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Renal resistive index (RRI) of ultrasonography is a useful and potent tool for the assessment of patients who have undergone transplantations. The aim of this study was to evaluate the association of RRI with renal function 1 year after transplant.We retrospectively evaluated 93 kidney allograft recipients. Data were collected from transplantations performed in our medical center between January 2014 and September 2018. Patients with acute loss of the renal function and renal survival1 year were excluded from the study. We longitudinally compared the RRI at the first week after transplant and the third month, with estimated glomerular filtration rate (eGFR, by Chronic Kidney Disease Epidemiology Collaboration equation) at the end of the first year of transplantation. RRI was divided into 2 groups (RRI ≤0.80 or0.80).From the total of 86 recipients, 59 (68.6%) were male recipients and 27 female recipients with a mean age of 48.3 ± 12.1 years. No correlations were found between the first week's RRI with sex and age of both donors and recipients (P.05). Similarly, the first week's RRI was not correlated with delayed graft function (DGF) and 1-year eGFR after transplant (P.05). On the contrary, RRI performed at the third month was strongly correlated to DGF and eGFR at the end of the first year. Last but not least, neither higher recipient age nor sex affects the value of resistive index in the third month after transplantation (P.05).RRI values0.80 in the third month after kidney transplantation were related to better annual renal function and a lower incidence of DGF.

The occurrence of diabetes mellitus is common after kidney transplantation (posttransplant diabetes mellitus [PTDM]) and enhances the cardiovascular risk and risk for kidney graft loss. The incidence of PTDM is about 5% to 40%. This study aimed to examine the potential risk factors that determine the occurrence of PTDM.This study retrospectively included 298 patients from transplantation unit of Evangelismos who underwent kidney transplantation during a 10-year period (January 1, 2009, to January 1, 2019). Kidney transplant recipients with diabetes mellitus prior to transplantation or those with follow-up of6 months were rejected from the study. In total, the study included 274 recipients with a mean age of 50 ± 18 years. The mean time of monitoring was 63 ± 18 months. The PTDM diagnosis was based on the 2018 criteria of the American Diabetes Association.Of 274 kidney transplant recipients, PTDM developed in 38 (13.8%) patients over a period of 11 ± 9 months after transplantation. Given that immunosuppressive therapy was identical in most patients, statistical analysis did not correlate the incidence of diabetes with treatment. However, there was a correlation for the occurrence of PTDM between the presence of hypomagnesemia and increased uric acid levels. Finally, there was a negative correlation between the age of the recipient and the time of PTDM onset.Hypomagnesemia and hyperuricemia increased the risk of PTDM in these patients. Given the association between hypomagnesemia and the development of diabetes mellitus after kidney transplantation, prospective studies are needed to identify the causes of PTDM and to develop prevention strategies.

Background Spontaneous remission of secondary hyperparathyroidism after kidney transplantation requires time to occur. The aim of the present study was to investigate factors that may be related to the reduction of parathyroid hormone (PTH) after transplantation as well as the rate of its reduction. Methods We studied 81 kidney transplant recipients at our transplantation center between January 2014 and September 2017. The relationship of PTH values during the first year after transplant with renal function, type of kidney graft origin (deceased or living), and delayed renal graft function was examined. Moreover, we determined the correlation of the rate of PTH reduction within the first year with the value of PTH before transplant. Results Of the total of 81 recipients, 28 (35.1%) were women and 53 (64.8%) were men, with a mean age of 47 ± 11.87 years. At the same time, there was a decrease of PTH by 33% in the first half of the first year after transplantation and by 57% in the second. In addition, a statistically significant correlation of PTH with renal function was found (P = .001), with PTH values decreasing as the glomerular filtration rate increased. Finally, transplants from deceased donors were associated with higher values of PTH, whereas the value of PTH before transplant was positively correlated with the value after it (P = .001). Conclusions Secondary hyperparathyroidism, which accompanies end-stage chronic renal failure, usually resolves adequately after transplantation. The determinants of this resolution are the recipient's renal function, the kidney graft origin (deceased), and the pretransplant PTH values.

