Salvaging of severely ruptured living-related renal allograft secondary to acute antibody mediated rejection

INTRODUCTION

Spontaneous renal allograft rupture (RAR) is a serious and potentially life-threatening complication of kidney transplantation. Debate on the management of RAR has focused on graft nephrectomy versus salvaging in cases where: the allograft rupture site is surgically manageable; the bleeding can be controlled; and/or leaving the renal allograft in situ does not compromise patient survival.

PRESENTATION OF CASE

A 45-year-old, living-related, female, kidney allograft recipient experienced RAR on the fourth day post transplantation. Surgical exploration showed 12 cm laceration along the convex border of the graft. Histologically the graft demonstrated mild acute kidney injury and linear deposition of C4d along the cortical peritubular capillaries; morphological features for violent humoral or cellular rejection were not identified. The graft was surgically salvaged with excellent clinical and biochemical improvement.

DISCUSSION

Observations arising from this case are: (1) RAR caused by rejection is still encountered in clinical practice despite effective immunosuppressive management; (2) the severity of the histopathological features of rejection does not necessarily correlate with the extent of graft rupture; and (3) salvaging the graft should be attempted whenever possible as current immunosuppression and advances in surgical techniques may have an impact on long-term graft function and survival, differing from those previously published.

CONCLUSION

With modern immunosuppression therapy and proven surgical procedures, the efficacy of salvaged renal grafts and graft survival rates may improve substantially.     

Views,experiences and contributory factors related to medication errors associated with direct oral anticoagulants: a qualitative study with physicians and nurses

Background

Direct oral anticoagulants (DOACs) have become preferable for the management of thromboembolic events. Recent publications have however identified high volume of medication errors related to DOACs. There is limited literature on why and how such errors occur or happen in clinical practice.

Aim

This study aimed to explore views, experiences, contributory factors related to DOACs medication errors from the perspectives of healthcare professionals.

Method

Semi-structured interviews using online videoconferencing were conducted with physicians and nurses from tertiary care hospitals in three different regions in Saudi Arabia. Questions included views, experiences and perceived factors contributing to errors. Interviews were transcribed verbatim and were thematically analyzed using MAXQDA Analytics Pro 2020 (VERBI Software).

Results

The semi-structured interviews (n?=?34) included physicians (n?=?20) and nurses (n?=?14) until data saturation was achieved. The analysis identified five themes: Factors related to healthcare professionals (e.g. knowledge, confidence and access to guidelines); Factors related to patients (e.g. comorbidity, polypharmacy, medication review, and communication barriers); Factors related to organization (e.g. guidelines, safety culture and incidents reporting system); Factors related to the DOACs medications (e.g. lack of availability of antidotes and dosing issues); and Strategies for error prevention/mitigation (e.g. the need for professional training and routine medication review).

Conclusion

Healthcare professionals identified errors in relation to DOACs as multifactorial including their own and patient lack of knowledge, lack of clinical guidelines and organizational factors including safety culture. Medication review and reconciliation on discharge were key strategies suggested to reduce DOACs related errors. These strategies support the role of pharmacists as direct patients care providers to minimize DOACs errors.

     

Acute diffuse proliferative post‐infectious glomerulonephritis in renal allograft – A case report and literature review

PVN is a well‐known cause of renal allograft dysfunction and failure. The diagnosis is established by examination of tissue from the renal graft, and confirmed by immunohistochemical or in situ hybridization techniques. Electron microscopy can be utilized as an ancillary modality to identify the viral particles ultrastructurally. The tubular epithelial cells are the primary target of PV cytopathic effect; however, PV‐associated glomerular changes have also been described. Immune‐type electron‐dense deposits in the TBMs have been described in the setting of PVN, and rarely, likewise have glomerular subepithelial hump‐like deposits. Diffuse immune‐mediated proliferative glomerulonephritis in the setting of PVN has not been reported before. In this report, we describe an 11‐yr‐old kidney transplant recipient boy who developed immune‐mediated glomerulonephritis with light microscopic, immunofluorescence, and ultrastructural features compatible with acute PIGN superimposing chronic PVN, discuss this unusual association and the possible mechanisms of antigen clearance in PVN and present a literature review.     

Factors associated with recovery delay in a sample of patients diagnosed by MERS‐CoV rRT‐PCR: A Saudi Arabian multicenter retrospective study

Background

Research evidence exists that poor prognosis is common in Middle East respiratory syndrome coronavirus (MERS‐CoV) patients.

