Substitution of Oral for Intravenous Cyclophosphamide in Membranous Nephropathy.

Background: Optimal immunosuppressive treatment for membranous nephropathy is still a matter of controversy. Current recommendations include oral cyclophosphamide combined with steroids (modified Ponticelli regimen) as first-line treatment in patients who are high risk. However, concerns about the cumulative toxicity of oral cyclophosphamide persist. In the last 30 years, a protocol based on low-dose intravenous cyclophosphamide plus steroids has been used to treat membranous nephropathy in Uruguay. We aimed to assess the efficacy of this regimen to induce clinical remission in patients with membranous nephropathy. Methods: In this retrospective, observational cohort study, we analyzed the outcome of 55 patients with membranous nephropathy treated between 1990 and 2017 with a 6-month course of alternating steroids (months 1, 3, and 5) plus intravenous cyclophosphamide (single dose of 15 mg/kg on the first day of months 2, 4, and 6). Results: At 24 months, 39 (71%) patients achieved clinical response with complete remission observed in 23 patients (42%) and partial remission in 16 (29%). Median time to achieve partial and complete remission was 5.9 and 11.5 months, respectively. Absence of response was observed in 16 patients (29%), five of whom started chronic RRT after a median follow-up of 3.5 years. Clinical relapse occurred in nine of 33 (27%) patients at a median of 34 months after treatment discontinuation. Conclusions: Replacement of oral cyclophosphamide with a single intravenous pulse on months 2, 4, and 6 of the modified Ponticelli regimen can be an effective and safe alternative for treatment of membranous nephropathy. Podcast: This article contains a podcast at https://www.asn-online.org/media/podcast/K360/2020_09_24_KID0002802020.mp3.

Diez años del Registro Uruguayo de Peritonitis en Diálisis Peritoneal / Ten years of the Uruguayan Registry of Peritonitis in Peritoneal Dialysis

La peritonitis es una complicación grave de la diálisis peritoneal (DP), por lo que interesa conocer la incidencia y sensibilidad antibiótica de los gérmenes causantes. En Uruguay, desde el 1° de enero de 2004, se realiza un registro nacional de las peritonitis en DP, gérmenes, sensibilidad y evolución. Método: se analizaron los registros desde el 1° de enero de 2004 al 31 de diciembre de 2013. El registro fue aprobado por comités de ética institucionales. Resultados: en el período se registraron 850 peritonitis, con una incidencia que descendió de 0,49/paciente-año (2004-2005) a 0,37/paciente-año (2013). La incidencia de Staphylococcus aureus y Staphylococcus coagulasa negativo (SCoN) fue menor en 2009-2013 vs 2004-2005 (0,2 vs 0,12 peritonitis/paciente-año, test Poisson p<0,05). En 2009-2013: 14/54 S. aureus y 26/71 SCoN fueron meticilinorresistente, similar al período previo. El 98% de los gérmenes gramnegativos fueron sensibles a amikacina. En 145/467 (31%) episodios no se identificó germen. Se logró cura primaria en 71% de las peritonitis por grampositivos y en 45% por gramnegativos (chi2 p<0,05). En 2013 se observó mayor incidencia de peritonitis en los centros en los que no se controló el estado de portador nasal. Comentarios y conclusiones: se justifica implementar el control de portador de Staphylococcus aureus. La incidencia de peritonitis por S. aureus y SCoN meticilinorresistentes, la incidencia sostenida de gérmenes gramnegativos (con peor evolución), y el elevado porcentaje de cultivos sin desarrollo justifica mantener el protocolo antibiótico empírico inicial con vancomicina y amikacina. El descenso de la incidencia de S. aureus + SCoN podría ser atribuido a una mejor educación de los pacientes en DP.

