Peritoneal dialysis and cardiovascular disease

Cardiovascular (CV) death is the most frequent cause of dying in peritoneal dialysis (PD) patients. Risk factors include not only those that can be present in the general population, but also those related to the presence of end-stage renal disease (ESRD) and factors that are specific for PD modality. Hypertension is the most important general risk factor in PD patients, while obesity remains controversial. Inflammation, malnutrition, calcifications and probably endothelial dysfunction and oxidative stress are all CV risk factors present in ESRD that contribute to mortality in PD patients. Additional CV risk factors in PD are related to the glucose load, leading to increasing insulin resistance and a more atherogenic lipid profile. The presence of glucose degradation products in conventional dialysis solutions is mainly related to the development of peritoneal abnormalities, but not directly to cardiovascular disease. Loss of residual renal function and ultrafiltration failure promote overhydration, which is the most important PD-related risk factor for CV diseas

Peritoneal Albumin and Protein Losses Do Not Predict Outcome in Peritoneal Dialysis Patients

Clinical epidemiolog

An unusual case of acute kidney injury - idiopathic granulomatous tubulointerstitial nephritis

We present a case which emphasizes the importance of performing a kidney biopsy in each case of acute kidney injury (AKI) of unknown etiology. The unexpected histological diagnosis of granulomatous interstitial nephritis (GIN) is a rare cause of AKI. The main causes of GIN include drugs (NSAIDs, antibiotics), sarcoidosis, and infections (mycobacterial and fungal). In our case, a 68-year-old woman was admitted with AKI, absence of symptoms and unremarkable history, apart from coronary heart disease. Renal biopsy was performed, since history as well as clinical and laboratory data could not define a cause of AKI. A more meticulous clinical and laboratory investigation followed the histological diagnosis in order to rule out sarcoidosis, vasculitis or any other known causes of GIN. Finally the diagnosis was characterized as AKI due to idiopathic GIN. The patient responded well to corticosteroids. © 2015 Dustri-Verlag Dr. K. Feistle

Anticoagulant-related nephropathy: a case report and review of the literature of an increasingly recognized entity

Treatment with oral anticoagulants has been associated with worsening kidney function in patients with chronic kidney disease (CKD) as well as among patients without underlying CKD. Thus, anticoagulant-related nephropathy (ARN) is an increasingly recognized entity nowadays, mainly associated with warfarin anticoagulation. Recent evidence indicates that patients treated with the direct anticoagulants may also be at risk of ARN. However, the true incidence of anticoagulant-related nephropathy is difficult to determine. The typical histological lesion involves renal tubular occlusion by red blood cells (RBCs), tubular red blood cell casts on light microscopy and dysmorphic RBCs in the glomerulus on electron microscopy. In the absence of active glomerulonephritis or other inflammatory changes that could account for glomerular hemorrhage, the above findings confirm the diagnosis. Dabigatran etexilate was the first direct oral anticoagulant approved for stroke prevention in patients with non-valvular atrial fibrillation. In this article, we describe a rare case of dabigatran etexilate-induced nephropathy in a patient with preexisting IgA nephropathy and review the recent literature regarding this increasingly recognized entity. © 2017, Springer Science+Business Media Dordrecht

Crescentic glomerulonephritis and membranous nephropathy: a rare coexistence

Background: The coexistence of crescents and membranous glomerulonephritis (MGN) is a special characteristic in lupus nephritis. In the absence of the characteristic histological features of lupus nephritis, MGN with crescents should raise the possibility of two other histopathological entities: anti-GBM disease and necrotizing and crescentic glomerulonephritis. The last one includes patients with positive ANCA serology or not. Results and conclusions: Here, we describe a case of a male patient who presented with extrarenal vasculitis symptoms, acute renal failure, hematuria and nephrotic-range proteinuria. ANCA serology was positive, and the biopsy revealed crescentic vasculitis plus membranous nephropathy. Reviewing the whole literature about similar histological cases, we included 38 cases with ANCA-positive serology and 30 ones with no ANCA in serum. It seems that in the first category vasculitis symptoms predominate, while in the second one these symptoms are absent. Their histological features have no major differences. In any case, the clinical course of these patients is serious, and in most cases, immunosuppression is essential in order to avoid end-stage renal disease. © 2015, Springer Science+Business Media Dordrecht

Mineralocorticoid receptor antagonists for nephroprotection and cardioprotection in patients with diabetes mellitus and chronic kidney disease.

Diabetic kidney disease develops in about 40% of patients with diabetes and is the commonest cause of chronic kidney disease worldwide. Patients with chronic kidney disease, especially those with diabetes mellitus, are at high risk of both developing kidney failure and cardiovascular death. The use of renin-angiotensin system blockers to reduce the incidence of kidney failure in patients with diabetic kidney disease dates back to studies that are now 20 or more years old. During the last few years sodium-glucose co-transporter-2 inhibitors have shown beneficial renal effects in randomized trials. However, even in response to combined treatment with renin-angiotensin system blockers and sodium-glucose co-transporter-2 inhibitors, the renal residual risk remains high with kidney failure only deferred, but not avoided. The risk of cardiovascular death also remains high even with optimal current treatment. Steroidal mineralocorticoid receptor antagonists reduce albuminuria and surrogate markers of cardiovascular disease in patients already on optimal therapy. However, their use has been curtailed by the significant risk of hyperkalaemia. In The FInerenone in reducing kiDnEy faiLure and dIsease prOgression in Diabetic Kidney Disease (FIDELIO-DKD) study comparing the actions of the non-steroidal mineralocorticoid receptor antagonist finerenone with placebo, finerenone reduced the progression of diabetic kidney disease and the incidence of cardiovascular events with a relatively safe adverse event profile. This document presents in detail the available evidence on the cardioprotective and nephroprotective effects of mineralocorticoid receptor antagonists, analyses the potential mechanisms involved and discusses their potential future place in the treatment of patients with diabetic chronic kidney disease