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Y. Akascha, M.B.A., M.B.B.S., M.H.S.

Associate Professor, Medical College of Georgia at Augusta University

Introduction: Adenovirus can lead to serious conditions in the immunocompromised transplant recipients. It infects urothelium and causes acute hemorrhagic cystitis and either nephritis or acute rejection causing functional deterioration of transplanted kidney. After 6 months, he presented with right lower quadrant abdominal pain, hematuria, dysuria, productive cough, fever, conjunctivitis, sore throat and diarrhea. Biopsy of transplant kidney showed mild tubulo-interstitial rejection with transplant glomerulitis and negative for adenovirus nephritis. Discussion: Disseminated adenovirus infection after renal transplantation is becoming more prevalent. The approach to therapy is unclear due to no standard guidelines for selection, timing and efficacy of treatment modalities, which requires further investigation. Minsk Scientific and Practical Center of Surgery Transplantology and Hematology, Minsk, Belarus. Background: the reasons for establishing an automated waiting list system were as follow: the main clinical information about patients was available only on paper, there was a problem of optimal choice from the list of compatible donor-recipient pairs based on a large number of factors, there were difficulties with information transfer rate, security and reliability. Results: Web application helps to allocate donor organs by medical and social principles of selection. The social principles are: priority of patients who waited kidney transplant longer considering of donor and recipient territorial compatibility increased chances for kidney transplant patients with "incomplete" phenotype (homozygotes) priority for highly sensitized patients priority for children priority for patients who needed multiple-organ transplantation Medical principles: balance between the potential kidney transplant and recipient survival stratified accounting of histocompatibility degree between donor and recipient reduction of kidney transplant cold preservation time creation of transplantation priority conditions for patients who needed urgent kidney transplantation initial kidney graft function prognosis accounting Scoring system is based on the fact that the main feature of social justice (maximum waiting period) is equated tomain medical principle of effectiveness (maximum compatibility degree). The allocation of organs accounts the risk of early graft dysfunction (automatic kidney graft functioncalculator based on multifactor analysis of donor - and recipient-dependent risk factors is integrated). The final result is a prioritized list of recipients with a score of each factor and to perform the final selection of the council of physicians. Conclusions: the software application allows to keep records, make statistical data analysis of potential recipient, distribute the organs anytime, anywhere in the world where the Internet is available. We report a case of unusually late onset, recurrent sarcoidosis in transplanted kidney with successful treatment. Risk factors for recurrence include primary renal disease related to sarcoidosis and a shorter delay between the last sarcoidosis flare and renal transplantation. Recurrence typically occurred shortly after transplantation, averaging 13 months after transplantation. Introduction: Nocardiosis is an uncommon opportunistic Gram-positive bacterial infection caused by aerobic actinomycetes in the genus Nocardia. Nocardia can cause localized or systemic suppurative diseases involving eyes, kidneys, skin, lungs, bone, and Central nervous system. Case Description: We report the case of a 55-year-old African American kidney transplant recipient on maintenance immunosuppression, who was diagnosed with cutaneous and pulmonary Nocardiosis. Presenting symptoms were shortness of breath, bilateral lower extremities pain and swelling. Tissue culture grew gram-positive bacilli specified as Nocardia farcinica from thigh and gluteal abscesses (figure 1). Patient was managed with immunosuppression reduction and specific treatment with high dose Bactrim in conjunction with linezolid. Combination antibiotics were continued for four weeks, thereafter Bactrim alone was continued for twelve months, at which point all lesions had healed. The reported patient had disseminated Nocardiosis involving lungs and skin, though lungs were thought to be the primary source of infection. However, early diagnosis and appropriate antibiotic coverage, had a favorable outcome, in a renal transplant recipient. Case Description: A 66-year old man with history of liver transplantation was hospitalized on post-transplant day 230 for worsening kidney function (serum creatinine 4. The early posttransplant course was complicated by reactivation of muco-cutaneous herpes simplex virus-1, and Clostridium difficile colitis. Urinalysis was positive for 3+ leucocyte esterase with a full field of leucocytes and 10-50 red blood cells per high power field. To evaluate the cause of the persistent renal failure, a renal biopsy was performed, revealing acute tubular injury and focal severe interstitial nephritis. He had underwent a deceased-donor kidney transplant ten years before, and maintained on mycophelonate mofetil (1.

