Hypoxia-inducible factor prolyl hydroxylase inhibitors for anaemia in chronic kidney disease: a document by the European Renal Best Practice board of the European Renal Association

Anaemia is a common complication of chronic kidney disease (CKD) and is associated with poor long-term outcomes and quality of life. The use of supplemental iron, erythropoiesis stimulating agents (ESAs) and blood transfusions has been the mainstay of treatment of anaemia in CKD for more than three decades. Despite available treatments, CKD patients with anaemia are undertreated and moderate-to-severe anaemia remains prevalent in the CKD population. Anaemia has consistently been associated with greater mortality, hospitalisation, cardiovascular events, and CKD progression in patients with CKD, and the risk increases with anaemia severity. Hypoxia-inducible factor (HIF) prolyl hydroxylase (PH) inhibitors have a novel mechanism of action by mimicking the body's response to hypoxia and have emerged as an alternative to ESAs for the treatment of anaemia in CKD. Their efficacy in correcting and maintaining haemoglobin has been demonstrated in over 30 phase 3 clinical trials. Additionally, HIF activation results in various pleiotropic effects beyond erythropoiesis with cholesterol reduction and improved iron homeostasis and potential anti-inflammatory effects. The long-term safety of these agents, particularly with respect to cardiovascular and thromboembolic events, and their possible effect on tumor growth requires to be fully elucidated. This document presents in detail the effects of HIF-PH inhibitors, describes their mechanisms of action and pharmacologic properties, and discusses their place in the treatment of anaemia in CKD according to the available evidence.

Worldwide trends in underweight and obesity from 1990 to 2022: a pooled analysis of 3663 population-representative studies with 222 million children, adolescents, and adults

BACKGROUND

Underweight and obesity are associated with adverse health outcomes throughout the life course. We estimated the individual and combined prevalence of underweight or thinness and obesity, and their changes, from 1990 to 2022 for adults and school-aged children and adolescents in 200 countries and territories.

METHODS

We used data from 3663 population-based studies with 222 million participants that measured height and weight in representative samples of the general population. We used a Bayesian hierarchical model to estimate trends in the prevalence of different BMI categories, separately for adults (age ≥20 years) and school-aged children and adolescents (age 5-19 years), from 1990 to 2022 for 200 countries and territories. For adults, we report the individual and combined prevalence of underweight (BMI <18·5 kg/m2) and obesity (BMI ≥30 kg/m2). For school-aged children and adolescents, we report thinness (BMI <2 SD below the median of the WHO growth reference) and obesity (BMI >2 SD above the median).

FINDINGS

From 1990 to 2022, the combined prevalence of underweight and obesity in adults decreased in 11 countries (6%) for women and 17 (9%) for men with a posterior probability of at least 0·80 that the observed changes were true decreases. The combined prevalence increased in 162 countries (81%) for women and 140 countries (70%) for men with a posterior probability of at least 0·80. In 2022, the combined prevalence of underweight and obesity was highest in island nations in the Caribbean and Polynesia and Micronesia, and countries in the Middle East and north Africa. Obesity prevalence was higher than underweight with posterior probability of at least 0·80 in 177 countries (89%) for women and 145 (73%) for men in 2022, whereas the converse was true in 16 countries (8%) for women, and 39 (20%) for men. From 1990 to 2022, the combined prevalence of thinness and obesity decreased among girls in five countries (3%) and among boys in 15 countries (8%) with a posterior probability of at least 0·80, and increased among girls in 140 countries (70%) and boys in 137 countries (69%) with a posterior probability of at least 0·80. The countries with highest combined prevalence of thinness and obesity in school-aged children and adolescents in 2022 were in Polynesia and Micronesia and the Caribbean for both sexes, and Chile and Qatar for boys. Combined prevalence was also high in some countries in south Asia, such as India and Pakistan, where thinness remained prevalent despite having declined. In 2022, obesity in school-aged children and adolescents was more prevalent than thinness with a posterior probability of at least 0·80 among girls in 133 countries (67%) and boys in 125 countries (63%), whereas the converse was true in 35 countries (18%) and 42 countries (21%), respectively. In almost all countries for both adults and school-aged children and adolescents, the increases in double burden were driven by increases in obesity, and decreases in double burden by declining underweight or thinness.

INTERPRETATION

The combined burden of underweight and obesity has increased in most countries, driven by an increase in obesity, while underweight and thinness remain prevalent in south Asia and parts of Africa. A healthy nutrition transition that enhances access to nutritious foods is needed to address the remaining burden of underweight while curbing and reversing the increase in obesity.

FUNDING

UK Medical Research Council, UK Research and Innovation (Research England), UK Research and Innovation (Innovate UK), and European Union.

The Role of Probiotics in the Prevention of Clostridioides difficile Infection in Patients with Chronic Kidney Disease

In patients suffering from chronic kidney disease (CKD), substantial unfavourable alterations in the intestinal microbiota composition, i.e., dysbiosis, have been noted. The main causes of such dysbiosis among others are insufficient dietary fibre content in the diet, fluid restrictions, medications used, and physical activity limitation. One clinically important consequence of dysbiosis in CKD patients is high risk of Clostridioides difficile infection (CDI). In observational studies, it was found that CDI is more frequent in CKD patients than in the general population. This appears to be related to high hospitalization rate and more often antibiotic therapy use, leading up to the occurrence of dysbiosis. Therefore, the use of probiotics in CKD patients may avert changes in the intestinal microbiota, which is the major risk factor of CDI. The aim of this review paper is to summarize the actual knowledge concerning the use of probiotics in CDI prevention in CKD patients in the context of CDI prevention in the general population.

Lipid disorders before and after successful liver transplantation

INTRODUCTION

Liver transplantation (LTx) is the only successful treatment for end-stage liver disease. The results of liver transplantation depend not only on graft survival but may be also affected by superimposed cardiovascular morbidities. The aim of this retrospective study was to assess the prevalence of lipid disorders as one of the important cardiovascular risk factors in patients before and after successful LTx.

MATERIAL AND METHODS

One hundred eleven patients who underwent liver transplantation because of liver cirrhosis and survived at least 2 years with functioning graft between November 2005 and May 2014 were included in this retrospective analysis. The mean age of the patients at the time of liver transplantation was 49.7±12.2 years. The prevalence of dyslipidemia was assessed before and two years after liver transplantation. This was analyzed in relation to the etiology of liver disease, including alcohol toxicity, viral or autoimmune diseases.

RESULTS

The prevalence of hypertriglyceridemia before and after LTx was 13.5% and 40.5%, respectively (P<0.001). Similarly, hypercholesterolemia was noted in 17.1% and 51.4% respectively (P<0.001). The annual incidence of hypertriglyceridemia and hypercholesterolemia during the first two years after LTx was 16.2% and 20.7%, respectively. The prevalence of hypertriglyceridemia (18.5% vs 66.7%, P<0.001) and hypercholesterolemia (29.6% vs 70.0%, P=0.002) was significantly lower in patients with the autoimmune cause of liver cirrhosis in comparison to patients with the alcoholic liver disease.

CONCLUSIONS

The prevalence of dyslipidemia is increased after liver transplantation. The prevalence of dyslipidemia may be related to the cause of liver injury before LTx.

Association between Kidney Donor Risk Index, kidney graft function and histological changes in early post-transplant graft biopsy

Background

Proper assessment of donor organ quality is crucial for optimal kidney allocation and best long-term outcomes. The aim of this study was to analyze the association between the Kidney Donor Risk Index (KDRI) and histological parameters in early post-transplant graft biopsy in a Polish cohort of kidney transplant recipients.

Methods

In 418 consecutive kidney transplant recipients, a histological evaluation of very early [at median 11 (9-13) post-transplant day] protocol core needle biopsy was performed and analyzed according to the Banff classification. Subjects were divided into quartiles of the KDRI value. Kidney graft function, patient and graft survival were also analyzed over a median follow-up period of 44 (26-56) months.

Results

There was a significant trend toward greater intensity of chronic histology changes along the KDRI quartiles (χ2 = 20.8; P < .001), including interstitial fibrosis, tubular atrophy, mesangial matrix increase and arteriolar hyalinosis. Stepwise multivariate regression analysis revealed that only higher KDRI value independently increased the severity of chronic graft injury (rpartial = 0.340, P < .001). KDRI values were valuable in the determination of both early and long-term graft function.

