Prevenzione della preeclampsia nella nefropatica cronica: ruolo delle eparine a basso peso molecolare.

Sempre più donne affette da malattia renale cronica (Chronic Kidney Disease CKD) decidono di intraprendere una gravidanza ed una nefropatia è sempre più frequentemente diagnosticata durante la gravidanza. Si stima quindi che circa il 3% delle gravidanze sia complicata da una CKD. Tutte le pazienti affette da CKD dovrebbero essere considerate a rischio aumentato di sviluppare complicanze legate alla gravidanza, soprattutto la preeclampsia (PE). Pur non esistendo a tutt'oggi uno specifico trattamento per la gravidanza in corso di CKD, la prognosi delle pazienti nefropatiche che intraprendono una gravidanza è molto migliorata nel corso degli anni. Questo è dovuto verosimilmente a tre elementi: 1) la pianificazione della gravidanza 2) la personalizzazione delle terapie 3) la stratificazione del rischio e conseguentemente del follow-up. Individuare le pazienti a rischio appare quindi cruciale per un buon esito della gravidanza. Tuttavia ancora poco si conosce su quale approccio terapeutico usare a scopo preventivo. Mentre solidi dati scientifici ci supportano nell'utilizzo dell'acido acetil salicilico (ASA), non ne esistono di concordi sull'utilizzo delle eparine a basso peso molecolare (Low Molecular Weight Heparin LMWH) Questa rassegna si propone di valutare i meccanismi biologici e fisiopatologici alla base dell'utilizzo delle LMWH come prevenzione della preeclampsia e di eseguire una revisione critica della letteratura, evidenziando le questioni aperte e gli aspetti che tutt'ora rimangono irrisolti e da chiarire

Le diete ipoproteiche ed ipofosforiche riducono il rischio cardiovascolare nei pazienti con insufficienza renale cronica in terapia conservativa

