Prevalence of diverticulosis and incidence of bowel perforation after kidney transplantation in patients with polycystic kidney disease

Sigmoid perforation due to diverticulitis is a life-threatening complication in the postoperative course of allogenic kidney transplantation. The incidence of diverticulosis is especially high among patients with autosomal dominant polycystic kidney disease (ADPKD). Thus, those who undergo allogenic kidney transplantation represent a high-risk group. The aim of this study was to evaluate the prevalence of diverticulosis in ADPKD patients awaiting renal transplantation and the incidence of bowel perforation following allogenic kidney transplantation due to ADPKD. Within the group of 1128 patients who underwent transplantation between January 1974 and January 1990, there were 46 patients (4.07 %) whose indication for transplantation was ADPKD. There was one patient who developed a sigmoid perforation under postoperative immunosuppression. Surgical treatment was a discontinuity resection of the sigmoid (Hartmann's procedure). The postoperative course was favorable, the bowel continuity has already been restored, and the graft is still functioning well. Fifteen of the 28 (53.5 %) ADPKD patients awaiting transplantation had colon diverticulosis (12 male and 3 female patients). No case of bowel perforation has thus far been observed in 15 of these patients who have undergone transplantation. A sigmoid resection was necessary in one patient due to diverticulitis without perforation. We did not find a higher prevalence of diverticulosis in patients with ADPKD, nor did we see a higher incidence of sigmoid perforation during post-transplant immunosuppression in this study. Received: 30 January 1997 Received after revision: 15 July 1997 Accepted: 19 August 1997     

Kidney transplantation in valvular heart disease and pulmonary hypertension: Consensus in waiting

Kidney transplantation induces a lesser anesthetic, surgical, and physiological alterations than other solid organ transplantation. Concomitant valvular pathologies expose these patients to poor postoperative outcome. There is a critical gap in knowledge and lack of coherence in the guidelines related to the management in patients with end‐stage renal disease with valvular heart disease. The individualized diagnostic and management plan should be based on the assessment of perioperative outcomes. Similarly, pulmonary hypertension in end‐stage renal disease poses a unique challenge, it can manifest in isolation or may be associated with other cardiac lesions, namely left‐sided valvular heart disease and left ventricular systolic and diastolic dysfunction. Quantification and stratification according to etiology are needed in pulmonary hypertension to ensure an adequate management plan to minimize the adverse perioperative outcomes. Lack of randomized controlled trials has imposed hindrance in proposing a unified approach to clinical decision‐making in these scenarios. In this review, we have described the magnitude of the problems, pathophysiologic interactions, impact on clinical outcomes and have also proposed a management algorithm for both the scenarios.     

Polycystic kidney disease — a truly pediatric problem

Polycystic kidney disease (PKD) represents the most common inherited cause of chronic renal failure. PKD is a relatively uncommon cause of chronic renal failure or mortality in childhood and adolescence, but is nevertheless often responsible for symptoms of renal disease. Current research into the pathogenesis of PKD suggests that disturbance of the normal regulation of growth and development of tubular epithelium is intrinsic to cyst formation and growth. Features of cystic epithelium that are analogous to earlier stages of renal development include altered composition of the extracellular matrix, abnormal cell proliferation, and the persistence of a secretory pattern of fluid and electrolyte transport. The potential for early diagnosis and electrolyte transport. The potential for early diagnosis and intervention in PKD makes it an area of great interest to the pediatric nephrologist. Animal and in vitro studies have achieved modification of cyst growth by reduction of dietary protein, use of amiloride and its analogs, antagonism of the epidermal growth factor receptor system, anti-inflammatory therapy, and most recently with the use of taxol, an agent that inhibits microtubule assembly. PKD may represent an area in which childhood diagnosis and intervention will have a significant impact on the prevalence of chronic renal failure in adult life.     

Monogenic causes of chronic kidney disease in adults

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Imaging-Based Diagnosis of Autosomal Dominant Polycystic Kidney Disease

