Protected: Anti-angiogenic drugs and hypertension: from multidisciplinary collaboration to greater care

Abstract

Anti-angiogenic drugs are widely used in cancer therapy. Their main targets of action are the vascular endothelial growth factor (VEGF) and its receptors (VEGF-R). Anti-angiogenic drugs are used to reduce the growth of the tumor and its metastases by acting on the phenomenon of tumor neo-angiogenesis. However, they are known for their side effects such as hypertension, acute kidney injury (AKI), and congestive heart failure.
Methods: retrospective study conducted on 57 consecutive patients known for ovarian cancer. Patients treated with Bevacizumab, as first-line, relapse, or maintenance treatment (2015-2022).
Results: according to FIGO staging, 98.2% (56 out of 57) of the patients in the study had third degree disease (G3). 49% of patients developed hypertension after starting Bevacizumab therapy (82% grade 2 according to CTCAE v.5). 89% of hypertensive patients started treatment and its management was multidisciplinary with nephrological consultation in 68% of cases. Only 3 out of 57 women discontinued treatment due to hypertension, and in only one of them it was not possible to restart it.
Conclusions: the evaluation of the patient by a multidisciplinary team (gynecologist and nephrologist) is essential to minimize the morbidity and mortality of patients, and to avoid the interruption of antineoplastic treatment.

Keywords: anti-angiogenic drugs, kidney injury, proteinuria, hypertension, ovarian cancer, multidisciplinary team

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Controversy in estimating glomerular filtration rate through traditional equations in transgender people: discussion through a case report

Abstract

Introduction: Chronic kidney disease (CKD) and the number of transgender people is on the rise. Hormone replacement therapy may be associated with the development of adverse effects, including kidney disease.
Objective: To report the case of a transgender patient using hormone therapy who developed CKD.
Case Report: Male transgender patient, 28 years old, using testosterone cypionate every 15 days, without any comorbidity. Evolved with hypertensive peaks of 160-150/110 mmHg and loss of kidney function (Ur 102 mg/dl, Cr 3.5 mg/dl, estimated Glomerular Filtration Rate (eGFR) of 22 ml/min/1.73m2 considering male gender and 16.6 ml/min/1.73m2 considering female gender). Abdominal ultrasound showed chronic parenchymal nephropathy. Due to the significant reduction in eGFR, the patient was referred for kidney transplantation, but he was not included in the list because he had a creatinine clearance of 23 ml/min/1.73m2 for males and 21.5 ml/min/1.73m2 for females in the most recent tests.
Conclusion: Hormone replacement may have contributed to the increase in the patient’s blood pressure and, consequently, to the development of CKD. There is still no well-established consensus on the best way to estimate the GFR in transgender people, and it seems to be more appropriate to consider the gender to which the person self-identifies or to perform the calculation for both genders, obtaining an estimate of the range in which the patient’s GFR lies.

Keywords: Transgender persons, chronic renal insufficiency, hypertension, hormone replacement therapy.

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Introduzione

La malattia renale cronica (MRC) è un grave problema di salute pubblica in tutto il mondo, che colpisce tra il 9,1% e il 15% degli adulti [1, 2]. In Brasile, l’insufficienza renale cronica ha mostrato un numero crescente negli ultimi decenni, con oltre 144 000 pazienti attualmente in dialisi [3]. Parallelamente, c’è un numero crescente di persone transgender, con una stima di oltre 1 milione negli Stati Uniti e 150 000 in Canada [46]. In un recente studio epidemiologico, è stato stimato che in Brasile l’1,9% della popolazione si identifica come non binaria e lo 0,69% come transgender [7], che corrisponderebbe a circa 1,4 milioni di transgender. 

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Psychological Assessment of a sample of women with ADPKD: quality of life, body image, anxiety and depression

Abstract

Introduction: The Autosomal Dominant Polycystic Kidney Disease (ADPKD) is a chronic renal disease that has not yet been the subject of psychological research. There are only a few studies related to the consequences and complications of this pathology on female patients, although women affected by this disease present serious problems.

