Emphysematous Pyelonephritis — NEJM

Emphysematous Pyelonephritis — NEJM
http://www.nejm.org/doi/full/10.1056/NEJMicm1501812
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Images in Clinical Medicine

Emphysematous Pyelonephritis

Yasumitsu Hirose, M.D.Hayato Kaida, M.D.

N Engl J Med 2016; 375:1671October 27, 2016DOI: 10.1056/NEJMicm1501812

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A 51-year-old man presented with fever and general malaise of 2 weeks' duration. He had had diabetes mellitus for the preceding 20 years, and at the time of presentation this condition was poorly controlled. On admission to the hospital, his white-cell count was 10,800 per cubic millimeter (normal range, 3900 to 9800). The C-reactive protein level was 8.6 mg per deciliter, blood urea nitrogen 90 mg per deciliter (32 mmol per liter), creatinine 4.9 mg per deciliter (430 μmol per liter), and glycated hemoglobin 11.2%. Abdominal radiography (Panel A) and computed tomography (Panel B) revealed gas collection in the parenchyma (arrows) and perinephric space (arrowhead) of the left kidney. The patient received a diagnosis of emphysematous pyelonephritis, possibly caused by retrograde infection related to diabetes-associated neurogenic bladder. Escherichia coli was isolated in blood culture but not in urine cultures. The patient was treated with antibiotics; the infection resolved, and renal function improved (the blood urea nitrogen level declined to 23 mg per deciliter [8 mmol per liter] and creatinine to 2.6 ml per deciliter [230 μmol per liter]).

Yasumitsu Hirose, M.D.
Kurume University School of Medicine, Kurume, Japan
shinnichiizm@piano.ocn.ne.jp

Hayato Kaida, M.D.
Kindai University, Osakasayama, Japan

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Light chain podocytopathy mimicking recurrent focal segmental glomerulosclerosis - Khalighi - 2016 - American Journal of Transplantation - Wiley Online Library

Light chain podocytopathy mimicking recurrent focal segmental glomerulosclerosis - Khalighi - 2016 - American Journal of Transplantation - Wiley Online Library
http://onlinelibrary.wiley.com/doi/10.1111/ajt.14088/abstract;jsessionid=126DD36F68B49E3B8A1375AC92FF6189.f04t02
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Case Report

Light chain podocytopathy mimicking recurrent focal segmental glomerulosclerosis

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• Accepted manuscript online: 24 October 2016
• DOI: 10.1111/ajt.14088View/save citation
• Cited by: 0 articles
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• This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1111/ajt.14088

Abstract

Kidney injury related to paraproteinemia is common and typically occurs after the 4^th decade of life in association with an underlying plasma cell dyscrasia or other lymphoproliferative disease. Kidney transplantation in paraprotein-related kidney disease can be successful in conjunction with treatment of the underlying hematopoietic process; however, when hematologic response to therapy is not achieved, recurrent kidney injury is frequently seen. We describe a young male patient who presented with end stage kidney disease at the age of 23 years thought to be secondary to focal segmental glomerulosclerosis who ultimately received two kidney allografts. He experienced recurrent proteinuria in both kidneys with a biopsy from his second allograft showing kappa-restricted crystalline light chain podocytopathy, which was identified in both his native and first allograft kidneys upon retrospective review. Recurrent light chain podocytopathy has not been previously reported but poses a diagnostic challenge as it can mimic focal segmental glomerulosclerosis, particularly in young patients where paraprotein-related kidney injury is usually not suspected.

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10.1111/ajt.14088

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Publication History

• Accepted manuscript online: 24 October 2016
• Manuscript Accepted: 9 October 2016
• Manuscript Revised: 6 October 2016
• Manuscript Received: 18 September 2016

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Efficacy and Safety of Everolimus Plus Low-dose Tacrolimus Versus Mycophenolate Mofetil Plus Standard-dose Tacrolimus in De Novo Renal Transplant Recipients: 12-month Data

AJT - Early Efficacy and Safety of Everolimus Plus Low-dose Tacrolimus Versus Mycophenolate Mofetil Plus Standard-dose Tacrolimus in De Novo Renal Transplant Recipients: 12-month Data