Abstract Peritonitis is a severe complication of peritoneal dialysis (PD), so it is important to learn about the incidence and antibiotic sensitivity of the germs that cause it. In Uruguay, since January 1, 2004, a national record is kept for peritonitis in PD, germs, sensitivity and evolution. Method: the records from January 1, 2004 through December 31, 2013 were analyzed. The registry was approved by institutional ethical committes. Results: during the above mentioned period, 850 cases of peritonitis were recorded, and incidence dropped from 0.49/patient-year (2004-2005) to 0.37/patient-year (2013). Incidence of Staphylococcus aureus and coagulase-negative staphylococci (SCoN) was lower in 2009-2013 vs 2004-2005 (0.2 vs 0.12 peritonitis/patient-year, test Poisson p<0.05). In 2009-2013: 14/54 S. aureus and 26/71 SCoN were methicillin-resistant, similar to the previous period. 98% of Gram-negative were sensitive to amikacin. No germ was identified in 145/467 (31%) of episodes. Primary cure was achieved in 71% of peritonitis for Gram-positive and 45% for Gram-negative bacteria (chi2 p<0.05). In 2013 a greater incidence of peritonitis was observed in those centers where the nasal carriage was not controlled. Comments and conclusions: controlling Staphylococcus aureus nasal carriages is worth doing. The incidence of peritonitis by methicillin-resistant S. aureus y SCoN, the sustained incidence of Gram-negative germs (with a worse evolution), and the high percentage of cultures with no development justify keeping the initial empirical antibiotic protocol with vancomycin and amikacin. Reduction in the incidence of S. aureus + SCoN could be explained by a greater education in PD patients.

Resumo A peritonite é uma complicação grave da diálise peritoneal (DP), sendo, portanto, importante conhecer a incidência e a sensibilidade antibiótica dos gérmens causadores. No Uruguai, desde 1 de janeiro de 2004, realiza-se um registro nacional das peritonites em DP, com dados sobre gérmens, sensibilidade e evolução. Método: foram analisados os registros do período 1 de janeiro de 2004 - 31 de dezembro de 2013. O registro foi aprovado pelos comitês de ética das instituições envolvidas. Resultados: foram registradas 850 peritonites no período estudado; a incidência diminuiu de 0,49/paciente-ano no período 2004-2005 a 0,37/paciente-ano em 2013. A incidência de Staphylococcus aureus e Staphylococcus coagulase negativo (SCoN) foi menor no período 2009-2013 comparada com 2004-2005 (0,2 vs 0,12 peritonite/paciente-ano, teste de Poisson p<0,05). No período 2009-2013: 14/54 S. aureus e 26/71 SCoN foram resistentes à meticilina, similar ao período prévio. 98% dos gérmens gramnegativos eram sensíveis a amicacina. Não se pode identificar o gérmen em 145/467 (31%) episódios. Em 71% das peritonites por grampositivos e em 5% por gramnegativos (chi2 p<0,05) foi possível obter cura primária. Em 2013 foi observada uma maior incidência de peritonite nos centros em que não se realizava controle de portador nasal. Comentários e conclusões: justifica-se a realização de controle de portador de Staphylococcus aureus. A incidência de peritonite por S. aureus e SCoN resistentes à meticilina, a incidência constante de gérmens gramnegativos (com pior evolução), e a alta porcentagem de cultivos sem crescimento justificam manter o protocolo antibiótico empírico inicial com vancomicina e amicacina. A redução da incidência de S. aureus + SCoN poderia ser atribuída a melhor educação dos pacientes em DP.

The Latin American Dialysis and Transplant Registry: report 2006.

The Latin American Dialysis and Transplant Registry collects information on end-stage renal disease and its treatment in 20 countries of the region. By December 2005, a total of 257,974 patients were on renal replacement therapy, for a prevalence of 478.2 cases per million population; 57% were on hemodialysis, 23% on peritoneal dialysis, and 20% had a functioning kidney graft. The prevalence on renal replacement therapy continued to grow at a rate of approximately 6% annually. Hemodialysis continued to be the treatment of choice in the region, except for in Mexico, Nicaragua, El Salvador, the Dominican Republic, and Guatemala, where peritoneal dialysis predominated. Diabetes remained the leading cause of end-stage renal disease, and the highest incidences were reported in Puerto Rico (65%), Mexico (51%), Venezuela (42%), and Colombia (35%). Forty-four percent of incident patients were aged > 65 years. The rate of transplantation remained unchanged at 15 per million population, which is not sufficient to satisfy the demand of the growing number of patients in the waiting list. Close to 50% of transplants came from cadaver donors. A total of 137 simultaneous kidney-pancreas transplants were performed, 123 in Brazil, 6 in Argentina, 3 in Uruguay, 2 each in Colombia and Mexico, and 1 in Chile. In addition, 1 cardiorenal transplant (Argentina) and 1 liver-renal transplant (Chile) were reported. In conclusion, the incidence and prevalence of renal replacement therapy continued to grow. Prevention of chronic kidney disease and an integrated approach of affordable dialysis and transplantation are urgently needed in the region.