Julien Demiselle

Transplantation of kidneys from uncontrolled donation after circulatory determination of death: comparison with brain death donors with or without extended criteria and impact of normothermic regional perfusion.

The aim of this study was to compare the outcomes of kidney transplants from uncontrolled DCD (uDCD) with kidney transplants from extended (ECD) and standard criteria donors (SCD). In this multicenter study, we included recipients from uDCD (n = 50), and from ECD (n = 57) and SCD (n = 102) who could be eligible for a uDCD program. We compared patient and graft survival, and kidney function between groups. To address the impact of preservation procedures in uDCD, we compared in situ cold perfusion (ICP) with normothermic regional perfusion (NRP). Patient and graft survival rates were similar between the uDCD and ECD groups, but were lower than the SCD group (P < 0.01). Although delayed graft function (DGF) was more frequent in the uDCD group (66%) than in the ECD (40%) and SCD (27%) groups (P = 0.08 and P < 0.001), graft function was comparable between the uDCD and ECD groups at 3 months onwards post‐transplantation. The use of NRP in the uDCD group (n = 19) was associated with a lower risk of DGF, and with a better graft function at 2 years post‐transplantation, compared to ICP‐uDCD (n = 31) and ECD. In conclusion, the use of uDCD kidneys was associated with post‐transplantation results comparable to those of ECD kidneys. NRP preservation may improve the results of uDCD transplantation.

Low Serum Complement C3 Levels at Diagnosis of Renal ANCA-Associated Vasculitis Is Associated with Poor Prognosis

Background Recent studies have demonstrated the key role of the complement alternative pathway (cAP) in the pathophysiology of experimental ANCA-associated vasculitis (AAV). However, in human AAV the role of cAP has not been extensively explored. In the present work, we analysed circulating serum C3 levels measured at AAV onset and their relation to outcomes. Methods We conducted a retrospective observational cohort study including 45 consecutive patients with AAV diagnosed between 2000 and 2014 with serum C3 measurement at diagnosis, before immunosuppressive treatment initiation. Two groups were defined according to the median serum C3 level value: the low C3 group (C3<120 mg/dL) and the high C3 level group (C3≥120 mg/dL). Patient and renal survivals, association between C3 level and renal pathology were analysed. Results Serum complement C3 concentration remained in the normal range [78–184 mg/dL]. Compared with the high C3 level, the patients in the low C3 level group had lower complement C4 concentrations (P = 0.008) and lower eGFR (P = 0.002) at diagnosis. The low C3 level group had poorer patient and death-censored renal survivals, compared with the high C3 level group (P = 0.047 and P = 0.001, respectively). We observed a significant negative correlation between C3 levels and the percentage of glomeruli affected by cellular crescent (P = 0.017, r = -0.407). According to the Berden et al renal histologic classification, patients in the crescentic/mixed category had low C3 levels more frequently (P<0.01). Interestingly, we observed that when patients with the crescentic/mixed histologic form were analysed according to C3 level, long term renal survival was significantly greater in the high C3 level group than in the low C3 level group (100% vs 40.7% at 6 years, p = 0.046). No relationship between serum C4 and renal outcome was observed. Conclusion A Low C3 serum level in AAV patients at diagnosis is associated with worse long-term patient and renal survival.

Hypogammaglobulinemia and risk of severe infection in kidney transplant recipients.

Recent data have outlined a link between hypogammaglobulinemia (HGG) and infection risk and suggested that HGG correction may decrease post‐transplant infections.

Total Artificial Heart and Chronic Haemodialysis: A Possible Bridge to Transplantation.

Background: Total artificial heart (TAH) device is sometimes necessary to treat end stage heart failure (HF). After surgery, renal impairment can occur with the need of renal replacement therapy. Method: We report the case of a 51-year-old man who was treated with conventional hemodialysis (HD) while on support with TAH. Results: The patient underwent HD while on TAH support during 14 months. He benefited from conventional HD, 6 sessions per week. HD sessions were well tolerated, and patients condition and quality of life improved significantly. The main difficulty was to maintain red blood cell level because of chronic hemolysis due to TAH, which required repetitive blood transfusions, resulting in a high rate of human leukocyte antigen sensitization. Unfortunately, the patient died of mesenteric ischemia due to anticoagulation under dosing. Conclusion: We conclude that HD treatment is possible despite TAH and should be considered in patients with both end stage renal and HF.

