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Several organ allocation protocols give priority to wait-listed simultaneous kidney-pancreas (SPK) transplant recipients to mitigate the higher cardiovascular risk of patients with diabetes mellitus on dialysis. The available information regarding the impact of preemptive simultaneous kidney-pancreas transplantation on recipient and graft outcomes is nonetheless controversial. To help resolve this, we explored the influence of preemptive simultaneous kidney-pancreas transplants on patient and graft survival through a retrospective analysis of the OPTN/UNOS database, encompassing 9690 simultaneous transplant recipients between 2000 and 2017. Statistical analysis was performed applying a propensity score analysis to minimize bias. Of these patients, 1796 (19%) were transplanted preemptively. At ten years, recipient survival was significantly superior in the preemptive group when compared to the non-preemptive group (78.9% vs 71.8%). Dialysis at simultaneous kidney-pancreas transplantation was an independent significant risk for patient survival (hazard ratio 1.66 [95% confidence interval 1.32-2.09]), especially if the dialysis duration was 12 months or longer. Preemptive transplantation was also associated with significant superior kidney graft survival compared to those on dialysis (death-censored: 84.3% vs 75.4%, respectively; estimated half-life of 38.57 [38.33 -38.81] vs 22.35 [22.17 - 22.53] years, respectively). No differences were observed between both groups neither for pancreas graft survival nor for post-transplant surgical complications. Thus, our results sustain the relevance of early referral for pancreas transplantation and the importance of pancreas allocation priority in reducing patient mortality after simultaneous kidney-pancreas transplantation.

Given the increased COVID-19 observed in kidney transplant recipients (KTRs) and haemodialysis patients, several studies have tried to establish the efficacy of mRNA vaccines in these populations by evaluating their humoral and cellular responses. However, there is currently no information on clinical protection (deaths and hospitalizations), a gap that this study aims to fill.Observational prospective study involving 1,336 KTRs and haemodialysis patients from three dialysis units affiliated to Hospital Clínic of Barcelona, Spain, vaccinated with two doses of mRNA-1273 (Moderna) or BNT162b2 (Pfizer-BioNTech) SARS-CoV-2 mRNA vaccines. The outcomes measured were SARS-CoV-2 infection diagnosed by a positive RT-PCR fourteen days after the second vaccine dose, hospital admissions derived from infection, and a severe COVID-19 composite outcome, defined as either ICU admission, invasive and non-invasive mechanical ventilation, or death.Six per cent (18/302) of patients on haemodialysis were infected, of whom four required hospital admission (1.3%), only one (0.3%) had severe COVID-19, and none of them died. In contrast, 4.3% (44/1034) of KTRs were infected, and presented more hospital admissions (26 patients, 2.5%), severe COVID-19 (11 patients, 1.1%) or death (4 patients, 0.4%). KTRs had a significantly higher risk of hospital admission than HD patients, and this risk increased with age and male sex (HR 3.37 and 4.74, respectively).The study highlights the need for booster doses in KTRs. In contrast, the haemodialysis population appears to have an adequate clinical response to vaccination, at least up to four months from its administration.

Here, we report a case of a patient with cloudy effluent that was initially diagnosed as bacterial peritonitis. The persistence of a cloudy effluent despite antibiotic therapy led to an extensive peritoneal dialysis (PD) effluent analysis, with the final diagnosis being high-grade B-cell lymphoma. This case will increase the awareness of this rare presentation of a lymphoproliferative disorder reminding clinicians to consider this diagnosis as a part of the differential diagnosis PD effluent.

BackgroundThe age of patients referred for kidney transplantation has increased progressively. However, the precise influence of age on transplant outcomes is controversial.MethodsEtrospective study in which graft and recipient survival were assessed in a cohort of ≥75 years old kidney recipients and compared with a contemporary younger one aged 60-65 years through a propensity score analysis.ResultsWe included 106 recipients between 60-65 and 57 patients of ≥75 years old with a median follow-up of 31 [13-54] months. Unadjusted one- and five-year recipient survival did not significantly differ between the older (91% and 74%) and the younger group (95% and 82%, P=0.06). In the IPTW weighted Cox regression analysis, recipient age was not associated with an increased risk of death (HR 1.88 95%CI [0.81-4.37], P=0.14). Unadjusted one- and five-year death-censored graft survival did not significantly differ between both groups (96% and 83% for the older and 99% and 89% for the younger group, respectively, P=0.08). After IPTW weighted Cox Regression analysis, recipient age ≥75 years was no associated with an increased risk of graft loss (HR 1.95, 95%CI [0.65-5.82], P=0.23).ConclusionsThese results suggest that recipient age should not be considered itself as an absolute contraindication for kidney transplant