Conclusion

The KDRI values correlate with chronic histological changes found in early post-implantation kidney biopsies and can also be helpful in the prediction of graft outcome.

Global variation in diabetes diagnosis and prevalence based on fasting glucose and hemoglobin A1c

Fasting plasma glucose (FPG) and hemoglobin A1c (HbA1c) are both used to diagnose diabetes, but these measurements can identify different people as having diabetes. We used data from 117 population-based studies and quantified, in different world regions, the prevalence of diagnosed diabetes, and whether those who were previously undiagnosed and detected as having diabetes in survey screening, had elevated FPG, HbA1c or both. We developed prediction equations for estimating the probability that a person without previously diagnosed diabetes, and at a specific level of FPG, had elevated HbA1c, and vice versa. The age-standardized proportion of diabetes that was previously undiagnosed and detected in survey screening ranged from 30% in the high-income western region to 66% in south Asia. Among those with screen-detected diabetes with either test, the age-standardized proportion who had elevated levels of both FPG and HbA1c was 29-39% across regions; the remainder had discordant elevation of FPG or HbA1c. In most low- and middle-income regions, isolated elevated HbA1c was more common than isolated elevated FPG. In these regions, the use of FPG alone may delay diabetes diagnosis and underestimate diabetes prevalence. Our prediction equations help allocate finite resources for measuring HbA1c to reduce the global shortfall in diabetes diagnosis and surveillance.

Novel anemia therapies in chronic kidney disease: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference

Anemia is common in patients with chronic kidney disease and is associated with a high burden of morbidity and adverse clinical outcomes. In 2012, Kidney Disease: Improving Global Outcomes (KDIGO) published a guideline for the diagnosis and management of anemia in chronic kidney disease. Since then, new data from studies assessing established and emerging therapies for the treatment of anemia and iron deficiency have become available. Beginning in 2019, KDIGO planned 2 Controversies Conferences to review the new evidence and its potential impact on the management of anemia in clinical practice. Here, we report on the second of these conferences held virtually in December 2021, which focused on a new class of agents-the hypoxia-inducible factor-prolyl hydroxylase inhibitors (HIF-PHIs). This report provides a review of the consensus points and controversies from this second conference and highlights areas that warrant prioritization for future research.

Nephro-oncology: clinical and biochemical aspects of kidney disease and cancer

Onco-nephrology is a new field of medicine which combines many aspects of kidney injury in cancer patients and cancers in patients with kidney disease. This connection takes many forms and includes drug-induced nephrotoxicity, electrolyte disorders, numerous paraneoplastic syndromes and an increased rate cancers in dialysis and transplanted patients. The appropriate laboratory assessment of the kidney function allows to optimize chemotherapy and thus minimizes the risk of complications. This article focuses on acute kidney injury (AKI), chronic kidney disease (CKD), various electrolyte and acid-base disorders, the most common cancers after kidney transplantation and the kidney disorders associated with HSCT (hematopoietic stem cell transplantation). The possibility of the application of novel cancer therapy, such as cancer immunotherapy and proton therapy in transplant recipients was also discussed.

Intestinal Permeability in Patients Early after Kidney Transplantation Treated with Two Different Formulations of Once-Daily Tacrolimus

Adequate tacrolimus blood exposure is crucial in the early post-renal transplant period and a gut epithelial barrier integrity may play a role. We prospectively investigated several markers of intestinal permeability in recent kidney transplant recipients (KTRs) treated with different tacrolimus extended-release formulations. Within each of the 49 KTR pairs that received grafts from the same donor, an early randomized conversion was performed from twice-daily (Prograf) to once-daily tacrolimus formulation: Advagraf or Envarsus. Plasma zonulin, calprotectin, circulating lipopolysaccharide (LPS), LPS-binding protein (LBP), intestinal fatty acid binding protein (FABP-2), and CD-14 levels were measured. There was no difference in the recipient age, dialysis vintage, BMI, and residual diuresis between Advagraf and Envarsus groups. FABP-2 and LPS levels were significantly associated with tacrolimus trough level, 3-h level, and area under the curve (AUC) in the Envarsus but not in the Advagraf group. AUC was independently increased by LPS and decreased by age, FABP-2 concentration, and the use of Envarsus formulation as compared with Advagraf. Functional changes of gastrointestinal tract in patients treated with Envarsus may influence intestinal tacrolimus absorption to a greater extent than in Advagraf-treated KTRs and may lead to inadequate variability of tacrolimus exposure early after kidney transplantation.

Hyponatremia in patients with arterial hypertension: pathophysiology and management

Sodium is the main cation in the extracellular space. In physiological conditions, sodium concentration in plasma is 135-145 mmol/l. The kidneys play the most important role in the regulation of sodium homeostasis. In recent years, a significant role of glycosaminoglycans, localized mainly in the subcutaneous tissue, and the role of glycocalyx on the surface of vascular endothelial cells, have been documented in the regulation of sodium metabolism. Hyponatremia is defined by a plasma sodium concentration lower than 135 mmol/l. Hyponatremia significantly worsens the prognosis of patients with different chronic diseases. In patients with arterial hypertension, the risk of hyponatremia is 1.5 times higher than in the general population. One of the causes of hyponatremia in patients with arterial hypertension is the use of thiazide or thiazide-like diuretics. The symptoms of hyponatremia are caused mainly by the swelling of cells in the central nervous system. Treatment of hyponatremia depends on the degree and duration (acute or chronic) of hyponatremia as well as presence of clinical symptoms. Too rapid correction of hyponatremia might result in a potentially fatal osmotic demyelinating syndrome. In the present review paper, pathophysiology and management of hyponatremia in patients with arterial hypertension are discussed.

Effect of Renal Denervation on the Plasma Adiponectin Concentration in Patients with Resistant Hypertension

(1) Introduction: Adiponectin is synthetized by white adipose tissue and has anti-diabetic, anti-atherosclerotic, anti-thrombotic, anti-inflammatory, and cardioprotective properties. In patients with arterial hypertension, plasma concentration of adiponectin is lower than in healthy subjects. Renal denervation, i.e., percutaneous ablation of fibers from the sympathetic nervous system located in the wall of the renal arteries by radio frequency waves, is a method of resistant arterial hypertension treatment. (2) The aim of this single center, interventional, clinical study was to assess the effect of renal denervation on the plasma adiponectin concentration in patients with resistant arterial hypertension. (3) Materials and methods: 28 patients (13 women, 15 men) aged 54.4 ± 9.2 years with resistant hypertension who underwent renal denervation using Simplicity catheters (Medtronic, Inc., Northridge, CA, USA) were enrolled in the study. Plasma adiponectin concentration was determined using the Human Adiponectin ELISA Kit (Otsuka Pharmaceutical Co, Tokyo, Japan) before the renal denervation and 6 and 12 months after this procedure. (4) Results: Blood pressure (BP) values before renal denervation and 6 and 12 months after this procedure were as follows: systolic BP 190.4 ± 24.5, 160.8 ± 14.5, 155.7 ± 17.9 mmHg (p < 0.001) and diastolic BP 111.7 ± 18.9, 88.9 ± 8.3, 91.2 + 10.2 mmHg (p < 0.001), respectively. Body mass index (BMI) before renal denervation, 6 and 12 months after this procedure were 31.5 ± 4.2, 30.5 ± 4.4, 30.2 ± 4.0 kg/m2, (p = 0.057), respectively. Plasma adiponectin concentration before the renal denervation and 6 and 12 months after this procedure were 4.79 (3.95; 9.49), 7.58 (5.04; 9.51), 6.62 (4.57; 11.65) [µg/mL] (p = 0.007), respectively. (5) Conclusions: Plasma adiponectin concentration increases significantly after successful renal denervation in patients with resistant hypertension. Higher plasma adiponectin concentration may participate—beyond blood pressure reduction—in the cardiovascular benefits related to successful renal denervation; however’ clinical consequences of these results need further investigations.

