COVID-19 vaccine uptake rates, perceptions, and attitudes among dialysis patients: Experience across a national sample.

INTRODUCTION: Dialysis patients are at increased risk of severe COVID-19 infection making vaccination a priority. We explored COVID-19 vaccine uptake and perceptions in our dialysis population, associated COVID-19 infection, and hospitalization rates. METHODS: This is a single-center retrospective study using telephone questionnaires and hospital records to investigate COVID-19 vaccine uptake and attitudes behind vaccination status. RESULTS: A total of 230 patients were interviewed. Vaccine uptake was 97.8% (two doses) and 86.6% (booster dose), with 79.5% vaccinated at Renal Unit. Most (58.5%) cited healthcare worker advice as a contributing factor and 54% sought protection through vaccination. COVID-19 hospitalization was higher in unvaccinated and patients vaccinated with one dose, compared to two doses (63.2% vs. 20%, p = 0.05) and booster dose (63.2% vs. 22.2%, p = 0.02). CONCLUSION: Our dialysis population recognized the importance of COVID-19 vaccination. Intensive patient education and easy access to the COVID-19 vaccine may have facilitated vaccine uptake in these patients.

Treatment of renal AA-Amyloidosis associated with human immunodeficiency virus infection: a case report.

We present a case of a young adult male who was treated successfully for renal AA-amyloidosis secondary to human immunodeficiency virus (HIV) infection using highly active anti-retroviral therapy (HAART). He presented with lobar pneumonia, acute kidney injury, nephrotic syndrome and newly diagnosed HIV infection and was initiated on HARRT and haemodialysis. Kidney biopsy was consistent with amyloid deposition of the AA-type. His clinical condition improved gradually and after 10 months of therapy, he regained sufficient excretory function to become dialysis independent. Two years later, he remained well, with a recovered CD4 count and a glomerular filtration rate of 63 mL/min/1.73 m2. Patients with renal AA-amyloidosis typically present with slowly progressive chronic kidney disease, often leading to end-stage kidney disease within months. To our knowledge, this is the first reported case of biopsy proven renal AA-amyloidosis in a newly diagnosed HIV positive patient to present with acute kidney injury leading to dialysis dependence over a period of 2 weeks, which was successfully treated using HAART.

Positive Luminex and negative flow cytometry in kidney transplantation: a systematic review and meta-analysis.

The presence of pre-formed donor-specific antibodies (DSAs) in kidney transplantation is associated with worse overall outcomes compared with DSA-negative transplantation. A positive complement-dependant cytotoxic crossmatch presents a high immunological risk, while a negative flow cytometry crossmatch is at the lower end of the risk spectrum. Yet, the presence of low-level DSA detected by Luminex alone, that is, positive Luminex and negative flow (PLNF) cytometry crossmatch lacks robust scientific exploration. In this systematic review and pooled analysis, we investigate the glomerular filtration rate, acute rejection (AR), graft survival and patient survival of PLNF transplants compared with DSA-negative transplants. Our analysis identified seven retrospective studies consisting of 429 PLNF transplants and 10 677 DSA-negative transplants. Pooled analysis identified no significant difference in the incidence of AR at 1 year [relative risk (RR) = 1.35, 95% confidence interval (CI) 0.90-2.02, Z = 1.46, P = 0.14, I2 = 0%], graft failure at 1 year (RR = 1.66, 95% CI 0.94-2.94, Z = 1.75, P = 0.08, I2 = 23%), graft failure at 5 years (RR = 1.29, 95% CI 0.90-1.87, Z = 1.38, P = 0.17, I2 = 0%), patient mortality at 1 year (RR = 0.89, 95% CI 0.31-2.56, Z = 0.22, P = 0.82, I2 = 0%) and patient mortality at 5 years (RR = 1.76, 95% CI 0.48-6.48, Z = 0.85, P = 0.39, I2 = 61%). Pooled analysis of graft function was not possible due to insufficient data. Current evidence suggests that low-level DSA detected by Luminex alone does not pose significant risk at least in the short-medium term. Considering the shortage of kidney transplants and the ever-increasing waiting time, the avoidance of PLNF transplants may be unwarranted especially in patients who have been enlisted for a long time.