Methods: this retrospective cohort study included the patients who started hemodialysis in a large U. Background: Malnutrition is highly prevalent and is a significant contributor to adverse outcomes among hemodialysis patients. Methods: We included 6,649 hemodialysis patients who initiated dialysis treatment in a large United States dialysis organization between January 1, 2007, and December 31, 2011. Discussion: Fluoroquinolones have been associated with hypoglycemia in diabetic and non-diabetic persons. Although our patient received his chronic dose of cipro (250mg daily), it is possible that lack dialysis for several days may have led to accumulation of cipro. Future prospective data, using clear definitions and stratified for subpopulations, are critical to estimate relative survival benefit in clinical practice. Thirst and xerostomia contribute to non-adherence with fluid restricted diets resulting in fluid retention and chronic volume overload. Dietary sodium restriction may reduce thirst and xerostomia, which may, in turn, reduce fluid intake and retention. On average they were on 17 medicines among which 7 (Mean) had prior evidence to induce xerostomia. The feasibility and efficacy of longterm meal provision for reducing thirst, xerostomia, and chronic volume overload need to be further evaluated in future studies. Background: Minimal data exists regarding effect of palliative dialysis on clinical outcomes and quality measure. Frail, elderly patients may find thrice weekly, 3-5 hour hemodialysis treatments burdensome. This study shows the impact of reduction in dialysis frequency and time on quality standards and hospice utilization in the seriously ill elderly. Methods: A retrospective chart review was performed on four deceased patients who received palliative dialysis in one ambulatory dialysis center. Quality standards reviewed included: dialysis adequacy (Kt/V), metabolic control, nutrition, hemoglobin and ultrafiltration rate. Results: All four patients were elderly with reduced functionality, heavy symptom burden and difficulty tolerating regular hemodialysis sessions. Despite decreased treatment time and frequency, most quality measures did not differ from baseline. Most patients tolerated palliative dialysis, remained free of hospitalization, successfully transitioned to hospice and did not experience serious clinical issues. Lack of negative impact on quality measurements were attributed to patients poor oral intake, loss of body mass and minimal weight gains between dialysis sessions. Patients were observed to have a better quality of life and better utilization of time with family. Conclusions: Palliative care, incorporating the patient and family, appears to be a good option for patients and families who are not ready to withdraw from dialysis. In addition, with our recent experiences with covid 19 infections, this practice might be a possible option for someone with serious illness, hoping to avoid unwanted hospitalization and aggressive medical treatment. Goals of care conversation, timely plan of care for transition of care and close monitoring of patients are essential for palliative dialysis. This systematic review aims to compare survival outcomes on survival in dialysis and conservative care treatment pathways. Meta-analysis was performed on outcomes of studies with limited clinical heterogeneity. Results: From 6,126 citations, 21 observational cohort studies were included covering 20,212 adult patients. Meta-analysis of studies (N=12) reporting survival adjusted for age, sex, and/or comorbid conditions, showed a pooled adjusted hazard ratio for death of 0. Survival benefit in patients choosing dialysis with severe comorbidities was highly reduced. At the end of follow-up, we analyzed evolution during follow-up and survival status. Poster Thursday Hemodialysis and Frequent Dialysis - 4 and inability to adjust for demographics. Each centre has an attending nephrologist who reviews code status yearly with every patient.

