A 53-year-old man with diabetes mellitus who underwent decreased donor kidney transplant 9 months prior presented with cough and dyspnea. Chest computed tomography scan demonstrated multiple bilateral cavitary lesions with surrounding ground glass opacities. Bronchoscopy and bronchoalveolar lavage culture demonstrated Nocardia nova. High-dose oral sulfamethoxazole-trimethoprim (1600-320 mg every 8 h) was initiated. Over the next 3 days the patient developed oliguria and serum creatinine increased from 2.0 mg/dl to a peak of 3.3 mg/dl. Automated urinalysis revealed the following: pH 6.0, small blood, and few amorphous crystals. The nephrologist who performed urine microscopy noted 0-1 amorphous crystals per high-power field with a 'shock of wheat' appearance ( Figure 1). These were consistent with sulfamethoxazole crystals. The drug was discontinued and meropenem and minocycline were substituted. Hemodialysis was initiated for diuretic unresponsive hypervolemia in the setting of acute kidney injury (AKI). The patient began to recover kidney function after 72 h, and dialysis was discontinued with serum creatinine returning to baseline. Sulfa-containing medications, especially when used in high doses, may cause crystal-induced nephropathy when risk factors such as volume depletion, underlying kidney disease, and acidic urine are present. AKI generally develops within 7 days of treatment and is often associated with oliguria. Sulfa-containing medications cause AKI through intratubular deposition, and impairment of venous blood flow from interstitial congestion and hemorrhage. Associated interstitial inflammation may also contribute to tubular injury. Treatment consists of intravenous fluid repletion, alkalinization of the urine, and hemodialysis when indicated. 1 Sulfa-induced crystal nephropathy is often reversible and should be considered in any patient who develops AKI that is temporally related to exposure to an offending agent. The diagnosis can be made by a simple manual urine microscopy. REFERENCE 1. Perazella MA. Crystal-induced acute renal failure. Am J Med 1999; 106: 459-465.

Background: Gout occurs frequently in patients with kidney disease and can lead to a significant burden on quality of life. Gout prevalence, and its association with outcomes in hemodialysis (HD) and peritoneal dialysis (PD) populations located in North America, is unknown. Methods: We used data from North America cohorts of 70,297 HD patients (DOPPS, 2012-2020) and 5,117 PD patients (PDOPPS, 2014-2020). We used three definitions of gout for this analysis: (1) having an active prescription for colchicine or febuxostat; (2) having an active prescription for colchicine, febuxostat, or allopurinol, or (3) having an active prescription for colchicine, febuxostat, or allopurinol, or prior diagnosis of gout. Propensity score matching was used to compare outcomes among patients with vs. without gout. Outcomes included erythropoietin resistance index (ERI = ESA dose/(hemoglobin*weight)), all-cause mortality, hospitalization, and patient-reported outcomes (PROs). Results: Gout prevalence was 13% in HD and 21% in PD; it was highest among incident dialysis patients. Description of previous history of gout was rare, and identification of gout defined by colchicine (2-3%) or febuxostat (1%) prescription was less frequent than by allopurinol (9-12%). Both HD and PD patients with gout (vs. no gout) were older, more likely male, with higher BMI, and higher prevalence of cardiovascular comorbidities. About half of patients with a gout history were prescribed urate lowering therapy. After propensity score matching, mean ERI was 3-6% higher for gout vs. non-gout patients, while there was minimal evidence of association with clinical outcomes or PROs. Conclusion: In a large cohort of PD and HD patients in North America, we found that gout occurs frequently and is likely underreported. Gout was not associated with adverse clinical or patient-reported outcomes.

A 60-year-old male Dialysis patient presented with altered mental status and Hypertensive Urgency. He had a significant lesion noted on his glans penis. He was treated for infection and hypertension with expectant management, without significant improvement in his mental acuity. Laboratory and radiologic workup were unrevealing for the etiology. Upon detailed review it was noted he had recently been given Acyclovir for a presumed Herpes Simplex Virus infection. He had been prescribed what is considered correct dosing for an ESRD patient. An Acyclovir level was obtained and urgent Dialysis was undertaken, presuming Acyclovir neurotoxicity may be the culprit. Initially no improvement was noted and a 2nd level and hemodialysis were undertaken. This case and review of the literature will highlight key aspects of acyclovir neurotoxicity in ESRD patients, including how to diagnose and treat, which laboratory tests to obtain and what one can expect from various dialysis modalities. We will also reveal how to dose Acyclovir to avoid toxicity and other key elements of the drug.

Objective Substantial disparities exist in clinical trial participation, which is problematic in diseases such as lupus that disproportionately affect racial/ethnic minority populations. Our objective was to examine the effectiveness of an online educational course aiming to train medical providers to refer Black and Latino patients to lupus clinical trials (LCTs). Methods The American College of Rheumatology's Materials to Increase Minority Involvement in Clinical Trials (MIMICT) study used an online, randomized, 2‐group, pretest/posttest design with medical and nursing providers of multiple specialties. We exposed intervention group participants to an education course, while the control group participants received no intervention. Controlling for the effects of participant characteristics, including specialty, and professional experience with lupus, we modeled relationships among exposure to the education course and changes in knowledge, attitudes, self‐efficacy, and intentions to refer Black and Latino patients to LCTs. We also examined education course satisfaction. Results Compared to the control group, the intervention group had significantly higher posttest scores for knowledge, self‐efficacy, and intentions to refer Black and Latino patients to LCTs. Both medical and nursing trained intervention group participants had significantly higher mean posttest scores for knowledge and intentions to refer compared to the medical and nursing trained control group participants. Attitude was insignificant in analysis. The online education course, which received a favorable summary score, indicated that satisfaction and intentions to refer were strongly and positively correlated. Conclusion The MIMICT education course is an effective method to educate medical providers about LCTs and to improve their intentions to refer Black and Latino patients.

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