Background. Referral for kidney transplant (KT) is variable, with women often disadvantaged. This study aimed to better characterize Canadian transplant referral practices and identify potential differences by respondent and/or patient gender using surveys targeted at healthcare practitioners (HCPs) involved in KT. Methods. Surveys consisting of 25 complex patient cases representing 7 themes were distributed to KT HCPs across Canada (March 3, 2022–April 27, 2022) using national nephrology/transplant society email registries. Respondents were asked whether they would refer the patient for transplant. Two identical surveys were created, differing only by gender/gender pronouns used in each case. Multivariable logistic regression was used to assess the association of respondent demographics and patient themes (including case gender) with the odds of transplant referral (overall and stratifying by respondent gender). Results. Overall, the referral rate was 58.0% among 97 survey respondents (46.4% male). Case themes associated with a lower likelihood of referral included adherence concerns (adjusted odds ratio [aOR] 0.65; 95% confidence interval [CI], 0.45-0.94), medical complexity (aOR 0.57; 95% CI, 0.38-0.85), and perceived frailty (aOR 0.63; 95% CI, 0.47-0.84). Respondent gender was not associated with differences in KT referral (aOR 0.91; 95% CI, 0.65-1.26 for male versus female respondents) but modified the association of frailty (less referral for male than female respondents, P = 0.005) and medical complexity (less referral for female than male respondents, P = 0.009) with referral. There were no differences in referral rate by case gender (P = 0.82). Conclusions. KT referral practices vary among Canadian HCPs. In this study, there were no differences in likelihood of transplant referral by candidate gender.

Background: Post-transplant diabetes mellitus (PTDM) is an important complication after kidney transplantation that results in reduced patient and allograft survival. While there are established risk factors for PTDM, whether pre-transplant C-peptide levels associate with PTDM is unknown. Therefore, in this study we aimed to examine the association of pre-transplant C-peptide levels with PTDM. Methods: This was a cohort study of non-diabetic adult patients who underwent kidney transplant in Nova Scotia, Canada, between 01-01-2016 to 03-31-2021 with fasting C-peptide levels measured prior to transplant. Multivariable logistic regression was used to determine the association of pre-transplant C-peptide (dichotomized around the median) with PTDM at one-year post-transplant. Given the known association between pre-transplant obesity and PTDM, we repeated our primary analysis in a cohort restricted to BMI 20-35 kg/m2. Results: Median C-peptide value was 3251 (Q1 2480, Q3 4724); pre-transplant C-peptide level was dichotomized at 3000 pmol/L. PTDM occurred in 25 individuals (18.9%). 29.6% of patients in the high and only 2.0% of patients in the low C-peptide groups developed PTDM, p-value < 0.001. C-peptide level ≥3000 was strongly associated with PTDM in multivariable analysis (OR 18.9, 95% CI 2.06-174.2). In a restricted cohort with BMI 20-35 kg/m2, an elevated pre-transplant C-peptide remained independently associated with the risk of PTDM (OR 15.7, 95% CI 1.64-150.3). C-peptide was the only factor independently associated with PTDM in this restricted BMI cohort. Conclusions: A pre-transplant C-peptide level ≥3000 pmol/L was associated with a nearly 20-fold increased odds of PTDM at one-year post-kidney transplantation. Identifying patients with high pre-transplant C-peptide levels may therefore help identify those at risk for PTDM who may benefit from focused preventative and therapeutic interventions and support.

Rationale: Q fever is a zoonotic infection that may lead to acute or long-term renal injury. Given its rare incidence, Q fever is not often considered on the initial differential diagnosis for glomerular disease which can lead to delays in treatment. This case highlights the importance of avoiding early diagnostic closure and revisiting the differential diagnosis in the setting of an atypical clinical presentation or response to treatment. Presenting Concerns: A 52-year-old female was referred for assessment of possible glomerulonephritis. She described a 3-month history of bilateral lower extremity rash, intermittent knee pain with swelling, and a 2-year history of subjective fevers. Urinalysis showed persistent microscopic hematuria, and her creatinine was elevated at 94 umol/L (baseline 59 umol/L). Her initial investigations included an elevated C-reactive protein (CRP) and rheumatoid factor with a weakly positive anti nuclear antibody (ANA). Diagnoses: Kidney biopsy was consistent with an immune complex mesangial proliferative glomerulonephritis. Light microscopy showed diffuse global mesangial hypercellularity. Immunofluorescence was positive for trace mesangial IgG and kappa, 1+ IgM, lambda and C1q, and 2+ C3. Electron microscopy showed mesangial electron dense deposits. These findings were felt to be most in keeping with mesangial proliferative lupus nephritis; however, it was acknowledged that clinical and laboratory findings supporting this diagnosis were lacking. Interventions: Following treatment with oral prednisone her symptoms resolved, and renal function improved. However, she was unable to taper off prednisone completely without her symptoms returning. Additional immunosuppressive therapies were trialed, but she remained steroid dependent with disease flares related to prednisone tapers. Her atypical response to treatment led to consideration of alternative diagnoses, and further investigation revealed positive Q fever serology (phase-I IgG 1:1892, phase II IgG 1:8192, phase-I and -II IgM < 1:16). She was diagnosed with long-term Q fever and was treated with doxycycline and hydroxychloroquine. Outcomes: She remained on treatment for 2 years. During this time, her symptoms resolved, hematuria disappeared, and her creatinine returned to baseline. Following cessation of therapy, her Q fever IgM titres rose, and she was restarted on doxycycline and hydroxychloroquine indefinitely. Teaching Points: (1) Keeping a broad differential diagnosis in the setting of atypical clinical features or unexpected response to therapy is important for ensuring accurate diagnosis and appropriate treatment. (2) Clinical improvement in relation to immunosuppressive therapy does not preclude an infectious cause of glomerular disease.