ABSTRACT
Introduction: Anti-glomerular basement membrane (anti-GBM) disease is a severe entity with few therapeutic options including plasma exchange and immunosuppressive agents. The aim of this study was to analyze the clinical and pathological features that predict the evolution of end-stage kidney disease (ESKD) and the kidney survival in a cohort of patients with anti-GBM disease with renal involvement in real life. Methods: A retrospective multicentre observational study including 72 patients from 18 nephrology departments with biopsy-proven anti-GBM disease from 1999 to 2019 was performed. Progression to ESKD in relation to clinical and histological variables was evaluated. Results: Creatinine at admission was 8.6 (± 4) mg/dL and 61 patients (84.7%) required dialysis. Sixty-five patients (90.3%) underwent plasma exchange. Twenty-two patients (30.6%) presented pulmonary hemorrhage. Kidney survival was worse in patients with creatinine levels > 4.7 mg/dL (3 vs. 44% p < 0.01) and in patients with > 50% crescents (6 vs. 49%; p = 0.03). Dialysis dependence at admission and creatinine levels > 4.7 mg/dL remained independent significant predictors of ESKD in the multivariable analysis [HR (hazard ratio) 3.13 (1.25-7.84); HR 3 (1.01-9.14); p < 0.01]. The discrimination value for a creatinine level > 4.7 mg/dL and 50.5% crescents had an area under the curve (AUC) of 0.9 (95% CI 0.82-0.97; p < 0.001) and 0.77 (95% CI 0.56-0.98; p = 0.008), respectively. Kidney survival at 1 and 2 years was 13.5 and 11%, respectively. Patient survival at 5 years was 81%. Conclusion: In real life, patients with severe anti-GBM disease (creatinine > 4.7 mg/dL and > 50% crescents) remained with devastating renal prognosis despite plasma exchange and immunosuppressive treatment. New therapies for the treatment of this rare renal disease are urgently needed.
ABSTRACT
INTRODUCTION: Retrospective observational study to evaluate the technique of cannulation guided by ultrasound of the left internal jugular vein (LIJV) using a lateral oblique axis (LOAX) approach with variable angulation in the placement of tunneled central venous catheters (CVC) for hemodialysis. METHODS: Seventy-one patients with 77 LIJV vascular accesses aged 16 or older who needed CVC for hemodialysis were evaluated. The catheters were inserted, guided by LOAX ultrasound with variable angulation, depending on the angulation of the left brachiocephalic trunk. The success rate, additional instrumentation needs, and number of immediate and late complications were analyzed. FINDINGS: Central venous catheters placement was possible in all cases and none of the peelable introducers folded. A placement guide was needed in only eight patients, whose brachiocephalic trunk elongation and angulation was 90°. We found no major complications, and only five cases of minor complications (6.5%): four periprocedural and one displacement of the catheter a week after placement. DISCUSSION: Tunneled CVC percutaneous cannulation in LIJV guided by ultrasound with the LOAX approach with variable angulation provides very good results, allows visualization of the needle and the vascular structures at the same time, and reduces the number of manoeuvers required for placement and complications that might arise.
Subject(s)
Catheterization, Central Venous/methods , Jugular Veins/diagnostic imaging , Ultrasonography, Interventional/methods , Adult , Aged , Aged, 80 and over , Female , Humans , Male , Middle Aged , Retrospective StudiesABSTRACT
A minor graft and patient survival are described in renal transplant recipients with hepatitis C virus (HCV) and human immunodeficiency virus (HIV) coinfection than in recipients infected with only HIV. The high efficacy of direct-acting antivirals could improve the results. The experience reported in renal transplant recipients with coinfection is very limited. MATERIAL AND METHODS: We analyzed the evolution of renal recipients with HIV-HCV coinfection treated with direct-acting antivirals in our center. Clinical, analytical, and microbiological variables were collected before and after treatment. RESULTS: From 2001 to 2018 we performed 11 renal transplants in patients with HIV infection, and 6 (54.5%) had HIV-HCV coinfection. One patient lost the graft before the development of direct-acting antivirals. Another patient with functioning graft has refused to receive any treatment. Four patients have been treated with direct-acting antivirals. One was treated 18 months before the transplant; 3 received treatment after transplant. All received sofosbuvir-based therapies. All had a sustained virologic response after 12 weeks and an improvement of liver function. In the patients treated after renal transplant, time post transplant at the beginning of treatment was 99.6 (SD, 22.8) months, and follow-up after treatment in all patients was 40.2 (SD, 8.16) months. To modify immunosuppressive regimen was not necessary, although 2 patients required an increase of tacrolimus doses. We do not observe deterioration of renal function. All have maintained a good immunologic and microbiological control without requiring changes in antiretrovirals. We do not observe complications associated with treatment. CONCLUSIONS: Direct-acting antivirals therapy is safe and effective and may offer new possibilities to patients with HIV-HCV coinfection.