BACKGROUND AND AIMS The evidence regarding the benefits of performing preemptive SPK (pSPK) is controversial. The aim of the present study was to evaluate the impact of pSPK on long-term patient and grafts outcomes when compared with npSPK and pKTA through a national registry study with recipients reported to the Organ Procurement and Transplantation Network/United Network for Organ Sharing (OPTN/UNOS) registry, and to analyse the potential benefits associated with pSPK not only in patients with T1D but also in patients with T2D. METHOD To explore the survival advantage of performing a pSPK, we compared the outcomes in pSPK with nonpreemptive SPK (npSPK) recipients between 2000 and 2017 from the OPTN/UNOS registry. To account for the potential benefit provided solely by the kidney transplant, we further compared to recipients of preemptive Kidney Transplantation Alone (pKTA) with diabetes. A propensity score analysis was applied. RESULTS A total of 1522 patients received a pSPK, 7894 an npSPK and 3343 a pKTA. Overall recipient survival was superior for the pSPK group when compared with the pKTA (97.7%, and 80.9% versus 97.7% and 72.9% at 1 and 10 years, respectively, P CONCLUSION In conclusion, the observed survival benefit of performing an SPK preemptively reinforces the need for early referral for transplantation in patients with insulin-dependent diabetes and advanced chronic kidney disease.

BACKGROUND AND AIMS Seroconversion after a two-dose course of mRNA COVID-19 vaccination in kidney transplant recipients ranges between 30% and 50% in different series. We previously demonstrated that a substantial proportion of patients (35%) without a humoral response, develop a cellular response after the second dose assessed by the ELISpot technique. We aim to study the evolution of both humoral and cellular responses in the same cohort before and 1 month after the administration of the third dose of 100 mcg of mRNA-1273 COVID-19 vaccine. METHOD Final population included 129 KTRs studied at four time-points: at baseline before the first dose, after the second dose (median 42 days) and before (203 days) and after (232 days) the third dose. At all the time-points, IgG and IgM were assessed as well as N- and S-protein specific ELISpot. The main outcome was seroconversion after the third dose. RESULTS After the second dose, 26.7% of naïve cases experienced seroconversion. Before the third dose and in the absence of clinically evident COVID-19, this percentage increased to 61.9%. After the third dose, seroconversion was observed in 80.0% of patients. S-ELISpot positivity after the second dose was significantly associated with final seroconversion [OR (95% CI) 3.14 (1.10–8.96); P = .032], while transplantation CONCLUSION A substantial proportion of KTRs vaccinated with mRNA-1273 develops a late seroconversion after two doses and only a fifth remained seronegative after a third. Cellular immunity seems to play a major role in the development of a final strong humoral response.

BACKGROUND AND AIMS Dialysis catheter-associated bacteraemia in Intensive Care Units (ICUs) increases morbidity and mortality, prolongs hospital admission and increases admission costs. TauroLock™ is a lock solution containing (cyclo)-taurolidine (1.35%) and citrate (4%). (Cyclo)-taurolidine has broad antimicrobial activity against gram-positive and gram-negative bacteria and fungi. The objective of this study was to analyse the effect of systematic sealing of haemodialysis catheters in the ICUs of the Hospital Clínic de Barcelona on the incidence of bacteraemia associated with haemodialysis catheters (BACH). METHOD BACH episodes of patients who underwent intermittent haemodialysis (IHD) during ICU admission were reviewed. The period analysed as pre-Taurolock™ was from 2010 to 2014 and post-TauroLock™ from 2015 to 2018. Patients who only received renal replacement therapy with continuous techniques were excluded. RESULTS A total of 279 patients received IHD in the pre-TauroLock™ period and 331 in the post-TauroLock™ period. The number of BACH in the pre-TauroLock™ period was 18 (6.45%) and 9 (2.72%) in the post-TauroLock™ period. All infections were from percutaneous catheters (acute patients) except three catheters that were tunnelled. In the pre-TauroLock™ period, femoral catheters predominated (61.1%) while in the post-TauroLock they were jugular (66.7%). There was no association between the location of the catheter and the incidence of BACH. Of the 27 patients with BACH, 14 (51.8%) were men with a mean age of 63 years, with no significant differences between the two groups. The most frequent reasons for admission to the ICU in the pre-TauroLock™ period were post-cardiac surgery, cardiogenic, septic or hypovolemic shock and acute myocardial infarction (3 patients per group) and in the post-TauroLock™ period, septic shock and pancreatitis (3 and 2 patients respectively). The most frequent isolated bacteria were Gram-positive (in total 48.38%: pre-TauroLock™ 47.61% and post-TauroLock™ 50%), with a global predominance of staphylococcus epidermidis (32.25%) (Table). There were no significant differences in the median days from the start of haemodialysis to bacteraemia (23.5 pre-TauroLock™ versus 21 post-TauroLock™). There were also no significant differences between the days of ICU stay in the BACH in both groups or in mortality, being the overall mortality of 70.4%. CONCLUSION In our cohort, the systematic application of TauroLock™ in the sealing of dialysis catheters in critically ill patients reduces the incidence of BACH in ICUs.