Aim: The purpose of this study is to perform a psychological assessment (quality of life, anxiety, depression, body image) on a sample of 37 women with ADPKD.

Materials and Methods: The assessment is based on ad hoc social and personal record, KDQOL-SF (to evaluate health-related quality of life), HADS (for anxiety and depression) and BUT (for perceived body image). This assessment is administrated in a specific outpatient clinic.

Results: Results show that kidney disease has a negative impact on health-related quality of life. Concerns about body image are linked to anxious and depressive symptomatology: an increase in these concerns is related to a worsening of anxiety and depressive symptoms in patients. Moreover, a higher psychological malaise emerges in hypertensive ADPKD patients, in terms of mood and quality of life, compared to those without this concomitant pathology. Finally, it is important to note that social support, real or perceived, is of paramount importance in maintaining psychological well-being.

Conclusions: The psychological evaluation of ADPKD patients can be used in clinical practice as a supplemental model in multidisciplinary Nephrology team.

 

Keywords: Quality of life, ADPKD, body image, psychological assessment, hypertension.

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Introduzione

Nel corso degli ultimi anni, la collaborazione dello Psicologo Clinico con le Unità Operative di Nefrologia e Dialisi si è consolidata tanto da promuovere lo sviluppo della Psiconefrologia [1]. Tale disciplina ha l’obiettivo di identificare precocemente la presenza di situazioni di disagio psicologico legate alle patologie renali croniche e di agire su quest’ultime, con interventi di supporto psicologico il più possibile specializzati. 

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Neprilysin inhibition and chronic kidney disease

Abstract

Patients with chronic kidney disease (CKD) have a higher incidence of cardiovascular (acute and chronic) events, which in turn have an increased risk of progression to end-stage renal disease (ESRD)

Inhibition of neprilysin, in addition to offering a new therapeutic target in patients with heart failure, could represent a potential improvement strategy in cardiovascular and renal outcome of patients with CKD.

Inhibition of neprilysin by inhibiting the breakdown of natriuretic peptides, increases their bioavailability resulting in an increase in diuresis and sodium excretion and, in addition to exerting an inhibition of the renin – angiotensin – aldosterone (RAAS) system.

Inhibition of RAAS, in turn, generates a series of counter-regulations that can balance the adverse effects present in CKD and heart failure (HF).

The idea of ​​blocking neprilysin is not very recent, but the first drugs used as inhibitors had an inadmissible incidence of angioedema.

Among the latest generation molecules that can perform a specific inhibitory action on the neprilysin receptor and, at the same time, on the angiotensin II receptor thanks to the association with valsartan there is the LCZ696 (sacubitril / valsartan). This drug has shown promising benefits both in the treatment arterial hypertension and heart failure. It is hoped that equally positive effects may occur in CKD patients, particularly those with macroproteinuria.

Key words: neprilysin, natriuretic peptides, sacubitril/valsartan, hypertension, heart failure, CKD

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INTRODUZIONE

I pazienti affetti da CKD presentano un rischio più elevato, rispetto alla popolazione generale, di progressione verso l’ESRD (1, 2), nonché un’incidenza particolarmente elevata di morbidità e mortalità cardiovascolare. Diversi fattori di rischio cardiovascolare, tradizionali e non, concorrono alla maggiore incidenza di eventi cardiovascolari nella popolazione affetta da CKD: aterosclerosi, infiammazione cronica, ipertensione arteriosa, iperattività del sistema nervoso simpatico ed un rimodellamento strutturale cardiaco (ad es. ipertrofia ventricolare sinistra) fattore quest’ultimo che può condurre ad una situazione di scompenso cardiaco (2).

Nella naturale evoluzione della CKD e delle sue complicanze, l’aterosclerosi, che rappresenta il primum movens nelle alterazioni a carico del sistema cardio-vascolare, perde man mano importanza nella genesi della mortalità cardio-vascolare. Allo stato attuale, le alterazioni strutturali presenti a livello cardiaco sono considerate le principali responsabili della maggiore incidenza di aritmie cardiache, quali la fibrillazione atriale e gli episodi di morte cardiaca improvvisa (3).
 

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