Diminishing benefits of urban living for children and adolescents' growth and development

Optimal growth and development in childhood and adolescence is crucial for lifelong health and well-being1-6. Here we used data from 2,325 population-based studies, with measurements of height and weight from 71 million participants, to report the height and body-mass index (BMI) of children and adolescents aged 5-19 years on the basis of rural and urban place of residence in 200 countries and territories from 1990 to 2020. In 1990, children and adolescents residing in cities were taller than their rural counterparts in all but a few high-income countries. By 2020, the urban height advantage became smaller in most countries, and in many high-income western countries it reversed into a small urban-based disadvantage. The exception was for boys in most countries in sub-Saharan Africa and in some countries in Oceania, south Asia and the region of central Asia, Middle East and north Africa. In these countries, successive cohorts of boys from rural places either did not gain height or possibly became shorter, and hence fell further behind their urban peers. The difference between the age-standardized mean BMI of children in urban and rural areas was <1.1 kg m-2 in the vast majority of countries. Within this small range, BMI increased slightly more in cities than in rural areas, except in south Asia, sub-Saharan Africa and some countries in central and eastern Europe. Our results show that in much of the world, the growth and developmental advantages of living in cities have diminished in the twenty-first century, whereas in much of sub-Saharan Africa they have amplified.

Guidelines for the diagnosis and management of osteoporosis in Poland. Update 2022

Guidelines to provide an update of the previously published Polish recommendations for the management of women and men with osteoporosis have been developed in line with advances in medical knowledge, evidence-based data, and new concepts in diagnostic and therapeutic strategies. A Working Group of experts from the Multidisciplinary Osteoporosis Forum and from the National Institute of Geriatrics, Rheumatology, and Rehabilitation in Warsaw performed a thorough comprehensive review of current relevant publications in the field (including all age groups of people and management of secondary osteoporosis), and they evaluated epidemiological data on osteoporosis in Poland and the existing standards of care and costs. A voting panel of all co-authors assessed and discussed the quality of evidence to formulate 29 specific recommendations and voted independently the strength of each recommendation. This updated practice guidance highlights a new algorithm of the diagnostic and therapeutic procedures for individuals at high and very high fracture risk and presents a spectrum of general management and the use of medication including anabolic therapy. Furthermore, the paper discusses the strategy of primary and secondary fracture prevention, detection of fragility fractures in the population, and points to vital elements for improving management of osteoporosis in Poland.

Potential Utility of Neutrophil-to-Lymphocyte, Platelet-to-Lymphocyte, and Neutrophil, Lymphocyte, and Platelet Ratios in Differential Diagnosis of Kidney Transplant Acute Rejection: A Retrospective, Propensity Score Matched Analysis

BACKGROUND Acute kidney transplant rejection can negatively affect long-term graft function. The neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio have been proposed as non-invasive predictors of acute rejection in stable kidney transplant recipients. The aim of this study was to validate the predictive value of these ratios, as well as neutrophil, lymphocyte, and platelet ratios in the diagnosis of acute rejection during the early post-transplant period. MATERIAL AND METHODS After propensity score matching, we compared 71 kidney recipients with biopsy-proven acute rejection with 71 patients without rejection and also subjects with different histologic types of rejection. All 3 types of blood cell count-derived ratios were calculated 6 and 3 days prior to biopsy and on the day of biopsy. RESULTS There were 15 patients with T cell-mediated rejection, 33 with vascular rejection, and 23 with antibody-mediated rejection. The values of all examined ratios did not differ between subgroups with and without rejection. However, at all post-transplant study time-points, patients with antibody-mediated rejection had significantly higher values of all analyzed ratios than subjects with other types of rejection. In multivariate regression models, higher values of blood cell count-derived ratios were independently associated with the occurrence of antibody-mediated rejection. CONCLUSIONS In the early post-transplant period, the values of neutrophil-to-lymphocyte, platelet-to-lymphocyte, and neutrophil, lymphocyte, and platelet ratios were similar in patients with and without an acute rejection episode, but significantly higher values were found in subjects with antibody-mediated rejection as compared with other types of rejection and those without rejection. High values of analyzed ratios in patients with satisfactory early kidney graft function may be helpful in selecting subjects with increased risk of subclinical antibody-mediated rejection.

Cardiovascular Risk Factors in Patients Before and After Successful Liver Transplantation

Background

Liver transplantation (LTx) is useful in the treatment of end-stage liver disease. Outcomes of transplantation are dependent upon graft survival and can also be affected by superimposed cardiovascular morbidities. The present retrospective study was performed to assess the prevalence of cardiovascular risk factors before and after LTx.

Material/Methods

A retrospective review of 130 patients undergoing liver transplantation between October 2005 and April 2014 was completed. The mean age of the patients was 49.3±11.9 years. The prevalence of cardiovascular risk factors was assessed before and 2 years after transplantation. The prevalence of cardiovascular risk factors was assessed using a comparison based upon the etiologies of liver disease resulting in transplantation including alcohol, viral, and autoimmune processes using a chi-square analysis.

Results

The prevalence of diabetes mellitus before and 2 years after liver transplantation (LTx) were 18% and 48% (P<0.001). Hypertension was documented in 24% of patients at baseline and 70% after 2 years of follow-up (P<0.001). The prevalence rates of diabetes mellitus before and 2 years after LTx were 18% and 48% (P<0.001). The prevalence of hypertriglyceridemia before and after LTx was 15% and 38%, respectively (P<0.001). Hypercholesterolemia was noted in 16% and 46%, respectively (P<0.001). Thirteen percent of patients before LTx and 18% after were obese (body mass index higher than 30 kg/m²). The annual incidence of diabetes mellitus, hypertension, hypertriglyceridemia, hypercholesterolemia, and obesity during the first 2 years after LTx was 15%, 23.5%, 15%, 18.5%, and 6%, respectively. Twenty-four percent of patients before and 10% after LTx admitted to tobacco use (P<0.001). The prevalence of diabetes (38% vs 67%, P=0.02), hypertriglyceridemia (19% vs 63%, P<0.001), hypercholesterolemia (28% vs 67%, P=0.002), and obesity (9% vs 33%, P=0.02) was lower in patients with an autoimmune cause of liver cirrhosis in comparison to patients with alcoholic disease.

Conclusions

The prevalence of hypertension and glucose and lipid metabolism abnormalities may increase in patients after liver transplantation. The prevalence of cardiovascular risk factors in patients after LTx may be related to the cause of liver injury before LTx.

Ethical Aspects of Kidney Donation and Transplantation for Migrants

Migrants represent a large and diverse population globally that includes international refugees, stateless persons, expatriate workers, and more. Many migrants face significant barriers in accessing health care, especially scarce and costly resources such as dialysis and kidney transplantation. Improving equity of access to these kidney replacement therapies for migrant populations may present a range of complex ethical dilemmas, particularly in the setting of crises and when considering the use of residency status and citizenship as eligibility criteria for access to treatment. In this article, we discuss ethical obligations to provide kidney care for migrants, the implications of the self-sufficiency concept with regard to access to deceased donation and transplantation, factors that may influence evaluation of the risks and benefits of transplantation for migrants with insecure access to care, and the vulnerability of migrants to organ trafficking. We also present a set of general recommendations to assist in preventing and managing ethical dilemmas when making decisions about policy or practice regarding kidney care for migrants.

Increased EBV DNAemia after Anti-SARS-CoV-2 Vaccination in Solid Organ Transplants

The reactivation of latent viruses during SARS-CoV-2 infection is well recognized, and coinfection with Epstein−Barr virus (EBV) has been associated with severe clinical cases of COVID-19 infection. In transplant patients, EBV infection presents a significant challenge. Assessing the potential impact of SARS-CoV-2 vaccinations on EBV infections in stable kidney and liver transplant recipients was the objective of our study. Ten solid-organ-transplant (SOT) patients (eight kidney and two liver) vaccinated with standard doses of mRNA COVID-19 vaccines were included. EBV DNA viral load measurements were conducted prior to the vaccination and during a follow-up period (at the first month and after six months) after the second vaccine dose. After the second dose, a significant increase in median viremia was observed (p < 0.01) in 9 patients, and in one patient, the reactivation of EBV infection was found. Six months later, the median viremia decreased significantly (p < 0.05). The EBV viral load should be closely monitored as it could lead to the earlier diagnosis and treatment of EBV-related complications. Despite experiencing a decrease in the viral load six months post-vaccination, some patients still had a viral load over the baseline, which increased the risk of potential complications.

