AIM:The COVID-19 pandemic caused widespread global disruptions to healthcare systems. There has been no assessment of this on dialysis practice at a binational level. METHODS:A multi-centre retrospective observational cohort study using data from the ANZDATA Registry was performed, with adult incident dialysis patients (1 January 2018 to 31 December 2022). Patients commencing dialysis during 2020-2022 were compared to 2018-2019 for the primary outcome of dialysis incidence rate. Secondary outcomes included estimated glomerular filtration rate (eGFR) at dialysis start, initial treatment location (home vs. facility), modality (haemodialysis vs. peritoneal dialysis), haemodialysis access, frequency, and duration. Commencement during lockdown in 2020-2021 was also analysed. RESULTS:11 690 patients commenced dialysis during 2020-2022 and 7366 commenced during 2018-2019, with no differences in incidence rate across the pandemic years (2020: p = 0.163, 2021: p = 0.139, 2022: p = 0.190). Compared to pre-pandemic years, uptake of home-based therapies was higher in 2020 (OR = 1.16, 95% CI 1.06-1.27, p = 0.002) with no difference in 2021 and 2022. Peritoneal dialysis uptake was higher in 2020 (OR = 1.15, 95% CI 1.04-1.26, p = 0.005) and 2021 (OR = 1.11, 95% CI 1.01-1.21, p = 0.037) with no difference in 2022. Haemodialysis patients were less likely to commence with an arteriovenous fistula or graft in 2022, compared to pre-pandemic years (OR = 0.87, 95% CI 0.78-0.96, p = 0.005). Odds of commencing haemodialysis with an arteriovenous fistula or graft were reduced during lockdown (OR = 0.79, 95% CI 0.65-0.95, p = 0.014). CONCLUSION:There was no change in the incidence rate of dialysis patients during 2020-2022, although there were differences in home dialysis uptake and starting access type.

The COVID-19 pandemic impacted greatest among patients with pre-existing chronic health conditions, including chronic kidney disease. This retrospective cohort study aimed to investigate the 30-day mortality of patients receiving kidney replacement therapy (KRT) after infection with COVID-19, living in Australia and New Zealand between 2020 and 2022, including patients on haemodialysis (HD), peritoneal dialysis (PD) and renal transplant (KT) recipients. This is a retrospective cohort study using data from the Australian and New Zealand Dialysis and Transplant Registry (ANZDATA). Patients were included if they tested positive for COVID-19 infection while receiving KRT between the first reported infection in January 2020 and the end of November 2022. Multivariable logistic regression was used to assess the relationship between KRT modality and 30-day mortality following COVID-19 infection, with all potential confounders included. A total of 9828 patients requiring KRT tested positive for COVID-19 within Australia and New Zealand between 2020 and 2022. The crude mortality rate by KRT modality was 3.0% for HD, 3.8% for PD and 2.4% for KT. In the adjusted model, there was a significant increase in the odds of mortality for increasing age, diabetes, peripheral vascular disease, having ever smoked and having received dialysis for ≥5 years. Relative to HD, KT recipients had increased odds of death in 2021 and 2022 but not 2020. The 30-day mortality rate following COVID-19 infection in patients requiring KRT was significantly higher than the general population, with several risk factors identified associated with increased mortality rates.

SUMMARY AT A GLANCEThis KHA‐CARI Guideline laid down principles for the care of patients undergoing kidney biopsy, and provides management guidelines from with‐holding of antiplatelet and anticoagulant agents, application of desmopressin to postbiopsy bleeding care.

