Day 3 :
Keynote Forum
Roy Michael Culpepper
University of South Alabama College of Medicine, USA
Keynote: Kidney involvement in micro-angiopathic disease – A case analysis
Time : 09:30-10:10
Biography:
R Michael Culpepper received the MD Degree from the University of Alabama in Birmingham School of Medicine where he also completed Nephrology Fellowship. He has served on the Faculty at Loma Linda University, School of Medicine, the Health Science Center of the University of Texas in Houston, the Medical College of Virginia, and, for the past 25 years, at the University of South Alabama, College of Medicine where he is Professor of Medicine and past Director of the Division of Nephrology and Dialysis Services. He has served on the National Board of Directors of the National Kidney Foundation and has held grants from the NIH and various pharmaceutical grants for clinical research.
Abstract:
Microangiopathic disease (MAP) is characterized by intravascular hemolysis resulting in anemia with presence of schistocytes on a peripheral blood smear, and with a rise in serum lactate dehydrogenase (LDH) followed by a fall in serum haptoglobin levels and with thrombocytopenia. In virtually every case of MAP, the kidney shows some degrees of injury, ranging from the appearance of proteinuria and active urinary sediment to acute kidney injury and incremental decreases in GFR. Three primary MAP’s have now been identified, based on the underlying pathophysiology and characterized according to the expectations for renal injury and the disease-specific treatment. These syndromes include classical hemolytic-uremic syndrome (HUS), thrombotic thrombocytopenic purpura (TTP), and atypical hemolytic-uremic syndrome (aHUS). Classical HUS is associated with enteric infection, most commonly shiga-like toxin-producing E.coli O157:H7 (STEC-HUS), with a dominant prevalence in childhood. TTP specifically arises from decreased activity of ADAM TS13, a metallaprotease that cleaves large multimers of Von Willebrand factor (vWF) causing inactivation of vWf; the deficiency of ADAM TS13 resulting in sustained presence and activity of vWf multimers. Lastly, aHUS has been linked to uncontrolled activation of the complement system by the lack of counter-regulatory factors, chiefly, factors H, I, or B. This deficiency in regulation can result from production of anti-factor F antibodies or a host of genetic mutations that affect factors F, I, or B production of activity. In addition to these well-defined syndromes, MAP with kidney injury can occur sporadically in a wide variety of unrelated disease processes. In every instance, prompt disease-specific treatment can prevent or ameliorate severe or long-term renal damage. For classical HUS, use of antibiotics to address the infection is not indicated and may be counter-productive while plasmapheresis is not beneficial. Supportive care with dialysis when indicated is the preferred mode of care. A diagnosis or strong presumption of TTP demands initiation of plasmapheresis as soon as possible with administration of corticosteroids. Rituximab may be started as initial therapy or added for disease resistance to steroid and apharesis. Absence of evidence for classical HUS or TTP, aHUS must be considered, given the high risk for progressive kidney damage. Eculizumab, a mono-specific antibody that inhibits complement factor C5 and interferes with the terminal portion of the complement cascade is the required treatment for aHUS. The expense of this drug makes it desirable to secure the correct diagnosis of the complement-mediated basis of disease by measuring factors H, I, and B activity. In the presence of normal activity of these factors, other diseases that may give rise to sporadic MAP need to be considered. A case-based analysis will be used to outline a reasonable approach to management of MAP with renal involvement.
Keynote Forum
Fumihiko Hinoshita
National Center for Global Health and Medicine, Japan
Keynote: Why don’t you use a very effective herbal medicine, Shao-yao-gan-cao-tang (Japanese name: Shakuyaku-kanzo-to), for muscle cramp in patients on hemodialysis?
Time : 10:10-10:50
Biography:
Fumihiko Hinoshita has completed his graduation from Tokyo Medical and Dental University in 1981 (MD) and has completed his PhD from the same university, and Post-doctoral study from Harvard Medical School. He is the Head of Department of Nephrology, National Center for Global Health and Medicine, a prestigious national medical center of Japan. He has published more than 30 papers in reputed journals and served as the Lead Guest Editor for the special issue on “Hemodialysis-Associated Problems to solve: Current and Future” of the Scientific World Journal in 2013.
