Solomon Menahem

Impact of heart failure and changes to volume status on liver stiffness: non‐invasive assessment using transient elastography

The impact of cardiac dysfunction on the liver is known as cardiac hepatopathy. In certain instances this can result in significant hepatic fibrosis or cirrhosis. The validity of non‐invasive tools to assess hepatic fibrosis, such as FibroScan® which measures liver stiffness (LSM), has not been established in this setting. We examined the impact of cardiac dysfunction on LSM using FibroScan® and the influence of volume changes on LSM.

Hyperbaric oxygen in the treatment of calciphylaxis: A case series and literature review

Calcific uraemic arteriolopathy (CUA) or calciphylaxis is most commonly seen in end‐stage renal disease and is associated with significant morbidity and mortality. The aim of this study was to determine whether hyperbaric oxygen therapy (HBOT) is effective in healing calciphylaxis lesions and to determine if there are any patient factors that can predict wound healing and patient survival.

Induction and maintenance therapy in ANCA-associated systemic vasculitis

Date written: November 2006

Systemic arterial stiffness in infants with bronchopulmonary dysplasia: potential cause of systemic hypertension

Objective:Systemic hypertension is common among preterm infants with severe bronchopulmonary dysplasia (BPD); the exact cause is unknown. The objective of this preliminary hypothesis generating study was to examine systemic arterial structure and vasomotor function in a cohort of preterm infants with severe BPD, using a cohort of preterm infants without BPD and a cohort of term infants for comparison.Study Design:After obtaining informed consent, we measured aortic wall thickness and vasomotor function by ultrasonography in 20 infants with severe BPD, 7 infants with no BPD, and compared them with 20 healthy term infants.Results:Maximum aortic thickness was significantly higher in infants with BPD (827±163 μm) compared to those with no BPD (674±22 μm) and term infants (657±67 μm) (unadjusted P<0.0001). The input impedance was similarly elevated in the infants with BPD (574±127 dynes s cm−5) compared to those with no BPD (325±24 dynes s cm−5) or term infants (328±113 dynes s cm−5) (unadjusted P<0.0001). Stiffness index was significantly higher in the infants with BPD (3.4±0.6) compared to those with no BPD (2.6±0.3) or term infants (2.3±0.4) (unadjusted P<0.0001). Systemic vascular resistance was also significantly elevated in the infants with BPD. The results remained significant even after adjusting for gestational age and birth weight. Measures of vasomotor function significantly correlated with blood pressure.Conclusion:The aortic wall thickness and vasomotor function are significantly altered in preterm infants with severe BPD. These findings may explain the higher incidence of systemic hypertension in this population.

Long-Term Successful Outcomes From Kidney Transplantation After Lung and Heart-Lung Transplantation

BACKGROUND Renal dysfunction is common after lung and heart-lung transplantation (Tx), and it limits the recipients survival and quality of life. This study analyzed the outcomes of simultaneous and late kidney Tx following lung and heart-lung Tx. METHODS From a single-center retrospective chart review of 1031 lung and heart-lung Tx recipients, we identified 13 simultaneous or late kidney Tx cases in 12 patients. RESULTS Three patients underwent simultaneous deceased donor lung and kidney Tx. Eight patients underwent lung and heart-lung Tx, followed by nine living donor kidney Tx (including one ABO-incompatible Tx). One additional patient underwent a late deceased donor kidney Tx following heart-lung Tx. The median time from lung and heart-lung Tx to later kidney Tx was 127 (interquartile range [IQR], 23 to 263) months. Three patients died, 1 of sepsis, 1 of multiple organ failure, and 1 of transplant coronary disease. At a median follow-up of 33 (IQR, 10 to 51) months, 9 patients are alive and well. Eight patients required dialysis before kidney Tx for a median time of 14 months (IQR, 5 to 49). Kidney graft loss occurred in 1 patient at 51 months. After kidney Tx, dialysis was necessary in association with acute allograft dysfunction in 2 patients. No acute kidney rejection has been detected in any patient. Treatable acute lung rejection was seen in 1 patient. Well-preserved pulmonary function was noted in recipients of late kidney Tx. CONCLUSIONS Simultaneous kidney Tx and late deceased donor kidney Tx have challenges in the setting of lung Tx. By contrast, late living related kidney Tx after lung Tx is associated with excellent long-term survival and acceptable kidney and lung allograft function.

Radiological insertion of Tenckhoff catheters for peritoneal dialysis: a 1-year single-centre experience

