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The coronavirus disease 2019 (COVID)-19 pandemic significantly affected transplantation care strategies due to the heightened vulnerability of transplant recipients to severe illness. We present a unique case of a 31-year-old female with COVID-19 pneumonia following a recent kidney transplant managed with immunosuppressant reduction and tocilizumab therapy. The patient underwent live donor kidney transplantation and was considered a low immunologic risk recipient. Following surgery, she presented with fever, headache, and fatigue, and subsequent testing confirmed active COVID-19 infection. Imaging revealed characteristic pneumonia features. Standard approaches, including immunosuppressant reduction and antibiotic therapy, initially failed to halt clinical deterioration. Progressive radiological findings and increasing inflammatory markers raised concerns of impending graft failure and cytokine storm. Considering the severity of the condition, tocilizumab, an interleukin-6 (IL-6) receptor antagonist, was administered alongside continued supportive care and adjusted immunosuppression. Within a day post-tocilizumab infusion, the patient showed significant improvement in clinical parameters, with resolution of respiratory distress and systemic symptoms. Laboratory markers gradually normalized, and subsequent lung imaging showed improvement. The patient was discharged with follow-up recommendations. Managing COVID-19 in postoperative transplant patients requires nuanced approaches due to immunosuppression-related complexities. Despite limited guidance, our case highlights the successful use of tocilizumab in treating COVID-19 pneumonia shortly after transplantation, showcasing its potential effectiveness and safety in this context. Reporting such experiences is crucial for refining management strategies for immunocompromised transplant recipients facing COVID-19 complications.

Introduction The implementation of artificial intelligence (AI) in radiology as a medical decision support system has the potential to enhance diagnostic accuracy and improve patient outcomes. This retrospective study aimed to evaluate the diagnostic capabilities of GPT-4o in interpreting radiological imaging, specifically X-ray, CT, and MRI images, across various organ systems and disease types. Methods A total of 377 cases were collected and presented to GPT-4o with a standardized prompt and no clinical context. The responses were assessed by three independent raters using a five-point rating system. Results X-ray imaging exhibited a 2.21 times higher chance, on average, of being interpreted accurately compared to CT scans (odds ratio (OR): 2.21; 95% confidence interval (CI): 1.33 - 3.69), while pelvic imaging had a 6.25 times lower chance, on average, of being interpreted accurately when compared to images of the abdomen (OR: 0.16; 95% CI: 0.02 - 0.56). Additionally, neoplastic conditions had a 2.7 times lower chance, on average, of being interpreted accurately compared to bleeding conditions (OR: 0.37; 95% CI: 0.16 - 0.84). Conclusion A bimodal distribution of median ratings highlights an overreliance on comparability to prior image encounters and emphasizes the need to develop a systematic approach to image analysis. Future research should prioritize eliminating hallucination, establishing standardized evaluation criteria, and exploring methods to integrate visual and text-based data in a balanced manner. Additionally, efforts should be directed towards enhancing dataset diversity to improve the model's overall accuracy and generalizability.

