Clinical presentation, treatment and outcome of focal segmental glomerulosclerosis in Far North Queensland Australian adults.

AIM: The aim is to describe the clinical features, treatment and outcomes in Australian adults with focal segmental glomerulosclerosis and identify predictors of disease progression and all-cause mortality. METHODS: The study included all patients with biopsy confirmed focal segmental glomerulosclerosis between January 1997 and June 2014 at participating hospitals. Clinical factors, histopathological findings, biochemical markers and treatments were analysed and potential predictors of doubling serum creatinine, end stage kidney disease or death identified. RESULTS: A total of 98 patients were included with a median follow up of 4.3 years. Thirty-four (35%) patients were Aboriginal or Torres Strait Islander. Focal segmental glomerulosclerosis not-otherwise-specified was the most common variant. Seventeen (59%) patients initially treated with immunosuppression experienced an improvement in renal function. At the end of follow up, 43 (44%) patients had progressed to the composite outcome. Baseline tubulointerstitial scarring and lower haemoglobin predicted shorter time to doubling serum creatinine. Dual diagnosis, higher serum creatinine, lower estimated glomerular filtration rate and doubling creatinine were associated with shorter time to end stage kidney disease with remission the only protective factor. Age was the only variable associated with all-cause mortality. CONCLUSION: Focal segmental glomerulosclerosis holds serious implications for patients. Concomitant diabetic nephropathy, higher serum creatinine and lower estimated glomerular filtration rate at renal biopsy were associated with poorer renal prognosis. Indigenous people had a female predominance and are over-represented in relation to their population size, however, were not associated with poorer prognosis. Remission was the only modifiable variable and thus should be at the forefront of patient management goals and future studies.

Endovascular Stent Placement for Hemodialysis Arteriovenous Access Stenosis.

This study aims to report the outcomes of nitinol and polytetrafluoroethylene covered stent placement to treat hemodialysis arteriovenous access stenosis at a single center over a five-year period. Clinical and radiological information was reviewed retrospectively. Poststent primary and secondary patency rates were determined using Kaplan-Meier analysis. Ten clinical variables were subjected to multivariate Cox regression analysis to determine predictors of patency after stent placement. During the study period 60 stents were deployed in 45 patients, with a mean follow-up of 24.5 months. The clinical and anatomical success rate was 98.3% (59/60). Poststent primary patency rates at 6, 12, and 24 months were 64%, 46%, and 35%, respectively. Poststent secondary patency rates at 6, 12, and 24 months were 95%, 89%, and 85%, respectively. Stent placement for upper arm lesions and in access less than 12 months of age was associated with reduced primary patency (adjusted hazards ratio [HR] 5.1, p = 0.0084, and HR 3.5, p = 0.0029, resp.). Resistant or recurrent stenosis can be successfully treated by endovascular stent placement with durable long-term patency, although multiple procedures are often required. Stent placement for upper arm lesions and in arteriovenous access less than 12 months of age was associated with increased risk of patency loss.

Factors associated with patency following angioplasty of hemodialysis fistulae.

PURPOSE: Patency after percutaneous transluminal angioplasty of native hemodialysis arteriovenous fistulae (AVFs) is highly variable. This study aimed to identify predictors of patency following angioplasty in native AVFs. MATERIALS AND METHODS: All endovascular procedures performed in native AVFs between 2005 and 2013 at two institutions were retrospectively reviewed. Clinical, anatomic, biochemical, and medication variables were subjected to univariate and multivariate Cox regression analysis to identify predictors of postintervention primary and secondary patency. RESULTS: During the study period, 207 patients underwent first angioplasty of their AVF. Follow-up ranged from 14 days to 8 years, during which another 247 endovascular interventions were performed to maintain patency. Postintervention primary patency rates at 6, 12, and 24 months were 66%, 49%, and 29%, respectively. Postintervention secondary patency rates at 6, 12, and 24 months were 94%, 84%, and 79%, respectively. On multivariate adjusted Cox regression analysis, upper-arm AVFs (P = .00072), AVFs less than 6 months of age (P = .0014), presence of multiple stenoses (P = .019), and degree of initial stenosis (P = .016) were significantly associated with shorter postintervention primary patency. A previously failed AVF was the only significant predictor of postintervention secondary patency loss (P = .0053). CONCLUSIONS: Anatomic factors related to the AVF location, AVF age, and the extent of the lesion are important predictors of restenosis after balloon angioplasty. Traditional cardiovascular risk factors, metabolic and inflammatory markers, and medications were not associated with postintervention patency.

Predictors of patency after balloon angioplasty in hemodialysis fistulas: a systematic review.

Percutaneous transluminal angioplasty (PTA) is an established treatment for dysfunctional hemodialysis fistulas. This article systematically reviews evidence for predictors of patency after PTA. Outcomes assessed were primary, assisted primary, and secondary patency after intervention, and findings were summarized descriptively. This review included 11 nonrandomized observational studies of 965 fistulas in 939 patients. Follow-up ranged from 0 days to 10 years. Study quality was overall suboptimal. Newer fistulas and longer lesion length may be associated with primary patency loss after PTA. Further studies are needed to confirm these findings, to identify potentially modifiable factors, and to guide the testing of new endovascular devices.

Non-candidal fungal peritonitis in Far North Queensland: a case series.

BACKGROUND: Fungal peritonitis is a recognized complication in patients with end-stage renal failure treated with peritoneal dialysis (PD). Most infections are attributable to Candida species. In approximately one third of cases, the causative fungus is a non-Candida species. Recent reports in the literature show a rising incidence of non-candidal fungal peritonitis (NCFP). We report a case series of NCFP, together with two hitherto unreported species of fungi causing peritonitis, from a tropical geographic area (Far North Queensland). METHODS: This series of 10 cases of NCFP was identified from the PD peritonitis database in Far North Queensland between 1998 and 2010. All 10 patients were from the Aboriginal and Torres Strait Islander ethnic group, 8 of whom lived in remote locations. All but 1 patient had type 2 diabetes mellitus. Of the 10 cases, 7 occurred while the patients received continuous ambulatory PD. Only 1 patient avoided catheter removal, and 5 patients were permanently transferred to hemodialysis. No patient died as a result of the fungal infection. All 10 fungi represented different species. Most (6 of 10) were saprophytic; only 2 were normal skin flora. Two of the causative species (Chaetomium and Beauveria) have rarely been associated with any form of human infection. In 7 patients, the infection occurred during the wet season (November - April). All cases met clinical criteria for peritonitis. DISCUSSION AND CONCLUSIONS: The NCFP cases described in this series involved a variety of previously known fungal species and also two new species that have not been reported to cause disease in humans. Indigenous patients from Far North Queensland are particularly predisposed to infection with these exotic fungi as a result of environmental and social factors. Further understanding is desirable to help devise preventive strategies to avoid the consequences of catheter failure.