"Eculizumab First" in the Management of Posttransplant Thrombotic Microangiopathy

Introduction

Posttransplant thrombotic microangiopathy (PT-TMA) is an uncommon event that characterizes approximately 3% to 14% of kidney transplants (KTs), and that is associated with a higher risk of delayed graft function and graft loss. PT-TMA occurs more frequently within the first 3 months after transplant and can be a manifestation of de novo disease or the recurrence of previous atypical hemolytic uremic syndrome (aHUS). Abnormalities in complement regulation genes could explain the increased susceptibility of some patients to PT-TMA. Eculizumab is a humanized monoclonal antibody that inhibits the formation of the membrane attack complex C5b-9. The aim of this study is to evaluate the efficacy of eculizumab as treatment for PT-TMA.

Methods

We retrospectively analyzed clinical records of 45 KT patients who received eculizumab immediately after the clinical diagnosis of PT-TMA.

Results

Kidney biopsy was performed in 91.1% of patients, and complement genetic study was performed in 64.4%. Of the kidney biopsies, 85.4% showed signs of TMA; genetic analysis revealed 1 pathogenetic variant, 2 variants of uncertain significance, 1 likely benign variant, 8 risk polymorphisms, and 27 risk haplotypes. After 2 weeks from the treatment starting, hemoglobin and platelets significantly increased. A remarkable improvement in kidney function was also observed. After 6 months, 28.8% of patients had a complete renal recovery whereas 44.4% had a partial recovery.

Conclusion

This is, to our knowledge, the largest series of KT patients with PT-TMA treated with eculizumab. These data suggest that eculizumab is associated with a normalization of hemolysis indices and an important and progressive improvement of graft function.

Rituximab as possible therapy in TNF inhibitor-induced IgA vasculitis with severe renal involvement

BACKGROUND

We observe the increasing use of tumor necrosis factor (TNF) inhibitors in patients affected by chronic inflammatory diseases. These drugs provide good control of symptoms, contributing to significant improvement in the quality of life in individuals with high disease burden. On the other hand, along with their wider use and longer follow-up periods the number of reports regarding their adverse effects is also increasing. The reported complications include drug-induced vasculitis with possible kidney involvement. In the literature we can distinguish more frequently described ANCA-associated vasculitis and more rarely occurring immunoglobulin A vasculitis. Although uncommon, such complications may present with potentially life-threatening vital organ dysfunction; therefore, adequate monitoring and effective therapy are necessary.

CASE PRESENTATION

We report two cases of TNF inhibitor-induced vasculitis with severe acute worsening of renal function and significant proteinuria. The first patient was receiving golimumab therapy for ankylosing spondylitis and the second patient was treated with adalimumab for psoriasis and psoriatic arthritis. In the second case dialysis treatment was necessary and the patient presented recurrence of vasculitis after rechallenge with adalimumab. Both patients underwent renal biopsy which showed findings compatible with drug-induced IgA vasculitis and both were treated successfully with corticosteroids and rituximab.

CONCLUSIONS

To the best of our knowledge this is the first report of rituximab use in drug-induced IgA vasculitis with renal involvement. Combination of corticosteroids and rituximab can be an effective therapy in case of vasculitis with kidney failure and a preferable option for selected patients with drug-induced IgA vasculitis compared to cyclophosphamide. More studies are necessary to establish suitable short- and long-term treatment. Given the rarity of this disorder, case reports and case series can provide practical guidance until additional studies become available.

Histological findings of diabetic kidneys transplanted in non-diabetic recipients: a case series

BACKGROUND

Diabetic donors are recognized as a reliable source of organs, although the discard rate of kidneys is still high. Few data are available on the histological evolution of these organs especially on kidneys transplanted into non-diabetic patients who remain euglycemic.

METHODS

We describe the histological evolution of ten kidney biopsies performed on non-diabetic recipients of diabetic donors.

