Incremental peritoneal dialysis: a 10 year single-centre experience

INTRODUCTION: Incremental dialysis consists in prescribing a dialysis dose aimed towards maintaining total solute clearance (renal + dialysis) near the targets set by guidelines. Incremental peritoneal dialysis (incrPD) is defined as one or two dwell-times per day on CAPD, whereas standard peritoneal dialysis (stPD) consists in three-four dwell-times per day. PATIENTS AND METHODS: Single-centre cohort study. Enrollement period: January 2002-December 2007; end of follow up (FU): December 2012. INCLUSION CRITERIA: incident patients with FU ≥6 months, initial residual renal function (RRF) 3-10 ml/min/1.73 sqm BSA, renal indication for PD. RESULTS: Median incrPD duration was 17 months (I-III Q: 10; 30). There were no statistically significant differences between 29 patients on incrPD and 76 on stPD regarding: clinical, demographic and anthropometric characteristics at the beginning of treatment, adequacy indices, peritonitis-free survival (peritonitis incidence: 1/135 months-patients in incrPD vs. 1/52 months-patients in stPD) and patient survival. During the first 6 months, RRF remained stable in incrPD (6.20 ± 2.02 vs. 6.08 ± 1.47 ml/min/1.73 sqm BSA; p = 0.792) whereas it decreased in stPD (4.48 ± 2.12 vs. 5.61 ± 1.49; p < 0.001). Patient survival was affected negatively by ischemic cardiopathy (HR: 4.269; p < 0.001), peripheral and cerebral vascular disease (H2.842; p = 0.006) and cirrhosis (2.982; p = 0.032) and positively by urine output (0.392; p = 0.034). Hospitalization rates were significantly lower in incrPD (p = 0.021). Eight of 29 incrPD patients were transplanted before reaching full dose treatment. CONCLUSIONS: IncrPD is a safe modality to start PD; compared to stPD, it shows similar survival rates, significantly less hospitalization, a trend towards lower peritonitis incidence and slower reduction of renal function

END-DIALYSIS OVERWEIGHT AND CHRONIC INFLAMMATION. A DANGEROUS CONNECTION

INTRODUCTION AND AIMS: Attaining dry body weight is paramount in dialysis practice, but this goal is not always reached. We hypothesized that the amount of enddialysis overweight (edOW), could be associated to increased chronic inflammation and mortality. Aim of the study: to evaluate the effect of edOW on serum C-reattive protein(hsCRP) concentrations and on survival in a cohort of 182 prevalent HD patients (pts) followed for 36 months. METHODS: In 182 pts (117 men, age 65612 years, vintage 48 months; range 6-336), edOW was present in 98/182 (54%) pts. Mean value was 0.460.2 Kg (range: 0.1-1.4). In the 98 pts with edOW (Group 1) and in the other 84 (Group 2) we evaluated: Ultrafiltration rate(UFR), hsCRPdry body weight (dBW), Kt/V, protein catabolic rate (PCRn), interdialytic weight gain (IDWG), mean arterial pressure (MAP). Unpaired Student’s t test was employed to compare groups, linear regression analysis to test correlations, log-rank test and Kaplan-Meier curves to evaluate survival. RESULTS: Mean UFR was 11.762.8 ml/Kg/hour, dBW 64612 Kg, hsCRP 6.6 (0.2-36) mg/L, Kt/V 1.2760.09, PCRn 1.0660.10 g/Kg/day, IDWG 2.860.4 Kg, MAP 9766.5 mmHg. edOW and hsCRP were directly and significantly correlated (r= 0.67; p<0.0001). Comparison between pts with (Group 1) and without (Group 2) edOW showed significant differences in: UFR (12.762.6 vs 10.962.6 ml/Kg/hour; p< 0.0001), hsCRP (13.068.1 vs 5.265.3 mg/L; p< 0.0001), and PCRn (1.0360.09 vs 1.0860.10 g/Kg/day; p<0.004). 98 pts (54%) died during follow-up for cardiovascular complications in 69% of cases. Survival curves showed significantly greater mortality in Group 1 vs Group 2 in relation to the amount of edOW, and hsCRP (p<0.0001). CONCLUSIONS: : edOW and chronic inflammation are directly correlated in HD pts, and both are associated to a greater long-term risk of mortality

Recurrent exercise-induced acute renal failure in a young Pakistani man with severe renal hypouricemia and SLC2A9 compound heterozygosity.