SESSION TITLE: Transplant SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, November 1, 2017 at 01:30 PM - 02:30 PM PURPOSE: Calcineurin inhibitors (CNI) are considered a key component of maintenance immunosuppression following lung transplantation. However, CNI nephrotoxicity is a common and serious problem amongst lung transplant recipients. Everolimus (ERL), an inhibitor of the mechanistic target of rapamycin (mTOR), has been used as a CNI sparing immunosuppressive agent to allow renal recovery in patients with progressive renal impairment. Nevertheless, there is limited evidence to support the efficacy of this strategy to prevent rejection. This study aimed to evaluate the effect of ERL on renal and lung function in lung transplant recipients. METHODS: We conducted a retrospective analysis within a state-wide lung transplant service in Australia. Medical and pharmacy records were used to identify lung transplant recipients who were commenced on ERL from 2004 to 2015. Patients who received at least 6 consecutive months of ERL therapy during this period were included in the analysis. We recorded renal function and lung function 6 months before and 6 months after the initiation of ERL. Creatinine clearance (CrCl), derived from the Cockroft-Gault equation, was used as a measure of renal function. Lung function was reported as the percent predicted FEV1 and FVC. RESULTS: 44 patients were included in the analysis. The mean age was 49 ± 15 years. ERL was initiated at a median of 476 days (interquartile range 219-1247) post-transplant. The indication for ERL was renal impairment in 94%, malignancy in 4% and CNI related neurotoxicity in 2% of patients. After initiating ERL, 46% of patients had CNI ceased and the rest had a substantial dose reduction. At ERL initiation, mean CrCl was 52.6 ± 3.3 ml/min, mean percent predicted FEV1 70 ± 3% and FVC 77 ± 3%. In the 6 months prior to commencing ERL, there was a mean change in CrCl of -8.9 ± 2.4 ml/min (P=0.003), FEV1 -3.4 ± 1.9% (p=0.696), and FVC -1.2 ± 1.5% (p=1.000). 6 months after initiating ERL, the mean change in CrCl was +11.2 ± 2.4 ml/min (p<0.0001), FEV1 -5.3 ± 1.7% (p=0.024), and FVC -3.9 ± 1.4% (p=0.049). Excluded from the analysis were 8 patients who were on ERL for less than 6 months. 6 patients had ERL ceased; 2 for rejection, 2 for suspected pneumonitis, 1 for drug intolerance and 1 to aid wound healing after a motor vehicle accident. There were 2 deaths during this period; one due to chest sepsis and the other from liver failure, neither of which could be directly related to toxicity from ERL. These 8 patients received ERL for at least 3 months and were included in a 3-months analysis. At 3 months, there was a similar increase in CrCl of +11.6 ± 2.3 ml/min (p<0.0001) and no significant change in FEV1 and FVC. CONCLUSIONS: In lung transplant recipients with renal impairment, the use of ERL as a CNI sparing agent is associated with improvement in renal function. However, the efficacy of this maintenance immunosuppression strategy in preventing rejection requires elucidation with further studies. CLINICAL IMPLICATIONS: The use of ERL allows CNI withdrawal and renal recovery in lung transplant recipients with renal impairment. These patients should be closely followed up with frequent monitoring of lung function. DISCLOSURE: The following authors have nothing to disclose: Shaun Yo, Tim Coughlan, Steve Ivulich, Eldho Paul, Gregory Snell, Solomon Menahem No Product/Research Disclosure Information

NephrologyVolume 20, Issue 3 p. 224-225 Correspondence Segmental Arterial Mediolysis Mimicking Medium-Vessel Vasculitis Irene Ruderman, Irene Ruderman Department Renal Medicine, Alfred Hospital, Melbourne, Victoria, AustraliaSearch for more papers by this authorSolomon Menahem, Solomon Menahem Department Renal Medicine, Alfred Hospital, Melbourne, Victoria, AustraliaSearch for more papers by this author Irene Ruderman, Irene Ruderman Department Renal Medicine, Alfred Hospital, Melbourne, Victoria, AustraliaSearch for more papers by this authorSolomon Menahem, Solomon Menahem Department Renal Medicine, Alfred Hospital, Melbourne, Victoria, AustraliaSearch for more papers by this author First published: 24 February 2015 https://doi.org/10.1111/nep.12360Citations: 3 Conflict of Interest: No author has a competing or conflict of interest. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article.Citing Literature Volume20, Issue3March 2015Pages 224-225 RelatedInformation

