Live longer with kidney transplant
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Kidney transplantation provides significant survival benefits compared to dialysis. Patients who receive a kidney transplant from a living or deceased donor can expect the transplanted kidney to function for 8 to 20 years on average, depending on the donor. Those who receive a transplant before starting dialysis live 10 to 15 years longer than if they remained on dialysis. Even older adults between ages 65-75 who receive a transplant gain an average of 4 extra years of life compared to staying on dialysis. Five-year survival rates are also much higher for transplant patients compared to those who remain on dialysis.
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This document discusses loin pain-hematuria syndrome (LPHS), a rare condition characterized by severe flank pain and microscopic or gross hematuria. It provides background on the epidemiology, signs and symptoms, pathophysiology, diagnosis and various treatment approaches for LPHS. Specifically, it summarizes two studies that found that laparoscopic nephrectomy with renal autotransplantation resulted in better pain control and quality of life for LPHS patients. A 14-year study also found the procedure to be safe for survival and renal outcomes, despite postoperative risks. Autotransplantation is recommended for patients with severe pain requiring high doses of analgesics or those for whom extensive nonsurgical therapies failed.
Klotho in kidney Ischemia/Reperfusion Injury and Kidney Transplantation
1) Complement activation downregulates Klotho expression in renal ischemia-reperfusion injury and delayed graft function through NF-kB signaling in tubular epithelial cells.
2) Inhibition of complement with C1 inhibitor preserved Klotho expression in a swine model of renal IRI and suppressed NF-kB activation.
3) Transplant patients with delayed graft function had significantly lower Klotho expression in allograft biopsies and lower serum Klotho levels long-term, indicating Klotho deficiency may contribute to chronic allograft dysfunction.
Bariatric Surgery and Kidney Stones
Bariatric surgery, especially malabsorptive procedures like Roux-en-Y gastric bypass, significantly increases the risk of kidney stones compared to obese controls. The risk is highest with malabsorptive procedures and correlates with the degree of fat malabsorption and enteric hyperoxaluria. However, bariatric surgery does not appear to increase the risk of chronic kidney disease. Further research is still needed to fully understand the mechanisms by which bariatric surgery leads to hyperoxaluria and kidney stone formation.
HIV in Kidney Transplantation
This document summarizes research on kidney transplantation between HIV-positive donors and recipients. A study in South Africa found that outcomes for 27 HIV-positive recipients of kidneys from 15 deceased HIV-positive donors were comparable to recipients of HIV-negative organs over 2-3 years. However, applying this approach in the U.S. may pose challenges due to higher rates of antiretroviral resistance and limited access to dialysis in South Africa altering risk-benefit calculations. While expanding access to transplant, ethics require caution given limited long-term outcomes data from HIV-positive donors.
Rituximab as Induction Immunosuppression in Compatible Kidney Transplantation...
Rituximab as Induction Immunosuppression in Compatible Kidney Transplantation...Wisit Cheungpasitporn
Rituximab as Induction Therapy After Renal Transplantation: A Randomized, Double-Blind, Placebo-Controlled Study of Efficacy and Safety. This study evaluated the efficacy and safety of rituximab (RTX) as induction therapy in renal transplant patients. The study randomized 280 patients to receive either a single dose of RTX or placebo before transplantation. The primary outcome was biopsy-proven acute rejection within 6 months. The results showed no difference in rejection rates between the overall RTX and placebo groups. However, among high-immunological risk patients, RTX showed a trend toward lower rejection rates compared to placebo. Patient and graft survival did not differ between groups afterRenal Function After Off-Pump CABG: Journal Club
Off-pump (OPCAB) and on-pump coronary artery bypass graft (CABG) surgery techniques are compared. A randomized controlled trial found OPCAB reduced acute kidney injury (AKI) risk after surgery, especially in patients with pre-existing chronic kidney disease (CKD). However, long-term kidney function was similar between groups one year later. Larger trials are needed to definitively determine if preventing AKI can preserve long-term kidney function.