RESULTS

Mean donor age was 69 ± 7 years, 60% were males. Two donors were treated with insulin, eight with oral antidiabetic drugs. Mean recipient age was 59.9 ± 7 years, 70% were males. The pre-existing diabetic lesions identified in the pre-implantation biopsies, encompassed all histological classes, and were associated with mild IF/TA and vascular damages. The median follow-up was 59.5 [IQR 32.5-99.0] months; at follow-up, 40% of cases did not change histologic classification, two patients with class IIb downgraded to IIa or I and one with class III downgraded to IIb. Conversely, three cases showed a worsening, from class 0 to I, I to IIb or from IIa to IIb. We also observed a moderate evolution of IF/TA and vascular damages. At follow-up visit, estimated GFR was stable (50.7 mL/min vs. 54.8 at baseline) and proteinuria was mild (51.1 ± 78.6 mg/day).

CONCLUSIONS

Kidneys from diabetic donors show variable evolution of the histologic features of diabetic nephropathy after transplant. This variability may be associated to recipients characteristics such as euglycemic milieu, in case of improvement, or obesity and hypertension, in case of worsening of histologic lesions.

Rare Single Nucleotide and Copy Number Variants and the Etiology of Congenital Obstructive Uropathy: Implications for Genetic Diagnosis

SIGNIFICANCE STATEMENT

Congenital obstructive uropathy (COU) is a prevalent human developmental defect with highly heterogeneous clinical presentations and outcomes. Genetics may refine diagnosis, prognosis, and treatment, but the genomic architecture of COU is largely unknown. Comprehensive genomic screening study of 733 cases with three distinct COU subphenotypes revealed disease etiology in 10.0% of them. We detected no significant differences in the overall diagnostic yield among COU subphenotypes, with characteristic variable expressivity of several mutant genes. Our findings therefore may legitimize a genetic first diagnostic approach for COU, especially when burdening clinical and imaging characterization is not complete or available.

BACKGROUND

Congenital obstructive uropathy (COU) is a common cause of developmental defects of the urinary tract, with heterogeneous clinical presentation and outcome. Genetic analysis has the potential to elucidate the underlying diagnosis and help risk stratification.

METHODS

We performed a comprehensive genomic screen of 733 independent COU cases, which consisted of individuals with ureteropelvic junction obstruction ( n =321), ureterovesical junction obstruction/congenital megaureter ( n =178), and COU not otherwise specified (COU-NOS; n =234).

RESULTS

We identified pathogenic single nucleotide variants (SNVs) in 53 (7.2%) cases and genomic disorders (GDs) in 23 (3.1%) cases. We detected no significant differences in the overall diagnostic yield between COU sub-phenotypes, and pathogenic SNVs in several genes were associated to any of the three categories. Hence, although COU may appear phenotypically heterogeneous, COU phenotypes are likely to share common molecular bases. On the other hand, mutations in TNXB were more often identified in COU-NOS cases, demonstrating the diagnostic challenge in discriminating COU from hydronephrosis secondary to vesicoureteral reflux, particularly when diagnostic imaging is incomplete. Pathogenic SNVs in only six genes were found in more than one individual, supporting high genetic heterogeneity. Finally, convergence between data on SNVs and GDs suggest MYH11 as a dosage-sensitive gene possibly correlating with severity of COU.

CONCLUSIONS

We established a genomic diagnosis in 10.0% of COU individuals. The findings underscore the urgent need to identify novel genetic susceptibility factors to COU to better define the natural history of the remaining 90% of cases without a molecular diagnosis.

