Fluorite-related iridate Pr3IrO7: crystal growth, structure, magnetism, thermodynamic, and optical properties

Spin-orbit coupling in heavy 5dmetal oxides, in particular, iridates have received tremendous interest in recent years due to the realization of exotic electronic and magnetic phases. Here, we report the synthesis, structural, magnetic, thermodynamic, and optical properties of the ternary iridate Pr₃IrO₇. Single crystals of Pr₃IrO₇have been grown by the KF flux method. Structural analysis shows that Pr₃IrO₇crystallizes in an orthorhombic phase withCmcmsymmetry. The electron energy loss spectroscopy study indicates that Pr is in a 3+ valence state, which implies a 5+ oxidation state of Ir. Magnetization data measured at high and low magnetic fields do not exhibit any bifurcation betweenM_ZFCandM_FC, however, a weak hump inM(T) is observed atT∗∼10.4 K. The specific heat data reveal two maxima at ∼253 and ∼4.8 K. The optical conductivityσ1(ω)spectrum shows 24 infrared-active phonon modes and reveals an insulating behavior with an optical gapΔOPof size ∼500 meV. During cooling down, the temperature-dependent reflectivity spectrum reveals eight extra phonon modes below the structural phase transition (∼253 K). An anomaly is observed at aroundT∗in the temperature evolution of infrared-active mode frequencies suggesting the presence of significant spin-phonon coupling in the system.

The Length of Leukocyte and Femoral Artery Telomeres in Patients with Peripheral Atherosclerosis

The length of telomeres (TLs) that protect chromosome ends may reflect the age of cells as well as the degree of genetic material damage caused by external factors. Since leukocyte telomere length is associated with cardiovascular diseases, the aim of this study was to evaluate whether leukocyte TL reflects femoral artery wall telomeres of patients with atherosclerosis and lower limb ischemia. Samples of femoral artery wall and blood were collected from 32 patients qualified to surgical revascularization. The analysis included blood and artery wall telomere length measurement and biochemical parameters. The study indicated that there was a moderate correlation between artery wall TL and leukocyte TL. Leukocyte TL was, on average, two times shorter than artery wall TL and correlated with the number of white blood cells. In turn, artery TL was impacted by total cholesterol level. The results suggest that the length of leukocyte telomeres may reflect artery wall TL and indirectly reflect the processes taking place in the artery wall in patients with atherosclerosis.

Anti-ETAR and suPAR as markers of disease activity in renal ANCA-associated vasculitis

PURPOSE

In anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), there is a lack of reliable biomarkers of disease activity. The aim of the study was to evaluate soluble urokinase plasminogen activator receptor (suPAR) and anti-endothelin-1 type A receptor (anti-ETAR) antibodies levels in active phase and remission of AAV.

PATIENTS AND METHODS

We enrolled 60 patients (median age 63.0 years) with renal AAV into this study. Plasma suPAR, urine suPAR (expressed as urine suPAR/creatinine ratio) and serum anti-ETAR antibodies were assayed by ELISA. Disease activity was assessed using Birmingham Vasculitis Activity Score (BVAS) and patients were divided into 2 subgroups based on their BVAS scores, namely: active AAV subgroup (BVAS≥1) and remission subgroup (BVAS ​= ​0). Median follow-up was 12 months.

RESULTS

Patients with active AAV had higher levels of all candidate biomarkers in comparison to those in remission (p ​< ​0.05). C-statistics for plasma suPAR, urine suPAR/creatinine ratio and serum anti-ETAR were 0.807, 0.713 and 0.783, respectively. In multivariable analysis, no clear associations were found between serum anti-ETAR and BVAS, while both plasma suPAR and serum anti-ETAR were independently influenced by estimated glomerular filtration rate (eGFR).

CONCLUSIONS

Plasma suPAR better discriminated between active AAV and remission in comparison to urine suPAR/creatinine ratio and serum anti-ETAR antibodies.

Multisystem Amyloidosis in a Coal Miner with Silicosis: Is Exposure to Silica Dust a Cause of Amyloid Deposition?

The over-secretion of monoclonal immunoglobulin light chains by clonal B cells followed by the aggregation and extracellular deposition of fibrillar deposits are responsible forthe clinical course AL amyloidosis. It is well documented that silica significantly increases the number of immunoglobulin-secreting cells. In the present paper, we report on a coal miner with silicosis and fast progressing primary amyloidosis with predominantly heart, kidney, and lung manifestations. Severeheart failure due to myocardial hypertrophy resulted in the patient’s death. We conclude that long-term environmental silica exposure and silica deposition may contribute to the development of monoclonal gammopathy and amyloidosis due to chronic stimulus and the dysregulation of the immune system.

The Femoral Vein as a Long-Term Aorto-Iliac Graft for Aortic Infection and Aortitis

Background

Reconstruction of the aorto-iliac segment with femoral vein (FV) as substitute for infected synthetic grafts or mycotic aneurysms constitutes the most sustainably convenient alternative. The aim of this study was to evaluate the long-term outcome of up to 16 years of follow-up, analysing the morphologic adaption of the FV with special emphasis on the distal and proximal anastomoses.

Methods

We conducted a retrospective study of 22 patients with 109 computed tomography angiograms (CTAs) treated between August 2001 and January 2020 in case of aortic infection/aortitis. Morphologic changes like anastomotic dilatation/stenosis as well as changes of FV wall thickness were retrospectively analysed in pre- and postoperative CTAs.

Results

Elective procedure was done in 17/22 (77%) cases, and 5/22 (23%) patients required emergent surgery. The median follow-up was 91.5 months (P₂₅;P₇₅ = 21;117). Cross-sectional diameter of proximal (20.38 ± 3.77 vs 22.04 ± 3.97 mm, p = 0.007) and distal anastomoses (13.05 ± 4.23 vs 14.61 ± 5.19 mm, p = 0.05) increased significantly, as well as the proximal and distal anastomotic areas (3.36 ± 1.29 vs 4.32 ± 1.63 mm², p = 0.04 and 0.99 ± 0.48 vs 1.25 ± 0.72 mm², p = 0.023, respectively). Venous wall thickness was significantly reduced at the anastomotic site (1.74 ± 0.46 vs 1.24 ± 0.31 mm, p = 0.001). The upper thigh diameter did not differ before and after harvesting of the FV (161.6 ± 29.1 vs. 178.2 ± 23.3 mm, p = 0.326, respectively).

