in peritoneal dialysis-treated kidney allograft recipients

BACKGROUND Post-transplant diabetes mellitus (PTDM) is a common metabolic complication in kidney allograft recipients, significantly contributing to the elevated cardiovascular morbidity after renal transplantation and increased risk of chronic transplant dysfunction. The aim of the present investigation was to evaluate the factors influencing PTDM development. Under particular consideration were the elements, existing before the transplantation, especially the modality of dialysis treatment significance, i.e. haemodialysis (HD) versus peritoneal dialysis (PD). METHODS Three hundred and seventy-seven consecutive outpatients who underwent renal transplantation (RTx) in our institution between January 2003 and December 2005 were analysed. PTDM was diagnosed according to the current American Diabetic Association/World Health Organization criteria. Statistical inference was conducted by means of univariate methods (one factor versus PTDM) and multivariate methods in frames of generalized linear model. RESULTS In the study group, 72 patients (23.4%) developed PTDM after RTx (55 HD and 17 PD patients). PTDM incidence at 3, 6 and 12 months was 15.9%, 22.1% and 23.4%, respectively. The mean interval from transplantation to the onset of PTDM was 3.08 ± 2.73 months. In univariate analysis, the factors associated with the elevated risk of PTDM appearance were older recipient age, positive family history of diabetes, hypertensive nephropathy as end-stage renal disease cause, higher body mass index at transplantation, treatment by PD, and the graft from an older donor. In multivariate verification, statistical significance remained: older recipient age (P < 0.001), positive family history of diabetes (P = 0.002), and treatment by PD (P = 0.007). CONCLUSIONS Treatment by PD appears to be a possible novel factor, not yet reported, which may increase the risk of PTDM development.

Effective treatment of Kaposi sarcoma with everolimus in a patient with membranous glomerulonephritis.

A 78-year-old female patient with hypertension, atrial fibrillation, drug-induced diabetes mellitus and chronic kidney disease stage 3 was diagnosed with heavy nephrotic syndrome. A renal biopsy proved membranous nephropathy, serum antibodies against phospholipase A2 receptor (anti-PLA2R antibodies) were negative (Fig. 1A). The secondary causes of nephrotic syndrome were excluded. Tests for autoantibodies, viral infection (hepatitis B virus, hepatitis C virus, human immunodeficiency virus), serum protein electrophoresis and immunofixation for monoclonal protein were normal. Carcinoma antigens, except for Ca 125 antigen (132.3 U/mL, N: 0–35 U/mL), were negative. Transvaginal ultrasound revealed normal images of the uterus and ovaries and the presence of fluid in the Pouch of Douglas. We recognised that increased Ca 125 antigen corresponded to nephrotic syndrome. Due to persistent severe nephrotic syndrome with impaired renal function (serum albumin 17 g/L N: 35–52, total protein 42 g/L N: 66–83, daily proteinuria 7 g, serum creatinine 174 μmol/L, N: 62–115), the patient received steroids with the starting dose of 40 mg/day with cyclosporine of 125 mg/day (trough level 129.7 ng/mL), replaced after 2 months by tacrolimus 2 mg/day (trough 4.5 ng/mL). Partial remission of nephrotic syndrome was obtained (serum albumin 31 g/L, total protein 52 g/L, daily proteinuria 1.4 g). During the fifth month of the treatment, several lifted purple nodules appeared on the patient’s calves and shins. The lesions gradually spread to the thighs, the trunk and the left forearm (Fig. 1B). During the histopathologic examination of skin samples Kaposi sarcoma (KS) was identified (Fig. 1C,D). One month later, additional 5 mm maculopapular KS lesion developed in the right eye (Fig. 1E). The presence of serum anti-human herpesvirus-8 (HHV-8) IgG antibodies confirmed the history of infection.