La malattia renale cronica è un grosso problema di salute pubblica per la prevalenza, in costante aumento, per gli scarsi outcomes e per gli alti costi dei trattamenti. Negli ultimi anni, studi epidemiologici hanno evidenziato una forte associazione tra malattia renale e aumento delle patologie cardiovascolari, essendo queste ultime una frequente causa nonché complicanza della malattia renale. Di conseguenza, morbidità e mortalità cardiovascolare sono eventi tutt’altro che rari nei pazienti nefropatici, e ne determinano spesso l’esito infausto. Ai fattori di rischio noti per le malattie cardiovascolari (ipertensione arteriosa, ipertrofia ventricolare sinistra, ipercolesterolemia, obesità, fumo, ecc.) viene aggiunta oggi anche la malattia renale cronica (CKD), che presenta una serie di fattori di rischio correlati strettamente alla patologia renale, e pertanto “non tradizionali”. In questa tesi verrà discusso il ruolo di questi fattori, strettamente connessi con la CKD: disfunzione endoteliale, proteinuria, dislipidemia, stato infiammatorio, anemia, alterato metabolismo dei carboidrati e alterato metabolismo calcio fosforo. I vari tipi di terapia dietetica da noi utilizzati nei pazienti con CKD (dieta ipoproteica-ipofosforica standard e dieta vegetariana con proteine complementari negli stadi II°-IV°, e la dieta fortemente ipoproteica supplementata con aminoacidi essenziali e chetoanaloghi nello stadio V°) e che sono tutte a contenuto controllato di sodio, possono avere effetto protettivo sui pazienti con CKD agendo sia sui fattori di rischio cardiovascolari tradizionali che su quelli non tradizionali, intimamente correlati alla fisiopatologia dell’uremia cronica. Quindi, potrebbero avere un ruolo molto importante nella prevenzione del rischio cardiovascolare nei pazienti nefropatici. Il nostro studio si pone lo scopo di valutare l’impatto della terapia nutrizionale sugli eventi cardiovascolari nei pazienti con CKD, confrontandolo con i dati riportati nella letteratura. Il campione è costituito da pazienti affetti da malattia renale cronica dallo stadio II allo stadio V-NKF in terapia conservativa sia farmacologica che dietetica. Di ciascun soggetto arruolato abbiamo considerato l’età, lo stadio dell’insufficienza renale, la funzione renale, il controllo pressorio, l’anamnesi positiva per fattori di rischio tradizionali, e l’entità della proteinuria. Sono stati arruolati nello studio 101 pazienti di età compresa fra 18 e 86 anni. La funzione renale residua è stata valutata calcolando la clearance della creatinina (ml/min) e, in molti casi è stato determinato il GFR con il metodo della clearance del DTPA-Tc99m normalizzato per la superficie corporea). Il controllo pressorio è stato definito scarso/buono usando come valore cut-off 130/80 mmHg; la proteinuria è stata misurata in g/24h e suddivisa nei seguenti range 0-1/1,1-2/2,1-3/oltre 3. Tra gli eventi cardiovascolari si sono inclusi: sindromi coronariche acute, ictus cerebri, arteriopatia polidistrettuale (vasi cerebro-afferenti o arti inferiori), cardiopatia ischemica cronica, interventi di PTCA e by-pass aorto-coronarici. L’età media dei 101 pazienti arruolati (68 M e 33 F), all’inizio della terapia dietetica, era 50,8 ± 13,5 anni; il 66,3% presentava almeno un fattore di rischio cardiovascolare tradizionale e all’8,9% era già stato diagnosticato un evento cardiovascolare. Questi dati sono stati poi confrontati con quelli raccolti dopo 6,9 ± 4,3 anni di terapia dietetica. Si è evidenziato un significativo miglioramento nel controllo pressorio (35% buono all’ inizio vs 71% buono a fine osservazione). La distribuzione del campione si è modificata durante il follow-up passando da un maggior numero di pazienti in stadio II, III e IV NKF ad un maggior numero in stadio IV e V NKF. Nonostante questo comportamento, si è osservato un miglioramento della proteinuria in ogni stadio. Durante il periodo di osservazione si sono verificati 27 nuovi eventi cardiovascolari (26.7% del campione) in 21 pazienti. Suddiviso il nostro campione negli stadi NKF di funzione renale residua (Stadio II, GFR>=60, Stadio III fra 59 e 30, Stadio IV fra 29 e 15, Stadio V <15 ml/min), sono stati sono valutati tutti i nuovi eventi cardiovascolari per ogni gruppo. Essi sono risultati essere rispettivamente 0,06/0,2/0,1/0,3/0,5. Messi a confronto con i dati della letteratura (0,08/0,2/0,5/1,2/2,7) gli eventi nel nostro campione sono risultati inferiori o simili nei gruppi aventi funzionalità renale più alta, e significativamente inferiori nei gruppi con funzione renale residua al IV-V stadio. Va anche sottolineato che la durata del periodo di osservazione nello studio dal quale sono stati ricavati i dati per confrontarli con i risultati del nostro studio è risultato essere molto più breve (2,84 anni vs 6,87). Inoltre, nella nostra serie, 10 pazienti su 21 hanno manifestato il primo evento entro un solo anno dall’inizio della terapia dietetica. Si può quindi concludere che una corretta terapia nutrizionale, associata alla terapia farmacologica (antiipertensiva, ipolipemizzante, ecc.) svolge un ruolo sicuramente importante nella prevenzione degli eventi cardiovascolari in pazienti con CKD, come dimostrato dalla minor prevalenza rispetto ai dati riportati dalla letteratura, e riferiti a pazienti a dieta non controllata. Infine, la dieta sembrerebbe manifestare i suoi maggiori benefici proprio in quei pazienti con funzione renale maggiormente compromessa, e che hanno seguito la terapia dietetica per periodi di tempo più lunghi

Sepsis complicated by brain abscess following ESWL of a caliceal kidney stone: a case report

A 47-year old, Caucasian man underwent extracorporeal shock wave lithotripsy (ESWL) of a 14mm calcium stone in the right renal pelvis, without urinary tract obstruction or sepsis. 24 hours after ESWL septic shock occurred and the patient was admitted to the Intensive Care Unit (ICU). Escherichia coli emerged from the blood and urine culture. The patient developed acute renal failure and it was necessary to start a continuous renal replacement therapy (CRRT). Infection was successfully treated, patient recovered renal function and an improvement of general condition occurred. The patient was then discharged but three day later the patient returned to the hospital to seek treatment for left facial hemiparesis and hypotonia of his left arm. The brain computed tomography showed a wide abscesso (55x75mm) in the frontal right parietal region. A neurosurgical intervention was then performed and the culture of the drained material resulted positive for Escherichia coli. The guidelines of European and American Associations of Urology do not suggest a prophylactic antibiotic therapy for pre-ESWL (except in the presence of risk factors). The serious complication that occurred in the described low risk patient raises the question of whether routine culture and/or antibiotic prophylaxis, is appropriate

Sepsis complicated by brain abscess following ESWL of a caliceal kidney stone: a case report