The incidence, predictors, and prognosis of acute kidney injury after transcatheter aortic valve implantation
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INTRODUCTION AND AIMS: Transcatheter aortic valve implantation (TAVI) is an alternative procedure for patients with symptomatic aortic stenosis unfit for open heart surgery. Notwithstanding the safer profile, TAVI can still result in serious complications including acute kidney injury (AKI). MATERIALS AND METHODS: We conducted a single-center retrospective study to investigate the incidence of AKI following TAVI, identify any predictors, and assess the impact on patient survival. RESULTS: A total of 104 patients underwent TAVI at a mean age of 76.7 ± 7.2 years. AKI occurred in 35.9% of patients; 26.2% stage 1, 5.8% stage 2, and 3.9% stage 3. These patients had higher incidence of chronic kidney disease (CKD) (37.8 vs. 18.2%; p = 0.035), higher median EuroSCORE-II (4.2, IQR: 5.7 vs. 2.7, IQR: 3.6; p = 0.019), longer hospital stay (6 days, IQR: 7 vs. 5 days, IQR: 3; p = 0.016), and higher all-cause mortality (35.1 vs. 12.1%, p = 0.01) compared to patients without AKI. None of the patient mortality was directly related to the TAVI-AKI event. EuroSCORE-II (OR: 1.19, CI: 1.05 - 1.37, p = 0.009) and CKD (OR: 2.74, CI: 1.10 - 6.82, p = 0.03) were established as independent predictors for AKI. Cumulative survival was lower in patients with AKI (log-rank; χ2 = 6.43, p = 0.011). AKI was established as a hazard for mortality (HR: 2.97, CI: 1.23 - 7.19, p = 0.016). CONCLUSION: More than a third of patients undergoing TAVI developed AKI. These had significantly higher incidence of CKD, higher EuroSCORE-II, higher all-cause mortality, and longer hospital stay. Finally, EuroSCORE-II and CKD were established as independent predictors for AKI and can therefore be used for risk stratification.
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Early urological complications after kidney transplantation: An overview.

Urological complications, especially urine leaks, remain the most common type of surgical complication in the early post-transplant period. Despite major advances in the field of transplantation, a small minority of kidney transplants are still being lost due to urological problems. Many of these complications can be traced back to the time of retrieval and implantation. Serial ultrasound examination of the transplanted graft in the early post-operative period is of key importance for early detection. The prognosis is generally excellent if recognized and managed in a timely fashion. The purpose of this narrative review is to discuss the different presentations, compare various ureterovesical anastomosis techniques and provide a basic overview for the management of post-transplant urological complications.

Basic concepts in kidney transplant immunology.

Advances in the field of immunohistocompatibility and immunogenetics have been crucial for improvements in kidney transplant outcomes. This review provides a practical outline of these important breakthroughs for the general physician, at a time when demand for kidney transplants is increasing.

Outcome of Kidney Transplant in Antineutrophil Cytoplasmic Antibody-Associated Vasculitis.

OBJECTIVES: Kidney transplant outcomes in patients with antineutrophil cytoplasmic antibody-associated vasculitis are comparable with outcomes in patients transplanted for other causes. Here, we report our single center experience of kidney transplant in patients with this condition and a pooled analysis of published studies. MATERIALS AND METHODS: This retrospective study included all patients with end-stage kidney disease secondary to antineutrophil cytoplasmic antibody-associated vasculitis who received a kidney transplant between 1987 and 2013 in the East of Scotland. We examined patient and graft survival and disease recurrence after transplant. We also performed a pooled analysis of published literature. RESULTS: We identified 24 patients who received a total of 31 kidney allografts. Median age at first transplant was 45.5 years (range, 18-68 y), and median follow-up after transplant was 60 months (range, 0.5-226 mo). All patients were positive for antineutrophil cytoplasmic antibody (71% by proteinase 3 and 29% by myeloperoxidase) at diagnosis. Patient survival at 1 and 5 years was 92% and 88%, with corresponding death-censored allograft survival of 93% and 71%. Overall patient and allograft relapse rates were 0.022 and 0.016 relapse/patient-years. The pooled analysis comprised 20 studies (1169 patients). Patient/graft survival ranged from 64% to 80%/77% to 100% at 5 years and from 60% to 100%/59% to 84% at 10 years. Relapse rate was significantly higher in patients with positive antineutrophil cytoplasmic antibody at transplant (14% vs 5%; P = .042). CONCLUSIONS: Our experience shows that kidney transplant remains a safe option for patients with end-stage kidney disease secondary to antineutrophil cytoplasmic antibody-associated vasculitis. Disease relapse posttransplant is uncommon and associated with pretransplant relapse. Pooled analyses suggest that relapse rate is higher in patients with positive antineutrophil cytoplasmic antibody at transplant. Multicenter registry data are needed to define renal outcome predictors in antineutrophil cytoplasmic antibody-associated vasculitis.

Seasonal Variation in the Peritoneal Dialysis-Related Infections: A Single Center Experience in the Mediterranean.