BACKGROUND: Familial renal hypouricemia (RHUC) is a hereditary disease characterized by hypouricemia, high renal fractional excretion of uric acid (FE-UA) and can be complicated by acute kidney failure and nephrolithiasis. Loss-of-function mutations in the SLC22A12 gene cause renal hypouricemia type 1 (RHUC1), whereas renal hypouricemia type 2 (RHUC2) is caused by mutations in the SLC2A9 gene. CASE PRESENTATION: We describe a 24-year-old Pakistani man who was admitted twice to our hospital for severe exercise-induced acute renal failure (EIARF), abdominal pain and fever; he had very low serum UA levels (0.2 mg/dl the first time and 0.09 mg/dl the second time) and high FE-UA (200% and 732% respectively), suggestive of RHUC. Mutational analyses of both urate transporters revealed a new compound heterozygosity for two distinct missense mutations in the SLC2A9 gene: p.Arg380Trp, already identified in heterozygosity, and p.Gly216Arg, previously found in homozygosity or compound heterozygosity in some RHUC2 patients. Compared with previously reported patients harbouring these mutations, our proband showed the highest FE-UA levels, suggesting that the combination of p.Arg380Trp and p.Gly216Arg mutations most severely affects the renal handling of UA. CONCLUSIONS: The clinical and molecular findings from this patient and a review of the literature provide new insights into the genotype-phenotype correlation of this disorder, supporting the evidence of an autosomal recessive inheritance pattern for RHUC2. Further investigations into the functional properties of GLUT9, URAT1 and other urate transporters are required to assess their potential research and clinical implications

Supportive treatment for cast nephropathy in patients with multiple myeloma; a pilot study

Introduction: Cast nephropathy is a prevalent cause of acute kidney injury (AKI) in patients with myeloma. Objectives: The aim of this study is to define the outcome of a standardized supportive therapy for cast nephropathy. Patients and Methods: Retrospective analysis of the outcome of cast nephropathy in a University hospital for a period of five years. Data analysed; serum creatinine, estimated glomerular filtration rate (eGFR; mL/min/1.73 m2 BSA) and need for dialysis. Standardized therapy with the aim of preventing/removing tubular casts; fluid administration and mannitol to increase urine flow, sodium bicarbonate to alkalize the urine and low dose steroid to reduce peritubular inflammation. Statistical analysis: Student's t-test or the Mann-Whitney test according to data distribution. A two-tailed P value <0.05 was considered statistically significant. Survival curve was drawn according to Kaplan and Meier. Results: Twenty-seven cases were reviewed. Upon admission, mean serum creatinine was 7.1±4.9 mg/dL and mean eGFR 6±4 mL/min/1.73 m2 BSA; 30% of patients had oligo-anuria. Diagnosis of cast nephropathy was presumptive in 23 patients, and renal biopsy proven in four. Hemodialysis was required by 10 (37%) patients, two of whom continued dialysis after discharge. At discharge, serum creatinine was 3.7±2.5 mg/dL and eGFR 20±13 mL/min/1.73 m2 BSA (P=0.002), and after a median of 3.4 months, the values were 2.9±2.1 mg/dL and 35±32 mL/min/1.73 m2 BSA, respectively. Patient survival was 60% after 24 months. Conclusion: Administration of fluid, mannitol, sodium bicarbonate and low-dose steroid may improve the outcome of cast nephropathy. Despite the fact that the study has many limitations, its findings could be the base for prospective controlled trials on cast nephropathy and could be useful in those countries where the expensive extracorporeal treatments are not available