Conclusion

This long-term CTA follow-up study showed that the FV wall becomes thinner at the anastomotic site, and the anastomoses dilate with time without rupture. The FV is a durable conductor after replacement of the aorto-iliac segment due to aortic infection. Further CTA studies from more centres are warranted to evaluate the risk of vein rupture.

The efficacy of single suture for exit site wound closure and stabilization of hemodialysis central tunneled catheter

Introduction:

The majority of the end-stage renal disease patients begin hemodialysis with the central tunneled catheter as a permanent or bridge vascular access. The procedure of central tunneled catheter insertion can be complicated by exit site bleeding, prolonged tunnel healing, and infection. The study aimed at evaluating whether the catheter exit site wound closing with a single-suture method is equally effective as the double suture method, which is most frequently applied. The assumption was that the single-suture method, which is less traumatizing for the skin, could offer an advantage for the patients with “paper” skin, that is, elderly, after long-term immunosuppressive treatment.

Methods:

Insertion of central tunneled catheter with antegrade tunnel formation was performed in 140 patients divided randomly into two groups of 70 patients using either single-suture method or double suture method.

Results:

Follow-up observations revealed a comparable number of early complications, that is, bleeding or exit site infection, in about 26% of the patients from both groups. No difference appeared in the catheter displacement, either. The percentage of patients with a prolonged central tunneled catheter exit site wound healing was not significantly lower in the single-suture method group: 5.8% versus 11.3%, p = 0.367. There was no impact of single-suture method versus double suture method on the central tunneled catheter long-term function and survival.

Conclusion:

The single-suture method of the central tunneled catheter exit closure is equal in efficacy to the double suture method. Its potential benefit for the patients with an increased risk of poor wound healing should be tested in further study.

The Impact of the Introduction of Innovative REDS Scale for the Evaluation of Central Tunnelled Catheter (CTC) Exit Site on Infection Prevention in Long-Term Haemodialyzed Patients

Central tunneled catheter (CTC)-related infections are a leading cause of a catheter loss, thus being the source of significant morbidity and mortality. The study aims at evaluating the impact of the implementation of the innovative redness, edema, discharge and tenderness, symptoms (REDS) scale (devised by the authors) for the description of the tunnel condition on the frequency of infection in long-term catheter users. The same cohort of the 40 patients was observed for 4 years altogether: 2 years before and 2 years after REDS application. The results, as well as follow-up evaluation of participants, were compared. The 2-year cumulative incidence of the CTC exit site infection (ESI) dropped significantly (log-rank p < 0.001) from 0.89 episode/1,000 catheter days (53.5%, 95% CI [35.9%; 66.2%]) in the period before REDS was used—to 0.26 episode/1,000 catheter days (18.6%, 95% CI [6.1%; 29.4%]) in the time of REDS application. There were also significantly fewer episodes of ESI complicated with catheter-related blood stream infection (CRBSI) requiring the CTC removal (0.6 episode/1,000 catheter days; 18.6%, 95% CI [6.1%; 29.4%] vs. 0.3 episode/1,000 catheter days; 4.7%, 95% CI [0.0; 10.7%]; log-rank p = 0.04, in pre-REDS and REDS time, respectively). The REDS scale appears to be a simple, cost-effective tool reducing the frequency of the tunneled CTC exit site infection and associated bloodstream infections.

Fat Injection for Cases of Severe Burn Outcomes: A New Perspective of Scar Remodeling and Reduction

BACKGROUND

Despite civilization and progress, burns occur frequently in the world. Remarkable discoveries of wound healing mechanisms have been reported. On the other hand, long-term outcomes from burn injuries represent a barrier to improvement of patients' social, functional, and psychological condition. Lipofilling, described since the 1980s, currently is used for several clinical applications. This study aimed to verify whether lipofilling could ameliorate scar remodeling in three clinical cases.

METHODS

Three adult patients with hemifacial hypertrophic scars and keloids resulting from severe burns 2 to 13 years previously were selected. The patients were treated by injection of adipose tissue harvested from abdominal subcutaneous fat and processed according to Coleman's technique. Two injections (with a 13-month interval between) were administered at the dermohypodermal junction. Histologic examination of scar tissue punch biopsies (hematoxylin-eosin staining) before and after the treatment was performed as well as magnetic resonance scan with contrast.

RESULTS

The clinical appearance and subjective patient feelings after a 6-month follow-up period suggest considerable improvement in the mimic features, skin texture, and thickness. Histologic examination shows patterns of new collagen deposition, local hypervascularity, and dermal hyperplasia in the context of new tissue, with high correspondence to the original.

CONCLUSIONS

The preliminary results show that lipofilling improves scar quality and suggest a tissue regeneration enhancing process.

Aesthetic results following breast cancer surgery: A prospective study on 6515 cases from ten Italian Senonetwork breast centers

Breast cancer treatment has deeply changed in the last decades, since clinical and oncological cure cannot be achieved without patient's satisfaction in term of aesthetic outcomes. Several methods have been proposed to objectively assess these results. However, Italian breast centers have not yet agreed on measurable, reproducible and validated aesthetic outcome indicators to monitor their performance.

METHODS

The study was designed and conducted by Senonetwork, a not-for-profit association of Italian breast centers. Ten breast centers were selected based on specific eligibility criteria. This multicentre observational prospective study recruited 6515 patients with diagnosis of in situ or invasive breast cancer who underwent breast surgery in the years 2013-2016. Thirteen indicators of aesthetic results and of related quality of care were analyzed. Data collection and analysis were conducted using a common study database.

RESULTS

On average, seven out of ten centers were able to collect data on the proposed indicators with a proportion of missing values < 25%. By expert consensus based on study results, some seven indicators have been defined as "mandatory" while the remaining six have been defined as "recommended" because they require further refinement before they can be proposed for monitoring aesthetic outcomes or because there are doubts on the feasibility of data collection. The minimum standard is reached for 5 of 13 indicators. This finding and the wide range between centers reveal that there is ample room for improvement.

CONCLUSIONS

From the present study useful measurable aesthetic parameters have emerged, leading to the definition of target objectives that breast centers can use for benchmarking and improvement of quality of care.