SummaryVarious methods of peritoneal dialysis (PD) catheter insertion are available. The purpose of this study was to evaluate a percutaneous insertion technique using ultrasound (US) and fluoroscopy performed under conscious sedation and as day case procedure. Data of 87 percutaneous inserted dialysis catheters were prospectively collected, including patients' age, gender, body mass index, history of previous abdominal surgery and cause of end stage renal failure. Length of hospital stay, early complications and time to first use were also recorded. Institutional review board approval was obtained. A 100% technical success rate was observed. Early complications included bleeding (n = 3), catheter dysfunction (n = 6), exit site infection (n = 1) and exit site leakage (n = 1). All cases of catheter dysfunction and one case of bleeding required surgical revision. Median time of follow‐up was 18 months (range 3–35), and median time from insertion to first use was days 14 (1–47). Of the 82 patients who started dialysis, 20 (23%) ceased PD at some stage during follow‐up. Most frequently encountered reasons include deteriorating patient cognitive or functional status (n = 5), successful transplant kidney (n = 4) and pleuro‐peritoneal fistula (n = 4). Sixty‐two (71%) PD catheter insertions were performed as day case. The remaining insertions were performed on patients already admitted to the hospital. Percutaneous insertion of dialysis catheter using US and fluoroscopy is not only safe but can be performed as day case procedure in most patients, even with a medical history of abdominal surgery and/or obesity.

Calcific uraemic arteriolopathy (CUA) or calciphylaxis is most commonly seen in end‐stage renal disease and is associated with significant morbidity and mortality. The aim of this study was to determine whether hyperbaric oxygen therapy (HBOT) is effective in healing calciphylaxis lesions and to determine if there are any patient factors that can predict wound healing and patient survival.

We report a case of steroid- and cyclophosphamide-resistant nephrotic syndrome secondary to minimal-change disease occurring in an otherwise healthy 19-year-old female, responding rapidly to two doses of rituximab therapy. Complete disease remission has been sustained up to last follow-up (32 months) despite CD19 recovery. Literature review suggests emerging evidence that rituximab may have a role to play in recurrent and/or refractory minimal-change disease.