CHRONIC INFLAMMATION AND END-DIALYSIS OVERWEIGHT. A 36 MONTH PROSPECTIVE OBSERVATIONAL STUDY

Introduction and Aims: Attaining dry body weight is paramount in dialysis practice, but this goal is not always reached.We hypothesized that the amount of end-dialysis overweight (edOW), could be associated to increased chronic inflammation and mortality. Aim of the study: to evaluate the effect of edOWon serum C-reattive protein (hsCRP) concentrations and on survival in a cohort of 182 prevalent HD patients ( pts) followed for 36 months. Methods: In 182 pts (117 men, age 65±12 years, vintage 48 months; range 6-336), edOWwas present in 98/182 (54%) pts. Mean value was 0.4±0.2 Kg (range: 0.1-1.4). In the 98 pts with edOW(Group 1) and in the other 84 (Group 2) we evaluated: Ultrafiltration rate(UFR), hsCRPdry body weight (dBW), Kt/V, protein catabolic rate (PCRn), interdialytic weight gain (IDWG), mean arterial pressure (MAP). Unpaired Student’s t test was employed to compare groups, linear regression analysis to test correlations, log-rank test and Kaplan-Meier curves to evaluate survival. Results: Mean UFR was 11.7±2.8 ml/Kg/hour, dBW 64±12 Kg, hsCRP 6.6 (0.2-36) mg/L, Kt/V 1.27±0.09, PCRn 1.06±0.10 g/Kg/day, IDWG 2.8±0.4 Kg, MAP 97±6.5 mmHg. edOWand hsCRP were directly and significantly correlated (r= 0.67; p<0.0001). Comparison between pts with (Group 1) and without (Group 2) edOW showed significant differences in: UFR (12.7±2.6 vs 10.9±2.6 ml/Kg/hour; p< 0.0001), hsCRP (13.0±8.1 vs 5.2±5.3 mg/L; p< 0.0001), and PCRn (1.03±0.09 vs 1.08±0.10 g/Kg/day; p<0.004). 98 pts (54%) died during follow-up for cardiovascular complications in 69% of cases. Survival curves showed significantly greater mortality in Group 1 vs Group 2 in relation to the amount of edOW, and hsCRP (p<0.0001). Conclusions: edOWand chronic inflammation are directly correlated in HD pts, and both are associated to a greater long-term risk of mortality

Factors influencing the decision to start renal replacement therapy: results of a survey among European nephrologists

Background: Little is known about the criteria nephrologists use in the decision of when to start renal replacement therapy (RRT) in early referred adult patients. We evaluated opinions of European nephrologists on the decision for when to start RRT. Study Design: European web-based survey. Predictors: Patient presentations described as uncomplicated patients, patients with unfavorable clinical and unfavorable social conditions, or patients with specific clinical, social, and logistical factors. Setting & Participants: Nephrologists from 11 European countries. Outcomes & Measurements: We studied opinions of European nephrologists about the influence of clinical, social, and logistical factors on decision making regarding when to start RRT, reflecting practices in place in 2009. Questions included target levels of kidney function at the start of RRT and factors accelerating or postponing RRT initiation. Using linear regression, we studied determinants of target estimated glomerular filtration rate (eGFR) at the start of RRT. Results: We received 433 completed surveys. The median target eGFR selected to start RRT in uncomplicated patients was 10.0 (25th-75th percentile, 8.0-10.0) mL/min/1.73 m(2). Level of excretory kidney function was considered the most important factor in decision making regarding uncomplicated patients (selected by 54% of respondents); in patients with unfavorable clinical versus social conditions, this factor was selected by 24% versus 32%, respectively. Acute clinical factors such as life-threatening hyperkalemia refractory to medical therapy (100%) and uremic pericarditis (98%) elicited a preference for an immediate start, whereas patient preference (69%) and vascular dementia (66%) postponed the start. Higher target eGFRs were reported by respondents from high-versus low-RRT-incidence countries (10.4 [95% CI, 9.9-10.9] vs 9.1 mL/min/1.73 m(2)) and from for-profit versus not-for-profit centers (10.1 [95% CI, 9.5-10.7] vs 9.5 mL/min/1.73 m(2)). Limitations: We were unable to calculate the exact response rate and examined opinions rather than practice for 433 nephrologists. Conclusions: Only for uncomplicated patients did half the nephrologists consider excretory kidney function as the most important factor. Future studies should assess the weight of each factor affecting decision making. Am J Kidney Dis. 60(6): 940-948. (C) 2012 by the National Kidney Foundation, In

