ABSTRACT SARS-Cov2 infection is a highly transmissible disease associated with serious pulmonary disease. Renal involvement is frequent and associated with poor prognosis; however, mechanisms of kidney injury are not well established. We present a SARS-Cov2 patient with severe acute kidney injury. Kidney biopsy findings revealed a pattern of acute tubular necrosis with isometric vacuolization of the proximal tubule. The interstitium and glomeruli were normal. Electronic microscopy showed multiple viral-like particles in both the glomeruli and proximal tubule. This case study shows how SARS-Cov 2 infection can result in different kinds of kidney lesion.

ABSTRACT Severe hypercalcemia can be either acute or decompensate from a chronic state to a medical emergency, the hypercalcemic crisis. The presence of symptoms such as altered mental status or potentially fatal ECG abnormalities demand an expeditious decrease in serum calcium levels. Standard medical therapy consists of vigorous volume replacement, calcitonin and, depending on the etiology, bisphosphonates, cinacalcet or glucocorticoids. Hypercalcemic crisis is a rare indication for urgent hemodialysis and is reserved for patients with severe symptoms, ineffective medical therapy or end stage renal disease. The use of hemodialysis in this scenario is not commonly reported. We hereby report a patient who presented with altered mental status and acute kidney injury due to a hypercalcemic crisis secondary to primary hyperparathyroidism. Treatment included urgent hemodialysis to effectively lower calcium levels.

Simultaneous kidney pancreas transplantation, if feasible, is the treatment of choice for the management of end-stage renal disease in patients with type 1 diabetes. This intervention can offer glycemic control and might also stabilize or even reverse some of the metabolic complications of diabetes. Chronic kidney disease has become a critical problem in orthotopic liver transplantation due to multiple risk factors, including post-transplant diabetes mellitus and immunosuppression. This has a major impact on graft and patient survival. In this paper we present the case of a 42-year-old man submitted to a simultaneous pancreas kidney transplant after a successful liver transplantation 18 years earlier. The surgical procedure was uneventful, and the patient was discharged 18 days after admission. The case findings support that simultaneous pancreas and kidney transplantation is an effective method for the treatment of chronic kidney disease in patients with diabetes and a previous liver transplant.

Typhlitis is a clinical entity rare in adults, reported in immunosuppressed patients. It is a life-threatening condition that occurs in neutropenic patients due to compromised integrity of the bowel wall and its exact pathogenesis is not completely understood. We report a 35-year-old man with a post deceased donor renal and pancreas transplantation status who presented fever and febrile neutropenia. Three days after admission he presented hematochezia with a hemoglobin drop. Colonoscopy revealed "ileum mucosa with multiforme ulcers" and since no other etiology was found, typhlitis was considered. He gradually improved with support treatment and was able to be managed non-operatively. To our knowledge, there are only six other reports of typhlitis in kidney transplant recipients.

A rejeição subclínica após transplante renal está associada a pior desfecho, que é prevenível se reconhecida precocemente. As biópsias protocoladas surgiram como uma opção para identificar e tratar a rejeição subclínica, embora o timingideal para realização da mesma não esteja estabelecido. Avaliámos retrospectivamente uma coorte de 52 doentes transplantados renais de novo de 2007 a 2010, com baixo risco clínico e imunológico. Obtivemos 2 grupos baseados na realização ou não de biópsia precoce protocolada do enxerto: Grupo A - 32 doentes (61,5%) foram submetidos a biópsia protocolada previamente à alta hospitalar, e Grupo B - 20 doentes (38,5%) em que a biópsia protocolada foi dispensada, por motivos diversos. Analisámos dados demográficos, complicações da biópsia, função do enxerto, episódios de rejeição e sobrevida do enxerto e dos doentes durante um período de seguimento de 63,3 meses (50,3-83,7). Os doentes do grupo A e do grupo B eram diferentes no que diz respeito ao género (mais mulheres no grupo A), tempo prévio em diálise (maior no grupo A), human leucocyte antigen mismatch (maior no grupo A) e protocolo de indução (mais doentes submetidos a timoglobulina do que basiliximab no grupo A). As biópsias protocoladas documentaram alterações histológicas em quatro doentes (12,5%) do grupo A (2 rejeições celulares e 2 borderline), todas tratadas. Registaram-se dois hematomas moderados peri renais (3,9% das biópsias). Apesar do risco mais elevado do grupo A, função renal à altura da alta era melhor do que no grupo B (p < 0,05 para creatinina sérica e eGFR). Durante o seguimento dos doentes, o número de rejeições foi idêntico nos dois grupos. No final do seguimento (mediana de 63,3 meses), a proteinúria e a função renal eram semelhantes nos dois grupos. No modelo de regressão multivariada, e apesar das diferenças clínicas iniciais, os doentes submetidos a biópsias protocoladas apresentaram resultados excelentes, semelhantes aos doentes de risco mínimo, não biopsados (p = 0,5). O momento da realização da biópsia protocolada precoce deve ser ajustado de acordo com o risco clínico e imunológico do doente