Kidney Graft Failure and Patient Survival Modelling Based on Competing Risks Under Nonproportional Hazards

We analyze data on Silesian patients after kidney transplantation under competing events scenarios where time to death and time to graft failure are considered as absorbing competing events. Our objectives are to use model diagnostics in identifying violations of proportionality assumption under the framework of subdistribution and cause-specific hazards. We use the Fine-Gray proportional hazards model for the subdistribution. Under the cause-specific hazards (CSH) scenario we use the Cox proportional hazards model and Gray's time-varying coefficients model and available model diagnostics. We show that violation of proportional subdistribution hazards assumption may be conveniently identified using residual diagnostics and properly accounted for by involving time interactions with appropriate model predictors. We also show that although the nonproportional effects on cumulative incidence do not necessarily translate in those on cause-specific hazards, they often take place simultaneously, and a violation of the proportionality assumption needs to be checked rigorously. Time-varying effects have a profound impact on clinical inference under competing risks. They do not translate directly between the frameworks of subdistribution and cause-specific hazards because the cumulative incidence is obtained via integrating the cause-specific hazard weighted by the overall survival function. Also, a different definition of the risk set is in place under the cumulative incidence and CSH framework, respectively. However, a simultaneous violation of the proportionality assumption under both frameworks is still possible. Clinical inference may change considerably when such a violation occurs. Nonproportional effects may be properly identified under each framework using available model diagnostics.

Acute kidney injury in patients with COVID-19: Epidemiology, pathogenesis and treatment

Acute kidney injury occurs in about 30% of patients hospitalized with coronavirus disease 2019 (COVID-19) and is one of the most common extrapulmonary complications of this disease. The highest risk of acute kidney injury is found in hospitalized patients who require mechanical ventilation. The pathogenesis of acute kidney injury in COVID-19 is multifactorial and seems to not be fully understood. Both direct and indirect mechanisms of kidney injury caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) should be considered. The histological picture of kidney specimens obtained from patients with acute kidney injury in the course of COVID-19 is dominated by acute tubular necrosis. Some patients also have acute interstitial nephritis, blood clots in the kidney vessels and focal segmental glomerulosclerosis (the variant with collapsing vascular loops). Acute kidney injury in COVID-19 is primarily caused not by direct viral effect, but by indirect pathophysiological mechanisms. The histopathological findings in these patients does not differ from the majority of the other patients with acute kidney injury. The main pathophysiological mechanisms underlying acute kidney injury in COVID-19 are: hemodynamic abnormalities, hypoxia and cytokine storm. The methods of treating the underlying disease, i.e., COVID-19 in patients with acute kidney injury and those without acute kidney injury are similar. However, it should be stressed that in the treatment of COVID-19 accompanied by acute kidney injury, the contraindication to remdesivir is estimated using glomerular filtration rate (eGFR) <30 mL/min/1.73 m2. The general principles of management in patients with both, COVID-19 and acute kidney injury do not differ from the principles of management in patients with acute kidney injury due to the other causes.

The molecular phenotypes of injury, steatohepatitis, and fibrosis in liver transplant biopsies in the INTERLIVER study

To extend previous molecular analyses of rejection in liver transplant biopsies in the INTERLIVER study (ClinicalTrials.gov #NCT03193151), the present study aimed to define the gene expression selective for parenchymal injury, fibrosis, and steatohepatitis. We analyzed genome-wide microarray measurements from 337 liver transplant biopsies from 13 centers. We examined expression of genes previously annotated as increased in injury and fibrosis using principal component analysis (PCA). PC1 reflected parenchymal injury and related inflammation in the early posttransplant period, slowly regressing over many months. PC2 separated early injury from late fibrosis. Positive PC3 identified a distinct mildly inflamed state correlating with histologic steatohepatitis. Injury PCs correlated with liver function and histologic abnormalities. A classifier trained on histologic steatohepatitis predicted histologic steatohepatitis with cross-validated AUC = 0.83, and was associated with pathways reflecting metabolic abnormalities distinct from fibrosis. PC2 predicted histologic fibrosis (AUC = 0.80), as did a molecular fibrosis classifier (AUC = 0.74). The fibrosis classifier correlated with matrix remodeling pathways with minimal overlap with those selective for steatohepatitis, although some biopsies had both. Genome-wide assessment of liver transplant biopsies can not only detect molecular changes induced by rejection but also those correlating with parenchymal injury, steatohepatitis, and fibrosis, offering potential insights into disease mechanisms for primary diseases.

Impaired fertility in women and men with chronic kidney disease

Chronic kidney disease (CKD) is accompanied by a great number of comorbidities. One of the most clinically important, present in women as well as in men, is infertility. In this review paper, the entire issue of impaired fertility in women and men with CKD is discussed. In both genders, impaired fertility is caused by the interconnection of several factors. In women, these are as follows: the accumulation of uremic toxins; endocrine disorders (e.g., reduced renal clearance of different hormones, disturbed activity of the pituitary-gonadal axis); the impairment of the ovarian function; a reduced ovarian reserve; sexual function disorders; and depression. In men, quite similarly: the accumulation of uremic toxins; endocrine disorders; the impairment of spermatogenesis; direct testicular damage; erectile dysfunction (ED); and depression. The prevalence of impaired fertility increases with the degree of kidney function deterioration in women and men. The highest prevalence of these disturbances is observed in patients with CKD stage 5. Successful kidney transplantation (KTx) in women reduces the accumulation of uremic toxins, restores the function of the endocrine system and improves, but does not normalize, fertility. Similarly in men, KTx restores the function of the endocrine system and improves fertility up to a point, but cannot fully reverse the morphological damage already done to the gonads by the uremia itself. Infertility is one of the important, yet sometimes depreciated complications in women and men with CKD. The etiology and pathogenesis of infertility in CKD is complicated. Kidney transplantation alleviates, but does not fully reverse fertility impairment in CKD patients.

Health status and its socio-economic covariates in the older population in Poland - the assumptions and methods of the nationwide, cross-sectional PolSenior2 survey

INTRODUCTION

Population ageing constitutes an increasing medical, social, and economic burden worldwide. Optimal senior policy should be based on well-assessed knowledge on the prevalence and control of age-related diseases, multimorbidity, disabilities, and their social determinants. The objective of this paper is to describe the assumptions, methods, and sampling procedures of the PolSenior2 survey, which was aimed at characterising the health status of old and very-old adults in Poland.

MATERIAL AND METHODS

The project was conducted in the period 2018-2019 as a cross-sectional survey of a representative sample of people aged 60 years and over. Subjects were selected using three-stage stratified and proportional random sampling in seven equally sized (n = 850) age groups. The study protocol consisted of face-to-face interviews, specific geriatric scales and tests, and anthropometric and blood pressure measurements performed by well-trained nurses at participants homes as well as blood and urine sample laboratory tests.

RESULTS

In the Polsenior2 study a group of 5987 subjects underwent the questionnaire parts of the survey, and almost all (n = 5823) agreed to blood or urine sample collection.

CONCLUSIONS

In recent decades several studies focused on various aspects of elderly health and life conditions had been carried out in Poland and Central and Eastern Europe. However, none of them is so complex and has covered so many issues as PolSenior2, which is the largest study devoted to the health status of older persons in Poland and one of the largest and the most comprehensive in Europe. The results of the study will help to improve health policy targeted at the elderly population in Poland.

Daprodustat for the Treatment of Anemia in Patients Not Undergoing Dialysis

BACKGROUND

Daprodustat is an oral hypoxia-inducible factor prolyl hydroxylase inhibitor. In patients with chronic kidney disease (CKD) who are not undergoing dialysis, the efficacy and safety of daprodustat, as compared with the conventional erythropoiesis-stimulating agent darbepoetin alfa, are unknown.

METHODS

In this randomized, open-label, phase 3 trial with blinded adjudication of cardiovascular outcomes, we compared daprodustat with darbepoetin alfa for the treatment of anemia in patients with CKD who were not undergoing dialysis. The primary outcomes were the mean change in the hemoglobin level from baseline to weeks 28 through 52 and the first occurrence of a major adverse cardiovascular event (MACE; a composite of death from any cause, nonfatal myocardial infarction, or nonfatal stroke).

