Protected: Acute kidney failure in differentiation syndrome: a possible complication during therapy with differentiating agents for acute promyelocytic leukemia. A case report

Abstract

Differentiation syndrome (DS), previously known as retinoic acid syndrome or ATRA (all-trans retinoic acid) or ATO (arsenic trioxide) syndrome, is a life-threatening complication of the therapy with differentiating agents in patients with acute promyelocytic leukemia (APL). The latter is a rare subtype of acute myeloid leukemia and represents a hematological emergency. The clinical manifestations of DS, after induction therapy with differentiating agents, include unexplained fever, acute respiratory distress with interstitial pulmonary infiltrates, unexplained hypotension, peripheral edema, congestive heart failure and acute renal failure. The therapy is based on early intravenous administration of high-dose dexamethasone, in order to counteract the cytokine storm responsible for the DS. Among the supportive measures for the management of DS, furosemide (in 87% of patients) and dialysis (12% of patients) are used to manage acute renal failure, peripheral and pulmonary edema.

We describe a case of acute renal failure, treated with haemodialysis, in a young patient with APL and an early and severe DS after induction therapy. This is a rare condition, not well known among nephrologists, where early recognition and treatment are crucial for the prognosis.

Keywords: acute kidney failure, dialysis, acute promyelocytic leukemia, differentiation syndrome, all-trans retinoic acid, dexamethasone. 

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Acute kidney injury in elderly patients

Abstract

In the last few years, more and more studies have been focusing on Acute Kidney Injury (AKI) because of its incidence, its effects on patients, and the costs associated to its treatment. Elderly patients are especially in danger of developing AKI given the para-physiological deterioration of their renal functions and the presence of several co-morbidities. Together with sepsis, AKI is in fact one of the most common complications occurring during hospitalization. However, some strategies have proved to help in preventing renal damage in the elderly.

Fluid overload, malnutrition and sepsis, which are far more common and momentous in older patients, can conceal or minimize rising creatinine levels. As such, it is not always possible to rely on the creatinine behaviour to diagnose AKI as proposed by KDIGO, AKIN e RIFLE guidelines. On the one hand, these and other peculiarities make AKI very difficult to diagnose and treat in elderly patients. On the other, the dialysis treatment, with its intrinsic “un-physiology”, further complicates matters and (if it is very aggressive in terms of efficiency and removal of fluids) can destabilize these fragile patients and their poor haemodynamic compensation.

 

Keywords: acute kidney injury, comorbidity, elderly patients, renal functional decline, dialysis

Sorry, this entry is only available in Italian.

Nutritional diet therapy in the management of the patient with Chronic Kidney Disease in advanced phase to delay the beginning and reduce the frequency of dialysis. An option also in the pre-emptive transplant program

Abstract

The Italian nephrology has a long tradition and experience in the field of dietetic-nutritional therapy (DNT), which is an important component in the conservative management of the patient suffering from a chronic kidney disease, which precedes and integrates the pharmacological therapies. The objectives of DNT include the maintenance of an optimal nutritional status, the prevention and / or correction of signs, symptoms and complications of chronic renal failure and, possibly, the delay in starting of dialysis.

The DNT includes modulation of protein intake, adequacy of caloric intake, control of sodium and potassium intake, and reduction of phosphorus intake. For all dietary-nutritional therapies, and in particular those aimed at the patient with chronic renal failure, the problem of patient adherence to the dietetic-nutritional scheme is a key element for the success and safety of the DNT and it can be favored by an interdisciplinary and multi-professional approach of information, education, dietary prescription and follow-up. This consensus document, which defines twenty (20) essential points of the nutritional approach to patients with advanced chronic renal failure, has been written, discussed and shared by the Italian nephrologists together with representatives of dietitians (ANDID) and patients (ANED).

Keywords: CKD, Nutritional treatment, diet, dialysis, kidney transplant, chronic renal failure.

Sorry, this entry is only available in Italian.