Abstract:
Most of the physicians in Western countries don’t know that the current traditional herval medicines, which are often used in East Asia, are very useful and effective for specific medical problems or symptoms. One of these is Shao-yao-gan-cao-tang (Japanese name: Shakuyaku-kanzo-to), an anti-cramping medicine, which exhibits an outstanding effect against muscle cramp in the patients on hemodialysis (HD), one of the most common complications of HD. Shakuyaku-kanzo-to consists of equal amounts of paeony and licorice roots and has a prophylactic anti-cramping effect. It has frequently been used for more than 20 years in Japan since the author and a few other groups started to make use of it. In our first report (Am J Chin Med 31:445-453, 2003), Shakuyaku-kanzo-to (EK-68®, Kracie Pharma, Ltd., Tokyo, Japan) at 6 g per day was prospectively administered for 4 weeks to five patients on HD who were suffering from frequent muscle cramps. Consequently, skeletal muscle cramps completely disappeared in two of the patients after the start of oral administration of Shakuyakukanzo-to. Moreover, the frequency of cramping was significantly decreased in two of the remaining three patients after persistent administration without any serious side effects. The severity of muscle cramps was also decreased by this treatment in the responsive patients. The inhibitory effect of Shakuyaku-kanzo-to on muscle contraction was also experimentally confirmed by using phrenic nerve-diaphragm preparations from male Wistar rats. Conclusively I suggest that Shakuyaku-kanzo-to of remarkable efficacy should be used to relieve pain with muscle cramp in hemodialyzed patients as soon as possible.
- Hypertension and Kidney Disease | Cardiovascular Impacts of Kidney Disease | Glomerular-Tubulointerstitial Disorders | Kidney and Bladder stones
Session Introduction
Ekamol Tantisattamo
Oakland University William Beaumont School of Medicine, USA
Title: Hypertension after kidney transplantation: multifactoial etiologies and transplant outcomes
Time : 11:10-11:40
Biography:
Ekamol Tantisattamo has completed his MD from the Faculty of Medicine, Siriraj Hospital, Mahidol University in Bangkok, Thailand and pursued his specialty training in internal medicine at the University of Hawaii John A Burns School of Medicine. He then completed sub-specialty training in Nephrology at Emory University School of Medicine. Since his special interest is in clinical transplantation, he went to transplant nephrology fellowship training at Northwestern University Feinberg School of Medicine. He is currently a staff Physician at Multi-Organ Transplant Center, Division of Nephrology, Department of Internal Medicine, William Beaumont Hospital in Royal Oak, Michigan and Assistant Professor of Medicine at the Oakland University William Beaumont School of Medicine in Rochester, Michigan. He is interested in clinical research in the areas of Nephrology and Transplantation including clinical hypertension, clinical pancreas-kidney transplantation, transplant renal artery stenosis, Chronic Kidney Disease-Mineral Bone Disorder (CKD-MBD) and nutrition-related post-kidney transplantation, and vascular calcification.
Abstract:
Hypertension is one of the most common causes of cardiovascular morbidity and mortality worldwide. Several factors contribute to the development of hypertension. Similar to non-transplant population, hypertension remains high prevalence in kidney transplant recipients. Among kidney transplant recipients with pre-transplant hypertesion, the majority of them still continue to be hypertensive after successful kidney transplantation; however, some kidney transplant recipients become normotensive. Etiology of hypertension is difficulty to determined and it is likely multifactorial including genetic and acquired conditions. Kidney is thought to be one contributing factor of hypertension and this may represent in the form of genetic kidney disease. Native nephrectomy in non-transplant patient is one possible way to manage uncontrolled hypertension. Our previous data demonstrated that kidney transplant recipients who received living-unrelated renal transplantation appeared to have lower prevalence of post-transplant hypertension compared to the recipients receiving living-related renal transplantation. For deceased donor renal transplantation, hypertensive patients receiving kidney transplantation from the same donor (mated kidney transplantation) seemed to convert to normotensive or remain hypertensive at the same direction. This may implies a potential role of genetic kidney diseases. In addition to potential genetic causes of post-transplantation hypertension, other treditional non-genetic risk factors of post-transplant hypertension are still important since these may be reversible or preventable conditions. These common conditions or diseases include obesity. Since post-transplant hypertension is high prevalent and crucial for kidney transplant outcomes both renal allograft and patient survivals, identifing the causes of post-transplant hypertension should lead to strategies for preventing post-transplant hypertension and mitigate poor kidney transplant outcomes.