RESULTS

Overall, 3872 patients were randomly assigned to receive daprodustat or darbepoetin alfa. The mean (±SD) baseline hemoglobin levels were similar in the two groups. The mean (±SE) change in the hemoglobin level from baseline to weeks 28 through 52 was 0.74±0.02 g per deciliter in the daprodustat group and 0.66±0.02 g per deciliter in the darbepoetin alfa group (difference, 0.08 g per deciliter; 95% confidence interval [CI], 0.03 to 0.13), which met the prespecified noninferiority margin of -0.75 g per deciliter. During a median follow-up of 1.9 years, a first MACE occurred in 378 of 1937 patients (19.5%) in the daprodustat group and in 371 of 1935 patients (19.2%) in the darbepoetin alfa group (hazard ratio, 1.03; 95% CI, 0.89 to 1.19), which met the prespecified noninferiority margin of 1.25. The percentages of patients with adverse events were similar in the two groups.

CONCLUSIONS

Among patients with CKD and anemia who were not undergoing dialysis, daprodustat was noninferior to darbepoetin alfa with respect to the change in the hemoglobin level from baseline and with respect to cardiovascular outcomes. (Funded by GlaxoSmithKline; ASCEND-ND ClinicalTrials.gov number, NCT02876835.).

Daprodustat for the Treatment of Anemia in Patients Undergoing Dialysis

BACKGROUND

Among patients with chronic kidney disease (CKD), the use of recombinant human erythropoietin and its derivatives for the treatment of anemia has been linked to a possibly increased risk of stroke, myocardial infarction, and other adverse events. Several trials have suggested that hypoxia-inducible factor (HIF) prolyl hydroxylase inhibitors (PHIs) are as effective as erythropoiesis-stimulating agents (ESAs) in increasing hemoglobin levels.

METHODS

In this randomized, open-label, phase 3 trial, we assigned patients with CKD who were undergoing dialysis and who had a hemoglobin level of 8.0 to 11.5 g per deciliter to receive an oral HIF-PHI (daprodustat) or an injectable ESA (epoetin alfa if they were receiving hemodialysis or darbepoetin alfa if they were receiving peritoneal dialysis). The two primary outcomes were the mean change in the hemoglobin level from baseline to weeks 28 through 52 (noninferiority margin, -0.75 g per deciliter) and the first occurrence of a major adverse cardiovascular event (a composite of death from any cause, nonfatal myocardial infarction, or nonfatal stroke), with a noninferiority margin of 1.25.

RESULTS

A total of 2964 patients underwent randomization. The mean (±SD) baseline hemoglobin level was 10.4±1.0 g per deciliter overall. The mean (±SE) change in the hemoglobin level from baseline to weeks 28 through 52 was 0.28±0.02 g per deciliter in the daprodustat group and 0.10±0.02 g per deciliter in the ESA group (difference, 0.18 g per deciliter; 95% confidence interval [CI], 0.12 to 0.24), which met the prespecified noninferiority margin of -0.75 g per deciliter. During a median follow-up of 2.5 years, a major adverse cardiovascular event occurred in 374 of 1487 patients (25.2%) in the daprodustat group and in 394 of 1477 (26.7%) in the ESA group (hazard ratio, 0.93; 95% CI, 0.81 to 1.07), which also met the prespecified noninferiority margin for daprodustat. The percentages of patients with other adverse events were similar in the two groups.

CONCLUSIONS

Among patients with CKD undergoing dialysis, daprodustat was noninferior to ESAs regarding the change in the hemoglobin level from baseline and cardiovascular outcomes. (Funded by GlaxoSmithKline; ASCEND-D ClinicalTrials.gov number, NCT02879305.).

The Relationship between Initial Tacrolimus Metabolism Rate and Recipients Body Composition in Kidney Transplantation

There are several premises that the body composition of kidney transplant recipients may play a role in tacrolimus metabolism early after transplantation. The present study aimed at analyzing the relationship between the body composition parameters assessed by bioimpedance analysis (BIA) and initial tacrolimus metabolism. Immediately prior to transplantation, BIA using InBody 770 device was performed in 122 subjects. Tacrolimus concentration-to-dose (C/D) ratio was calculated based on the first blood trough level measurement. There was no difference in phase angle, visceral fat area, lean body mass index (LBMI) and the proportion of lean mass as a percentage of total body mass between the subgroups of slow and fast metabolizers. However, subjects with LBMI ≥ median value of 18.7 kg/m², despite similar initial tacrolimus dose per kg of body weight, were characterized by a significantly lower tacrolimus C/D ratio (median 1.39 vs. 1.67, respectively; p < 0.05) in comparison with the subgroup of lower LBMI. Multivariate regression analysis confirmed that age (r_partial = 0.322; p < 0.001) and LBMI (r_partial = −0.254; p < 0.01) independently influenced the tacrolimus C/D ratio. A LBMI assessed by BIA may influence the tacrolimus metabolism in the early post-transplant period and can be a useful in the optimization of initial tacrolimus dosing.

Clinical insights into the role of immunosuppression and its disturbances in solid organ transplant recipients with coronavirus disease 2019

BACKGROUND

The ongoing COVID-19 pandemic has disproportionately affected patients who have undergone solid organ transplantation.

OBJECTIVES

To analyze a cohort of transplant recipients in our practice who developed COVID-19, with a focus on immunosuppressive regimen, tacrolimus blood levels, clinical course, and patient and graft outcomes.

METHODS

During the first 12 months of the pandemic, we identified patients diagnosed with SARS-CoV-2 infection among our ambulatory cohort, including kidney, liver, and heart transplant recipients. Baseline and follow-up data concerning graft function, immunosuppression details, and patient and graft outcomes were analyzed.

RESULTS

Of 2091 ambulatory patients, 201 (9.6%) with diagnosed SARS-CoV-2 infection were identified, including 112 kidney, 56 heart, and 33 liver transplant recipients. COVID-19 cases were significantly more common among those who had recently undergone kidney (during 2015-2020) or heart transplantation (during 2020) than earlier recipients. Additionally, blood levels of tacrolimus measured during or shortly after COVID-19 in 23 kidney graft recipients were significantly increased (median increase, 76.1%; interquartile range: 47.4%-109.4%) relative to pre-dose trough levels, but liver function values were not concomitantly elevated, necessitating a tacrolimus dose reduction in 73.9% of these patients.

CONCLUSIONS

In our cohort of transplant recipients, we found substantial disturbances of tacrolimus metabolism in kidney recipients, which may play a role in the worsening of kidney function during SARS-CoV-2 infection. In addition, we found that infections were more common with recent kidney or heart transplantation, and results suggest the potential importance of immunosuppressive regimen strength for SARS-CoV-2 infection-related morbidity.

Type 1 Diabetic Patients After Simultaneous Pancreas and Kidney Transplantation Have Less Intense Periodontal Inflammation Compared to Kidney Recipients Treated with Insulin

BACKGROUND Long-term diabetes predisposes to pathological changes in periodontal tissues. Improvement in this respect can be expected in patients after pancreas transplantation. The aim of this study was to assess and compare the intensity of periodontium pathological lesions and inflammation markers concentration in gingival crevicular fluid (GCF) in patients with type 1 diabetes (T1D) after kidney (KTx) or simultaneous pancreas and kidney transplantation (SPK). MATERIAL AND METHODS The study included 20 T1D patients after SPK and 16 after KTx, and 15 non-diabetic kidney recipients (control). Periodontal clinical parameters and concentration of selected biochemical markers of inflammation in GCF were assessed. The following tests were used in statistical data analysis: Shapiro-Wilk test, the t test, the Mann-Whitney U tests, one-way ANOVA with Tukey's post hoc test, and χ² test (also with Yate's correction). Moreover, linear regression and Pearson or Spearman correlation coefficient was used. RESULTS There were no differences in modified Sulcus Bleeding Index (mSBI) and GCF volume between the SPK group and control group, whereas values of these parameters in the KTx group were higher than in the SPK and control groups. Maximal clinical attachment loss and pocket depth and Periotest values were higher in diabetic recipients compared to controls, and did not differ between SPK and KTx. The concentration of IL-1ß, MMP-8, resistin, TNFalpha, and YKL40 in the GCF in the KTx group was higher than in the SPK and control groups. In the combined group of T1D patients, there was a correlation between blood HbA1c and mSBI, GCF volume, and resistin, TNF-alpha and YKL40 concentrations, and between resistin concentration and mSBI. CONCLUSIONS T1D patients after SPK show lower levels of inflammatory markers in GCF and present reduced intensity of periodontitis compared to kidney recipients treated with insulin. The severity of morphological changes in periodontium in T1D patients after KTx or SPK is higher than in non-diabetic kidney recipients.

