Late onset tacrolimus-induced life-threatening polyneuropathy in a kidney transplant recipient patient

A 59-year-old kidney recipient was diagnosed with a late onset of severe chronic inflammatory demyelinating polyradiculoneuropathy and almost fully recovered after stopping tacrolimus and one course of intravenous immunoglobulin treatment. Unique features of this patient are the unusually long time lapse between initiation of tacrolimus and the adverse effect (10 years), a strong causality link and several arguments pointing toward an inflammatory etiology. When facing new neurological signs and symptoms in graft recipients, it is important to bear in mind the possibility of a drug-induced adverse event. Discontinuation of the suspect drug and immunomodulation are useful treatment options

Case Report: A Rare Truncating Variant of the CFHR5 Gene in IgA Nephropathy.

IgA nephropathy (IgAN) is the most common primary glomerulonephritis worldwide. Despite appropriate therapy, 20-40% of affected-patients evolve toward end-stage kidney disease (ESKD). Mesangial IgA deposits are the hallmark of IgAN, and complement deposition (C3) seems to differentiate latent IgA mesangial deposits from active IgAN. Atypical hemolytic uremic syndrome (aHUS), another disease in which complement plays an important role, is caused by inherited or acquired deregulation of the alternative pathway (AP) of complement. A subgroup of IgAN shows thrombotic microangiopathy (TMA) lesions in kidney biopsies, the histological characteristic of aHUS. Genetic variants of complement Factor H (CFH), known to be present in aHUS, have been associated with rapidly progressive forms of IgAN and a clinical pattern of aHUS. Genome-wide association studies (GWAS) have confirmed that the 1q32 region, encoding for CFH and its related proteins, is an IgAN susceptibility locus. A 30 year-old man was admitted for seizures and malignant hypertension. The kidney biopsy showed IgAN associated with features of TMA. Despite five plasma exchanges, the patient remained dialysis-dependent, and ESKD was diagnosed. Functional and genetic complement analysis were performed. A monoallelic protein-truncating, likely loss-of-function variant was identified in the CFHR5 gene. Eculizumab is the treatment of aHUS. As it has been successfully used in a few cases of rapidly progressive IgAN, it was decided to administer eculizumab over a period of 12 months in addition to the usual immunosuppression for renal transplantation. After a follow-up of 3 years, there was no clinical disease recurrence. Systematic biologic and genetic screening of complement in individuals with IgAN might be useful to better delineate the role of the AP of complement in renal disease progression, and this may have therapeutic implications

Disposition of valganciclovir during continuous renal replacement therapy in two lung transplant recipients

Objectives To determine whether valganciclovir 450 mg every 48 h for cytomegalovirus (CMV) prophylaxis provides appropriate ganciclovir exposure in solid organ transplant recipients during continuous renal replacement therapy (CRRT). Patients and methods Ganciclovir pharmacokinetics was intensively studied in two lung transplant recipients under valganciclovir 450 mg every 48 h over one dosing interval. In vitro experiments using blank whole blood spiked with ganciclovir further investigated exchanges between plasma and erythrocytes. Results Ganciclovir disposition was characterized by apparent total body clearance of 3.3 and 5.8 L/h, terminal half-life of 16.9 and 14.1 h, and apparent volume of distribution of 60.3 and 104.9 L in Patients 1 and 2, respectively. The observed sieving coefficient was 1.05 and 0.96, and the haemofiltration clearance was 3.3 and 3.1 L/h. In vitro experiments confirmed rapid efflux of ganciclovir from red blood cells into plasma, increasing the apparent efficacy of haemofiltration. Conclusions A valganciclovir dosage of 450 mg every 48 h appears adequate for patients under CRRT requiring prophylaxis for CMV infection, providing concentration levels in the range reported for 900 mg once daily dosing outside renal failur

