Efficacy and safety of non-vitamin K antagonist oral anticoagulants post-kidney transplantation

BACKGROUND Novel oral anticoagulants(NOACs)were developed as alternatives to vitamin K antagonists,primarily warfarin,as they do not require routine monitoring and have limited drug-drug and drug-food interactions.However,the efficacy and safety of these agents in kidney transplantation are not well studied.AIM To assess the profile and safety of NOACs for patients who had kidney transplantation,and to provide recommendations and guidelines on therapeutic strategies in these patients.METHODS This was a retrospective study carried out among adult patients who were actively on the following NOACs(apixaban,rivaroxaban or dabigatran)in our renal transplantation program from December 2015 to December 2016.The patients were identified primarily through electronic medical record system(patient data linkage).Data on the clinical and laboratory profile of the patients were retrieved and analyzed with SPSS 22.0.RESULTS Complete data on 42 renal transplant patients were retrieved:59.5%males,90.5%were whites and 66.7%were older than 60 years old.The mean duration since renal transplantation of the patients was 8.8±7.4 years.The most common risk factors for the development of end-stage renal disease in the subjects were hypertension(19.0%),polycystic kidney disease(19.0%),followed by diabetic nephropathy(16.7%)and chronic glomerulonephritis(16.7%).The main indications for NOACs use in the cohort were atrial fibrillation in 25 patients(59.5%)and venous thromboembolism in 10 patients(23.8%).Overall,29 patients(69%)were treated with apixaban,10 patients(23.8%)with rivaroxaban and 3 patients(7.14%)with dabigatran.No(0%)thromboembolic events were observed during the one-year period,but 3(7.1%)bleeding events occurred in the cohort consisting of 1 patient treated with rivaroxaban 15 mg daily and 2 patients who received apixaban 2.5 mg twice daily.There were no significant changes in serum tacrolimus level three days after the initiation of NOACs among patients treated with tacrolimus(pre-and post-NOACs tacrolimus levels were 7.2516 and 7.8867 ng/m L,P=0.55,respectively).Also,after one-year of treatment with NOACs there were no significant changes in the pre-and post-NOACs serum creatinine level(P=0.772)and estimated glomerular filtration rates(P=0.232).CONCLUSION No thromboembolic events or significant changes in renal profile were observed in our cohort of kidney transplant recipients who were treated with NOACs for at least a year.However,a few bleeding events were observed.This calls for further well-planned randomized controlled trials to assess the efficacy and safety of NOACs among renal transplant recipients.

Acute kidney injury and post-reperfusion syndrome in liver transplantation

In the past decades liver transplantation(LT) has become the treatment of choice for patients with end stage liver disease(ESLD). The chronic shortage of cadaveric organs for transplantation led to the utilization of a greater number of marginal donors such as older donors or donors after circulatory death(DCD). The improved survival of transplanted patients has increased the frequency of long-term complications, in particular chronic kidney disease(CKD). Acute kidney injury(AKI) post-LT has been recently recognized as an important risk factor for the occurrence of denovo CKD in the long-term outcome. The onset of AKI post-LT is multifactorial, with pre-LT risk factors involved, including higher Model for End-stage Liver Disease score, more sever ESLD and pre-existing renal dysfunction, either with intra-operative conditions, in particular ischaemia reperfusion injury responsible for post-reperfusion syndrome(PRS) that can influence recipient's morbidity and mortality. Post-reperfusion syndrome-induced AKI is an important complication post-LT that characterizes kidney involvement caused by PRS with mechanisms not clearly understood and implication on graft and patient survival. Since preLT risk factors may influence intra-operative events responsible for PRS-induced AKI, we aim to consider all the relevant aspects involved in PRS-induced AKI in the setting of LT and to identify all studies that better clarified the specific mechanisms linking PRS and AKI. A Pub Med search was conducted using the terms liver transplantation AND acute kidney injury; liver transplantation AND post-reperfusion syndrome; acute kidney injury AND post-reperfusion syndrome; acute kidney injury AND DCD AND liver transplantation. Five hundred seventy four articles were retrieved on Pub Med search. Results were limited to title/abstract of English-language articles published between 2000 and 2015. Twenty-three studies were identified that specifically evaluated incidence, risk factors and outcome for patients developing PRS-induced AKI in liver transplantation. In order to identify intra-operative risk factors/mechanisms specifically involved in PRSinduced AKI, avoiding confounding factors, we have limited our study to "acute kidney injury AND DCD AND liver transplantation". Accordingly, three out of five studies were selected for our purpose.