Renal Vessel Extension With Cryopreserved Vascular Grafts: Overcoming Surgical Pitfalls in Living Donor Kidney Transplant

In LDKT, right kidneys and kidneys with anomalous vascularization are often deferred because of concerns on complications and vascular reconstructions. To date, only few reports have examined renal vessel extension with cryopreserved vascular grafts in LDKT. The aim of this study is to investigate the effect of renal vessel extension on short-term outcomes and ischemia times in LDKT. From 2012 to 2020, recipients of LDKT with renal vessels extension were compared with standard LDKT recipients. Subset analysis of rights grafts and grafts with anomalous vascularization, with or without renal vessel extension, was performed. Recipients of LDKT with (n = 54) and without (n = 91) vascular extension experienced similar hospital stays, surgical complications and DGF rates. For grafts with multiple vessels, renal vessel extension granted a faster implantation time (44±5 vs. 72±14 min), which resulted comparable to that of standard anatomy grafts. Right kidney grafts with vascular extension had a faster implantation time compared to right kidney grafts without vascular lengthening (43±5 vs. 58±9 min), and a comparable implantation time to left kidney grafts. Renal vessel extension with cryopreserved vascular grafts allows faster implantation time in right kidney grafts or grafts with anomalous vascularization, maintaining similar surgical and functional outcomes.

Current Perspectives in ABO-Incompatible Kidney Transplant

For a long time, ABO incompatible living donor kidney transplantation has been considered contraindicated, due to the presence of isohemagglutinins, natural antibodies reacting with non-self ABO antigens. However, as the demand for kidney transplantation is constantly growing, methods to expand the donor pool have become increasingly important. Thus, in the last decades, specific desensitization strategies for ABOi transplantation have been developed. Nowadays, these regimens consist of transient removal of preformed anti-A or anti-B antibodies by using plasmapheresis or immunoadsorption and B-cell immunity modulation by CD20+ cells depletion with rituximab, in association with maintenance immunosuppression including corticosteroids, tacrolimus and mycophenolate mofetil. The outcome in ABOi kidney transplantation have markedly improved over the years. In fact, although randomized trials are still lacking, recent meta analysis has revealed that there is no difference in terms of graft and patient's survival between ABOi and ABO compatible kidney transplant, even in the long term. However, many concerns still exist, because ABOi kidney transplantation is associated with an increased risk of bleeding and infectious complications, partly related to the effects of extracorporeal treatments and the strong immunosuppression. Thus, a continuous improvement in desensitization strategies, with the aim of minimize the immunosuppressive burden, on the basis of immune pathogenesis, antibodies titers and/or ABO blood group, is warranted. In this review, we discuss the main immune mechanisms involved in ABOi kidney transplantation, the pathogenesis of tolerance and the desensitization regimens, including immunoadsorption and plasmapheresis and the immunosuppressive protocol. Finally, we provide an overview on outcome and future perspectives in ABOi kidney transplant.

The Role of Vitamin K in CKD-MBD

PURPOSE OF REVIEW

We describe the mechanism of action of vitamin K, and its implication in cardiovascular disease, bone fractures, and inflammation to underline its protective role, especially in chronic kidney disease (CKD).

RECENT FINDINGS

Vitamin K acts as a coenzyme of y-glutamyl carboxylase, transforming undercarboxylated in carboxylated vitamin K-dependent proteins. Furthermore, through the binding of the nuclear steroid and xenobiotic receptor, it activates the expression of genes that encode proteins involved in the maintenance of bone quality and bone remodeling. There are three main types of K vitamers: phylloquinone, menaquinones, and menadione. CKD patients, for several conditions typical of the disease, are characterized by lower levels of vitamin K than the general populations, with a resulting higher prevalence of bone fractures, vascular calcifications, and mortality. Therefore, the definition of vitamin K dosage is an important issue, potentially leading to reduced bone fractures and improved vascular calcifications in the general population and CKD patients.