Introduction According to a 2023 poll by the International Society of Nephrology, 850 million individuals worldwide suffer from chronic kidney disease (CKD) and hemodialysis (HD) is the primary treatment for 69% of the patients with CKD. While HD effectively regulates fluid balance and electrolyte levels, patients often face challenges such as weakness, exhaustion, and cognitive changes, which impact their quality of life. Sleep-related issues, including poor quality, excessive morning sleepiness, insomnia, and restless leg syndrome (RLS), are particularly common among HD patients. These disturbances stem from various factors, including psychological discomfort and biochemical imbalances. Dialysis shifts, despite their importance, remain poorly studied regarding their impact on sleep and biochemical parameters. Our study aims to address these gaps, exploring how different dialysis shifts affect sleep quality and biochemical parameters. Our hypothesis suggests that the particular dialysis shift that hemodialysis patients undergo has an impact on the quality of sleep, with various groups exhibiting varying degrees of sleep disturbance. Simultaneously, we believe that the time of dialysis shifts could influence biochemical parameter variations, which in turn could affect the quality of sleep in hemodialysis patients. Methodology This cross-sectional study focuses on assessing sleep problems and analyzing biochemical variables among hemodialysis (HD) patients in Georgia. A total of 150 participants were selected from morning, afternoon, and evening dialysis shifts, with strict inclusion criteria and exclusion criteria. Assessment procedures involved questionnaires on sleep quality, restless leg syndrome (RLS), daytime sleepiness, and severity of insomnia. Biochemical variables were obtained from the hospital records. Statistical analyses were performed using Graph Pad Prism software (GraphPad, San Diego, USA), including ANOVA and Chi-square tests for association between biochemical variables and dialysis shifts, as well as logistic regression for assessing the influence of biochemical variables on insomnia and poor sleep quality. The significance level was set at 95%. Results Results showed that patients in the afternoon shift undergo longer sessions of hemodialysis compared to other shifts. Notably, a larger proportion of morning shift patients reported poor sleep quality, while a smaller fraction of evening shift patients experienced insomnia. There were no significant associations between dialysis shift and excessive morning sleepiness or restless leg syndrome. Potassium emerged as the sole biochemical variable exhibiting an association with all three dialysis shifts. Biochemical parameters showed no discernible impact on insomnia or poor sleep quality. Conclusion Our findings suggest an association between poor sleep quality and insomnia with dialysis shifts. Hemodialysis does influence potassium levels. However, biochemical variables like sodium, potassium, calcium, phosphorus, vitamin D3, parathyroid gland hormone (PTH), and hemoglobin do not seem to affect poor sleep quality and insomnia. Further research is needed to explore potential sleep issues with nocturnal shifts and to assess if creatinine and chloride have any influence on poor sleep quality. It is important to acknowledge dialysis shift as a contributor to sleep problems, emphasizing the need for targeted interventions to enhance the quality of life for these patients.

Chronic kidney disease (CKD) and its associated complications, such as anemia and secondary hyperparathyroidism (SHPT), pose significant challenges to global healthcare systems. This study explores the demographic and clinical characteristics of 284 kidney failure (KF) patients undergoing hemodialysis, in an effort to shed light on the possible association between anemia and SHPT. A proven connection between the two could theoretically influence the management plans for CKD patients, with the hopes of achieving lower morbidity and/or mortality in this patient group. A retrospective, cross-sectional, real-world data analytical study was conducted at a hemodialysis center in Tbilisi, Georgia, encompassing a sample size of n = 284 patients on maintenance hemodialysis. The data analyzed was extracted from patients' medical records. According to our results, the prevalence of anemia was strikingly high at 82.04%, underlining its substantial burden within this patient population. Our analysis revealed a notable systemic association between anemia and SHPT, particularly when considering hemodialysis vintage. However, our final analysis model revealed no statistically significant association between anemia and intact parathyroid hormone (iPTH) levels.  Conclusion: Our study revealed a significant systemic relationship between anemia and SHPT when hemodialysis duration was considered, despite initial analyses showing no direct association. Future research should focus on longitudinal and multi-center studies to better understand this relationship, aiming to enhance the care and management of CKD patients on hemodialysis.

