Lina María Serna-Higuita

Histoplasmosis in Renal Transplant Patients in an Endemic Area at a Reference Hospital in Medellin, Colombia

BACKGROUND Histoplasmosis is an uncommon systemic fungal infection, but it is potentially fatal in immunosuppressed populations. In Latin America, which is considered an endemic area for this mycosis, there have been no published reports regarding the incidence, clinical presentation, morbidity, and mortality of histoplasmosis in renal transplant patients. The objective of this study was to describe cases of histoplasmosis in renal transplant patients treated at the Pablo Tobon Uribe Hospital (Medellin, Colombia) between 2006 and 2013. METHODS This is a descriptive, retrospective study. RESULTS The incidence of histoplasmosis in our renal transplant population was 1.1%. The ages of the 9 patients (4 men and 5 women) ranged between 27 and 59 years. In 2 of these patients, histoplasmosis appeared during the first year after transplantation. At the time of transplantation, 66% of patients received induction with alemtuzumab; 88% had a prior rejection episode and required increased immunosuppressive medication; 88% had renal graft dysfunction with creatinine levels >1.5 mg/dL; and the primary clinical presentation was disseminated histoplasmosis followed by the pulmonary form of the disease. Diagnoses were performed by histology in 6 patients, blood culture in 2 patients, and antigenuria in 1 patient. Three patients required treatment with amphotericin B for the severity of their infection, and 2 of these patients died before receiving the cumulative dose of amphotericin B. The 7 remaining patients received itraconazole for 12 months and had a successful treatment response. Regarding complications, 2 patients had hemophagocytic syndrome. At the 1-year follow-up appointment, renal function remained stable in all patients, and no patients had acute rejection or required renal replacement therapy. Thus, the overall mortality rate observed was 22.2%. CONCLUSIONS In this series, histoplasmosis in renal transplant patients presented as an aggressive opportunistic infection with a higher incidence than that previously reported in the literature. The following risk factors have been associated with histoplasmosis: renal graft dysfunction, previous acute rejection, immunosuppression with tacrolimus-mycophenolate, and induction with alemtuzumab. The clinical presentation of histoplasmosis was nonspecific, which complicated disease diagnosis, and the treatment regimens were highly toxic and associated with significant morbidity and mortality rates.

Síndrome hemolítico urémico atípico en un paciente joven con compromiso renal, neurológico, ocular y cardiovascular

We present the case of a 23-year-old man with a 3-month history of headache, loss of vision, loss of appetite, and ocular involvement; ocular damage is not frequently reported in the literature.1,2 In more than half of the patients with aHUS, it is possible to identify the complement mutation or the mutation in other foamy urine. In the previous week, he had been bedridden, with sensory disturbances, oliguria, and dyspnoea. Upon molecules leading to abnormal complement regulation. How-

Peritoneal dialysis-related peritonitis: twenty-seven years of experience in a Colombian medical center

UNLABELLED Peritonitis has been the most common complication of continues ambulatory peritoneal dialysis (CAPD) since it was first implemented, and it remains the leading cause of treatment failure and transfer to other renal replacement therapies. This study presents a Colombian series with a total of 2,469 episodes of peritonitis in 914 patients from a cohort of 1,497 patients on PD, who were followed for almost three decades at a single center. This is the largest Latin American series of patients with PD-related peritonitis. OBJECTIVE To describe the CAPD-related peritonitis in a cohort of patients followed for 27 years at a single center, and compare the results with those observed elsewhere in the world. STUDY DESIGN Prospective study of incident patients on CAPD from March 1981 to December 2008. RESULTS In our center, the rate of peritonitis has been steady between 0.8 and 0.9 since 1981 and no significant changes have been noticed in the 27 years of follow up. The rate remains similar to that described nowadays by other large dialysis centers in the world, which have reported significant improvements in recent decades. No significant differences were found in the isolates of gram-positive and gram-negative microorganisms or fungi with respect to those reported by other large series, or in the frequency of culture-negative peritonitis. CONCLUSION This study presents the largest Latin American series of patients with CAPD-related peritonitis with a total of 2,469 patients. In this study, the rate of CAPD-related peritonitis remained almost the same during the three decades of observation despite having used three different CAPD systems. Our hypothesis is that the socio-economic conditions of the patients admitted for peritoneal dialysis influences the rate of peritonitis.