Background The aim of this study was to determine the effects of Kidney Donor Profile Index (KDPI) and body mass index (BMI) of the deceased donor on the kidney allograft outcome 1 year after transplantation. Methods We retrospectively studied 98 deceased kidney allograft donors with a mean age of 56 ± 12 years. The donors were divided into 5 groups according to their BMI: Normal ΒΜΙ = 25 (n = 25); ΒΜΙ 25 to 29 = Overweight (n = 33); ΒΜΙ 30 to 34.9 = Obese class I (n = 19); ΒΜΙ 35 to 39 = Obese class ΙΙ (n = 11); and ΒΜΙ >40 = Obese class III (n = 10). We examined the impact of the deceased donor's BMI and KDPI on delayed graft function (DGF) and estimated renal glomerular filtration rate (eGFR) (measured by the Chronic Kidney Disease Epidemiology Collaboration equation) 1 year after transplantation. Results Donor BMI significantly increased the prevalence of DGF (P = .031), and it was associated with higher cold ischemia time (P = .021). However, there was no significant association between the aforementioned BMI groups and 1-year eGFR (P = 0.57), as deceased grafts from donors with increased BMI (BMI > 40) gained sufficient renal function during the first year of transplantation. Moreover, high KDPI was associated not only with DGF (P = .015), but also with decreased values of eGFR (P = .033). Conclusion In this population, we identified no significant association between donor BMI and long-term clinical outcomes in deceased donor kidney transplants. KDPI, and not ΒΜΙ, of the deceased donor seems to be a good prognostic factor of renal function at the end of the first year after kidney transplant, whereas high BMI and high KDPI markedly induce DGF.

Aims Diagnosis of primary membranous nephropathy (PMN) is mainly based on immunofluorescence/immunohistochemistry findings. However, assessment of specific features on optical microscopy can help to estimate the severity of the disease, guide treatment and predict the response. The aim of this study was to identify, classify and grade the precise histological findings in PMN to predict renal function outcome and guide treatment. Methods and results Histological parameters, including focal segmental sclerosis (FSGS), tubular atrophy (TA), interstitial fibrosis (IF) and vascular hyalinosis (VH), were re‐evaluated in 752 patients with PMN. Their predictive value was estimated separately, and also in a combination score (FSTIV) graded from 0 to 4. Finally, the impact of histology was assessed in the response to immunosuppressive treatment. Mean age of patients was 53.3 (15–85) years and most presented with nephrotic syndrome. FSGS was present in 32% and VH in 51% of the patients, while TA and IF were graded as stage ≥1 in 52% and 51.4%, respectively. The follow‐up period was 122.3 (112–376) months. FSGS, TA and IF and VH were associated with impaired renal function at diagnosis (P = 0.02, P 50% eGFR reduction, FSGS (P = 0.001) and TA (P = 0.02). Also, patients presented with FSGS, IF, VH and/or with FSTIV > 1 could benefit from immunosuppression, regardless of clinical presentation. Conclusions The presence and degree of four histological indices, FSGS, VH, TA and IF, assessed separately or in combination, and FSTIV score not only predict renal function outcome after long‐term follow‐up, but can also help in the choice of appropriate treatment. Decisions concerning immunosuppressive treatment can be guided by pathology regardless of clinical findings.

Background and Aims Kidney biopsy is the gold standard for establishing the diagnosis of ANCA-associated glomerulonephritis (GN). Previous studies have validated the prognostic significance of histopathological classification for the development of end stage renal disease (ESRD). We sought to evaluate the prognostic value of the EUVAS histopathological classification in terms of renal and overall survival (OS) in a single center retrospective cohort study. Method Forty-six consecutive patients (mean age 69, range; 29-84 years) with biopsy-proven ANCA-associated GN diagnosed at our hospital between January 2003 and January 2019 were included in the study. All biopsies had ≥10 glomeruli and were reviewed by two independent pathologists blinded to clinical data. Renal morphology was classified as sclerotic (if ≥50% globally sclerotic glomeruli), focal (if ≥50% normal glomeruli), crescentic (if ≥50% crescents with cellular component) and mixed. Probabilities of renal and overall survival were estimated using Kaplan-Meier method. Cumulative incidence function for ESRD was estimated using death as competing risk. Results Three biopsies were classified as focal (6%), twenty-nine as crescentic (63%), ten as mixed (22%) and four as sclerotic (9%). With a median follow-up of 39 months the 3-year probability of renal survival was 100% for the focal class, 66,37% for the crescentic class, 64% for the mixed class and 50% for the sclerotic class (p>0.05). Other parameters associated with increased probability of ESRD were interstitial fibrosis (IF) and eGFR at time of diagnosis. IF of ≥40% at diagnosis was associated with high incidence of ESRD, while IF of 20-40% and 0.05). Conclusion Our results suggest that the focal class has the best and the sclerotic the worst outcome, while both crescentic and mixed subtype are of intermediate risk. Although our results did not reach statistical significance, due to primarily the small number of patients included, the incidence of ESRD and the probability of renal survival in each histopathological subtype in our cohort are comparable to those reported by larger studies. Thus, the EUVAS histological classification of ANCA-associated glomerulonephritis appears to be a useful predictor of renal outcome at the time of diagnosis. As previously reported, no significant prognostic difference was observed between the crescentic and mixed subtype. Thus, this classification system should be optimized by inclusion of other histological characteristics, such as the specific percentage of normal glomeruli, tubular atrophy and interstitial fibrosis. These characteristics may prove useful in highlighting significant differences between mixed and crescentic classes.