Cognitive disorders in patients with chronic kidney disease: specificities of clinical assessment

Neurocognitive disorders are frequent among chronic kidney disease (CKD) patients. Identifying and characterizing cognitive impairment (CI) can help to assess the ability of adherence to CKD risk reduction strategy, identify potentially reversible causes of cognitive decline, modify pharmacotherapy, educate the patient and caregiver and provide appropriate patient and caregiver support. Numerous factors are associated with the development and progression of CI in CKD patients and various conditions can influence the results of cognitive assessment in these patients. Here we review clinical warning signs that should lead to cognitive screening; conditions frequent in CKD at risk to interfere with cognitive testing or performance, including specificities of cognitive assessment in dialysis patients or after kidney transplantation; and available tests for screening and observed cognitive patterns in CKD patients.

Safety of Antithymocyte Globulin Use in Kidney Graft Recipients During the COVID-19 Pandemic

Background

There are many safety concerns regarding the use of antithymocyte globulin (ATG) in kidney transplant recipients (KTRs) during the ongoing COVID-19 pandemic. Hereby, we present our recent experience with ATG administration both as induction therapy and as an anti-rejection treatment.

Material/Methods

We retrospectively analyzed all patients transplanted during the first 12 months of the COVID-19 pandemic who were treated with thymoglobulin. The ATG dosing, lymphocyte number and percentage in blood smear, adverse effects (thrombocytopenia and infectious complications), and kidney graft function up to 12 months and patients’ outcomes were analyzed and compared to KTRs who received basiliximab induction.

Results

During pandemic, a total of 31 patients were treated with ATG and 59 received basiliximab. The median cumulative ATG doses were 275 (175–325) mg in the induction subgroup and 263 (200–275) mg in the anti-rejection treatment subgroup. Mild thrombocytopenia was noted in 7 (22.6%) and 13 (29.5%) patients, respectively. There were more infectious complications among patients treated with ATG as compared with the basiliximab subgroup (32.3 vs 10.2%, P<0.01), but there were similar incidence rates of thrombocytopenia. Kidney graft function up to 12 months after transplant was comparable (1.1 [1.0–1.9] vs 1.1 [1.0–1.4] mg/dl, respectively).

Conclusions

1. ATG use in the induction protocol or as the anti-rejection treatment during the COVID-19 pandemic appears to be safe and the risk of adverse events is acceptable. 2. During the COVID-19 pandemic the necessary use of ATG should not be postponed, especially in KTRs with increased immunologic risk.

Patterns of multimorbidity in 4588 older adults. Implications for non-geriatrician specialist

INTRODUCTION

Multimorbidity has been recognized as an important factor in the geriatric medicine. However, its importance for other specialists is still to be fully appreciated.

OBJECTIVES

To assess the prevalence and patterns of multimorbidity in older subjects drawn from general population.

PATIENTS AND METHODS

PolSenior was a nationwide, multicenter, cross-sectional survey of aged population in Poland. Questionnaire, physical examination and laboratory data were gathered. Multimorbidity was defined as a coexistence of two and more chronic diseases or medical problems out of 17 identified. Factor analysis was employed to identify clusters of conditions.

RESULTS

Of 4588 subjects 51.9% were men, 640 were aged 55-59, 3948 were aged ≥ 65 years, and 1757 ≥ 80 years. Multimorbidity depended on age and sex, and was diagnosed in 70.9% of those aged 55-59, 88.4% of 65-79, and 93.9% of those aged ≥80 years. Only 8.5% participants aged 55-59, 2.2% aged 65-79 years, and 0.9%  aged ≥ 80 years had no diagnosis of chronic disease. Hypertension, metabolic diseases and obesity predominated in 55-59 and 65-79 years age-groups, whereas hypertension, eye disorders, and cognitive impairment prevailed in the oldest group. The highest likelihood of multimorbidity was found in the youngest subjects who had stroke, kidney disease, cancer, or a composite of Parkinson's/epilepsy; in 65-79 years old with history of stroke, and in ≥80 years old with history of stroke or heart failure.

CONCLUSIONS

The age-specific analysis of clustering revealed differences in prevalence and patterns of comorbidities, which stresses the importance of individual approach to older patients.

Beneficial Effect of Successful Simultaneous Pancreas-Kidney Transplantation on Plasma Profile of Metalloproteinases in Type 1 Diabetes Mellitus Patients

It is not fully elucidated whether the restoring of normal glucose metabolism after successful simultaneous pancreas-kidney transplantation (SPK) improves vascular wall morphology and function in type 1 diabetic (T1D) patients. Therefore, we compared arterial stiffness, assessed by pulse wave velocity (PWV), carotid intima-media thickness (IMT), and biomarkers of arterial wall calcification in T1D patients after SPK or kidney transplantation alone (KTA). In 39 SPK and 39 KTA adult patients of similar age, PWV, IMT, circulating matrix metalloproteinases (MMPs) and calcification biomarkers were assessed at median 83 months post transplantation. Additionally, carotid plaques were visualized and semi-qualitatively classified. Although PWV and IMT values were similar, the occurrence of atherosclerotic plaques (51.3 vs. 70.3%, p < 0.01) and calcified lesions (35.9 vs. 64.9%, p < 0.05) was lower in SPK patients. There were significantly lower concentrations of MMP-1, MMP-2, MMP-3, and osteocalcin in SPK subjects. Among the analyzed biomarkers, only logMMP-1, logMMP-2, and logMMP-3 concentrations were associated with log HbA_1c. Multivariate stepwise backward regression analysis revealed that MMP-1 and MMP-3 variability were explained only by log HbA_1c. Normal glucose metabolism achieved by SPK is followed by the favorable profile of circulating matrix metalloproteinases, which may reflect the vasoprotective effect of pancreas transplantation.

Difficulties in the diagnostics of chronic hyponatremia based on the case study of a 66-year old female patient during antihypertensive therapy

Clinical consequences of hyponatremia might be serious. It is often related to the administration of diuretics, especially thiazide and thiazide-like diuretics. It is known that elderly subjects are prone to thiazide induced hyponatremia (TIH).

A CASE REPORT

A 66-year old female patient was admitted to our Department. The aim of the admission was to complete a differential diagnosis of chronic hyponatremia. For about two years the patient had suffered from the following symptoms: severe headaches, fatigue, episodic mental confusions, stomachaches, and diarrhea. Before admission to the hospital, the patient was treated with bisoprolol, amlodipine, telmisartan, indapamide, furosemide, acetylsalicylic acid, thiamazole, and zolpidem. The general clinical picture might suggest that the cause of hyponatremia was the indapamide diuretic therapy. However, only moderate hyponatremia, normokalemia, as well as, an increased antidiuretic hormone serum concentration were observed. These findings are not typical for TIH. Despite those findings, natremia improved after the cessation of indapamide therapy.

CONCLUSIONS

This case report described the atypical presentation of TIH resembling SIADH. TIH diagnosis should be primarily based on the improvement of hyponatremia after the termination of thiazide or thiazide-like diuretic treatment.

Serum testosterone concentrations in male patients with end-stage kidney disease treated with haemodialysis

INTRODUCTION

Testosterone deficiency is frequently found in male patients with chronic kidney disease (CKD) and may participate in the pathogenesis of osteoporosis, sarcopaenia, anaemia, impotence, infertility, and other comorbidities observed in these patients. The aim of the study was the evaluation of the frequency of testosterone deficiency in male patients with CKD on maintenance haemodialysis (HD).