Factores de riesgo de lesión renal aguda en una unidad de cuidados intensivos pediátrica: cohorte retrospectiva

BACKGROUND The incidence of acute kidney injury in the pediatric population and its associated risk factors are currently not clear. OBJECTIVES The objective of the study was to assess the incidence of acute kidney injury in critically ill pediatric patients and to determine its associated risk factors. METHODS We conducted a retrospective study of pediatric patients (<14 years old) admitted to a tertiary pediatric intensive care unit. Acute kidney injury (AKI) was classified using the Kidney Disease: Improving Global Outcomes definition KDIGO. RESULTS A total number of 382 patients were assessed: acute kidney injury was found in 11.5% of them (incidence rate 0.99 persons-day). The following parameters analyzed with multivariate regression analysis were associated with acute kidney injury: low platelet count (R = 2.947; 95% CI= 1.276-6.805) and the need of vasopressor support (OR= 4.601; 95% CI= 1.665-12.710). Children with acute kidney injury had an increased length of stay in the hospital and an increased mortality compared with patients with no kidney injury (19 days vs. 5 days and 3.7/person-day vs. 0.32/person-day). CONCLUSIONS Acute kidney injury is common among critically ill children and it is associated with adverse outcomes, including increased length of stay in the hospital and death. Low platelet count and vasopressor support were independently associated with the development of acute kidney injury in this population.

Tratamiento exitoso de mucormicosis rino-órbito-cerebral en un paciente trasplantado renal

Rhino-orbital-cerebral mucormycosis is a potentially fatal mycotic infection in immunosuppressed patients. The main risk factors for acquiring this infection are poorly controlled diabetes mellitus, iron overload, potent immunosuppression and chronic steroid use. In this review, we present the case of a kidney transplant patient who, after treatment of an acute rejection episode with high doses of steroids and potent immunosuppression with tacrolimus and mycophenolate, presented with rapidly progressing rhino-orbital-cerebral mucormycosis that required aggressive surgical treatment, immunosuppression discontinuation and potent antifungal treatment.

Successful treatment of thrombotic microangiopathy associated with dengue infection: A case report and literature review

Dengue infection has been associated with multiple renal complications, including glomerulonephritis, acute tubular necrosis, tubulointerstitial nephritis, and thrombotic microangiopathy (TMA), this last one being a rare complication of dengue, with only a few reported cases. TMA associated with dengue can be explained by an alteration in the activity of the enzyme ADAMTS13, leading to thrombotic thrombocytopenic purpura; or it can be secondary to direct or indirect endothelial injury by the virus, which leads to hemolytic uremic syndrome. Here, we present a case of severe TMA, not related to ADAMTS13, which was clearly associated with dengue infection.

Insuficiencia respiratoria hipoxémica grave por Pneumocystis jirovecii después de trasplante renal

Pneumonia caused by Pneumocystis jirovecii is an uncommon infection in kidney transplant patients that can have an acute and rapid progression to respiratory failure and death. The period of greatest risk occurs in the first six months after the transplant, and it relates to the high doses of immunosuppression drugs required by patients. However, it may occur late, associated with the suspension of prophylaxis with trimethoprim-sulfamethoxazole.We present two cases of renal transplant patients who had severe hypoxemic respiratory failure due to P. jirovecii six years after transplantation. In addition to steroids, they received treatment with trimethoprim-sulfamethoxazole. One patient died, while the other had clinical recovery, with preservation of the renal graft function.

Malakoplakia after kidney transplantation: Case report and literature review.

