Risk factors for in-hospital mortality among patients hospitalized with COVID-19 and end-stage kidney disease.

AIMS: The mortality rate for -COVID-19 infection varies significantly depending on age and comorbidities but remains high in hospitalized patients overall. Several retrospective studies have identified patients with end-stage kidney disease (ESKD) to be at increased risk. The objective of this study was to study in-hospital outcomes of ESKD patients at an academic medical center and identify characteristics that place them at a higher risk for in-hospital mortality. MATERIALS AND METHODS: A retrospective chart review was conducted including adult patients (≥ 18 years old) admitted to Loma Linda Medical Center for COVID-19 infection with a previous diagnosis of ESKD. Patients with prior kidney transplants were excluded. The main outcome of this study was the rate of in-hospital mortality. RESULTS: 21 of the 91 patients died with a mortality rate of 23%. Age, D-dimer > 0.4 µg/mL, ejection fraction less than 50%, and ferritin > 300 ng/mL were predictors for mortality in unadjusted univariate analysis. Adjusted multivariable analysis demonstrated that only an ejection fraction of less than 50% was associated with increased mortality risk. CONCLUSION: Cardiovascular disease is the leading cause of mortality for ESKD patients and also places them at increased risk of mortality in the setting of severe COVID-19 infection.

Early Resumption of Peritoneal Dialysis Post Laparoscopic Appendectomy: A Case Report and Literature Review.

Abdominal pain and fever in patients on peritoneal dialysis (PD) raise suspicion of PD-associated peritonitis. However, other causes of peritonitis such as appendicitis should be considered. The laparoscopic approach is the standard of care in many of these situations. This technique allows PD catheter preservation and early resumption of PD. Here, we report a case where PD was resumed successfully 48 hours after laparoscopic appendectomy. A 45-year-old man with end-stage renal disease on chronic PD presented with acute abdominal pain. On examination, the patient was febrile and had lower abdomen tenderness without a rebound. The exit site of the PD catheter was clean. An initial diagnosis of PD-associated peritonitis was made, and an intraperitoneal antibiotic was given. Abdominal computed tomography revealed appendicitis. It was confirmed that the patient had severe nonperforated appendicitis following a laparoscopic appendectomy. The PD catheter was preserved, although the patient reported good residual kidney function; his electrolyte abnormalities with rising creatinine and potassium indicated the need to resume dialysis. Low-volume PD in a strict supine position was resumed 48 hours after surgery. The patient tolerated low-fill PD without any complications. He was discharged home on post-op day 4, and further follow-up revealed no complications. Resuming PD early in patients who go under laparoscopic surgery with low-volume PD is a reasonable option in select cases. Close follow-up from the dialysis team to detect and manage complications is necessary.

Community-level reorganizations following migratory pollinator dynamics along a latitudinal gradient.

Predicting how communities re-arrange in response to changes in species composition remains a key challenge in ecology. Migratory species, which enter and leave communities across latitudinal gradients, offer us a unique opportunity to evaluate community- and species-level responses to a shift in community composition. We focused on a migratory hummingbird and the communities that host it along a latitudinal and species diversity gradient. Our results show higher niche overlap in more diverse communities, allowing resident species to compensate for the loss of the migrant in providing pollination services. Contrastingly, in less diverse communities, the migrant behaves as a specialist, monopolizing abundant resources. In its absence, its role is not fully covered by resident species, resulting in a decrease in the fruit set of the migrant's preferred plant species. These results help us understand the potential impacts of biodiversity loss and have important implications for community persistence given expected changes in the migratory behaviours of some species.

Contrasting PTH Response of Denosumab Use in Dialysis Patients: A Report of 2 Cases.

A common complication of end-stage renal disease (ESRD) is mineral and bone disorder. Yet, many anti-osteoporotic drugs are contraindicated in ESRD patients. Denosumab, a monoclonal antibody, does not require renal dose adjustment. However, its use is uncertain due to a lack of safety and efficacy of data in this population. Two hemodialysis patient cases of contrasting responses in parathyroid hormone (PTH) after denosumab administration were observed. Patient 1, a 62-years-old male received denosumab 60 mg at Day 0. His calcium decreased from 8.8 mg/dL to 6.8 mg/dL on Day 30. The PTH level increased from 265 pg/mL to 372 pg/mL after 30 days. Calcium and PTH levels approached normal range after increasing doses of vitamin D/calcium supplements, and calcitriol. Patient 2, a 72-years-old male on hemodialysis also received denosumab 60 mg on Day 0. His baseline calcium and PTH were 9.2 mg/dL and 420 pg/mL, respectively. On Day 30, his calcium level decreased (6.8 mg/dL) but, PTH level drastically increased (>5,000 pg/mL). Denosumab commonly causes hypocalcemia and hyperparathyroidism since it inhibits osteoclast activation, reduces calcium release from bone and increases PTH levels as a compensatory mechanism. With a wait-and-watch approach, Patient 2's levels approached the normal range (calcium 9.6 mg/dL and PTH 274 pg/mL at Day 90).

