Dermatological Conditions Seen in Kidney Transplant Recipients: Prevalence and Risk Factors.

OBJECTIVES: In kidney transplant, the use of immunosuppressive drugs, indispensable to avoid organ rejection, implies an increased risk of several infectious and neoplastic diseases. Cutaneous infections have a high incidence in kidney transplant recipients and are diagnosed in 55% to 97% of these patients. The objectives of this study were to identify the most frequent skin diseases and their clinical risk factors within a population of kidney transplant recipients. MATERIALS AND METHODS: We reviewed the medical records of 200 kidney transplant recipients at Sahloul Teaching Hospital, Tunisia, between November 2007 and January 2018. We analyzed the clinical data of patients who sought skin consultations with either dermatologists or plastic surgeons within the hospital. We collected patient sociodemographic data, type of donor, and type of immunosuppressive therapy used by recipients. We also obtained history of skin lesions and examination findings. RESULTS: Among 200 patients included in our study cohort, 131 were male and 69 were female. Age ranged from 6 to 75 years with a mean age of 30.51 ± 12 years. Patients had received kidneys from either living or deceased donors, with available data indicating 96.5% living donors and 3.5% deceased donors. The mean time interval from transplant to first skin consultation was 31 month (range, 3 months to 10 years). Prevalence of various skin conditions was 48.5%. We found that 62.9% of cases were skin infections, 59.8% were drug-induced skin conditions, and 2.9% were skin cancers. The estimated risk factors for skin lesions include use of cyclosporin and duration of immunosuppression. CONCLUSIONS: Our study demonstrated the spectrum of skin conditions that can be expected after kidney transplant. Careful dermatological screening and long-term follow-up are needed for these patients to reduce posttransplant skin complications.

Nephrotic syndrome with Minimal Change Disease and Atopy in NorthAfrican adults.

INTRODUCTION: In adults, minimal change disease (MCD) accounts for 15 to 25% of nephrotic syndrome (NS). Numerous reports have suggested a link between NS and atopy. However, data on treatment and prognosis of NS associated with allergy are limited. AIM: To examine the presenting characteristics, treatments and outcomes of adults with allergic MCD in a North African center. METHODS: This was an observational study using retrospectively collected data. Patients were recruited from the Nephrology department of Sahloul Hospital (Sousse, Tunisia) from January 2006 to December 2020. Adults with a biopsy proved MCD, which was associated with atopy, were included. RESULTS: Fifteen patients (eight males, age mean±SD: 34±13 years) were included. High eosinophil and immunoglobulin E (IgE) levels were noted in three and twelve patients respectively. The IgE mean level at the initial presentation was 1431 IU/ml. Allergic skin tests were positive in nine patients. All patients were treated with corticosteroids, five had anti-histamine therapy and five had hyposensitization therapy, which was successful in two patients. Thirteen patients had relapsed during follow-up. Mean eosinophil level was significantly higher in patients with frequent relapses compared to those with infrequent relapses (5415/mm³ vs. 239.12/mm³, respectively, p=0.022). Two patients had progressed to chronic renal failure. CONCLUSION: It is important to search for atopic disorders in patients with MCD to better control this disease and use specific treatments. However, the efficacy of anti-allergic therapies has to be proven.

Sarcoid-Like Reaction in the Kidney Following Rituximab for Mantle Lymphoma in a 60-Year-Old Man.