Subclinical rejection following renal transplant is associated with worse outcomes, which can be prevented if recognized early. Protocol allograft biopsies have emerged as an option to identify and allow treatment of subclinical rejection, but optimal timing for their performance is not established. We retrospectively evaluated a cohort of 52 low immunological risk patients, who were submitted, from 2007 to 2010, to de novo renal transplant. We separated them into two groups depending on performing an early graft protocol biopsy before hospital discharge: Group A - 32 patients (61.5%) performed a protocol biopsy, and group B - 20 patients (38.5%) did not, the biopsy being considered not essential for various reasons. We analysed patients’ demographics, biopsy complications, graft function, rejection episodes, and patient and graft survival for a median follow-up time of 63.3 months (50.3-83.7). Group A and group B differed in gender (more female patients were biopsied), dialysis vintage (higher in group A), human leucocyte antigen mismatch (higher in group A), and induction protocol (more patients submitted to thymoglobulin than to basiliximab in group A). Protocol biopsy detected histological changes in four patients (12.5%) in group A (2 cellular and 2 borderline rejections), and all were treated accordingly. Moderate peri-graft hematoma was reported in two cases (3.9%). Despite the increased risk in group A, renal function at discharge was better than in group B (p < 0.05 for serum creatinine and eGFR). During follow-up, rejection episodes were similar in the two groups. By the end of follow-up (median 63.3 months), proteinuria and renal function were similar between the two groups. Using a multivariate regression model, and despite the initial differences, at the end of follow-up, patients submitted to early protocol biopsies had similar excellent prognosis as the very low-risk patients who were not biopsied. (p = 0.5). Following our results, we propose that timing of early protocol biopsy should be individualized according to the patient’s clinical and immunological risk

Introdução: Apesar dos acessos vasculares serem essenciais para uma hemodiálise eficiente, o uso sistemático do património venoso dos doentes pode eventualmente levar a uma exaustão dos locais disponíveis para a colocação de um novo acesso vascular. Caso Clínico: Apresentamos dois destes casos. No primeiro, foi inserido um cateter de 55cm através da veia ilíaca externa esquerda, no segundo colocou-se um cateter de 40cm translombar. Ambas as intervenções foram efectuadas por via percutânea e sob controlo radiológico. Os doentes foram anticoagulados após o procedimento. Conclusão: O uso de locais alternativos para a colocação de cateteres de hemodiálise, pode em casos selecionados oferecer uma alternativa viável e segura para estes doentes.

Background:Although vascular access is essential for adequate haemodialysis delivery, the systematic use of a patient's venous patrimony may eventually lead to exhaustion of suitable sites for placement of a new vascular access. Case Report: We present two cases of such patients. In the first one we inserted a 55cm catheter through the left external iliac vein, and a 40cm translumbar catheter was placed in the second one. Both interventions were performed percutaneously under radiological guidance. Both patients were anticoagulated after the procedure. Conclusion: Unusual sites for haemodialysis catheter placement may be life saving in selected situations and offer safe and viable alternatives for adequate haemodialysis delivery.