Background Infections related to vascular access (VA) remain one of the most serious complications in hemodialysis (HD), contributing substantially to patient morbidity and mortality. Central venous catheters (CVCs) confer a substantially higher infection risk compared to arteriovenous fistulas (AVFs), but local epidemiological data are limited. Objective We aimed to investigate the incidence of VA-related infections by access type (CVC vs. AVF, using access-days) and to identify risk factors, with secondary outcomes including infection-related hospitalization and mortality, in HD patients at the largest single center in Tbilisi, Georgia (2022-2025). Methods A retrospective cohort study was conducted on 386 adult HD patients from January 2022 to January 2025. Demographic, clinical, and VA data were analyzed. Cox proportional hazards and logistic regression models assessed associations between VA type, diabetes, and infection or hospitalization, accounting for person-time at risk. Kaplan-Meier curves compared time-to-infection, and incidence rates were calculated per 1,000 access-days with corresponding incidence rate ratios (IRRs) and attributable fractions. Results Out of 386 patients, 208 (53.9%) used CVCs and 178 (46.1%) used AVFs. A total of 116 (30.1%) patients developed bacterial infections, of which 69 (59.5%) were access-related. The infection rate was markedly higher among CVC users compared with AVF users (0.731 vs. 0.042 infections per 1,000 access-days; incidence rate ratio (IRR) = 17.25; 95% confidence interval (CI): 8.21-41.79; p < 0.001). The incidence rate difference was 0.689 infections per 1,000 access-days (95% CI: 0.50-0.88; p < 0.001), with an attributable fraction among the exposed of 94.2% (95% CI: 87.8-97.6). In the univariate Cox regression analysis, CVC use was strongly associated with an increased hazard of bloodstream infections (BSIs) (hazard ratio (HR) = 19.18; 95% CI: 8.72-42.23; p < 0.001) and infection-related hospitalization (HR = 4.10; 95% CI: 2.50-6.71; p < 0.001). Diabetes mellitus was not significantly associated with BSIs (HR = 0.91; 95% CI: 0.55-1.51; p = 0.715) but showed a weak association with hospitalization (HR = 1.04; 95% CI: 1.00-1.07; p = 0.041). Age was not significantly related to either outcome. Infection-related mortality occurred in 23 (19.8%) patients. Conclusions Using CVCs is a significant and modifiable risk factor for VA-related infections in HD patients. Strategies to reduce CVC use focus on timely AVF placement, and strengthening infection control protocols is essential to decrease infection-related morbidity and mortality.

AbstractObjectiveTo determine the global capacity (availability, accessibility, quality, and affordability) to deliver kidney replacement therapy (dialysis and transplantation) and conservative kidney management.DesignInternational cross sectional survey.SettingInternational Society of Nephrology (ISN) survey of 182 countries from July to September 2018.ParticipantsKey stakeholders identified by ISN’s national and regional leaders.Main outcome measuresMarkers of national capacity to deliver core components of kidney replacement therapy and conservative kidney management.ResultsResponses were received from 160 (87.9%) of 182 countries, comprising 97.8% (7338.5 million of 7501.3 million) of the world’s population. A wide variation was found in capacity and structures for kidney replacement therapy and conservative kidney management—namely, funding mechanisms, health workforce, service delivery, and available technologies. Information on the prevalence of treated end stage kidney disease was available in 91 (42%) of 218 countries worldwide. Estimates varied more than 800-fold from 4 to 3392 per million population. Rwanda was the only low income country to report data on the prevalence of treated disease; 5 (<10%) of 53 African countries reported these data. Of 159 countries, 102 (64%) provided public funding for kidney replacement therapy. Sixty eight (43%) of 159 countries charged no fees at the point of care delivery and 34 (21%) made some charge. Haemodialysis was reported as available in 156 (100%) of 156 countries, peritoneal dialysis in 119 (76%) of 156 countries, and kidney transplantation in 114 (74%) of 155 countries. Dialysis and kidney transplantation were available to more than 50% of patients in only 108 (70%) and 45 (29%) of 154 countries that offered these services, respectively. Conservative kidney management was available in 124 (81%) of 154 countries. Worldwide, the median number of nephrologists was 9.96 per million population, which varied with income level.ConclusionsThese comprehensive data show the capacity of countries (including low income countries) to provide optimal care for patients with end stage kidney disease. They demonstrate substantial variability in the burden of such disease and capacity for kidney replacement therapy and conservative kidney management, which have implications for policy.

Objective To assess the prevalence of microalbuminuria and kidney dysfunction in low-income countries and in the USA. Design Cross-sectional study of screening programmes in five countries. Setting Screening programmes in Nepal, Bolivia, the USA (National Health and Nutrition Examination Survey (NHANES) 2005–2008) Bangladesh and Georgia. Participants General population in Nepal (n=20 811), Bolivia (n=3436) and in the USA (n=4299) and high-risk subjects in Bangladesh (n=1518) and Georgia (n=1549). Primary and secondary outcome measures Estimated glomerular filtration rate (eGFR)<60ml/min/1.73 m2 and microalbuminuria (defined as urinary albumin creatinine ratio values of 30–300 mg/g) were the main outcome measures. The cardiovascular (CV) risk was also evaluated on the basis of demographic, clinical and blood data. Results The prevalence of eGFR<60ml/min/1.73 m2 was 19%, 3.2% and 7% in Nepal, Bolivia and the USA, respectively. In Nepal, 7% of subjects were microalbuminuric compared to 8.6% in the USA. The prevalence of participants with predicted 10-year CV disease (CVD) risk ≥10% was 16.9%, 9.4% and 17% in Nepal, Bolivia and in the USA, respectively. In Bangladesh and Georgia, subjects with eGFR<60 ml/min/1.73 m2 were 8.6% and 4.9%, whereas those with microalbuminuria were 45.4% and 56.5%, respectively. Predicted 10-year CVD risk ≥10% was 25.4% and 25% in Bangladesh and Georgia, respectively. Conclusions Renal abnormalities are common among low-income countries and in the USA. Prevention programmes, particularly focused on those with renal abnormalities, should be established worldwide to prevent CVD and progression to end-stage renal disease.