Seasonal variation in the incidence of peritoneal dialysis-related infections (PDRI) has been sparingly investigated, especially in the Mediterranean. Our aim was to explore this association in Malta. All PDRI occurring between Jan-2008 and Dec-2012 were retrospectively studied.A total of 137 patients were followed-up for a median time of 32.5 months (range: 2-81). During this time, 19% never had PDRI, 11.7% transferred permanently to hemodialysis and 6.6% received a kidney transplant. A total of 279 PDRI were identified, equating to 145 catheter-related infections (CRI) and 144 peritonitis episodes (including 10 catheter related peritonitis). A spring peak in the overall gram positive PDRI (0.61 vs. 0.34/patient-year-at-risk, P=0.05), together with a peak in gram negative peritonitis in the warm period (0.13 vs. 0.07/patient-year at risk, P=0.04) was identified. The incidence rate ratios (Confidence Interval) involving the overall gram positive PDRI, gram positive peritonitis, coagulase-negative Streptococci (CoNS) and Streptococci were 1.82 (1.18-2.82, P=0.007), 2.20 (1.16-4.16, P=0.02), 2.65 (1.17-6.02, P=0.02] and 3.18 (1.03-9.98, P=0.04) in spring when compared to winter. No significant difference in the overall PDRI, peritonitis or CRI rates between seasons or warm/cold period was identified.To our knowledge, this is the first study which examines the effect of seasons on the incidence of PDRI in the Mediterranean basin. Findings suggest that spring confers a higher risk for gram positive PDRIs, gram positive peritonitis, CoNS and Streptococcus, whilst the warm period was associated with a peak in the gram negative peritonitis.

Nephrolithiasis, stone composition, meteorology, and seasons in Malta: Is there any connection?

CONTEXT: The effect of seasons and meteorology on the incidence of nephrolithiasis has been studied in various regions around the globe, but seldom in the Mediterranean. AIMS: This retrospective analysis aims at investigating these putative effects in the Maltese Islands, whose climate is typically Mediterranean, followed by a systematic review of the literature. MATERIALS AND METHODS: Submission rate and chemical composition of all kidney stones after spontaneous passage or surgical removal between January 2009 and December 2011 were analyzed according to seasons and corresponding meteorology. RESULTS: A total of 389 stones were analyzed. A higher stone submission rate was observed in summer compared to winter (31.6% vs. 20.8%, P = 0.0008) and in the warm period compared to the cold period (57.1% vs. 42.9%, P = 0.0001). Significant correlation was established between the monthly number of stones and mean monthly maximum temperature (r = 0.50, P = 0.002), mean monthly temperature (r = 0.49, P = 0.003) and mean monthly Humidex (r = 0.49, P = 0.007). Humidex was found to be an independent predictor for stone submission (ß = 0.49, P = 0.007). The majority of stones contained calcium (83.3%), combined with oxalate (77.6%), phosphate (14.7%), and carbonate (2.8%). Some stones (11.8%) contained a mixture of >1 negatively charged molecules. Urate (11.6%), cysteine (4.6%), and ammonium-magnesium-phosphate (0.5%) constituted the rest. There was no association between chemical composition and seasons. Literature review included 25 articles. Higher ambient temperature and warm seasons were the most commonly encountered risk factors for both presentation and etiology of nephrolithiasis. CONCLUSIONS: A significant positive correlation was noted between ambient temperature and stone submission rate, which was significantly higher during the warm months in Malta.

Induction Immunosuppression in High-risk Kidney Transplant Recipients.

Kidney transplant remains the best type of renal replacement therapy in most patients with end-stage kidney disease, even in those with high immunologic risk. Immunosuppression in these patients is regarded as more complex, owing to the higher risk of both acute and chronic rejection. The advent of induction immunosuppression has resulted in a lower incidence of acute rejection and consequently improved short-term patient and allograft outcomes. Indeed, the use of these agents, especially in high-risk recipients, has become standard of care at most transplant centers. Transplant physicians are constantly faced with the challenge of estimating the recipients' immunologic risk and tailoring their immunosuppression accordingly. This review article aims to provide an up-to-date evaluation of the various studies available, which investigated the use of induction agents in kidney transplant, specifically in high-risk recipients. It evaluates the use of the most frequently used polyclonal antibody (rabbit antithymocyte globulin) versus the less commonly used monoclonal antibody alemtuzumab, superseded agents such as muromonab-CD3, and potentially emerging agents such as rituximab, bortezomib, and eculizumab. With this systematic review, we hope to inform the scientific community and facilitate this controversial decision through the implementation of robust scientific evidence.

Chronic kidney disease referral practices among non-nephrology specialists: A single-centre experience.

