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Background: Renal cell carcinoma (RCC) commonly metastasizes, and unusual sites of spread are characteristic. However, metastatic RCC without an identified primary site is extremely rare, and only a few cases have been documented. We report the first case of clear cell RCC identified in retroperitoneal, supraclavicular, and mediastinal lymph nodes (LN) without a primary site in a kidney transplant patient.Case report: A 68-year-old patient presented with abdominal pain accompanied by weight loss, decreased appetite, and night sweats 6 months post female living donor kidney transplant. A CT scan revealed retroperitoneal, supraclavicular, and mediastinal lymphadenopathy. An excisional supraclavicular LN biopsy stained for markers consistent with RCC (pancytokertain, PAX8, CD10, and vimentin). Subsequent karyotyping revealed a female aneuploid cell line and raised suspicion for a donor derived RCC. A primary site for the RCC could not be identified on imaging of the native and allograft kidneys. The patient expired waiting for the pathology report, and an autopsy was performed to identify the origin of the RCC. Autopsy could not identify a primary site and cytologic studies indicated that the cell line was derived from the patient. Additional chromosomal abnormalities identified in the cytologic studies (loss of VHL, PBRM1, SETD2, BAP1, CDKN2A/B TP53) narrowed the diagnosis to clear cell RCC. Conclusion:Metastatic RCC can present without a primary site. IHC plays a vital role in making the diagnosis and cytologic studies can confirm the diagnosis and exclude the renal allograft as the origin in a kidney transplant patient.

Introduction: Direct Oral Anticoagulants (DOACs) have overtaken warfarin in the treatment of non-valvular Atrial Fibrillation (AF) and venous thromboembolism (VTE). However, there is very limited data that explores the safety of DOACs for patients that are morbidly obese (BMI >40). Methods: In this multi-center retrospective study, we sought to use the Michigan Anticoagulation Quality Improvement registry (MAQI) to see how treatment of non-valvular AF or VTE with DOAC vs. warfarin affects bleeding in morbidly obese patients. Specifically, we compared average major, clinically relevant non-major (CRNM), and minor bleeding events per 100 patient years that were adjusted for statistically significant baseline characteristics (p<0.05). Results: There were a total of 1028 patients with BMI >40 included in the registry between June 2015 and September 2019. 434 patients were treated with DOACs, while 594 patients were treated with warfarin. Baseline characteristics between the two groups included age (61.5 vs 57.8, p<0.001), gender (63.6% vs 61.1% female, p=0.42), race (76.5% vs 64.3% white, p<0.001), and HAS-BLED score (2.3 vs 2.3, p=0.96). The DOAC treated group had a higher event rate of major (4.3 vs 3.7, p=0.006), CRNM (10.7 vs. 7.4, p=0.002), and minor bleeding (19.1 vs. 13.2 p<0.001) compared to the warfarin treated group. Conclusions: There is a higher rate of major, CRNM, and minor bleeding in morbidly obese patients treated with DOAC compared to warfarin. Further studies to compare the two anticoagulants and understand bleeding drivers in this population are needed.

Background: Between 2016 and 2021, the average length of stay for congestive heart failure (CHF) patients at our Veterans Affairs (VA) Hospital has ranged from 0.8 to 1.9 days longer than comparable VA hospitals. This extended length of stay (LOS) results in increased healthcare costs and is an institutional focus to increase quality of care. Current cardiology guidelines for patients admitted with an acute CHF exacerbation recommend aggressive diuresis, defined as high-dose loop diuretics at least twice a day. We sought to analyze our institution’s compliance with this guideline-directed care. Methods: We performed a retrospective chart review of Veterans admitted between July and September 2021 with a primary diagnosis of CHF exacerbation. We tabulated the average LOS, days IV diuretics were administered, time(s) of administration, and the number of IV diuretic doses per day. Results: 44 patients were identified. The average LOS and number of days of IV diuretics a Veteran received was 7.5 (SD 3.5) and 4.5 (SD 1.4) days, respectively. The average number of IV diuretics given during days of IV diuresis was 1.4 (SD 0.5). We noted that 11.5% of IV diuretic doses were given before 8AM. Conclusions: Our results demonstrate that the diuresing patterns at our VA hospital fall short of the recommended guidelines. Receiving an average of 1.4 doses of IV diuretic, rather than at least 2, likely contributes to extended length of stay and cost. Additionally, we note that very few doses of diuretics are administered prior to 8AM, which may delay or prevent subsequent dosing. This project identifies clear targets for future quality improvement projects at our institution aimed at improving length of stay and Veteran care by increasing the number of IV diuretic doses per day.

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