A 53-year-old Sudanese woman was admitted to our hospital with a 4-week history of headache, nasal congestion, and bilateral periorbital pain 11 months after deceased-donor renal transplant. Her past medical history included hypertension, gastroesophageal reflux, treated cerebral tuberculosis, and end-stage renal disease secondary to IgA nephropathy. Before transplantation she had been on hemodialysis for 6 years. The transplant had been uncomplicated apart from 2 weeks of delayed graft function. Immunosuppression included induction therapy with basiliximab and ongoing triple maintenance therapy with tacrolimus, mycophenolate mofetil (MMF), and prednisolone. With respect to the CMV match, the donor was of equivocal status, whereas the recipient was CMV positive. The patient had received 5 months of prophylactic oral valganciclovir therapy and had undetectable CMV virus by PCR on routine screening throughout this period and up until 3 months before her presentation. At the time of presentation, immunosuppression included tacrolimus 7 mg bd (level 4.7 μg/L), MMF 750 mg bd, and prednisolone 5 mg daily. Steroid dose had been gradually weaned from 20 mg at the time of transplantation and MMF dose had been recently reduced from 1000 mg bd because of anemia (hemoglobin, 77 g/L) and lymphopenia (lymphocyte count, 0.13 × 10^9/L) without neutropenia. Serum creatinine was 1.92 mg/dL. On examination, the patient was afebrile with extremely tender forehead and facial bones and significant nasal congestion. A CT scan of her sinuses revealed near-complete opacification of the right paranasal and maxillary sinuses with associated maxillary wall destruction and lesser involvement of the left side (Fig. 1). She subsequently underwent surgical debridement and washout of her sinuses. Smears and cultures for bacterial, fungal, and acid fast organisms were all negative. Histologic examination of the sinus tissue revealed active chronic inflammation with numerous intracellular cytomegalic inclusions immunoreacting with CMV antibodies diagnostic for active CMV sinusitis (Fig. 2A and B). There was no other clinical or investigative evidence of disseminated CMV infection.FIGURE 1: CT scan showing near-complete opacification of the patient’s right paranasal and maxillary sinuses with associated maxillary wall destruction and lesser involvement of the left side. 135×135 mm (96×96 DPI).FIGURE 2: A, Chronic active sinusitis with numerous intracellular CMV inclusions (arrow) (H & E), 173×129 mm (300×300 DPI). B, CMV inclusions present in cells (CMV immunoperoxidase). 173×129 mm (300×300 DPI).HIV serology was negative as was HIV PCR. The patient was commenced on intravenous ganciclovir (2.5 mg/kg/day) as well as intravenous antibiotics for possible superimposed bacterial infection of her sinuses. Her prednisolone dose was increased to 50 mg daily because of her active sinusitis, MMF dose was reduced to 250 mg bd, and tacrolimus dose was decreased to 6 mg bd (level, 3.0–4.5 μg/L). For the first 2 weeks of therapy, CMV viral load continued to increase and peaked at 32,320 copies/mL. She had daily nasal washouts and required further surgical debridement. By week 3, CMV viral load began to fall and the patient’s symptoms subsided. She continued on intravenous ganciclovir for a total of 4 weeks and was converted to oral valganciclovir (450 mg/day) when her CMV viral load had fallen to 1,175 copies/mL. At last review, 3 months after presentation, the patient’s CMV viral load was undetectable, and her symptoms had completely resolved. She remains on valganciclovir 450 mg daily, as well as MMF 250 mg bd, tacrolimus 6 mg bd (level 5.1 μg/L), and prednisolone 10 mg daily. Last serum creatinine was 2.24 mg/dL. In light of the uncommonness of the clinical presentation, follow-up testing was performed to assess the patient’s immune competency. The patient was not known to have any immune deficiency prior to transplantation and had responded appropriately while on dialysis to vaccination for hepatitis B. Subsequent testing confirmed normal quantitative immunoglobulin levels but B and T cell lymphopenia. CD19+ (B Cells) were 28 μL (normal, 80–400/μL) and CD3+ (T-cells) were 390/μL (normal, 530–2030/μL). These abnormalities improved following dose reduction in MMF. CMV sinusitis is an uncommon clinical entity and has been reported in patients with impaired cellular immunity mainly in association with HIV infection (1–4) and more rarely, in patients undergoing bone marrow transplant for hematologic malignancies (5, 6). A review of the literature revealed one case report of CMV sinusitis in an immunocompetent patient in association with bacterial infection (7). In line with published reports of CMV sinusitis in HIV-infected individuals, our case demonstrates that early surgical intervention as a diagnostic and therapeutic modality with timely initiation of ganciclovir is necessary in advanced sinus infections (8). The correlation between plasma CMV viral load and disease activity in CMV sinusitis remains unclear, although we were guided by the evolution of clinical symptoms and viral load when defining treatment response and duration. High-dose steroids were used to treat localized inflammation of the sinus mucosa in our patient. This may explain the initial rise in the patient’s CMV viral load that was observed, despite the simultaneous reduction in MMF and tacrolimus dose. Literature review confirmed that steroids have not been part of the treatment of CMV sinusitis, especially in HIV patients (1–4, 7). Inhaled steroids could be used as an alternative, with less potentially less immunosuppressive effects. To our knowledge this is the first case report of CMV sinusitis occurring in an HIV-negative patient after solid organ transplantation, suggesting that this is a rare complication. We have demonstrated successful treatment of the disease with a combination of surgery, antiviral treatment, and immunosuppression reduction. Anuksha Gujadhur 1 Napier Thomson1 Ar Kar Aung2 Catriona Mclean3 Solomon Menahem1 1Department of Renal Medicine Alfred Hospital, Melbourne, Australia 2Department of Infectious Diseases Alfred Hospital, Melbourne, Australia 3Department of Anatomical Pathology Alfred Hospital Melbourne, Australia

Fig. 2. Bilateral femoral artery aneurysms (white arrows) together with large polycystic kidneys.Note incidental finding of calcified cyst in left polycystic kidney (black arrow).

