Bilateral Renal Infarct in a Young Adult: Unveiling an Autoimmune Enigma.

A man in his late 20s presented to the emergency department with sudden-onset abdominal pain. Urinalysis was significant for hematuria and slightly elevated creatinine. A computed tomography (CT) scan with IV contrast revealed bilateral renal infarcts, which was corroborated by a computed tomography angiogram (CTA). Further evaluation by an autoimmune panel demonstrated a positive antinuclear antibody, while echocardiography showed left ventricular non-compaction cardiomyopathy. The workup included consultations with multiple specialities and additional investigations to assess hypercoagulability, vasculitis, and infectious etiologies. Following supportive care, the patient was discharged in stable condition with a plan for outpatient follow-up and further workup, including screening of first-degree family members for left ventricular non-compaction and associated cardiovascular risks. Here we describe a report of a rare case of bilateral renal infarct of possible thromboembolic etiology due to an underlying rare genetic cardiovascular condition.

Independent Predictors and Causes of Thirty-Day Gastrointestinal Readmissions Following COVID-19-Related Hospitalizations: Analysis of the National Readmission Database.

Background: The coronavirus disease 2019 (COVID-19) pandemic led to significant mortality and morbidity in the United States. The burden of COVID-19 was not limited to the respiratory tract alone but had significant extrapulmonary manifestations. We decided to examine the causes, predictors, and outcomes of gastrointestinal (GI)-related causes of 30-day readmission following index COVID-19 hospitalization. Methods: We used the National Readmission Database (NRD) from 2020 to identify hospitalizations among adults with principal diagnosis of COVID-19. We identified GI-related hospitalizations within 30 days of index admission after excluding elective and traumatic admissions. We identified the top causes of GI-related readmission, and the outcomes of these hospitalizations. We used a multivariate Cox regression analysis to identify the independent predictors of readmission. Results: Among 1,024,492 index hospitalizations with a primary diagnosis of COVID-19 in the 2020 NRD database, 644,903 were included in the 30-day readmission study. Of these 3,276 (0.5%) were readmitted in 30 days due to primary GI causes. The top five causes of readmissions we identified in this study were GI bleeding, intestinal obstruction, acute diverticulitis, acute pancreatitis, and acute cholecystitis. Multivariate Cox regression analysis done adjusting for confounders showed that renal failure, alcohol abuse, and peptic ulcer disease were associated with increased odds of 30-day readmission from GI-related causes. Conclusions: GI manifestations of COVID-19 are not uncommon and remain an important cause of readmission. Targeted interventions addressing the modifiable predictors of readmission identified will be beneficial in reducing the burden on already limited healthcare resources.

Overview of pregnancy in solid-organ transplantation.

PURPOSE OF REVIEW: Pregnancy in solid organ transplantation (SOT) is a very complex part of transplant medicine wherein there is scarce information available in the literature. Solid organ transplant recipients often have comorbidities, such as hypertension and diabetes, which add additional risk to a pregnancy. RECENT FINDINGS: We present this review article on the various aspects of different types of immunosuppressant medications used in pregnancy with added inputs on contraception and fertility after transplant. We described the antepartum and postpartum considerations and discussed the adverse effects of the immunosuppressive medications. Maternal and fetal complications of each SOT have been also discussed in this article. SUMMARY: This article will serve as the primary review articles for the use of immunosuppressive medications during pregnancy with consideration during pregnancy after SOT.

The Diagnostic Conundrum of Glomerular Crescents With IgA Deposits.