Kenjiro Honda
University of Tokyo graduate school of medicine, Japan
Title: Recent topics of autosomal dominant polycystic kidney disease (ADPKD)
Time : 11:40-12:10
Biography:
Kenjiro Honda graduated from The University of Tokyo in 2005, and completed his PhD from The University of Tokyo Graduate School of Medicine in 2013. His work is genetics in kidney including ADPKD, and peripheral arterial disease. He is now an Associate Professor in Department of Nephrology and Endocrinology, The University of Tokyo Graduate School of Medicine.
Abstract:
Autosomal dominant polycystic kidney disease (ADPKD) is one of the most common hereditary kidney diseases that develop end-stage kidney disease. Usage of renin-angiotensin-aldosterone system inhibitors and educational campaign such as salt restriction and metabolic syndrome have successfully delayed initiation of dialysis in the other kidney diseases. However, ADPKD patients have obtained littele benefit from these appearance of medicine or activities. As a result, ADPKD now requires dialysis at a younger age than the other kidney diseases. Tolvaptan is the first drug that directly inhibits growth of kidney cysts. TEMPO 3:4 study clinically showed efficacy and safety of tolvaptan treatment among ADPKD patients with creatinine clearance more than 60 mL/min. This medicine improved decline of kidney function as well as enlargement of total kidney volume. Polyuria is frequently present, and tolvaptan requires sufficient fluid intake. According to TEMPO 3:4 study, tolvaptan can be administered to ADPKD patients with chronic kidney disease (CKD) G1-G4 since 2014 in Japan. Tolvaptan has been administered to ore than 1,000 ADPKD patients. Approval of indication including CKD G3 and G4 resulted in the current situation that CKD G3 and G4 is dominant in tolvaptan-treated patients. I will introduce therapeutic effect and amount of fluid intake and urine volume in tolvaptan treatment.
Kyra Borchhardt
Medical University of Vienna, Austria
Title: Vitamin D repletion after kidney transplantation
Time : 12:10-12:40
Biography:
Kyra Borchhardt has completed her studies at Medical University of Vienna and Post-doctoral studies from Stanford University School of Medicine. She is the Medical Director of the Dialysis Institut of Klagenfurt, Austria.
Abstract:
Objectives: Vitamin D deficiency has been associated with detrimental renal allograft outcome, yet interventional studies on vitamin d supplementation after kidney transplantation are not available. We aimed to test whether treatment of vitamin d deficiency improves renal allograft function by preventing infections and acute rejections, and improves bone mineral density one year after kidney transplantation.
Design: The study is a single-center randomized double-blind placebo-controlled clinical trial with one-year follow-up.
Setting: The study was conducted at the Medical University of Vienna, austria between may 2009 and august 2014. Participants: we studied 203 deceased-donor kidney-only transplant recipients with vitamin D deficiency (25-hydroxyvitamin D levels <20 ng/ml) at the time of transplantation. Patients who underwent re-transplantation more than twice, as well as immunologically high-risk patients were excluded.
Interventions: Participants were randomly assigned to receive daily treatment with oral vitamin D3 (6800 international units) or placebo for one year. Main outcome measures: primary outcome was renal allograft function at one year post-transplant (estimated by serum creatinine) with the combined event rate of acute rejections and infections as a co-primary endpoint. Secondary outcomes included time course analyses of serum creatinine and c-reactive protein levels, bone mineral density, serum levels of parathyroid hormone, 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D, and cathelicidine. Besides intention-to-treat analyses, per-protocol analyses were performed at twelve (n=63 in the vitamin D3 and n=60 in the placebo group) and six months (n=70 in the vitamin D3 and n=65 in the placebo group), including patients who completed the follow-up.
