Núria Serra Cabañas

Introduccion: La medida de la dosis de hemodialisis basada en la cinetica de la urea (Kt/VUREA) adolece de problemas de aplicabilidad en el paciente critico con insuficiencia renal aguda (IRA). No obstante, las recomendaciones de consenso sobre la dosis se basan en el Kt/VUREA. Objetivo: Evaluar la utilidad de la medida en tiempo real de la dosis de dialisis suministrada (Kt) mediante dialisancia ionica (KtDI) en el paciente critico y el grado de adecuacion de la dosis en comparacion con la medida estandar del Kt/VUREA. Material y metodos: Estudio prospectivo observacional de medida de dosis en 17 pacientes criticos con IRA sometidos a 3 sesiones de dialisis intermitente con prescripcion predefinida para este estudio (en total 51 medidas). Resultados: El Kt/VUREA medio suministrado por sesion fue de 1,19 ± 0,14, con un 59% de sesiones consideradas adecuadas por lo recomendado por la ADQI. Por el contrario, la media de KtDI obtenida fue de 37,6 ± 1 l, con solo un 29,4% igual o por encima del valor minimo recomendado. Conclusiones: La monitorizacion de la dosis mediante KtDIrevela un menor grado de adecuacion en comparacion con el Kt/VUREA. El caracter dinamico de la medida de KtDI puede permitir la adaptacion de cada sesion de dialisis («K» y/o «t») con el fin de lograr el objetivo de dosis minima.

Abstract Background and Aims Chronic kidney disease is a frequent complication of heart transplant recipients (HT) and is associated with worse survival. Current literature shows that probably the best renal replacement therapy option for these patients is kidney transplantation (KT). The aim of our work is to assess the results of renal transplantation in HT recipients. Method Retrospective descriptive single-center study including all heart transplant recipients patients who received a kidney transplantation in our center between 1992 and 2022. Data on renal and overall vital survival as a well as the factors that could have influenced them and associated complications were analyzed. Results We included 14 patients, 64% men, with a mean age of 56 years at the time of the KT. A total of 30.8% received an anticipated KT. A total of 85.7% received a KT from a cadaveric donor. In 90% the induction immunosuppression consisted of thymoglobulin, prednisone, mycophenolate, and differed tacrolimus. The mean time between heart and kidney transplantation was 15 years. Six months after KT the mean GFR was 40 mil/min/1,73 m2, at 12 months 35 ml/min/1,73 m2 and at 5 years 30 ml/min/1,73 m2. Renal graft survival was 84% and patient survival was 93% at 10 years. Regarding complications, the most frequent were urological (38.5%) followed by infectious (30.8%). The incidence of acute rejection was 18%. Conclusion Our data confirms that kidney transplantation in heart transplant recipients has very positive results. It is necessary to promote collaboration between CT and RT units with the aim of identifying promptly those patients who are candidates for KT, being able to perform it in the best conditions (preemptive transplantation, possibility of living donor transplanation).

Abstract Background and Aims Cancer is one of the main causes of morbidity and mortality in kidney transplant (KT) patients. The use of immune checkpoint inhibitors (ICPIs) in these patients has been controversial because of the lack of robust evidence regarding their efficacy and safety. However, recent studies indicate that with and adequate management of the basal immunosuppression and a multidisciplinary approach in the follow-up of these patients, its use is feasible. Our study aims to describe our experience and results of using ICPIs in KT patients. Method Prospective study of KT patients with cancer who have received treatment with ICPIs. Before starting ICPIs treatment, according to our protocol, mycophenolate acid was discontinued, tacrolimus levels were reduced (to 4–6 ng/ml) and treatment with 5 mg of prednisone was maintained. Epidemiological, clinical and analytical data were collected, as well as immunological complications related to ICPIs treatment. Results Were included 6 patients, 66% male, mean age 63 +/− 7 years. Cancer's origin: 16% cutaneous, 50% bowel, 34% lung. All patients were in an advanced stage of cancer and had not responded to other treatments. Median creatinine level at the start of treatment: 125 µmol/L. Mean of baseline tacrolimus levels: 7.5 ng/ml. ICPIs used: 84% Pembrolizumab and 16% Atezolizumab. Mean follow-up time was 9 months. No episodes of rejection were observed. Any patient developed de novo DSA. 33% developed acute tubulointerstitial nephritis, which were treated with high doses of prednisone, resulting in a good response. Mean tacrolimus levels during treatment: 5.2 ng/ml. Median serum creatinine levels (at 1 m, 3 m, 6 m after KT): 138 µmol/L, 130 µmol/L and 146 µmol/L, respectively. 100% of patients had a very good oncological response. Mortality rate: 0%. One patient started dialysis 6 months after completing treatment, but he had poor renal function prior to the treatment. Conclusion Our results indicate that ICPIs can be appropriate treatments for KT patients with cancer, with acceptable complications on the renal allograft and very good oncological outcomes. Large studies are needed to confirm these results and optimize the management of immunosuppression in this context.