Renal cortical necrosis. A literature review and new diagnostic tools

Ostra martwica kory nerek (ARCN) jest rzadką przyczyną ostrego uszkodzenia nerek (AKI) w populacji ogólnej, częściej zdarza się u kobiet w II i III trymestrze ciąży. Wśród przyczyn położniczych najczęstszą jest przedwczesne odklejenie się łożyska, natomiast wśród niepołożniczych — zespół hemolityczno-mocznicowy i posocznica. Jej podstawową cechą patomorfologiczną jest wybiórcza niedokrwienna martwica wszystkich elementów warstwy korowej (naczyń, kłębuszków i cewek). Charakterystyczna triada objawów — bezmocz, krwiomocz i ból w okolicy lędźwiowej — wyróżnia ARCN spośród innych postaci AKI u kobiet w ciąży, jednak podejrzenie choroby najczęściej budzi dopiero przedłużający się bezmocz. W diagnostyce wykorzystuje się ultrasonografię, tomografię komputerową i biopsję nerki. Ciekawym nowym narzędziem diagnostycznym jest ultrasonografia z podaniem środka kontrastującego. Podstawami są leczenie choroby wywołującej ARCN, wyrównanie zaburzeń hemodynamicznych i dializoterapia. Rokowanie jest, niestety, niepomyślne — dysfunkcja nerek zwykle jest nieodwracalna, a śmiertelność wysoka (ok. 50%).Acute renal cortical necrosis (ARCN) is the rare cause of acute kidney injury (AKI) in the world population, it is more common among women in the 2nd and 3rd trimester of gravity. Amid obstetrical causes placental abruption is the most frequent, whereas hemolytic uremic syndrome and sepsis are one of the non-obstetrical causes. Its basic pathomorphological feature is the ischemic necrosis of all cortex elements (vessels, glomeruli and tubules). The characteristic triad of symptoms: anuria, hematuria and flank pain distinguishes RCN among other forms of AKI during pregnancy, although anuria is what arouses suspicion. Ultrasonography, computed tomography and renal biopsy are used in diagnostics. A very interesting new diagnostic tool is contrast-enhanced ultrasound. The first thing to do is to treat the disease which caused RCN, align hemodynamic disorders and perform dialysis. Unfortunately prognosis in the disease is bad, kidney dysfunction is usually irreversible and mortality very high

Local and Systemic Immunity Are Impaired in End-Stage-Renal-Disease Patients Treated With Hemodialysis, Peritoneal Dialysis and Kidney Transplant Recipients Immunized With BNT162b2 Pfizer-BioNTech SARS-CoV-2 Vaccine

Vaccination against COVID-19 in patients with end-stage renal disease (ESRD) on replacement therapy and kidney transplant recipients (KTRs) is particularly important due to the high mortality rate. Here, we tested the local and systemic immunity to the novel Pfizer BioNTech (BNT162b2) messenger RNA (mRNA) in ESRD, KTR patients, and healthy individuals (150 subjects). The ESRD group was divided into: hemodialysis (HD) and peritoneal dialysis (PD). We investigated the local and systemic immunity based on anti-N (nucleoprotein) and anti-S (spike1/2) Immunoglobulin A (IgA) and Immunoglobulin G (IgG) antibodies, respectively. Additionally, we performed an Interferon gamma (IFN-γ) release test Interferon-gamma release assay (IGRA) to monitor the cellular component of vaccine response. The control group had the highest level of anti-S IgG antibodies (153/2,080 binding antibody units (BAU)/ml) among all analyzed patients after the 1st and 2nd dose, respectively. The HD group (48/926 BAU/ml) had a diminished antibody level compared to PD (93/1,607 BAU/ml). Moreover, the seroconversion rate after the 1st dose was lower in HD than PD (56% vs. 86%). KTRs had extremely low seroconversion (33%). IgA-mediated immunity was the most effective in the control group, while other patients had diminished IgA production. We observed a lower percentage of vaccine responders based on the IFN-γ level in all research participants (100% vs. 85% in control, 100% vs. 80% in PD, 97% vs. 64% in HD). 63% of seropositive KTRs had a positive IGRA, while 28% of seronegative patients produced IFN-γ. Collectively, PD patients had the strongest response among ESRD patients. Two doses of the Pfizer vaccine are ineffective, especially in HD and KTRs. A closer investigation of ESRD and KTRs is required to set the COVID-19 vaccine clinical guidance.Clinical Trial Registration Numberwww.ClinicalTrials.gov, identifier: NCT04 905 86

