Leptospirosis and kidneys: a clinical case

Abstract

We describe here the case of a young patient, employed in agriculture, who entered the emergency room with fever, headache, hematuria and a worsening of renal function; we diagnosed leptospirosis with renal involvement. As the patient lamented very generic symptoms, the anamnesis was fundamental in leading us to suspect an infection, execute the right laboratory analysis, and correctly diagnose a pathology which is currently very rare in Italy.

Keywords: case report, leptospirosis, AKI

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Introduzione

La leptospirosi umana è considerata una delle più diffuse e potenzialmente fatali zoonosi, è determinata da un batterio Gram negativo appartenente alla famiglia delle Spirochetales ordine Leptospiracee e si associa ad elevata morbilità e mortalità, in particolare nei pazienti di età superiore ai 60 anni [1]. 

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Choice and management of anticoagulation during CRRT

Abstract

Continuous renal replacement therapies (CRRT) are widely used in the treatment of acute kidney injury. Several causes, related to the treatment itself or to the patient’s condition, determine the coagulation of the extracorporeal circuit. These interruptions (or down-time) have a negative impact on the effectiveness of the treatment in terms of solute clearance and fluid balance. Historically, the choice of anticoagulant has fallen on unfractionated heparin because it is cheap and easy to use. Today, the use of citrate is recommended in most instances because of its high efficacy and safety. Several studies demonstrate the superiority of citrate in terms of filter survival. The reduction of down-time results in a reduction of the delta between the prescribed dialysis dose and the dose that is actually administered (ml/Kg/hour of collected effluent). The literature also agrees that there is a reduction in the incidence of major bleeding events when citrate is used instead of heparin, although there is no impact on mortality rates.

Some technical and clinical complexities, secondary to citrate action both as anticoagulant and buffer, still exist in the use of regional citrate anticoagulation. However, complications due to citrate use, such as acid-base balance disorders and hypocalcaemia, are rare and easily reversible.

There is not much data about the costs and benefits of using citrate instead of heparin; according to the experience within our own Unit, we have observed a reduction in costs when the data is normalized for 35 ml of effluent administered. Appropriate protocols, accurate surveillance and the automated management of regional citrate anticoagulation thanks to dedicated software make this technique safe and effective.

Keywords: anticoagulation, citrate, acute kidney injury, CRRT

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Introduzione

Le terapie sostitutive della funzione renale con metodiche extracorporee continue (CRRT) sono diffusamente utilizzate nel trattamento del danno renale acuto in area critica. Durante CRRT coesistono diverse potenziali cause di attivazione della cascata coagulativa e delle piastrine che possono contribuire alla coagulazione del circuito. Alcuni fattori sono relativi allo stesso trattamento extracorporeo e alle modalità con cui viene condotto (contatto del sangue con le superfici sintetiche per quanto biocompatibili, contatto aria-sangue, flusso turbolento o stasi, emoconcentrazione). Altri fattori dipendono invece in maniera più specifica dalle condizioni del paziente, con particolare riferimento alle alterazioni dell’omeostasi coagulativa secondarie allo stato flogistico sistemico di cui il danno renale può essere conseguenza o concausa [1]. 

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Differential diagnosis of acute kidney injury in critically ill patients: the nephrologist’s role in identifying the different causes of parenchymal damage

Abstract

The management of acute kidney injury in the critical area is complex and necessarily multidisciplinary, but the nephrologist should maintain a pivotal role, both in terms of diagnosis and of indication, prescription and management of extracorporeal replacement therapy.

The most frequent causes of AKI in the critically ill patients are correlated to sepsis and major surgery, but the incidence of different causes, of strict nephrological relevance, is probably higher than the estimate.

Nephrologists have the competence to evaluate data relating to renal functions, urinary electrolytes, urinary sediment, and to identify which specific examinations can be useful to define the cause of AKI. A nephrological consultation will therefore improve the clinical management of AKI by guiding and integrating the diagnostic path with traditional or more advanced assessments, useful for the identification of the different causes of acute kidney damage and consequently of the most appropriate therapy.

The etiological diagnosis of AKI will also be crucial in defining the renal prognosis and therefore an appropriate nephrological follow up.

Keywords: Acute kidney injury, differential diagnosis, critical care nephrology

Sorry, this entry is only available in Italian. For the sake of viewer convenience, the content is shown below in the alternative language. You may click the link to switch the active language.

Introduzione

Il danno renale acuto nei pazienti critici ricoverati in terapia intensiva è frequentemente gestito, in Italia come in altri Paesi, dai Rianimatori. Questo ha una forte ricaduta sia sulle competenze nefrologiche, che sulla gestione clinica del paziente.

La letteratura disponibile riguarda, con poche eccezioni, due ambiti prevalenti: il riconoscimento del danno renale acuto, inteso come quantificazione della riduzione della capacità escretoria renale, e la gestione della terapia extracorporea eventualmente necessaria. 

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