Wireless capsule endoscopy in the investigation of patients with chronic renal failure and obscure gastrointestinal bleeding (preliminary data)

AIM： To investigate the role of wireless capsule endoscopy （WCE） in detection of small bowel （SB） pathology in patients with chronic renal failure （CRF） and obscure bleeding. METHODS： Consecutive CRF patients with obscure bleeding were prospectively studied. Patients with normal renal function and obscure bleeding, investigated during the same period with WCE, were used for the interpretation of results. RESULTS： Seventeen CRF patients （11 overt, 6 occult bleeding） and 51 patients （33 overt, 18 occult bleeding） with normal renal function were enrolled in this study. Positive SB findings were detected in 70.6% of CRF patients and in 41.2% of non-CRF patients （P〈0.05）. SB angiodysplasia was identified in 47% of CRF patients and in 17.6% of non-CRF patients. Univariate logistic regression revealed CRF as a significant predictive factor for angiodysplasia （P〈0.05）. Therapeutic measures were undertaken in 66% of the patients with the positive findings. CONCLUSION： According to our preliminary results, SB angiodysplasia was found in an increased prevalence among CRF patients with obscure bleeding. WCE is useful in diagnosis of gastrointestinal pathologies and in planning appropriate therapeutic intervention and, therefore, should be included in the work-up of this group of patients.

Cardiovascular disease: Risk factors and applicability of a risk model in a Greek cohort of renal transplant recipients

AIM To investigate the incidence and the determinants of cardiovascular morbidity in Greek renal transplant recipients(RTRs) expressed as major advance cardiac event(MACE) rate. METHODS Two hundred and forty-two adult patients with a functioning graft for at least three months and availabledata that were followed up on the August 31, 2015 at two transplant centers of Western Greece were included in this study. Baseline recipients' data elements included demographics, clinical characteristics, history of comorbid conditions and laboratory parameters. Follow-up data regarding MACE occurrence were collected retrospectively from the patients' records and MACE risk score was calculated for each patient. RESULTS The mean age was 53 years(63.6% males) and 47 patients(19.4%) had a pre-existing cardiovascular disease(CVD) before transplantation. The mean estimated glomerular filtration rate was 52 ± 17 mL /min per 1.73 m2. During follow-up 36 patients(14.9%) suffered a MACE with a median time to MACE 5 years(interquartile range: 2.2-10 years). Recipients with a MACE compared to recipients without a MACE had a significantly higher mean age(59 years vs 52 years, P < 0.001) and a higher prevalence of pre-existing CVD(44.4% vs 15%, P < 0.001). The 7-year predicted mean risk for MACE was 14.6% ± 12.5% overall. In RTRs who experienced a MACE, the predicted risk was 22.3% ± 17.1% and was significantly higher than in RTRs without an event 13.3% ± 11.1%(P = 0.003). The discrimination ability of the model in the Greek database of RTRs was good with an area under the receiver operating characteristics curve of 0.68(95%CI: 0.58-0.78).CONCLUSION In this Greek cohort of RTRs, MACE occurred in 14.9% of the patients, pre-existing CVD was the main risk factor, while MACE risk model was proved a dependable utility in predicting CVD post RT.

Renal transplantation with expanded criteria donors: Which is the optimal immunosuppression?

