Calciphylaxis following kidney transplantation: a case report

Introduction: Calciphylaxis occurring after kidney transplantation is rare and rarely reported. It results in chronic non-healing wounds and is associated with a poor prognosis and is often fatal. We present a case of proximal lower limb calciphylaxis that occurred early after kidney transplantation. The patient had no classic associated risk factors. He had previously had a total parathyroidectomy but had normal serum calcium-phosphate product and parathyroid hormone levels. The clinical outcome of this case was favorable and highlights some fundamental issues relating to management. Case prsentation: A 70-year-old British Caucasian man with end-stage renal failure secondary to IgA nephropathy presented six months post kidney transplantation with cutaneous calciphylaxis lesions involving the medial aspect of the thigh bilaterally. Conclusion: To the best of our knowledge, this is the first reported case of rapid onset cutaneous calciphylaxis occurring soon after kidney transplantation that was associated with a favorable outcome. Cutaneous calciphylaxis lesions should be promptly managed with meticulous wound care, antimicrobial therapy and the correction of calcium-phosphate product where indicated

Cardiovascular, muscular and perceptual contributions to physical fatigue in prevalent kidney transplant recipients

Physical fatigue is debilitating and common among kidney transplant recipients (KTRs). This study investigated the mechanistic aetiology of physical fatigue in this setting through examinations of muscle mass, muscular and cardiovascular function, and perceived exertion. The incidence of physical fatigue, its association with quality of life (QoL), and the predictors of perceived exertion, were evaluated. This single‐centre observational cross‐sectional study enrolled 55 KTRs. Muscle mass was quantified using dual‐energy x‐ray absorptiometry. Muscular function was assessed by jumping mechanography. Cardiovascular function (maximal oxygen consumption and oxygen pulse) was estimated during submaximal exercise testing, with perceived exertion determined using age‐adjusted Borg scale‐ratings. Physical fatigue was measured using Multi‐Dimensional Fatigue Inventory‐20. QoL was assessed using Medical Outcomes Study Short Form‐36. Demographic, clinical, nutritional, psychosocial and behavioural predictors of perceived exertion were assessed. Of clinical importance, increased perceived exertion was the only independent predictor of physical fatigue (P = 0.001), with no association found between physical fatigue and muscular or cardiovascular parameters. Physical fatigue occurred in 22% of KTRs, and negatively impacted on QoL (P < 0.001). Predictors of heightened perception included anxiety (P < 0.05) and mental fatigue (P < 0.05). Perception is a key determinant of physical fatigue in KTRs, paving the way for future interventions

Metabolomic perfusate analysis during kidney machine perfusion : the pig provides an appropriate model for human studies

Hypothermic machine perfusion offers great promise in kidney transplantation and experimental studies are needed to establish the optimal conditions for this to occur. Pig kidneys are considered to be a good model for this purpose and share many properties with human organs. However it is not established whether the metabolism of pig kidneys in such hypothermic hypoxic conditions is comparable to human organs.Standard criteria human (n = 12) and porcine (n = 10) kidneys underwent HMP using the LifePort Kidney Transporter 1.0 (Organ Recovery Systems) using KPS-1 solution. Perfusate was sampled at 45 minutes and 4 hours of perfusion and metabolomic analysis performed using 1-D 1H-NMR spectroscopy.There was no inter-species difference in the number of metabolites identified. Of the 30 metabolites analysed, 16 (53.3%) were present in comparable concentrations in the pig and human kidney perfusates. The rate of change of concentration for 3-Hydroxybutyrate was greater for human kidneys (p<0.001). For the other 29 metabolites (96.7%), there was no difference in the rate of change of concentration between pig and human samples.Whilst there are some differences between pig and human kidneys during HMP they appear to be metabolically similar and the pig seems to be a valid model for human studies

Kliničke praktične smjernice za perioperacijsku i poslijeoperacijsku skrb o arterijsko-venskim fistulama i umetcima za hemodijalizu u odraslih