Bone Mineral Density Changes in Long-Term Kidney Transplant Recipients: A Real-Life Cohort Study of Native Vitamin D Supplementation

Vitamin D insufficiency has been associated with reduced bone mineral density (BMD) in kidney transplant patients (KTRs). However, the efficacy of vitamin D supplementation on BMD remains poorly defined, especially for long-term KTRs. We aimed to investigate the effect of native vitamin D supplementation on the BMD of KTRs during a 2-year follow-up. Demographic, clinical, and laboratory data were collected. BMD was evaluated with standard DEXA that was performed at baseline (before vitamin D supplementation) and at the end of study period. BMD was assessed at lumbar vertebral bodies (LV) and right femoral neck (FN) by a single operator. According to WHO criteria, results were expressed as the T-score (standard deviation (SD) relative to young healthy adults) and Z-score (SD relative to age-matched controls). Osteoporosis and osteopenia were defined as a T-score ≤ -2.5 SD and a T-score < -1 and a > -2.5 SD, respectively. Based on plasma levels, 25-OH-vitamin D (25-OH-D) was supplemented as recommended for the general population. Data from 100 KTRs were analyzed. The mean study period was 27.7 ± 3.4 months. At study inception, 25-OH-D insufficiency and deficiency were recorded in 65 and 35 patients. At the basal DEXA, the percentage of osteopenia and osteoporosis was 43.3% and 18.6% at LV and 54.1% and 12.2% at FN, respectively. At the end of the study, no differences in the Z-score and T-score gains were observed. During linear mixed model analysis, native vitamin D supplementation was found to have a negative nitration with Z-score changes at the right femoral neck in KTRs (p < 0.05). The mean dose of administered cholecalciferol was 13.396 ± 7.537 UI per week; increased 25-OH-D levels were found (p < 0.0001). Either low BMD or 25-OH-vitamin D concentration was observed in long-term KTRs. Prolonged supplementation with 25-OH-D did not modify BMD, Z-score, or T-score.

OUP accepted manuscript

Chronic kidney disease mineral and bone disorder may persist after successful kidney transplantation. Persistent hyperparathyroidism has been identified in up to 80% of patients throughout the first year after kidney transplantation. International guidelines lack strict recommendations about the management of persistent hyperparathyroidism. However, it is associated with adverse graft and patient outcomes, including higher fracture risk and an increased risk of all-cause mortality and allograft loss. Secondary hyperparathyroidism may be treated medically (vitamin D, phosphate binders and calcimimetics) or surgically (parathyroidectomy). Guideline recommendations suggest medical therapy first but do not clarify optimal parathyroid hormone targets or indications and timing of parathyroidectomy. There are no clear guidelines or long-term studies about the impact of hyperparathyroidism therapy. Parathyroidectomy is more effective than medical treatment, although it is associated with increased short-term risks. Ideally parathyroidectomy should be performed before kidney transplantation to prevent persistent hyperparathyroidism and improve graft outcomes. We now propose a roadmap for the management of secondary hyperparathyroidism in patients eligible for kidney transplantation that includes the indications and timing (pre- or post-kidney transplantation) of parathyroidectomy, the evaluation of parathyroid gland size and the integration of parathyroid gland size in the decision-making process by a multidisciplinary team of nephrologists, radiologists and surgeons.

Denosumab-Induced Hypocalcemia and Hyperparathyroidism in de novo Kidney Transplant Recipients

INTRODUCTION

Denosumab represents a realistic treatment option to increase bone mineral density in kidney transplant recipients (KTRs). It is still unknown how and at what extent posttransplantation bone disease and graft function influence the effects of denosumab on mineral metabolism indexes. In this study, we analyze risk factors of hypocalcemia and parathyroid hormone (PTH) increase after denosumab administration in eighteen de novo KTRs and its management before and after this treatment.

METHODS

We conducted a monocentric, observational, prospective study on de novo KTRs. All KTRs enrolled received a single 60 mg subcutaneous dose of denosumab every 6 months. Before kidney transplantation, no patients were treated with calcio-mimetic. After kidney transplantation and before antiresorptive therapy, no patients were treated with calcio-mimetic drugs and/or vitamin D receptor agonists, while all patients received nutritional vitamin D supplementation (from 1,000 IU to 1,500 IU daily).