New biochemical markers of ethyl alcohol abuse – new possibilities in clinical practice

Alkohol jest w krajach rozwiniętych jednym z głównych czynników behawioralnych utraty zdrowia i życia. Jego nadużywanie ma poważne skutki społeczne i ekonomiczne: przyczynia się do większej liczby wypadków w pracy, kolizji drogowych oraz nieobecności w zakładach pracy. Rozpoznawanie i leczenie alkoholizmu jest bardzo trudne, dlatego wykorzystanie obiektywnych wskaźników biochemicznych nadużywania alkoholu etylowego może przyczynić się do wcześniejszego rozpoznawania, skuteczniejszego leczenia i wiarygodnego monitorowania okresu abstynencji. Celem pracy jest przedstawienie dostępnych w Polsce czułych i swoistych wskaźników szkodliwego spożywania alkoholu ze szczególnym uwzględnieniem możliwości ich praktycznego wykorzystania. Takie testy mogą znaleźć zastosowanie m.in. w programach odzyskiwania prawa jazdy przez kierowców zatrzymanych z powodu jazdy pod wpływem alkoholu, wczesnego wykrywania osób nadużywających alkoholu wśród pracowników podczas rutynowych badań w zakładach pracy, do monitorowania abstynencji w trakcie leczenia odwykowego, przed planowanymi zabiegami przeszczepiania narządów, do wykrywania szkodliwego spożywania alkoholu wśród kobiet ciężarnych i w sekcjach sądowo-lekarskich. Niezbędna jest standaryzacja metod oznaczania wskaźników w materiale biologicznym, a istotnym problemem we właściwej interpretacji wyników mogą być choroby współistniejące. Mimo tych ograniczeń obiektywne wskaźniki biochemiczne nadużywania alkoholu etylowego mogą być pomocne w opiece nad pacjentami. Szczególną rolę mogą pełnić w diagnostyce w medycynie pracy, przyczyniając się do wzrostu bezpieczeństwa na drogach publicznych oraz bezpieczeństwa pracowników w zakładach pracy.Alcohol ranks as one of the leading behavioral threats to health and life in developed countries. Alcohol abuse triggers serious social and economic effects: it contributes to higher prevalence of work-related and road accidents, as well as absence from work. The diagnosis and treatment of alcoholism still remain very difficult. Hence, the use of objective biochemical markers of alcohol abuse may contribute to earlier detection, more effective therapy and reliable teetotalism control. The aim of this study is to present the sensitive and specific biomarkers of alcohol abuse available in Poland, with particular emphasis on the practical use possibilities. Such tests may be widely used, e.g., in driving license regranting cases involving drivers whose licenses were suspended for driving when intoxicated, for the early detection of persons abusing alcohol in employment-related health controls, for abstinence monitoring during withdrawal treatment, for detecting alcohol consumption in transplant settings, for assessing the prevalence of alcohol drinking in pregnancy, as well as in autopsical examinations. The standardization of biomarkers measurement methods is essential. Moreover, concomitant disorders may pose a significant problem in the proper outcome analysis. Despite these limitations, objective biochemical markers of ethyl alcohol abuse may become helpful tools in medical care. They can play a particular role in occupational medicine diagnostics, contributing to the higher level of safety on public roads and to worker safety

Haff disease – are we threatened with another epidemic?