Background and Aims Renal resistive index (RRI) of ultrasonography is a useful and potent tool for assessment and evaluation of renal hyperfiltration status of the transplanted patients. The aim of this study was to evaluate the association of RRI with renal function one year after transplant. Method We evaluated retrospectively 98 kidney allograft recipients. Data were collected from transplantations performed in our medical center between 01/2014 and 09/2018. Patients with acute loss of the renal function and renal survival less than a year were excluded from the study. We compared longitudinally the RRI at the first week after transplant and the third month, with glomerular filtration rate (eGFR, by CKD-EPI) at the end of the first year of transplantation. RRI was measured on the interlobular artery level, in each of the aforementioned time periods, and results were classified into 2 groups, RRI 0,8. In addition, age, gender and delayed graft function (DGF) were also determined in all patients. Results Sixty seven (67) of the recipients were males and 31 females with a mean age of 48±12years. The corresponding demographics for the donors were 46 males and 52 females with a mean age of 53 ±14. No correlations were found between RRI of the first week with gender and age, of both donors and recipients (p>0.05). Similarly, RRI of the first week was not correlated with DGF and one-year eGFR after transplant (p>0.05). On the contrary, RRI performed at the third month was strongly correlated to DGF and eGFR at the end of the first year. In other words, allograft recipients with a resistive index less than 0.80, had a higher eGFR and reduced frequency of DGF (p=0.01 and 0.03 respectively). Last but not least, higher recipient age and not gender was the main determinant of an increase of resistive index in the third month after transplant (P=0.02). Conclusion RRI offers interesting and helpful data on kidney allograft function. RRI of the third month less than 0.8 was related to better renal function at the end of the first year after transplant mainly and a lower incidence of DGF.

IgA nephropathy (IgAN) is one of the most common recurrent glomerulonephritis after renal transplantation. Rarely, it is accompanied with the presence of crescents that leads to rapid deterioration of renal function and graft loss. We present a 54-year-old patient with IgAN that received a cadaveric kidney allograft, but developed biopsy proven recurrent IgAN 7 months after renal transplantation. He was treated with intravenous steroids and angiotensin-converting enzyme inhibitor and remission was achieved. 4 years later, he presented again with heavy proteinuria, hematuria and deterioration of renal function. Allograft biopsy revealed recurrent IgAN with crescents, which was successfully treated with pulse intravenous steroids and six monthly doses of intravenous cyclophosphamide. This regime resulted in long-term sustained remission with a stable functioning graft 3 years later. Although it is not an established treatment as in native kidneys, intravenous cyclophosphamide should probably be considered in kidney transplants with potentially reversible recurrent crescentic IgAN.

A staging system for patients with renal AL amyloidosis, based on eGFR ( 100) at 3 months had a 2-year progression to dialysis of 0% vs 24% for patients who either did not reduce to or still had a ratio >100 (P = .001); similar results were obtained by applying the same criteria at 6 months; thus, the evaluation of treatment effect on renal function may be identified early. Furthermore, primary bortezomib-based therapy was more effective than lenalidomide-based therapy, in terms of renal outcomes, especially in patients at intermediate renal risk, but without affecting overall survival.

