Karl Lhotta

Introduction: Ochrobactrum anthropi, a ubiquitous Gram-negative bacterium of low virulence, is an increasingly recognized cause of infection in immunocompromised hosts such as patients with kidney failure treated by dialysis. Case report: We report the case of a male hemodialysis patient with a central venous catheter, who developed an asymptomatic blood stream infection caused by Ochrobactrum anthropi. The infection was cured, and the dialysis catheter salvaged with intravenous meropenem and an antibiotic lock solution with ciprofloxacin. Conclusion: We identified 13 further cases of Ochrobactrum infection in hemodialysis patients and 10 cases in peritoneal dialysis patients in the literature. Antibiotic treatment depends on the results of susceptibility testing. In many patients, however, removal of the central venous or peritoneal dialysis catheter is required to cure the infection.

Objective: To characterize the incidence, type, and risk factors of severe infections (SI) in patients with autoimmune kidney diseases treated with rituximab (RTX).Methods: We conducted a multicenter retrospective cohort study of adult patients with immune-related kidney diseases treated with at least one course of RTX between 2015 and 2019. As a part of the ABCDE Registry, detailed data on RTX application and SI were collected. SI were defined by Common Terminology Criteria for Adverse Events v5.0 as infectious complications grade 3 and above. Patients were dichotomized between “nephrotic” and “nephritic” indications. The primary outcome was the incidence of SI within 12 months after the first RTX application.Results: A total of 144 patients were included. Twenty-five patients (17.4%) presented with SI, mostly within the first 3 months after RTX administration. Most patients in the nephritic group had ANCA-associated vasculitis, while membranous nephropathy was the leading entity in the nephrotic group. Respiratory infections were the leading SI (n= 10, 40%), followed by urinary tract (n=3, 12%) and gastrointestinal infections (n=2, 8%). On multivariable analysis, body mass index (BMI, 24.6 kg/m²versus 26.9 kg/m², HR: 0.88; 95%CI: 0.79-0.99; p=0.039) and baseline creatinine (HR: 1.25; 95%CI: 1.04-1.49; p=0.017) were significantly associated with SI. All patients in the nephritic group (n=19; 100%) who experienced a SI received oral glucocorticoid (GC) treatment at the time of infection. Hypogammaglobulinemia was frequent (58.5%) but not associated with SI.Conclusions: After RTX administration, impaired kidney function and lower BMI are independent risk factors for SI. Patients with nephritic glomerular diseases having concomitant GC treatment might be at higher risk of developing SI.

Vaccination against SARS-CoV-2 is the most important advance in the fight against the ongoing coronavirus pandemic. Recent case reports show that the SARS-CoV-2 vaccines can very rarely cause de novo or relapsing glomerular disease. Here, we report two female patients with microscopic polyangiitis, who developed severe glomerulonephritis after immunisation with the BNT162b2 mRNA vaccine. One patient with a possible ongoing but undiagnosed disease developed severe necrotising glomerulonephritis after the second vaccination. In the other patient with a long-lasting disease, rituximab maintenance therapy had been postponed because of the coronavirus pandemic. She noted macrohematuria immediately after the second vaccine dose and developed a severe renal relapse leading to end-stage kidney disease. We suggest that patients with ANCA-associated vasculitis be carefully monitored for disease activity immediately before and after receiving the SARS-CoV-2 vaccination, especially if maintenance therapy has been interrupted. Ultimately, mRNA vaccines should probably be avoided in these patients.

Background: Anti-glomerular basement membrane disease (GBM) disease is a rare autoimmune disease causing rapidly progressive glomerulonephritis and pulmonary haemorrhage. Recently, an association between COVID-19 and anti-glomerular basement membrane (anti-GBM) disease has been proposed. We report on a patient with recurrence of anti-GBM disease after SARS-CoV-2 infection.Case presentation: The 31-year-old woman had a past medical history of anti-GBM disease, first diagnosed 11 years ago, and a first relapse 5 years ago. She was admitted with severe dyspnoea, haemoptysis, pulmonary infiltrates and acute on chronic kidney injury. A SARS-CoV-2 PCR was positive with a high cycle threshold. Anti-GBM autoantibodies were undetectable. A kidney biopsy revealed necrotising crescentic glomerulonephritis with linear deposits of IgG, IgM and C3 along the glomerular basement membrane, confirming a recurrence of anti-GBM disease. She was treated with steroids, plasma exchange and two doses of rituximab. Pulmonary disease resolved, but the patient remained dialysis-dependent. We propose that pulmonary involvement of COVID-19 caused exposure of alveolar basement membranes leading to the production of high avidity autoantibodies by long-lived plasma cells, resulting in severe pulmonary renal syndrome.Conclusion: Our case supports the assumption of a possible association between COVID-19 and anti-GBM disease.