Drug Dosing Considerations in Critically Ill Patients Receiving Continuous Renal Replacement Therapy.

Acute kidney injury is very common in critically ill patients requiring renal replacement therapy. Despite the advancement in medicine, the mortality rate from septic shock can be as high as 60%. This manuscript describes drug-dosing considerations and challenges for clinicians. For instance, drugs' pharmacokinetic changes (e.g., decreased protein binding and increased volume of distribution) and drug property changes in critical illness affecting solute or drug clearance during renal replacement therapy. Moreover, different types of renal replacement therapy (intermittent hemodialysis, prolonged intermittent renal replacement therapy or sustained low-efficiency dialysis, and continuous renal replacement therapy) are discussed to describe how to optimize the drug administration strategies. With updated literature, pharmacodynamic targets and empirical dosing recommendations for commonly used antibiotics in critically ill patients receiving continuous renal replacement therapy are outlined. It is vital to utilize local epidemiology and resistance patterns to select appropriate antibiotics to optimize clinical outcomes. Therapeutic drug monitoring should be used, when possible. This review should be used as a guide to develop a patient-specific antibiotic therapy plan.

Temporal dynamics of the hummingbird-plant interaction network of a dry forest in Chamela, Mexico: a 30-year follow-up after two hurricanes.

BACKGROUND: Interactions among species are a driving force of community structure. The species composition of animal-plant interaction networks can be highly dynamic on a temporal scale, even though the general network structure is usually not altered. However, few studies have examined how interaction networks change over long periods of time, particularly after extreme natural events. We analyzed herein the structure of the hummingbird-plant interaction network in a dry forest of Chamela, Mexico, comparing the structure in 1985-1986 with that in 2016-2017 following the passage of two hurricanes (category 2 Jova in 2011 and category 4 Patricia in 2015). METHODS: The fieldwork was carried out in the Chamela-Cuixmala Biosphere Reserve in Jalisco, Mexico. In the last 30 years, three severe drought events and two hurricanes have affected this region. Previously, from 1985-1986, hummingbird-plant interactions were recorded monthly for one year in the study area. Then, from 2016-2017, we replicated the sampling in the same localities. We compared the network parameters describing the plant-hummingbird interactions of each period using adjacency matrices. RESULTS: We found differences in the number and identity of interacting species, especially plants. The plant species missing in 2016-2017 were either the least connected in the original network (1985-1986) or belonged to groups such as cacti, epiphytes, or trees. The new plant species incorporated in the 2016-2017 network were herbs, vines, and shrubs, or other species barely connected. These changes in the composition are consistent with reports on vegetation damage after strong hurricanes at other study sites. Conversely, all hummingbird species remained in the network, with the exception of Heliomaster constantii, which was primarily connected to a plant species absent in the 2016-2017 network. Migratory and habitat generalist species (i.e., Archilochus spp.) showed higher abundances following the disturbance events. CONCLUSIONS: Most of the parameters describing the hummingbird-plant network structure remained unchanged after 30 years, with the exception of an increase in plant robustness and hummingbird niche overlap. However, the network's generalist core was affected by the loss of some species. Also, core plant species such as Ipomoea bracteata, Combretum farinosum, and Justicia candicans were found to be important for maintaining the hummingbird-plant interaction network. The temporal perspective of this study provides unique insights into the conservation of plant-hummingbird networks across time and extreme natural events.

The Interdisciplinary Team and the Patient: Working Together to Achieve Buy-In for a UF Rate Less Than 13 mL/Kg/Hr.

The Centers for Medicare & Medicaid Services (CMS) metric for reporting ultrafiltration (UF) recommends limiting UF at a range of 10 to 13 mL/Kg/Hr to avoid organ stunning. All organ stunning has an impact on patient quality of life (QoL). As this new standard of UF is implemented, the interdisciplinary team (IDT) and the patient must work together toward achieving a less than 13 mL/Kg/Hr UF buy-in. Understanding the CMS goals and target date of January 1, 2018, for data collection purposes was key to early initiation of staff and patient education. Dialysis treatment centers must rise to implement mandated fluid removal objectives. Education and knowledge are the best facilitators of success when implementing change. The IDT must work together to continually reinforce the standards set by CMS.

Post-Transplant Diabetes Mellitus After Kidney Transplant in Hispanics and Caucasians Treated with Tacrolimus-Based Immunosuppression.

