Bhasin, Bhavna

Background: Plasma cell dyscrasia (PCD) is a rare but important cause of end stage kidney disease (ESKD). Kidney transplant is the treatment of choice in patients with ESKD. However, the complexity of PCD care and risk of disease recurrence poses challenges to kidney transplant candidacy and outcomes. We examined the current clinical practice patterns of clinicians who care for patients with PCD and identified barriers to kidney transplantation for patients with PCD. Methods: A web-based survey was developed and distributed from January to July 2024 to kidney transplant clinicians (American Society of Transplant (AST) members), hematologists (PCD experts), and onco-nephrologists. Results: Seventy clinicians (50 transplant nephrologists, 18 hematologists, and two surgeons) from 42 transplant centers in the US participated in the survey. Clinical practice patterns pre and post kidney transplant for patients with PCD are highly variable among institutions, and only 36% reported having a protocol for pre- and post-transplant management for patients with PCD. Particularly, the requirement for pre-transplant hematologic remission criteria, induction and maintenance immunosuppression regimens and protocols for prophylaxis and screening for opportunistic infection are areas of future study. Clinicians listed lack of data and practice guidance as well as communication challenges among multiple specialties especially hematology and kidney transplant clinicians as notable barriers. Conclusions: Our study identified the highly variable current practice patterns when evaluating and managing patients with PCD for kidney transplant. Our findings emphasize the need for collecting and sharing clinical data to support standardized practices and serve as a basis for the upcoming multi-societal management recommendation for kidney transplant for patients with PCD.

Abstract Acute kidney injury (AKI) frequently follows hematopoietic cell transplantation (HCT). Soluble urokinase-type plasminogen activator receptor (suPAR) is a biomarker of AKI in the general population. We evaluated suPAR and its association with AKI requiring dialysis (AKI-D) in patients undergoing allogeneic HCT (alloHCT). Performance of suPAR was compared with serum creatinine (sCr) and neutrophil gelatinase-associated lipocalin (NGAL). Data were obtained from the Blood and Marrow Transplant Clinical Trials Network 1202 cohort, an observational study of 1709 alloHCT recipients. Adults aged ≥18 years with AKI-D after HCT were included. Adults who did not develop AKI were included as controls and matched 1:1. Periodic serum samples (7-90 days) were analyzed for NGAL, suPAR, and sCr. The 1:1 matched case-control groups (n = 62 each) were balanced in demographic variables, except for graft-versus-host disease prophylaxis. The median time from transplant to AKI-D was 2.6 months (range, 0.03-20.39). The day +7 suPAR level after HCT was higher in patients with AKI (median, 2.7 ng/mL) than in controls (2.1 ng/mL; P = .002). In the multivariate analysis, the day +7 suPAR level was associated with the development of AKI-D (P = .009). The area under the curve for the receiver operating characteristic curve for day +7 suPAR levels was 0.75. Neither NGAL nor sCr were associated with AKI-D. Elevated day +7 suPAR levels predicted AKI and lower overall survival (OS). The suPAR level at day +7 after HCT may be an early prognostic factor for the development of AKI-D and OS. Future prospective studies could evaluate this at different stages of AKI. This trial was registered at www.ClinicalTrial.gov as #NCT01879072.

The indications for immune checkpoint inhibitor (ICI) use in cancer treatment continue to expand. This is attributable to their proven anticancer activity in addition to their tolerability and favorable toxicity profile as compared to conventional chemotherapeutic agents. ICIs work by blocking the inhibitory signals between tumor cells and T-cells, thereby enhancing the T-cell cytotoxic activity to inhibit tumor growth. Because of their immune-stimulating effect, ICIs are linked to adverse renal outcomes in both native and transplanted kidneys. The risk of kidney allograft rejection in the setting of ICI use has been reported to be around 40%, leading to an increased risk of graft loss. In this report, we review the literature examining outcomes in kidney transplant recipients receiving ICIs for various oncologic indications.

ABSTRACT Point-of-care ultrasonography (POCUS) has rapidly evolved from a niche technology to an indispensable tool across medical specialties, including nephrology. This evolution is driven by advancements in technology and the visionary efforts of clinicians in emergency medicine and beyond. Recognizing its potential, medical schools are increasingly integrating POCUS into training curricula, emphasizing its role in enhancing diagnostic accuracy and patient care. Despite these advancements, barriers such as limited faculty expertise and ‘lack of’ standardized guidelines hinder widespread adoption and regulation. The International Alliance for POCUS in Nephrology (IAPN), through this position statement, aims to guide nephrologists in harnessing the diagnostic power of POCUS responsibly and effectively. By outlining core competencies, recommending training modalities and advocating for robust quality assurance measures, we envision a future where POCUS enhances nephrology practice globally, ensuring optimal patient outcomes through informed, evidence-based decision-making. International collaboration and education are essential to overcome current challenges and realize the full potential of POCUS in nephrology and beyond.

Point-of-care ultrasonography (POCUS) is emerging as a valuable tool in nephrology, providing real-time insights into the etiology of acute kidney injury (AKI). This narrative review explores POCUS applications in AKI, emphasizing its role in diagnostic kidney ultrasound and comprehensive hemodynamic assessments. AKI, prevalent in hospitalized patients, poses significant morbidity and mortality risks. POCUS aids in unraveling AKI’s multifaceted origins, categorizing it into hemodynamic, obstructive, and intrinsic renal causes. We discuss the utility of POCUS in urinary obstruction by identifying hydronephrosis and detecting stones and providing prompt diagnostic assistance. In intrinsic AKI, POCUS has limited utility but can potentially differentiate between acute and chronic kidney disease and identify infectious complications. POCUS-assisted hemodynamic AKI assessment involves thorough evaluation of the cardiac, lung, and end organ venous congestion. As technology advances, the role of POCUS in the diagnosis and management of AKI is likely to increase, offering a portable, cost-effective, and radiation-free bedside diagnostic modality. This also has the potential to improve patient outcomes. However, proper training in techniques of POCUS and an understanding of the limitations of POCUS are essential elements in ensuring its optimal and appropriate use in the right clinical context.

AbstractHyponatremia (serum sodium <135 mEq/L) is a frequent electrolyte abnormality complicating the clinical care of hospitalized patients. Hyponatremia has been associated with an increased risk of mortality. Hyponatremia can be seen in patients with euvolemia, hypovolemia, or hypervolemia. Evaluation of hyponatremia relies on clinical assessment and estimation of serum sodium, urine electrolytes, and serum and urine osmolality in addition to other case‐specific laboratory parameters. In addition, point‐of‐care ultrasonography is an important adjunct to physical assessment in estimation of volume status. Understanding the pathophysiology of the underlying process can lead to a timely diagnosis and appropriate management of hyponatremia.