Mário Campos

Renal transplantation with expanded criteria donors: the experience of one portuguese center

BACKGROUND The shortage of kidneys available for transplantation has led to enlarged criteria donors (ECD): namely, donors older than 60 years or aged between 50 and 59 years with 2 of the following characteristics-hypertension, predonation serum creatinine level higher than 1.5 mg/dL or cerebrovascular disease as the cause of death. The aim of this study was to analyze renal transplants using ECD compared with standard criteria donors (SCD) concerning the incidences of delayed graft function (DGF), acute rejection episodes (ARE), and patient and graft survivals. MATERIALS AND METHODS This retrospective study of 409 cadaveric renal transplants over the last 4 years identified ECD in contrast with SCD. RESULTS Of the transplants, 24.4% used ECD. The baseline characteristics of recipients of ECD versus SCD kidneys were similar, except for age and cold ischemia time. Comparing ECD and SCD, we observed an higher incidence of DGF (35% vs 18%), occurrence of ARE (34.4% vs 16.6%), average serum creatinine levels at 6 (1.87 vs 1.4 mg/dL), and 12 months (1.88 vs 1.43 mg/dL) as well as lower graft survival at 1 (82% vs 91%) and 3 years (75% vs 84%) after transplantation. Recipient survival at 1 year was not different. Multivariate analysis identified recipient age, cold ischemia time, ARE, and DGF as risk factors for graft failure. CONCLUSIONS Renal transplantation with grafts from ECD shows significantly worse outcomes with higher rates of DGF and ARE, worse graft function, and lower graft survival.

Acute kidney injury by cantharidin poisoning following a silly bet on an ugly beetle.

Cantharidin is a poisonous substance secreted by blister beetles, including the ‘Spanish fly’. Historically, cantharidin was used as an aphrodisiac, vesicant and abortifacient. Symptoms of poisoning include gastrointestinal and genitourinary mucosal irritation along with renal dysfunction. We present the case of a reckless 23-year-old soldier who accepted the challenge of eating a beetle (Berberomeloe majalis). Six hours later he was admitted to the emergency room with abdominal pain, dysuria, gross haematuria with clots, hypotension, fever and renal insufficiency. With intravenous fluid therapy, he recovered clinically. Laboratory parameters returned to normal within 1 week.

Random spot urine protein/creatinine ratio: a reliable method for monitoring lupus nephritis?

Background Lupus nephritis (LN) is a common and severe manifestation of systemic lupus erythematosus (SLE) that can lead to end-stage renal disease. According to the Kidney Disease Outcomes Global Improving clinical Guidelines for Glomerulonephritis, spot urine protein/creatinine (P/C) ratio should be used for monitoring LN. However, some reports write that the random spot urine P/C ratio is unreliable in monitoring proteinuria in SLE glomerulonephritis patients. The aim of this study was to evaluate the agreement of these two assay methods. Methods The prospective observational study was performed. Fifty-three paired (total 106) spot and 24-h urine collections were evaluated. Statistical analysis: SPSS 20.0. Results Paired samples t-test did not reveal significant differences between the two-paired assay methods (spot P/C ratio versus 24-h proteinuria and 24-h P/C ratio) and a statistically significant correlation was observed between them: Pearsons coefficient of 0.847 (P < 0.001) and 0.863 (P < 0.001), respectively. However, after stratifying by degrees of proteinuria, a poor correlation was found in the range of <500 mg/day and only 26.6% of 24-h P/C ratio was explained by the spot P/C ratio. Adding to this, for proteinuria range between 500 and 1000 mg/day, there was no correlation (Pearsons −0.098; P > 0.05). In fact, only 1% of 24-h measurements could be explained by the spot P/C ratio. Conclusions Our study demonstrated a good correlation between 24-h proteinuria and random P/C ratio among patients with LN. However, this correlation was poor for proteinuria under 500 mg/day and did not exist in a range between 500 and 1000 mg/day. This finding is of greater importance because this range is quite common in patients with LN remission. Until further clarification, to the best of our knowledge, we maintain reluctant to completely substitute the 24-h collection by the P/C ratio especially when a renal flare is suspected, or before any change in therapy.

Severe acute kidney injury and multiple myeloma: Evaluation of kidney and patient prognostic factors

BACKGROUND Patients with multiple myeloma (MM) manifesting acute kidney injury (AKI) and who later recover renal function and independence from renal replacement therapy (RRT) are considered to have a better outcome. The aim of this work was to study the factors associated with renal function recovery (independence of hemodialysis) and longer survival in these patients. METHODS A retrospective single center study including patients with a diagnosis of MM and severe AKI, defined as stage 3 of the Kidney Disease: Improving Global Outcomes (KDIGO) criteria: 3.0 times baseline increase in serum creatinine (sCr) or increase in sCr to ≥4.0mg/dL or initiation of RRT, was conducted. Data was registry-based and collected between January 2000 and December 2011. We examined demographic and laboratorial data, presenting clinical features, precipitating factors, need for RRT and chemotherapy. Death was considered the primary endpoint. RESULTS Lower serum β2-microglobulin was the only independent factor associated with recovery of renal function and independence of RRT (OR 0.95, 95% CI: 0.91-0.99, P=0.02). The median survival after AKI was 10.7±12.1months. The factors associated with longer survival were independence of RRT (HR 2.21; 95% CI: 1.08-4.49; P=0.02), lower CRP (HR 1.07; 95% CI: 1.03-1.12; P=0.001) and younger age (HR 1.03; 95% CI: 1.01-1.06; P=0.005). CONCLUSIONS Our study suggests that MM patients with lower serum β2-microglobulin have a higher likelihood of recovering renal function after severe AKI. Independence of RRT, lower CRP and younger age are associated with longer survival.