RESULTS

Hypocalcemia was related to the degree of lumbar osteoporosis (p = 0.047); the increase in the PTH level was correlated to baseline bone turnover markers (bone alkaline phosphatase, serum osteocalcin, and β-C-terminal telopeptide), the 25 OH status, and eGFR. The introduction of calcitriol, after the PTH increase, in addition to cholecalciferol was necessary to ensure an adequate control of serum calcium and PTH during a follow-up of 15 months. Following the treatment with denosumab, it was observed an improvement of areal bone mineral density both at lumbar and femoral sites with a mean percentual increase of 1.74% and 0.25%, respectively.

CONCLUSIONS

Denosumab is an effective treatment for bone disease in KTRs. In our study, the increase in PTH is not a transient event but prolonged throughout the follow-up period and requires continuous supplementation therapy with calcitriol.

MO520SARS-COVID19 INFECTION AT VARIOUS STAGES OF KIDNEY DISEASE: A SINGLE CENTRE EXPERIENCE

Background and Aims

Several chronic medical conditions appear to increase the risk of severe COVID-19. Chronic kidney disease (CKD) patients have a high risk of symptomatic infection and severe respiratory symptoms because of chronic inflammation, uremic toxins accumulation, endothelial dysfunction and an impaired immune response. Even though the presence of one or more comorbidities increases the risk of mortality, information of the outcome of COVID-19 in CKD patients is not yet available. The aim of the study is to present the incidence and outcome of COVID-19 in patients referring to our Nephrology Unit considering CKD patients, dialysis patients and kidney transplant recipients.

Method

This study is prospective single centre carried out considering patients referring to the Nephrology Unit of St. Orsola University Hospital in Bologna with COVID 19 diagnosis from 15^THMarch to 30^THMay 2020.

Results

Our cohort included 52 patients admitted to our Nephrology Unit because of Sars Cov2 infection confirmed by positive reverse transcriptase polymerase chain reaction on nasopharyngeal swab. The mean age was 67.2 ± 13.8 years (range, 33-88 years). Demographic, clinical and radiological features in Table 1. Forty-eight patients (92.3%) underwent chest TC. The main findings were: several bilateral interstitial pneumonia (39 patients, 81.2%), monolateral peripheral ground-glass opacities (6 patients, 12.5%), no signs of pneumonia (3 patients, 6.2 %). Clinical course is highly variable: 18 patients (34.6 %) were asymptomatic, 23 patients (44 %) had a mild course requiring low flux oxygen therapy and 11 patients (21%) presented severe pneumonia and respiratory distress that requires ventilatory support in intensive care unit. Forty patients (70%) had hydroxychloroquine-azithromycin dual therapy, 3 patients (6%) had antiviral therapy in addiction. Sixteen patients (31%) with P/F <150 mmHg were treated with Tocilizumab. Heparin Therapy, to prevent the thromboembolic risk of Sars-Cov2 infection, was administered according to the body weight in forty patients (70%);, but not in patients in warfarin therapy (12 patients, 30%). Twenty-six patients (50%) needed antibiotics for bacterial infections combined to the Sars-Cov2 infection. Steroid therapy was added in 40% of cases. The average time of negativization for Sars Cov2, tested with two nasopharyngeal swab specimens made seven days apart, was 31±15 day. Fifty-one patients, 98% of diagnosed cases, required hospitalization with an average stay of 35 ± 26 days. Thirty patients (25%) died. Mean age of non-survivors was 72 ± 11years while mean age of survivors was 64± 11years. No differences in pre-existing comorbidities were observed between survivors and non survivors; oxygen saturation on presentation was statistically lower in non survivors.

Conclusion

CKD is an independent risk factor for COVID-19 associated in-hospital mortality. The mortality rate (25%), much higher than in general population (1.8-8%) may be explained by the older age of patients and the presence of more pathological conditions, especially cardiovascular disease.