Management of the Primary Membranous Nephropathy (PMN) usually involves administration of immunosuppressives. Cyclophosphamide (Cyclo) and Calcineurin Inhibitors (CNIs) are both widely used but only limited data exist to compare their efficacy in long term follow-up.Aimof the present study was to estimate and compare long term effects of Cyclo and CNIs in patients with PMN.Patients-MethodsClinical data, histologic findings and long term outcome were retrospectively studied. The response to treatment and rate of relapse was compared between patients treated with CNIs or Cyclo based immunosuppressive regimens.ResultsTwenty three centers participated in the study, with 752 PMN patients (Mean age 53.4(14-87)yrs, M/F 467/285), followed for 10.1±5.7 years. All patients were initially treated with Renin Angiotensin Aldosterone System inhibitors (RAASi) for at least 6 months. Based on their response and tolerance to initial treatment, patients were divided into 3 groups, group I with spontaneous remission, who had no further treatment, group II, continued on RAASi only, and group III on RAASi+immunosuppression. Immunosuppressive regimes were mainly based on CNIs or Cyclo. Frequent relapses and failure to treatment were more common between patients who had started on CNIs (n=381) compared to those initially treated with Cyclo (n=110), relapse rate: 25.2% vs. 6.4%, pConclusionsLong term follow up showed that administration of Cyclo in PMN is followed by better preservation of renal function, increased response rate and less frequent relapses, compared to CNIs.

Background The purpose of the present study was to determine whether patients with DM1 have shown improvement, stabilization or deterioration of their urine albumin excretion levels during a close follow-up. Patients and Methods A cohort of 84 patients, 18–76 years of age, a median duration of diabetes of 24 years (1–50 years) and a median follow-up duration of 12 years (1–37 years) were included in the study. Results Among the 84 patients for whom we had UAE levels at the beginning and by the end of the study, mean glycosylated hemoglobin was statistically significantly decreased during the follow-up period, from 8.02±2.04–7.06±1.05% (p=0.036). Normoalbuminuria was present in 66 patients and remained so in 56 patients while 9 patients progressed to microalbuminuria and one patient to macroalbuminuria by the end of the study. Microalbuminuria was present in 15 patients: regression was observed in 8 patients, and progression in one patient. Regression of macroalbuminuria to microalbuminuria was noted in one patient and to normoalbuminuria was noted in one participant, too. Conclusions Improvement of glycemic control with close monitoring of DM1 patients together with the appropriate use ACE or AT2 inhibitors and statins, seems to exert nephron-protective potential and to delay or even reverse the presence of micro/macroalbuminuria. This long term follow-up study has demonstrated a statistically significant increase in serum HDLcholesterol levels. The study also revealed that intensively treated diabetes patients may show reductions in serum ALP levels. Whether this finding is related to diabetic nephropathy, NAFLD, or diabetic hepatosclerosis remains to be assessed in future trials.

IntroductionManagement of the Primary Membranous Nephropathy (PMN) usually involves administration of immunosuppressives. Cyclophosphamide (Cyclo) and Calcineurin Inhibitors (CNIs) are both widely used but only limited data exist to compare their efficacy in long term follow-up.AimThe aim of the present study was to estimate and compare long term effects of Cyclo and CNIs in patients with PMN.Patients-methodsClinical data, histologic findings and long term outcome were retrospectively studied. The response to treatment and rate of relapse was compared between patients treated with CNIs or Cyclo based immunosuppressive regimens.ResultsTwenty three centers participated in the study, with 752 PMN patients (Mean age 53.4(14-87) yrs, M/F 467/285), followed for 10.1±5.7 years. All patients were initially treated with Renin Angiotensin Aldosterone System inhibitors (RAASi) for at least 6 months. Based on their response and tolerance to initial treatment, patients were divided into 3 groups, group I with spontaneous remission, who had no further treatment, group II, continued on RAASi only, and group III on RAASi+immunosuppression. Immunosuppressive regimes were mainly based on CNIs or Cyclo. Frequent relapses and failure to treatment were more common between patients who had started on CNIs (n = 381) compared to those initially treated with Cyclo (n = 110), relapse rate: 25.2% vs. 6.4%, pConclusionsLong term follow up showed that administration of Cyclo in PMN is followed by better preservation of renal function, increased response rate and less frequent relapses, compared to CNIs.