Hydration for contrast induced nephropathy
LVEDP-guided hydration reduces the risk of CI-AKI and major adverse events at 6 months compared to standard hydration. In a randomized controlled trial of 350 patients with chronic kidney disease undergoing cardiac catheterization, the incidence of CI-AKI was lower in those receiving LVEDP-guided intravenous fluids (8%) compared to standard hydration (23%). LVEDP-guided hydration also reduced the composite of death, myocardial infarction, or need for renal replacement therapy at 6 months. No safety issues were reported with LVEDP measurement or fluid administration in this trial.
Journal Club: Hepcidin, Vitamin D and Anemia of CKD
Vitamin D plays a role in regulating hepcidin, an iron-regulatory hormone. The study found that vitamin D suppresses hepcidin expression in human cells through direct transcriptional repression. In vitro, vitamin D decreased hepcidin mRNA and increased ferroportin and cathelicidin expression. In healthy volunteers, a single high dose of vitamin D supplementation decreased circulating hepcidin levels over 72 hours. The findings suggest vitamin D may help manage anemia by suppressing hepcidin and improving iron availability; future studies are needed to explore vitamin D's clinical implications for anemia treatment.
Renal Handling of Glucose, organic acid, uric acid and protein
This document summarizes renal handling of various substances including glucose, proteins, amino acids, organic acids, cations, anions, and uric acid. It describes that glucose and amino acids are freely filtered by the kidneys and nearly completely reabsorbed in the proximal tubule via secondary active transport. Proteins and peptides are also reabsorbed, with peptides being degraded into amino acids. Organic acids and cations may be filtered and secreted from the blood into the urine via active transport mechanisms in the proximal tubule. Uric acid is produced from purine metabolism and is primarily excreted by the kidneys within normal limits to avoid precipitation and gout.
Nephrolithiasis (Kidney Stones)
This document discusses nephrolithiasis (kidney stones). It begins with a case of a 78-year-old man who presented with gross hematuria and was found to have a kidney stone. The stone was removed, and analysis showed it was calcium oxalate. The document then reviews epidemiology, natural history, stone formation process, clinical presentation, evaluation, etiologies including calcium, uric acid, struvite and cystine stones, and treatment options including medical management and urological interventions.
Renal handling of water
kidney tubule
Collecting
duct
lumen
Filtrate
300 mOsm
Medullary
interstitial
fluid
Collecting duct cell
Vasa
recta
600 mOsM
600 mOsM
700 mOsM
1. The kidney plays a pivotal role in maintaining water homeostasis by conserving water during deprivation and excreting excess water. This is accomplished through a complex anatomical arrangement of the nephron and renal vasculature.
2. Key elements include a hypertonic medullary interstitium generated by active transport of solutes out of the thick ascending limb of the loop of Henle and collecting
Induction for Transplantation
Induction therapy is used to prevent or delay acute rejection in kidney transplant recipients. Common induction agents include antithymocyte globulin (Thymoglobulin), basiliximab, alemtuzumab, and corticosteroids. Induction agents are either monoclonal antibodies like daclizumab and basiliximab, or polyclonal antibodies like Thymoglobulin. Depleting agents like Thymoglobulin and alemtuzumab cause T-cell depletion, while non-depleting agents do not. High-risk patients may benefit more from depleting induction to improve graft survival. However, depleting agents also carry higher risks of infections and side effects. Current guidelines recommend IL-2 receptor antagonists like basil
Journal Club- Urinary cell mRNA profile and acute cellular rejection
A three-gene urinary cell mRNA signature including CD3ε, IP-10, and 18S rRNA can diagnose and predict acute cellular rejection in kidney transplants. In a study of 485 kidney transplant recipients, urinary mRNA levels distinguished acute cellular rejection from other conditions with 71-79% sensitivity and 72-78% specificity. Elevated signature levels weeks before a biopsy showing rejection indicate potential for preemptive therapy. The signature was also associated with future graft dysfunction. However, the study had limitations including missing biopsy-matched urine samples and small numbers of antibody-mediated rejections.