The switch from proteasome to immunoproteasome is increased in circulating cells of patients with fast progressive immunoglobulin A nephropathy and associated with defective CD46 expression

The proteasome to immunoproteasome (iPS) switch consists of β1, β2 and β5 subunit replacement by low molecular weight protein 2 (LMP2), LMP7 and multicatalytic endopeptidase-like complex-1 (MECL1) subunits, resulting in a more efficient peptide preparation for major histocompatibility complex 1 (MHC-I) presentation. It is activated by toll-like receptor (TLR) agonists and interferons and may also be influenced by genetic variation. In a previous study we found an iPS upregulation in peripheral cells of patients with immunoglobulin A nephropathy (IgAN). We aimed to investigate in 157 IgAN patients enrolled through the multinational Validation Study of the Oxford Classification of IgAN (VALIGA) study the relationships between iPS switch and estimated glomerular filtration rate (eGFR) modifications from renal biopsy to sampling. Patients had a previous long follow-up (6.4 years in median) that allowed an accurate calculation of their slope of renal function decline. We also evaluated the effects of the PSMB8/PSMB9 locus (rs9357155) associated with IgAN in genome-wide association studies and the expression of messenger RNAs (mRNAs) encoding for TLRs and CD46, a C3 convertase inhibitor, acting also on T-regulatory cell promotion, found to have reduced expression in progressive IgAN. We detected an upregulation of LMP7/β5 and LMP2/β1 switches. We observed no genetic effect of rs9357155. TLR4 and TLR2 mRNAs were found to be significantly associated with iPS switches, particularly TLR4 and LMP7/β5 (P < 0.0001). The LMP7/β5 switch was significantly associated with the rate of eGFR loss (P = 0.026), but not with eGFR at biopsy. Fast progressors (defined as the loss of eGFR >75th centile, i.e. -1.91 mL/min/1.73 m2/year) were characterized by significantly elevated LMP7/β5 mRNA (P = 0.04) and low CD46 mRNA expression (P < 0.01). A multivariate logistic regression model, categorizing patients by different levels of kidney disease progression, showed a high prediction value for the combination of high LMP7/β5 and low CD46 expression.

SO065TYPE OF EXERCISE INTERVENTION AND MUSCLE FUNCTIONS IN CHRONIC HEMODIALYSIS PATIENTS

Background and Aims

Decreased exercise capacity due to muscle weakness and exercise intolerance reduces the ability to perform activities of daily living in patients with end-stage kidney disease. Data on exercise type in dialysis population and its muscle effects are scarce. We aimed to determine the impact of training type (strength, resistance and mixed) on cardiovascular performance, muscle function (strength-speed parameters, electrophysiological function of muscles) in patients on hemodialysis maintenance.

Method

Eighty six dialysis patients underwent claster randomisation and were assigned to an exercise intervention groups: A - controlled endurance training during haemodialysis using rotors (MOTOmed letto2), B - controlled force training (resistance), C - Tai Chi training on non dialysis days. Intervention lasted 6 months, 3 times a week (A, B) and 2 times a week (C) for 60 minutes. The outcome measures were spiroergometry (VO2/VO2max), strength of the lower limbs and electromyographic examination. Values at the baseline and 6 months later were compared.

Results

45 patients completed intervention period and were analysed. Mean age in group A was 64±12y (n-16), in B was 60,5±10y. (n-15) and in C – 68,5±9y. (n-14). Patients did not differ markedly between groups in term of sex, BMI, dialysis vintage and comorbidities.

After 6 months of training, VO2 and VO2max increased significantly only in group B (resistance training) Δ12.7 % for VO2 and 12.9% for VO2max but not in A and C group (Fig.1.). Regarding force torque of quadriceps (ΔPT) in isometric conditions the highest peak values were measured in group B (resistance training), namely increase by 13.6% (p=0.0004) in right (R) and 14% (p&lt;0.0001) in left (L); in group A (endurance) 3.2% in R and 3.7% in L; in group C (Tai Chi group) by 7% (p&lt;0.05) in R and 6.8% (p&lt;0.05) in L. In terms of changes in electrophysiological function of right (QEMG_R) and left (QEMG_L) quadriceps, there were increases: for group A by 10.5% (p&lt;0.0001) and 9.6% (p&lt;0.05); B 9.7% (p=0.0002) and 20.1% (p=0.0001); for C by 4.5% and 6.2% for R and L, respectively (Fig.2).

In groups B and C significant increases in static force moments (Δ%PT) was associated with increases in electrophysiological action (Δ%QEMG), but in group A increase in EMG activity did not correspond with rise in muscle force (Fig.2).

Conclusion

Differences in muscle strength and functions were observed after 6 months of various type of exercise intervention in dialysis patients. Resistance training during dialysis showed the largest improvement in cardiorespiratory function and isometric leg muscle strength.

Tunnelled Haemodialysis Catheter Removal: An Underappreciated Problem, Not Always Simple and Safe

BACKGROUND

Optimal care of patients treated with a central tunneled catheter (CTC) as vascular access for hemodialysis requires a number of procedures. One of them is CTC removal, usually carried out using mostly the cut-down method (CDM) and the traction method (TM). The procedure seems to be simple and safe; however, occasionally, serious complications may occur. To eliminate the risk of such events, we have introduced a modified cut-down method (MCDM).

METHODS

The study included the analysis of retrospective results of 143 CTC removal procedures, 76 of which were performed using the standard cut-down method (CDM), and in 67 cases, the modified cut-down method (MCDM) was applied.

RESULTS

As minor side effects occurred in patients treated with both methods with comparable frequency, serious complications were observed only in the CDM patients group.

CONCLUSIONS

In our opinion, the new MCDM procedure is the simplest and safest method of CTC removal.

The impact of symptoms on health-related quality of life in elderly pre-dialysis patients: effect and importance in the EQUAL study

BACKGROUND

Quality of life (QoL) is an important outcome in chronic kidney disease (CKD). Patients feel that symptoms are an important determinant of QoL. However, this relation is unknown. The aims of this study were to investigate the impact of the number and severity of symptoms on QoL in elderly pre-dialysis patients, assessed by both the effect of symptoms and their importance relative to kidney function, and other clinical variables on QoL.

METHODS

The European Quality study (EQUAL study) is an ongoing European prospective follow-up study in late Stage 4/5 CKD patients aged ≥65 years. We used patients included between March 2012 and December 2015. Patients scored their symptoms with the Dialysis Symptom Index, and QoL with the research and development-36 (RAND-36) item Health Survey (RAND-36). The RAND-36 results in a physical component summary (PCS) and a mental component summary (MCS). We used linear regression to estimate the relation between symptoms and QoL at baseline and after 6 months, and to calculate the variance in QoL explained by symptoms.