Objectives

This study estimates recovery delay intervals and identifies associated factors in a sample of Saudi Arabian patients admitted for suspected MERS‐CoV and diagnosed by rRT‐PCR assay.

Methods

A multicenter retrospective study was conducted on 829 patients admitted between September 2012 and June 2016 and diagnosed by rRT‐PCR procedures to have MERS‐CoV and non‐MERS‐CoV infection in which 396 achieved recovery. Detailed medical charts were reviewed for each patient who achieved recovery. Time intervals in days were calculated from presentation to the initial rRT‐PCR diagnosis (diagnosis delay) and from the initial rRT‐PCR diagnosis to recovery (recovery delay).

Results

The median recovery delay in our sample was 5 days. According to the multivariate negative binomial model, elderly (age ≥ 65), MERS‐CoV infection, ICU admission, and abnormal radiology findings were associated with longer recovery delay (adjusted relative risk (aRR): 1.741, 2.138, 2.048, and 1.473, respectively). Camel contact and the presence of respiratory symptoms at presentation were associated with a shorter recovery delay (expedited recovery) (aRR: 0.267 and 0.537, respectively). Diagnosis delay is a positive predictor for recovery delay (r = .421; P = .001).

Conclusions

The study evidence supports that longer recovery delay was seen in patients of older age, MERS‐CoV infection, ICU admission, and abnormal radiology findings. Shorter recovery delay was found in patients who had camel contact and respiratory symptoms at presentation. These findings may help us understand clinical decision making on directing hospital resources toward prompt screening, monitoring, and implementing clinical recovery and treatment strategies.     

Renal histopathology spectrum in children with kidney diseases in Saudi Arabia, 1998-2017

Objectives:To identify the trends in the diagnostic frequency of glomerular disease subtypes by renal biopsy in children in Saudi Arabia over the last 20 years.Methods:In this retrospective observational study, we identified all patients aged <18 years for whom native kidney biopsy was performed between 1998 and 2017. The period during which biopsy was performed (1998-2004, 2005-2011, and 2012-2017) and the demographic information and their association with the prevalence of various glomerular disease subtypes were our primary outcomes.Results:A total of 326 cases with renal biopsy were analyzed; the mean age of participants being 11 years and 45.4% of them were girls. Unexpectedly, secondary glomerulonephritis accounted for 42.3% of the cases, and lupus nephritis was the most common cause noted in 20.7% of the cases. The minimal change and focal segmental glomerulosclerosis were the most common glomerulonephritis in 59% of the cases. The frequency of membranoproliferative glomerulonephritis and mesangioproliferative glomerulonephritis significantly decreased from 15% and 17% in the period prior to 2004 to 3.3% (p=0.003) and 1.7% in 2012-2017 (p<0.001).Conclusions:We found a considerable shift in the frequency of many glomerular disease subtypes in 1998-2017, which make clinical predication of the underlying etiology challenging for clinician. Renal biopsy still remains a critical diagnostic procedure for managing a considerable proportion of renal diseases.     

Low‐grade papillary cystadenocarcinoma of the parotid gland: Presentation of a case with cytological,histopathological, and immunohistochemical features and pertinent literature review

Cystadenocarcinoma of the salivary glands is a very rare, slow growing, low‐grade malignant neoplasm. However, when it occurs, it poses a diagnostic challenge. They are usually well circumscribed and exhibit multicystic appearance. The cytological features of fine‐needle aspirates show bland appearing papillary and micropapillary neoplasm with variable cellularity and absence of cytological atypia. The cells are small to medium in size with abundant and occasionally vacuolated cytoplasm. The nuclei are eccentric, bland appearing, round, and at the most part uniform in size without anaplasia or mitotic activity. The background is commonly mucoid. Histologically, the neoplasm is usually well circumscribed and contains variably sized multicystic spaces with papillary structures. Foci of definite stromal invasion by tumor cells have to be present to justify the diagnosis of carcinoma. The remainders of the cytological features are similar to these seen on cytological smears. Typically, they are slow growing and conservative, but complete surgical excision is considered adequate. We present a case in a 57‐year‐old Saudi man that we believe the first from our region demonstrating the clinical and pathological features. Diagn. Cytopathol. 2009. © 2008 Wiley‐Liss, Inc.