Outcomes of renal transplantation in patients with AL amyloidosis: an international collaboration through The International Kidney and Monoclonal Gammopathy Research Group

Effective systemic therapies suppress toxic light chain production leading to an increased proportion of patients with light chain (AL) amyloidosis who survive longer albeit with end-stage renal disease. There is a critical need to identify patients in this population who benefit from renal transplantation. This multicenter, observational study from five countries includes 237 patients with AL amyloidosis who underwent renal transplantation between 1987 and 2020. With a median follow-up of 8.5 years, the median overall survival from renal transplantation was 8.6 years and was significantly longer in patients with complete and very good partial hematologic responses (CR + VGPR) compared to less than VGPR (9 versus 6.8 years; HR: 1.5, P = 0.04 [95% CI: 1–2.1]) at renal transplantation. Median graft survival was 7.8 years and was better in the CR + VGPR group (8.3 vs 5.7 years, HR: 1.4, P = 0.05 [95% CI: 1–2]). The frequency and time to amyloid recurrence in the graft was also lower (16% vs 37%, p = 0.01) and longer (median time not achieved vs 10 years, p = 0.001) in the CR + VGPR group. Comparing CR vs. VGPR there was no difference in overall or graft survival. Although 69 patients (29%) experienced hematologic relapse, treatment effectively prevented graft loss in the majority (87%). Renal transplantation in selected AL amyloidosis patients is associated with extended overall and renal graft survival. Patients with hematologic CR or VGPR have the most favorable outcomes, and these patients should be considered for renal transplantation

Kidney Transplantation in Multiple Myeloma and Monoclonal Gammopathy of Renal Significance

Recent advances in the treatment of plasma cell disorders (PCDs) have provided a wealth of therapy alternatives and improved overall survival tremendously. Various types of PCDs are associated with kidney injury and end-stage kidney disease in a considerable number of patients. Kidney transplantation (KTx) is the best option for renal replacement therapy in select patients in terms of both quality of life parameters and overall survival. Even with modern therapies, all PCDs carry the risk of hematologic progression, whereas histologic recurrence and graft loss are other prevailing concerns in these patients. The risk of mortality is also higher in some of these disorders compared with KTx recipients who suffer from other causes of kidney disease. Unlike solid cancers, there is no well-defined “waiting time” after hematologic remission before proceeding to KTx. Thus, clinicians are usually reluctant to recommend KTx to patients who develop end-stage kidney disease due to PCDs. This review aims to provide the current evidence on KTx outcomes in patients with monoclonal gammopathy of renal significance and multiple myeloma. Although immunoglobulin light chain amyloidosis is a monoclonal gammopathy of renal significance subtype, KTx outcomes in this group are mentioned in another chapter of this issue

The Relationship between Oral Hygiene Index and Gastric Helicobacter Pylori Positivity

Objective: Helicobacter pylori (HP) is a bacterial patho­gen that leads to gastroduodenal inflammation, gastric and duodenal ulcer and atrophic gastritis. Colonization of bacteria can be shown by using rapid-urease test during endoscopy. There are conflicting data about the route of transmission and reservoir. It’s thought to be transmitted primarily by oral route. Many studies showed results sup­porting that the presence of bacteria in dental plaques has effects on gastric colonization and eradication. There are data about the potential inhibitory effect of oral flora on HP. We aimed to analyze the association of simplified oral hygiene index -a possible representation of a healthy oral flora- with HP positivity. Methods: Patients undergoing upper gastrointestinal system endoscopy for symptoms of dyspepsia were as­sessed by a dentist for the simplified oral hygiene index (OHI). Patients were classified as good, poor and bad groups based on oral hygiene index scale. Pre-pyloric biopsy materials were assessed using rapid-urease test. Oral hygiene indexes were analyzed retrospectively, groups were compared for HP positivity. Results: 66 patients (30 females, 45.5%) were included. Mean age of patients was 34.17±14.7 years. 11 (16.7%), 29 (43.9%) and 26 (39.4%) patients were classified as in good, poor and bad hygiene index groups, respectively. In patients with good OHI gastric HP positivity was less frequent. Conclusion: Decreased frequency in gastric HP may be observed with maintaining an ideal oral hygiene

Associations between mild hyponatremia and geriatric syndromes in outpatient settings

Purpose: The impact of mild hyponatremia on geriatric syndromes is not clear. Our aim was to determine associations between mild hyponatremia and results of comprehensive geriatric assessment tools in outpatient settings. Methods: We reviewed medical records of 1255 consecutive outpatient elderly subjects and compared results of comprehensive geriatric assessment measures among patients with mild hyponatremia (serum Na+ 130–135 mEq/L) versus normonatremia (serum Na+ 136–145 mEq/L). The comprehensive geriatric assessment measures included the Basic and Instrumental Activities of Daily Living, Mini Mental State Examination, Geriatric Depression Score, Tinetti Mobility Test, the Timed Up&Go Test, the Mini Nutritional Assessment, the handgrip test, the Insomnia Severity Index, polypharmacy, recurrent falls, urinary incontinence, orthostatic hypotension, and nocturia. Results: Of the 1255 patients, 855 were female (68.1%), and the mean age was 73.7 ± 8.3 years. Mild hyponatremia was detected in 108 patients (8.6%). The median serum sodium was 140.5 [interquartile range (IQR) 138.4–141.8] versus 133.8 [IQR, 132.3–134.2] in normonatremia and mild hyponatremia groups, respectively (p < 0.001). The only significant difference for comorbidities between normonatremia and mild hyponatremia groups was the frequency of hypertension (66.9% versus 76.7%, respectively (p = 0.041). None of the comprehensive geriatric assessment tools conferred a significant association with mild hyponatremia. Of the 1061 subjects with available survival data, 96 (9.0%) deceased within 3–4 years of follow-up (p = 0.742). Hyponatremia as an independent variable did not have a significant effect on mortality in univariate logistic regression analysis (OR 1.13, 95% CI 0.55–2.33, p = 0.742). Conclusion: Mild hyponatremia does not apparently affect results of geriatric assessments significantly. Whether particular causes of hyponatremia may have different impacts should be tested in further studies

