SARS-CoV-2-induced remission of Hodgkin lymphoma A 61-year-old man was referred to the haematology department with progressive lymphadenopathy and weight loss. He was receiving haemodialysis for end-stage renal failure secondary to IgA nephropathy. He had been off immunosuppressive therapy for three years after a failed renal transplant. Needle-core biopsy of a supraclavicular node demonstrated Epstein-Barr virus (EBV)-positive classical Hodgkin lymphoma [EBV viral polymerase chain reaction (PCR) 4800 copies/ml; log 10 3Á68]. Fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) revealed avid stage IIIs disease (left image, PET scan, and supplementary image PET/CT). Shortly after diagnosis he was admitted with breathlessness and wheeze and was diagnosed with PCR-positive SARS-CoV-2 pneumonia. After 11 days of best supportive ward-based care he was discharged to convalesce at home. No corticosteroid or immunochemotherapy was administered. Four months later, palpable lymphadenopathy had reduced and an interim PET/CT scan revealed widespread resolution of the lymphadenopathy and reduced metabolic uptake throughout (right image and supplementary image). The EBV viral PCR had also fallen to 413 copies/ml (log 10 2Á62). We hypothesise that the SARS-CoV-2 infection triggered an anti-tumour immune response, as has been described with other infections in the context of high-grade non-Hodgkin lymphoma. 1 The putative mechanisms of action include cross-reactivity of pathogen-specific T cells with tumour antigens and natural killer cell activation by inflammatory cytokines produced in response to infection.

Palliative care and conservative care pathways have become very important components of the care of our patients in Nephrology and this article reviews many aspects of this. ABSTRACT:Patients with end-stage kidney disease have significantly increased morbidity and mortality. While greater attention has been focused on advanced care planning, end-of-life decisions, conservative therapy and withdrawal from dialysis these must be supported by adequate palliative care incorporating symptom control. With the increase in the elderly, with their inherent comorbidities, accepted onto dialysis, patients, their nephrologists, families and multidisciplinary teams, are often faced with end-of-life decisions and the provision of palliative care. While dialysis may offer a better quality and quantity of life compared with conservative management, this may not always be the case; hence the patient is entitled to be well-informed of all options and potential outcomes before embarking on such therapy. They should be assured of adequate symptom control and palliative care whichever option is selected. No randomized controlled trials have been conducted in this area and only a small number of observational studies provide guidance; thus predicting which patients will have poor outcomes is problematic. Those undertaking dialysis may benefit from being fully aware of their choices between active and conservative treatment should their functional status seriously deteriorate and this should be shared with caregivers. This clarifies treatment pathways and reduces the ambiguity surrounding decision making. If conservative therapy or withdrawal from dialysis is chosen, each should be supported by palliative care. The objective of this review is to summarize published studies and evidence-based guidelines, core curricula, position statements, standards and tools in palliative care in end-stage kidney disease.

The addition of polatuzumab vedotin to bendamustine and rituximab (Pola-BR) has been shown to improve overall survival (OS) in stem cell transplant (SCT)-ineligible patients with relapsed/refractory (R/R) diffuse large B-cell lymphoma (DLBCL). It is also increasingly used as bridging to CAR T-cell therapy (CAR-T). We retrospectively analysed the efficacy of Pola-BR in 133 patients at 28 UK institutions. Treatment intent was bridging to CAR-T for N=40, re-induction with planned SCT for N=13 and stand-alone treatment for N=78. The overall response rate (ORR) was 57.0% (complete response (CR) 32.8%). After median 7.7 months follow-up, median PFS and OS were 4.8 months and 8.2 months respectively. For stand-alone treatment shortened PFS was associated with bulk disease (>7.5cm) (HR 2.32 (95% CI 1.23-4.38), p=0.009), >1 prior treatment (HR 2.17 (95% CI 1.19-3.95), p=0.01) and refractoriness to the last treatment (HR 3.48 (95% CI 1.79-6.76), p<0.001). For CAR-T bridging the ORR was 42.1% (CR 18.4%) and for treatment after CAR-T failure the ORR was 43.8% (CR 18.8%). These data demonstrate efficacy for Pola-BR as a treatment for SCT-ineligible patients with R/R DLBCL, help to delineate which patients may benefit most, and provide preliminary evidence of efficacy as bridging to CAR-T and after CAR-T failure.

Healthcare professionals' beliefs, values and knowledge of palliative care influence their end-of-life care decisions. The influence of patient, family and clinicians involves negotiation and equivocation. Health professionals support the early discussion of end-of-life care in CKD at predialysis education to enable clearer decision making.

With increased numbers of the elderly, including nursing home patients, being accepted for end-stage kidney disease (ESKD) management, there is heightened interest and focus on end of life decisions, advanced care planning and directives, withdrawal from dialysis and palliative care in this setting. Despite this, care at the individual patient level can vary greatly. Here, we present two contrasting cases to highlight the importance of early and ongoing involvement of palliative care in patients with ESKD. In the first case, a high quality of life was preserved before the patient died with dignity, with early interdisciplinary palliative care involvement. In the second case there was a long protracted period of poor quality of life prior to death. This was associated with resistance to the involvement of palliative care, mainly from the family. Addressing end of life care issues early in the chronic kidney disease (CKD) trajectory and ensuring patients, their families and health care providers are well informed, may contribute to a better outcome for the patient and their family.