Application and management of continuous glucose monitoring in diabetic kidney disease

Diabetic kidney disease(DKD)is a common complication of diabetes mellitus that contributes to the risk of end-stage kidney disease(ESKD).Wide glycemic var-iations,such as hypoglycemia and hyperglycemia,are broadly found in diabetic patients with DKD and especially ESKD,as a result of impaired renal metabolism.It is essential to monitor glycemia for effective management of DKD.Hemoglobin A1c(HbA1c)has long been considered as the gold standard for monitoring glycemia for>3 months.However,assessment of HbA1c has some bias as it is susceptible to factors such as anemia and liver or kidney dysfunction.Continuous glucose monitoring(CGM)has provided new insights on glycemic assessment and management.CGM directly measures glucose level in interstitial fluid,reports real-time or retrospective glucose concentration,and provides multiple glycemic metrics.It avoids the pitfalls of HbA1c in some contexts,and may serve as a precise alternative to estimation of mean glucose and glycemic variability.Emerging studies have demonstrated the merits of CGM for precise monitoring,which allows fine-tuning of glycemic management in diabetic patients.Therefore,CGM technology has the potential for better glycemic monitoring in DKD patients.More research is needed to explore its application and management in different stages of DKD,including hemodialysis,peritoneal dialysis and kidney transplantation.

Acute pancreatitis as a complication of acute COVID-19 in kidney transplant recipients

BACKGROUND Acute pancreatitis is a rare extrapulmonary manifestation of coronavirus disease 2019(COVID-19)but its full correlation with COVID-19 infection remains unknown.AIM To identify acute pancreatitis’occurrence,clinical presentation and outcomes in a cohort of kidney transplant recipients with acute COVID-19.METHODS A retrospective observational single-centre cohort study from a transplant centre in Croatia for all adult renal transplant recipients with a functioning kidney allograft between March 2020 and August 2022 to record cases of acute pancreatitis during acute COVID-19.Data were obtained from hospital electronic medical records.Severe acute respiratory syndrome coronavirus 2(SARS-CoV-2)infection was proven by a positive SARS-CoV-2 real-time reverse transcriptase-polymerase chain reaction on the nasopharyngeal swab.RESULTS Four hundred and eight out of 1432(28.49%)patients who received a renal allograft developed COVID-19 disease.The analyzed cohort included 321 patients(57%males).One hundred and fifty patients(46.7%)received at least one dose of the anti-SARS-CoV-2 vaccine before the infection.One hundred twenty-five(39.1%)patients required hospitalization,141(44.1%)developed pneumonia and four patients(1.3%)required mechanical ventilation.Treatment included immunosuppression modification in 233 patients(77.1%)and remdesivir in 53 patients(16.6%),besides the other supportive measures.In the study cohort,only one transplant recipient(0.3%)developed acute pancreatitis during acute COVID-19,presenting with abdominal pain and significantly elevated pancreatic enzymes.She survived without complications with a stable kidney allograft function.CONCLUSION Although rare,acute pancreatitis may complicate the course of acute COVID-19 in kidney transplant recipients.The mechanism of injury to the pancreas and its correlation with the severity of the COVID-19 infection in kidney transplant recipients warrants further research.

Update on the reciprocal interference between immunosuppressive therapy and gut microbiota after kidney transplantation

Gut microbiota is often modified after kidney transplantation.This principally happens in the first period after transplantation.Antibiotics and,most of all,immunosuppressive drugs are the main responsible.The relationship between immunosuppressive drugs and the gut microbiota is bilateral.From one side immunosuppressive drugs modify the gut microbiota,often generating dysbiosis;from the other side microbiota may interfere with the immunosuppressant pharmacokinetics,producing products more or less active with respect to the original drug.These phenomena have influence over the graft outcomes and clinical consequences as rejections,infections,diarrhea may be caused by the dysbiotic condition.Corticosteroids,calcineurin inhibitors such as tacrolimus and cyclosporine,mycophenolate mofetil and mTOR inhibitors are the immunosuppressive drugs whose effect on the gut microbiota is better known.In contrast is well known how the gut microbiota may interfere with glucocorticoids,which may be transformed into androgens.Tacrolimus may be transformed by microbiota into a product called M1 that is 15-fold less active with respect to tacrolimus.The pro-drug mycophenolate mofetil is normally transformed in mycophenolic acid that according the presence or not of microbes producing the enzyme glucuronidase,may be transformed into the inactive product.