Background Short-term treatment for people with type 2 diabetes using a low dose of the selective endothelin A receptor antagonist atrasentan reduces albuminuria without causing significant sodium retention. We report the long-term effects of treatment with atrasentan on major renal outcomes.Methods We did this double-blind, randomised, placebo-controlled trial at 689 sites in 41 countries. We enrolled adults aged 18-85 years with type 2 diabetes, estimated glomerular filtration rate (eGFR) 25-75 mL/min per 1.73 m(2) of body surface area, and a urine albumin-to-creatinine ratio (UACR) of 300-5000 mg/g who had received maximum labelled or tolerated renin-angiotensin system inhibition for at least 4 weeks. Participants were given atrasentan 0.75 mg orally daily during an enrichment period before random group assignment. Those with a UACR decrease of at least 30% with no substantial fluid retention during the enrichment period (responders) were included in the double-blind treatment period. Responders were randomly assigned to receive either atrasentan 0.75 mg orally daily or placebo. All patients and investigators were masked to treatment assignment. The primary endpoint was a composite of doubling of serum creatinine (sustained for >= 30 days) or end-stage kidney disease (eGFR = 90 days, chronic dialysis for >= 90 days, kidney transplantation, or death from kidney failure) in the intention-to-treat population of all responders. Safety was assessed in all patients who received at least one dose of their assigned study treatment. The study is registered with ClinicalTrials. gov, number NCT01858532.Findings Between May 17, 2013, and July 13, 2017, 11 087 patients were screened; 5117 entered the enrichment period, and 4711 completed the enrichment period. Of these, 2648 patients were responders and were randomly assigned to the atrasentan group (n=1325) or placebo group (n=1323). Median follow-up was 2.2 years (IQR 1.4-2.9). 79 (6.0%) of 1325 patients in the atrasentan group and 105 (7.9%) of 1323 in the placebo group had a primary composite renal endpoint event (hazard ratio [HR] 0.65 [95% CI 0.49-0.88]; p=0.0047). Fluid retention and anaemia adverse events, which have been previously attributed to endothelin receptor antagonists, were more frequent in the atrasentan group than in the placebo group. Hospital admission for heart failure occurred in 47 (3.5%) of 1325 patients in the atrasentan group and 34 (2.6%) of 1323 patients in the placebo group (HR 1.33 [95% CI 0.85-2.07]; p=0.208). 58 (4.4%) patients in the atrasentan group and 52 (3.9%) in the placebo group died (HR 1.09 [95% CI 0.75-1.59]; p=0.65).Interpretation Atrasentan reduced the risk of renal events in patients with diabetes and chronic kidney disease who were selected to optimise efficacy and safety. These data support a potential role for selective endothelin receptor antagonists in protecting renal function in patients with type 2 diabetes at high risk of developing end-stage kidney disease. Copyright (C) 2019 Elsevier Ltd. All rights reserved.

Chronic hypokalemia is the main finding in patients with Gitelman’s syndrome (GS). GS, a variant of Bartter’s syndrome, is an autosomal recessive renal disorder characterized by hypokalemia, hypomagnesemia, metabolic alkalosis, and hypocalciuria. GS is caused by inactivating mutations in the thiazide-sensitive sodium-chloride cotransporter gene. It is also called the “milder” form of Bartter’s syndrome, as patients with GS are usually diagnosed in adulthood during routine investigation. Our objective is to highlight the impact of correct distinction between the causes of hypokalemia on management and the need of long-term follow- up after the restoration of normokalemic status. Herein, we report an asymptomatic 40-year-old male, whose persistent hypokalemia was due to GS. The diagnosis was first established by laboratory tests, and he was treated with low-dose aldosterone antagonists (spironolactone), angiotensin-converting enzyme inhibitors, and potassium and magnesium supplements. Genetic testing confirmed the diagnosis of GS and revealed a rare mutation. We conclude that GS is a rare and real diagnostic and therapeutic challenge, for which a close collaboration between endocrinologists and nephrologists is mandatory, as also the thorough genetic investigation of the mutations associated with this syndrome.

Patients with various inflammatory diseases of the gastrointestinal tract, skin, liver, kidneys, and musculoskeletal system-connective tissues, often undergo different anti-inflammatory therapies to maintain remission and avoid serious and/or life-threatening complications. Available data so far show an increased rate of hospitalization in such patients during the COVID19 pandemic. The key points of our position statement are summarized below: Patients with inflammatory diseases who receive moderate or high-risk anti-inflammatory therapies might be considered as an increased risk group for severe COVID-19 and appropriate measures should be taken in order to protect them. Initiation of immuno-suppressive/modulatory therapies should be done with caution, taking into account the severity of the underlying inflammatory disease, the type of anti-inflammatory treatment, and the risk of exposure to the SARS-CoV-2 virus. Discontinuation of anti-inflammatory therapies in patients who have not been exposed to or infected with the SARS-CoV-2 virus is not recommended. In patients who become infected with SARS-CoV-2, anti-inflammatory therapies should be discontinued, except in special cases. Specialty physicians should actively participate in the Interdisciplinary Teams caring for patients with inflammatory diseases during COVID19 infection.