Choroba Zalewu Wiślanego (Haff disease) jest zespołem objawów spowodowanych rabdomiolizą rozwiniętą po spożyciu niektórych gatunków ryb i skorupiaków. Patofizjologia choroby pozostaje nieznana. Jej ogniska epidemiczne były do tej pory odnotowywane w wielu regionach świata. W niniejszym artykule przedstawiono przypadek 38-letniego pacjenta, zawodowego rybaka, u którego wysunięto podejrzenie choroby Zalewu Wiślanego. Jako objawy chory podawał rozlane bóle mięśniowe, ból głowy, uczucie ucisku w klatce piersiowej, ciemne zabarwienie moczu oraz podwyższone wartości ciśnienia tętniczego. Dominującymi nieprawidłowościami w badaniach laboratoryjnych były podwyższone stężenia kinazy kreatynowej oraz kreatyniny w surowicy krwi. W trakcie hospitalizacji pacjent wymagał leczenia nerkozastępczego. W wyniku zastosowanego postępowania uzyskano poprawę kliniczną oraz laboratoryjną. Pacjenta wypisano do domu w stanie ogólnym dobrym. Choroba Zalewu Wiślanego powinna być uwzględniana w diagnostyce różnicowej rabdomiolizy. Kluczowe w postawieniu prawidłowej diagnozy jest szczegółowe badanie podmiotowe, a przede wszystkim istotne są pytania o ostatnio spożywane pokarmy oraz narażenie zawodowe. Med. Pr. 2021;72(5):605–610Haff disease is a group of symptoms caused by rhabdomyolysis following ingestion of some species of fish and crayfish. Pathophysiology remains unknown. Outbreaks of the Haff disease have been reported in many regions of the world. In this article we present the case of a 38-years-old patient, professional fisherman, suspected of suffering from Haff disease. He developed symptoms of diffuse myalgia, headache, chest pressure, brown-colored urine and elevated blood pressure. Predominant laboratory abnormalities were elevated serum creatine kinase and creatinine concentrations. During hospitalization the patient required the renal replacement therapy. As a result of applied procedures, clinical and laboratory improvement was achieved. The patient was discharged home in good general condition. The Haff disease should be included in the differential diagnosis of rhabdomyolysis. Detailed medical interview, especially questions about recently consumed food and occupational exposure, is crucial in making a proper diagnosis. Med Pr. 2021;72(5):605–1

Predictors of Humoral Response to mRNA COVID19 Vaccines in Kidney Transplant Recipients: A Longitudinal Study—The COViNEPH Project

Background: The efficacy of SARS-CoV-2 vaccination among kidney transplant recipients (KTR) is low. The main goal of this study was to analyze factors that may influence the humoral response to vaccination. Methods: We analyzed the titer magnitude of IgG antibodies directed against spike (S)-SARS-CoV-2 antigen after the second dose of the mRNA vaccine in 142 infection naïve KTR (83 men, i.e., 58.4%) with a median age (IQR) of 54 (41–63), and 36 respective controls without chronic kidney disease. mRNA-1273 or BNT162b2 were applied in 26% and 74% of KTR, respectively. Results: S-specific immune response (seroconversion) was seen in 73 (51.41%) of KTR, and in all controls 36 (100%). Independent predictors of no response were elder age, shorter transplantation vintage, and a more than two-drug immunosuppressive protocol. In subgroup analyses, the seroconversion rate was highest among KTR without MMF/MPS treatment (70%), treated with no more than two immunosuppressants (69.2%), treated without corticosteroid (66.7%), younger patients aged <54 years (63.2%), and those vaccinated with the mRNA-1273 vaccine (62.16%). The independent predictors of higher S-antibody titer among responders were younger age, treatment with no more than two immunosuppressants, and the mRNA-1273 vaccination. Conclusions: Our study confirmed a low rate of seroconversion after vaccination with the mRNA vaccine in KTR. The major modifiable determinants of humoral response were the composition of the immunosuppressive protocol, as well as the type of vaccine. The latter could be taken into consideration when initial vaccination as well as booster vaccination is considered in KTR

SARS-CoV-2 infection in vaccinated maintenance hemodialysis patients despite anti-spike seroconversion: a report of 3 breakthrough cases