Inapparent charges for the assistance to nephropathic patient on dialysis

Abstract

The increasing technological effectiveness has undoubtedly produced an improvement in clinical parameters of dialysis patients, but this satisfactory therapeutic result did not follow an adequate improvement in mortality or in the perception of quality of life as per patients. Furthermore, dialysis treatment is often associated with “inapparent charges” that reduce the perception of well-being, independently of clinical changes.

Thirty years ago, we carried out a national survey on inapparent charges, which represent frustrating aspects that negatively affect patients’ perception of their quality of life.

Thirty years later, it seemed important for us to repeat the survey to understand if Italian legislative remodeling have introduced changes in procedures and social aspects of dialysis, as preservation of quality of life is an important aspect of the replacement treatment.

Keywords: dialysis, inapparent charges, public and private, geographical areas

Sorry, this entry is only available in Italian.

Direct-acting antiviral agents, hepatitis C and dialysis: an update

Abstract

Hepatitis C virus infection is still common among patients with chronic kidney disease, particularly within Dialysis Units all over the world. Although the full extent of HCV transmission in dialysis units is unknown, outbreaks of HCV infection continue to occur all over the world. Evidence has been accumulated in the last decade suggesting that HCV plays consistent activity at hepatic and extra-hepatic level. A recent systematic review of the medical literature with a meta-analysis of clinical studies retrieved 15 longitudinal studies (n=2,299,134 patients); we found a significant relationship between anti-HCV positive serologic status and higher frequency of CKD; the summary estimate for adjusted hazard risk with HCV across the surveys, 1.54 (95% CI, 1.26; 1.87) (P<0.0001). The advent of direct-acting antiviral agents has revolutionized the therapy of HCV, including patients with advanced chronic kidney disease. Two regimens based on DAAs have been recently approved for the antiviral therapy of HCV in patients with CKD stage 4/5: elbasvir/grazoprevir and glecaprevir/pibrentasvir. Such regimens have been provided with high efficacy and safety, according to the results given by C-SURFER and EXPEDITION-4, respectively. Sofosbuvir, a non-structural 5B polymerase inhibitor, is the backbone of many anti-HCV drug regimens, and has significant renal excretion. As a result, the use of sofosbuvir is not recommended in patients with an eGFR <30 mL/min/1.73m2. In summary, recent studies have shown that several combinations of DAAs are currently available for CKD patients, including those with CKD stage 4/5. These drugs have reported high efficacy and satisfactory tolerability, regardless of HCV genotype or renal impairment. We need to improve the screening for HCV and the access to DAAs in patients with CKD stage 4/5.

 

Keywords: Chronic kidney disease; Dialysis; Direct-acting antiviral agents; Hepatitis C; Sustained virological response

Sorry, this entry is only available in Italian.

Dystrophic Calcinosis Cutis: a rare fearsome issue of Chronic Kidney Disease

Abstract

Disorders of calcium-phosphate-parathormone balance, are very important issues in ESRD patients, that may lead to severe complications, as dystrophic calcinosis cutis, a rare disease, caused by calcium salt deposits in cutaneous or subcutaneous tissues and many organs.

We present the case of a 47 years old woman, in ESRD due to membranous glomerulopathy, treated by peritoneal dialysis, who, after 7 months of dialysis, developed painful masses on second finger and fifth metacarpus of the right hand.

Laboratory and instrumental data showed hyperparathyroidism with a parathyroid mass consistent with adenoma.

Increasing of therapy with phosphate binders and cinacalcet only, was not effective to solve cutaneous masses, that were biopsied. Histological exam revealed deposition of amorphic material with calcific component, consistent with cutaneous dystrophic calcinosis.

We further increased dialysis and therapy and we observed complete regression of masses in 2 months.

 

Key words: dystrophic calcinosis cutis, end stage renale disease, calcium-phosphate metabolism, dialysis

Sorry, this entry is only available in Italian.