The growing gap between demand and supply for kidney transplants has led to renewed interest in the use of expanded criteria donor(ECD) kidneys in an effort to increase the donor pool. Although most studies of ECD kidney transplantation confirm lowerallograft survival rates and, generally, worse outcomes than standard criteria donor kidneys, recipients of ECD kidneys generally have improved survival compared with wait-listed dialysis patients, thus encouraging the pursuit of this type of kidney transplantation. The relative benefits of transplantation using kidneys from ECDs are dependent on patient characteristics and the waiting time on dialysis. Because of the increased risk of poor graft function, calcineurin inhibitor(CNI)-induced nephrotoxicity, increased incidence of infections, cardiovascular risk, and malignancies, elderly recipients of an ECD kidney transplant are a special population that requires a tailored immunosuppressive regimen. Recipients of ECD kidneys often are excluded from transplant trials and, therefore, the optimal induction and maintenance immunosuppressive regimen for them is not known. Approaches are largely center specific and based upon expert opinion. Some data suggest that antithymocyte globulin might be the preferred induction agent for elderly recipients of ECD kidneys. Maintenance regimens that spare CNIs have been advocated, especially for older recipients of ECD kidneys. CNI-free regimens are not universally accepted due to occasionally high rejection rates. However, reduced CNI exposure and CNI-free regimens based on mammalian target of rapamycin inhibitors have shown acceptable outcomes in appropriately selected ECD transplant recipients.

Subclinical proximal tubulopathy in hepatitis B:The roles of nucleot(s)ide analogue treatment and the hepatitis B virus

BACKGROUND The recommended monitoring tools for evaluating nucleot(s)ide analogue renal toxicity,such as estimated glomerular filtration rate(eGFR)and phosphatemia,are late markers of proximal tubulopathy.Multiple early markers are available,but no consensus exists on their use.AIM To determine the 24 mo prevalence of subclinical proximal tubulopathy(SPT),as defined with early biomarkers,in treated vs untreated hepatitis B virus(HBV)-monoinfected patients.METHODS A prospective,non-randomized,multicenter study of HBV-monoinfected patients with a low number of renal comorbidities was conducted.The patients were separated into three groups:Naïve,starting entecavir(ETV)treatment,or starting tenofovir disoproxil(TDF)treatment.Data on the early markers of SPT,the eGFR and phosphatemia,were collected quarterly.SPT was defined as a maximal tubular reabsorption of phosphate/eGFR below 0.8 mmoL/L and/or uric acid fractional excretion above 10%.The prevalence and cumulative incidence of SPT at month 24(M24)were calculated.Quantitative data were analyzed using analyses of variance or Kruskal-Wallis tests,whereas chi-squared or Fisher’s exact tests were used to analyze qualitative data.Multivariate analyses were used to adjust for any potential confounding factors.RESULTS Of the 196 patients analyzed,138(84 naïve,28 starting ETV,and 26 starting TDF)had no SPT at inclusion.At M24,the prevalence of SPT was not statistically different between naïve and either treated group(21.1%vs 30.7%,P<0.42 and 50.0%vs 30.7%,P=0.32 for ETV and TDF,respectively);no patient had an eGFR lower than 50 mL/min/1.73 m²or phosphatemia less than 0.48 mmoL/L.In the multivariate analysis,no explanatory variables were identified after adjustment.The cumulative incidence of SPT over 24 mo(25.5%,13.3%,and 52.9%in the naïve,ETV,and TDF groups,respectively)tended to be higher in the TDF group vs the naïve group(hazard ratio:2.283,P=0.05).SPT-free survival at M24 was 57.6%,68.8%,and 23.5%for the naïve,ETV,and TDF groups,respectively.The median survival time without SPT,evaluated only in the TDF group,was 5.9 mo.CONCLUSION The prevalence and incidence of SPT was higher in TDF-treated patients compared to naïve patients.SPT in the naïve population suggests that HBV can induce renal tubular toxicity.