Krvožilni pristup omogućuje hemodijalizu koja spašava život. Stoga je nužna dobra funkcija krvožilnog pristupa koja omogućuje prikladan krvni protok radi uklanjanja tvari koje se u uremiji zadržavaju u krvi bolesnika, uz istodobno sniženje rizika od sustavne infekcije na najmanju moguću mjeru. Godine 2007. Europske smjernice najbolje prakse (engl. European Best Practice Guidelines – EBPG), prethodnice trenutačne Europske najbolje bubrežne prakse (engl. European Renal Best Practice – ERBP), donijele su nacrt skupine preporuka – vodiča pri donošenju odluka o upućivanju na pregled radi krvožilnog pristupa, o procjeni i nadzoru izbora pristupa te o postupcima kod komplikacija. (1) Otad su se znatno razvili ne samo dokazi na kojima se temelje ove preporuke nego i procesi nastajanja smjernica. (2) Kao odgovor na to, ERBP je ažurirao prethodno djelo u suradnji s raznim stručnjacima iz tog područja uključujući i predstavnike Društva za krvožilni pristup (engl. Vascular Access Society – VAS), kirurge za krvožilni pristup, radiologe, medicinske sestre za dijalizu, znanstvenike, bolesnike i one koji se za njih brinu. Nastojanje da se pridržavaju sve strože metodike izrade smjernica nalagalo je određena odricanja u pogledu područja obuhvata ovih smjernica. Posljedično, one ne „pokrivaju” baš sve iste teme kao njihova prethodna verzija. Neka su područja zajednička, a neka su arhivirana da bi ustupila mjesto novim pitanjima kojima su prednost dali i pružatelji zdravstvene skrbi i oni za koje se skrbi. Odvojeno su objavljene pojedinosti postupka izbora djelokruga problematike koju su smjernice obuhvatile. (3) Nastajanje ovih smjernica slijedilo je strog proces pregleda i procjene dokaza koji se temeljio na sustavnim pregledima rezultata kliničkih istraživanja te opservacijskih podataka gdje je to bilo potrebno. Strukturirani pristup slijedio je model sustava GRADE (hrv. stupanj), koji svakoj preporuci pripisuje stupanj s obzirom na sigurnost sveukupnih dokaza te snagu. (4) Gdje je to bilo primjereno skupina za izradu smjernica unijela je nestupnjevan savjet za kliničku praksu, a koji nije proistekao iz pregleda sustavnih dokaza. Kliničke praktične smjernice iz 2019. godine specifično pokrivaju peritransplantacijske i poslijetransplantacijske aspekte arterijsko-venskih (AV) fistula i umetaka (graftova). Drugi dio, koji je bio u nastajanju kada su ove smjernice išle u tisak, pokrit će aspekte izbora krvožilnog pristupa, prijeoperacijske procjene krvnih žila i središnje venske katetere. Unatoč nedostatku dokaza velike sigurnosti za većinu područja krvožilnih pristupa, ERBP se posvetio izradi smjernica velike kakvoće, dajući smjernicu gdje god je moguće, a popis preporuka za istraživanje ondje gdje se nije moglo uputiti smjernicom. Nadamo se da će ove smjernice i one planirane pomoći stručnoj zajednici pri donošenju odluka o postupcima, postupnicima i skrbi vezanima s krvožilnim pristupima, pomoći bolesnicima i onima koji se za njih brinu da steknu uvid u problematiku te olakšati zajedničko donošenje odluka u tom području

Age is just a number: Is frailty being ignored in vascular access planning for dialysis?