A staging system for patients with renal AL amyloidosis, based on eGFR (50 ml/min/1.73 m

Objectives To report a case of intravascular lymphoma (IVL) in a Caucasian patient who presented with anasarca as his sole clinical sign. Material and Methods A man presented with anasarca-type oedema and fatigue. After excluding heart failure, hepatic cirrhosis, nephrotic syndrome, hypothyroidism, AL-amyloidosis and adverse drug reaction which can all cause oedema, we turned our attention to capillary permeability disorders. Results Closer review of the bone marrow aspirate demonstrated haemophagocytic histiocytosis, while core, renal and duodenal biopsies showed a B-cell IVL. Conclusion The differential diagnosis of anasarca, a relatively common clinical sign, should include IVL although the diagnosis may still be challenging. LEARNING POINTS Anasarca-type oedema is an unusual initial presentation of intravascular lymphoma (IVL) and is normally attributed to capillary permeability disorders. Two clinical forms of IVL have been recognized: a Western form and an Asian variant which is characterized by haemophagocytosis. Patients of Caucasian origin who have the clinical features of the Asian variant of IVL make the diagnosis of this condition even more challenging.

In this phase 1/2 study, we explored the feasibility and activity of an oral regimen of lenalidomide with low-dose dexamethasone and low-dose oral cyclophosphamide (RdC) in patients with primary systemic light chain amyloidosis. RdC was given for up to 12 cycles in prespecified cohorts at escalated doses: 13 patients were treated in phase 1 and 24 in phase 2; 65% were previously untreated, and most had renal and/or cardiac involvement and elevated cardiac biomarkers. Lenalidomide 15 mg/d and cyclophosphamide 100 mg/d were further evaluated in phase 2. On intention to treat, 20 (55%) patients achieved a hematologic response, including 3 (8%) complete remissions. Hematologic responses were seen at all dose levels and in 4 of 5 patients who had received bortezomib previously. An organ response was recorded in 22% of patients on intention-to-treat and in 40% of patients who survived at least 6 months. The median time to progression was 10 months and the 2-year survival was 41%. Fatigue, nonneutropenic infections, and rash were the most common toxicities. The results of the present study show that RdC is an oral regimen with activity in primary systemic light chain amyloidosis and may be an additional treatment option, especially for patients with preserved organ function or for patients who cannot receive or who relapse after bortezomib. This study is registered at www.clinicaltrials.gov as NCT00981708.

Sclerosing peritonitis (SP) is a rare but serious complication of peritoneal dialysis (PD), characterized by a fibrous peritoneal thickening. The etiology of this condition remains unknown but is likely to be multifactorial. Patients with SP almost invariably develop ultrafiltration and clearance failure. Although a number of pharmacologic drug treatment options have been tried with various results, surgical treatment and cessation of PD are almost always necessary and transfer to hemodialysis is the only practical option. Despite some evidence supporting the recovery of gastrointestinal function after renal transplantation in such patients, SP may very rarely appear much later after the cessation of PD and even after renal transplantation. We report an interesting case of a former PD patient who 2 years after renal transplantation presented with abdominal discomfort, vomiting, and malnutrition due to SP. Despite the initial conservative treatment, the symptoms persisted and a surgical treatment was decided upon. After that the patient recovered with no further complications. Although the appearance of SP after renal transplantation is extremely rare, it must be included in the differential diagnosis of every case of unexplained malnutrition and abdominal obstruction in a patient with a PD history.

The pattern of end-stage renal disease (ESRD) has changed significantly with the emerging predominance of elderly patients. Age is no longer seen as a contraindication to dialysis. Based on 2004 data, in the USA, patients aged 45–64 years old comprise the largest portion of the incident population, while patients aged 75 and older have the highest incident rates of ESRD. Mortality is higher among the elderly dialysis patients for whom cardiovascular diseases and infections are the most common causes of death. The quality of life (QoL) of these patients has been found to vary in different investigations, dependent on such factors as the investigator(s), the composition of the study group and the criteria used, among others; however, age was always found one of the major determinants of their QoL. Quality-of-life data suggest that older dialysis patients have similar levels of social functioning and mental health as younger dialysis patients but that their level of physical functioning is poorer. As such, the survival and QoL of elderly patients depends mainly on the severity of the comorbid conditions. The rationing of dialysis on the basis of age alone is not justified as dialysis can provide elderly patients with the means to gain the health status that permits them to enjoy life, but in their own way.