MATERIAL AND METHODS

In 79 male HD patients, serum total (TT), free (FT) testosterone, C-reactive protein (CRP), and interleukin 6 (IL-6) serum concentrations were assessed before an HD procedure. Patients were divided into three subgroups based on age categories: 19-39 years (18 patients), 40-59 years (34 patients), and ≥ 60 years (27 patients). TT insufficiency and deficiency were diagnosed when the serum TT concentration was below 4.0 ng/mL and 2.9 ng/mL, respectively. FT deficiency was diagnosed in patients with serum FT concentration below 8.9, 6.6, and 4.9 pg/mL in the abovementioned age subgroups, respectively.

RESULTS

In the abovementioned age subgroups the serum TT concentration was 5.9 (4.6-7.1), 4.8 (3.9-5.4), and 4.6 (3.9-5.3) ng/mL, respectively. The serum FT concentration was 7.9 (5.2-10.1), 6.1 (5.1-7.2), and 6.0 (5.0-7.1) pg/mL, respectively. In the whole group TT insufficiency was found in 40%, TT deficiency in 15% of patients, and FT deficiency in 50% of patients. Significant negative correlations were found between both serum TT and FT concentrations and age (r = -0.23, p = 0.05 and r = -0.27, p = 0.02, respectively). Additionally, negative correlations were found between both serum TT and FT and IL-6 concentrations (r = -0.43, p < 0.05 and r = -0.29, p < 0.05), respectively.

CONCLUSIONS

1. Testosterone deficiency is common in male patients with chronic kidney disease treated with HD. 2. In HD patients the serum testosterone concentration decreases with age. 3. Chronic inflammation may participate in the pathogenesis of testosterone deficiency in haemodialysis patients.

The molecular diagnosis of rejection in liver transplant biopsies: First results of the INTERLIVER study

Molecular diagnosis of rejection is emerging in kidney, heart, and lung transplant biopsies and could offer insights for liver transplant biopsies. We measured gene expression by microarrays in 235 liver transplant biopsies from 10 centers. Unsupervised archetypal analysis based on expression of previously annotated rejection-related transcripts identified 4 groups: normal "R1_normal " (N = 129), T cell-mediated rejection (TCMR) "R2_TCMR " (N = 37), early injury "R3_injury " (N = 61), and fibrosis "R4_late " (N = 8). Groups differed in median time posttransplant, for example, R3_injury 99 days vs R4_late 3117 days. R2_TCMR biopsies expressed typical TCMR-related transcripts, for example, intense IFNG-induced effects. R3_injury displayed increased expression of parenchymal injury transcripts (eg, hypoxia-inducible factor EGLN1). R4_late biopsies showed immunoglobulin transcripts and injury-related transcripts. R2_TCMR correlated with histologic rejection although with many discrepancies, and R4_late with fibrosis. R2_TCMR , R3_injury , and R4_late correlated with liver function abnormalities. Supervised classifiers trained on histologic rejection showed less agreement with histology than unsupervised R2_TCMR scores. No confirmed cases of clinical antibody-mediated rejection (ABMR) were present in the population, and strategies that previously revealed ABMR in kidney and heart transplants failed to reveal a liver ABMR phenotype. In conclusion, molecular analysis of liver transplant biopsies detects rejection, has the potential to resolve ambiguities, and could assist with immunosuppressive management.

Vitamin D and Arterial Hypertension: Facts and Myths

PURPOSE OF REVIEW

Vitamin D and its derivatives are biologically active fat-soluble steroid hormones, which are transcription factors for numerous genes. The results of several observational studies suggest the relationship between plasma concentration of vitamin D and the risk of arterial hypertension, as well as between the intensity of insolation and the risk of arterial hypertension.

RECENT FINDINGS

Based on the results of the abovementioned studies, it was hypothesized that vitamin D is characterized by the antihypertensive properties. Animal experiments have shown that vitamin D reduces activity of the renin-angiotensin-aldosterone system and improves vasorelaxation of blood vessels. Results of clinical studies did not confirm these results. Moreover in interventional clinical trials, it was documented that supplementation of vitamin D did not reduce blood pressure. The influence of exposure to sunshine at different wave lengths on blood pressure was examined in clinical studies and it was found that ultraviolet A radiation (UVA) lead to the release of nitric oxide from the skin. This might explain lower level of blood pressure in subjects from the regions with a higher rate of insolation. The aim of this review is to summarize current knowledge concerning the relationship between vitamin D and arterial hypertension based on both observational and interventional studies.

Influence of Chronic Periodontitis on the Long-Term Mortality and Cardiovascular Events in Kidney Transplant Recipients

Chronic periodontitis (CP) is associated with cardiovascular disease and mortality in different populations. The aim of this study was to examine an association of CP with hard endpoints in patients after kidney transplantation during a 15-year follow-up period. Study group consist of 117 patients (77M/40F, median age 44 years) divided into two subgroups: those with initially advanced CP (CPITN 3-4) and those with no or moderate CP (CPITN 0-2). All cardiovascular events, graft losses, and re-transplantations were recorded. All deaths were noted and verified, including those occurred after the return to dialysis therapy, the causes of death were identified. Cox regression with Firth's penalized maximum likelihood models were used for data analysis. During the observation period, 49 deaths occurred. Advanced CP (n = 35) was not associated with overall mortality but was associated with increased risk of death with functioning graft (DWFG) [HR 3.54 (1.20-10.45); p < 0.05]. Risk of graft loss was not associated with CP status. In conclusion, an advanced CP was independently associated with increased risk of DWFG, but not all-cause or cardiovascular mortality after renal transplantation.

Clostridium difficile infection in patients after solid organ transplantations

Clostridium difficile is the most common identified pathogen causing nosocomial and antibiotic-associated diarrhea. The incidence of Clostridium difficile infection (CDI) has increased over the last decades. The occurrence of severe and recurrent CDI is also more often recently observed. Patients after solid organs transplantation are more prone to Clostridium difficile infection that the general population. This is associated mainly with immunosuppressive therapy, more frequent hospitalizations and frequent antibiotic therapy. Due to the growing number of CDI, it is important to correctly diagnose this infection and to implement the proper treatment. The main drugs used to treat CDI are vancomycin and fidaxomicin. In the case of CDI recurrence, fecal microbiota transplantation remains to be considered. The rationale use of antibiotics and avoiding proton pump inhibitors may also prevent CDI. Results of recent observational study suggest that one of the probiotics – Lactobacillus plantarum 299v prevents CDI in patients during immunosuppressive therapy. The efficacy and safety of using probiotics in CDI prophylaxis in this group of patients requires, however, further studies.

Early graft function and intrarenal resistant index after kidney transplantation using Biolasol-A new solid organ preservation fluid

Biolasol is a newly developed preserving solution for cold organ storage prior to transplantation. To date, only animal model experiments results are available. The aim of this single-center analysis was to summarize the clinical experience concerning the early post-transplant course of kidney grafts preserved with Biolasol in comparison with other preservation solutions. Before transplantation, 173 kidney grafts were preserved using Biolasol and 240 organs with other solutions (University of Wisconsin-UW, Institute Georges Lopez-IGL-1, or StoreProtect Plus solutions). Early graft function was defined based on serum creatinine concentration at day 3 (<3 mg/dL-immediate graft function, IGF or >3 mg/dL-slow graft function, SGF) or the need of dialysis therapy during first post-operative week (delayed graft function, DGF). The analysis included intrarenal resistive indices measured by Doppler sonography early after transplantation and before discharge from the hospital. IGF was more frequent in patients with organs preserved with IGL-1 (33.5%) and StoreProtect Plus (38.8%) than Biolasol (18.5%), whereas there was no difference in the occurrence of DGF. Both initial and discharge median resistance index values were significantly higher in the Biolasol subgroup (0.77 and 0.75) than in all three other subgroups (P values for all comparisons <.001), also after 1:1 propensity score matching for baseline characteristics. Multiple logistic regression analysis based on the propensity score-matched cohort revealed that the use of Biolasol solution [OR 0.59 (0.35-0.98); P < .05] independently decreased the occurrence of IGF. In our single-center clinical experience, kidney preservation using Biolasol solution was associated with significantly higher intrarenal resistant index in comparison with other preservation fluids, as well as worse early graft function than in the IGL-1 and the StoreProtect Plus subgroups. Long-term follow-up is needed in order to assess the kidney graft and patient survival.