Current international guidelines advocate fistula creation as first choice for vascular access in haemodialysis patients, however, there have been suggestions that in certain groups of patients, in particular the elderly, a more tailored approach is needed. The prevalence of more senior individuals receiving renal replacement therapy has increased in recent years and therefore including patient age in decision making regarding choice of vascular access for dialysis has gained more relevance. However, it seems that age is being used as a surrogate for overall clinical condition and it can be proposed that frailty may be a better basis to considering when advising and counselling patients with regard to vascular access for dialysis. Frailty is a clinical condition in which the person is in a vulnerable state with reduced functional capacity and has a higher risk of adverse health outcomes when exposed to stress inducing events. Prevalence of frailty increases with age and has been associated with an increased risk of mortality, hospitalisation, disability and falls. Chronic kidney disease is associated with premature ageing and therefore patients with kidney disease are prone to be frailer irrespective of age and the risk increases further with declining kidney function. Limited data exists on the relationship between frailty and vascular access, but it appears that frailty may have an association with poorer outcomes from vascular access. However, further research is warranted. Due to complexity in decision making in dialysis access, frailty assessment could be a key element in providing patient-centred approach in planning and maintaining vascular access for dialysis

Early cannulation grafts for haemodialysis: An updated systematic review.

PURPOSE Early cannulation grafts are specifically designed for dialysis, whereas standard expanded polytetrafluoroethylene grafts were not. There is developing collective experience and literature available to allow the assessment of outcomes of these early cannulation grafts. The aim of this review was to review the evidence for both short- and long-term outcomes of early cannulation grafts. METHODS Using standardized searches of electronic databases in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses, the primary outcomes for this study were primary and secondary patency rates for early cannulation grafts for dialysis at 12 months and beyond. Secondary outcomes were timing of first cannulation, rates of access thrombosis, steal syndrome, pseudo-aneurysm and infection. RESULTS A total of 19 studies were identified and included. These were divided into different graft types. Flixene™, Avflo™, Acuseal™ and Vectra™ grafts all showed that early cannulation within 72 h is possible. Twelve-month pooled primary and secondary patency rates were 43.3% (95% confidence interval: 31.6-55.4) and 73.4% (95% confidence interval: 63-82.7) for the Flixene graft, 58.2% (95% confidence interval: 48-68.1) and 79.2% (95% confidence interval: 68-88.7) for the Avflo graft, 43.6% (95% confidence interval: 30.7-56.9) and 70.5% (95% confidence interval: 49.7-87.8) for the Acuseal graft and 63.7% (95% confidence interval: 53.4-73.4) and 85.8% (95% confidence interval: 82.9-88.4) for the Vectra graft. Data for outcome beyond 12 months were limited to the more recent studies. CONCLUSION This review confirms that early cannulation is not detrimental on the early outcome of early cannulation graft patencies. It has also shown that both Vectra and Avflo grafts have adequate long-term patencies. The data do not allow specific graft recommendations, as comparative trials would be required

Recipient and allograft survival following donation after circulatory death versus donation after brain death for renal transplantation: A systematic review and meta-analysis.

BACKGROUND-OBJECTIVES Current evidence based on retrospective and prospective studies demonstrates that donation after circulatory death (DCD) grafts are more susceptible to delayed graft function (DGF) than donation after brain death (DBD) grafts. The short- and long-term survival outcomes of the two cohorts are unclear. Therefore, we performed a systematic review and meta-analysis to estimate the patient and allograft survival outcomes for DCD and DBD in renal transplant surgery. METHODS Systematic literature searches were conducted by searching various databases. Fixed and random effects models were used to assess the accumulation of evidence over time. RESULTS The five-year patient survival rate was significantly better in the DBD than in the DCD cohort. Non-significant differences were observed in 1-, 3- and 10-year patient survival and in the 1-, 3-, 5-, and 10-year graft survival rates between the two cohorts. The acute rejection rate was lower in the DCD cohort than in the DBD cohort. Extended criteria of donor status, delayed graft function and primary non-function were significantly higher in the DCD cohort than in the DBD cohort. CONCLUSIONS This study demonstrates that the short- and long-term survival graft and patient benefits are similar between DCD and DBD kidney transplants. Therefore, large, controlled DCD kidney programmes are urgently needed worldwide in order to increase the number of kidney transplants