Background: The ongoing SARS-CoV-2 pandemic forced many countries to implement strict and unprecedented precautions to stop the spread of the virus. On top of these measures, hemodialysis units have adopted their own rules to protect wards and patients from infection with SARS-CoV-2. Despite the rapidly growing knowledge on epidemiology, virology, and clinical disease, little is known about how these measures are perceived by patients themselves on hemodialysis. Methods: The study was performed in the three hemodialysis units in Vorarlberg, Austria’s westernmost state. A questionnaire was developed consisting of 22 questions on patients’ perceptions of the COVID-19 crisis and their feelings about the general precautions and specific steps implemented on dialysis wards. All adult patients were asked to fill out the questionnaire anonymously. Results: Of 202 patients on hemodialysis, 148 completed the questionnaire (66.9% men, mean age 68.3±13.3 years). The vast majority (83.1%) were worried by the COVID-19 crisis, but only 28.4% reported a negative effect on emotional well-being. Daily life was most affected by the general ban on visitors (58.6%) and home confinement (35.9%). Of the patients, 64.2% feared contracting COVID-19, 30.7% were afraid of financial consequences, and 14.6% were afraid of loneliness and isolation. The safety measures on dialysis wards were classified as adequate by 97.3% of the respondents. Of the patients, 78.2% felt safe during dialysis treatment. All dialysis-specific precautions (individual patient transport, health check, hand disinfection, wearing a face mask, and physical distancing) were rated important or very important by almost all patients. To date, none of the patients have acquired SARS-CoV-2 infection. Conclusions: Although the SARS-CoV-2 crisis brought worry to and affected the lives of most patients on hemodialysis, its effect on their emotional well-being was moderate. Patients felt safe on dialysis wards, and acceptance of specific precautions was high.

Background: Pregnancy is rare in women on hemodialysis. Recommendations for the treatment of secondary hyperparathyroidism (sHPT) and preservation of bone health in pregnant dialysis patients are lacking. Case presentation: We present the case of a young woman with end-stage kidney disease (ESKD) due to lupus nephritis, who developed multiple brown tumors while on hemodialysis during her second pregnancy. During her first pregnancy sHPT was well controlled and no skeletal complications occurred. Before the second pregnancy she developed severe sHPT. During pregnancy, dialysis time was increased to 24 h per week, the patient was given oral calcitriol, and the dialysate calcium concentration was set at 1.5 mmol/l. In week 20 the patient complained about bone pain in her left hip. Magnetic resonance imaging revealed a cystic lesion compatible with a brown tumor. The baby was delivered in the 36th week by cesarean section. Further assessment identified multiple brown tumors of her skeleton, including the acetabulum, tibia, ribs, skull, thoracic spine and thumb. She required multiple orthopedic surgeries. Three months after pregnancy, etelcalcetide was started, which brought about a gradual improvement in her sHPT. Conclusions: This case demonstrates that the combination of pregnancy and severe sHPT in dialysis patients can have deleterious consequences for bone health.

Antiglomerular basement membrane (anti-GBM) antibody disease is a rare condition causing pulmonary hemorrhage and necrotizing glomerulonephritis (pulmonary renal syndrome). We report a 30-year-old woman who presented with life-threatening pulmonary hemorrhage and an active urinary sediment, with normal glomerular filtration rate in the 13th week of pregnancy. Anti-GBM antibodies in serum were negative, but perinuclear antineutrophil cytoplasmatic antibodies (p-ANCA) were detected. A renal biopsy revealed necrotizing glomerulonephritis with linear IgG deposits along the glomerular basement membrane. A diagnosis of pulmonary renal syndrome caused by anti-GBM antibodies and p-ANCA (double-positive) was made. Plasma exchange was started but had to be changed to immunoadsorption because of an allergic reaction to fresh frozen plasma. Oral steroids were introduced. The patient also received one dose of intravenous cyclophosphamide followed by two 1-g doses of rituximab. The patient responded quickly to treatment with resolution of pulmonary hemorrhage and urinary abnormalities. The infant was delivered in the 38th week of pregnancy by caesarian section. It was small for age but otherwise completely healthy with a normal B-cell count. To our knowledge, this is the first report of a double-positive pulmonary renal syndrome in pregnancy. Presentation in mid-pregnancy allowed for the application of cyclophosphamide without causing malformations and rituximab without B-cell depletion in the infant. .