Challenges of pancreas transplantation in developing countries,exploring the Turkey example

Pancreas transplantation significantly improves the quality of life for people with type 1 diabetes,primarily by eliminating the need for insulin and frequent blood glucose measurements.Despite the growing numbers of solid organ transplantations worldwide,number of pancreas transplantations in the developing countries`remain significantly low.This difference of pancreas transplantation practices was striking among the participating countries at the 1st International Transplant Network Meeting which was held in Turkey on 2018.In this meeting more than 40 countries were represented.Most of these counties were developing countries located in Africa,Middle East or Asia.The aim of this article is to identify the challenges and limiting factors for pancreas transplantations in these developing countries,by exploring the Turkish example.The challenges faced by the developing countries are broadly classified in four categories;wait-listing,donor pool,team work and follow up.Under these categorical titles,issues are further discussed in detail,giving examples from Turkish practice of pancreas transplantation.Additionally,several solutions to these challenges have been proposed-some of which have already been undertaken by the Turkish Ministry of Health.With the insight and methods presented in this article,pancreas transplantation should be made possible for the potential recipients in the developing countries.

Renal Vein Thrombosis Suggestive of Extramembranous Glomerulonephritis Associated with Sjögren’s Syndrome (Case Report)

Introduction: Glomerular damage during Gougerot-Sjgren syndrome is much rarer than interstitial damage, and is essentially extra-membranous and membrano-proliferative glomerulonephritis. Observation: We report the case of a 44-year-old woman with primary Sjgrens syndrome, confirmed by clinical dryness syndrome, positive anti-SSA and anti-SSB antibodies, and a salivary gland biopsy revealing grade 4 lymphocytic sialadenitis according to CHISHOLMs classification. Later, the patient developed nephrotic syndrome, along with hypertension. Renal function remained normal with a creatinine level of 9.3 mg/l, and hematuria was absent. Only antinuclear antibodies tested positive, while anti-PLA2R antibodies were negative. A renal biopsy was performed, which was complicated on the same day by hemodynamic instability with hematuria. Renal CT scan with contrast injection revealed a posterior perirenal hematoma without contrast extravasation. Additionally, bilateral renal vein thrombosis was incidentally discovered, suggesting extramembranous glomerulonephritis. The patients hemodynamic status stabilized after fluid resuscitation with isotonic saline solution (0.9%), without the need for blood transfusion. Renal biopsy confirmed extramembranous glomerulonephritis with interstitial fibrosis and minimal tubular atrophy. The initial etiological assessment was negative. The patient was started on oral corticosteroids, angiotensin-converting enzyme inhibitors, and therapeutic anticoagulation for renal vein thrombosis. The patients condition improved, with the disappearance of the syndrome and spontaneous regression of the hematoma. Discussion: The association of nephrotic syndrome and renal vein thrombosis primarily suggests glomerulopathy, in particular extra-membranous glomerulonephritis. Sjgrens syndrome can be associated with extra-membranous glomerulonephritis without being its direct cause. Like, it is possible that it is a cause of glomerulonephritis, essentially extra membranous and membrano-proliferative. Conclusion: Sjgrens syndrome is generally underestimated cause of glomerulonephritis, which should be considered in cases of extra-membranous glomerulonephritis.

Fluid resuscitation in acute pancreatitis: Normal saline or lactated Ringer's solution?