Hanford Double-Shell Tank Extent-of-Condition Construction Review - 14174

During routine visual inspections of Hanford double-shell waste tank 241-AY-102 (AY-102), anomalies were identified on the annulus floor which resulted in further evaluations. Following a formal leak assessment in October 2012, Washington River Protection Solutions, LLC (WRPS) determined that the primary tank of AY-102 was leaking. The formal leak assessment, documented in RPP-ASMT-53793,Tank 241-AY-102 Leak Assessment Report, identified first-of-a-kind construction difficulties and trial-and-error repairs as major contributing factors to tank failure. To determine if improvements in double-shell tank (DST) construction occurred after construction of tank AY-102, a detailed review and evaluation of historical construction records were performed for the first three DST tank farms constructed, which included tanks 241-AY-101, 241-AZ-101, 241-AZ-102, 241-SY-101, 241-SY-102, and 241-SY-103. The review for these six tanks involved research and review of dozens of boxes of historical project documentation. These reviews form a basis to better understand the current condition of the three oldest Hanford DST farms. They provide a basis for changes to the current tank inspection program and also provide valuable insight into future tank use decisions. If new tanks are constructed in the future, these reviews provide valuable �lessons-learned� information about expected difficulties as well as construction practices and techniques that are likely to be successful

Rituximab as monotherapy for the treatment of chronic active antibody-mediated rejection after kidney transplantation.

Chronic active antibody-mediated rejection (caAMR) is a major cause of allograft loss after kidney transplantation (1). The BANFF 2013 classification redefined caAMR by the presence of donor-specific anti-HLA antibodies (DSA) together with immuno-histopathological evidence for active vascular lesions of the endothelium (C4d deposits, glomerulitis, peritubular capillaritis) as well as evidence of chronic tissue injury (transplant glomerulopathy, peritubular capillary basement membrane multilayering or arterial intimal fibrosis) (2,3). Humoral immunity, detected by the presence of DSA, and B cells are considered pivotal in the development of caAMR. Gosset et al. showed that circulating DSA are responsible for accelerated allograft fibrosis independently of acute AMR (1). This article is protected by copyright. All rights reserved

241-AY-102 Leak Detection Pit Drain Line Inspection Report

This document provides a description of the design components, operational approach, and results from the Tank AY-102 leak detection pit drain piping visual inspection. To perform this inspection a custom robotic crawler with a deployment device was designed, built, and operated by IHI Southwest Technologies, Inc. for WRPS to inspect the 6-inch leak detection pit drain line

Is the left-right scale a valid measure of ideology? Individual-level variation in associations with "left" and "right" and left-right self-placement

In order to measure ideology, political scientists heavily rely on the so-called left-right scale. Left and right are, however, abstract political concepts and may trigger different associations among respondents. If these associations vary systematically with other variables this may induce bias in the empirical study of ideology. We illustrate this problem using a unique survey that asked respondents open-ended questions regarding the meanings they attribute to the concepts "left" and "right". We assess and categorize this textual data using topic modeling techniques. Our analysis shows that variation in respondents’ associations is systematically related to their self-placement on the left-right scale and also to variables such as education and respondents’ cultural background (East vs. West Germany). Our findings indicate that the interpersonal comparability of the left-right scale across individuals is impaired. More generally, our study suggests that we need more research on how respondents interpret various abstract concepts that we regularly use in survey questions

A comparison of the original and simplified Pulmonary Embolism Severity Index.

The Pulmonary Embolism Severity Index (PESI) is a validated clinical prognostic model for patients with pulmonary embolism (PE). Recently, a simplified version of the PESI was developed. We sought to compare the prognostic performance of the original and simplified PESI. Using data from 15,531 patients with PE, we compared the proportions of patients classified as low versus higher risk between the original and simplified PESI and estimated 30-day mortality within each risk group. To assess the models' accuracy to predict mortality, we calculated sensitivity, specificity, and predictive values and likelihood ratios for low- versus higher-risk patients. We also compared the models' discriminative power by calculating the area under the receiver-operating characteristic curve. The overall 30-day mortality was 9.3%. The original PESI classified a significantly greater proportion of patients as low-risk than the simplified PESI (40.9% vs. 36.8%; p<0.001). Low-risk patients based on the original and simplified PESI had a mortality of 2.3% and 2.7%, respectively. The original and simplified PESI had similar sensitivities (90% vs. 89%), negative predictive values (98% vs. 97%), and negative likelihood ratios (0.23 vs. 0.28) for predicting mortality. The original PESI had a significantly greater discriminatory power than the simplified PESI (area under the ROC curve 0.78 [95% CI: 0.77-0.79] vs. 0.72 [95% CI: 0.71-0.74]; p<0.001). In conclusion, even though the simplified PESI accurately identified patients at low-risk of adverse outcomes, the original PESI classified a higher proportion of patients as low-risk and had a greater discriminatory power than the simplified PESI

