ABSTRACT Vancomycin and aminoglycosides are potentially nephrotoxic broad-spectrum antibiotics, which can be used both in the treatment of severe infections and in surgical prophylaxis, in pediatric patients. Prolonged antibiotic therapy and high trough concentrations are associated with toxicity. Additionally, several individual factors contribute to nephrotoxicity increasing the risk of acute kidney injury (AKI) and consequente chronic kidney disease in the future. We developed a retrospective and observational study in the Pediatrics Department of a tertiary hospital in Portugal, to analyze clinical practice regarding monitoring and surveillance of vancomycin and aminoglycosides. The results showed low rates of monitoring, which reinforces the importance of raising awareness about this issue, recognizing its importance, and adopting preventive measures that may mitigate the risk of toxicity and improve children’s renal prognosis in adult life.

ABSTRACT Currently, patients older than 75 years are the fastest-growing group starting dialysis worldwide. However, the benefits of dialysis become doubtful among frail older patients and conservative kidney management (CKM) has emerged as a feasible therapeutic strategy for some patients, with a focus on quality of life and comfort. Even though it is a challenge to recognize which is the most suitable therapeutic option for elderly patients. We report a case of an 81-year-old woman who initially chose CKM, but later accepted to start hemodialysis due to difficult control of hypervolemia. During the period on dialysis, she had several complications, the most serious related to lower limb amputation, as a result of severe chronic ischemia. This case reflects the complexity of managing an older stage 5 chronic kidney disease patient, both on dialysis or CKM. Treatment decisions are complex and prognosis estimation is challenging. Time is essential to understand the benefits and burdens of different treatment strategies for each patient and the priority should be centered on optimizing care for older adults with advanced kidney disease.

ABSTRACT Pneumocystis jirovecii (PJ) opportunistic infections occur in immunocompromised patients impacting significantly hospitalizations and mortality. Trimethoprim-sulfamethoxazole (TMP-SMX) is universally used as prophylaxis of Pneumocystis jirovecii pneumonia (PJP) and therefore, this infection is rare condition in solid organ transplant (SOT) recipients. We present a case of a 46-years-old male, who received an ABO-incompatible transplant with prior desensitization protocol with plasmapheresis, rituximab, and anti-CMV immunoglobulin. IgG anti-B title pre-desensitization was 1:128. The patient had 6 ABDR mismatches, without HLA antibodies, and the CDC crossmatch for T and B cells was negative. Both recipient and donor were CMV positive (D+/R+). The patient received induction immunosuppression with corticosteroids, basiliximab, calcineurin inhibitor, and mycophenolate mofetil. Immediate kidney function was verified, and three additional plasmapheresis sessions were performed. At discharge serum creatinine (sCr) was 1.38 mg/dL, but kidney function declined during the first 6 months (sCr 2.5 mg/dL). Urinalysis was unremarkable. A kidney biopsy was declined by the patient. Unit protocol maintained the prophylaxis for PJP and cytomegalovirus (CMV) infection with TMP-SMX and valganciclovir. The patient was admitted to the emergency department 20 months after the transplant with respiratory symptoms and was diagnosed with PJP. Bronchoalveolar lavage fluid was also positive for CMV. Intensive care unit (ICU) admission was necessary due to clinical deterioration, with subsequent good evolution without mechanical ventilation. At discharge, prophylaxis with TMP-SMX and valganciclovir was maintained for more than six months. Here we discuss the late onset of PJP, and the main risk factors related to severe infection. Transplant subgroups in which longer PJP prophylaxis could be beneficial and the indication to re-start PJP prophylaxis is still under discussion.

ABSTRACT Older to older living kidney transplantation is an acceptable alternative to avoid dialysis, improve quality of life and maintain favorable long-term outcomes of patients with end-stage kidney disease. However, the management of these patients is complex and the acceptance of older donors and recipients to kidney transplantation remains controversial. The older recipients usually have several comorbidities that may complicate the postoperative course and increase the risk of end-stage kidney disease. We present a clinical case of living kidney transplantation between an older donor and recipient, both over 70 years old, who evolved to a stage 3 chronic kidney disease, without proteinuria, hypertension, or other complications, three years after transplantation. Our case reinforces favorable outcomes in older living transplantation, both for recipient and donor, as has been demonstrated in several published studies.