AIM: To investigate whether administration of Ringer's solution(RL) could have an impact on the outcome of acute pancreatitis(AP).METHODS: We conducted a retrospective study on 103 patients [68 men and 35 women,mean age 51.2 years(range,19-92 years)] hospitalized between 2011 and 2012. All patients admitted to the Department of Gastroenterology of the Central Clinical Hospital of the Ministry of Interior(Poland) with a diagnosis of AP who had disease onset within 48 h of presentation were included in this study. Based on the presence of persistent organ failure(longer than 48 h) as a criterion for the diagnosis of severe AP(SAP) and the presence of local complications [diagnosis of moderately severe AP(MSAP)],patients were classified into 3 groups: mild AP(MAP),MSAP and SAP. Data were compared between the groups in terms of severity(using the revised Atlanta criteria) and outcome. Patients were stratified into 2 groups based on the type of fluid resuscitation: the 1-RL group who underwent standard fluid resuscitation with a RL 1000 m L solution or the 2-NS group who underwent standard fluid resuscitation with 1000 m L normal saline(NS). All patients from both groups received an additional 5% glucose solution(1000-1500 m L) and a multi-electrolyte solution(500-1000 m L).RESULTS: We observed 64(62.1%) patients with MAP,26(25.24%) patients with MSAP and 13(12.62%) patients with SAP. No significant difference in the distribution of AP severity between the two groups was found. In the 1-RL group,we identified 22(55.5%) MAP,10(25.5%) MSAP and 8(20.0%) SAP patients,compared with 42(66.7%) MAP,16(24.4%) MSAP and 5(7.9%) SAP cases in the 2-NS group(P = 0.187). The volumes of fluid administered during the initial 72-h period of hospitalization were similar among the patients from both the 1-RL and 2-NS groups(mean 3400 m L vs 3000 m L,respectively). No significant differences between the 1-RL and 2-NS groups were found in confirmed pancreatic necrosis [10 patients(25%) vs 12 patients(19%),respectively,P = 0.637]. There were no statistically significant differences between the 1-RL and 2-NS groups in the percentage of patients who required enteral nutrition(23 patients vs 17 patients,respectively,P = 0.534). Logistic regression analysis confirmed these findings(OR = 1.344,95%CI: 0.595-3.035,P = 0.477). There were no significant differences between the 1-RL and 2-NS groups in mortality and the duration of hospital stay(median of 9 d for both groups,P = 0.776).CONCLUSION: Our study failed to find any evidence that the administration of RL in the first days of AP leads to improved clinical outcomes.

Factors associated with irritable bowel syndrome symptoms in hemodialysis patients

AIM: To investigate clinical characteristics associated with the presence of irritable bowel syndrome (IBS) symptoms in hemodialysis (HD) patients.METHODS: This was a cross-sectional study. A questionnaire based on the Bowel Disease Questionnaire that records gastrointestinal symptoms was given to 294 patients in 4 dialysis centers. A total of 196 (67%) subjects returned the survey. A multivariable logistic regression model was used to identify factors significantly associated with IBS symptoms. RESULTS: Symptoms compatible with IBS were present in 27 (13.8%) subjects and independently associated with low post-dialysis serum potassium [OR = 0.258, 95% CI (0.075-0.891), P = 0.032], paracetamol use [OR = 3.159, 95% CI (1.214-8.220), P = 0.018], and Kidney Disease Quality of Life (KDQOL) cognitive function score [OR = 0.977, 95% CI (0.956-0.999), P = 0.042]. Univariate regressions were also performed and the reported significance is for multivariate analysis. No association was detected for age, gender, depressed mood, smoking (present or past), body mass index, albumin level, Kt/V, sodium preor post-dialysis level, change in potassium level during HD, proton pump inhibitor or H2 blocker use, aspirin use, residual diuresis, hepatitis B or C infection, diabetes mellitus, marital status and education level. CONCLUSION: This study examined potential risk factors for symptoms compatible with IBS in HD patients and identified an association with paracetamol use, post-dialysis potassium level and KDQOL-cognitive function score.

COVID-19 infection in a kidney transplant recipient—special emphasis on pharmacokinetic interactions:A case report