ABSTRACT A 47-year old, Caucasian man underwent extracorporeal shock wave lithotripsy (ESWL) of a 14mm calcium stone in the right renal pelvis, without urinary tract obstruction or sepsis. 24 hours after ESWL septic shock occurred and the patient was admitted to the Intensive Care Unit (ICU). Escherichia coli emerged from the blood and urine culture. The patient developed acute renal failure and it was necessary to start a continuous renal replacement therapy (CRRT). Infection was successfully treated, patient recovered renal function and an improvement of general condition occurred. The patient was then discharged but three day later the patient returned to the hospital to seek treatment for left facial hemiparesis and hypotonia of his left arm. The brain computed tomography showed a wide abscess (55×75mm) in the frontal right parietal region. A neurosurgical intervention was then performed and the culture of the drained material resulted positive for Escherichia coli. The guidelines of European and American Associations of Urology do not suggest a prophylactic antibiotic therapy for pre-ESWL (except in the presence of risk factors). The serious complication that occurred in the described low risk patient raises the question of whether routine culture and/or antibiotic prophylaxis, is appropriate

Medical mystery: Deposition of calcium oxalate and phosphate stones in soft tissues

Calcinosis cutis (CC) [1] is an unusual disorder characterized by calcium-phosphate deposition into cutaneous and subcutaneous tissues. There are five subtypes: dystrophic, metastatic, idiopathic, iatrogenic and calciphylaxis.Calciphylaxis or calcifying panniculitis is defined as small vessel calcification mainly affecting blood vessels of the dermis and subcutaneous fat. Despite the predominance of cases in patients with ESRD, calciphylaxis can also be found in patients with normal renal function and normal levels of calcium and phosphate. These cases are often referred to as nonuremic calciphylaxis (NUC), a heterogeneous category with several associations. Literature reveals an association with hyperparathyroidism (28%), malignancy (22%), alcoholic liver disease (17%) and connective tissue diseases (11%) while obesity, liver disease, high-serum calcium (Ca) &times; phosphorus (P) levels, combined therapies of calcium salts with vitamin D, warfarin and corticosteroids have been observed to increase the likelihood of this disease [2]. The lesions in both nonuremic and uremic calciphylaxis tend to be indistinguishable from each other, initially presenting as tender subcutaneous plaques that progress into nonhealing ulcers with overlying black eschar. Skin changes often begin with a livedo reticularis pattern that can progress to livedo racemes and ultimately retiform purpura.In our clinical case, we describe a patient with multiple risk factors for calciphylaxis, intense widespread calcification (vessels, tendons, joints) and cutaneous calcific stone of calcium and phosphate oxalate not elsewhere described before

Near total parathyroidectomy for the treatment of renal hyperparathyroidism

Background: Different surgical strategies are used to treat medical refractory renal hyperparathyroidism. Our preferred choice in patients with moderate secondary hyperparathyroidism (SHPT) and in patients with low compliance with medical treatment is to leave a very small parathyroid remnant in situ: we name this operation "near total parathyroidectomy" (ntPTX). We report here our results with this technique. Methods: Retrospective study [2001-2015] of all patients submitted to ntPTX in a single centre. Results: Forty-seven patients were submitted to ntPTX (32 males) aged 47.3 years. Follow-up time is 8.5 years. Thirty-five patients (74%) are alive, 12 are dead. One patient in this series had a functioning renal transplant at time of ntPTX (tertiary hyperparathyroidism), and other 27 subsequently received a renal transplantation (RTx) after ntPTX (still functioning at last follow-up or at death in 19). Amongst the 35 current survivors, the renal graft is functioning in 16 (45.7%). Parathyroid hormone (PTH) at follow-up was 116.1±135.5 pg/mL and calcium 8.6±0.9 mg/dL. Among patients with a functioning RTx PTH was 83 pg/mL and calcium 8.7 mg/dL. There was no persistent disease, and 3 patients (6.4%) had a relapse of hyperparathyroidism at follow-up. Conclusions: ntPTX is associated to very satisfying rates of normal parathyroid function and of relapse of hyperparathyroidism (6.4%) at long term, either in case of RTx or of maintenance hemodialysis: the concept of "small amount" remnant represents a valuable choice for patients undergoing PTX with a realistic chance of receiving a RTx

Near total parathyroidectomy for the treatment of renal hyperparathyroidism

Background: Different surgical strategies are used to treat medical refractory renal hyperparathyroidism. Our preferred choice in patients with moderate secondary hyperparathyroidism (SHPT) and in patients with low compliance with medical treatment is to leave a very small parathyroid remnant in situ: we name this operation "near total parathyroidectomy" (ntPTX). We report here our results with this technique. Methods: Retrospective study [2001-2015] of all patients submitted to ntPTX in a single centre. Results: Forty-seven patients were submitted to ntPTX (32 males) aged 47.3 years. Follow-up time is 8.5 years. Thirty-five patients (74%) are alive, 12 are dead. One patient in this series had a functioning renal transplant at time of ntPTX (tertiary hyperparathyroidism), and other 27 subsequently received a renal transplantation (RTx) after ntPTX (still functioning at last follow-up or at death in 19). Amongst the 35 current survivors, the renal graft is functioning in 16 (45.7%). Parathyroid hormone (PTH) at follow-up was 116.1±135.5 pg/mL and calcium 8.6±0.9 mg/dL. Among patients with a functioning RTx PTH was 83 pg/mL and calcium 8.7 mg/dL. There was no persistent disease, and 3 patients (6.4%) had a relapse of hyperparathyroidism at follow-up. Conclusions: ntPTX is associated to very satisfying rates of normal parathyroid function and of relapse of hyperparathyroidism (6.4%) at long term, either in case of RTx or of maintenance hemodialysis: the concept of "small amount" remnant represents a valuable choice for patients undergoing PTX with a realistic chance of receiving a RTx

