Prasad, Bhanu

Background Patients on home dialysis therapies experience technique failure, which is associated with morbidity and mortality. Reasons for technique failure are complex, and often related to functional decline in the patient or caregiver. Frailty is associated with an increased risk of adverse health outcomes. We investigated the impact of frailty on technique failure and mortality in a prospective cohort of patients on home dialysis therapies. Methods We collected objective (Fried criteria and Short Physical Performance Battery [SPPB]), and subjective (physician and nurse impression) measures of frailty from 109 prevalent home dialysis patients. Our primary outcome was a composite of technique failure, defined as a permanent unplanned transition (> 30 days in duration) to facility-based hemodialysis or all-cause death. The association between different frailty assessment tools and the primary composite outcome was evaluated using Cox models. Results Fried criteria and physician impression was associated with a greater than 2-fold increase in risk of our composite outcome (HR: 2.10 [95% CI 1.09 – 3.99], 2.15 [95% CI 1.15 – 4.00, respectively] in adjusted analyses. Weakness and weight loss subdomains of the Fried criteria were both associated with an increased risk of our composite outcome in adjusted analyses (HR: 2.16 [95% CI 1.23 – 3.78], 2.69 [95% CI 1.39 – 5.40], respectively). Conclusions Objective and subjective measures of frailty are associated with a more than 2-fold higher risk of technique failure or death in patients undergoing home dialysis. Assessing frailty as part of the clinical evaluation for home dialysis therapies may be useful for prognostication and clinical management.

Crystalglobulinemia is an extremely rare complication of monoclonal gammopathy. We report a 49-year-old female who presented with acute kidney injury, microhematuria, and non-nephrotic range proteinuria. Eight weeks prior to presentation, she developed a lower urinary tract infection and acute kidney injury, but her creatinine failed to resolve after resolution of her symptoms with antibiotics. Kidney biopsy revealed a membranoproliferative pattern of injury, and numerous crystals were noted in the glomerular capillaries on electron microscopy. On immunofluorescence, positive staining for immunoglobulin G and kappa was demonstrated in the capillary lumen along the capillary walls. Based on the biopsy, a diagnosis of crystalglobulinemia was made. On serum protein electrophoresis, there was presence of a monoclonal band, which was too small to quantify. Urine immunofixation was negative. Patient was treated with cyclophosphamide, bortezomib, and dexamethasone regime and made a remarkable renal recovery.