Observation that 1,25-Dihydroxyvitamin-D3 has an immunomodulatory effect on innate and adaptive immunity raises the possible effect on clinical graft outcome. Aim of this study was to evaluate the correlation of biopsy-proven acute rejection, CMV infection, BKV infection, with 1,25-Dihydroxyvitamin-D3 deficiency and the benefit of calcitriol supplementation before and during the transplantation. Risk factors and kidney graft function were also evaluated. All RTRs received induction therapy with basiliximab, cyclosporine, mycophenolic acid, and steroids. During the first year, the incidence of BPAR (4% vs 11%, P=.04), CMV infection (3% vs 9%, P=.04), and BKV infection (6% vs 19%, P=.04) was significantly lower in users compared to controls. By multivariate Cox regression analysis, 1,25-Dihydroxyvitamin-D3 deficiency and no calcitriol exposure were independent risk factors for BPAR (HR=4.30, P<.005 and HR=3.25, P<.05), for CMV infection (HR=2.33, P<.05 and HR=2.31, P=.001), and for BKV infection (HR=2.41, P<.05 and HR=2.45, P=.001). After one year, users had a better renal function: eGFR was 62.5±6.7 mL/min vs 51.4±7.6 mL/min (P<.05). Only one user developed polyomavirus-associated nephropathy vs 15 controls. Two users lost their graft vs 11 controls. 1,25(OH)2-D3 deficiency circulating levels increased the risk of BPAR, CMV infection, BKV infection after kidney transplantation. Administration of calcitriol is a way to obtain adequate 1,25(OH)2-D3 circulating levels.
Purpose: Optical coherence tomography angiography (OCTA) is a non-invasive and objective tool for the evaluation of the retinal microvascular changes in Fabry disease (FD). We investigated changes in retinal vasculature in FD patients, and the possible correlation with systemic parameters, by using OCTA, and reviewed the current status of literature.Methods: Thirteen FD patients (eight females, five males, mean age 49.85 ± 14.7 years) were compared with 13 age- and sex-matched healthy controls. OCTA 3 × 3 mm macular scans were performed in all subjects. We evaluated the vessel density and vessel perfusion in distinct macular areas (whole, inner, and outer) of both the superficial capillary plexus (SCP VD and SCP VP) and of the deep capillary plexus (DCP VD and DCP VP). We also evaluated the foveal avascular zone (FAZ) metrics (area, perimeter, and circularity), and correlation between systemic and OCTA parameters. A literature review on the current understanding of OCTA in FD is then presented.Results: FD patients showed significantly lower SCP VD values in the whole area (17.37 ± 2.08 mm−1 vs. 18.54 ± 1.21 mm−1; p-value 0.022), as well as in the outer area (17.46 ± 2.10 mm−1 vs. 19.08 ± 1.14 mm−1; p-value 0.002), but not in the inner. Even the DCP VD was significantly lower in all the imaged areas: whole (17.75 ± 3.93 mm−1 vs. 19.71 ± 1.20 mm−1; p-value 0.024), outer (18.25 ± 4.17 mm−1 vs. 20.33 ± 1.20 mm−1; p-value 0.023), and inner (19.54 ± 4.17 mm−1 vs. 21.96 ± 1.55 mm−1; p-value 0.011). There were no significant differences in vessel perfusion parameters (both SCP VP and DCP VP ones) and FAZ. No significant correlations were found between the OCTA parameters and systemic parameters (maximal left ventricular wall thickness and glomerular filtration rate) in FD patients.Conclusions: OCTA can be considered as a promising non-invasive tool, which enables a quantitative evaluation of retinal vascular involvement in FD, despite the varying data reported in literature. Our results support the use of OCTA as an objective tool to evaluate retinal vascular abnormalities in FD. The utility of OCTA in FD needs to be validated by longitudinal studies taking into account the overall progression of the disease.