Malakoplakia is a granulomatous disease associated with an infectious etiology, usually involving the urinary tract. It reveals itself as a recurrent urinary tract infection (r‐UTI), and in some cases, it is associated with impairment of renal function. Immunosuppression is one of its main associated factors, and it has been increasingly described in patients with solid organ transplantation (SOT), mainly kidney transplantation. Macroscopically, it can form masses and sometimes it may be confused with neoplasia, which is why histological findings are fundamental for the diagnosis. Here, we present a case of bladder malakoplakia, manifested by r‐UTI from Escherichia coli in a patient with renal transplantation, refractory to long‐term antibiotic treatment and reduction in immunosuppression, which resolved after surgical management. We also summarize the clinical characteristics of malakoplakia and compare them with previous reports in the literature on SOT.

Falla respiratoria hipoxemica grave por Pneumocystis jirovecii en postrasplante renal tardío

Pneumonia caused by Pneumocystis jirovecii is an uncommon infection in kidney transplant patients that can have an acute and rapid progression to respiratory failure and death. The period of greatest risk occurs in the first six months after the transplant, and it relates to the high doses of immunosuppression drugs required by patients. However, it may occur late, associated with the suspension of prophylaxis with trimethoprim-sulfamethoxazole.We present two cases of renal transplant patients who had severe hypoxemic respiratory failure due to P. jirovecii six years after transplantation. In addition to steroids, they received treatment with trimethoprim-sulfamethoxazole. One patient died, while the other had clinical recovery, with preservation of the renal graft function.

Alemtuzumab en trasplante renal pediátrico: experiencia de 5 años en el Hospital Pablo Tobón Uribe de Medellín, Colombia

8. Golli-Bennour EE, Kouidhi B, Dey M, Younes R, Bouaziz C, Zaied C, et al. Cytotoxic effects exerted by polyarylsulfone dialyser membranes depend on different sterilization processes. Int Urol Nephrol. 2011;43:483–90. 9. Schulman G, Hakim R, Arias R, Silverberg M, Kaplan AP, Arbeit L. Bradykinin generation by dialysis membranes: Possible role in anaphylactic reaction. J Am Soc Nephrol. 1993;3:1563–9. 10. Martín-Navarro JA, Gutiérrez-Sánchez MJ, Petkov-Stoyanov V. Hipersensibilidad a membranas sintéticas de hemodiálisis. Nefrología. 2014;34(6):807–8.l trasplante renal es el tratamiento de elección en la población ediátrica, con enfermedad renal crónica terminal (ERCT)1. En a población pediátrica hay pocos estudios que evalúen la efecividad y la seguridad a largo plazo del alemtuzumab en el rasplante renal. Este es un estudio descriptivo retrospectivo realizado en el ospital Pablo Tobón Uribe; se incluyeron todos los pacienes trasplantados renales, menores de 18 años, durante el eriodo 2005-2012, que recibieron alemtuzumab como terapia e inducción. El protocolo de inmunosupresión utilizado incluía la admiistración de alemtuzumab y terapia triple de mantenimiento, on un anticalcineurínico (tacrolimus o ciclosporina), antimeabolito (azatioprina o micofenolato) y esteroides. Este estudio ontó con la aprobación del comité de ética del Hospital Pablo obón Uribe. Durante el período 2005-2012, se realizaron 21 trasplantes enales pediátricos, que recibieron alemtuzumab como teraia de inducción, el 57,1% fueron varones, la edad tuvo una ediana de 13 años (p25-75: 9-15), las malformaciones de as vías urinarias fue la causa más frecuente de enfermedad enal crónica (42,9%), el estado serológico para citomegaovirus fue receptor negativo-donante positivo en el 23,8%, eceptor positivo-donante positivo en el 71,4% y receptor posiivo donante-negativo en el 4,8%, y el tiempo de isquemia fría uvo una mediana de 18 h (p25-75: 12-20). La supervivencia de los pacientes a 6, 12, 24, 36 y 60 meses, uego del trasplante renal fue del 100, 100, 95,2, 95,2 y 95,2%, espectivamente. La mortalidad se presentó en un paciente.