The clinical use of conventional ultrasonography (US) in autosomal dominant polycystic kidney disease (ADPKD) is currently limited by reduced diagnostic sensitivity, especially in at-risk subjects younger than 30 years of age. In this single-center prospective study, we compared the diagnostic performance of MRI with that of high-resolution (HR) US in 126 subjects ages 16–40 years born with a 50% risk of ADPKD who underwent both these renal imaging studies and comprehensive PKD1 and PKD2 mutation screening. Concurrently, 45 healthy control subjects without a family history of ADPKD completed the same imaging protocol. We analyzed 110 at-risk subjects whose disease status was unequivocally defined by molecular testing and 45 unaffected healthy control subjects. Using a total of >10 cysts as a test criterion in subjects younger than 30 years of age, we found that MRI provided both a sensitivity and specificity of 100%. Comparison of our results from HR US with those from a previous study of conventional US using the test criterion of a total of three or more cysts found a higher diagnostic sensitivity (approximately 97% versus approximately 82%) with a slightly decreased specificity (approximately 98% versus 100%) in this study. Similar results were obtained in test subjects between the ages of 30 and 40 years old. These results suggest that MRI is highly sensitive and specific for diagnosis of ADPKD. HR US has the potential to rival the diagnostic performance of MRI but is both center- and operator-dependent.     

Imaging approaches to patients with polycystic kidney disease

Imaging is an important approach to diagnosis, monitoring, and predicting outcomes for patients with autosomal-dominant polycystic kidney disease. This article reviews three common clinical imaging techniques, ultrasonography, computed tomography, magnetic resonance imaging, and their role in the management of autosomal-dominant polycystic kidney disease. Ultrasonographic criteria for diagnosis in children and adults are reviewed. Total kidney volume, as measured by magnetic resonance imaging, is suggested as an important potential marker to determine disease progression and overall prognosis. Renal blood flow and a novel approach to interpreting noncystic renal parenchyma by computed tomography images are other innovative imaging approaches described.     

前列腺素E_1治疗慢性肾脏病基础上急性肾损伤的疗效观察

目的:探讨前列腺素E1治疗在慢性肾脏病基础上急性肾损伤(A/C)的疗效。方法:将78例A/C患者分为两组,治疗组(40例)予常规治疗,并加用前列腺素E1静脉滴注,对照组(38例)予常规治疗。疗程2周,观察治疗前后两组患者肾功能和24h尿蛋白排泄量的变化,比较两组的治疗效果;同时分析A/C发生的危险因素。结果:导致A/C发生的危险因素中,两组均以严重感染、恶性高血压为多见;治疗组于治疗2周后肾功能及尿蛋白排泄量明显改善(P<0.01),而对照组仅肾功能有所改善(P<0.05),治疗组肾功能及尿蛋白排泄量改善程度比对照组明显(P<0.01)。结论:及时诊断和纠正慢性肾脏病基础上急性肾损伤的危险因素,在常规治疗基础上联合应用前列腺素E1治疗可进一步改善患者肾功能,减少尿蛋白,延缓慢性肾脏病的进展。     

Renal medicine in the intensive care unit: a narrative review

Kidney disease, both acute and chronic, is commonly encountered on the intensive care unit. Due to the role the kidneys play in whole body homeostasis, it follows that their dysfunction has wide-ranging implications and can affect prescribing and therapeutic management. This narrative review discusses the pathophysiology of acute kidney injury and chronic kidney disease, and how this relates to critically unwell patients. We cover several aspects of the management of renal dysfunction on the critical care unit, exploring some of the recurrent themes within the literature, including type and timing of kidney replacement therapy, management of acute kidney injury, as well as discussing how novel biomarkers for acute kidney injury may help to identify patients suffering from acute kidney injury as well as risk stratifying these patients. We discuss how early involvement of specialist nephrology services can improve outcomes in patients with kidney disease as well as offer valuable diagnostic and specialist management advice, particularly for patients with established end stage kidney disease and patients who are already known to nephrology services. We also explore some of the ongoing research questions that need to be answered within this arena.     

Global perspective of kidney diseases: Challenges and changes

Chronic kidney disease (CKD) is a major public health issue worldwide. Although strategies for prevention, early detection and treatment to reduce the progression of CKD should remain continuous endeavours, public funding for kidney replacement therapy is urgently needed in low-income countries (LICs) and lower-middle-income countries (LMICs). A multisectoral approach is needed to tackle the global burden of kidney disease. Getting a new drug, from first testing to final approval by a regulatory agency and ultimately to market, is a long, costly and risky process. While clinical trials and research have delivered new therapies and devices to patients with kidney disease during the last decade, there remains a significant residual risk for patients with CKD. Therefore, developing new drugs for better treatment and patient care is essential. For this purpose, the ISN held a consensus meeting entitled ‘TRANSFORM; TRAnslational Nephrology Science FOR new Medications’, which connected experts in the global kidney community and provided guidance on optimal management of translational animal studies for the development of new drugs to treat kidney diseases.