Predicting outcomes after kidney transplantation: Can Pareto’s rules help us to do so?

Kidney transplantation is the best option for kidney replacement therapy,even considering that most of the times the grafts do not survive as long as their recipients.In the Khalil et al's experience,published in this issue of the Journal,they analyze their second kidney graft survival and describe those significant predictors of early loss.This editorial comments on the results and put in perspective that most of the times,long-term graft survival could be inadvertently jeopardized if the immunosuppressive therapy is reduced or withdrawn for any reason,and that it could happen frequently if the transplant physician intends to innovate with the clinical care without proper evidence-based data.

Translation and cross-cultural adaptation of the Kidney Transplant Questionnaire 25 to Greek

BACKGROUND Kidney transplantation leads to continuous improvement in the survival rates of kidney transplant recipients(KTRs)and has been established as the treatment of choice for patients with end-stage kidney disease.Health-related quality of life(HRQoL)has become an important outcome measure.It is highly important to develop reliable methods to evaluate HRQoL with disease-specific questionnaires.AIM To translate the disease-specific instrument Kidney Transplant Questionnaire 25(KTQ-25)to the Greek language and perform a cross-cultural adaptation.METHODS The translation and adaptation of the original English version of the KTQ-25 to the Greek language were performed based on the International Quality of Life RESULTS Eighty-four KTRs(59 males;mean age 53.5±10.7 years;mean estimated glomerular filtration rate 47.7±15.1 mL/min/1.73 m2;mean transplant vintage 100.5±83.2 months)completed the Greek version of the KTQ-25 and the 36-item Short-Form Health Survey,and the results were used to evaluate the reliability of the Greek KTQ-25.The Cronbach alpha coefficients for all the KTQ-25 dimensions were satisfactory(physical symptoms=0.639,fatigue=0.856,uncertainty/fear=0.661,appearance=0.593,emotions=0.718,total score=0.708).The statistically significant correlation coefficients among the KTQ-25 dimensions ranged from 0.226 to 0.644.The correlation coeffi-cients of the KTQ-25 dimensions with the SF-36 physical component summary(PCS)ranged from 0.196 to 0.550;the correlation coefficients of the KTQ-25 with the SF-36 mental component summary(MCS)ranged from 0.260 to 0.655;and the correlation coefficients of the KTQ-25 with the total scores with the SF-36 PCS and MCS were 0.455 and 0.613,respectively.CONCLUSION According to the findings,the Greek version of the KTQ-25 is valid and reliable for administration among kidney transplant patients in Greece.

Challenges to establishing and maintaining kidney transplantation programs in developing countries:What are the coping strategies?

Kidney transplantation(KT)is the optimal form of renal replacement therapy for patients with end-stage renal diseases.However,this health service is not available to all patients,especially in developing countries.The deceased donor KT programs are mostly absent,and the living donor KT centers are scarce.Single-center studies presenting experiences from developing countries usually report a variety of challenges.This review addresses these challenges and the opposing strategies by reviewing the single-center experiences of developing countries.The financial challenges hamper the infrastructural and material availability,coverage of transplant costs,and qualification of medical personnel.The sociocultural challenges influence organ donation,equity of beneficence,and regular follow-up work.Low interests and motives for transplantation may result from high medicolegal responsibilities in KT practice,intense potential psychosocial burdens,complex qualification protocols,and low productivity or compensation for KT practice.Low medical literacy about KT advantages is prevalent among clinicians,patients,and the public.The inefficient organizational and regulatory oversight is translated into inefficient healthcare systems,absent national KT programs and registries,uncoordinated job descriptions and qualification protocols,uncoordinated on-site investigations with regulatory constraints,and the prevalence of commercial KT practices.These challenges resulted in noticeable differences between KT services in developed and developing countries.The coping strategies can be summarized in two main mechanisms:The first mechanism is maximizing the available resources by increasing the rates of living kidney donation,promoting the expertise of medical personnel,reducing material consumption,and supporting the establishment and maintenance of KT programs.The latter warrants the expansion of the public sector and the elimination of non-ethical KT practices.The second mechanism is recruiting external resources,including financial,experience,and training agreements.

