Impact of obesity on dialysis and transplant and its management

Obesity is increasing to unprecedented levels, including in the end-stage kidney disease population, where upwards of 60% of kidney transplant patients are overweight or obese. Obesity poses additional challenges to the care of the dialysis patient, including difficulties in creating vascular access and inserting Tenckhoff catheters, higher rates of catheter malfunction and peritonitis, the need for longer and/or more frequent dialysis (or peritoneal dialysis [PD] exchanges) to achieve adequate clearance, increased metabolic complications particularly with PD, and obesity is a barrier to kidney transplantation. In this article, we review special considerations in performing PD, hemodialysis and transplant in the obese patient, as well as the evidence behind medical and surgical management of obesity in dialysis patients.     

COVID-19: mobilising CT as a frontline management tool

As the COVID-19 pandemic has spread across the globe, questions have arisen about the approach healthcare systems should adopt in order to optimally manage patient influx. With a focus on the impact of COVID-19 on the NHS, we describe the frontline experience of a severely affected hospital in close proximity to London. We highlight a protocol-driven approach, incorporating the use of CT in the rapid triage, assessment and cohorting of patients, in an environment where there was a lack of readily available, onsite RT-PCR testing facilities. Furthermore, the effects of the protocol on the effective streamlining of patient flow within the hospital are discussed, as are the resultant improvements in clinical management decisions within the acute care service. This model may help other healthcare systems in managing this pandemic whilst assessing their own needs and resources.     

B-type natriuretic peptide and cardiac dysfunction in Duchenne muscular dystrophy

Serum levels of B-type natriuretic peptide have moderate utility for detection of early ventricular dysfunction in adults and in experimental muscular dystrophy. To determine if B-type natriuretic peptide levels are useful in the detection of early left ventricular dysfunction in Duchenne muscular dystrophy patients, measurements were obtained in 21 patients being evaluated by echocardiography for left ventricular dysfunction. Two patients with clinical evidence of heart failure were excluded (mean B-type natriuretic peptide level of 352 pg/ml). Age range of the remaining 19 patients was 9-21 yrs. Fractional shortening was abnormal (<30%) in 14/19 and early diastolic tissue Doppler velocities were abnormal in 13/16. In these patients B-type natriuretic peptide levels were clearly normal (<30 pg/ml) in 15/19 and only mildly elevated (30-80 pg/ml) in 4/19. The 4 patients with mildly elevated B-type natriuretic peptide had significantly lower fractional shortening (12.6+/-5.9 versus 19.8+/-5.3, p<0.05). In conclusion, B-type natriuretic peptide levels are normal in the majority of Duchenne muscular dystrophy patients with asymptomatic left ventricular dysfunction and only mildly elevated when fractional shortening is markedly reduced.     

Use of HCV Ab+/NAT− donors in HCV naïve renal transplant recipients to expand the kidney donor pool

Hepatitis C (HCV) disease transmission from the use of HCV antibody‐positive and HCV nucleic acid test‐negative (HCV Ab+/NAT?) kidneys have been anecdotally reported to be absent. We prospectively analyzed kidney transplant (KT) outcomes from HCV Ab+/NAT? donors to HCV naïve recipients under T‐cell depleting early steroid withdrawal immunosuppression. Allografts from 40 HCV Ab+/NAT? donors were transplanted to 52 HCV Ab? recipients between July 2016 and February 2018. Thirty‐three (82.5%) of donors met Public Health Service (PHS) increased risk criteria. De novo HCV infection was detected at 3 months post‐KT in one recipient (1.9%). This was a case of transmission from a HCV Ab+ NAT+ donor with an initial false‐negative NAT completed using sample collected on donor hospital admission (day 2). At the time of HCV diagnosis, a stored donor sample collected during procurement (day 4) was tested and resulted NAT‐positive. Subsequently, sustained virologic response (SVR) was achieved with 12 weeks of glecaprevir/pibrentasvir. One death with functioning graft at 261 days post‐KT was determined not related to HCV or donor factors. This experience provides evidence of a low transmission rate of HCV from HCV Ab+/ NAT? kidney donors, thereby arguing for increasing utilization.