Abstract

In this 12-month, multicenter, randomized, open-label, non-inferiority study, de novo renal transplant recipients (RTxRs) were randomized (1:1) to receive everolimus plus low-dose tacrolimus (EVR+LTac) or mycophenolate mofetil plus standard-dose Tac (MMF+STac) with induction therapy (basiliximab or rabbit anti-thymocyte globulin). Non-inferiority of composite efficacy failure rate (tBPAR/graft loss/death/loss to follow-up) in EVR+LTac versus MMF+STac, was missed by 1.4% considering the non-inferiority margin of 10% (24.6% vs 20.4%; 4.2%

[-3.0, 11.4]). Incidence of tBPAR (19.1% vs 11.2%; P<0.05) was significantly higher, while graft loss (1.3% vs 3.9%; P<0.05) and composite of graft loss/death/lost to follow-up (6.1% vs 10.5%, P = 0.05) were significantly lower in EVR+LTac versus MMF+STac groups, respectively. Mean eGFR was similar between EVR+LTac and MMF+STac groups (63.1 [22.0] vs 63.1 [19.5] mL/min/1.73 m²) and safety was comparable. In conclusion, EVR+LTac missed non-inferiority versus MMF+STac based on the 10% non-inferiority margin. Further studies evaluating optimal immunosuppression for improved efficacy will guide appropriate dosing and target-levels of EVR and LTac in RTxRs.

This article is protected by copyright. All rights reserved.

http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2Fajt.14090

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Mycophenolate and Pregnancy: Teratology Principles and National Transplantation Pregnancy Registry Experience

AJT - Early Mycophenolate and Pregnancy: Teratology Principles and National Transplantation Pregnancy Registry Experience

We, the investigators of the National Transplantation Pregnancy Registry (NTPR), read with concern King and colleagues' Pregnancy Outcomes Related to Mycophenolate Exposure in Female Kidney Transplant Recipients [1], based on a limited subset of our data, which concludes that first trimester exposure to mycophenolate (MPA) may not be associated with increased fetal risks. We disagree with their interpretation of the data and feel strongly that their conclusions convey false information regarding MPA safety during pregnancy. In contrast, our analysis of this data finds: (1) the significant risks to pregnancies exposed to MPA any time in the first trimester are miscarriage and phenotypic birth defects, and (2) no association between discontinuing MPA products <6 weeks preconception and the risk of graft loss at 5 years. We attribute the authors' invalid conclusions to systematic errors in assigning recipients to their comparison groups and missing information.

This article is protected by copyright. All rights reserved.

http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2Fajt.14085

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Prevention and Management of Tuberculosis in Transplant Recipients: From Guidelines to Clinical Practice

Transplantation - Most Popular Articles Prevention and Management of Tuberculosis in Transplant Recipients: From Guidelines to Clinical Practice

Abstract: Transplant recipients are at increased risk for tuberculosis (TB), which can adversely affect graft viability and patient survival. Scientific societies and official organizations have therefore issued guidelines and consensus statements for TB prevention and treatment. However, due to the poor supporting evidence, the current recommendations largely rely on expert opinion rather than on properly designed studies. In this overview, we aim to gather together the previous experience and compare and contrast the main current guidelines on the prevention and treatment of TB in solid organ transplantation and hematopoietic stem cell transplantation.


http://journals.lww.com/transplantjournal/Fulltext/2016/09000/Prevention_and_Management_of_Tuberculosis_in.15.aspx

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Cancer Screening Recommendations for Solid Organ Transplant Recipients: A Systematic Review of Clinical Practice Guidelines

http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2Fajt.13978

Solid organ transplant recipients (SOTRs) are at increased risk of developing and dying from cancer. However, controversies exist around cancer screening in this population owing to reduced life expectancy and competing causes of death. This systematic review assesses the availability, quality and consistency of cancer screening recommendations in clinical practice guidelines (CPGs). We systematically searched bibliographic databases and gray literature to identify CPGs and assessed their quality using AGREE II. Recommendations were extracted along with their supporting evidence. Thirteen guidelines were included in the review. CPGs for kidney recipients were the most frequent source of screening recommendations, and recommendations for skin cancer screening were most frequently presented. Some screening recommendations differed from those for the general population, based on literature demonstrating higher cancer incidence among SOTRs versus direct evidence of screening effectiveness. Relevant stakeholders such as oncology specialists, primary care providers and public health experts were not involved in the formulation of the screening recommendations. In conclusion, although several guidelines make recommendations for cancer screening in SOTRs, the availability of cancer screening recommendations varied considerably by transplanted organ. More studies are required to inform cancer screening recommendations in SOTRs, and guideline development should involve transplant patients, oncologists and cancer screening specialists.