Depressive symptoms but not chronic pain have an impact on the survival of patients undergoing maintenance hemodialysis

Introduction More than 1/3 of patients with end-stage renal disease who are in a chronic dialysis program suffer from chronic pain and depression/anxiety. The aim of the study was to determine the impacts of symptoms of depression/anxiety, chronic pain and quality of life (QoL) on 6-year patient survival. Material and methods Observational study of end-stage renal disease patients on maintenance hemodialysis (n = 205) who met the inclusion criteria. Patients from three dialysis centers in Lower Silesia were asked to complete a battery of validated questionnaires: the Hospital Anxiety and Depression Scale (HADS), the 36-item Short Form Health Survey Questionnaire, the Verbal Rating Scale (VRS) and the Visual Analog Scale (VAS). Clinical and biochemical data (dialysis adequacy) were recorded. Results One hundred thirty from 205 enrolled hemodialysis patients (63.4%) suffered from chronic pain. Patients with pain were on maintenance dialysis for longer times and had higher levels of parathyroid hormone, more depressive symptoms and a lower QoL than those without pain. In the 6-year period, 96 (46.8%) patients died. The most common cause of death was cardiovascular disease in 44 (45.8%) patients. Highly depressed patients (HADS depression score > 8) exhibited higher mortality (< 8 vs. > 8 points; p = 0.016) independent of age, diabetes, cardiovascular disease, C-reactive protein or albumin level. Conclusions Chronic pain, although common among hemodialysis patients, did not lower survival. Depressive symptoms are an important predictor for all-cause mortality in hemodialysis patients, with the relationship independent of nutritional or inflammatory status.

Hepatitis C-associated glomerulonephritis mimicking systemic lupus erythematosus

Hepatitis C virus (HCV) infection is known to be responsible for many autoimmune reactions but its association with systemic lupus erythematosus (SLE) has not yet been established. We present the c...

Pathogenic role of antibodies against monomeric C‐reactive protein in tubulointerstitial nephritis and uveitis syndrome

Antibodies against monomeric C‐reactive protein, which is a target antigen expressed both in kidney tubules and uveal cells, have been recently detected in patients with active tubulointerstitial nephritis and uveitis syndrome. We report the case of an 65‐year‐old woman with acute renal failure caused by biopsy‐proven tubulointerstitial nephritis and the onset of uveitis 21 months later. The expression of monomeric C‐reactive protein in kidney oligobiopsy was confirmed by immunohistochemical staining using mouse monoclonal antibody against human monomeric C‐reactive protein. The levels of antibodies against monomeric C‐reactive protein were 117% of the reference during the flare and 22% during the remission of the disease. The difference in the levels of antibodies against monomeric C‐reactive protein during flare and remission, and above all positive biopsy staining, supports their pathogenic role in this disease.

Novel PKD1 mutations - the effect on clinical phenotype of ADPKD patients in Lower Silesia.

INTRODUCTION Autosomal dominant polycystic kidney disease (ADPKD) is characterized by the development and progressive enlargement of cysts in the kidneys. The diagnosis of ADPKD is usually determined by criteria of renal ultrasound imaging of the development and number of cysts. However, in atypical cystic disease, for the recognition of ADPKD, DNA-based assays may be required. MATERIALS AND METHODS In the present study PCR amplified fragments of the PKD1 gene (covering exons 15 and 43- 44) from genomic DNA of 134 Lower Silesia patients were analyzed for mutations and polymorphisms. Among them, the clinical significance of different PKD1 mutations was investigated in 81 persons. RESULTS Eight new, previously undescribed, and 2 recurrent mutations were discovered. The presence of 3 known polymorphisms was confirmed. Seven of the 8 new discovered mutations were heterozygous. DISCUSSION The results of the present study demonstrated that the frequency of genetic abnormalities in the analyzed fragments of the PKD1 gene in the Lower Silesian population is smaller than previously reported. Moreover, we could not detect deletions and insertions, which are often present is these regions of the PKD1 gene, which may be due to the limited number of screened patients. We conclude that none of the discovered changes in the PKD1 gene had any effect on clinical phenotype of the disease.