Early post-transplant serum IgA level is associated with IgA nephropathy recurrence after kidney transplantation

IgA nephropathy (IgAN), the most frequent primary glomerulonephritis, affects young patients and is associated with a high risk of progression to end-stage renal disease. Consequently, patients with IgAN constitute an important proportion of candidates for kidney transplantation. Several studies showed a significant risk of IgAN recurrence on kidney graft, but the risks factors for recurrence remain to be accurately evaluated. Indeed, early identification of at risk patients may allow the optimization of treatment and the reduction of recurrence rate on the graft. In the present work, we studied the relationship between post-transplant serum IgA (sIgA) levels and the risk of IgAN recurrence after kidney transplantation. Recipients with IgAN had higher levels of sIgA as compared to patients with other nephropathies (p<0.05). The prevalence of IgAN recurrence was 20.8% during the period of analysis (mean follow-up of 6 ± 3.2 years). Serum IgA levels at M6, M12 and M24 post-transplant were significantly higher in patients with IgAN recurrence as compared to those without (p = 0.009, p = 0.035 and p = 0.029, respectively). Using receiver operating curve (ROC), sIgA at M6 and M12 post-transplant were significantly associated with IgAN recurrence (AUC = 0.771, p = 0.004 and AUC = 0.767, p = 0.016, respectively), while serum creatinine and proteinuria were not. Serum IgA level at month 6 was significantly associated with the occurrence of post-transplant IgA recurrence, whether it was analyzed as a continuous or a categorical variable. After successive adjustment on age, gender and proteinuria, sIgA remained a significant risk factor of post-transplant IgAN recurrence. Finally, survival free of IgAN recurrence was significantly better in patients with sIgA<222 mg/dL at month 6 as compare to IgAN patients with sIgA≥222 mg/dL (p = 0.03). Thus, the present work supports a link between post-transplant sIgA levels and IgAN recurrence and suggests that sIgA may be a valuable predictive biomarker of IgAN recurrence in kidney transplant recipients.

Is there still a place for the Swan–Ganz catheter? Yes

Swan–Ganz catheter use in the intensive care unit (ICU) is an endless matter of debate. In the past decade echocardiography has emerged as a major tool for understanding mechanisms of shock. We do not deny the utmost importance of echocardiography in the early phase of management of patients with shock. However, the use of echocardiography as a monitoring device is highly time consuming and operator dependent. For these reasons, we exclude echocardiography from this pro/con debate. As experts have no clear-cut opinion between Swan– Ganz catheter versus transpulmonary thermodilution for the diagnosis and monitoring of patients with shock states, we will review and defend Swan–Ganz catheter advantages. Modern hemodynamics approach in ICU relies on theoretical concepts that have been validated through heart catheterization. The Swan–Ganz catheter was the first device to make possible the application of heart catheterization at the bedside [1] and allowed us to build our common knowledge of systemic, as well as pulmonary hemodynamics. For these historical reasons, Swan–Ganz catheters represent a key pedagogical tool for teaching, learning and understanding hemodynamics and shock pathophysiology [2]. Moreover, in patients with acute respiratory distress syndrome (ARDS), it provides meaningful information for correct interpretation of gas exchange [3]. Swan–Ganz catheter provides measurements of right and left ventricular preloads by the direct measurement of pressures (central venous pressure, right atrial pressure, pulmonary artery pressure and pulmonary artery occlusion pressure), as well as cardiac output (using thermodilution principle, a robust technique) and mixed venous oxyhemoglobin saturation (SvO2). The Swan– Ganz catheter allows calculation of important metabolic variables such as oxygen delivery, consumption and extraction. Furthermore, it allows estimation of vasomotor tone through pulmonary and systemic vascular resistance indexes. The most recent version of Swan–Ganz catheters with continuous cardiac output and SvO2 monitoring are especially appreciated in patients with low cardiac output. Of note, Swan–Ganz catheters without these automatic and continuous monitoring options are less adequate for early warning. Despite the development of other monitoring tools in the ICU, the Swan–Ganz catheter is the only device offering the possibility to assess easily and monitor continuously right ventricle function [4]. This is helpful to diagnose right ventricle failure in everyday life, which is reflected by increased right atrial pressure and decreased

Before the ICU: does emergency room hyperoxia affect outcome?