Chronic Renal Failure, Anemia, and Parenteral Iron Treatment: From Bench to Bedside

Anemia is one of the common chronic renal failure (CRF) complications. Reduced renal erythropoietin (EPO) production and a shortened life span of erythrocytes due to uremic environment and iron deficiency are the main causes of anemia in patients with CRF. Correcting of iron deficiency constitutes the basis for the treatment of anemia in patients with CRF. Iron replacement can be done orally or intravenously. The seriousness of anemia and iron deficiency, tolerance of tablet use, response to previous treatments, and the presence of a ready vascular access determine the manner in which iron treatment is done. New generation parenteral iron preparations have complex carbohydrate structures that strongly bind to iron and reduce plasma free iron release. New generation iron molecules correct iron deficiency without causing an inflammatory process. The point that should be kept in mind is that new formulations may have a side effect profile that has not yet been experienced, in addition to various advantages. When using new iron molecules, precaution measures should be taken with regard to the development of arrhythmia, unstable angina, and hypophosphatemia

Rat models of colistin nephrotoxicity: previous experimental researches and future perspectives

Colistin is an old antibiotic, which is abandoned decades ago because of high nephrotoxicity rates. However, it is reintroduced to clinical medicine due to lack of newly discovered antibiotics and is still widely used for the treatment of resistant gram-negative infections. Discovering mechanisms to reduce nephrotoxicity risk is of significant importance since exposed patients may have many other factors that alter kidney functions. Several agents were evaluated in animal models of colistin nephrotoxicity as a means to prevent kidney injury. Considerable heterogeneity exists in terms of reporting colistin dosing and experimental designs. This issue leads clinicians to face difficulties in designing studies and sometimes may lead to report dosing strategies inadequately. Here, we present a review according to animal models of colistin nephrotoxicity using data gathered from previous experiments to draw attention on possible complexities that researchers may encounter

The prevalence and clinical significance of loss of appetite in older patients with chronic kidney disease

Purpose To determine predictors of loss of appetite among older adults with chronic kidney disease (CKD). Methods Demographic and clinical data, and scores of comprehensive geriatric assessment parameters of patients who were ≥ 60 years old and have CKD according to an estimated glomerular filtration rate (eGFR) of < 60 mL/min/1.73 m2 were reviewed. Loss of appetite was defined as a score of ≤ 28 in The Council on Nutrition Appetite Questionnaire. Logistic regression analysis was performed to determine the predictors of loss of appetite. Results Of the 398 patients included, 288 (72%) were female, and the mean age was 80 ± 7. Loss of appetite was present in 233 (59%) of patients. The frequency appeared to significantly increase with a decline in eGFR to < 45 mL/min/1.73 m2 (p < 0.05). Older age, female sex, the presence of frailty, and higher scores of Insomnia Severity Index and geriatric depression scale-15 were associated with a higher risk of loss of appetite, while longer time on education, higher levels of hemoglobin, eGFR, and serum potassium, and higher scores of handgrip strength, Tinetti gait and balance test, basic and instrumental activities of daily living, and Mini-Nutritional risk Assessment (MNA) were associated with a lower risk (p < 0.05). Associations between insomnia severity and geriatric depression remained significant after adjustment for all parameters including the MNA score. Conclusion Loss of appetite is quite common in older adults with CKD and may be a sign of poor health status in older people with CKD. There is a close relationship between loss of appetite and insomnia or depressive mood

Risk factors for high fall risk in elderly patients with chronic kidney disease

Purpose: Patients with chronic kidney disease (CKD) usually represent an aging population, and both older age and CKD are associated with a higher risk of falling. Studies on risk factors among subjects with CKD are lacking. Methods: Records of outpatients from one geriatric clinic in Turkey were retrospectively reviewed. A result of ≥ 13.5 s on the timed up and go (TUG) test was accepted as a high risk of falls. Independent predictors of an increased risk of falls among subjects with CKD (estimated glomerular filtration rate of < 60 mL/min/1.73 m2) were identified using logistic regression models. Results: Patients with CKD (n = 205), represented the 20.2% of the entire cohort and was identified as an independent predictor of increased fall risk (OR 2.59). Within the CKD cohort, serum folic acid levels and frailty were independent predictors of an increased risk of falls. The CKD/fall risk group was older, had a lower median years of education, lower vitamin D levels, and lower serum folic acid levels than the CKD/non-fall risk group. In addition to higher serum creatinine and potassium levels, the only significant difference between patients with CKD/fall risk and a matched non-CKD/fall risk was a lower median folic acid level in the former group. Conclusions: Frailty and low folic acid levels are independently associated with an increased risk of falls among elderly outpatients with CKD. Prevention of frailty may reduce the risk of falls in these subjects. Possible benefit of folic acid supplementation requires further studies