BACKGROUND AND AIMS The actual definition of chronic kidney disease (CKD) applied to patients ˃80 years has generated an increase in the number of referrals to Nephrology for consultation. Nowadays there is a debate about the evolution of kidney function in elderly patients, from physiological evolution of kidney function to identifying which factors are associated with a real progression of CKD. The aim of this study is to analyse the evolution of kidney function in patients ˃80 years referred to Nephrology for consultation for the first time. METHOD A single-centre retrospective study in which we included patients ˃80 years with an estimated glomerular filtration rate (eGFR) <60 mL/min/1,73m2 who were referred to Nephrology consultation from 2015 to 2018. We collected clinical and analytical parameters at the following points in time: 12 months before the visit, baseline and 12 months after the initial visit. We divided patients into two groups based on annual eGFR loss: Group 1 progressors (>5 mL/min/1.73m2) and group 2 non-progressors (≤5 mL/min/1.73m2). RESULTS A total of 348 patients were included in the study, 55.2% were women and the mean age was 84 years (80–97). At the time of first medical visit, the mean creatinine value was 1.6 ± 0.6 mg/dL, median eGRF was 38 mL/min/1.73m2 (29–44) and median albumin/creatinine ratio was 55 mg/g (6–419), with 12% of the patients, presenting albuminuria over 1000 mg/g. The most frequent referral criteria were worsening of renal function (85.6%). Comorbidities were very common, and hypertension, dyslipidaemia and diabetes mellitus were present in 89.4%, 42.8% and 42.2% respectively. A total of 51% of the patients met the definition of progressor at baseline (initial-progressors) and 29.4% were progressors after a 12-month follow-up. Interestingly, only 21.6% of initial-progressors kept meeting this definition 12 months after (Figure 1). The main risk factors for progression were a higher baseline eGFR (P < 0.001) and albuminuria (P < 0.002). No association with comorbidities was found in the multivariate analysis. CONCLUSION The majority of patients ˃80 years evaluated by a Nephrologist were non-progressors at 12 months according to our definition (70.6%). It is more important to estimate the progression of CKD patients and request albuminuria and/or proteinuria than an isolated GFR value. It is likely that non-progressors do not need to be followed by a Nephrologist and may remain under primary care control.

BACKGROUND AND AIMS Intravitreal administration of vascular endothelial growth factor (VEGF) inhibitors is the treatment of a wide variety of retinal diseases. Kidney damage caused by systemic administration is widely known. However, there is not enough information in the literature on the renal effect of these drugs after intravitreal injection. The aim of the study is to analyse the effect of intravitreal anti-VEGF on kidney function in diabetic patients. METHOD A prospective cohort study of diabetic patients with and without chronic kidney disease (CKD) who received intravitreal anti-VEGF from January 2018 to December 2019. Clinical and analytical parameters were analysed. The follow-up time was 24 months. RESULTS We included 45 patients (55.6% male) with a mean age of 74.4 ± 11.5 (50–91) years. Approximately 64.4% of patients had CKD [estimated glomerular filtration rate (eGFR) <60 mL/min]. The types of anti-VEGF used were: bevacizumab 57.8% and ranibizumab 42.2%. The average number of doses administered was 7.6 ± 4.8 (1–22). The initial eGFR was 48.7 ± 25.3 mL/min and the Alb/Cr ratio 145 (49.45) mg/g. A significant decrease in the eGFR was observed at 6, 12 and 24 months (Table 1). There was a significant increase in proteinuria at 12 and 24 months. This drop in eGFR was independent of the presence of CKD, the anti-VEGF type or the number of doses. After the admistration of the first dose, five patients (17.2%) in the CKD group required renal replacement therapy (mean time 22 ± 12 months). CONCLUSION A significant decrease in eGFR and an increase in proteinuria are observed after administration of anti-VEGF in diabetic patients. For this reason, a close monitoring of renal function is needed to establish an early diagnosis and management of possible complications.

Background and Aims Longer survival in renal transplantation means an increase in the number of patients who return to dialysis after graft loss. There is little literature about the management of immunosupression(IS) in these patients and the complications derived from its maintenance and its withdrawal/reduction. Method We conducted a retrospective study involving a cohort of patients who returned to dialysis after graft failure at Doce de Octubre Hospital from 2015 to 2022. We analyzed baseline characteristics, IS withdrawal scheme, and the complications derived in the 27 months following the restart of dialysis. Results A total of 50 patients were enrolled in the study: 58% male, 86% hypertensive, 30% diabetic and 52% with heart disease. The median age at transplant was 41.5 (33.7-53.2). 70% of donations were in brain death, 18% asystole and 10% alive. The duration of the graft was 8.5 years (5,14), 96% of patients developed anti-HLA antibodies and 40% suffered active rejection. Upon restarting dialysis, all the patients were receiving IS: 84% calcineurin inhibitors (CNI) (tacrolimus, cyclosporine), 58% antimetabolites (mycophenolate, azathioprine), and 10% mTOR inhibitors (everolimus). Haemodialysis was performed in 70% of patients through central venous catheterization in 68.6%. The median time to stop IS was 10 months (6,19). Between the first and the third month, imTOR [0(0.4)] and antimetabolite [1(0.3)] were finalized. Discontinuance of CNI and steroids was at 2 months (1,8) and 8 months (3,15.7) respectively. As complications derived of IS, 64% of patients developed serious infection and 12% were diagnosticated of neoplasms. On the other hand, eighteen patients presented immunological intolerance to the graft, 100% requiring an increase of steroids, 72.2% percutaneous embolization and finally 50% require a transplantectomy. The rate of immunological intolerance, embolization and transplantectomy was higher in patients with withdrawal IS during the first year. Patients on haemodialysis (HD) had higher rate of graft intolerance compared to peritoneal dialysis (PD) (40.5% vs 23%), attributable to early suspension of IS (62% before the first year), but similar rate of infection (61.5%PD, 64.8%HD). At 27 months (14.5,44.2) of follow-up after returning dialysis, 64% of patients remained on dialysis (30% on waiting list for a second kidney transplantation), 28% were retransplanted, and 8% were died. Conclusion Most of transplant recipients returned to haemodialysis through a venous catheter. Withdrawal of immunosuppression was performed on a median of 10 months, faster in mTOR and antimetabolites, and more progressive in CNI and steroids. Stop IS before the first year is more common in haemodialysis group and it is associated with a higher rate of graft intolerance. Finally we want to highlight the significant percentage of embolizations in our hospital, that let us avoid a 12.2% of the transplantectomies.