Lactic Acidosis
Lactic acidosis occurs when there is an imbalance between the production and use of lactic acid in the body. It can be caused by tissue hypoxia (type A) or other non-hypoxic factors like malignancy, liver disease, or drugs (type B). The document discusses the pathophysiology of lactic acidosis including lactate metabolism, cytokine effects, and the Warburg effect seen in cancer. Treatment focuses on resolving the underlying cause, with sodium bicarbonate used cautiously and alternatives like hemodialysis considered to correct acidosis and remove lactate when needed.
Alport syndrome
This document describes a case of a 19-year-old male who presented with proteinuria and microscopic hematuria. Renal biopsy revealed glomerulus and tubules appeared normal on light microscopy but electron microscopy showed glomerular basement membrane lamellation and thinning, consistent with a diagnosis of autosomal dominant Alport syndrome. The patient was prescribed lisinopril and showed stable kidney function on follow up. The background provided on Alport syndrome discusses its inheritance patterns, pathophysiology involving mutations in type IV collagen genes, and clinical features.
Normal Saline is not Normal? ; Chloride liberal vs. Chloride restrictive IV F...
Normal Saline is not Normal? ; Chloride liberal vs. Chloride restrictive IV F...Wisit Cheungpasitporn
Normal Saline is not Normal?
Evidence Based Medicine
Chloride liberal vs. Chloride restrictive IV Fluid
Wisit Cheungpasitporn, MDAutosomal Dominant Polycystic Kidney Disease
Autosomal dominant polycystic kidney disease (ADPKD) is a genetic disorder characterized by multiple bilateral renal cysts that can lead to kidney failure, with mutations in two genes causing cyst formation through disordered polycystin function; it commonly causes hypertension, pain, infection, and kidney failure and can involve the liver and other organs; management focuses on slowing progression through blood pressure control, pain management, and potentially targeting the renin-angiotensin system or mTOR pathway.
Hypercalcemia; How to approach
This document discusses calcium homeostasis and hypercalcemia. It explains that blood calcium levels are tightly regulated by the parathyroid hormone (PTH), vitamin D, gut, bone and kidneys. The main causes of hypercalcemia are primary hyperparathyroidism, malignancy-related hypercalcemia from bone metastases, and hypervitaminosis D from excessive vitamin D intake or production. The document provides details on the pathophysiology, clinical evaluation and management of hypercalcemia.
Thalassemia screening in pregnancy, Quality improvement and Evidence based pr...
Thalassemia screening in pregnancy, Quality improvement and Evidence based pr...Wisit Cheungpasitporn
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Klotho in kidney Ischemia/Reperfusion Injury and Kidney Transplantation
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Journal Club: Hepcidin, Vitamin D and Anemia of CKD
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Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
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3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
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Live longer with kidney transplant
- 1. Live longer with kidney transplant Wisit Cheungpasitporn
- 2. Survival Compared with diaysis • Longer Life with a Transplant • On the other hand, patients who receive a kidney transplant typically live longer than those who stay on dialysis. A living donor kidney functions, on average, 12 to 20 years, and a deceased donor kidney from 8 to 12 years. • Patients who get a kidney transplant before dialysis live an average of 10 to 15 years longer than if they stayed on dialysis. Younger adults benefit the most from a kidney transplant, but even adults as old as 75 gain an average of four more years after a transplant than if they had stayed on dialysis. N Engl J Med. 1999 Dec 2;341(23):1725-30.
- 3. Patient Survival Rates for Dialysis and Transplant Patients • At 85.5 percent, the 5-year survival rate for transplant patients is more than twice the 35.8 percent survival rate for dialysis patients. National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC)
- 4. • For recipients of a living donor kidney, patient survival rate at five years posttransplantation is 91 percent. • For those who receive a deceased nonextended criteria donor transplant, the survival rate is 84 percent. • For those who receive a deceased extended criteria donor transplants, the respective value is 70 percent. Am J Transplant. 2005;5(4 Pt 2):843. Am J Transplant. 2009;9(4 Pt 2):894.