Vitamin D Effects on Bone Homeostasis and Cardiovascular System in Patients with Chronic Kidney Disease and Renal Transplant Recipients

Poor vitamin D status is common in patients with impaired renal function and represents one main component of the complex scenario of chronic kidney disease-mineral and bone disorder (CKD-MBD). Therapeutic and dietary efforts to limit the consequences of uremia-associated vitamin D deficiency are a current hot topic for researchers and clinicians in the nephrology area. Evidence indicates that the low levels of vitamin D in patients with CKD stage above 4 (GFR < 15 mL/min) have a multifactorial origin, mainly related to uremic malnutrition, namely impaired gastrointestinal absorption, dietary restrictions (low-protein and low-phosphate diets), and proteinuria. This condition is further worsened by the compromised response of CKD patients to high-dose cholecalciferol supplementation due to the defective activation of renal hydroxylation of vitamin D. Currently, the literature lacks large and interventional studies on the so-called non-calcemic activities of vitamin D and, above all, the modulation of renal and cardiovascular functions and immune response. Here, we review the current state of the art of the benefits of supplementation with native vitamin D in various clinical settings of nephrological interest: CKD, dialysis, and renal transplant, with a special focus on the effects on bone homeostasis and cardiovascular outcomes.

Application of Inverse Finite Element Method to Shape Sensing of Curved Beams

Curved beam, plate, and shell finite elements are commonly used in the finite element modeling of a wide range of civil and mechanical engineering structures. In civil engineering, curved elements are used to model tunnels, arch bridges, pipelines, and domes. Such structures provide a more efficient load transfer than their straight/flat counterparts due to the additional strength provided by their curved geometry. The load transfer is characterized by the bending, shear, and membrane actions. In this paper, a higher-order curved inverse beam element is developed for the inverse Finite Element Method (iFEM), which is aimed at reconstructing the deformed structural shapes based on real-time, in situ strain measurements. The proposed two-node inverse beam element is based on the quintic-degree polynomial shape functions that interpolate the kinematic variables. The element is C² continuous and has rapid convergence characteristics. To assess the element predictive capabilities, several circular arch structures subjected to static loading are analyzed, under the assumption of linear elasticity and isotropic material behavior. Comparisons between direct FEM and iFEM results are presented. It is demonstrated that the present inverse beam finite element is both efficient and accurate, requiring only a few element subdivisions to reconstruct an accurate displacement field of shallow and deep curved beams.

The Off-Target Effects, Electrolyte and Mineral Disorders of SGLT2i

The sodium-glucose cotransporter 2 inhibitors (SGLT2i) are a relatively new class of antidiabetic drugs that, in addition to emerging as an effective hypoglycemic treatment, have been shown to improve, in several trials, both renal and cardiovascular outcomes. In consideration of the renal site of action and the associated osmotic diuresis, a negative sodium balance has been postulated during SGLT2i administration. Although it is presumable that sodium and water depletion may contribute to some positive actions of SGLT2i, evidence is far from being conclusive and the real physiologic effects of SGLT2i on sodium remain largely unknown. Indeed, no study has yet investigated how SGLT2i change sodium balance in the long term and especially the pathways through which the natriuretic effect is expressed. Furthermore, recently, several experimental studies have identified different pathways, not directly linked to tubular sodium handling, which could contribute to the renal and cardiovascular benefits associated with SGLT2i. These compounds may also modulate urinary chloride, potassium, magnesium, phosphate, and calcium excretion. Some changes in electrolyte homeostasis are transient, whereas others may persist, suggesting that the administration of SGLT2i may affect mineral and electrolyte balances in exposed subjects. This paper will review the evidence of SGLT2i action on sodium transporters, their off-target effects and their potential role on kidney protection as well as their influence on electrolytes and mineral homeostasis.