Background and Aims Post-transplant lymphoproliferative disorders (PTLD) are one of the most common malignancies in kidney transplant (KT) recipients. Immunosuppressive therapy and Epstein Barr Virus (EBV) play a main role in their pathogenesis. Method In this study we retrospectively analyze the characteristics, clinical evolution and treatments of a group of KT recipients performed between 1986 and 2020 in a single center. Results We included 31 patients (64.5% males). Polycystic kidney disease was the most frequent cause of renal failure. Before KT a 6.5% of the patients presented another malignancy, 10% were EBV seronegative and one received immunosuppressive therapy secondary to his primary disease. Mean age at KT was 43±12 years. 68% of the KT came from brain-dead donors. The most frequent immunosuppressive regime consisted in tacrolimus, mycophenolic acid and prednisone (61.3%). Basiliximab and Timoglobulin were used in the same proportion for the induction therapy (22.6%). Before PTLD appearance the immunosuppressive therapy was reduced in the 54.8% of the recipients. 13% of them presented acute allograft rejection. The majority of PTLD were diagnosticated between 2016 and 2020. Median time to develop PTLD was 13 years. 54.3% of the patients presented with extranodal involvement. Although all the patients positivized EBV serology, 60% of them had undetectable EBV viral load. The main therapeutical strategy after PTLD consisted in a reduction of the immunosuppressive therapy. In this way, 28.6% of the recipients was treated with monotherapy with a calcineurin inhibitors and 21.5% with monotherapy with a mTOR inhibitor. In other hand 16.7% received a combination of tacrolimus with a mTOR inhibitor. Rejections were not observed in our group and all the patients presented a preserved kidney function at the end of follow up. Four recipients died because of PTLD. The remaining 27 presented a complete response or stabilization of the disease. Conclusion Most of the PTLD were detected between 2016-2020. The time from transplantation to PTLD appearance was long, being EBV viral load negative in the majority of the cases. Graft survival after chemotherapy and reduction of immunosuppressive therapy was excellent, with a low risk of rejection and a good prognosis for hematologic disease. It is possible that a reduction in immunosuppression in selected patients could prevent the development of PTLD.

Background and Aims Monoclonal gammopathy of uncertain significance (MGUS) is a frequent condition with an estimated prevalence of 3% in people over 50 years of age in the general population. Nowadays, more kidney transplants (KT) are performed in a population susceptible to present MGUS, and the evolution of this entity in KT recipients is currently unknown. Method We carried out a retrospective study of a cohort of KT recipients diagnosed with MGUS between 1996 and 2020, including patients with MGUS identified prior to kidney transplantation or during follow-up. We describe baseline, kidney transplantation, and hematological characteristics, analyzing the evolution of the hematological parameters according to the moment of appearance of MGUS. Results A total of 51 patients were included; in 28 (54.9%) MGUS appeared before transplantation, and in 23 (45.1%) after transplantation. Thirty-two (62.7%) were males, with glomerular pathology in 17 (33.3%) as the leading cause of chronic kidney disease. Hypertension (90.2%) and diabetes (27.5%) were the most common comorbidities. At renal transplantation, the median age is significantly higher in the pre-transplant MGUS group (62 years [IQR 54-66]) vs. 48 years [IQR 40-68]; p = 0.04). This group had a higher induction immunosuppression load than the post-transplant MGUS group (p = 0.01) due to a greater incidence of immunized KT recipients (p = 0.05). There were no differences in rejection, infections, or post-transplant neoplasia between both groups; however, higher renal graft loss was observed in the post-transplant MGUS group (10.7% vs. 43.5%; p = 0.02), probably explained by a longer follow-up time in this group. The most detected paraprotein was IgG (60.8%) and lambda light chain (51%), with a median blood concentration of 0.4 g/dl (IQR 0.2-1.4). In 45.1% of the cases, the paraprotein remained stable; it disappeared in 27.5%, and MGUS progressed to hematological neoplasia in 21.6%, including multiple myeloma, amyloidosis, and post-transplant proliferative syndrome. We did not detect significant differences in the evolution according to the moment of diagnosis of the MGUS (p = 0.7). Twelve renal biopsies were performed during post-transplant follow-up, detecting renal involvement by paraprotein in 5 (9.8%). Only 1 of them (1.96%) was defined as a monoclonal gammopathy of renal significance for not meeting the criteria for malignancy. Conclusion Close monitoring of MGUS in KT recipients is still necessary given the possibility of progression to hematological neoplasia, with a non-negligible percentage in our serie of patients. Our cohort does not allow us to detect significant differences with an impact on the clinical course of MGUS or KT regarding the moment of the development of MGUS before or after transplantation.