Introduction: Glomerulonephritis (GN) with crescents and IgA deposits in kidney biopsy poses a frequent diagnostic and therapeutic dilemma because of multiple possibilities. Methods: Native kidney biopsies showing glomerular IgA deposition and crescents (excluding lupus nephritis) were identified from our biopsy archives between 2010 and 2021. Detailed clinicopathologic features were assessed. One-year clinical follow-up on a subset of cases was obtained. Results: A total of 285 cases were identified, and these clustered into IgA nephropathy (IgAN, n = 108), Staphylococcus or other infection-associated GN/infection-related GN (SAGN/IRGN, n = 43), and antineutrophil cytoplasmic antibody-associated GN (ANCA-GN, n = 26) based on a constellation of clinicopathologic features, but 101 cases (group X) could not be definitively differentiated. The reasons have been elucidated, most important being atypical combination of clinicopathologic features and lack of definitive evidence of active infection. Follow-up (on 72/101 cases) revealed that clinicians' working diagnosis was IgAN in 43%, SAGN/IRGN in 22%, ANCA-GN in 28%, and others in 7% of the cases, but treatment approach varied from supportive or antibiotics to immunosuppression in each subgroup. Comparing these cases as "received immunosuppression" versus "non-immunosuppression," only 2 features differed, namely C3-dominant staining, and possibility of recent infection (both higher in the no-immunosuppression group) (P < 0.05). Renal loss was higher in the non-immunosuppression subgroup, but not statistically significant (P = 0.11). Conclusion: Diagnostic overlap may remain unresolved in a substantial number of kidney biopsies with glomerular crescents and IgA deposits. A case-by-case approach, appropriate antibiotics if infection is ongoing, and consideration for cautious immunosuppressive treatment for progressive renal dysfunction may be needed for best chance of renal recovery.

A Rare Case of Recurrent Immunotactoid Glomerulonephritis.

Immunotactoid glomerulopathy is an uncommon cause of glomerular disease that results from deposits derived from immunoglobulins. This rare disease can occur in native kidneys and in transplant patients. They are present only in 0.5% to 1.4% of native kidney biopsies. Treatment of this disease is directed at the underlying monoclonal gammopathy, infection, and B-cell lymphoproliferative disorders. Prognosis is very guarded with 50% of people developing ESRD within five years of diagnosis. We present an interesting, rare case of recurrent immunotactoid glomerulonephritis which responded appropriately to rituximab therapy.

A Single-Center Case Series of Successful Abdominal Organ Transplantation From SARS-CoV-2-infected Donors to Uninfected Recipients-Do We Need Rigorous Monitoring?

There is limited documentation of hematogenous transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in non-lung transplants from infected donors to uninfected recipients. Methods: We analyzed 16 recipients (7 liver, 9 kidney) transplanted from SARS-CoV-2 nucleic acid test+ deceased donors from December 25, 2021, to February 28, 2022, who were followed-up for at least 90 d. Primary outcomes included coronavirus disease 2019-positivity, allograft loss, and all-cause mortality. Secondary outcomes included biopsy-proven rejection (BPAR), donor-specific antibodies, delayed graft function, and opportunistic infections. Unlike previous studies, we followed the recipients clinically with the intent to treat if they developed SARS-CoV-2 symptoms. Results: All donors were SARS-CoV-2 polymerase chain reaction-positive 72 h before donation. No recipients developed SARS-CoV-2 infection. The nadir serum creatinine and estimated glomerular filtration rate were 1.33 mg/dL and 64 mL/min/1.732 m2 for kidney transplantation (KTx) respectively. The median alanine transaminase was 14.5 IU/L, aspartate aminotransferase 13 IU/L, and alkaline phosphatase 74 IU/L. Two KTx patients lost allograft, and 1 liver transplantation patient died with a failed allograft. However, this was unrelated to their SARS-CoV-2-positive donor status. One BPAR in the liver transplantation was treated with steroids. No donor-specific antibodies or BPAR were reported in the KTx. Six KTx patients experienced delayed graft function, and 4 are off dialysis. Two KTx patients developed cytomegalovirus infection because of an error in reporting the cytomegalovirus serostatus by the donor center. We did not do serial testing for SARS-CoV-2 by polymerase chain reaction, imaging, or cycle threshold score pre- or posttransplant for donor/recipient and had comparable outcomes with previous studies. Conclusions: Because of the low risk of transmission, serial testing might not be necessary and, thus, could be reciprocated at small-volume transplant centers.