The sarcoid-like reaction is a rare autoinflammatory disease that can affect lymph nodes or organs but does not meet the diagnostic criteria for systemic sarcoidosis. Several drug classes have been associated with the development of a systemic sarcoid-like reaction, which defines drug-induced sarcoidosis-like reactions and can affect a single organ. Anti-CD20 antibodies (rituximab) have rarely been reported as responsible for this reaction and this adverse effect has mainly been described during the treatment of Hodgkin's lymphoma. We report a unique case of a sarcoid-like reaction complicating rituximab following the treatment of a mantle cell lymphoma and interesting only the kidney. The 60-year-old patient presented with severe acute renal failure 6 months after the end of his r-CHOP protocol and the urgent renal biopsy revealed acute interstitial nephritis rich in granulomas without caseous necrosis. After ruling out other causes of granulomatous nephritis, a sarcoid-like reaction was retained since infiltration was limited to the kidney. The temporal relationship between rituximab administration and the sarcoid-like reaction onset in our patient supported the diagnosis of a rituximab-induced sarcoidosis-like reaction. Oral corticosteroid treatment led to rapid and lasting improvement in renal function. Clinicians should be warned of this adverse effect and regular and prolonged monitoring of renal function should be recommended during the follow-up of patients after the end of treatment with rituximab.

Thrombotic microangiopathy due to acquired complement factor I deficiency in a male receiving interferon-beta treatment for multiple sclerosis.

AIMS: Interferon-beta (IFNß), the most widely prescribed medication for multiple sclerosis, is generally considered safe. Nevertheless, rare serious and/or life-threatening side effects have been reported such as thrombotic microangiopathy. A few mechanisms have been proposed to explain how interferon causes thrombotic microangiopathy, but immunological studies have been unable to pin this phenomenon down to a single pathophysiologic pathway. The aim of this article was to report a new mechanism explaining Interferon beta related thrombotic microangiopathy. METHODS: We report thrombotic microangiopathy in a 28-year-old male receiving interferon-beta treatment for multiple sclerosis. RESULTS: After three years of starting interferon beta therapy, the patient presented with malignant hypertension causing seizures, rapidly progressive renal failure requiring haemodialysis and haemolytic anaemia. Corticosteroid and plasma exchange sessions permitted haemolysis control. Nonetheless, the patient remained hemodialysis-dependent. Exploration of the complement system found a complement factor I deficiency whose activity normalized at the control carried out after 2 years. CONCLUSION: IFNß treatment may cause complement factor I deficit, which can lead to thrombotic microangiopathy and severe renal failure.

Severe Acute Interstitial Nephritis, Dermatitis, and Hemolytic Anemia due to Polyparasitic Infection in an Immunocompetent Male Patient.

Acute interstitial nephritis (AIN) is a relevant cause of acute renal failure. Drugs are the predominant cause, followed by infections and idiopathic lesions. AIN, as a form of hypersensitivity reaction, is an uncommon manifestation in the setting of human parasitic infections. We report a case of a polyparasitic infection (Giardia lamblia, Entamoeba coli, and Endolimax nana) resulting in a severe biopsy-proven AIN in a 61-year-old male patient. Despite the antiparasitic treatment followed by corticosteroid therapy, and during the 6-month follow-up period, the patient remained dialysis-dependent, and he developed autoimmune hemolytic anemia. Extensive search for another infection or neoplasia was negative. Immunological tests were also negative. The resulting hypersensitivity reaction to the triple parasite infection would have led to fatal evolution for the kidneys affected by this unusual type of AIN.

New-Onset Diabetes as a Complication After Kidney Transplant: Incidence and Outcomes.

OBJECTIVES: Diabetes after kidney transplant is a common complication. It may increase the risk of cardiovascular disease and mortality after kidney transplant. The aim of this study was to examine the effects of diabetes that developed after transplant on outcomes in kidney transplant recipients. MATERIALS AND METHODS: This study included renal allograft recipients without diabetes who received transplants from 2008 to 2019 in our Department of Nephrology at Sahloul Hospital (Tunisia). Demographic and clinical data at transplant time and clinical events during the study period were collected. Patient and graft survival rates were analyzed. Patients with and without diabetes after transplant were compared. RESULTS: In the 257 patients (median age of 36 years) included in our study, the overall incidence of diabetes after transplant was 21.8%. Laboratory data (serum cholesterol, serum creatinine at discharge, and 24-hour proteinuria) were similar in those with and without diabetes after transplant. We observed no significant differences in cardiovascular diseases and infectious complication rates between patients with and without diabetes after transplant. There was also no significant difference in graft loss at 5 years between those with and without diabetes after transplant (P = .582). The 5-year patient survival rate in kidney transplant recipients with diabetes after transplant was 87.5%. There was no significant difference in death rate between those with and without diabetes after transplant (P = .566). CONCLUSIONS: Diabetes after transplant affected graft and patient survival and increased the incidence of posttransplant cardiovascular disease. The incidence and impact of diabetes after transplant can be minimized through pre- and posttransplant screening to identify patients at higher risk.

