Prognostic Factors of Peritonitis in Patients on Peritoneal Dialysis: a Retrospective Observational Study

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Stefano Mancin

DOI: 10.69097/41-03-2024-011

Cinzia Fabbri1,2, Elisa La Malfa3, Mattia Ricco3, Lea Godino2,4, Stefano Mancin5, Walter Longo1,2, Giovanni Spadafora1,2, Beatrice Del Grosso3, Marco Sguanci2,6, Maria Pia Zito2, Sergio Cinocca7, Domenica Gazineo2,7

1 Nephrology, Dialysis, Hypertension Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna
2 SIAN, Italian Nephrological Nursing Society, Olbia, Italy
3 Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
4 Medical Genetics Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
5 IRCCS Humanitas Research Hospital, Rozzano, Italy
6 Department of Medicine and Surgery, Research Unit of Nursing Science, Università Campus Bio-Medico di Roma, Italy
7 Governo Clinico e Qualità, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy

Corresponding author:
Dr. Stefano Mancin
IRCCS Humanitas Research Hospital,
Via Manzoni 56, 20089
Rozzano, Italia
E-mail: stefano.mancin@humanitas.it

 

Abstract

Background/Objectives. Peritoneal dialysis stands as an established form of renal replacement therapy; yet peritonitis remains a major complication associated with it. This study, analyzing two decades of data from the Nephrology, Dialysis, and Hypertension Division of the University-Hospital IRCCS in Bologna, aimed to identify prognostic factors linked to peritonitis events. It also sought to evaluate the suitability of different peritoneal dialysis techniques, with a focus on Automated Peritoneal Dialysis (APD) and Continuous Ambulatory Peritoneal Dialysis (CAPD). Additionally, the study assessed the impact of an educational program introduced in 2005 on peritonitis frequency.
Methods. Conducting an observational, retrospective, single-center study, 323 patients were included in the analysis, categorized based on their use of APD or CAPD.
Results. Despite widespread APD usage, no significant correlation was found between the dialysis technique (APD or CAPD) and peritonitis onset. The analysis of the educational program’s impact revealed no significant differences in peritonitis occurrence. However, a clear relationship emerged between regular patient monitoring at the reference center and the duration of peritoneal dialysis.
Conclusions. Despite the absence of a distinct association between peritonitis onset and dialysis technique, regular patient monitoring at the reference center significantly correlated with prolonged peritoneal dialysis duration.

Keywords: end-stage renal disease, peritoneal dialysis, peritonitis, peritoneal catheter

Sorry, this entry is only available in Italian.

Introduction

Peritoneal dialysis (PD) is an effective treatment option for patients with end-stage renal disease, particularly for populations such as elderly individuals, diabetics, and those with concomitant pathologies [1, 2]. This technique involves the exchange of solutes and fluids between the patient’s peritoneal capillary blood and the introduced dialysis solution, a process made feasible by the Tenckhoff catheter [3]. This catheter has multiple benefits, including effective fluid exchange, a barrier against infections, and cost-effectiveness [4].

Since 2001, there has been a significant rise in the number of patients opting for dialysis treatments, witnessing an annual growth of approximately seven per cent [5, 6]. This surge can be attributed to an aging population, improved life expectancy for those with end-stage renal disease, and increased access to dialysis for younger patients [7]. The decision between PD and hemodialysis (HD) depends largely on regional and individual circumstances. In developed countries, the choice might be driven by patient preference or accessibility constraints to HD units. In contrast, economic challenges in less affluent regions might render PD as the primary choice [6]. 

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“Green” Hemodialysis: The Centralized Acidic Concentrate from the Dialysis Center of Policlinico of Modena

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Gabriele Donati

DOI: 10.69097/41-03-2024-010

Giuseppe Di Chiaro1*, Gaetano Alfano2*, Ylenia Cancelli1, Floriana Cannito1, Roberto Angelo Pulizzi2, Lucia Stipo2, Fabio Olmeda2, Lucia Palmieri2, Salvatore Perrone2, Vittoria Malaguti2, Gianni Cappelli 1,2, Gabriele Donati1,2

1 Department CHIMOMO, University of Modena and Reggio Emilia, Modena, Italy
2 Nephrology Dialysis and Kidney Transplant Unit, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy

* Both authors contributed equally as first author

Corresponding author:
Gabriele Donati
Dipartimento Chirurgico, Medico, Odontoiatrico e di Scienze Morfologiche con interesse Trapiantologico, Oncologico e di Medicina Rigenerativa (CHIMOMO), Università degli Studi di Modena e Reggio Emilia
Largo del Pozzo 71
41125 Modena, Italia
Tel. 0594222485
E-mail: gabriele.donati@unimore.it

 

Abstract

Introduction and aim of the study. The centralized preparation and distribution system of acidic concentrate represents a true innovation in hemodialysis, when compared to acid bags, in terms of convenience and eco-sustainability. The aim of this study is to compare the use of traditional acid bags with the centralized distribution system of acidic concentrate, with particular attention to differences in terms of eco-sustainability and convenience.
Methods. At the Nephrology Dialysis and Renal Transplantation Unit of the University Hospital of Modena was installed the Granumix system® (Fresenius Medical Care, Bad Homburg, Germany). Data collected before the introduction of the Granumix® system (including the used acid bags, boxes and pallets used for their packaging, liters of acid solution used and kilograms of waste generated from wood, plastic, cardboard and residual acid solution) were compared with those collected after the implementation of the Granumix® system. Factors such as material consumption, volume of waste generated, unused and wasted products, time required for dialysis session preparation and nurses’ satisfaction were analyzed to document which system was more environmentally sustainable.
Results. Data collected in 2019 at our Dialysis Center showed a consumption of 30,000 acid bags, which generated over 20,000 kg of waste from wood, plastic and cardboard, and approximately 12,000 liters of residual acid solution to be disposed of, with a handling weight by operators reaching nearly 160,000 kg. The use of the centralized distribution system of acidic concentrate resulted in a significant reduction in waste generated (2,642 kg vs 13,617 kg), residual acid solution to be disposed of (2,351 liters vs 12,100 liters) and weights handled by operators (71,522 kg vs 158,117 kg).
Conclusions. The acidic concentrate appears to be better suited to the sustainability challenge that dialysis must faces today, particularly due to the significant increase in the number of patients, which leads to a higher number of treatments and, therefore, a growing demand for eco-sustainable products.

Keywords: Hemodialysis, Innovation, Sustainability, Acidic Concentrate, Central Dialysis Fluid Delivery System

 

Sorry, this entry is only available in Italian.

Introduzione

Dopo circa 80 anni dal primo trattamento emodialitico, sono tante le sfide che la dialisi deve ancora affrontare. Tra le più importanti va menzionato il significativo trend dell’aumento del numero di pazienti in dialisi che di conseguenza porterà a un aumento nell’utilizzo di risorse naturali e nella produzione di rifiuti [1].  La consapevolezza che la maggior parte dei rifiuti della dialisi viene smaltita senza entrare nel processo del riciclaggio (materiale contaminato da sangue o fluidi biologici, prodotti assimilabili a farmaci) è uno stimolo a una crescente necessità di sviluppare e adottare soluzioni ecosostenibili che riducano l’impatto ambientale e l’inquinamento. Inoltre, l’adozione di soluzioni eco-friendly rappresenta un investimento per le aziende del settore sanitario poiché può generare vantaggi economici nel lungo periodo. Una recente innovazione tecnologica in ambito emodialitico è l’implementazione di un sistema automatizzato per la produzione e distribuzione del concentrato acido.  

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An Unusual Case of Alcoholic Liver Disease Associated with Secondary IgA Vasculitic Nephritis presenting as Rapidly Progressive Glomerulonephritis

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Shruthi Muralidharan

DOI: 10.69097/41-03-2024-09

Shruthi Muralidharan1, Gerry George Mathew1, Varadharajan Jayaprakash1, Sreedhar Sailapathy1

1 SRM, Medical College Hospital and Research Centre

Corresponding author:
Shruthi Muralidharan
8-9E 3 RD PHASE, Wood Creek County, ST
Thomas Mount PO
Chennai 600016
Phone: +91 9884075591
E-mail: shruthi.muralidharan@gmail.com

 

Abstract

IgA nephropathy (IgAN) is a fairly common association with alcoholic liver disease. However, IgA vasculitis (IgAV) is quite an uncommon association with alcoholic liver cirrhosis and only a handful of cases have been reported in literature. Secondary IgAN usually presents in a docile manner, progressing slowly in about 5-25 years. It is usually responsive to steroid therapy, very rarely progressing to End-Stage Renal Disease.