Portal hypertension was ruled out by transjugular hepatic venous pressure gradient measurement and liver biopsy did not show any evidence of chronic liver disease. Meanwhile literature review suggested association of amplodipine with chylous ascites and it was stopped but he continued to develop recurrent ascites. This recurrent chylous ascitic fluid drainage continued for 6 months then we decided to discontinue minoxidil as it is known to cause fluid accumulation including pleural and percardial. He showed immediate improvement after stopping minoxidil and never developed ascites again. Discussion: Minoxidil causes vasodilatation like calcium channel blockers though by a different mechanism so the mechanisim of chylous ascites formation could be the same that it is also a lipophilic drug allowing it to pass rapidly into the lymphatic system and causes relaxation of smooth muscles of lymphatic vessels, interferes with lymphatic drainage, increases the hydrostatic pressure in lymph vessels and causing it to leak in the peritoneum. Minoxidil must be considered as a probable cause of atraumatic drug induced chylous ascites. Background: Although a number of donor factors are known to affect outcome following deceased donor kidney transplantation, many units have no clear criteria for acceptance. Kidneys were transplanted in 24%, declined due to concern over donor risk in 44%, with recipient and other factors responsible for non-transplantation in 32%. Background: Infections are an important cause of morbidity and mortality among kidney transplant recipients. However, the role of immunosuppression in the outcomes of these patients is not well understood. We compared them with affected patients without a kidney transplant and without any kind of immunosuppressive medication (control). Sixteen of the 33 (48%) were admitted to the hospital (median age of 56, 68% males, 93% African American) vs 2201 admissions (25%) for the control group (median age 66, 48% males, 65% African-American), i. Percentage of patients with hypertension in the transplant group was numerically higher (93% vs 80%, p = 0. Among transplant patients, those hospitalized were more likely to be on prednisone (75% vs 35%, p = 0. Waiting for a Better Offer Shan Shan Chen,2 Igor Litvinovich,2 Ashish Kataria,2 Yiliang Zhu,2 Christos Argyropoulos,2 Yue-Harn Ng. Background: Currently, no tools exist to facilitate patients with decisions to accep or refuse an offer. Using the scientific registry of transplant recipients database, we formulated a risk calculator for allograft failure and patient mortality risk (if offer accepted) vs. Methods: Using a multi-state model approach, we created multiple competing risk models for: 1) first kidney offer or dying on wait-list without any offer; 2) if offer is refused, the probability of a) receiving a transplant vs. Table 1 depicts the hazard ratio for each stage described above and the kidney offer risk calculator created using the estimates generated from the models. Next, we will refine our calculator to account for repeated offers and include other variables that may affect allograft offer and survival. Usually, it is asymptomatic, but some patients may suffer severe infections, often presenting with recurrent flares despite standard treatment. This measure joined the End Stage Renal Disease Quality Incentive Program in performance year 2020, with a weight of 4%. There were 5363 (77%) facilities in metropolitan areas, 954 (14%) in micropolitan areas, 550 (8%) in small towns, and 132 (2%) in rural areas. The physical distance between residence and transplant center may preclude many patients in non-metropolitan areas from completing the process of kidney transplant evaluation. Because Medicare covers only 80% of healthcare costs, most patients require supplemental insurance, often Medigap. Conclusions: the composition of attendees at recipient selection meetings may influence listing outcomes of potential kidney transplant candidates. Background: To be considered for kidney transplant, patients with advanced kidney disease must participate in a formal evaluation and selection process. Conclusions: To be considered for kidney transplant, patients had little choice but to engage in a rigid, demanding, and opaque evaluation process over which neither they nor their local clinicians had much control. These findings call for a more evidence-based, transparent, and individualized approach to the kidney transplant evaluation process.