SINGLE-SHELL TANKS LEAK INTEGRITY ELEMENTS/SX FARM LEAK CAUSES AND LOCATIONS - 12127

Washington River Protection Solutions, LLC (WRPS) developed an enhanced single-shell tank (SST) integrity project in 2009. An expert panel on SST integrity was created to provide recommendations supporting the development of the project. One primary recommendation was to expand the leak assessment reports (substitute report or LD-1) to include leak causes and locations. The recommendation has been included in the M-045-9IF Hanford Federal Facility Agreement and Consent Order (Tri-Party Agreement) as one of four targets relating to SST leak integrity. The 241-SX Farm (SX Farm) tanks with leak losses were addressed on an individual tank basis as part of LD-1. Currently, 8 out of 23 SSTs that have been reported to having a liner leak are located in SX Farm. This percentage was the highest compared to other tank farms which is why SX Farm was analyzed first. The SX Farm is comprised of fifteen SSTs built 1953-1954. The tanks are arranged in rows of three tanks each, forming a cascade. Each of the SX Farm tanks has a nominal I-million-gal storage capacity. Of the fifteen tanks in SX Farm, an assessment reported leak losses for the following tanks: 241-SX-107, 241-SX-108, 241-SX-109, 241-SX-111, 241-SX-112, 241-SX-113, 241-SX-114 and 241-SX-115. The method used to identify leak location consisted of reviewing in-tank and ex-tank leak detection information. This provided the basic data identifying where and when the first leaks were detected. In-tank leak detection consisted of liquid level measurement that can be augmented with photographs which can provide an indication of the vertical leak location on the sidewall. Ex-tank leak detection for the leaking tanks consisted of soil radiation data from laterals and drywells near the tank. The in-tank and ex-tank leak detection can provide an indication of the possible leak location radially around and under the tank. Potential leak causes were determined using in-tank and ex-tank information that is not directly related to leak detection. In-tank parameters can include temperature of the supernatant and sludge, types of waste, and chemical determination by either transfer or sample analysis. Ex-tank information can be assembled from many sources including design media, construction conditions, technical specifications, and other sources. Five conditions may have contributed to SX Farm tank liner failure including: tank design, thermal shock, chemistry-corrosion, liner behavior (bulging), and construction temperature. Tank design did not apparently change from tank to tank for the SX Farm tanks; however, there could be many unknown variables present in the quality of materials and quality of construction. Several significant SX Farm tank design changes occurred from previous successful tank farm designs. Tank construction occurred in winter under cold conditions which could have affected the ductile to brittle transition temperature of the tanks. The SX Farm tanks received high temperature boiling waste from REDOX which challenged the tank design with rapid heat up and high temperatures. All eight of the leaking SX Farm tanks had relatively high rate of temperature rise. Supernatant removal with subsequent nitrate leaching was conducted in all but three of the eight leaking tanks prior to leaks being detected. It is possible that no one characteristic of the SX Farm tanks could in isolation from the others have resulted in failure. However, the application of so many stressors - heat up rate, high temperature, loss of corrosion protection, and tank design - working jointly or serially resulted in their failure. Thermal shock coupled with the tank design, construction conditions, and nitrate leaching seem to be the overriding factors that can lead to tank liner failure. The distinction between leaking and sound SX Farm tanks seems to center on the waste types, thermal conditions, and nitrate leaching