There is now ample evidence that hyperox(em)ia—that is, increased inspired oxygen concentrations (FIO2) and the subsequent rise in arterial oxygen tensions (PaO2)—coincides with aggravated mortality [1]. Most of the data originate from retrospective analyses, but a single-center trial showed that “conservative” PaO2 (70–100 mmHg) halved mortality when compared to “conventional” targets (≤ 150 mmHg) [2]. The available studies mostly refer to data from intensive care unit (ICU) patients, but despite its frequent use in daily practice, the impact of hyperox(em)ia remains much less clear for patients in the emergency department (ED) and/or even prior to hospital admission. Hyperox(em)ia is often present after initiation of mechanical ventilation, most likely for fear of hypoxemia when blood gas analyses are not readily available. However, supplemental O2 can also yield hyperoxemic PaO2 levels without mechanical ventilation: in the aforementioned clinical trial demonstrating the beneficial effect of targeting “conservative” PaO2 levels in the ICU, upon admission into the study only 2/3 of the patients investigated were mechanically ventilated [2]. However, the duration of mechanical ventilation per se is directly related to adverse outcome in ED patients. Mechanical ventilation in the ED is mostly initiated upon the necessity for airway management, in particular in the unconscious patient (e.g., in the context of intoxication, metabolic crises, and/or traumatic brain injury (TBI)), respiratory failure (e.g., pneumonia and/or exacerbation of chronic obstructive pulmonary disease (COPD)), circulatory shock, and/or after cardiac arrest. Hence, the question arises: depending on the underlying conditions, does hyperox(em)ia affect the outcome of patients in the ED, in particular when they require mechanical ventilation? It is well established that hyperoxemia (defined as a PaO2 > 100 mmHg) is associated with adverse outcome in patients necessitating mechanical ventilation due to exacerbation of chronic lung disease (i.e., asthma or COPD) [3]. While there are no clinical studies on the impact of hyperox(em)ia in patients with community-acquired pneumonia, a recent retrospective study in this journal showed that hyperoxemia (defined as PaO2 > 120 mmHg) increased the risk of ventilator-associated pneumonia in patients receiving mechanical ventilation for more than 48 h [4]. The recent HYPER2S trial yielded deleterious effects of hyperoxemia in patients with septic shock (44% of pulmonary origin): FIO2 = 1.0 during the first 24 h after initial hemodynamic stabilization increased mortality at days 28 and 90 despite a significantly lower sequential organ failure assessment (SOFA) index at day 7, but without affecting the rate of secondary pneumonia or infection in general [5]. During the acute phase of circulatory shock, “the administration of oxygen should be started immediately to increase oxygen delivery and prevent pulmonary hypertension” [6]. The results of the HYPER2S trial suggest that hyperox(em)ia is deleterious in situations of distributive shock where “the main deficit lies in the periphery, with ... altered oxygen extraction” [6]. What about shock characterized by low cardiac output and, hence, inadequate oxygen transport? While there are no data on the outcome effects of hyperox(em)ia in cardiogenic shock, it is well established that it increases systemic vascular resistance in patients with congestive heart failure [7]. In line with this, two large randomized, controlled trials have shown that hyperoxemia started already during the prehospital phase offers no survival benefit at all [8] and can even increase mortality [9] in patients with acute myocardial infarction, possibly to the preferential vasoconstrictor effect of oxygen in the coronary circulation [7]. In contrast, the role of hyperox(em)ia during hypovolemia, in particular due to trauma and hemorrhage, is much less clear: due to the blood loss-related drop in oxygen transport capacity, hyperox(em)ia is frequently used to restore tissue oxygen * Correspondence: enrico.calzia@uni-ulm.de Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, Helmholtzstrasse 8/1, 89081 Ulm, Germany Full list of author information is available at the end of the article

An Unusual Cause of Abdominal Pain: Lupus Enteritis

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Contents Vol. 42, 2016

-see front matter 2016 Elsevier Inc. All rights reserved. is nonspecific, and main symptoms include focal or diffuse abdominal pain, vomiting, diarrhea, and fever. Even if there is no pathognomonic imaging feature of lupus enteritis, computed tomography may be suggestive. Typical computed tomography features that have been reported are bowel wall thickening over 3 mm (“target sign”) with abnormal bowel-wall contrast enhancement, dilatation of intestinal segments, and engorgement of mesenteric vessels (“comb sign”).

Bunches of grapes in renal polyarteritis nodosa

121 Selected Abstracts from the 34th Vicenza Course on AKI & CRRT Vicenza, June 7–10, 2016 (available online only)