A Case of Bilateral Pneumothorax With COVID-19 Infection.

Bilateral spontaneous pneumothorax is a serious complication of coronavirus disease 2019 (COVID-19). The incidence of any spontaneous pneumothorax in patients with the aforementioned viral infection when hospitalized is about 1%. Treatment can involve management such as oxygen support, tube thoracostomy, pleurodesis, or even invasive surgery. The associated mortality with this complication is about 33% to 52%. We present a case of bilateral pneumothorax in a patient diagnosed with COVID-19 without any history of smoking or underlying lung disease. Careful vigilance and close monitoring of this serious complication are mandatory in inpatients.

Looking Beyond the Allograft Survival: Long-Term, 5-Year Renal Outcome in Lung Transplant Recipients.

With the increased incidence and survival of lung transplant (LTx) recipients, the risk for chronic sequelae such as chronic kidney disease (CKD) is on the rise. Data on the long-term renal outcome are scarce. We performed a retrospective chart review of 171 adults with LTx from January 1, 2014, to January 1, 2019. Primary outcomes were prevalence of CKD/end-stage renal disease, acute kidney injury (AKI) as a risk factor for future CKD, and all-cause mortality in recipients with CKD compared with the non-CKD group. Secondary outcomes were frequency of utilization of modalities for CKD (urinalysis, imaging, biopsy, nephrology consultations). Baseline median creatinine and estimated glomerular filtration rate (eGFR) were 0.8 mg/dL and 90 mL/min/1.73 m2, respectively. Of the participants, 60% (96 of 161), 67% (102 of 153), 79% (37 of 47), 86% (10 of 12) had CKD at the end of 6, 12, 36, and 60 months, respectively, and 16% were on dialysis at the end of the study period; 3% received a subsequent renal transplant, and 27% mortality was noted over a 5-year follow-up period. The odds of CKD development in patients with an AKI during index hospitalization vs no AKI was 6.22 (2.87 to 13.06, P < .0001). The odds ratio of all-cause mortality in patients with CKD compared with non-CKD was 3.36 (95% confidence interval, 1.44-8.64, P = .005). Measurement of hematuria/proteinuria, imaging, and renal biopsy were infrequently used. Given the high prevalence of AKI and CKD in this population, a multidisciplinary team approach with an early nephrology consultation will be key to improve the overall and renal outcomes in LTx recipients.

Can Antinuclear Antibodies (ANA) be Monoclonal?

BACKGROUND: Nuclear staining by immunofluorescence in a kidney biopsy is often seen in patients with positive antinuclear antibodies (ANA) in the serum. These ANA are usually polyclonal, but herein we report 9 cases with an unusual finding of monoclonal nuclear staining by immunofluorescence on kidney biopsy. Case Presentation. Nine cases with predominant stain for kappa or lambda light chain were identified by searching the renal pathology laboratory database for the past 10 years. All cases had positive stain for only kappa (six cases) or lambda (three cases) light chain in the nuclei. Eight out of nine cases had positive nuclear IgG stain, and one case had positive nuclear IgA stain. Among cases with positive nuclear IgG staining, six cases were positive for IgG1 subclass, one case was positive for IgG2 subclass, and one case was positive for IgG3 subclass. All patients with positive IgG nuclear stain, who had testing for ANA, had positive ANA. Patients with positive IgG1 subclass did not have monoclonal protein in the serum or urine, but the patient with positive IgG2 subclass and lambda light chain stain in the nuclei had IgG lambda monoclonal gammopathy. CONCLUSIONS: We identified a new unique pattern of nuclear stain by immunofluorescence in kidney biopsies that suggests the presence of monoclonal ANA. Workup for underlying monoclonal gammopathy is warranted in such patients.