Uncommon Cause of Chest Pain in a Renal Transplantation Patient With Autosomal Dominant Polycystic Kidney Disease: A Case Report

Autosomal dominant polycystic kidney disease (ADPKD) is a common cause of end-stage renal disease (ESRD) and, because of its intrinsic systemic involvement, its treatment can be a medical and surgical challenge. This condition is often associated with the presence of hepatic cysts and their prevalence generally increases with age. Most patients remain asymptomatic, but some of these will develop complications associated with enlargement and infection of their cysts. Chest pain is a rare manifestation of these complications and, after exclusion of more common cardiovascular and pulmonary causes, should raise the suspicion of an infected hepatic cyst in these patients. We report the case of a 62-year-old male who underwent a kidney transplantation from a cadaveric donor in 1997 (etiology of the ESRD was ADPKD), and was admitted to the emergency department with complaints of chest pain radiating to both shoulders and the interscapular region. An echocardiogram was showed compression of the right atrium by a large liver cyst without associated ventricular dysfunction. Computer tomography-guided drainage of the cyst was performed and an Enterobacter aerogenes sensitive to carbamapenemes was isolated from respective cultures. The patient presented a favorable clinical outcome with prolonged administration of antibiotic therapy according to the antibiotic susceptibility testing. There was no need for surgical intervention.

Gitelman syndrome with hiponatremia, a rare presentation.

CASE REPORT A 34 year old caucasian woman with no prior medical presented with severe hypokalemia; hypomagnesemia and mild hyponatremia. Her past medical and family history were unremarkable. She was on no medication and denied any symptoms, unless for occasionally muscle cramps. Water intake ≥3L/ day. She was normotensive, no edemas and normal urine output. The review of systems was otherwise negative.

Acute liver failure due to primary amyloidosis in a nephrotic syndrome: a swiftly progressive course

AL amyloidosis is a clonal plasma cell proliferative disorder characterised by extracellular tissue deposits of insoluble fibrils derived from κ or λ immunoglobulin light chains. The most common organs affected by AL amyloidosis are the kidney, presenting with nephrotic syndrome and/or progressive renal dysfunction, and the heart, with restrictive cardiomyopathy. Hepatic deposition of fibrils occurs in half the cases but the liver is rarely the predominantly affected organ. The most common presentation of hepatic amyloidosis is hepatomegaly with elevated alkaline phosphatase. Acute liver failure with cholestasis and jaundice is a rare complication, with a prevalence of approximately 5%, and is usually associated with a worse prognosis. We report a case of a 39-year-old man admitted to our nephrology department with an unusual presentation of primary amyloidosis with nephrotic syndrome and acute liver failure, complicated by obstructive cholestasis resulting in death 2 months after diagnosis.

Cast nephropathy: an extremely rare renal presentation of Waldenström's macroglobulinaemia.

Renal involvement in Waldenströms macroglobulinaemia (WM) is very unusual when compared to multiple myeloma. We report a case of a patient who developed anuric acute kidney injury secondary to cast nephropathy, dependent on high-flux haemodialysis. Complementary study revealed the presence of blood IgM monoclonal gammopathy and a massive bone marrow lymphoplasmacytic infiltration. There were no osteolytic lesions and no clinical signs/symptoms of hyperviscosity syndrome. The diagnosis of WM was established and a dexamethasone plus cyclophosphamide regime was started, in addition to plasmapheresis. The patient partially recovered renal function allowing haemodialysis and plasmapheresis withdrawal. He remained asymptomatic with a good response to chemotherapy and 12 months after his renal function remained stable. This is a rare clinical case in which WM presented as an IgM cast nephropathy, which in turn is an extremely rare renal presentation of this equally rare haematological disorder.

Cardiovascular risk in peritoneal dialysis: a Portuguese multicenter study

BACKGROUND Cardiovascular (CV) disease is the major cause of mortality in patients undergoing renal replacement therapy. The primary aim of the study was to evaluate the CV risk profile and prevalence of CV disease in patients on peritoneal dialysis (PD) in Portugal. The secondary goal was to establish parameters most associated with CV disease. METHODS Retrospective, multicenter study of the prevalent adult population on PD. Six hundred patients were included (56.7% male; mean age 53.5 ± 15.3 years), on PD for 25.6 ± 21.9 months. Patients were divided into two groups: group 1 (n=166) with CV disease and group 2 (n=434) without CV disease. Comparisons were made regarding traditional CV risk factors and those associated with uremia and PD itself, and a multivariate analysis was performed to determine variables independently associated with CV disease. RESULTS At the end of the study, the prevalence of CV disease was 28%. At univariate analysis, group 1 presented a higher frequency of males (p<.01), older patients (p<.01), diabetics (p<.01), occurrence of left ventricular hypertrophy (LVH) (p<.01), mean C-reactive protein (CRP) (p=.04), lower mean parathormone level (p=.014), lower serum phosphorus (p=.02), lower daily urine output (p=.04), lower weekly Kt/V (p=.008), increased use of icodextrin and hypertonic glucose-based PD solutions (p<.001 and p=.006, respectively) and more were under continuous ambulatory PD (CAPD) (p=.014) and had a high peritoneal transport status (p=.02). Multivariate analysis provided a significant discriminatory influence pertaining to age >50 years, CRP>0.6 mg/dl, male gender, diabetes, LVH, CAPD and anuria, when comparing group 1 and group 2. CONCLUSIONS Risk factors most related to the development of CV disease in PD in Portugal are age >50 years, CRP>0.6 mg/dL, male gender, diabetes, LVH, CAPD and anuria.

De novo tacrolimus - associated hemolytic uremic syndrome after renal transplantation

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