Acute Kidney Injury due to Povidone-Iodine.

Povidone-iodine is a broad-spectrum antiseptic applied topically to treat wounds and prevent their infection. Despite the apparent innocuousness of this agent, several cases of acute kidney injury (AKI) due to iodine toxicity have been reported. We report a case of severe AKI that occurred in a 32-year-old female three days after a hysteroscopy for the diagnosis of primary sterility using povidone-iodine as the local antiseptic agent. We made a clinical diagnosis of tubular necrosis related to iodine toxicity in view of the clinical presentation and high blood iodine concentration. The patient was treated with hemodialysis until urine output and renal function improved. Physicians must be aware of the possible nephrotoxicity secondary to povidone-iodine use. Patients receiving povidone-iodine, especially those who already suffer from kidney failure, should be closely monitored. The discontinuation of this agent, with the use of hemodialysis, is usually effective.

Long-term clinical outcomes of peritoneal dialysis patients: 10-year experience of a single unit from Tunisia.

Published data on the outcome of maintenance peritoneal dialysis (PD) since the initiation of PD in Tunisia is poor. The purpose of this study is to report long-term clinical outcomes of PD patients through a 10-year experience at a single unit. This is a retrospective review of the medical records of 182 PD patients who were followed up from January 2006 to June 2016. All patients were followed till death, renal transplant, switch over to hemodialysis (HD) or the end of the study in June 2016. The mean age of the incident patients was 43.93 ± 16.95 years. Nineteen (10.4%) were aged >65 years and 59.3% were male. The average duration of follow-up was 27.75 ± 26.18 months. The mean duration of PD treatment was 27.75 ± 26.18 months. There were 186 episodes of peritonitis that occurred over the total study period (54 episodes during the 1st year). The overall incidence of peritonitis during the 10-year study period was 1 per 27.25 patient months. Mechanical complications were noted in 31.2% of cases. Thirty- two (17.6%) patients had catheter displacement. Only 26 cases of hemoperitoneum (14.3%) were recorded. Death occurred in 23.1% of cases. Twenty-two patients (27.5%) were transplanted; 56 patients (70%) were transferred to HD, one patient had renal recovery and one case had voluntarily interrupted PD. In Kaplan-Meier curves of residual renal function (RRF) loss, there was a significant difference between peritonitis group and peritonitis-free group (P = 0.01). Technique and patient survival were associated with diabetes with a significant difference. The main cause of technique failure was peritonitis (61.4%). Moreover, the main repertoried causes of death were cardiovascular and septic causes. The mortality of diabetic and elderly PD patients was higher than mortality in nondiabetic and nonelderly groups, respectively, in our study. Peritonitis was associated with loss of RRF and technique failure.

Pyogenic sacroiliitis and pyomyositis in a patient with systemic lupus erythematous.

Pyogenic sacroiliitis and pyomyositis are uncommon infectious diseases and their diagnoses are often delayed. They are typically seen in children and young adults and are rare in middle-aged people especially in those affected by rheumatic diseases. We present the first case of a Staphylococcus aureus related pyogenic sacroiliitis associated with iliacus and gluteal pyomyositis occurring in a patient with systemic lupus erythematosus. Antibiotic treatment was administered for a total of 6 weeks with a total recovery. Pyogenic sacroiliitis and pyomyositis, although remaining rare events, should be remembered as severe complications in immunosuppressed patients with inflammatory diseases. Early clinical suspicion, imaging diagnosis, and adequate therapy are decisive for the satisfactory outcome.