RESULTS

The baseline questionnaire was filled in by 1079 (73%) patients (median age 75 years, 66% male, 98% Caucasian), and the follow up questionnaire by 627 (42%) patients. At baseline, every additional symptom changed MCS with -0.81 [95% confidence interval (CI): -0.91 to -0.71] and PCS with -0.50 (95% CI: -0.62 to -0.39). In univariable analyses, number of symptoms explained 22% of MCS variance and 11% of PCS variance, whereas estimated glomerular filtration rate only explained 1%.

CONCLUSIONS

In elderly CKD Stage 4/5 patients, symptoms have a substantial impact on QoL. This indicates symptoms should have a more prominent role in clinical decision-making.

Uraemic symptom burden and clinical condition in women and men of ≥65 years of age with advanced chronic kidney disease: results from the EQUAL study

BACKGROUND

The epidemiology and prognosis of chronic kidney disease (CKD) differ by sex. We aimed to compare symptom prevalence and the clinical state in women and men of ≥65 years of age with advanced CKD receiving routine nephrology care.

METHODS

The European QUALity study on treatment in advanced chronic kidney disease (EQUAL) study follows patients from six European countries of ≥65 years of age  years whose estimated glomerular filtration rate (eGFR) dropped to ≤20 mL/min/1.73 m2 for the first time during the last 6 months. The Dialysis Symptom Index was used to assess the prevalence and severity of 33 uraemic symptoms. Data on the clinical state at baseline were collected from medical records. Prevalence was standardized using the age distribution of women as the reference.

RESULTS

The results in women (n = 512) and men (n = 967) did not differ with age (77.0 versus 75.7 years) or eGFR (19.0 versus 18.5). The median number of symptoms was 14 [interquartile range (IQR) 9-19] in women, and 11 (IQR 7-16) in men. Women most frequently reported fatigue {39% [95% confidence interval (CI) 34-45]} and bone/joint pain [37% (95% CI 32-42)] as severe symptoms, whereas more men reported difficulty in becoming sexually aroused [32% (95% CI 28-35)] and a decreased interest in sex [31% (95% CI 28-35)]. Anaemia [73% (95% CI 69-77) versus 85% (95% CI 82-87)] was less common in women than in men, as were smoking history and cardiovascular comorbidity. However, a diagnosis of liver disease other than cirrhosis, psychiatric disease and mild malnutrition were more common among women.

CONCLUSIONS

Women in secondary care with an incident eGFR ≤20 mL/min/1.73 m2 reported a higher symptom burden, while their clinical state was considered similar or even more favourable as compared with men.

Defective gene expression of the membrane complement inhibitor CD46 in patients with progressive immunoglobulin A nephropathy

BACKGROUND

Complement is thought to play a role in immunoglobulin A nephropathy (IgAN), though the activating mechanisms are unknown. This study focused on the gene expression of CD46 and CD55, two key molecules for regulating C3 convertase activity of lectin and alternative complement pathways at a cellular level.

METHODS

The transcriptional expression in peripheral white blood cells (WBCs) of CD46 and CD55 was investigated in 157 patients enrolled by the Validation of the Oxford Classification of IgAN group, looking for correlations with clinical and pathology features and estimated glomerular filtration rate (eGFR) modifications from renal biopsy to sampling. Patients had a previous median follow-up of 6.4 (interquartile range 2.8-10.7) years and were divided into progressors and non-progressors according to the median value of their velocity of loss of renal function per year (-0.41 mL/min/1.73 m2/year).

RESULTS

CD46 and CD55 messenger RNA (mRNA) expression in WBCs was not correlated with eGFR values or proteinuria at sampling. CD46 mRNA was significantly correlated with eGFR decline rate as a continuous outcome variable (P = 0.014). A significant difference was found in CD46 gene expression between progressors and non-progressors (P = 0.013). CD46 and CD55 mRNA levels were significantly correlated (P < 0.01), although no difference between progressors and non-progressors was found for CD55 mRNA values. The prediction of progression was increased when CD46 and CD55 mRNA expressions were added to clinical data at renal biopsy (eGFR, proteinuria and mean arterial blood pressure) and Oxford MEST-C (mesangial hypercellularity, endocapillary hypercellularity, segmental glomerulosclerosis, tubular atrophy/interstitial fibrosis, presence of any crescents) score.

CONCLUSIONS

Patients with progressive IgAN showed lower expression of mRNA encoding for the complement inhibitory protein CD46, which may implicate a defective regulation of C3 convertase with uncontrolled complement activation.

Type 2 diabetes and chronic kidney disease as important prognostic factors in acute pancreatitis

This study includes an analysis of acute pancreatitis (AP) prognostic factors was performed as well as a critical review of the most important AP prognostic scales (APACHE II, Ranson, BISAP, SOFA, Marshall). The limitations of each scale were described. Simultaneously, the clinical applicability in the early prognostic AP stratification was presented, along with the clinical value of the alcoholic and gallstones etiology in the differential diagnosis. Pre-existing type 2 diabetes and chronic kidney disease significantly worsen the course of AP and should be included in the prognostic scale. It was shown that the diabetes coexisting with a HBA1C level above 6.5% significantly increases the mortality of AP patients and prolongs the period of hospitalization for 5 days. It was also observed that chronic kidney disease significantly increases the frequency of infective AP complications and raises 3-months mortality.

Are Females More Prone Than Males to Become Obese After Kidney Transplantation?

Background

Being overweight for kidney transplant recipients can cause serious side effects. Weight gain affects two-thirds of kidney transplant recipients and has been attributed to a more liberal diet after transplantation, recovery of appetite due to lack of uremic toxicity, corticosteroid use, and inadequate lifestyle changes. The aim of this study was to assess gender-dependent profile of body mass index (BMI) changes after kidney transplantation (KTx).

Material/Methods

Sixty-two kidney transplant recipients (38 males and 24 females), aged 46.0±12.8 years at KTx, were observed according to weight gain after KTx. BMI was calculated before transplantation (pre-KTx) and at 6, 12, and 24 months post-KTx.