P1621VITAMIN D SUPPLEMENTATION: CHANGES IN BONE MINERAL DENSITY IN KIDNEY TRANSPLANT PATIENTS WITH LONG TERM DURATION OF THE GRAFT

Background and Aims

In the medical literature, several studies have linked bone mineral density (BMD) with vitamin D deficiency in kidney transplant patients (KTRs). However, in spite of the fact that ergocalciferol, cholecalciferol and calcifediol reduce parathyroid hormone (PTH) and improves calcium levels, their effects on the bone mineral density (BMD) in KTRs remain undefined. In consideration of the lack of data available, we aim at investigating the effect of inactive form of vitamin D supplementation on the BMD over a follow-up period up to 2 year, in a real-life cohort of long-term kidney transplant(KT).

Method

This study was carried out in KTRs who were followed up in a Nephrology Unit. Exclusion criteria were parathyroidectomy, therapy with bisphosphonate, previous history of bone fractures. Demographic, clinical and immunosuppressive agents were collected. Based on 25-OH-D levels, KTRs were classified as suffering from deficiency (&lt; 30 ng/mL). BMD was evaluated at lumbar vertebral bodies (LV) and right femoral hip (FH) by a single operator, using a standard dual energy X-ray absorptiometry. According to WHO criteria, results were expressed as T-score (standard deviation [SD] relative to young healthy adults), and Z-score (SD relative to age-matched controls). Osteoporosis and osteopenia were defined as T score ≤ −2.5 SD and T score &lt; −1 and &gt; −2.5 SD, respectively. Laboratory data, 25-OH-D, and BMD were measured at baseline and after 24 months of supplementation therapy. Vitamin D deficiency was corrected using standard treatment strategy recommended for general population. Continuous variables were expressed as mean ± SD whereas categorical variables as percentage. The Student’s t test and chi-square test were used to compare to compare continuous and categorical variables, respectively. For before and after comparisons of continuous variables, the paired t-test or one-sample Wilcoxon signed rank test were used based on variable’s distribution.

Results

Data pertaining to 111 out of 133 consecutive outpatients were collected, of whom most were males (69.4%), no-smokers (89.1%) and treated with glucocorticoids (84%). The mean age was 53.9±11.6 years and months after transplant was 161.6±128.3. No statistical differences were found among patients with normal BMD, osteopenia or osteoporosis at LV and FH in terms of age at transplant, gender distribution, time on dialysis, BMI and eGFR, serum calcium, serum phosphate, 25-OH-D and iPTH. At baseline, 25-OH-D was 13.9±7.2 ng/ml and the prevalence of osteopenia/osteoporosis was 40.9% (T-Score -1.69±0.37; Z-score -1.16±1.09) and 21.8 % (T-Score -3.15±0.50; Z-score -2.27±0.58) at LV; 55.3 % (T-Score -1.8±0.46; Z-score -0.84±0.633) and 14 % (T-Score -2.83±0.39; Z-score -1.65±0.49) at FH. After 27.6±3.7 months of therapy with cholecalciferol at mean dose of 13.396±7.537 UI at week, 25-OH-D values increased to 29.4±9.4 ng/ml (p&lt;0.0001) while no statistically significant changes were found in Z-score and T-score at both sites, except for a mild improvement in lumbar vertebral Z-score, reaching −0.82± 0.7 (p = 0.06) in KTRs with osteopenia

Conclusion

Our study showed BMD remained stable after up to 2 years of inactive vitamin D therapy in long-term kidney transplant with vitamin D deficiency. A mild increase in Z-score was observed in the L-spine. Further designated studies should be conducted to demonstrate the effect of vitamin D on BMD.

A case report of IgG4-related disease: an insidious path to the diagnosis through kidney, heart and brain

Background

IgG4-related disease, described around the years 2000 as a form of autoimmune pancreatitis, is now increasingly accepted as a systemic syndrome. The diagnosis is based on both comprehensive and organ-specific criteria. For the kidney, Mayo clinic classification and the guidelines of the Japanese Nephrology Society are used. Ultimately, together with parameters that characterize every organ or apparatus involved, the key element is the confirmation of growing levels of IgG4 in blood or in tissues.

