Macaulay Onuigbo

Cytomegalovirus-Induced Glomerular Vasculopathy in Renal Allografts: A Report of Two Cases

Cytomegalovirus (CMV) remains a major viral pathogen complicating renal transplantation. Tubulointerstitial nephritis is the commonly acknowledged and well‐characterized pathologic feature of renal allograft CMV disease. There is controversy about whether there is a distinct entity as a CMV glomerulopathy in the absence of tubulointerstitial disease. We describe two patients with renal allograft dysfunction who displayed distinct features of CMV glomerular vasculopathy, in the absence of overt viral cytopathic changes involving the tubules.

Expert Panel Recommendations for the Identification and Management of Hyperkalemia and Role of Patiromer in Patients with Chronic Kidney Disease and Heart Failure

Virtual panel meetings were conducted among 7 physicians, all of whom are independent experts, including 3 nephrologists, 2 cardiologists, and 2 emergency medicine physicians (the panel). The panel met with the purpose of discussing the current treatment landscape, treatment challenges, economic impact, and gaps in care for patients with hyperkalemia that is associated with heart failure and chronic kidney disease. The stated goal of the panel discussion was to develop practical solutions in the identification and management of hyperkalemia in this patient population. The panel noted that hyperkalemia is a serious condition that can lead to life-threatening complications, yet the treatment paradigm for hyperkalemia has remained without major advances for approximately 50 years, until the approval of patiromer. A number of issues still exist in the management of this patient population, including the lack of uniform treatment guidelines and consensus regarding the approach to treatment. As part of its effort, the panel developed an algorithm, the Proposed Diagnostic Algorithm for Hyperkalemia Treatment in the Acute Care Setting/Chronic Care. The panel agreed that patiromer appears to be a viable option for the management of hyperkalemia in patients with chronic kidney disease and/or heart failure and in patients who experience chronic hyperkalemia. DISCLOSURES This panel discussion was funded by Relypsa and facilitated by Magellan Rx Management. Rafique is a principal investigator for Relypsa and serves as a consultant for Instrumentation Laboratory, Magellan Health, Relypsa, and ZS-Pharma. Butler serves as consultant for Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, CardioCell, Janssen, Merck, Novartis, Relypsa, and ZS-Pharma. Lopes and Farnum are employed by Magellan Rx Management. Rafique designed the management protocol for this panel discussion and contributed to the writing and editing of this report document. The other authors report no conflicting interests. Relypsa is the manufacturer of Veltassa (patiromer).

Focus on Hyperkalemia Management: Expert Consensus and Economic Impacts

BACKGROUND: Hyperkalemia (HK) is a concern for patients with chronic kidney disease (CKD) and heart failure (HF), and for those receiving treatments that inhibit the renin-angiotensin-aldosterone system (RAASi). An analysis of 1.7 million medical records of patients in the United States revealed that among individuals with more than 2 potassium values during 2007 to 2012, HK was detected in 34.6% of patients with CKD and 30.0% of patients with HF. OBJECTIVE: To evaluate the association of HK and use of RAASi therapies at optimal and suboptimal doses in patients with CKD and/or HF with health care resource utilization and overall cost of care in a diverse cohort of commercially insured patients. METHODS: This retrospective cohort study was conducted using medical and pharmacy claims from multiple regional health plans. Qualifying patients were ≥ 18 years old, continuously enrolled for 6 months before and throughout the study period (January 1, 2014, to December 31, 2015) and had an ICD-9-CM or ICD-10-CM diagnosis code of CKD and/or HF. Health care resource utilization, including hospital visits, length of stay, office visits, and associated medical and pharmacy costs, were assessed according to the 3 cohorts (CKD alone, HF alone, and concomitant CKD and HF). For the 3 cohorts, the results were also compared between patients with and without HK and between patients with and without RAASi use at optimal and suboptimal doses. Generalized linear models were used to further examine the predictors of medical and overall costs. RESULTS: In this study, 15,999 patients met inclusion criteria. Among patients using RAASi therapy, 26.8% received the optimal dose. Optimal dosing of RAASi was associated with decreased median outpatient office visits (8, 10, and 15, respectively, for patients with CKD, HF, and both CKD and HF) compared with suboptimal dosing of RAASi (12, 15, and 23, respectively). Similarly, optimal dosing of RAASi was associated with decreased overall median medical costs (

Reversible personality changes caused by brain nocardiosis in a 74-year old Caucasian male renal transplant recipient following disease-specific antimicrobial therapy

2,092,

Late onset renal failure from angiotensin blockade (LORFFAB) and the syndrome of rapid onset endstage renal disease (SORO-ESRD) revisited – Two case reports from Mayo Clinic Health System, Northwestern Wisconsin, USA; a review paper

4,144, and

Sequential cerebral salt wasting complicating SIADH in a patient following head trauma

7,762, respectively, for patients with CKD, HF, and both CKD and HF) compared with suboptimal dosing of RAASi (

Acute Kidney Injury in Heart Failure Revisited—The Ameliorating Impact of “Decongestive Diuresis” on Renal Dysfunction in Type 1 Acute Cardiorenal Syndrome: Accelerated Rising Pro B Naturetic Peptide Is a Predictor of Good Renal Prognosis

3,121,

Pretransplant serum C-reactive protein and the risk of chronic allograft nephropathy in renal transplant recipients: A pilot case-control study

8,289, and

Evidence-based treatment of hypertension in patients with diabetes mellitus

12,749, respectively). Patients with CKD, HF, or both CKD and HF, all in combination with HK, had higher overall costs, compared with those without HK. CONCLUSIONS: The results of this real-world analysis suggest that HK and suboptimal dosing of RAASI were associated with a median increase in outpatient office visits as well as increased overall medical costs among patients with CKD and/or HF. This evaluation of median costs suggests effective HK management may potentially reduce costs in patients with CKD and/or HF, including those currently receiving RAASi therapy. J Manag Care Spec Pharm. 2017;23(4-a):S2-S9 Copyright

Macro–Aspartate Transaminasemia: The Macroenzyme Phenomenon as a Diagnostic Dilemma

The management of potentially life-threatening brain nocardiosis in an elderly renal transplant recipient with the relevant specific antimicrobial agents while still continuing anti-rejection immunosuppressive therapy poses major clinical, pharmaceutical and logistical problems. This is a case of a 70-plus year old Caucasian male renal transplant recipient on maintenance immunosuppression, who developed a left flank abscess that was later complicated by the onset of personality changes from brain nocardiosis. The evolution of the diagnosis, treatment and recovery in this case presentation highlight the need for microbial susceptibility testing, the need for pharmacovigilance to monitor drug intolerance and drug resistance as well as other overarching treatment strategies including a close collaboration between Infectious Diseases and Transplant Medicine specialties in the management of this complicated case.