Kaposi Sarcoma after Kidney Transplant: A Clinical Case Report

Kaposi sarcoma is a neoplasm caused by human herpesvirus 8 (HHV8) that most commonly affects immunosuppressed patients. The skin is the most affected area, but other sites can be involved such as the lung, digestive tract and lymph nodes. The classical presentation involves a violaceous skin lesion that can be small or hidden, leading to a delay in diagnosis. We report a clinical case of a kidney transplant patient, who presented, 14 months after kidney transplant, with unilateral edema of the inferior member and cutaneous rash misdiagnosed and taken initially for erysipelas. The diagnosis of Kaposi’s sarcoma was retained, on a lymph node biopsy of an inguinal adenopathy. The evolution was marked by a local and general improvement after systemic chemotherapy, reducing Tacrolimus and discontinuation of Mycophenolate mofetil. Graft function remained stable during the follow-up.

Echerichia coli Infection—Associated Glomerulonephritis in a Kidney Transplant Patient: A Case Report

Post infectious Glomerulonephritis (PIGN) in renal allograft is a rare entity. Only a few Cases have been described in the literature. The post streptococcal glomerulonephritis is the classic example in native kidney. A wide variety of organism has been associated with PIGN in renal allograft such as Staphylococcus, Cytomegalovirus and Polyomavirus. We describe one case of Infection associated glomerulonephritis due to Echericha Coli, developed 5 years after kidney transplantation, in 47 years old female patient. The Clinical presentation was characterized by a peripheral edema and high blood pressure, and biological tests showed a nephrotic syndrome, an acute kidney injury, a consumption of Complement fractions. The renal biopsy revealed a diffuse endocapillary cell proliferation with preponderant deposits of C3. Total recovery was achieved 4 months after Methyprednisolone pulse and Cyclophasphamid with antimicrobial treatment.

Gastrointestinal manifestations of long-term effects after COVID-19 infection in patients with dialysis or kidney transplantation:An observational cohort study

BACKGROUND Prolonged symptoms after corona virus disease 2019(Long-COVID) in dialysisdependent patients and kidney transplant(KT) recipients are important as a possible risk factor for organ dysfunctions,especially gastrointestinal(GI)problems,during immunosuppressive therapy.AIM To identify the characteristics of GI manifestations of Long-COVID in patients with dialysis-dependent or KT status.METHODS This observational,prospective study included patients with COVID-19 infection,confirmed by reverse transcription polymerase chain reaction,with the onset of symptoms between 1 January 2022 and 31 July 2022 which was explored at 3 mo after the onset,either through the out-patient follow-up or by telephone interviews.RESULTS The 645 eligible participants consisted of 588 cases with hemodialysis(HD),38 patients with peritoneal dialysis(PD),and 19 KT recipients who were hospitalized with COVID-19 infection during the observation. Of these,577(89.5%) cases agreed to the interviews,while 64(10.9%)patients with HD and 4(10.5%) cases of PD were excluded. The mean age was 52 ± 11 years with 52% women. The median dialysis duration was 7 ± 3 and 5 ± 1 years for HD and PD groups,respectively,and the median time post-transplantation was 6 ± 2 years. Long-COVID was identified in 293/524(56%) and 21/34(62%) in HD and PD,respectively,and 7/19(37%) KT recipients. Fatigue was the most prevalent(96%) of the non-GI tract symptoms,whereas anorexia(90.9%),loss of taste(64.4%),and abdominal pain(62.5%) were the first three common GI manifestations of Long-COVID. Notably,there were 6 cases of mesenteric panniculitis from 19patients with GI symptoms in the KT group.CONCLUSION Different from patients with non-chronic kidney disease,there was a high prevalence of GI manifestations of Long-COVID in dialysis-dependent patients and KT recipients. An appropriate long-term follow-up in these vulnerable populations after COVID-19 infection is possibly necessary.