BACKGROUND Development of post-transplant diabetes mellitus after kidney transplant (PTDM) significantly increases kidney graft loss and mortality. Several risk factors for PTDM have been reported, including Hispanic ethnicity and the use of calcineurin inhibitors and corticosteroids. The incidence and impact of PTDM in the Hispanic kidney transplant population is unknown. MATERIAL AND METHODS We retrospectively reviewed the medical records of 155 Hispanic and 124 Caucasian patients, who were not diabetics and underwent kidney transplant between January 2006 and December 2011. We analyzed their clinical outcomes at 12 months post-transplant, including the incidence of PTDM, acute rejection rates, and patient and graft survival. RESULTS Hispanics who developed PTDM (n=22) were more than 10 years older and had higher body mass index (BMI) than Hispanics without PTDM (p<0.001 and p=0.001, respectively). Caucasians with PTDM (n=13) were non-significantly older (2.5 years) and had higher BMI than Caucasians without PTDM (p=0.526, p=0.043, respectively). The incidence of PTDM was not significantly different between Hispanics and Caucasians treated with tacrolimus-based immunosuppression (14.2% and 10.5%, respectively). CONCLUSIONS PTDM did not cause significant difference in short-term outcomes after kidney transplant in Hispanics or Caucasians. Larger multicenter prospective and long-term clinical trials are needed to validate these findings.

Metastatic pheochromocytoma to liver without elevation of metanephrines and catecholamines.

INTRODUCTION: Malignant pheochromocytoma represents 10% of all patients with pheochromocytoma. Of these cases, only 5-9% presents without elevation of metanephrines and catecholamines. PRESENTATION OF CASE: A 43-year-old female patient presented with an abdominal tumor. An exploratory laparotomy was performed and the final report was a pheochromocytoma. After ten years, multiple liver lesions were detected and surgical treatment was performed. Pathological evaluation revealed a malignant pheochromocytoma with negative margins after 5 years of follow-up without evidence of disease. DISCUSSION: The recurrence rate of malignant pheochromocytoma is 15-20% at ten years and a 5-year survival rate that ranges from 50% to 80%. The presence of synchronous metastases is rare (10-27%), but have been reported until 20 years later with the most common metastatic sites being the local lymph nodes, bone (50%), liver (50%) and lung (30%). The prognostic factor such as size >6cm, age over 45 years, synchronous metastasis and no tumor excision are related with poor prognosis. CONCLUSION: Surgical treatment offers the best survival rate and the only chance of cure so far and the goal is an R0 resection as in our case. So it should be the treatment of choice.

Reproductive ecology and isolation of Psittacanthus calyculatus and P. auriculatus mistletoes (Loranthaceae).

BACKGROUND: Relationships between floral biology and pollinator behavior are important to understanding species diversity of hemiparasitic Psittacanthus mistletoes (c. 120 species). We aimed to investigate trait divergence linked to pollinator attraction and reproductive isolation (RI) in two hummingbird-pollinated and bird-dispersed Psittacanthus species with range overlap. METHODS: We investigated the phylogenetic relationships, floral biology, pollinator assemblages, seed dispersers and host usage, and the breeding system and female reproductive success of two sympatric populations of P. calyculatus and P. auriculatus, and one allopatric population of P. calyculatus. Flowers in sympatry were also reciprocally pollinated to assess a post-mating component of RI. RESULTS: Hummingbird assemblages differed between calyculatus populations, while allopatric plants of calyculatus opened more but smaller flowers with longer lifespans and produced less nectar than those in sympatry. Bayesian-based phylogenetic analysis indicated monophyly for calyculatus populations (i.e. both populations belong to the same species). In sympatry, calyculatus plants opened more and larger flowers with longer lifespans and produced same nectar volume than those of auriculatus; populations shared pollinators but seed dispersers and host usage differed between species. Nectar standing crops differed between sympatric populations, with lower visitation in calyculatus. Hand pollination experiments indicated a predominant outcrossing breeding system, with fruit set after interspecific pollination two times higher from calyculatus to auriculatus than in the opposite direction. CONCLUSIONS: Given the low genetic differentiation between calyculatus populations, observed trait divergence could have resulted from changes regarding the local communities of pollinators and, therefore, expected divergence for peripheral, allopatric populations. Using RI estimates, there were fewer heterospecific matings than expected by chance in P. calyculatus (RI4A = 0.629) as compared to P. auriculatus (RI4A = 0.20). When considering other factors of ecological isolation that affect co-occurrence, the RI4C values indicate that isolation by hummingbird pollinators was less effective (0.20) than isolation by host tree species and seed dispersers (0.80 and 0.60, respectively), suggesting that host usage is the most important ecological isolation factor between the two species. Accordingly, the absolute and relative cumulative strength values indicated that the host tree species' barrier is currently contributing the most to maintaining these species in sympatry.

Abdominal mysteries: pain, peritonitis, pancreatitis, pseudocyst.

The differential etiology of abdominal pain in patients on peritoneal dialysis (PD) is broad, and these patients may experience the same symptoms as those of the general population. This article provides an overview of the various types of abdominal pain in patients on PD, as well as their possible etiologies, symptoms, and treatment regimens.