Early Complications After Kidney Transplantation in Patients Aged 60 Years and Older: A Single-Center, Paired-Kidney Analysis

OBJECTIVES

As the population ages, the number of people suffering from cardiovascular diseases (CVD) and diabetes mellitus (DM) increases. The coexistence of these diseases can affect the results of kidney transplantation (KT) in the elderly. The aim of this study was to analyze surgical and nonsurgical complications in the early period after KT and to identify the factors that influence their development in recipients aged ≥ 60 years compared to younger recipients < 60 years.

METHODS

One hundred seventy-five recipients of KT ≥ 60 years and 175 recipients of KT < 60 years who received kidneys from the same deceased donor were enrolled into the study. The incidence of surgical and nonsurgical complications, factors that may influence their development, early graft function, and patient and kidney-graft survival were analyzed during a 3-month follow-up period. Donor sources complied with the Helsinki Congress and Istanbul Declaration and organs were not procured from prisoners and individuals who were coerced or paid.

RESULTS

Older recipients were characterized by higher body mass index ± SD (26.1 ± 3.5 vs 24.7 ± 3.4 kg/m²) and suffered more often from pretransplant DM (20.6% vs 11.4%) and CVD (34.3% vs 10.3%) and less frequently underwent previous KT (6.3% vs 20.0%). There were no differences between the ≥ 60 year old and < 60 year old groups in reference to surgical (20.6% vs 24%) and nonsurgical complications (28.6% vs 27.4%), early graft function, serum creatinine, and proteinuria. Recipients (95.4% vs 97.1%) and kidney-graft survival (93.1% vs 95.4%) were similar in both groups. The recipient factors that influenced the development of infectious complications were age, dialysis duration, pretransplant DM, and CVD.

CONCLUSIONS

Despite higher co-incidence of CVD and DM, the risk of surgical and nonsurgical complications in elderly recipients is comparable to younger recipients in the early period after KT.

Simultaneously Transplanted Pancreas Improves Salivation and Reduces Oral Fungal Infections Incidence in Type 1 Diabetic Renal Transplant Recipients

BACKGROUND

Long-lasting diabetes mellitus may lead to numerous pathologies in the oral cavity. The aim of the study was to assess the condition of the oral cavity, caries intensity, salivary parameters, and incidence of oral fungal infections in patients with type 1 diabetes (T1D) and end-stage renal disease (ESRD) after kidney transplantation (KTx) or simultaneous kidney and pancreas transplantation (SPK).

METHODS

Twenty-one patients after SPK, 18 T1D patients after KTx, and 14 kidney recipients without diabetes (control group) were included in the study. Donor sources complied with Helsinki Congress and the Declaration of Istanbul.

RESULTS

Approximal plague index in SPK (80% [68%-90%]) was comparable to KTx (80% [37.5%-92.5%]) but higher than in control group (46% [35%-50%]). All 3 groups did not differ in terms of decayed-missing-filled tooth index: 22.3 ± 4.8 vs 22.5 ± 4.5 vs 19.1 ± 4.9, respectively. Normal saliva resting secretion and consistency were more common in SPK (71.4% and 52%, respectively) than in KTx (27.8% and 50.0%, respectively). Stimulated saliva volume in the SPK, KTx and controls, pH value, and buffering capacity were comparable. In KTx higher incidence of Candida albicans infection (55.6%) compared with SPK (23.8%) and controls (no infection) was observed.

CONCLUSIONS

Simultaneously transplanted pancreas improves salivation and reduces the incidence of oral fungal infections in T1D kidney recipients. The severity of caries is higher and oral hygiene is worse in T1D kidney recipients compared with patients after KTx without diabetes.

Changes in Office Blood Pressure Control, Augmentation Index, and Liver Steatosis in Kidney Transplant Patients after Successful Hepatitis C Infection Treatment with Direct Antiviral Agents

Hepatitis C virus (HCV) infection in kidney transplant recipients (KTRs) can be successfully treated with direct antiviral agents (DAA). The aim of our study was to analyze different measures of vascular function during and after the DAA treatment. As we have observed the improvement of blood pressure (BP) control in some individuals, we have conducted an analysis of potential explanatory mechanisms behind this finding. Twenty-eight adult KTRs were prospectively evaluated before and 15 months after start of DAA therapy. Attended office BP (OBP), augmentation index (AIx), pulse wave velocity (PWV), flow-mediated dilation (FMD), liver stiffness measurement (LSM), and liver steatosis assessment (controlled attenuation parameter (CAP)) were measured. In half of the patients, improvement of OBP control (decline of systolic BP by at least 20 mmHg or reduction of the number of antihypertensive drugs used) and parallel central aortic pressure parameters, including AIx, was observed. There was a significant decrease in CAP mean values (241 ± 54 vs. 209 ± 30 dB/m, p < 0.05) only in patients with OBP control improvement. Half of our KTRs cohort after successful HCV eradication noted clinically important improvement of both OBP control and central aortic pressure parameters, including AIx. The concomitant decrease of liver steatosis was observed only in the subgroup of patients with improvement of blood pressure control.

A Rare Mutation in The APOB Gene Associated with Neurological Manifestations in Familial Hypobetalipoproteinemia

Clinical phenotypes of familial hypobetalipoproteinemia (FHBL) are related to a number of defective apolipoprotein B (APOB) alleles. Fatty liver disease is a typical manifestation, but serious neurological symptoms can appear. In this study, genetic analysis of the APOB gene and ophthalmological diagnostics were performed for family members with FHBL. Five relatives with FHBL, including a proband who developed neurological disorders, were examined. A sequencing analysis of the whole coding region of the APOB gene, including flanking intronic regions, was performed using the next-generation sequencing (NGS) method. Electrophysiological ophthalmological examinations were also done. In the proband and his affected relatives, NGS identified the presence of the pathogenic, rare heterozygous splicing variant c.3696+1G>T. Two known heterozygous missense variants-c.2188G>A, p.(Val730Ile) and c.8353A>C, p.(Asn2785His)-in the APOB gene were also detected. In all patients, many ophthalmologic abnormalities in electrophysiological tests were also found. The identified splicing variant c.3696+1G>T can be associated with observed autosomal, dominant FHBL with coexisting neurological symptoms, and both identified missense variants could be excluded as the main cause of observed clinical signs, according to mutation databases and the literature. Electroretinography examination is a sensitive method for the detection of early neuropathy and should therefore be recommended for the care of patients with FHBL.

The Preliminary Results of Bortezomib Used as A Primary Treatment for An Early Acute Antibody-Mediated Rejection after Kidney Transplantation-A Single-Center Case Series

Proteasome inhibitor bortezomib has been used in the treatment of refractory cases of acute and chronic antibody-mediated rejection (AMR) in kidney transplant recipients. However, its efficacy and safety as a primary treatment for early AMR has been scarcely investigated. We herein present our preliminary experience with bortezomib- and plasmapheresis-based primary treatment for early AMR. Thirteen patients transplanted between October 2015 and September 2019 were treated (starting at median 19th post-transplant day) with bortezomib/plasmapheresis protocol for early biopsy-proven AMR. Twelve out of thirteen patients received 4 doses and one patient recieved 3 doses of bortezomib (1.3 mg/m² per dose). In 11/13 patients, 4–7 concomitant plasmapheresis sessions were performed, with or without intravenous immunoglobulin (IVIG). Of note, rituximab was not used in all study patients. The kidney graft and patient survival were 100%. The mean 3-month estimated glomerular filtration rate (eGFR) was 55.3 (95%CI: 44.9–65.8) mL/min/1.73m², 8/13 patients completed 12-month follow-up with mean eGFR 60.4 (45.4–75.4) mL/min/1.73m², and 6/13 patients completed a 24-month follow-up period with mean eGFR 73.9 (56.7–91.1) mL/min/1.73m². Neutropenia < 1 G/L was observed in one patient, third or fourth grade thrombocytopenia in two patients, and eleven patients needed a blood transfusion (median: 2 units/patient). The mid-term results of a primary bortezomib-based treatment for kidney AMR showed its non-inferiority as compared to preceding regimens and acceptable safety. However, our data should be validated in a multicenter randomized trial.