Renal failure in the medicolegal evaluation of civil invalidity and social security disability (INPS)

Abstract

After a quick description of the anatomopathology and physiopathology of renal failure, the Authors delve into the problem of assessing its medicolegal aspects in the fields of civil invalidity and social security.

In Italy, civil invalidity involves protecting the psychological and physical welfare of the disabled, as sanctioned by law 118 of 1971; this law protects all citizens with a debilitating condition, including those who do not work or are not of working age. A disabled person is someone who, if of working age (between 18 and retirement) has a reduction of more than ⅓ (34%) of their general work capacity; if under or over the retirement age, they have a persistent difficulty in carrying out age-appropriate functions and tasks. In support of an application for being awarded civil invalidity, people can also refer to law no. 104 of 1992, which assesses social, relational and work disadvantages of a disabled person.

INPS (Italian Social Security Institute) protection, on the other hand, is a social security protection based on health requirements (having a capacity for work which is reduced by more than ⅓, as established by law no. 222 of 1984), as well as on the following administrative requirement: having paid, as a worker, at least 260 weekly contributions, equivalent to five years of contribution and insurance, of which 156, equal to three years of contribution and insurance, were made in the five-year period preceding the date of submitting the application. If this is the case, the protected person, thus insured, can enjoy protection for their illness by virtue of the stipulations for social security.

 

Keywords: Renal failure, civil invalidity, social security disability, Italian Social Security Institute (INPS)

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Introduzione

L’insufficienza renale può definirsi come la ridotta capacità del rene di mantenere il bilancio tra introduzione ed escrezione di acqua e minerali nell’organismo con il conseguente accumulo di vari prodotti terminali del metabolismo [1]. L’insufficienza renale può presentarsi clinicamente in forma acuta (IRA) con una manifestazione rapida, sovente reversibile. Si parla, invece, di insufficienza renale cronica (IRC) quando la perdita della funzionalità renale si palesa in maniera progressiva e sovente irreversibile in quanto costituisce lo stadio terminale di numerose patologie non emendabili del rene. 

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Practical approach to patient therapy affected by Autosomal Dominant Autosomic Polycystic Kidney Disease

Abstract

The Autosomal Dominant Polycystic Kidney Disease(ADPKD) is the most frequent renal genetic condition and involves 7 to 10% of subjects undergoing renal replacement therapy. It is estimated that between 24,000 and 34,000 subjects in Italy are affected by this condition. For an illness that has long been neglected due to a lack of treatment options, an attractive treatment possibility is now available: tolvaptan has shown clinical efficacy regarding disease progression in two clinical trials (ADPKD patients with mild renal failure and ADPKD patients with advanced renal failure). The possible liver toxicity expressed in about 4% of the subjects exposed to the drug and an important aquaretic effect suggest prudence and attention in the use of this new molecule. Based on these critical points, some clinicians with direct experience in the use of the drug have briefly collected in the pages to follow the main clinical recommendations for the treatment of ADPKD patients. The recommendations concern the general approach to the patient affected by ADPKD but with particular attention to the aspects related to the new treatment. The delicate task of introducing the opportunities and limitations of the offered therapy to the patient will be deepened. Finally, the document wants to suggest how best to organize a clinic dedicated to this condition.

Keywords: Autosomal Dominant Polycystic Kidney Disease, Renal failure, Cyst, Aneurysm, tolvaptan

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INTRODUZIONE

Riccardo Magistroni

 

Il Rene Policistico Autosomico Dominante (ADPKD) è la più frequente patologia genetica di interesse nefrologico e coinvolge dal 7 al 10% dei soggetti in trattamento sostitutivo renale (13).

 

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Hyperkalemia as a limiting factor in the use of drugs that block the Renin Angiotensin Aldosterone System (RAAS)

Abstract

Angiotensin-converting enzyme (ACE-I) inhibitors and ARBs have shown real efficacy in reducing blood pressure, proteinuria, in slowing the progression of chronic kidney disease (MRC) and in clinical improvement. in patients with heart failure, diabetes mellitus and ischemic heart disease. However, their use is limited by some side effects such as the increase in serum potassium (K), which can be particularly severe in patients with renal insufficiency. In the 23,000 patients followed by the PIRP project of the Emilia-Romagna Region, hyperkalaemia at the first visit (K> 5.5 mEq / L) was present in about 7% of all patients. The prevalence of K values> 5.5 mEq / L increased in relation to the CKD stage, reaching 11% in patients in stage 4 and 5. Among patients with values ​​of K> 5.5 at baseline, 44.8% were in therapy with ACE-I / ARB inhibitors, 3.8% with anti-mineralcortoid and a further 3.9% concurrently taking SRAA-blocking agents and K-sparing diuretics. Counter-measures to avoid the onset of hyperkalemia during treatment with drugs that block the RAAS range from the low-K diet, to diuretics and finally to drugs that promote fecal elimination of K. Among these, polystyrene sulfonates, which have more than 50 years of life, exchange K with sodium or calcium. These drugs, however, in chronic use, can lead to sodium or calcium overload and cause dangerous intestinal necrosis. Recently two new highly promising drugs have been introduced on the market for the treatment of hyperkalemia, the patiromer and sodium zirconium cyclosilicate. The patiromer, which is a potassium-calcium exchanger, acts at the level of the colon where there is a higher concentration of K and where the drug is most ionized. Sodium zirconium cyclosilicate (ZS-9) is a resin with micropores of well-defined dimensions, placed in the crystalline structure of the zirconium silicate. The trapped K is exchanged with other protons and sodium. However, even these drugs will have to demonstrate their long-term efficacy and safety to be considered true partners of RAAS blockers in some categories of patients.

Key words: potassium, hyperkalemia, ARB, ace-inhibitors, renal failure, patiromer, sodium zieconium cyclosylate, ZS-9, kayexalate

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Introduzione

Gli inibitori dell’enzima di conversione dell’angiotensina (ACE-I) ed i bloccanti dei recettori dell’angiotensina (ARB) hanno dimostrato una reale efficacia nel ridurre la pressione arteriosa,la proteinuria e nel rallentare la progressione della malattia renale cronica (13). Inoltre questi farmaci favoriscono il miglioramento clinico in pazienti con insufficienza cardiaca, diabete mellito e cardiopatia ischemica. Tuttavia, questa classe di farmaci è stata anche associata ad eventi avversi, a volte severi: comparsa di insufficienza renale acuta, iperkalemia severa (45) importanti riduzioni della pressione arteriosa.

Il timore verso gli effetti avversi dei bloccanti del Sistema Renina Angiotensina Aldosterone (SRAA), spesso comporta una loro sottoutilizzazione o un sottodosaggio, in particolare nei sottogruppi di pazienti che sono maggiormente a rischio di sviluppare complicanze. Uno studio turco che si è occupato di valutare le barriere che limitano l’uso di ACE-I e ARB in pazienti con insufficienza renale cronica, ha riconosciuto nell’iperkalemia, l’elemento principale che porta alla sospensione dei bloccanti il SRAA (6). Anche lo studio di Shirazian ha evidenziato che l’iperkalemia rappresenta la causa principale di sottoutilizzo di ACE-I e ARB (7)

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