BACKGROUND: Early referral of CKD patients to nephrology teams (NT) is vital to identify patients most likely to progress, delay decline of excretory function, and provide planned RRT. Unfortunately, many are still being referred late. METHODS: We conducted a retrospective analysis to investigate referral rates, predictors of non-referral, and performed urine investigations in hospitalised CKD patients. RESULTS: Out of 388 patients studied, 5.6%, 11.4%, and 16.4% in CKD3A, 3B, and 4+5, respectively, were referred to an NT upon discharge (CKD3A vs. CKD4+5, p=0.016). For every additional year of age, the odds of being referred decreased by 5% (OR: 0.95, CI: 0.92-0.98, p=0.003). Patients were more likely to be referred to an NT if they were males (OR: 2.31, CI: 1.09-4.90, p=0.029) and having reached CKD 4+5 (OR: 3.99, CI: 1.58-10.10, p=0.003). Only 28.8%, 43.9%, and 50.7% of patients with CKD3A, 3B, and 4+5 were followed up with urine investigations after discharge (p=0.001). CKD stage 3B (OR: 3.54, CI: 1.23-10.19, p=0.019), CKD stage 4+5 (OR: 6.06, CI: 1.69-21.67, p=0.006), DM (OR: 6.28, CI: 2.38-16.58, p<0.0001), and having been referred to a NT (OR: 20.95, CI: 3.54-123.92, p=0.001) were independent predictors for having urine investigations. CONCLUSION: The highest rate of referral was achieved in males, younger age group, and those who have reached CKD stage 4+5. Urine tests remain largely underutilised and only a minority (16.4%) of patients with an eGFR <30mL/min/1.73m(2) were referred to a NT.

De novo papillary carcinoma in a renal allograft: the pros and cons of immunosuppression.

We present a case of a multifocal kidney transplant renal cell carcinoma in a 35-year-old lady, presenting 16 years after kidney transplantation, diagnosed during investigation of recurrent urinary tract infections. The patient underwent a graft nephrectomy and subsequently maintained on haemodialysis. She remained disease-free after 4 years of surveillance and thus reactivated on the transplant list. This case reinforces the fact that immunosuppressive therapy has made kidney transplantation possible; however, it is accompanied by a higher incidence of malignancy. It also reinforces the importance of lifelong screening of both native and renal transplant grafts.

Pacemaker lead-associated thrombosis in cardiac resynchronisation therapy.

Pacemaker lead-associated thrombosis is a possible complication of any cardiac implantable electronic device. We present a case of a middle-aged woman with a history of ischaemic left ventricular failure, who presented with fever and other non-specific symptoms 4 months after cardiac resynchronisation therapy. A transoesophageal echocardiogram confirmed a vegetation-like structure originating from the pacemaker lead in the right atrium. The patient was treated with intravenous antibiotics followed by open heart surgery in order to remove this mass as well as the pacing device, including all three pacing leads. Histology and culture of the retrieved mass confirmed a sterile thrombus with no features to suggest an infected mass (vegetation). The patient made an uncomplicated recovery and there were no long-term sequelae on follow-up during the 2 years after the event.

Predictors of seasonal influenza vaccination in chronic asthma.

BACKGROUND: Guidelines advise annual influenza vaccination in chronic asthma. The aim of this study was to determine uptake of the influenza vaccine in a group of patients (n = 146) with moderate to severe chronic asthma and establish the main predictors of vaccination. METHOD: Patients attending a hospital asthma clinic were asked to complete a questionnaire in February 2012 (n = 146). These same patients were contacted a year later via telephone (n = 109 responded), and they were asked to complete the same questionnaire. RESULTS: Vaccination rate was 50.3% in winter 2011/12, and 57.8% in 2012/13. Using binary logistic regression, the predictors for vaccination in 2012 were patient advice (Odds ratio [OR] 15.37 p = 0.001), female gender (OR 2.75, p = 0.028), past side effects (OR 0.21, p = 0.001) and comorbidity (OR 0.39, p = 0.013). Stepwise regression resulted in age as predictor (T value = 3.99, p = 0.001). On analyzing the responses from the second questionnaire at one year after attendance to asthma clinic, predictors changed to compliance to medication (OR 9.52, p= 0.001) and previous exacerbations (OR 4.19, p = 0.026). Out of the 56 patients vaccinated in 2011/12, 33 reported asthma exacerbations before 2012, and 29 reported asthma exacerbations after receiving the influenza vaccine. Out of the 46 unvaccinated patients in 2012, 27 had asthma exacerbations before 2012 and 19 patients had exacerbations in 2013. Patients vaccinated in 2011/12 needed 0.59 courses of steroid/patient/year, and 1.23 visits for nebulizer/patient/year while non-vaccinated patients needed 0.18 courses of steroids/patient/year (p = 0.048), and 0.65 visits for nebulized/patient/year (p = 0.012). Patients' subjective statements broadly confirmed the predictors. 16/69 (23.1%) received the vaccine in winter 2012/13 despite reporting previous side effects. CONCLUSIONS: Advice to patient, female gender and patients' age predicted vaccination, while past side effects to the influenza vaccine, and presence of comorbidities predicted non vaccination. Symptomatic asthma patients are more likely to be vaccinated. One year after the first contact, treatment compliance and previous asthma exacerbations gained statistical significance as predictors of vaccination.