Here, we present a man in his late 50s, a known hypertensive and alcohol related liver-cirrhotic, who presented to our hospital with rash and rapidly progressive renal failure (RPRF). He was diagnosed with IgA nephritis with IgA vasculitis (IgAVN). His diagnosis was confirmed with skin and renal biopsy.

He was started on renal replacement therapy for his renal failure and began oral steroid therapy. After administration of steroid therapy for 6 months, the patient recovered and was dialysis independent with stable renal parameters.

Keywords: IgA nephropathy, Alcoholic Liver disease, rapidly progressive glomerulonephritis, IgA vasculitis

Background

Secondary IgA nephropathy is a well-known complication of alcohol related chronic liver disease [1], however, IgA vasculitis with nephropathy secondary to liver disease is quite rare and only a handful of cases have been reported in literature.

The presentation of IgA nephropathy secondary to liver cirrhosis varies from clinically silent disease to nephrotic or nephritic syndromes [2]. Very rarely, it can present as end-stage renal disease (ESRD) requiring renal replacement therapy (RRT). The natural progression involves development of end stage renal disease within 20 years of presentation [3]. The incidence of rapidly progressive renal failure in IgA nephropathy in less than 10%. 

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Chronic Kidney Disease Eligible for SGLT2 Inhibitors Through the Integration of Italian Administrative and Primary Care Data

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Calabria Silvia

DOI: 10.69097/41-03-2024-08

Carlo Piccinni1, Letizia Dondi1, Silvia Calabria1, Giulia Ronconi1, Antonella Pedrini1, Francesco Lapi2, Ettore Marconi2, Damiano Parretti2, Gerardo Medea2, Gaetano Piccinocchi2, Claudio Cricelli2, Roberto Pontremoli3,4, Nello Martini1, Aldo Pietro Maggioni1,5

1 Fondazione ReS (Ricerca e Salute) – Research and Health Foundation, Roma, Italy
2 Health Search - Istituto di Ricerca della S.I.M.G., Firenze, Italy
3 Dipartimento di Medicina Interna e Specialità mediche, Università di Genova, Italy
4 IRCCS Ospedale Policlinico San Martino, Genova, Italy
5 ANMCO Research Center Heart Care Foundation, Firenze, Italy

Corresponding author:
Silvia Calabria, Pharm D
Fondazione ReS (Ricerca e Salute) – Research and Health Foundation
Via dei Due Macelli, 48 - 00187 Roma, Italy.
Tel.: +39 327 523 7055
Email: calabria@fondazioneres.it
ORCID: 0000-0001-9345-2855

 

Abstract

Background. Patients with chronic kidney disease (CKD) can be successfully treated with sodium-glucose cotransporter-2 inhibitors (SGLT2-Is), regardless of diabetes. Fondazione Ricerca e Salute’s (ReSD) administrative and Health Search’s (HSD) primary care databases were combined in the Database Consortium ReS-HS to quantify and describe patients with CKD potentially eligible for SGLT2-Is and assess costs charged to the Italian National Health Service (SSN).
Methods. Patients aged ≥18 with CKD and estimated glomerular filtration rate (eGFR) <60 ml/min in 2018, without dialysis and/or renal transplantation, were included. HSD was used to develop and validate algorithms for estimating eGFR, based on covariates, within the ReSD. Comorbidities, dispensed drugs, and direct healthcare costs were assessed.
Results. In 2018, 66,297 (5.0% of HSD population) and 211,494 (4.4% of ReSD population) patients with CKD potentially eligible for SGLT2-Is were identified (females ≥58%). Prevalence increased with age with a peak at 75-84 years. Within HSD and ReSD cohorts, respectively: 31.0% and 41.5% had diabetes; in the observation periods, >82% and >96% received ≥1 pharmacological treatment, of which ≥50% and ≥25% received cardiovascular/blood agents and antidiabetics, respectively. From ReSD, mean per capita direct SSN cost was € 3,825 (CI 95%, € 3,655-€ 4,000): 50.1% due to hospitalizations, and 40.2% to pharmaceuticals (31.6% to cardiovascular drugs and 10.1% to antidiabetics).
Conclusion. The Database Consortium ReS-HS methodology found 5% of adult SSN beneficiaries with CKD potentially eligible for SGLT2-Is bringing with them a high cardio-metabolic burden which increases the risk of CKD progression.