Values of Donor Serum Lipids and Calcium in Predicting Graft Function after Kidney Transplantation:A Retrospective Study

Objective Delayed graft function(DGF)and early graft loss of renal grafts are determined by the quality of the kidneys from the deceased donor.As“non-traditional”risk factors,serum biomarkers of donors,such as lipids and electrolytes,have drawn increasing attention due to their effects on the postoperative outcomes of renal grafts.This study aimed to examine the value of these serum biomarkers for prediction of renal graft function.Methods The present study consecutively collected 306 patients who underwent their first single kidney transplantation(KT)from adult deceased donors in our center from January 1,2018 to December 31,2019.The correlation between postoperative outcomes[DGF and abnormal serum creatinine(SCr)after 6 and 12 months]and risk factors of donors,including gender,age,body mass index(BMI),past histories,serum lipid biomarkers[cholesterol,triglyceride,high-density lipoprotein(HDL)and low-density lipoprotein(DL)],and serum electrolytes(calcium and sodium)were analyzed and evaluated.Results(1)Donor age and pre-existing hypertension were significantly correlated with the incidence rate of DGF and high SCr level(≥2 mg/dL)at 6 and 12 months after KT(P<0.05);(2)The donor’s BMI was significantly correlated with the incidence rate of DGF after KT(P<0.05);(3)For serum lipids,merely the low level of serum HDL of the donor was correlated with the reduced incidence rate of high SCr level at 12 months after KT[P<0.05,OR(95%CI):0.425(0.202–0.97)];(4)The serum calcium of the donor was associated with the reduced incidence rate of high SCr level at 6 and 12 months after KT[P<0.05,OR(95%CI):0.184(0.045–0.747)and P<0.05,OR(95%CI):0.114(0.014–0.948),respectively].Conclusion The serum HDL and calcium of the donor may serve as predictive factors for the postoperative outcomes of renal grafts after KT,in addition to the donor’s age,BMI and pre-existing hypertension.

Donor-Derived Transmission of Scedosporiosis in Kidney Transplant Recipients from a Systemic lupus erythematosus donor

Donor-derived infection(DDI)associated with Scedosporium spp is extremely rare,and results in a very poor prognosis.The present study reports a probable DDI due to Scedosporium boydii(S.boydii)from a donor with neuropsychiatric systemic lupus erythematosus.Two recipients developed Scedosporiosis after kidney transplantation from the same donor.Recipient 1 died of central nervous system infection due to S.boydii based on the clinical presentations,and the positive metagenomic next-generation sequencing(mNGS)and culture results for the cerebrospinal fluid.The other recipient with urinary tract obstruction due to S.boydii,which was identified through the positive culture and mNGS results of the removed stents,was successfully treated by stent replacement and voriconazole administration.Undiagnosed disseminated donor infection and the transmission of S.boydii should be given attention,particularly when the donor and recipients have primary immunodeficiency disease.The screening of donors and recipients for S.boydii using mNGS may be helpful in guiding antifungal prophylaxis and treatment recipients,due to its higher sensitivity and shorter diagnostic time relative to other traditional techniques.

Psychological review of hemodialysis patients and kidney transplant recipients during the COVID-19 pandemic

BACKGROUND Kidney transplantation(KT)and end-stage renal disease(ESRD)requiring hemodialysis(HD)increase the incidence of morbidity and mortality associated with coronavirus disease 2019(COVID-19)infection.The COVID-19 pandemic has had a negative effect on the psychological well-being of COVID-19 patients,especially those with a high-risk of infectious complications.The prevalence of anxiety and depression is known to be higher in ESRD patients undergoing HD than in the general population.On the other hand,KT recipients have different treatment requirements compared to HD patients,including adherence to complex immunosuppressive regimens and compliance with follow-up appointments.We hypothesized that psychosocial difficulties and stressors would differ between ESRD patients undergoing HD and KT recipients during the COVID-19 pandemic.If so,each group may require different interventions to maintain their psychosocial well-being.AIM To measure and compare the levels of stress,anxiety,depression,concerns related to the pandemic,and coping skills in ESRD patients undergoing HD and KT recipients during the COVID-19 pandemic.METHODS This cross-sectional study was performed at a training and research hospital.The study included ESRD patients undergoing HD(HD group)and KT recipients(with stable graft function for≥6 mo prior to the study)(KT group).Patients completed a demographics form,the impact of events scale,the hospital anxiety and depression scale,and the Connor-Davidson resilience scale.Laboratory findings at the last clinical follow-up were recorded.Theχ^(2)test was used to assess the relationship between the HD and KT groups and the categorical variables.The relationships between the scale scores were analyzed using Pearson’s correlation test,and differences between the groups were analyzed using the independent groups t-test.RESULTS The study included 125 patients,of which 89(71.2%)were in the HD group and 36(28.8%)were in the KT group.The levels of anxiety and depression were higher in the HD group than in the KT group[9.36±4.38 vs 6.89±4.06(P=0.004)and 8.78±4.05 vs 6.42±4.26(P=0.004),respectively],whereas the post-traumatic stress score was higher in the KT group[46.75±13.98 vs 37.66±18.50(P=0.009)].The concern with the highest intensity in the HD group was transmission of COVID-19 to family and friends(93.3%)and in the KT group was loss of caregiver and social support(77.8%).Concerns regarding financial hardship,stigmatization,loneliness,limited access to health care services,failure to find medical supplies,and transmission of COVID-19 to family and friends were more prevalent in the HD group.Connor-Davidson resilience scale tenacity and personal competence,tolerance,and negative affect scores were higher in the KT group than in the HD group[43.47±11.39 vs 33.72±12.58,15.58±4.95 vs 11.45±5.05,and 68.75±17.39 vs 55.39±18.65(P<0.001),respectively].Biochemical parameters,such as creatine,urea,phosphorus,parathyroid hormone,and calcium,were lower,and the albumin and hemoglobin values were higher in the KT group than in the HD group(P<0.001).CONCLUSION Psychosocial difficulties and the level of stress differ in ESRD patients undergoing HD and KT recipients;therefore,psychosocial interventions should be tailored for each patient group.