It does this by executing statutory directives, including organizing, equipping, and training forces for the conduct of prompt and sustained combat operations on land, and by accomplishing missions assigned by the President, Secretary of Defense and combatant commanders. The Army is the most formidable ground combat force on earth and one of the largest employers in the United States. Soldiers receive training at the highest level, not only in the classroom, but also through rigorous instruction under intense pressure and realistic battlefield conditions. Many Army personnel are employed in highly technical roles that require lengthy and expensive specialized training. Particularly in light of these investments in personnel, recruitment and retention of capable and qualified soldiers is crucial to Army readiness. That certification was provided to Congress on July 22, 2011, following a process of review, both before and after passage of the repeal statute, of the impact of the change and of the training and other policy changes that would be necessary to implement it. Particularly among commanders in the field, there was an increasing awareness that there were already capable, experienced transgender service members in every branch, including on active deployment on missions around the world. The regulation eliminated a DoD-wide list of conditions that would disqualify persons from retention in military service, including the categorical ban on open service by transgender persons. As of August 2014, there was no longer a DoD-wide position on whether transgender persons should be disqualified for retention. In February 2015, just a few days after Secretary of Defense Ashton Carter took office, I accompanied him on a trip to Kandahar, Afghanistan, in my capacity as his chief of staff. On July 28, 2015, after consultations with the secretaries of the military departments, Secretary Carter directed Brad Carson, Acting Undersecretary of Defense for Personnel and Readiness, to convene a working group ("the "Working Group") to study the policy and readiness implications allowing transgender persons to serve openly in the Armed Forces. The Working Group was asked to start with the presumption that transgender persons could serve openly unless objective, practical impediments were identified, and to develop an implementation plan that addressed those issues with the goal of maximizing military readiness. By the time Secretary Carter directed the formation of the Working Group, I had moved out of my position in his office to become Acting Under Secretary of the Army. Subsequently, from November 3, 2015 to January 11, 2016, I served as Acting Secretary of the Army, and then as Secretary of the Army beginning May 18, 2016. The Working Group considered information from a variety of sources, including medical and other experts, drawn from both within and outside of the Department of Defense; senior military personnel who supervised transgender service members; and transgender people on active duty. The input of commanders reflected their high regard for the transgender staff serving under their command. Members of the Working Group discussed the evidence relating to the costs of permitting transgender persons to serve openly in the military, and the evidence relating to the impact of service by transgender people on operational effectiveness and readiness. Members of the Working Group noted that while transgender service members might have short periods when they were not deployable due to their medical treatment, such periods are not unusual for service members generally, who may take time off due to medical conditions or other reasons. The Working Group also considered that providing medical care for transgender individuals is becoming increasingly prevalent in both public and private sectors alike. Over a third of Fortune 500 companies currently offer employee health insurance plans with transgender-inclusive coverage. Similarly, nondiscrimination policies at two-thirds of Fortune 500 companies now cover gender identity. With respect to the public sector, the Working Group learned that all civilian federal employees have access today to a health insurance plan that provides comprehensive coverage for transgender-related care and medical treatment. Members of the Working Group also discussed the disruptive effect of banning service by transgender people, since such a ban necessitates the discharge of highly trained and experienced service members, leaving unexpected vacancies in operational units and requiring the expensive and time-consuming recruitment and training of replacement personnel. Members of the Working Group also discussed the negative impact of continuing to ban service by transgender people on overall military readiness because it reduces the pool of potential, qualified recruits for military service. At the conclusion of its discussion and analysis, the members of the Working Group did not identify any basis for a blanket prohibition on open military service of transgender people. Likewise, no one suggested to me that a bar on military service by transgender persons was necessary for any reason, including readiness or unit cohesion. The Working Group communicated its conclusions to the Secretary of Defense, including that permitting transgender people to serve openly in the United States military would not pose any significant costs or risks to readiness, unit cohesion, morale, or good order and discipline. The Working Group also agreed that the accession policy should be changed to allow transgender people to enlist. The Working Group agreed that the medical standards for accession into the Military Services by transgender persons should be based upon the same standards applied to persons with other medical conditions, which seek to ensure that those entering service are free of medical conditions or physical defects that may require excessive time lost from duty. The Working Group also provided comprehensive input regarding all aspects of implementing any change to related military policy.