Results

During the 24-month observation period, we found an increase in the incidence of kidney transplant recipients being overweight or obese (pre-KTx 43.5% increase and 24-month post-Ktx 61.3% increase, P=0.036). We analyzed a number of factors that could potentially influence a 24-month BMI gain including age at KTx, gender, pre-KTx BMI, time on dialysis, pre-KTx glucose metabolism disorder, and post-KTx diabetes mellitus. For female recipients, there was a significant step-wise post-KTx increase in BMI during the 24-month observation period. The overall pre-KTx to 24-month net increase for female BMI was 2 times greater than that observed for male recipients (1.90±2.20 kg/m² versus 0.89±1.85 kg/m², P<0.001).

Conclusions

Weight gain after KTx was observed in both sexes, but the net BMI increase was more than 2 times greater in females than in males at 24-months post-KTx. This indicated the need for diet education and strict weight control in kidney transplant recipients, especially in female patients.

Mortality predictor pattern in hemodialysis and peritoneal dialysis in diabetic patients

An excessive mortality in dialysis programs is the result of cardiovascular injuries and immune deficiency caused by uremic toxins. The vulnerability of dialysis patients is still increasing due to the growing number of diabetics, elderly and patients with a history of cardiovascular disease. Peritoneal dialysis (PD) and hemodialysis (HD) offer similar effectiveness during the first 2 years of the treatment. However, the survival advantage of HD subsequently appears. The problem of the factors responsible for the mortality during long-term PD and HD treatment was analyzed in our recently published investigation. A lower death risk for PD patients during the first several months was lessened over time, and, therefore, no survival advantage of PD was noticeable by the completion of the 2-year period. A sign of the diminishing benefit of PD was a high rate of modality switch - 57%, contrasting with 6% switched in the HD group. Longer observations confirmed that the extension of the treatment period above 2 years with HD was associated with improved survival among subgroups with cardiovascular disease and diabetes. A very relevant problem is the timely transfer of PD patients to the HD program, when an adequate nutritional intake cannot be ascertained and a decline of serum albumin level is observed. The aim of this overview was to compare the factors affecting the survival of diabetic patients in HD and PD patients.

Renal Artery Denervation Due to Refractory Hypertension in a Patient After Kidney Transplantation-3 Years of Observation: A Case Report

INTRODUCTION

Hypertension is prevalent in most patients after renal transplantation, and it is the main factor contributing to cardiovascular diseases that cause death of a significant number of these patients. Up to 95% of patients after transplantation have hypertension, and among them are patients with refractory hypertension. Elevated blood pressure is one of the causes of deterioration of transplant function and may accelerate transplant loss.

CASE REPORT

We present the first case in the world of a patient (who was 61 years old) in whom denervation of native renal arteries was performed after renal transplantation (2004). The patient was suffering from uncontrolled refractory hypertension. Antihypertensive therapy was used but the effect was not satisfactory. The patient received amlodipine, bisoprolol, clonidine, furosemide, and doxazosin in high doses. Clinical assessments with ambulatory blood pressure monitoring revealed a predominant blood pressure 149/96 with incidents of hypertensive crises. High blood pressure is a cardiovascular risk factor and it also has a significant influence on transplant failure, which was the reason for performing the denervation. The procedure was carried out through the femoral artery with the use of a 6F guiding catheter. During a 3-year observation, significant decreases in ambulatory blood pressure monitoring systolic and diastolic blood pressures were observed after the procedure (149/96 mm Hg vs 134/91 mm Hg before and after the denervation, respectively). There was a significant regression of left ventricle mass (577 g before denervation vs 470 g after 3 years). The functioning of the renal transplant became stable after 3 years of observation (38 mL/min before denervation and 38 mL/min after 3 years).

CONCLUSIONS

The first case in the world of a renal transplant patient who had denervation of native renal arteries has demonstrated a positive effect in controlling blood pressure over a 3-year observation. Three years after denervation, a reduction of heart hypertrophy and stabilization of renal function were noted. The presented case shows that denervation of native renal arteries denervation may be successful and safe in kidney transplant recipients.

Nutritional assessment of patients with end-stage renal disease using the MNA scale

BACKGROUND

Patient malnutrition is a significant problem in the process of rehabilitation and treatment. One of the tools that can reveal the risk of malnutrition is a series of standardized nutritional questionnaires.

OBJECTIVES

The aim of the study was to assess the nutritional status of patients with end-stage renal disease (ESRD) by means of the minimal nutritional assessment (MNA) scale.

MATERIAL AND METHODS

The study group included respondents suffering from ESRD who were patients of the Dialysis Center at the Clinic of Nephrology and Transplantation Medicine at the University Clinical Hospital in Wrocław. The study was conducted in 47 dialysis patients (22 women and 25 men), mean age 69.68 ±8.95 years. A standardized MNA scale was used to evaluate the nutritional status of the patients.

RESULTS

In the study group, women had a significantly lower score on the MNA scale than men (23.95 vs 25.26 points). Using the MNA scale, the risk of malnutrition was found in 13 patients, while malnutrition was found in 1 patient. Among females, the mean body mass index (BMI) was 27.28, and it was significantly correlated with the MNA score. In males, the mean BMI was 29.61, but it did not correlate with the MNA score. The time spent undergoing renal replacement therapy was 7.63 years for women and 7.24 years for men. This correlated significantly with the MNA score only in the case of men. Significant correlations were established between eating habits and MNA scores in both groups.

CONCLUSIONS

The results obtained using the MNA scale showed a significant risk of malnutrition in patients with ESRD. In women only, a low score on the MNA scale significantly correlated with the BMI. The time of renal replacement therapy had a significant impact on the MNA scale only in the case of men. An influence of comorbidities on the MNA scores recorded by men and women was not observed. Major health incidents and other stressful situations significantly affected the nutritional status in men.

Functional Activity of the Complement System in Deceased Donors in Relation to Kidney Allograft Outcome

Complement activation is considered one of the mediators of renal ischemia-reperfusion injury. Elevated levels of C5b-9, C3a, and C5a are detected in sera of deceased kidney donors. The goal of the study was to characterize the functional activity of complement pathways in donor sera and to assess their influence on transplant outcome.

MATERIALS AND METHODS

Sixty-four deceased kidney donors (age 45 ± 16 years; 28 female, 36 male) and 27 healthy controls (age 42 ± 12 years; 14 female, 13 male) were enrolled in the study. The results of transplantation for the respective 122 kidney recipients were included in the analysis. The functional activities of classical (CP), lectin (LP), and alternative (AP) pathways were measured using Wielisa-kit (reference normal level = 100%). In most cases, decreased functional activity reflects the activation status of the pathway.