Shifting perspectives in liver diseases after kidney transplantation

Liver diseases after kidney transplantation range from mild biochemical abnormalities to severe hepatitis or cirrhosis.The causes are diverse and mainly associated with hepatotropic viruses,drug toxicity and metabolic disorders.Over the past decade,the aetiology of liver disease in kidney recipients has changed significantly.These relates to the use of direct-acting antiviral agents against hepatitis C virus,the increasing availability of vaccination against hepatitis B and a better understanding of drug-induced hepatotoxicity.In addition,the emergence of the severe acute respiratory syndrome coronavirus 2 pandemic has brought new challenges to kidney recipients.This review aims to provide healthcare professionals with a comprehensive understanding of recent advances in the management of liver complications in kidney recipients and to enable them to make informed decisions regarding the risks and impact of liver disease in this population.

Successful treatment of a case of COVID-19 pneumonia following kidney transplantation using paxlovid and tocilizumab

BACKGROUND Since its initial detection in 2019,coronavirus disease 2019(COVID-19)pneumonia has rapidly spread throughout the world in a global pandemic.However,reports of COVID-19 pneumonia among patients following kidney transplantation have been limited and no uniform treatment guidelines for these patients have yet to be established.CASE SUMMARY Here,we report the case of a 39-year-old patient recovering from kidney transplantation who contracted perioperative COVID-19 pneumonia that was successfully controlled with oral paxlovid and a single intravenous drip infusion of tocilizumab following the discontinuation of immunosuppressive drugs.CONCLUSION Given the rapid spread of severe acute respiratory syndrome coronavirus 2 infections,clinicians should be aware of the potential for more cases of COVID-19 among patients following kidney transplantation and be familiar with appropriate treatment options and likely clinical outcomes.

Diagnosis and treatment of Whipple disease after kidney transplantation:A case report

BACKGROUND Kidney transplantation is the standard treatment for end-stage renal disease.Particularly,rare and specific pathogenic infections which are asymptomatic are often difficult to diagnose,causing delayed and ineffective treatment and thus seriously affecting prognosis.Tropheryma whipplei(T.whipplei)is a Gram-positive actinomycete widely found in soil,sewage,and other external environments and is present in the population as an asymptomatic pathogen.There is relatively little documented research on T.whipplei in renal transplant patients,and there are no uniform criteria for treating this group of post-transplant patients.This article describes the treatment of a 42-year-old individual with post-transplant T.whipplei infection following kidney transplantation.CASE SUMMARY To analyze clinical features of Whipple’s disease and summarize its diagnosis and treatment effects after renal transplantation.Clinical data of a Whipple’s disease patient treated in the affiliated hospital of Guizhou Medical University were collected and assessed retrospectively.The treatment outcomes and clinical experience were then summarized via literature review.The patient was admitted to the hospital due to recurrent diarrhea for 1 mo,shortness of breath,and 1 wk of fever,after 3 years of renal transplantation.The symptoms of the digestive and respiratory systems were not significantly improved after adjusting immunosuppressive regimen and anti-diarrheal,empirical antibiotic treatments.Bronchoscopic alveolar fluid was collected for meta-genomic next-generation sequencing(mNGS).The deoxyribonucleic acid sequence of Tropheryma whipplei was detected,and Whipple’s disease was diagnosed.Meropenem,ceftriaxone,and other symptomatic treatments were given,and water-electrolyte balance was maintained.Symptoms resolved quickly,and the patient was discharged after 20 d of hospitalization.The compound sulfamethoxazole tablet was continued for 3 mo after discharge.No diarrhea,fever,and other symptoms occurred during the 6-month follow-up.CONCLUSION Whipple’s disease is rare,with no specific symptoms,which makes diagnosis difficult.Polymerase chain reaction or mNGS should be immediately performed when the disease is suspected to confirm the diagnosis.

