Successful Treatment for BK Virus Nephropathy by Leflunomide in a Kidney Transplant Patient: A Case Report

IntroductionThe immunosuppressant agents in kidney transplantation (KT) may lead to various complications such as opportunistic infections and malignancies. BK virus associated nephropathy is a significant complication following KT, and it can result in graft failure. BK virus causes tubulointerstitial nephritis, ureter stenosis, and even graft failure in KT recipients with impaired immune system. We described a 63-year-old woman, who was a hepatitis C carrier and on dialysis for 22 years before KT, who received cadaveric-donor KT 2 years previously. She reported decreasing urine output and general weakness. The serum creatinine level was slightly increased from 2.94 to 4.38 mg/dL.MethodsImmunosuppressant medications including prednisolone, everolimus, cyclosporin, and mycophenolate sodium were continued as maintenance therapy post KT. Kidney biopsy was performed due to deterioration of graft function.ResultsThe kidney biopsy showed consistent results with early-stage polyomavirus nephropathy, characterized by focal viral cytopathic changes with positive immunohistochemical signals and mesangial proliferative glomerulonephritis, immune-complex-mediated (Fig 1 and Fig 2). Negative C4d staining at peritubular capillary was reported. The dosage of mycophenolate sodium was tapered from 720 to 360 mg daily and that of everolimus increased from 0.5 to 1.0 mg daily due to BK viral infection with BK nephropathy. The serum creatinine level was 2.75 mg/dL after treatment.ConclusionEarly detection of BK nephropathy and decreasing immunosuppressant agents are the mainstay of treatment. Substituting leflunomide for mycophenolate sodium and increasing dosage of everolimus has been proposed to solve BK nephropathy. We presented that the use of leflunomide in such situation is in a timely manner.     

轴向载荷分担比指导外固定器动力化的临床应用

目的:探讨轴向载荷分担比用于胫腓骨骨干骨折术后指导外固定器轴向动力化促进骨折愈合的有效性。方法:选取外固定器治疗的胫腓骨骨干骨折患者100例,随机分为观察组50例,对照组50例。观察组在轴向载荷分担比指导下行外固定器轴向动力化治疗,对照组未行动力化,随访比较两组的治疗效果。结果:所有患者均获随访,随访时间4～12个月,平均6.5个月,治疗期间所有患者均未出现外固定针断裂、松动及再骨折等并发症,观察组1例骨搬移患者轴向载荷分担比5%,X线片显示骨折断端有连续性骨痂通过,拆除外固定器连接杆后发生移位,恢复原数值行轴向加压再动力化,现已愈合。观察组除外1例骨搬移患者,其余49例患者外固定器固定时间为[(24.4±4.7)周],骨折临床愈合时间为[(22.4±4.7)周],与对照组50例患者外固定器固定时间[(29.3±5.6)周],骨折临床愈合时间[(27.3±5.6)周]比较,显著减少(P0.05)。结论:外固定器轴向载荷分担比指导胫腓骨骨干骨折外固定术后轴向动力化可以加速骨折愈合,但不适合骨搬移截骨端已硬化患者。     

红皮病患者低钾血症预后的影响因素分析

<正>机体的血钾参与并维持细胞代谢,保持细胞内液渗透压及酸碱平衡,并可维持神经肌肉组织兴奋及心肌功能~([1-2])。中重度低血钾主要表现为肌无力,可延及机体的躯干和呼吸肌,造成呼吸困难,还可引发腱反射减弱或消失、肠麻痹及心脏传导阻滞、节律异     

Outcomes of coronary artery bypass grafting in patients with heart failure with a midrange ejection fraction