BACKGROUND Solid organ transplant recipients are considered to be at high-risk of developing coronavirus disease 2019(COVID-19)-related complications.The optimal treatment for this patient group is unknown.Consequently,the treatment of COVID-19 in kidney transplant recipients should be determined individually,considering patient age and comorbidities,as well as graft function,time of transplant,and immunosuppressive treatment.Immunosuppressive treatments may give rise to severe COVID-19.On the contrary,they may also lead to a milder and atypical presentation by diminishing the immune system overdrive.CASE SUMMARY A 50-year old female kidney transplant recipient presented to the transplant clinic with a progressive dry cough and fever that started three days ago.Although the COVID-19 test was found to be negative,chest computed tomography images showed consolidation typical of the disease;thus,following hospital admission,anti-bacterial and COVID-19 treatments were initiated.However,despite clinical improvement of the lung consolidation,her creatinine levels continued to increase.Ultrasound of the graft showed no pathology.The tacrolimus blood level was determined and the elevation in creatinine was found to be related to an interaction between tacrolimus and azithromycin.CONCLUSION During the COVID-19 pandemic,various single or combination drugs have been utilized to find an effective treatment regimen.This has increased the possibility of drug interactions.A limited number of studies published in the literature have highlighted some of these pharmacokinetic interactions.Treatments used for COVID-19 therapy;azithromycin,atazanavir,lopinavir/ritonavir,remdesivir,favipiravir,chloroquine,hydroxychloroquine,nitazoxanide,ribavirin,and tocilizumab,interact with immunosuppressive treatments,most importantly with calcineurin inhibitors.Thus,their levels should be frequently monitored to prevent toxicity.

Is peri-transplant blood transfusion associated with worse transplant outcomes?A retrospective study

BACKGROUND Blood transfusion is common during the peri-transplantation period.The incidence of immunological reactions to blood transfusion after kidney transplantation and their consequences on graft outcomes have not been extensively studied.AIM To examine the risk of graft rejection and loss in patients who received blood transfusion in the immediate peri-transplantation period.METHODS We conducted a single-center retrospective cohort study of 105 kidney recipients,among them 54 patients received leukodepleted blood transfusion at our center between January 2017 and March 2020.RESULTS This study included 105 kidney recipients,of which 80%kidneys were from living-related donors,14%from living-unrelated donors,and 6%from deceased donors.Living-related donors were mostly first-degree relatives(74.5%),while the rest were second-degree relatives.The patients were divided into transfusion(n=54)and non-transfusion(n=51)groups.The average hemoglobin level at which blood transfusion was commenced was 7.4±0.9 mg/dL.There were no differences between the groups in terms of rejection rates,graft loss,or death.During the study period,there was no significant difference in creatinine level progression between the two groups.Delayed graft function was higher in the transfusion group;however,this finding was not statistically significant.A high number of transfused packed red blood cells was significantly associated with increased creatinine levels at the end of the study.CONCLUSION Leukodepleted blood transfusion was not associated with a higher risk of rejection,graft loss,or death in kidney transplant recipients.

Hypercalcemia: Is Dialysis Still an Option?

Hypercalcemia is a common disorder that can cause acute kidney failure, neurological damage up to coma, arrhythmia and cardiac arrest. The management of hypercalcemia is based on intravenous hydration with normal saline, when insufficient, bisphosphonate treatment is used. More recently, denosumab has shown significant benefit. Hemodialysis is an additional option in the treatment of severe refractory hypercalcemia when medical treatment is deemed ineffective or unavailable. It allows rapid correction of calcium levels, especially in patients with renal failure or cardiac co-morbidities, where hydration cannot be performed safely. The aim of our study was to compare hemodialysis as a therapeutic tool, to more conservative treatments. Our study is retrospective, descriptive, analytical and comparative, sprawling from January 2015 to June 2019 at the university hospital Hassan II in Fez. 78 patients with hypercalcemia were studied. The mean age was 55 ± 15 years and sex ratio M/F of 1.1. The mean corrected serum calcium at admission was 144 mg/l ± 23 mg/l. Malignancies represented 72.7% of all etiologies. Kidney injury was observed in 50 of our patients (64%). Mortality was noted in 16.6% of all cases. When comparing the 2 groups (patient on dialysis versus patient under other treatments), electrocardiogram abnormalities, patient who had high levels of calcium and those who had hyperparathyroidism were more likely to be on dialysis rate. In our study, even though we used relatively high calcium dialysate, we were able to achieve a decrease of 39% in patient’s calcemia in the hemodialysis group versus 27% decrease when using a combination of forced saline dieresis and bisphosphonate without a difference in term of mortality.