Low-protein diets for chronic kidney disease patients: The Italian experience

open20Nutritional treatment has always represented a major feature of CKD management. Over the decades, the use of nutritional treatment in CKD patients has been marked by several goals. The first of these include the attainment of metabolic and fluid control together with the prevention and correction of signs, symptoms and complications of advanced CKD. The aim of this first stage is the prevention of malnutrition and a delay in the commencement of dialysis. Subsequently, nutritional manipulations have also been applied in association with other therapeutic interventions in an attempt to control several cardiovascular risk factors associated with CKD and to improve the patient's overall outcome. Over time and in reference to multiple aims, the modalities of nutritional treatment have been focused not only on protein intake but also on other nutrients.openBellizzi, Vincenzo; Cupisti, Adamasco; Locatelli, Francesco; Bolasco, Piergiorgio; Brunori, Giuliano; Cancarini, Giovanni; Caria, Stefania; De Nicola, Luca; Di Iorio, Biagio R; Di Micco, Lucia; Fiaccadori, Enrico; Garibotto, Giacomo; Mandreoli, Marcora; Minutolo, Roberto; Oldrizzi, Lamberto; Piccoli, Giorgina B; Quintaliani, Giuseppe; Santoro, Domenico; Torraca, Serena; Viola, Battista FBellizzi, Vincenzo; Cupisti, Adamasco; Locatelli, Francesco; Bolasco, Piergiorgio; Brunori, Giuliano; Cancarini, Giovanni; Caria, Stefania; De Nicola, Luca; Di Iorio, Biagio R; Di Micco, Lucia; Fiaccadori, Enrico; Garibotto, Giacomo; Mandreoli, Marcora; Minutolo, Roberto; Oldrizzi, Lamberto; Piccoli, Giorgina B; Quintaliani, Giuseppe; Santoro, Domenico; Torraca, Serena; Viola, Battista F

Outcomes of pregnancies after kidney transplantation: lessons learned from CKD. A comparison of transplanted, nontransplanted chronic kidney disease patients and low-risk pregnancies: a multicenter nationwide analysis.

BACKGROUND: Kidney transplantation (KT) may restore fertility in CKD. The reasons why materno-foetal outcomes are still inferior to the overall population are only partially known. Comparison with the CKD population may offer some useful insights for management and counselling.Aim of this study was to analyse the outcomes of pregnancy after KT, compared with a large population of non-transplanted CKD patients and with low-risk control pregnancies, observed in Italy the new millennium. METHODS: We selected 121 live-born singletons after KT (Italian study group of kidney in pregnancy, national coverage about 75%), 610 live-born singletons in CKD and 1418 low-risk controls recruited in 2 large Italian Units, in the same period (2000-2014). The following outcomes were considered: maternal and foetal death; malformations; preterm delivery; small for gestational age baby (SGA); need for the neonatal intensive care unit (NICU); doubling of serum creatinine or increase in CKD stage. Data were analysed according to kidney diseases, renal function (staging according to CKD-EPI), hypertension, maternal age, partity, ethnicity. RESULTS: Materno-foetal outcomes are less favourable in CKD and KT as compared with the low-risk population. CKD stage and hypertension are important determinants of results. KT patients with e-GFR >90 have worse outcomes compared with CKD stage 1 patients; the differences level off when only CKD patients affected by glomerulonephritis or systemic diseases ('progressive CKD') are compared with KT. In the multivariate analysis, risk for preterm and early-preterm delivery was linked to CKD stage (2-5 versus 1: RR 3.42 and 3.78) and hypertension (RR 3.68 and 3.16) while no difference was associated with being a KT or a CKD patient. CONCLUSIONS: The materno-foetal outcomes in patients with kidney transplantation are comparable with those of nontransplanted CKD patients with similar levels of kidney function impairment and progressive and/or immunologic kidney diseas