Digital tools towards transplant first policy: Improving health literacy

End stage kidney disease (ESKD) is a prevalent health issue across the world and it is well established that kidney transplantation (KT), specifically from a living donor, is currently the best value-based treatment method. Ergo, it is crucial to invest heavily in making this care strategy the best possible option for the majority of eligible patients. Barriers to the kidney transplant process are mainly related to education and accessibility: awareness of the clinical and societal relevance of the therapy must be promoted at the level of patients, clinicians and health providers. A health-literacy-focused website has been developed as part of this, aiming to provide the general population, particularly potential organ receptors and donors, with better access to trustworthy information and data. This was meant to be the effective expression of knowledge diffusion and innovation as a result of an academic master thesis. This communication-focused digital resource is designed to combat these obstacles and to create a long-lasting, positive and significant impact.

Clinical impact of personalized sodium prescriptions in hemodialysis

Dialysate sodium prescription is often standardized. In some patients, this can be hypernatremic compared to serum sodium, causing a positive sodium balance at the end of treatment that will contribute to increased extracellular volume and interdialytic weight gain. A prospective study was carried out to monitor and compare the clinical implications between different prescriptions of sodium dialysate (isonatremic versus hyponatremic hemodialysis). For that purpose, we included hemodialysis patients in treatment for at least 9 months. The individual sodium setpoint was determined through the median of pre-dialysis sodium measurements, carried out for 6 treatments. The prescribed dialysate sodium was equal to the setpoint (isonatremic period) for 4 weeks and then 2 meq/L inferior to the setpoint (hyponatremic period) for another 4 weeks. The main outcome was interdialytic weight gain. Secondary outcomes were ultrafiltration rate, blood pressure at the beginning of treatment, intradialytic complications, and qualitative assessment of symptoms. Twenty patients were included. Pre-dialysis serum sodium assessments in both periods tended to be patient specific with a stable value. The interdialytic weight gain was lower in the hyponatremic period (1.83±0.50 kg versus 2.04±0.58 kg) but without statistical significance (p value=0.387). The same trend was found in mean ultrafiltration and blood pressure. Dialysis complications were low in both periods. The percentage of cramps and hypotension requiring intervention was higher in the hyponatremic period with no statistically significant differences. Concerning thirst, there was a symptomatic improvement with sodium customization. This improvement was even more significant in the hyponatremic period. This study allowed us to reinforce the existence of a “sodium setpoint” for each patient and the importance of an individualized dialysis prescription. Our results suggest the safety of using isonatremic hemodialysis with improving patients’ symptoms. Regarding hyponatremic hemodialysis, despite being beneficial, it seemed to be associated with a higher number of complications.

Immune dysfunction in chronic kidney disease

Chronic kidney disease is characterized by immune dysfunction that increases predisposition to infections, virus-associated cancers and impaired response to vaccination. The altered immune response is caused by impairment of both innate and adaptive immune systems, as well as other factors that are hallmarks of renal disease, such as uremia, malnutrition, chronic inflammation, mineral bone disease and anemia. The aim of this article is to review the causes and mechanisms that lead to immune dysfunction in patients with chronic kidney disease.

Living kidney donation and reasons for denial: A report from a Brazilian single-center cross-sectional study

Chronic kidney disease is increasingly more prevalent worldwide, and kidney transplant remains the best option for patient survival. Living kidney transplants (LKT) pose advantages over deceased donor transplants, such as longer graft survival, lower ischemia time, and better HLA match. However, LKT is not always attainable for multiples reasons, with the absence of a suitable living donor being a significant barrier. Therefore, meticulous donor screening must be performed in order to guarantee donation safety. We examined medical appointments of living kidney donors evaluated at Hospital do Rim, São Paulo, between January and December 2020. Reasons for not proceeding with the donation were evaluated and were categorized as medical, surgical, immunological, psychosocial, or other. A total of 506 donor -receptor pairs were enrolled for evaluation during the study period. More than half of screened donor -receptor pairs (N=296, 58.5%) were not considered feasible for LKT. The primary cause for refusal was medical contraindication (32.1%), followed by immune (21.3%) and social (19.3%) causes. In addition, a considerable proportion of patients voluntarily withdrew themselves at variable time points during the evaluation process (N=79). In our center, most patients did not meet the criteria for kidney donation owing to medical reasons, similarly to other centers, and this reflects the importance of meticulous donor screening. In addition, the current Covid -19 pandemic affected the living transplant program, contributing to delayed complete donor and receptor evaluation.