Chronically hemodialyzed (HD) patients are at a high risk of developing very severe forms of COVID-19 disease. In this article we describe three HD patients (all males, aged 70, 70 and 74 years) vaccinated intramuscularly with a two-dose mRNA BNT162b2 vaccine; BionTech/Pfizer Comirnaty, in whom subsequent breakthrough SARS-CoV-2 infections developed. All patients achieved post-vaccine seroconversion for anti-spike antibodies with IgG titers of 445, 227 and 92.5 AU/mL (cut-off, 13 AU/mL) case 1, 2 and 3 respectively. SARS-CoV-2 infection was diagnosed 44, 28 and 48 days after the second dose of BNT162b2 and confirmed with the polymerase-chain-reaction (PCR) test. Two asymptomatic patients underwent this test because of their direct contact with a person with confirmed COVID-19. The third patient reported only a non-significant drop in oxygen saturation, and was hospitalized (case 3). All these patients were characterized by a low post-vaccination neutralizing antibody titer and a high production of these antibodies after falling ill (795, 845 and 5770). Perhaps this production of antibodies is responsible for the mild course of the disease, and the likely reduction of mortality. These breakthrough cases in no way undermine the importance of the vaccinations, and on the contrary argue for their urgency

Waning Humoral Response after COVID-19 mRNA Vaccination in Maintenance Dialysis Patients and Recovery after a Complementary Third Dose

The aim of this study was to analyze the waning of anti-spike (S) antibodies after mRNA vaccination against COVID-19 in maintenance dialysis patients, and to assess the safety and effectiveness of the complementary third dose. This was a prospective, longitudinal study in which we analyzed the kinetics of antibodies up to six months after a two-dose vaccination (first protocol) in infection-naïve dialysis patients (IN-Ds), previously infected dialysis patients (PI-Ds) and subjects without chronic kidney disease (the controls), as well as their humoral response to the third dose of the same mRNA vaccine (second protocol). The respective reduction in antibody titer after 3 and 6 months by 82.9% and 93.03% in IN-Ds (n = 109), 73.4% and 93.36% in PI-Ds (n = 32) and 75.5% and 88.8% in the controls (n = 20) was demonstrated. Consequently, a protective antibody titer above 141 BAU/mL was found in only 47.7% and 23.8% of IN-Ds after 3 and 6 months, respectively. After the third vaccine dose, a significant increase in antibody titer was observed in all groups, with increases by a factor of ×51.6 in IN-Ds, ×30.1 in the controls and ×8.4 in PI-Ds. The median antibody titer after the third dose differed significantly between groups, and was the highest in PI-Ds: PI-Ds, 9090 (3300–15,000) BAU/mL; the controls, 6945 (2130–11,800); IN-Ds, 3715 (1470–7325) (p < 0.001). In conclusion, we observed similar degrees of antibody waning in all patients. After 3 months, over half of the infection-naïve dialysis patients had a very low antibody titer, and almost twenty percent of them had no antibodies at all. The humoral response to the third dose was very good, raising their titer of antibodies to a higher level than those in the general population who have received the primary two-dose scheme. The results support the administration of a complementary third dose of the mRNA vaccine for dialysis patients as soon as possible

Use of Sertraline in Hemodialysis Patients

Depression and anxiety are the most common psychiatric disorders in end-stage renal disease (ESRD) patients treated with hemodialysis (HD) and may correlate with lower quality of life and increased mortality. Depression treatment in HD patients is still a challenge both for nephrologists and psychiatrists. The possible treatment of depressive disorders can be pharmacological and non-pharmacological. In our article, we focus on the use of sertraline, the medication which seems to be relatively safe and efficient in the abovementioned population, taking under consideration several limitations regarding the use of other selective serotonin reuptake inhibitors (SSRIs). In our paper, we discuss different aspects of sertraline use, taking into consideration possible benefits and side effects of drug administration like impact on QTc (corrected QT interval) prolongation, intradialytic hypotension (IDH), chronic kidney disease-associated pruritus (CKD-aP), bleeding, sexual functions, inflammation, or fracture risk. Before administering the medication, one should consider benefits and possible side effects, which are particularly significant in the treatment of ESRD patients; this could help to optimize clinical outcomes. Sertraline seems to be safe in the HD population when provided in proper doses. However, we still need more studies in this field since the ones performed so far were usually based on small samples and lacked placebo control