Case presentation

We describe a male patient with chronic renal failure associated to hypertension without proteinuria. IgG4-related disease was diagnosed through renal biopsy. After an initial positive response to steroids, he presented tinnitus, and histological assessment showed cerebral and subsequently cardiac damage, both IgG4-related. This case appears unique for the type of histologically documented cardiac and neurological parenchymal involvement, and at the same time, exemplifies the subtle and pernicious course of the disease. Frequently, blurred and non-specific signs prevail. Here, kidney damage was associated with minimal urinary findings, slowly progressive renal dysfunction and other factors that can be equivocated in the differential diagnosis. Neurological involvement was represented by tinnitus alone, while cardiac alterations were completely asymptomatic.

Conclusions

This report is representative of the neurological and cardiac changes described in the literature for IgG4-related disease, which may be correlated or not with the renal form and highlights the need, in some cases, of targeted therapeutic approaches. In addition to glucocorticoids, as in this case, rituximab may be necessary.

Folic Acid and Vitamin B12 Administration in CKD, Why Not?

Patients affected by chronic kidney disease (CKD) or end-stage renal disease (ESRD) experience a huge cardiovascular risk and cardiovascular events represent the leading causes of death. Since traditional risk factors cannot fully explain such increased cardiovascular risk, interest in non-traditional risk factors, such as hyperhomocysteinemia and folic acid and vitamin B12 metabolism impairment, is growing. Although elevated homocysteine blood levels are often seen in patients with CKD and ESRD, whether hyperhomocysteinemia represents a reliable cardiovascular and mortality risk marker or a therapeutic target in this population is still unclear. In addition, folic acid and vitamin B12 could not only be mere cofactors in the homocysteine metabolism; they may have a direct action in determining tissue damage and cardiovascular risk. The purpose of this review was to highlight homocysteine, folic acid and vitamin B12 metabolism impairment in CKD and ESRD and to summarize available evidences on hyperhomocysteinemia, folic acid and vitamin B12 as cardiovascular risk markers, therapeutic target and risk factors for CKD progression.

Treatment with rituximab in idiopathic membranous nephropathy

BACKGROUND

Rituximab represents a valid therapeutic option to induce remission in patients with primary glomerulonephritis. Despite several studies proving its efficacy in improving outcomes in patients with membranous nephropathy (MN), its role in therapeutic protocols is not yet defined.

METHODS

We studied 38 patients with idiopathic MN treated with rituximab (in 13 patients as first-line therapy, in the remaining 25 after conventional immunosuppressive therapy). The patients were analyzed for a 15-month median (interquartile range 7.7-30.2) follow-up, with serial monitoring of 24-h proteinuria, renal function and circulating CD19⁺ B cells.

RESULTS

The percentages of patients who achieved complete remission, partial remission and the composite endpoint (complete or partial remission) were 39.5% (15 patients), 36.8% (14 patients) and 76.3% (29 patients), respectively. The 24-h proteinuria was reduced significantly during the entire period of follow-up (from a baseline value of 6.1 to 0.9 g/day in the last visit; P < 0.01), while albuminemia increased constantly (from a baseline value of 2.6 to 3.5 g/dL in the last observation; P < 0.01). Renal function did not significantly change during the observation period. Circulating CD19⁺ B cells were reduced significantly from the baseline value to the 24-month value (P < 0.01); data about anti-phospholipase A₂ receptor antibodies were available in 14 patients, 10 of which experienced a decreasing trend after treatment. No significant adverse events were described during and after infusions.

CONCLUSIONS

The present study confirmed that treatment with rituximab was remarkably safe and allowed for a large percentage of complete or partial remissions in patients with MN.