Renal biopsy in diabetic patients: Histopathological and clinical correlations

Introduction: Diabetes is the leading cause of chronic kidney disease and end-stage kidney disease worldwide. A kidney biopsy in a diabetic patient must be considered when non-diabetic renal disease is suspected, such as in the presence of a rapid decline in renal function or severe unexplained proteinuria. However, the timing and criteria of a biopsy remain controversial in these patients. We aimed to identify clinical and histological markers that could help differentiate diabetic and non-diabetic renal disease and decide if this invasive approach is needed or not. Subjects and Methods: We reviewed 30 years of biopsies from diabetic patients performed at a tertiary hospital. We collected patient demographic data, biopsy indications, histological findings, and clinical and analytical data both at the moment of the biopsy and extensive followup. Based on kidney biopsy findings, patients were categorized as isolated diabetic nephropathy, non-diabetic kidney disease, or non-diabetic kidney disease superimposed on diabetic nephropathy (diabetic kidney disease). Results and Discussion: We enrolled 92 patients, mostly with type 2 diabetes, with a mean age of 62.9 ± 13.2 years. Nearly half of them had isolated diabetic nephropathy (53.3%), and 15.2% had diabetic nephropathy superimposed on non-diabetic kidney disease, comprising a total of 63 patients (68.5%) with diabetic kidney disease. Twenty-nine patients (31.5%) were considered to have non-diabetic kidney disease. These last patients were significantly less likely to need insulin therapy (p=0.002), had more frequently an acute deterioration of renal function (p=0.01), lower albumin levels (p=0.03), and a higher prevalence of microhematuria (p=0.001). We found the latter to be an independent predictor of non-diabetic kidney disease. Further, patients with the primary diagnosis of diabetic nephropathy had higher survival than those who had nondiabetic kidney disease, contradicting published data. Conclusions: The criteria for performing a biopsy in diabetic patients still lack consensus, although the priority to identify non-diabetic kidney disease prevails. We believe the non-diabetic kidney disease predictors we describe may prove helpful for determining the need for a histological assessment in diabetic patients.

An atypical presentation of Ormond’s disease

Retroperitoneal fibrosis is a rare condition defined by an overproduction of fibro-inflammatory tissue in the retroperitoneum, usually involving the abdominal aorta, but also managing to invade adjacent structures. We report a case of a 47-year-old female patient with an atypical radiological presentation of retroperitoneal fibrosis, involving predominantly the right kidney. Ultimately, the diagnosis was performed by an immunohistochemical study that identified IgG4+ plasmocytes after kidney nephrectomy, also known as Ormond’s disease. There are no universal guidelines for the treatment of retroperitoneal fibrosis, due to its rarity and lack of randomized controlled trials comparing different therapeutic strategies.

Risk factors associated with hospitalization and evolution in kidney transplant patients with COVID-19: A single-center retrospective cohort study

Background: The SARS -CoV -2 infection has had a major impact on kidney transplant patients. Our single -center experience aims to analyze the risk factors for affected patient hospitalization and predictors of worse clinical outcome on admission. Material and methods: A retrospective cohort study with kidney transplant patients with positive PCR for SARS -CoV -19 between March 16th 2020 and February 11th 2021 was conducted. Demographic characteristics and clinical and laboratory information on admission was collected and analyzed to assess risk factors related to patient hospitalization and disease evolution. Results: Seventy -six kidney transplant recipients diagnosed with COVID -19 were included and divided into hospitalized (n=48) and non- -hospitalized (n=28) patients. Two hospitalized patients were not taken into account for the analysis due to a lack of data, and the remaining patients were divided into mild -moderate (n=25) and severe pneumonia (n=21). Lasso and multivariate logistic regression demonstrated that age (OR 1.041, p=0.039) and hypertension (OR 4.177, p=0.040) were risk factors for hospitalization, while time after transplant (OR 0.993, p=0.029) decreases the probability of being hospitalized. Analyses also revealed that SpO2 ≤92% on admission (OR 8.954, p= 0.026) and overweight/obesity (OR 13.453, p= 0.001) were related to a worse evolution and severe pneumonia among hospitalized recipients. Seven patients died due to COVID -19 complications. Conclusion: Age and hypertension are risk factors for hospitalization among positive COVID -19 patients, while time after transplant decreases the probability of being hospitalized. Overweight/obesity and levels of SpO2 ≤92% on admission were the main risk factors that could help to predict the severity of COVID -19 disease in our series.

The gray area between operational tolerance and overt rejection in kidney transplantation

Operational tolerance in kidney transplantation is characterized by stable serum creatinine < 1.7 mg/dL and proteinuria < 1 g/day in the absence of immunosuppression or immunodeficiency for over one year. However, simultaneous donor specific antibodies are common and serum creatinine is a poor surrogate of early lesions. Consequently, subclinical rejections will meet operational tolerance criteria if serum creatinine remains stable. We report a patient with operational tolerance criteria followed by biopsy-proven chronic active antibody mediated rejection, discussing the intricate challenges of immunosuppression management.