Although quality of life (QoL) is an important outcome measure, there are few studies of QoL in diabetic patients. We performed a cross-sectional study to assess QoL in such patients comparable for age, sex, and co-morbidity.Group CAPD: DM (n = 19, 12 males), diabetic CAPD patients; group CAPD: no DM (n = 26, 15 males) CAPD patients without diabetes; group TXP (n = 20, 10 males), diabetic transplant patients; and group CKD: DM (n = 20, 11 males), diabetics with chronic kidney disease. Two valid QoL instruments were used: a generic one (SF-36) and one that is disease-specific (RQLP).As a whole, CAPD patients scored badly as far as concerned the physical domain, but with a good mental adaptation. Diabetic CAPD patients exhibited worse QoL for physical functioning, energy, vitality, leisure activity, and eating/drinking limitations. Diabetic transplant patients exhibited the best QoL. The RQLP instrument had better discriminative power for domains such as eating/drinking, treatment effects, and psychosocial aspects. Using analysis of co-variance and adjusting for age, sex, and co-morbidity, QoL differences disappeared. In conclusion, diabetic CAPD patients exhibited the worst QoL though with a satisfactory mental adaptation, a renal-specific instrument had better discriminative power, and the prevention of co-morbidity is likely to improve QoL in such patients.

Kidney is involved in about 70% of patients with AL amyloidosis. End stage renal disease requiring dialysis has deleterious impact on the life of the patients. Recently, Palladini et al proposed that eGFR < 60 ml/min and proteinuria > 5gr/d at diagnosis were able to identify patients with low, intermediate or high probability of progression to dialysis. Also, achievement of at least hemVGPR was associated with favorable renal outcomes. The aim of our study was to validate the above prognostic criteria in a different population and to assess the role of primary therapy with novel agents (bortezomib or lenalidomide) in the renal outcomes of patients with AL amyloidosis. We analyzed 101 consecutive patients with newly diagnosed AL and kidney involvement, which were treated and followed in a single center (Department of Clinical Therapeutics, University of Athens). Because the prognosis of patients with AL is dominated by the degree of cardiac involvement and because many patients die to cardiac complications before reaching dialysis, our analysis was based on competing risk models (proposed by Fine & Gray), in which death without dialysis was treated as competing event. Median age was 65 years (range 40-84), 54% had also cardiac involvement, 27% were Mayo stage 1, 46% stage 2 and 27% stage 3. Median eGFR at the time of diagnosis was 57.5 ml/min; 52% had eGFR 5 gr/d. Nine (9%) patients who required dialysis at the time of diagnosis were excluded from further analysis. Primary therapy was bortezomib based (mainly VD) in 51%, lenalidomide-based in 29%, MDex in 11%, VAD in 5% and MP in 3%. After a median follow up of 4 years, 28% of the patients required dialysis, 33% died off-dialysis while 40% patients remain alive off-dialysis. One- and 3-year dialysis rates were 14% and 21%, while the incidence of death off-dialysis was 20% and 31% respectively. Thus, even among patients with renal involvement cardiac amyloidosis dominates their prognosis (Figure 1a). We then evaluated the staging system proposed by Palladini et al. One- and 3-year rate of dialysis for patients with eGFR < 60 ml/min was 20% & 34% vs 9% & 12% for those with eGFR ≥ 60 ml/min (p=0.009); there was no difference in the incidence of death off-dialysis (p=0.345). For patients with proteinuria > 5 gr/d vs those with ≤ 5 gr/d, the respective 1- and 3-year dialysis rate was 23% & 30% vs 5% & 15% (p=0.02) with similar incidence of death off dialysis (p=0.59). Thus, in patients with 0, 1 & 2 risk factors, the 1-year rate of dialysis was 0% vs 13% vs 28% and the 3-year rate was 0% vs 24% vs 37% (p20% was associated with excellent renal outcomes: at 3 years no patient who achieved a renal response required dialysis vs. 39% of non renal responders (p In conclusion, our data confirm previous observations that AL patients with renal involvement who present before severe renal damage occurs (i.e. when eGFR ≥ 60 ml/min and proteinuria ≤ 5gr/d) and which initiate therapy with effective agents, targeting at least hemVGPR, have excellent renal outcomes. In this regard, our data indicate that primary bortezomib-based therapy may be more effective than lenalidomide-based therapy. Figure 1 Figure 1. Disclosures Dimopoulos: Celgene: Consultancy, Honoraria.