Background Peritoneal dialysis (PD) is an important home-based dialysis modality for patients with end-stage kidney disease (ESKD). The initiation of PD requires timely and skilled insertion of a Tenckhoff catheter (TC). At most centres, TCs are inserted laparoscopically by surgeons under general anaesthetic. This requires access to increasingly scarce surgical, anaesthetic and hospital inpatient resources. Radiological insertion of TCs performed as a day procedure under local anaesthetic allows for easier access to the TC insertion with reduced resource requirements. We report our 1-year experience following the introduction of this technique to our PD programme. Methods This is a retrospective review of the outcomes for all patients who had TCs inserted radiologically (percutaneously with the assistance of ultrasound and fluoroscopy) over the 12-month period from December 2011 to December 2012. Relevant patient demographics collected included age, gender, body mass index (BMI), previous abdominal surgery and cause of ESKD. Extended details of the insertion procedure were also obtained including length of stay, early complications and time to first use of the catheter for PD. Results Thirty Argyle™ Swan Neck TCs were inserted under radiological guidance during the study period. The mean age of patients was 56 (SD ± 14). The male-to-female ratio was 2:1. The mean BMI was 25.7 (SD ± 4.8). PD was the initial dialysis modality in 22 (73%) patients. Of the 30 patients, 14 (46.7%) had previously undergone extraperitoneal abdominal surgery. All catheters were inserted successfully as day cases except four patients (13.3%) who had catheters inserted during an inpatient hospital admission. Most catheters were not accessed for a minimum of 10 days to reduce the chance of exit site leakage, in two cases the catheters were used within 5 days without complication. There were no cases of peritonitis or exit site infection during the observation period. Catheter migration occurred in four patients (13.3%) but only one required surgical intervention. Minor pain issues were noted in six patients (20%) and bleeding around the exit site requiring suturing in two patients (6.7%). The introduction of this technique at our institution saw a 67% increase in the number of patients performing PD. Conclusions Radiological insertion of TCs for PD provided improved access to catheter insertion in a timely manner with reduced resource requirements. Over the 12-month observation period we noted a high technical success rate with very few complications. Our study supports radiological insertion of TCs under local anaesthetic as a viable alternative to catheter insertion in theatre under general anaesthetic. The relative ease of radiological TC insertion has resulted in a significant increase in patient uptake of PD at our centre.

Segmental Arterial Mediolysis Mimicking Medium-Vessel Vasculitis

A 47-year-old male with no significant past medical history presented to our institution with several days of right iliac fossa pain and vomiting. He had a similar episode in 2011, which resolved spontaneously. Clinically, he was afebrile and normotensive, with bilateral renal angle tenderness. Investigations revealed wellpreserved renal function (creatinine 79 μmol/L) and normal inflammatory markers. He had no proteinuria or haematuria. An abdominal computed tomography (CT) demonstrated bilateral wedge-shaped renal infarcts. Further investigation with CT renal angiogram demonstrated segmental luminal narrowing of distal branches of both renal arteries with fusiform post-stenotic dilatation (Fig. 1). A diagnosis of medium-vessel vasculitis was made and the patient was commenced on pulse methylprednisolone followed by high-dose (75 mg) oral prednisolone. He was fully anticoagulated with warfarin. The remainder of vasculitic and thromboembolic screens were negative. Follow-up imaging 3 weeks post-discharge demonstrated a new enlarging aneurysm at the upper left renal pole (Fig. 1b). Formal renal angiogram demonstrated multiple saccular and fusiform aneurysms in the upper pole branch of left renal artery together with a small aneurysm of the distal splenic artery. The patient proceeded to successful coil embolization of this vessel with occlusion of the distal aneurysms. The presence of multiple evolving abdominal vessel aneurysms suggested a diagnosis of segmental arterial mediolysis (SAM) rather than medium-vessel vasculitis. In light of this, immunosuppression and warfarin were ceased. Serial CT angiography surveillance was planned. SAM is a rare non-inflammatory, non-atheroscelorotic condition involving patchy lysis of the medial layer of arterial walls, resulting in aneurysm formation and nearby regions of vascular stenosis. Radiologically, this appears as arterial gaps, which can resemble the classic beading pattern of fibromuscular dysplasia. The presence of multiple aneurysms can also mimic the appearance of polyarteritis nodosa, as was originally suspected in our case. SAM commonly affects smallto medium-sized intraabdominal vessels (particularly the splenic artery or coeliac trunk); however, it has also been described involving intracranial vessels. Eighty-five cases of SAM have been reported in the literature, with a male predominance and patients typically in their fifth decade of life. Previously often diagnosed at autopsy, improved radiological imaging has led to increased recognition of SAM as a cause of abdominal pain and renal infarction. Treatment includes surgical resection or endovascular management of aneurysms. Given limited long-term patient follow-up data, the incidence of recurrence is unknown; however, follow-up screening is considered useful.

Outcomes of simultaneous heart-kidney and lung-kidney transplantations: The Australian and New Zealand experience

Heart or lung transplantation alone in individuals with significant pre‐existing renal impairment results in high mortality and morbidity. Simultaneous heart–kidney (SHK) or simultaneous lung–kidney (SLK) transplantation may be considered in patients with dual organ failure not suitable for single organ transplantation.

Sustained complete remission of steroid-and cyclophosphamide-resistant minimal-change disease with a single course of rituximab therapy

We report a case of steroid- and cyclophosphamide-resistant nephrotic syndrome secondary to minimal-change disease occurring in an otherwise healthy 19-year-old female, responding rapidly to two doses of rituximab therapy. Complete disease remission has been sustained up to last follow-up (32 months) despite CD19 recovery. Literature review suggests emerging evidence that rituximab may have a role to play in recurrent and/or refractory minimal-change disease.

Identifying and integrating patient and caregiver perspectives in clinical practice guidelines for percutaneous renal biopsy: Consumer involvement in guidelines

Percutaneous renal biopsy is often essential for providing reliable diagnostic and prognostic information for people with suspected kidney disease, however the procedure can lead to complications and concerns among patients. This study aims to identify and integrate patient priorities and perspectives into the Kidney Health Australia – Caring for Australasians with Renal Impairment clinical practice guidelines for renal biopsy, to ensure patient‐relevance.