Efficacy and safety of local candida immunotherapy in recalcitrant warts in pediatric kidney transplantation:A case report

BACKGROUND Warts are common in recipients of kidney transplantation(KT).Resistant warts which are not amenable to conventional therapies may lead to significant morbidity.Limited data exists on safety and efficacy of local immunotherapy among immunocompromised KT recipients.CASE SUMMARY We report a seven-year-old child who presented with recalcitrant plantar periungual warts in the early KT period.Immunosuppression consisted of tacrolimus,mycophenolate and steroid.Due to failure of conventional anti-wart therapies,he was treated with two sessions of intralesional(IL)candida immunotherapy along with liquid nitrogen cryotherapy leading to complete resolution of the warts.Interestingly,de novo BK viremia was seen about three weeks following the last candida immunotherapy.This required reduction of immunosuppression and other anti-BK viral therapies.Allograft function remained stable but there were donor specific antibodies detected.There also was elevated level of plasma donor derived cell-free DNA.A pneumocystis jirovecii pneumonia occurred ten months following completion of immunotherapy that was successfully treated with trimethoprim-sulfamethoxazole.During this ten-month follow-up period,there have been no recurrence of warts,and transplant kidney function has remained stable.CONCLUSION Stimulation of cell-mediated immunity against the human papilloma virus induced by the IL candida immunotherapy is thought to be a cause for wart resolution.With this therapy,whether it is necessary to augment the immunosuppression to prevent rejection is unclear as that may come with a risk of infectious complications.Larger,prospective studies in pediatric KT recipients are needed to explore these important issues.

Infertility,pregnancy and breastfeeding in kidney transplantation recipients:Key issues

Chronic kidney disease(CKD),especially in advanced stages,is an important cause of infertility.In CKD patients,infertility has been linked to multiple factors.The pathophysiology of infertility related to CKD is complex and forked.Correction of modifiable factors can improve fertility in both genders.In males as well as females,successful kidney transplantation offers good chances of restoration of reproductive function.In female renal allograft recipients,recovery of reproductive functions in the post-transplant period will manifest as restoration of normal menses and ovulation.Owing to this improvement,there is a significant risk of unplanned pregnancy,hence the need to discuss methods of contraception before transplantation.In kidney transplant recipients,different contraceptive options for pregnancy planning,have been used.The selection of one contraception over another is based on preference and tolerability.Pregnancy,in renal transplanted females,is associated with physiologic changes that occur in pregnant women with native kidneys.Immunosuppressive medications during pregnancy,in a recipient with a single functioning kidney,expose the mother and fetus to unwanted complications.Some immunosuppressive drugs are contraindicated during pregnancy.Immunosuppressive medications should be discussed with renal transplant recipients who are planning to breastfeed their babies.In addition to antirejection drugs,other medications should be managed accordingly,whenever pregnancy is planned.

Cryptococcosis in kidney transplant recipients:Current understanding and practices