RESULTS

The median (interquartile range) functional activities of the pathways in donor sera were CP 118 (89-150)%, LP 80 (20-127)%, and AP 74 (50-89)%, and did not differ from the control values CP 110 (102-115)%, LP 81 (26-106)%, AP 76 (61-88)%. The frequency of pathway activation observed in controls was CP 0%, LP 11%, and AP 0%. Deceased donors did not differ in activation of classical (11%) and lectin (13%) pathways, but presented a higher rate of alternative pathway activation (19%, P = .03). No significant influence of any pathway functional activity or its activation was proved to influence the transplant outcome.

CONCLUSION

Complement activation via alternative pathway was observed in diseased donor sera. No predictive potential of donor complement functional activity on the transplant outcome could be proved.

Kidney Transplantation From Old Deceased Donors: Impact of Uric Acid Level-A Quarter-Century of Experience in One Transplant Center

BACKGROUND

The long-term burden of higher donor age on graft function and survival after kidney transplantation remains uncertain. Because both recipient and donor characteristics have evolved and the general population age is on the increase, we looked at the causes of kidney graft outcome.

AIM

The aim of this study was to evaluate the impact of different clinical parameters on long-term outcome of older-donor kidney transplantation. This retrospective study included 345 adult patients (58 patients received kidney from donors at least 55 years old) transplanted between January 1993 and December 2005 and were followed in one center throughout the post-transplant course (median, 9.4 years). Data included recipient and donor age, cold ischemia time, delayed graft function, panel reactive antibodies, HLA mismatch, time on dialysis, graft function at different time points, uric acid level, proteinuria, immunosuppression, and biopsy-proven rejection.

RESULTS

Improvement of estimated glomerular filtration rate at 36 months after transplantation was a good prognostic factor for long-term kidney function. Higher donor age decreased the chance for improvement of kidney function by 2.8% per year of life (P = .0244). Hyperuricemia was found in 46% of the study population; estimated glomerular filtration rate less than 50 mL/min/1.72 m² was associated with hyperuricaemia. A higher uric acid level was associated with inferior kidney function in recipient of older kidneys. Graft failure occurred late (median, 6.3 years post-transplantation) in 26 (44.8%) of older-donor recipients and in 87 (30.3%) of the remaining patients.

CONCLUSIONS

Our results suggest an important association between older donor age and decreased allograft function in kidney recipients with elevated uric acid level. Recipients of older kidneys with normal uric acid level presented satisfactory outcomes.

Histopathological Relevance of Angiotensin II Type 1 Receptor in Renal Transplant Biopsy

The occurrence of anti-angiotensin II type 1 receptor (AT1R) antibodies is thought to be a risk factor for transplant injury, but the relationship of AT1R to graft loss in renal transplantation has not been assessed. The aim of our study was to evaluate the expression of AT1R and its relationship with graft loss in patients who had a renal transplant biopsy for cause.

METHODS

AT1R immunoreactivity was analyzed in 170 renal transplant biopsies. Immunohistochemical evaluation of AT1R expression was performed on 4 μm-thick paraffin sections mounted on silanized slides. AT1R expression was analyzed in 5 compartments: 1. glomeruli, 2. renal blood vessels (small and intermediate arteries), 3. peritubular capillaries, 4. tubular epithelium, and 5. interstitium based on a 3-step scale.

RESULTS

Initially we checked 170 consecutive samples of biopsies for the immunoreactivity of the AT1R. The study finally included 118 renal transplant patients in 1-year observation after the biopsy. The renal allograft biopsy was performed between 6 days and 24 years after transplantation and the diagnosis was based on Banff criteria. We observed positive immunostaining of AT1R in tubular epithelium in 26.3% (42/118) of patients. A total of 7 patients had staining assessed as 2 and 35 as 1. One year post-biopsy graft loss in the AT1R (+) patients was 35.7 % (15/42) compared to 14.5% (11/76) in the AT1R (-) group (P = .008).

CONCLUSIONS

The expression of AT1R in tubular epithelium of the biopsy for cause was associated with significantly higher graft loss. The relevance of AT1R should be considered for better transplant immunological risk assessment.

Pretransplantation Oral Glucose Tolerance Test Can Prevent Posttransplant Diabetes Mellitus After Renal Transplantation: Preliminary Study

Posttransplant diabetes mellitus (PTDM) adversely affects renal graft and patient survival. Fasting plasma glucose (FPG) alone underestimates diagnosis of glucose metabolism disorders (GMD) detected using the oral glucose tolerance test (OGTT-75). Prediabetes including impaired fasting glucose (IFG): 100 to 125 mg/dL (5.6-6.9 mmol/L) and impaired glucose tolerance (IGT): 140 to 199 mg/dL (7.8-11 mmol/L) 2 hours post 75-g OGTT in the pretransplant period can have a connection with the occurrence of PTDM after renal transplantation (RTx). The aim of our study was to assess the benefit of performing OGTT-75 in dialyzed chronic kidney disease (stage 5) patients on the waiting list for kidney transplantation as a useful tool to prevent PTDM.

MATERIALS AND METHODS

Pretransplant glucose testing using OGTT-75 was performed in nondiabetic dialyzed chronic kidney disease patients on the waiting list for renal transplantation in the southwest region of Poland. GMD were diagnosed according to current criteria. Patients with recognized prediabetic stage were recommended a low carbohydrate diet, lifestyle modification, and increased physical activity. In the 12-month posttransplant period we estimated the prevalence of PTDM in the study group based on FPG >126 mg/dL (7 mmol/L) in 2 measurements or random blood glucose >200 mg/dL (11.1 mmol/L).

RESULTS

A total of 80 nondiabetic dialysis patients (65 hemodialysis/15 peritoneal dialysis; 47 male/33 female) met initial entry criteria. In pretransplant glucose testing prediabetes was found in 31 out of 80 patients (39%). Among them, 5 patients (6.25%) had combined IGT/IFG, 18 patients (22.5%) had IGT, and 8 patients (10%) had IFG. One year after RTx we recognized PTDM in 14% of all analyzed patients (11/80) and noticed a significant frequency of glucose disorders status change after RTx (P  =  .002).

CONCLUSION

Our findings suggest early detection of prediabetes using the OGTT-75 test in nondiabetic dialysis patients waiting for RTx to prevent occurrence of PTDM.