Different Relevance of Peripheral, Central or Nighttime Blood Pressure Measurements in the Prediction of Chronic Kidney Disease Progression in Patients with Mild or No-Proteinuria

Background/Aims: Arterial hypertension is one of the leading factors aggravating the course of chronic kidney disease (CKD). It seems that the novel parameters used in the assessment of the blood pressure (BP) load (i.e. central blood pressure, nighttime blood pressure) may be more precise in predicting the cardiovascular risk and the progression of CKD in comparison with the traditional peripheral blood pressure measurements in the office conditions. The aim of the study was to assess the impact of the central, or nighttime blood pressure on the progression of CKD in patients with mild or no-proteinuria (autosomal, dominant polycystic kidney disease or IgA nephropathy). Methods: In each of the enrolled 46 patients with CKD stage 3 or 4, serum creatinine concentration was assessed, eGFR (MDRD) was calculated, also central blood pressure and pulse wave velocity (PWV) was assessed and the 24-hour ambulatory blood pressure monitoring (ABPM) was conducted at the beginning of the study and then repeated after one-year observation period. Results: During the observation period mean eGFR decreased from 44.1 (33.2-50.6) mL/min to 36.7 (29.7-46.3) mL/min. No significant differences were observed in the peripheral blood pressure or central blood pressure parameters. After one-year observation period the values of diastolic blood pressure dipping during the night significantly decreased from 16 (13-19) mmHg to 12 (10-15) mmHg; p< 0.05. The values of systolic dipping during the night or the mean BP values recorded in ABPM did not change significantly. Additionally, no significant differences in the PWV values were found. In the multivariate regression model the change of serum creatinine concentration was explained by the initial diastolic dipping values. Conclusion: 1. In patients with CKD stages 3 or 4 and mild or no- proteinuria, peripheral and central blood pressure did not change significantly during a one-year observation period despite the significant decline of eGFR and seems not to participate in the CKD progression. 2. Reduced magnitude of the diastolic dipping, which reflects the increase of diastolic blood pressure load during the nighttime, may play an important role in the pathogenesis of deterioration of kidney function in these patients.

Stem cell mobilization in patients with dialysis-dependent multiple myeloma: Report of the polish multiple myeloma group

High‐dose chemotherapy with autologous hematopoietic stem cell transplantation (auto‐HSCT) improves the outcome of patients with multiple myeloma (MM). It seems that auto‐HSCT is also a feasible therapeutic option in MM dialysis‐dependent (MMDD) patients. However, to perform transplantation, a sufficient number of stem cells must be collected.

Autologous peripheral blood stem cell transplantation in dialysis-dependent multiple myeloma patients-DAUTOS Study of the Polish Myeloma Study Group

Dialysis‐dependent (DD) multiple myeloma patients (MM) have a poor prognosis and high tumour burden, thus may benefit from autologous peripheral blood stem cell transplantation (auto‐PBSCT), however, these patients have an increased risk of toxicity.

The sleeve method for creation of radiocephalic arteriovenous fistulas in patients with calcified vessels

Introduction Creation of an arteriovenous fistula (AVF) in patients with advanced atherosclerotic changes of the artery is often a challenge for the physician due to difficulties in suturing the vein to the side of the frangible artery. The sleeve technique relies on advancing the end of the artery into the lumen of the vein and protecting the anastomosis by adventitial sutures. Material and Methods The sleeve technique was performed in 23 patients with chronic kidney disease stage IV and V and included hemodialysis patients. Their mean age was 60.8 ± 14.8 years and hemodialysis treatment time 49.8 ± 40.2 months. The most frequent causes of chronic kidney disease are ischemic nephropathy (43%, n = 10) and type l diabetes (21%, n = 5). Only patients with extremely advanced atherosclerotic were recruited and analyzed. Results The primary patency rate was 67%, 59%, 44% and 28% at 6, 12, 24, and 36 months, respectively. The secondary patency rate was 67%, 61%, 50% and 37% at 6, 12, 24, and 36 months, respectively. In three patients the AVF failed directly after the operation. Delayed fistula failure occurred in seven patients. The overall success in the creation of a functioning fistula was achieved in 15 of the 23 patients (65%). No serious complications were observed. Conclusions In patients with calcified atherosclerotic plaques, which constitute a barrier or make it difficult to suture the vein to the side of the artery, the sleeve method may be considered as an alternative before abandoning the creation of a fistula on the forearm. The technique is much simpler than the standard end-to-side or side-to-side anastomosis.