Systemic Capillary Leak Syndrome Secondary to COVID-19 Infection: Case Report

Introduction: Systemic capillary leak syndrome (SCLS) is an increasingly recognized rare syndrome. Its diagnosis is suggested by the occurrence of edema with arterial hypotension, hemoconcentration, and paradoxical hypoalbuminemia. SCLS can be idiopathic (Clarkson syndrome) or secondary. Secondary SCLS (SSCLS) is mainly triggered by infections (especially viruses), drugs (antitumor therapy), malignancies, and inflammatory diseases. We report a case of systemic capillary leak syndrome secondary to the COVID-19 infection. Observation: A 74-year-old chronic smoker with no particular history was initially admitted to the intensive care unit (ICU) with a picture of respiratory distress secondary to a COVID-19 infection with favorable evolution, hence his transfer to the emergency services. On Day 8 of hospitalization, following the installation of arterial hypotension, not responding to filling, associated with hypoalbuminemia, and generalized edematous syndrome, and in the absence of any other explanation for this clinical picture, a SCLS secondary to COVID-19 infection was suggested. On the balance sheet, after the discovery of acute renal failure, serum creatinine went from 7.9 mg/l to 16.6 mg/l with microalbuminuria at 420 mg/24h and leukocyturia at 20 elements/mm3 without germ-evoked tubulointerstitial nephritis (TIN) secondary to a viral infection with COVID-19. The evolution was marked by the spontaneous regression of the edema and the normalization of the blood pressure figures. Discussion: The classic triad combining hypotension, hemoconcentration, and hypoalbuminemia suggests the diagnosis of SCLS once all other causes of shock have been ruled out. Hemoconcentration is less constant in SSCLS than in ISCLS. This is the case with our patient. The exact pathophysiological process of SCLS is largely unknown. Viral infections are the most common infectious cause of SCLS. The kidneys are the second-most common organs affected by the SARS-Cov-2 coronavirus infection. The presence of nephritis can be used as an indicator of SCLS, which can be a predictor of serious complications such as fluid overload, respiratory failure, and the need for ICU admission. Conclusion: In the event of COVID-19 infection, the appearance of hypotension and hypoalbuminemia with the gradual onset of generalized edema should suggest SCLS. The establishment of close monitoring is mandatory, given the risk of fatal evolution. Fortunately, for our patient, the evolution was favorable.

Vlale patients with terminal renal failure exhibit low serum levels of antimullerian hormone

Male reproductive function is impaired during end-stage renal disease （ESRD）. Disturbance of the hypothalamic-pituitary-gonadal axis, and therefore the regulation of sex hormones, is one of the major causes. Our focus was to include antimLillerian hormone （AMH） and inhibin B concentrations. Twenty male patients on hemodialysis, median age 40 （26-48） years, were analyzed for follicle-stimulating hormone （FSH）, luteinizing hormone （LH）, prolactin, sex hormone-binding globulin （SHBG）, testosterone, estradiol, AMH and inhibin B levels. We used 144 proven fertile men, median age 32 （19-44） years as a control group and analyzed differences using multiple linear regression. Males with ESRD demonstrated higher mean values for prolactin, 742 versus normal 210 mlE 1-1 （95% confidence interval （Cl）： 60.3, 729）, LH, 8.87 versus normal 4.5 IE 1-1 （95% Ch 2.75, 6.14）, and estradiol 89.7 versus normal 79.0 pmol 1-1 （95% CI： -1.31, -0.15）. Mean value for AMH was lower, 19.5 versus normal 47.3 pmol 1-1 （95% Cl. -37.6, -11.6）. There were no differences found for FSH, SHBG, inhibin B and testosterone. The most important difference was found for AMH, a marker of Sertoli cell function in the testes, which decreased by close to 60% when compared with controls. Combined with an increase in LH, these findings may indicate a dysfunction of Sertoli cells and an effect on Leydig cells contributing to a potential mechanism of reproductive dysfunction in men with ESRD.