Background Antineutrophil cytoplasmic antibody associated vasculitis (AAV) is a group of diseases associated in most cases with the presence of anti-neutrophil cytoplasmic antibodies (ANCAs). Rituximab- based remission induction has been proven effective in ANCA associated vasculitis but scarce data exist in forms with severe renal involvement. In this case series, we report the outcomes in patients with de novo or recurrent MPO-AAV and severe renal involvement treated with rituximab without cyclophosphamide (CYC). Methods In this single centre retrospective study, we analysed patients with a clinical diagnosis of de novo or recurrent AAV who met the following criteria: detection of P-ANCA, creatinine clearance lower than 30 ml/min, induction of remission therapy with rituximab without concomitant CYC and a follow up period of at least 6 months. The primary outcomes were complete remission after induction therapy, renal function recovery and mortality after the induction treatment. Results Eight patients met the inclusion criteria. The M:F ratio was 1:7, the average age was 54 years old and the median follow up was 10 months (7–72); in 2 patients there was a MPA renal limited vasculitis. A renal biopsy was performed in 7 patients. The median BVAS score at rituximab induction was 14(range 6–21). Two patients required haemodialysis before the induction treatment. Four patients developed end stage renal disease (ESRD) that required haemodialysis. These data show a remission of the disease, associated with a stabilization of the kidney function in 50% of patients. In 3 patients who did not show a response, there was also no response to CYC. Conclusions This study shows a partial efficacy of rituximab in renal function recovery and a low risk of infectious complications in patients with MPO vasculitis with severe renal involvement, in particular in the short term. The optimal treatment in this subgroup of patients still has to be established because data are lacking.
Introduction: Considering that patients on dialysis showed a poor outcome during COVID-19 pandemic, and that COVID-19 symptoms in dialysis patients are often mild or absent, each dialysis unit should implement local strategies to early recognize patients affected by COVID-19. However, many available SARS-CoV-2 diagnostic tests demonstrated a moderate sensitivity, 70%-80% is probably a reasonable estimate. Consequently, having useful tools for differential diagnosis becomes essential. In this scenario, lung ultrasound (LUS) may have an important role in the evaluation of lung involvement in hemodialysis patients during COVID-19 pandemic. Methods: We present two cases of hemodialysis patients with COVID-19 pneumonia in whom LUS had a central role in the diagnostic process. Ultrasound images of COVID-19 pneumonia show a typical bilateral pattern characterized by multiple or confluent B-lines with spared areas, thickened and irregular pleural line, and rare subpleural consolidations. LUS showed high accuracy in diagnosing COVID-19 pneumonia.Findings: Despite both patients appeared clinically euvolemic and afebrile, they presented with acute diarrhea and oxygen saturation level of 92%-93%. Although clinical manifestations were mild and not specific in both patients, LUS raised suspicion on the possible COVID-19 diagnosis which was confirmed by a positive nasopharyngeal RT-PCR.Discussion: There are many reasons for a patient on dialysis to present shortness of breath, fever, and multiple B-lines at LUS assessment (such as heart failure, fluid overload, vascular access infection, interstitial pneumonia) but the recognition of typical ultrasound patterns of the COVID-19 pneumonia is helpful for differential diagnosis. LUS may have an important role in the screening process of hemodialysis patients during the COVID-19 pandemic, especially in oligosymptomatic patients before the SARS-CoV-2 diagnostic tests, and in those with suspected symptoms and/or known exposure with unexpected negative SARS-CoV-2 diagnostic tests.
Intradialytic hypotension (IDH) is a frequent and well-known complication of hemodialysis, occurring in about one third of patients. An integrated approach with different methods is needed to minimize IDH episodes and their complications. In this prospective observational study, recruited patients underwent a multiparametric evaluation of fluid status through a lung ultrasound (LUS) with the quantification of B-lines, a physical examination, blood pressure, NT-proBNP and chest X-rays. The evaluation took place immediately before and at the end of the dialysis session, and the patients were divided into IDH and no-IDH groups. We recruited a total of 107 patients. A pre-dialysis B-line number ≥ 15 showed a high sensitivity in fluid overload diagnosis (94.5%), even higher than a chest X-ray (78%) or physical examination (72%) alone. The identification at the beginning of dialysis of <8 B-lines in the overall cohort or <20 B-lines in patients with NYHA 3–4 class are optimal thresholds for identifying those patients at higher risk of experiencing an IDH episode. In the multivariable analysis, the NYHA class, a low pre-dialysis systolic BP and a low pre-dialysis B-line number were independent risk factors for IDH. At the beginning of dialysis, the B-line quantification at LUS is a valuable and reliable method for evaluating fluid status and predicting IDH episodes. A post-dialysis B-line number <5 may allow for an understanding of whether the IDH episode was caused by dehydration, probably due to due to an overestimation of the dry weight.
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