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Contrast-induced acute kidney injury (CIAKI) is a severe complication associated with the use of
iodinated contrast media (CM); a sudden but potentially reversible fall in glomerular filtration rate (GFR) typically
occurring 48-72 hours after CM administration. Principal risk factors related with the presentation of CIAKI
are preexisting chronic kidney disease and diabetes mellitus. Studies on CIAKI present considerable complexity
because of differences in CM type and dose, controversies in definition and baseline comorbidities. Despite that,
it should be noted that CIAKI poses a serious health problem because it is a very common cause of hospitalacquired
AKI, linked to increased morbidity and mortality and utilizing growing healthcare resources. The pathogenesis
of CIAKI is heterogeneous and, thus, is incompletely understood. Three basic mechanisms appear to
simultaneously occur for CIAKI development: Renal vasoconstriction and medullary hypoxia, tubular cell toxicity
and reactive oxygen species formation. The relative contribution of each one of these mechanisms is unknown
but they ultimately lead to epithelial and endothelial cell apoptosis and GFR reduction. Further research is needed
in order to better clarify CIAKI pathophysiology and accordingly introduce effective preventive and therapeutic
strategies.
AIMTo explore the benefits and harms of corticosteroid (CS) minimization following renal transplantation.METHODSCS minimization attempts to improve cardiovascular risk factors (hypertension, diabetes, dyslipidemia), to enhance growth in children, to ameliorate bone disease and to lead to better compliance with immunosuppressive agents. Nevertheless, any benefit must be carefully weighed against the reduction in net immunosuppression and the potential harm to renal allograft function and survival.RESULTSComplete CS avoidance or very early withdrawal (i.e., no CS after post-transplant day 7) seems to be associated with better outcomes in comparison with later withdrawal. However, an increased incidence of CS-sensitive acute rejection has been observed with all CS minimization strategies. Among the prerequisites for the safe application of CS minimization protocols are the administration of induction immunosuppression and the inclusion of calcineurin inhibitors in maintenance immunosuppression regimens.CONCLUSIONTransplant recipients at low immunological risk (primary transplant, low panel reactive antibodies) are thought as optimal candidates for CS minimization. CS avoidance may also be undesirable in patients at risk for glomerulonephritis recurrence or with severe delayed graft function and prolonged cold ischemia time. Thus, CS minimization is not yet ready for implementation in the majority of transplant recipients.
IA was shown efficacious in a small series of patients with recurrent FSGS in the graft. Renal function remained stable in eight of the 12 patients with FSGS recurrence.
Background. Posttransplant recurrence of primary focal segmental glomerulosclerosis (rFSGS) in the form of massive proteinuria is not uncommon and has detrimental consequences on renal allograft survival. A putative circulating permeability factor has been implicated in the pathogenesis leading to widespread use of plasma exchange (PLEX). We reviewed published studies to assess the role of PLEX on treatment of rFSGS in adults. Methods. Eligible manuscripts compared PLEX or variants with conventional care for inducing proteinuria remission (PR) in rFSGS and were identified through MEDLINE and reference lists. Data were abstracted in parallel by two reviewers. Results. We detected 6 nonrandomized studies with 117 cases enrolled. In a random effects model, the pooled risk ratio for the composite endpoint of partial or complete PR was 0,38 in favour of PLEX (95% CI: 0,23–0,61). No statistical heterogeneity was observed among included studies (I
2 = 0%, p = 0,42). On average, 9–26 PLEX sessions were performed to achieve PR. Renal allograft loss due to recurrence was lower (range: 0%–67%) in patients treated with PLEX. Conclusion. Notwithstanding the inherent limitations of small, observational trials, PLEX appears to be effective for PR in rFSGS. Additional research is needed to further elucidate its optimal use and impact on long-term allograft survival.
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