Results: Out of 610 consecutively screened kidney transplant candidates, 203 were included and randomly assigned to vitamin D3 (N=103 with mean 25-hydroxyvitamin D levels of 11.6±4.9 ng/ml at baseline) or placebo (N=100 with mean 25-hydroxyvitamin D levels of 11.1±4.8 ng/ml at baseline). The novel supplementation regimen led to a fast and persistent increase in 25-hydroxyvitamin D levels (+22.6 (quartiles 7.5-36.9) ng/ml in the vitamin D3 group vs. -0.3 (-4.6-3.9) ng/ml in the placebo group at one year post-transplant, p<0.001). One-year serum creatinine levels were similar in the vitamin D3 and placebo group in the intention-to-treat analyses, but were higher in vitamin D3-treated patients in the per-protocol analyses at twelve (1.54 (1.32-2.17) mg/dl vs. 1.42 (1.20-1.73) mg/dl, p=0.03) and six months (1.61 (1.36-2.13) mg/dl vs. 1.43 (1.19-1.82) md/dl, p=0.01). There was no group difference in the monthly combined event rate of acute rejections and infections (0.25 (0.09-0.44) in the vitamin D3 and 0.33 (0-0.71) in the placebo group, p=0.73) or the course of C-reactive protein levels or serum levels of cathelicidin. Changes in lumbar and femoral bone mineral density over time were similar in both groups. Vitamin D3 therapy resulted in significantly lower serum levels of parathyroid hormone (median 96 (quartiles 61-139) pg/ml vs. 128 (89-172) pg/ml, p=0.02), and significantly higher serum levels of 1,25-dihydroxyvitamin D (50 (38-75) pg/ml vs. 35 (24-49) pg/ml, p<0.001). Hypercalcemia was more common during vitamin D3 supplementation (30% vs. 17%, p=0.04).
Conclusions: Given the lack of an overall benefit of vitamin D supplementation, as well as its potential adverse effect on renal allograft function and its hypercalcemic potential, vitamin D supplementation is not justified in kidney transplant recipients.
Besut Daryanto
Saiful Anwar General Hospital, Indonesia
Title: Management of kidney trauma in Saiful Anwar Hospital (SAH) Malang, Indonesia: A retrospective study
Biography:
Besut Daryanto has completed his General Surgery study from Diponegoro University and obtained Urologist License from Airlangga University, Indonesia He is currently the Director of Urology Department in Faculty of Medicine Brawijaya University, Saiful Anwar General Hospital, Indonesia.
Abstract:
Kidney is the most commonly injured genitourinary organ (65%). Kidney trauma occurs in approximately 1-5% of all trauma cases. The present study was performed to describe and analyze the characteristics of hospitalized patients in Saiful Anwar Hospital (SAH). During January 2005 to December 2016, 63 of kidney trauma patients in SAH were retrospectively studied. The data were analyzed based on demographic characteristic, chief complaint, mechanism of injury, hemodynamic stability state, grading and location of trauma and management. The association of hemodynamic state, type of management, anemic condition, grade of kidney trauma to patient’s outcome was analyzed using SPSS. It occurred mostly in male patients (47/74.6%), pediatric involve (22/34.9%) of total patients. Motor vehicle injury was the most common mechanism of injury (50/79.4%). Most of the patients came with flank pain as a chief complain (42/66.7%). Trauma were occurred mostly due to blunt trauma (61/96.8%), more frequent cases involved right kidney (33/52.4%). Grade I kidney trauma is the most frequent occurred (40/63.5%) and stable hemodynamic state (52/82.5%). Mostly patients treated with non-operative management (60/95.2%) and no significant difference of length of hospitalization was noted between conservative and operative treatment (p=0.625). There were significant association between hemodynamic state and treatment options (p=0.047). However no association was noted between type of management and patients’ outcome (p=0.436). Severe grade of trauma revealed increasing nephrectomy rate (OR: 174, 95% CI: 8.62-315.174 p<0.01). Most of its patients in SAH were uneventfully treated by conservative treatment. Severe grade of trauma increased risk of nephrectomy.