Home blood pressure measurement as a systematic tool for clinical practice in CKD patients: A real-world picture

BACKGROUND: Arterial hypertension is very common in chronic kidney disease (CKD) patients and its prevalence increases with lowering estimated glomerular filtration rate (EGFR). Blood pressure (BP) control is a cornerstone in the treatment of CKD patients but still most treatment decisions are based on office BP measurement (OB PM). The aim of this cross-sectional, retrospective study is to investigate the prevalence of hypertension phenotypes in CKD patients and whether different home (HBPM) or OBPM are associated with a different CKD stage and cardiovascular comorbidities. METHODS: We analyzed 560 consecutive patients (359 men, age 70±13 years), affected by stage 3-5 CKD, who performed HBPM recording; OBPM during a single visit was also assessed. Uncontrolled hypertension was defined as OBPM values ≥140/90 mniHg and HBPM values ≥135/85 mmHg, respectively. RESULTS: Systolic and diastolic HBPM values were lower than OBPM values. A white coat effect (systolic BP + 18±12 mniHg) was detected in 62.5%, while a masked effect (systolic BP -14±10 mniHg) was detected in 22.1%. No relationship was found between BP differences and body weight, CKD stage, EGFR or presence of diabetes. Based on OBPM, 18.6% of patients showed controlled systolic and diastolic BP, whereas 37.8% had sustained hypertension. White-coat hypertension was detected in 23.4% and Masked hypertension in 12.1%. The multiple logistic regression model showed that masked uncontrolled hypertensive patients showed a higher probability of having ischemic heart disease (OR=2.54 [1.02-6.36]), while sustained hypertension was associated with an increased prevalence of stroke in comparison to normotensive or true control BP group (OR=4.72 [1.30-17.07]). Age, gender, diabetes or CKD stage, were not different among the four hypertension phenotypes. CONCLUSIONS: We observed a quite high rate of masked uncontrolled hypertension and of white coat hypertension in stage 3-5ND CKD patients. Office BP measurement, as a single tool, is an inadequate diagnostic procedure in the clinical management of CKD patients. HBPM should be routinely implemented for identifying hypertensive phenotypes and then for avoiding misdiagnosis and mistreatment of pre-dialysis CKD patients in a tertiary care setting

Radiation dose from medical imaging in end stage renal disease patients: a Nationwide Italian Survey

Background and objectives: End stage renal disease (ESRD) patients are exposed to the risk of ionizing radiation during repeated imaging studies. The variability in diagnostic imaging policies and the accompanying radiation doses across various renal units is still unknown. We studied this variability at the centre level and quantified the associated radiation doses at the patient level. Methods: Fourteen Italian nephrology departments enrolled 739 patients on haemodialysis and 486 kidney transplant patients. The details of the radiological procedures performed over one year were recorded. The effective doses and organ doses of radiation were estimated for each patient using standardized methods to convert exposure parameters into effective and organ doses RESULTS: Computed tomography (CT) was the major contributor (> 77%) to ionizing radiation exposure. Among the haemodialysis and kidney transplant patients, 15% and 6% were in the high ( 65 20 mSv per year) radiation dose groups, respectively. In haemodialysis patients, the most exposed organs were the liver (16 mSv), the kidney (15 mSv) and the stomach (14 mSv), while the uterus (6.2 mSv), the lung (5.7 mSv) and the liver (5.5 mSv) were the most exposed in kidney transplant patients. The average cumulative effective dose (CED) of ionizing radiation among centres in this study was highly variable both in haemodialysis (from 6.4 to 18.8 mSv per patient-year; p = 0.018) and even more so in kidney transplant (from 0.6 to 13.7 mSv per patient-year; p = 0.002) patients. Conclusions: Radiation exposure attributable to medical imaging is high in distinct subgroups of haemodialysis and transplant patients. Furthermore, there is high inter-centre variability in radiation exposure, suggesting that nephrology units have substantially different clinical policies for the application of diagnostic imaging studies