Infiltrative acute myeloid leukaemia

BACKGROUND:Peritoneal dialysis (PD) is an important home-based dialysis modality for patients with end-stage kidney disease (ESKD). The initiation of PD requires timely and skilled insertion of a Tenckhoff catheter (TC). At most centres, TCs are inserted laparoscopically by surgeons under general anaesthetic. This requires access to increasingly scarce surgical, anaesthetic and hospital inpatient resources. Radiological insertion of TCs performed as a day procedure under local anaesthetic allows for easier access to the TC insertion with reduced resource requirements. We report our 1-year experience following the introduction of this technique to our PD programme.METHODS:This is a retrospective review of the outcomes for all patients who had TCs inserted radiologically (percutaneously with the assistance of ultrasound and fluoroscopy) over the 12-month period from December 2011 to December 2012. Relevant patient demographics collected included age, gender, body mass index (BMI), previous abdominal surgery and cause of ESKD. Extended details of the insertion procedure were also obtained including length of stay, early complications and time to first use of the catheter for PD.RESULTS:Thirty Argyle(™) Swan Neck TCs were inserted under radiological guidance during the study period. The mean age of patients was 56 (SD ± 14). The male-to-female ratio was 2:1. The mean BMI was 25.7 (SD ± 4.8). PD was the initial dialysis modality in 22 (73%) patients. Of the 30 patients, 14 (46.7%) had previously undergone extraperitoneal abdominal surgery. All catheters were inserted successfully as day cases except four patients (13.3%) who had catheters inserted during an inpatient hospital admission. Most catheters were not accessed for a minimum of 10 days to reduce the chance of exit site leakage, in two cases the catheters were used within 5 days without complication. There were no cases of peritonitis or exit site infection during the observation period. Catheter migration occurred in four patients (13.3%) but only one required surgical intervention. Minor pain issues were noted in six patients (20%) and bleeding around the exit site requiring suturing in two patients (6.7%). The introduction of this technique at our institution saw a 67% increase in the number of patients performing PD.CONCLUSIONS:Radiological insertion of TCs for PD provided improved access to catheter insertion in a timely manner with reduced resource requirements. Over the 12-month observation period we noted a high technical success rate with very few complications. Our study supports radiological insertion of TCs under local anaesthetic as a viable alternative to catheter insertion in theatre under general anaesthetic. The relative ease of radiological TC insertion has resulted in a significant increase in patient uptake of PD at our centre.

The impact of cardiac dysfunction on the liver is known as cardiac hepatopathy. In certain instances this can result in significant hepatic fibrosis or cirrhosis. The validity of non-invasive tools to assess hepatic fibrosis, such as FibroScan which measures liver stiffness (LSM), has not been established in this setting. We examined the impact of cardiac dysfunction on LSM using FibroScan and the influence of volume changes on LSM.A prospective, cross-sectional study examined the use of FibroScan in subjects with left-sided heart failure (LHF, n 32), right-sided heart failure (RHF, n 9), and acute decompensated heart failure (ADHF, n 8). The impact of volume changes upon LSM was further examined in the ADHF group (pre- and post-diuresis) and in a haemodialysis group (HD, n 12), pre- and post-ultrafiltration on dialysis. Compared with healthy controls [n 55, LSM median 4.4 (25th percentile 3.6, 75th percentile 5.1) kPa], LSM was increased in all the cardiac dysfunction subgroups [LHF, 4.7 (4.0, 8.7) kPa, P 0.04; RHF, 9.7 (5.0, 10.8) kPa, P 0.001; ADHF, 11.2 (6.7, 14.3) kPa, P 0.001]. Alteration in volume status via diuresis did not change the baseline LSM in ADHF [11.2 (6.7, 14.3) to 9.5 (7.3, 21.6) kPa, P 0.05] with mean diuresis 5051 1585 mL, or ultrafiltration in HD [6.0 (3.6, 5.1) vs. 5.7 (4.8, 7.0) kPa, P 0.05] with mean diuresis 1962 233 mL.Our findings support the concept of increased LSM in the cardiac failure population. LSM was not altered to a statistically significant level with acute volume changes.