Cryptococcosis is the third most commonly occurring invasive fungal disease in solid organ transplant recipients(SOT).It is caused by encapsulated yeast,Cryptococcus species,predominantly Cryptococcus neoformans and Cryptococcus gattii.Though kidney transplant recipients are at the lowest risk of cryptococcosis when compared to other solid organ transplant recipients such as lung,liver or heart,still this opportunistic infection causes significant morbidity and mortality in this subset of patients.Mortality rates with cryptococcosis range from 10%-25%,while it can be as high as 50%in SOT recipients with central nervous system involvement.The main aim of diagnosis is to find out if there is any involvement of the central nervous system in disseminated disease or whether there is only localized pulmonary involvement as it has implications for both prognostication and treatment.Detection of cryptococcal antigen(CrAg)in cerebrospinal fluid or plasma is a highly recommended test as it is more sensitive and specific than India ink and fungal cultures.The CrAg lateral flow assay is the single point of care test that can rapidly detect cryptococcal polysaccharide capsule.Treatment of cryptococcosis is challenging in kidney transplant recipients.Apart from the reduction or optimization of immunosuppression,lipid formulations of amphotericin B are preferred as induction antifungal agents.Consolidation and maintenance are done with fluconazole;carefully monitoring its interactions with calcineurin inhibitors.This review further discusses in depth the evolving developments in the epidemiology,pathogenesis,diagnostic assays,and management approach of cryptococcosis in kidney transplant recipients.

Reasons and effects of the decline of willing related potential living kidney donors

BACKGROUND Although the availability of related living donors(LDs)provides a better chance for receiving kidney transplantation(KT),the evaluation protocols for LD selection remain a safeguard for the LD’s safety.These protocols are variable from one center to another,resulting in variable rates of decline of the potential LDs(PLDs).The decline of willing PLDs may occur at any stage of evaluation,starting from the initial contact and counseling to the day of operation.AIM To identify the causes of the decline of PLDs,the predictors of PLD candidacy,and the effect on achieving LDKT.METHODS A retrospective study was performed on the willing PLDs who attended our outpatient clinic for kidney donation to their related potential recipients between October 2015 and December 2022.The variables influencing their candidacy rate and the fate of their potential recipients were studied.Two groups of PLDs were compared:Candidate PLDs after a completed evaluation vs non-candidate PLDs with a complete or incomplete evaluation.A multivariate logistic regression was performed to assess the factors contributing to the achievement of PLD candidacy.RESULTS Of 321 willing PLDs,257 PLDs(80.1%)accessed the evaluation to variable extents for 212 potential recipients,with a mean age(range)of 40.5±10.4(18-65)years,including 169 females(65.8%).The remaining 64 PLDs(19.9%)did not access the evaluation.Only 58 PLDs(18.1%)succeeded in donating,but 199 PDLs(62.0%)were declined;exclusion occurred in 144 PLDs(56.0%)for immunological causes(37.5%),medical causes(54.9%),combined causes(9.7%),and financial causes(2.1%).Regression and release occurred in 55 PLDs(17.1%).The potential recipients with candidate PLDs were not significantly different from those with non-candidate PLDs,except in age(P=0.041),rates of completed evaluation,and exclusion of PLDs(P<0.001).There were no factors that independently influenced the rate of PLD candidacy.Most patients who failed to have KT after the decline of their PLDs remained on hemodialysis for 6 mo to 6 years.CONCLUSION The rate of decline of willing related PLDs was high due to medical or immunological contraindications,release,or regression of PLDs.It reduced the chances of high percentages of potential recipients in LDKT.

Sodium-glucose cotransporter-2 inhibitor use in kidney transplant recipients

Sodium-glucose cotransporter-2 inhibitors(SGLT2i)are novel oral hypoglycemic agents garnering much attention for their substantial benefits.These recent data have positioned SGLT2i at the forefront of diabetic chronic kidney disease(CKD)and heart failure management.SGLT2i use post-kidney transplant is an emerging area of research.Highlights from this mini review include the following:Empagliflozin is the most prescribed SGLT2i in kidney transplant recipients(KTRs),median time from transplant to initiation was 3 years(range:0.88-9.6 years).Median baseline estimated glomerular filtration rate(eGFR)was 66.7 mL/min/1.73 m2(range:50.4-75.8).Median glycohemoglobin(HgbA1c)at initiation was 7.7%(range:6.9-9.3).SGLT2i were demonstrated to be effective short-term impacting HgbA1c,eGFR,hemoglobin/hematocrit,serum uric acid,and serum magnesium levels.They are shown to be safe in KTRs with low rates of infections,hypoglycemia,euglycemic diabetic ketoacidosis,and stable tacrolimus levels.More data is needed to demonstrate long-term outcomes.SGLT2i appear to be safe,effective medications for select KTRs.Our present literature,though limited,is founded on precedent robust research in CKD patients with diabetes.Concurrent research/utilization of SGLT2i is vital to not only identify long-term patient,graft and cardiovascular outcomes of these agents,but also to augment management in KTRs.