Staphylococcus aureus is a common cause of catheter-related bloodstream infections (CRBSIs) in patients undergoing hemodialysis, although cerebral microabscesses resulting from septic emboli are exceedingly rare. We describe a 37-year-old woman on chronic hemodialysis through a tunneled central venous catheter who presented with headache, limb weakness, and confusion without fever. Blood cultures confirmed methicillin-sensitive Staphylococcus aureus, and brain MRI demonstrated multifocal diffusion-restricted lesions consistent with microabscesses. Following prompt catheter removal and a six-week course of intravenous antibiotics, the patient achieved full neurological recovery and was transitioned to permanent vascular access. This case highlights the importance of early recognition of unusual neurological manifestations of Staphylococcus aureus CRBSI and the critical role of timely imaging and definitive source control in improving outcomes.

Numerous studies have shown that dialysis may not be as beneficial to elderly, frail patients with chronic kidney failure and multiple comorbidities as comprehensive conservative therapy (CCT) and that dialysis may worsen the quality of life (QOL), increase hospitalization rates, and cause a significant decline in functional status. Several mortality predictors have been proposed to determine which patients would benefit more from CCT or dialysis. We estimated the short-term risk of death in an 81-year-old male patient with kidney failure and highly severe frailty using the REIN score, a dependable risk prediction model proposed by the European Renal Best Practice Group for the prediction of short-term risk mortality. This score indicated that the patient had a high chance of death in the ensuing three months. However, the patient's longer survival time and a notable increase in functional status and QOL following hemodialysis started to contradict the expected outcome. It is important to note that the patient had never undergone a frailty assessment before or had been on a nephrologist's follow-up. We suggest that uremia may exaggerate frailty levels in older persons and as a result, undermine the predictive usefulness of mortality prediction scores in this population.

ObjectivesThe Global Kidney Health Atlas (GKHA) is a multinational, cross-sectional survey designed to assess the current capacity for kidney care across all world regions. The 2017 GKHA involved 125 countries and identified significant gaps in oversight, funding and infrastructure to support care for patients with kidney disease, especially in lower-middle-income countries. Here, we report results from the survey for the second iteration of the GKHA conducted in 2018, which included specific questions about health financing and oversight of end-stage kidney disease (ESKD) care worldwide.SettingA cross-sectional global survey.ParticipantsKey stakeholders from 182 countries were invited to participate. Of those, stakeholders from 160 countries participated and were included.Primary outcomesPrimary outcomes included cost of kidney replacement therapy (KRT), funding for dialysis and transplantation, funding for conservative kidney management, extent of universal health coverage, out-of-pocket costs for KRT, within-country variability in ESKD care delivery and oversight systems for ESKD care. Outcomes were determined from a combination of desk research and input from key stakeholders in participating countries.Results160 countries (covering 98% of the world’s population) responded to the survey. Economic factors were identified as the top barrier to optimal ESKD care in 99 countries (64%). Full public funding for KRT was more common than for conservative kidney management (43% vs 28%). Among countries that provided at least some public coverage for KRT, 75% covered all citizens. Within-country variation in ESKD care delivery was reported in 40% of countries. Oversight of ESKD care was present in all high-income countries but was absent in 13% of low-income, 3% of lower-middle-income, and 10% of upper-middle-income countries.ConclusionSignificant gaps and variability exist in the public funding and oversight of ESKD care in many countries, particularly for those in low-income and lower-middle-income countries.