BackgroundDevelopment of post-transplant diabetes mellitus after kidney transplant (PTDM) significantly increases kidney graft loss and mortality. Several risk factors for PTDM have been reported, including Hispanic ethnicity and the use of calcineurin inhibitors and corticosteroids. The incidence and impact of PTDM in the Hispanic kidney transplant population is unknown.Material/MethodsWe retrospectively reviewed the medical records of 155 Hispanic and 124 Caucasian patients, who were not diabetics and underwent kidney transplant between January 2006 and December 2011. We analyzed their clinical outcomes at 12 months post-transplant, including the incidence of PTDM, acute rejection rates, and patient and graft survival.ResultsHispanics who developed PTDM (n=22) were more than 10 years older and had higher body mass index (BMI) than Hispanics without PTDM (p<0.001 and p=0.001, respectively). Caucasians with PTDM (n=13) were non-significantly older (2.5 years) and had higher BMI than Caucasians without PTDM (p=0.526, p=0.043, respectively). The incidence of PTDM was not significantly different between Hispanics and Caucasians treated with tacrolimus-based immunosuppression (14.2% and 10.5%, respectively).ConclusionsPTDM did not cause significant difference in short-term outcomes after kidney transplant in Hispanics or Caucasians. Larger multicenter prospective and long-term clinical trials are needed to validate these findings.
Acute kidney injury is very common in critically ill patients requiring renal replacement therapy. Despite the advancement in medicine, the mortality rate from septic shock can be as high as 60%. This manuscript describes drug-dosing considerations and challenges for clinicians. For instance, drugs’ pharmacokinetic changes (e.g., decreased protein binding and increased volume of distribution) and drug property changes in critical illness affecting solute or drug clearance during renal replacement therapy. Moreover, different types of renal replacement therapy (intermittent hemodialysis, prolonged intermittent renal replacement therapy or sustained low-efficiency dialysis, and continuous renal replacement therapy) are discussed to describe how to optimize the drug administration strategies. With updated literature, pharmacodynamic targets and empirical dosing recommendations for commonly used antibiotics in critically ill patients receiving continuous renal replacement therapy are outlined. It is vital to utilize local epidemiology and resistance patterns to select appropriate antibiotics to optimize clinical outcomes. Therapeutic drug monitoring should be used, when possible. This review should be used as a guide to develop a patient-specific antibiotic therapy plan.
A common complication of end-stage renal disease (ESRD) is mineral and bone disorder. Yet, many anti-osteoporotic drugs are contraindicated in ESRD patients. Denosumab, a monoclonal antibody, does not require renal dose adjustment. However, its use is uncertain due to a lack of safety and efficacy of data in this population. Two hemodialysis patient cases of contrasting responses in parathyroid hormone (PTH) after denosumab administration were observed. Patient 1, a 62-years-old male received denosumab 60 mg at Day 0. His calcium decreased from 8.8 mg/dL to 6.8 mg/dL on Day 30. The PTH level increased from 265 pg/mL to 372 pg/mL after 30 days. Calcium and PTH levels approached normal range after increasing doses of vitamin D/calcium supplements, and calcitriol. Patient 2, a 72-years-old male on hemodialysis also received denosumab 60 mg on Day 0. His baseline calcium and PTH were 9.2 mg/dL and 420 pg/mL, respectively. On Day 30, his calcium level decreased (6.8 mg/dL) but, PTH level drastically increased (>5000 pg/mL). Denosumab commonly causes hypocalcemia and hyperparathyroidism since it inhibits osteoclast activation, reduces calcium release from bone and increases PTH levels as a compensatory mechanism. With a wait-and-watch approach, Patient 2’s levels approached the normal range (calcium 9.6 mg/dL and PTH 274 pg/mL at Day 90).
Sergio Infante är lärare och forskare vid Stockholms Universitet, Institutionen för spanska och portugisiska. I detta och följande nummer av Moderna Språk ger han en övergripande presentation och beskrivning av den moderna spanskameriskanska romankonsten.
Abdominal pain and fever in patients on peritoneal dialysis (PD) raise suspicion of PD-associated peritonitis. However, other causes of peritonitis such as appendicitis should be considered. The laparoscopic approach is the standard of care in many of these situations. This technique allows PD catheter preservation and early resumption of PD. Here, we report a case where PD was resumed successfully 48 hours after laparoscopic appendectomy. A 45-year-old man with end-stage renal disease on chronic PD presented with acute abdominal pain. On examination, the patient was febrile and had lower abdomen tenderness without a rebound. The exit site of the PD catheter was clean. An initial diagnosis of PD-associated peritonitis was made, and an intraperitoneal antibiotic was given. Abdominal computed tomography revealed appendicitis. It was confirmed that the patient had severe nonperforated appendicitis following a laparoscopic appendectomy. The PD catheter was preserved, although the patient reported good residual kidney function; his electrolyte abnormalities with rising creatinine and potassium indicated the need to resume dialysis. Low-volume PD in a strict supine position was resumed 48 hours after surgery. The patient tolerated low-fill PD without any complications. He was discharged home on post-op day 4, and further follow-up revealed no complications. Resuming PD early in patients who go under laparoscopic surgery with low-volume PD is a reasonable option in select cases. Close follow-up from the dialysis team to detect and manage complications is necessary.
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