Aortic root dilation in kidney transplant recipients

INTRODUCTION Aortic root (AoR) dilation is associated with cardiac damage and higher cardiovascular risk. Cardiovascular disease is the most common cause of death in patients after kidney transplantation (KTx ). OBJECTIVES The aim of this study was to assess the prevalence of enlarged AoR diameter in KTx recipients. Patients with bicuspid aortic valve, significant valvular disease, or evidence of connective tissue disorder were excluded. PATIENTS AND METHODS A total of 87 KTx recipients were divided into 2 groups depending on immunosuppressive regimen: 41 patients receiving mammalian target of rapamycin inhibitors (mTORi) and 46 patients treated with calcineurin inhibitors (CNIs). In all patients, echocardiography was performed, laboratory and clinical markers of cardiovascular risk were assessed, and the AoR diameter was calculated. RESULTS There were no differences between groups in age, sex, body surface area, body mass index, frequency of diabetes, hypertension, dyslipidemia, time after replacement therapy, creatinine levels, and estimated glomerular filtration rate. In the CNI group, the observed and calculated AoR diameters were similar (P = 0.8). In the mTORi group, the observed AoR diameter was higher than the calculated one (P = 0.002). The concentric and eccentric left ventricular hypertrophy was similar in both groups (P = 0.12 and P = 0.69, respectively). In the stepwise regression analysis, the AoR diameter was associated with body surface area and mTORi treatment. CONCLUSIONS KTx recipients have a high prevalence of AoR dilation. Immunosuppressive regimen based on mTORi increases the incidence of AoR enlargement.

Endothelin A Receptors Expressed in Renal Blood Vessels of Renal Transplant Patients Are Connected With Acute Tubular Necrosis or Antibody-Mediated Rejection

BACKGROUND

The role of non-HLA antibodies named antiendothelin A receptor antibodies is potentially significant but not established. The significance of the endothelin A receptor (ETAR) and its expression in renal biopsy has not been defined. We decided to evaluate the presence and relevance of ETARs in renal transplant biopsy for cause. The aim of our study was to evaluate the immunoreactivity of the ETAR and its significance in patients who had a renal transplant biopsy due to deterioration of transplant function (biopsy for cause) with detailed characterization of staining in small and intermediate arteries of renal transplant biopsies.

METHODS

Immunohistochemical expression of ETARs was analyzed in 162 renal transplant biopsies. Microscopic evaluation of ETAR expression (polyclonal antibody) was performed on paraffin sections. ETAR expression was analyzed in renal blood vessels (small and intermediate arteries) based on three-step scale.

RESULTS

We analyzed 154 patients who had renal allograft biopsy between 6 days and 24 years (median 597 days) after transplantation. Positive staining of ETAR in small and intermediate arteries was noticed in 9 patients. Among these patients, 4 had early biopsies (<3 months after transplantation), all developed acute tubular necrosis, and 1 developed additionally acute humoral rejection. Further, 4 patients had late biopsy (1-8 years after transplantation) and all developed characteristics of antibody mediated rejection. Lastly, 1 patient had no characteristic changes in the biopsy 4 months after transplantation. Graft loss 1 year after biopsy was higher in patients who were ETAR-positive but statistical significance was not achieved.

CONCLUSIONS

The expression of endothelin receptors in renal blood vessels (small and intermediate arteries) seems to be important in diagnosis of damage during acute tubular necrosis and antibody-mediated rejection.

Different Relevance of Peripheral, Central or Nighttime Blood Pressure Measurements in the Prediction of Chronic Kidney Disease Progression in Patients with Mild or No-Proteinuria

BACKGROUND/AIMS

Arterial hypertension is one of the leading factors aggravating the course of chronic kidney disease (CKD). It seems that the novel parameters used in the assessment of the blood pressure (BP) load (i.e. central blood pressure, nighttime blood pressure) may be more precise in predicting the cardiovascular risk and the progression of CKD in comparison with the traditional peripheral blood pressure measurements in the office conditions. The aim of the study was to assess the impact of the central, or nighttime blood pressure on the progression of CKD in patients with mild or no-proteinuria (autosomal, dominant polycystic kidney disease or IgA nephropathy).

METHODS

In each of the enrolled 46 patients with CKD stage 3 or 4, serum creatinine concentration was assessed, eGFR (MDRD) was calculated, also central blood pressure and pulse wave velocity (PWV) was assessed and the 24-hour ambulatory blood pressure monitoring (ABPM) was conducted at the beginning of the study and then repeated after one-year observation period.

RESULTS

During the observation period mean eGFR decreased from 44.1 (33.2-50.6) mL/min to 36.7 (29.7-46.3) mL/min. No significant differences were observed in the peripheral blood pressure or central blood pressure parameters. After one-year observation period the values of diastolic blood pressure dipping during the night significantly decreased from 16 (13-19) mmHg to 12 (10-15) mmHg; p< 0.05. The values of systolic dipping during the night or the mean BP values recorded in ABPM did not change significantly. Additionally, no significant differences in the PWV values were found. In the multivariate regression model the change of serum creatinine concentration was explained by the initial diastolic dipping values.

CONCLUSION

1. In patients with CKD stages 3 or 4 and mild or no- proteinuria, peripheral and central blood pressure did not change significantly during a one-year observation period despite the significant decline of eGFR and seems not to participate in the CKD progression. 2. Reduced magnitude of the diastolic dipping, which reflects the increase of diastolic blood pressure load during the nighttime, may play an important role in the pathogenesis of deterioration of kidney function in these patients.

B Cell Activating Factor (BAFF) in Long-term Kidney Transplant Recipients Is Not a Prognostic Marker for Allograft Dysfunction or Survival

OBJECTIVE

B cell activating factor (BAFF) has been shown to play a role in B cell survival, maturation, and activation, and has been linked with renal transplant outcome. BAFF signaling has been associated with plasmablast survival, anti-HLA immunization, and loss of graft function. We aimed to analyze the interplay between BAFF, memory B cells, and plasmablasts in relation to allograft function in long-term kidney transplant (KTx) recipients and their anti-HLA sensitization.

MATERIALS AND METHODS

This study included 70 long-term KTx recipients on standard immunosuppression 15 ± 6 years post transplantation (44 stable, 26 chronic allograft dysfunction, CAD) and 25 healthy volunteers. CD19+ B cells, memory B cells (CD19+CD27+), and plasmablasts (CD19+CD24-CD27++CD38++) were enumerated with flow cytometry. BAFF serum level and anti-HLA antibodies were assessed by Luminex bead arrays.