Rajinder Yadav
Fortis Superspeciality Hospital, India
Title: Advanced retroperitoneoscopic surgery in renal stones
Biography:
Rajinder Yadav has completed his MCh in Urology from AIIMS in December 1980. After completion of MCh from AIIMS, he joined as Sr. Lecturer in Department of Surgery & Urology at PGI Medical College, Rohtak. . He is the Director of Urology, Kidney Transplant and Laparoscopic Oncosurgery at Fortis Healthcare, a premier healthcare organization. He has published and presented more than 15 papers in journals and conferences.
Abstract:
Introduction & Purpose: Staghorn and multiple renal stone diseases have been a challenging problem, and require multiple modalities for complete clearance. The purpose of this study is to discuss about the innovative and advanced retroperitoneoscopic surgery performed for this morbid condition.
Material & Method: Since 1992, 336 cases of urinary stones were operated by this technique out of which, 65 cases were of staghorn and multiple stone diseases. Apart from laparoscopic instruments, rigid and flexible nephroscope, dormia basket, grasping forceps and flushing cannula were used. Standard kidney position was used with 3 to 4 ports. 43 cases were male, 22 cases were female. The age of the patients ranged from 11 years to 65 years. Ureteric catheter or DJ stent was introduced before operation.
Results: All the operations were performed successfully except two conversations in initial period. Blood transfusion was given into two patients in the post-operative period (one unit in each patient). Post-operative urine leak stopped in 24 to 72 hrs. Duration of surgery ranged from two hours 45 minutes to four hours 35 minutes. Post-operative x-rays showed residual stones in kidney in three patients and in the retroperitoneum in four patients. Residual stones in kidney were treated by ESWL after six weeks. Hospital stay was 4-6 days. No postoperative urinary tract infection occurred from the surgery. Two patients had port infection. One patient had urinoma due to lockage of drain.
Conclusion: Retroperitoneoscopic surgery for staghorn and multiple stones is minimally invasive and less traumatic to kidney. It is comparable with open surgery and accepted by patients. Post-operative discomfort in more as compared By PCNL.
Onesmo A Kisanga
Muhimbili National Hospital, Tanzania
Title: Renal transplantation in sub-Saharan Africa: A case of Tanzania
Biography:
Onesmo A Kisanga has completed his MD, MMed (Internal Medicine) and MSc (Nephro) from University of Dar es Salaam and currently working at Muhimbilim University of Health Sciences. He is a Consultant Physician and a Nephrologist at Muhimbili National Hospital. He is serving as a Medical Director with Access Medical and Dialysis Centre and President of Nephrology Society of Tanzania (NESOT). His interest is in Kidney Transplant. His group started kidney registry in the country and expanded kidney biopsy programe.
Abstract:
Background: Renal replacement therapy (RRT) is the treatment of choice for patients with end stage renal failure, RRT include dialysis and kidney transplantation. Most sub-Saharan African countries have not developed renal transplantation services and are relying on referring patients to overseas countries. This study was carried out to describe renal transplantation experience in Tanzania.
Methods: Forty four renal transplant recipients were recruited in this study. Standardized questionnaire and Swahili version of standard form – 36 (SF-36) were used to collect socio-demographic information, clinical data, laboratory test results and health related quality of life information.
Results: Ages of transplant recipient ranged from 21 to 66 years with mean age of 45.9 ± 10.5 years. The leading causes of end stage renal failure among participants was hypertension 58.8% (25/44) followed by glomerulonephritis 15.9% (7/44). Twenty eight (63.6%) of transplantations were paid by the government. Most of the donors (97.7%) were living out of which 26 (59.1%) were siblings and 11 (25%) were second degree relatives (cousins and nephews). Most common complication noted following transplantation was diabetes mellitus 9 (20.5%) and 3 (6.8%) had chronic rejection. Mental health was the domain with highest mean score (75.6 ± 14.3) and role physical had the least mean score (44 ± 45.6).
Conclusions: Hypertension was the leading cause of ESRF in this study. Most of the donors were siblings and the costs of transplantation were largely covered by the government. There is a need for concerted effort to establish local kidney transplantation services in Tanzania.