Introduction: The medium cut-off Elisio HX dialyzer by Nipro became commercially available in Europe in 2021, but there are still no reports of in vivo data. This study aimed to evaluate the safety and efficacy of it compared with previously evaluated hemodialysis (HD), expanded HD (HDx), and postdilution hemodiafiltration (HDF) treatments. Methods: A prospective study was carried out on 18 patients who underwent 5 dialysis sessions: FX80 Cordiax in HD, Elisio H19 in HD, Elisio HX19 in HDx, Theranova 400 in HDx, and FX80 Cordiax in HDF. The reduction ratios of urea, creatinine, ß2-microglobulin, myoglobin, kappa FLC, prolactin, α1-microglobulin, α1-acid glycoprotein, lambda FLC, and albumin were compared. Dialysate albumin loss was measured. Results: The comparison between the different dialysis modalities revealed no difference for small molecules, but HDx and HDF were significantly more efficient than HD for medium and large molecule removal. The efficacy of Elisio HX19 dialyzer in HDx was similar to the Theranova 400, superior to both dialyzers in HD, and slightly lower than HDF. Albumin losses in dialysate with HD dialyzers were less than 1 g, but between 1.5 and 2.5 g in HDx and HDF. The global removal score (GRS) values with HDx treatments were statistically significantly higher than those with HD. The highest GRS was obtained with the helixone dialyzer in HDF. Conclusions: The new MCO dialyzer, Elisio HX, performs with excellent behavior and tolerance. It represents an upgrade compared to their predecessor and is very close to the removal capacity of HDF treatment.

Renal replacement therapy (RRT) in cirrhotic patients encompasses a number of issues related to the particular characteristics of this population, especially in the intensive care unit (ICU) setting. The short-term prognosis of cirrhotic patients with acute kidney injury is poor, with a mortality rate higher than 65% in patients with RRT requirement, raising questions about the futility of its initiation. Regarding the management of the RRT itself, there is still no consensus with respect to the modality (continuous versus intermittent) or the anticoagulation required to improve the circuit life, which is shorter than similar at-risk populations, despite the altered haemostasis in traditional coagulation tests frequently found in these patients. Furthermore, volume management is one of the most complex issues in this cohort, where tools used for ambulatory dialysis have not yet been successfully reproducible in the ICU setting. This review attempts to shed light on the management of acute RRT in the critically ill cirrhotic population based on the current evidence and the newly available tools. We will discuss the timing of RRT initiation and cessation, the modality, anticoagulation and fluid management, as well as the outcomes of the RRT in this population, and provide a brief review of the albumin extracorporeal dialysis from the point of view of a nephrologist.

According to preliminary data, seroconversion after mRNA SARS‐CoV‐2 vaccination might be unsatisfactory in Kidney Transplant Recipients (KTRs). However, it is unknown if seronegative patients develop at least a cellular response that could offer a certain grade of protection against SARS‐CoV‐2. To answer this question, we prospectively studied 148 recipients of either kidney (133) or kidney‐pancreas (15) grafts with assessment of IgM/IgG spike (S) antibodies and ELISpot against the nucleocapside (N) and the S protein at baseline and two weeks after receiving the second dose of the mRNA‐1273 (Moderna) vaccine. At baseline, 31 patients (20.9%) had either IgM/IgG or ELISpot positivity and were considered to be SARS‐CoV‐2‐pre‐immunized, while 117 (79.1%) patients had no signs of either cellular or humoral response and were considered SARS‐CoV‐2‐naïve. After vaccination, naïve patients who developed either humoral or cellular response were finally 65.0%, of which 29.9% developed either IgG or IgM and 35.0% S‐ELISpot positivity. Factors associated with vaccine unresponsiveness were diabetes and treatment with anti‐thymocytes globulins during the last year. Side effects were consistent with that of the pivotal trial and no DSAs developed after vaccination. In conclusion, mRNA‐1273 SARS‐CoV‐2 vaccine elicits either cellular or humoral response in almost two thirds of KTRs.

The number of octogenarians or older patients admitted to the intensive care unit (ICU) has been growing over the past several years. The aim of this study is to assess factors associated with acute renal replacement therapy (ARRT) requirement in these patients and the impact of this therapy on 90-day mortality. We also aimed to identify prognostic factors associated with mortality risk in the group of patients that required ARRT. Retrospective study of octogenarian or older patients admitted to the ICU at Hospital Clinic de Barcelona from June 2007 to April 2019. Patients on chronic dialysis treatment or with a kidney transplant, and patients with limitation of therapeutic support or admitted for less than 48 h were excluded. 217 patients were included in the study, of whom 36.4% required ARRT. Use of vasoactive drugs (VAD) and Sequential Organ Failure Assessment (SOFA) score on admission were higher in ARRT patients (P = 0.009 and