RESULTS

We found no difference in BAFF levels between KTx recipients and controls (median, interquartile range: 1.67, 1.40-1.97 vs 1.78, 1.63-1.93 ng/mL, P = .478) and no correlation between BAFF level and cell counts. Recipients presented lower plasmablast count than controls (22.5, 8-57 vs 79, 48-166 cells/mL, P < .001). There was a positive correlation between estimated glomerular filtration rate and plasmablasts (r_s = 0.30, P = .013) in recipients. Cell populations and BAFF were not related to the presence of anti-HLA antibodies. None of the parameters investigated was related to deterioration of allograft function during the 2-year follow-up.

CONCLUSION

BAFF serum level is not related to anti-HLA sensitization, circulating memory B cells, plasmablast count, or allograft function. Circulating plasmablasts are associated with current allograft function but are not prognostic for future course.

Pretransplant Immune Interplay Between Donor and Recipient Influences Posttransplant Kidney Allograft Function

BACKGROUND

Renal transplant candidates present immune dysregulation caused by chronic uremia, and deceased kidney donors present immune activation induced by brain death. Pretransplant donor and recipient immune-related gene expression were examined in the search for novel predictive biomarkers crosslinking recipient and donor pretransplant immune status with transplant outcome.

MATERIALS AND METHODS

This study included 33 low-risk consecutive renal transplant recipients and matched deceased donors. The expression of 29 genes linked to tissue injury, T-cell activation, cell migration, and apoptosis were assessed in postreperfusion kidney biopsies, as well as 14 genes in pretransplant peripheral blood of the kidney recipients. Gene expression was analyzed with real-time polymerase chain reaction on custom-designed low-density arrays.

RESULTS

Donor MMP9 expression was related to delayed graft function occurrence (P = .036) and short term kidney allograft function (14th day r_s = -0.44, P = .012; 1st month r_s = -0.46, P = .013). Donor TGFB1 expression was associated with short- and long-term graft function (14th day r_s = -0.47, P = .007; 3rd month r_s = -0.63, P = .001; 6th month r_s = -0.52, P = .010; 12th month r_s = -0.45, P = .028; 24th month r_s = -0.64, P = .003). Donor TGFB1 expression was not related to donor age (r_s = 0.32, P = .081), which was also an independent factor influencing the outcome. Recipient gene expression was not related to graft function but determined the acute rejection risk. Recipient IFNG and, to a lesser extent, IL18 expression were protective against acute rejection (area under the curve [AUC] 0.84, P < .001, and AUC 0.79, P < .001, respectively).

CONCLUSION

Kidney transplant outcome depends on the interplay between donor-related immune factors, which mostly affect allograft function and recipient immune milieu, influencing an alloreactive response.

The Impact of Functioning Arteriovenous Fistula on Blood Pressure Control and Renal Allograft Function

INTRODUCTION

The prevalence of hypertension in renal graft recipients is high. It was postulated that central arteriovenous anastomosis may significantly reduce blood pressure. This preliminary study evaluates the impact of functioning arteriovenous fistula (AVF) on blood pressure control and renal allograft function.

MATERIALS AND METHODS

One hundred sixty-two previously hemodialyzed kidney transplant recipients (108 males, 54 females, aged 52.7 ± 13.2 years, mean 6.9 ± 5.1 years after transplantation), who had scheduled visits in the first two weeks of March 2015, were included in the study. The recipients were divided into two groups depending on AVF function (65 AVF+ and 97 AVF-).

RESULTS

Functioning AVF was more prevalent in males than females (47.2 % vs 25.9 %, P = .009). Both groups presented similar allograft function despite the fact that interval from transplantation to examination day in the AVF+ group was significantly shorter than in the AVF- group (5.2 ± 5.3 vs 8.1± 4.5 years; P < .001). The mean systolic blood pressure (135.0 ± 17.0 vs 138.7 ± 14.1 mm Hg, P = .13) was similar in both study groups, but diastolic blood pressure in the AVF+ group was lower than in the AVF- group (80.0 ± 7.0 vs and 83.7 ± 9.2 mm Hg, P = .006). The proportion of patients with diastolic blood pressure >80 mm Hg was significantly higher in patients without functioning AVF (35 % in the AVF- group vs 20 % in the AVF+ group, P= .038). In multivariate analysis, AVF presence was the only factor significantly influencing a diastolic blood pressure with odds ratio 0.43 (95% CI 0.19-0.99, P = .048), which supports AVF as a potentially positive influence on blood pressure control.

CONCLUSIONS

The presence of AVF in renal transplant recipients was associated with a slight decrease in diastolic blood pressure without clear effect on renal function.

Acute Brain Damage in a 56-Year-Old Woman With a 20-Year-Old Transplanted Kidney as a Complicated Differential Diagnostic Process: A Case Report

INTRODUCTION

Acute central nervous system (CNS) damage in a patient who has received organ transplant is an extremely difficult and complex clinical issue that spans a wide spectrum of differential diagnoses with ischemia, post-transplant lymphoproliferative disorders (PTLDs), infections, lymphomas, and progressive multifocal leukoencephalopathy (PML). PTLDs are a clinically and histopathologically heterogeneous group of diseases that most often occur in heavily immunocompromised populations after solid organ transplantation (SOT), probably related to the infection or reactivation of Epstein-Barr virus (EBV) infection, whereas PML is an infectious disease caused by the John Cunningham virus (JCV).

CASE DESCRIPTION

A 56-year-old female, 20 years after renal transplantation from a deceased donor, was admitted to the hospital as an emergency due to sensory aphasia and memory disorders. Computed tomography (CT) examination revealed a diffuse expansive process in the temporo-parieto-occipital and left frontal area. Magnetic resonance imaging (MRI) results suggested changes associated with PML; however, JCV was not found in the cerebrospinal fluid. The disorders progressed quickly, both clinically and radiologically-the patient developed central facial palsy, paresis of limbs, and positive Babinski sign on the left. A second radiological examination (CT) also suggested PML. Due to the rapid deterioration of the patient's general condition, further diagnostic examinations (magnetic resonance with contrast and brain stereotactic biopsy) could not be performed. After almost 2 months of the commencement of the diagnostic process, the patient died. Autopsy revealed that the cause of death was acute CNS damage in the course of monomorphic PTLD (CNS-PTLD).

CONCLUSION

Rapid deterioration of mental status can be the first symptom of CNS-PTLD, a dangerous and life-threatening condition in immunocompromised patients after solid organ transplantation.