Oiabetes mellitus is the commonest cause of end-stage renal failure and is associated with considerable morbidity. Neuropathy is one of the most serious complications of diabetes, linked to the incidence of nephropathy and retinopathy. The prevalence of neuropathy increases with age and duration of diabetes. Peripheral sensorimotor neuropathy is the main manifestation of neurological dam -age in diabetes, while autonomic neuropathy, a devastating complication, is also present in a large number of patients with long-term diabetes. Clinical features of autonomic neuropathy are mainly cardiovascular disorders and abnormal visceral function. One of the most important sequelae of neuropathy is the development of the insensitive foot at risk of ulceration, deformation, Charcot neuroarthropathy, and amputation. Prevention, education, and identification of the at-risk patient are the key elements in managing these severe complications. Oialysis, and mainly peritoneal dialysis, still remains the main renal replacement therapy for end-stage renal disease (ESRO) diabetic patients. It is obvious from many studies that diabetes and its complications are major risk factors associated with poorer survival rates, increased morbidity, and decreased quality of life. Few, if any, data are available specifically evaluating quality of life in continuous ambulatory peritoneal dialysis (CAPO) diabetic patients. Fewer data are available estimating the impact of neuropathy on the quality of life of such patients. Specific studies must be carried out to further investigate quality-of-life issues and neuropathy in this vulnerable group of patients.

Lenalidomide (R) is an IMiD with significant activity in patients with myeloma. Two recent series have shown that R, especially in combination with dexamethasone (D), is active in AL patients and can induce organ responses in one third of them. However, when R was administered at the standard dose of 25 mg PO QD it was associated with significant toxicity and almost all patients required dose reductions. Furthermore, there is evidence from myeloma trials that when R is combined with low dose D, early death and toxicity rates are improved. Finally, alkylating agents have activity in patients with AL. Based on the above we designed a phase I/II trial of lenalidomide, intermediate dose dexamethasone and low dose cyclophosphamide (RDC) in order to determine the maximum tolerated dose (MTD) and the hematologic and organ responses in patients with AL. Patients receive dexamethasone 20 mg days 1–4, cyclophosphamide is given on days 1–10 and lenalidomide on days 1–21 according to dose level (dose level 0: R 10 mg, C 50 mg, level 1: R 10 mg, C 100 mg, level 2: R 15 mg, C 100 mg, level 3: R 20 mg C 100mg, level 4:R 25 mg, C 100 mg). Patients are observed for 2 cycles of therapy for determination of Dose Limiting Toxicity (DLT). If no DLT is encountered in the first 3 patients at any dose level, 3 patients are enrolled at the next dose level. If >1 of 3 patients experience DLT, Maximum Tolerated Dose (MTD) is considered to have been exceeded. If 1 of 3 patients experiences DLT, 3 more patients are enrolled at the same dose level. If no more patients experience DLT (1 of 6), 3 patients are enrolled at the next dose level. If ≥ 2 of 6 patients experience DLT, MTD will be considered to have been exceeded. Patients with a creatinine ≤2.5 mg/dL and adequate hepatic function (total bilirubin 2.5 mg/dL or on dialysis were treated with R at a dose adjusted according to their creatinine clearance (15 mg every other day for CrCl

Background Rates of invasive group B Streptococcus (GBS; Streptococcus agalactiae ) disease in adults are on the rise. Invasive GBS disease can be community- or healthcare-associated. We report an outbreak of GBS catheter-related bacteremia in a hemodialysis (HD) unit. Materials and methods Two patients undergoing HD at the same outpatient HD unit were admitted on the same day (within a few hours of each other) with catheter-related GBS bacteremia. A retrospective study was undertaken at the HD unit to address risk factors for febrile illness on the last HD session day. A detailed questionnaire was completed by all HD patients treated on the same day as the two GBS patients and by all members of the nursing and medical staff. Medical and nursing records of the HD unit were reviewed, as well as infection control and catheter care practices. Patients and staff members submitted swabs for culture. Results No rectal or vaginal culture of any HD patient or staff member was positive for GBS. The development of recent febrile disease was significantly associated with the presence of a hemodialysis catheter ( p =0.028) and care for more than 30min by a specific nurse during the last two HD sessions ( p =0.007). Conclusions We speculate that the GBS strain was transmitted from one patient to the other through the hands of medical personnel. No such outbreak has ever been reported in HD patients. The importance of strict infection control practices in HD units and the avoidance of catheters for long-term HD should be emphasized.