Modification in induction immunosuppression regimens to safely perform kidney transplants amid the COVID-19 pandemic: A single-center retrospective study.

BACKGROUND: The COVID-19 pandemic has negatively impacted organ donation and transplantation across the globe. METHODS: This study analyzed transplant outcomes during the pre-pandemic [PPE, 1/2019-2/2020] and pandemic era [PE, 3/2020-8/2020] based on changes in induction immunosuppression. During PPE, high immunological risk patients received 4-6 mg/kg, moderate risk 2-4 mg/kg, and low risk 1-2 mg/kg of ATG. During PE, ATG doses were reduced to 3-4 mg/kg for high risk, 1-2 mg/kg for moderate, and low changed to basiliximab. Primary outcomes are as follows: biopsy-proven rejection [BPAR], de-novo donor-specific antibody [DSA], delayed graft function [DGF], infection rates, graft loss, and all-cause of mortality. RESULTS: During PPE, 224 kidney transplants [KTx] and 14 kidney/pancreas transplants [KP] were included, while 180 KTx and 5 KP were included for PE. Basiliximab use increased by 30% in the PE. The odds of DGF were statistically significant between PE vs PPE, OR 1.7 [1.05, 2.8, p-value = .042]. The odds of developing DSAs and BPAR during the PE vs. PPE were 0.34 [0.16, 0.71, p-value = .004] and OR 0.34 (0.1 to 1.1, p-value, .104)], respectively. Cytomegalovirus [19% in PE, 37% in PPE] and BK virus [5.4% PE vs. 16% PPE] incidence reduced during PE vs. PPE. COVID-19, graft loss, and mortality were comparable between groups. CONCLUSION: KTx and KP transplants were performed safely during the COVID-19 pandemic with a reduction of induction immunosuppression.

Impact of Storage Lesion on Post-transfusion Rise in Hemoglobin.

BACKGROUND: The storage lesion is defined as the set of changes that occur in red blood cells (RBCs) during storage. Studies have shown that a prolonged storage period of RBCs is associated with increased destruction after transfusion. The aim of this study is to determine the impact of the storage lesion on the efficacy of RBC transfusions by comparing the mean rise in the hemoglobin of patients who received new vs old blood. METHODS: We did a retrospective chart review of all patients who received a single unit of pure red blood cell (PRBC) transfusion in a three-month period. Patients with hemolytic anemia and active bleeding were excluded. The storage lesion was estimated by calculating the number of days to expiration on the day of transfusion. Median days to expiration was calculated to be 11 days. Patients were divided into two groups based on days to expiration. Group A included patients who received old blood (days to expiration: 0-11) and group B included patients who received new blood (days to expiration: 11-38). The mean rise in hemoglobin between the two groups was compared using the paired t-test. RESULTS: The baseline characteristics of both groups were similar. There was no statistically significant difference in the mean rise in hemoglobin (1.01 vs 1.08- p-value 0.298), hematocrit (3.37 vs 3.61- p-value 0.249), and RBC count (0.42 vs 0.44- p-value 0.097) in the group that received old blood vs new blood, respectively. CONCLUSION: An RBC transfusion with a shorter storage period does not increase hemoglobin more than RBC with a longer storage period.

Severe Symptomatic Hyponatremia Secondary to Escitalopram-Induced SIADH: A Case Report with Literature Review.

Hyponatremia is a well-known medication related side effect of selective serotonin reuptake inhibitors; despite its association with escitalopram, the newest SSRI is very rare. We did a review of literature and came across only 14 reported case of this rare association of SIADH with escitalopram. We hereby report a case of a 93-year-old female who presented with generalized tonic-clonic seizure and was diagnosed with severe hyponatremia due to escitalopram-induced syndrome of inappropriate antidiuretic hormone secretion (SIADH). With this article, we want to emphasize clinicians about this rare side effect of escitalopram use and look for the risk factors leading to SIADH.