BackgroundCoronary artery bypass grafting (CABG) improves survival in patients with heart failure and severely reduced left ventricular systolic function (LVEF). Limited data exist regarding adverse cardiovascular event rates after CABG in patients with heart failure with midrange ejection fraction (HFmrEF; LVEF > 40% and < 55%).MethodsWe analyzed data on isolated CABG patients from the Veterans Affairs national database (2010-2019). We stratified patients into control (normal LVEF and no heart failure), HFmrEF, and heart failure with reduced LVEF (HFrEF) groups. We compared all-cause mortality and heart failure hospitalization rates between groups with a Cox model and recurrent events analysis, respectively.ResultsIn 6533 veterans, HFmrEF and HFrEF was present in 1715 (26.3%) and 566 (8.6%) respectively; the control group had 4252 (65.1%) patients. HFrEF patients were more likely to have diabetes mellitus (59%), insulin therapy (36%), and previous myocardial infarction (31%). Anemia was more prevalent in patients with HFrEF (49%) as was a lower serum albumin (mean, 3.6 mg/dL). Compared with the control group, a higher risk of death was observed in the HFmrEF (hazard ratio [HR], 1.3 [1.2-1.5)] and HFrEF (HR, 1.5 [1.2-1.7]) groups. HFmrEF patients had the higher risk of myocardial infarction (subdistribution HR, 1.2 [1-1.6]; P = .04). Risk of heart failure hospitalization was higher in patients with HFmrEF (HR, 4.1 [3.5-4.7]) and patients with HFrEF (HR, 7.2 [6.2-8.5]).ConclusionsHeart failure with midrange ejection fraction negatively affects survival after CABG. These patients also experience higher rates myocardial infarction and heart failure hospitalization.     

The prognostic value of elevated neutrophil–lymphocyte ratio for cardiac surgery-associated acute kidney injury: A systematic review and meta-analysis

Background

Patients undergoing cardiac surgery are at significant risk of developing postoperative acute kidney injury (AKI). Neutrophil–lymphocyte ratio (NLR) is a widely available inflammatory biomarker which may be of prognostic value in this setting.

Methods

We conducted a systematic review and meta-analysis of studies reporting associations between perioperative NLR with postoperative AKI. We searched Medline, Embase and the Cochrane Library, without language restriction, from inception to May 2022 for relevant studies. We meta-analysed the reported odds ratios (ORs) with 95% confidence intervals (CIs) for both elevated preoperative and postoperative NLR with risk of postoperative AKI and need for renal replacement therapy (RRT). We conducted a meta-regression to explore inter-study statistical heterogeneity.

Results

Twelve studies involving 10,724 participants undergoing cardiac surgery were included, with eight studies being deemed at high risk of bias using PROBAST modelling. We found statistically significant associations between elevated preoperative NLR and postoperative AKI (OR 1.45, 95% CI 1.18–1.77), as well as postoperative need for RRT (OR 2.37, 95% CI 1.50–3.72). Postoperative NLR measurements were not of prognostic significance.

Conclusions

Elevated preoperative NLR is a reliable inflammatory biomarker for predicting AKI following cardiac surgery.     

Optimizing access and configuration of trauma centre care in New South Wales

IntroductionGetting the right patient, to the right place, at the right time is dependent on a multitude of modifiable and non-modifiable factors. One potentially modifiable factor is the number and location of trauma centres (TC). Overabundance of TC dilutes volumes and could be associated with worse outcomes. We describe a methodology that evaluates trauma system reconfiguration without reductions in potential access to care. We used the mature trauma system of New South Wales (NSW) as a model given the perceived overabundance of urban major trauma centres (MTC).MethodsWe first evaluated potential access to TC care via ground and air transport through the use of geographic information systems (GIS) network analysis. Potential access was defined as the proportion of the population living within 60-min transport time from a potential scene of injury to a TC by ground or rotary-wing aircraft. Sensitivity analyses were carried out in order to account for potential pre-hospital interventions and/or transport delays; travel times of 15-, 30-, 45-, 60-, and 90-min were also analyzed. We then evaluated if the current configuration of the system (number of urban MTS in the Sydney basin) could be optimized without reductions in potential access to care using two GIS methodologies: location-allocation and individual removal of MTC.Results86% of the NSW population has potential access to a TC within 60 min ground travel time; potential access improves to 99% with rotary-wing transport. The 1% of the population without potential TC access lives in 48% of the land area (>384,000km2). Utilizing two different methodologies we identified that there was no change in potential access by ground transport after removing 1 or 2 MTC in the Sydney basin at the 30-, 45-, and 60-min transport times. However, 0.02% and 0.5% of the population would not have potential access to MTC care at 15 min after removing one and two MTC respectively.DiscussionRedistribution of the number of MTC in the Sydney basin could be achieved without a significant impact on potential access to care. Our approach can be utilized as an initial tool to evaluate a trauma system where overabundance of coverage is present.