Date written: November 2006Final submission: August 2007

Background: The catastrophic variant of the antiphospholipid syndrome (CAPS), also now known as Asherson's syndrome, is defined as a potential life-threatening variant of the antiphospholipid syndrome, which is characterized by multiple small-vessel thrombosis that can lead to multiorgan failure. Relapses in patients with the CAPS are very uncommon.Objective: To describe the clinical and laboratory features of patients with relapsing episodes of CAPS.Methods: Three patients with relapsing CAPS are presented with their clinical and laboratory features.Results: Seven episodes of CAPS that occurred in the 3 patients reported were analyzed. The median time between the episodes of CAPS was 12.5 months (range, 2.5-48). Precipitating factors were identified in 2 episodes only (Legionella respiratory tract infection and periodontal infection). The most significant manifestations of the episodes were renal involvement (5 episodes), central nervous system and cardiac involvement (4 episodes), and pulmonary and hepatic involvement (3 episodes each). Interestingly, laboratory features of definite microangiopathic hemolytic anemia (MHA) were present in 5 of 7 episodes of relapsing CAPS. The remaining episodes presented with thrombocytopenia, schistocytes, and anemia but data concerning hemolysis and Coombs tests were not reported. Rituximab was used in 2 episodes.Conclusions: Relapses occur very infrequently in patients with the CAPS. The presence of MHA is common in these patients, suggesting that an association between MHA and relapses of CAPS could be present and that a "continuum" between various MHAs might exist, as recently suggested. (C) 2008 Elsevier Inc. All rights reserved.

Background: Survival after lung transplantation has improved, but with the consequence that long-term toxicities of treatment are of growing importance. In particular, renal impairment is common, has many causes, and carries with it increased morbidity and mortality.Methods: We retrospectively analyzed clinical and laboratory data of 136 patients who underwent lung and heart-lung transplantation at our institution between 1990 and 2004 inclusive. Using multivariate analysis we considered the impact of age, gender, pulmonary diagnosis, transplant type (single lung, double lung, heart-lung), hypertension, diabetes mellitus, cigarette smoking, current immunosuppression, duration of calcineurin inhibitor (CNI) exposure and pre-existing renal impairment on renal function.Results: At transplantation, creatinine clearance (CrCl) for the patient population was 108 +/- 3.28 (mean +/- SEM) ml/min/1.73 m(2). At end of follow-up (6 +/- 0.32 years) there was a significant decline in glomerular filtration rate (GFR) to 56.7 +/- 1.78 ml/min/1.73 m(2) (p < 0.001). Five of 136 patients (3.7%) developed end-stage renal failure (ESRF). On multivariate analysis, factors most strongly associated with this decline included (in order of significance): CrCl at transplantation; pack-years of cigarette smoking; exposure to sirolimus (SLM); CNI exposure; and Age at transplantation. The rate of decline in GFR was linked to CrCI and age at the time of transplantation.Conclusions: This analysis has demonstrated that patients with a lower baseline CrCl, older age at transplantation, and a smoking history are at high risk for rapid loss of renal function after transplantation. To best preserve kidney function, these patients should be targeted for aggressive risk factor modification as well as minimization of CNI exposure wherever possible.