Keywords: Sodium-Glucose Transporter 2 Inhibitors, Chronic Kidney Diseases, Primary Care, Health Care Costs, National Healthcare System

This work was supported by an unconditional grant from Astra Zeneca Italy SpA. The financial support for this study was provided with a funding agreement ensuring maintenance of author independence in study design, data interpretation, writing, and decision to publish.

Competing interests: APM received personal fees for the participation in clinical studies supported by Bayer, Novartis, Sanofi and Astra Zeneca, outside the present work. FL and EM and provided consultancies in protocol preparation for epidemiological studies and data analyses for AstraZeneca and Mundipharma. DP, CC, GP and GM provided clinical consultancies for AstraZeneca. RP received honoraria for lectures from Lilly, Boehringer, AstraZeneca, Novo-Nordisk, Vifor, Alfa-Sigma, and Bayer, outside the present work. CP, LD, SC, GR and NM are employees of Fondazione Ricerca e Salute (ReS). AP is consultant for Fondazione Ricerca e Salute (ReS).  

Introduction

Sodium-glucose cotransporter-2 inhibitors (SGLT2-Is) have shown positive outcomes on the reduction of glycated hemoglobin (Hb1cA) levels, the protection from cardiovascular events in high-risk patients with type 2 diabetes mellitus (T2DM), the prevention of cardiovascular death and heart failure regardless of T2DM, and of the progression of chronic kidney disease (CKD) [1, 3]. The latter is likely to be independent from the glucose-lowering effects and favored by the glucose-related natriuresis and osmotic diuresis that reduce intraglomerular pressure; the DAPA-CKD (Dapagliflozin and Prevention of Adverse Outcomes in Chronic Kidney Disease) trial was based on this hypothesis and aimed at assessing the long-term efficacy and safety of dapagliflozin in patients with CKD, regardless of T2DM [4]. This trial has shown that patients with CKD assessed by an estimated glomerular filtration rate (eGFR) ranging from 25 to 75 ml/min, regardless of T2DM, have benefited from dapagliflozin through a significant reduction of the risk of sustained decline in eGFR of at least 50%, end-stage kidney disease (ESKD) and renal- or cardiovascular-related death [4]. 

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Peritoneal Dialysis Network in North-East Italy: Survey About the Peritoneal Catheter Exit-Site Infection Management and Comparison with ISPD Guidelines

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Antonino Previti

Antonino Previti1, Sabrina Milan Manani2, Vincenzo Cosentini3, Antonina Lo Cicero4, Marta Guizzo5, Apolloni Monica1, Marina Cappellari5, Sabina Rognini3, Mery Zuccolo4, Grazia Maria Virzì6, Giovanni Gambaro7.

1 UOS Nefrologia e Dialisi, Ospedale Alto Vicentino, Santorso (VI)
2 UOC Nefrologia e Dialisi, Ospedale Camposampiero e Cittadella (PD)
3 UOC Nefrologia e Dialisi, Ospedale Fracastoro, San Bonifacio (VR)
4 UOC Nefrologia e Dialisi, Ospedale si Sant’Antonio, San Daniele del Friuli (UD)
5 UOC Nefrologia e Dialisi, Ospedale Castelfranco Veneto, Castelfranco Veneto (TV)
6 UOC Nefrologia, Dialisi e Trapianto, Ospedale San Bortolo Vicenza (VI)
7 UOC Nefrologia e Dialisi, Azienda Ospedaliera Universitaria Integrata Verona, Verona

Corresponding author:
Antonino Previti
UOS Nefrologia e Dialisi, Ospedale Alto Vicentino
Via Garziere, 42
36014 Santorso (VI), Italia
Tel/Fax 0445 571252
E-mail: antonino.previti@aulss7.veneto.it

 

Abstract

Introduction. The Triveneto Peritoneal Dialysis (PD) Network aims to bring together doctors and nurses who deal with PD in a collaborative network in which to exchange mutual knowledge and optimize the use of this method of replacing renal function. A topic of particular interest was the management of peritoneal catheter exit-site infection, given the recent publication of the new guidelines of the International Society of Peritoneal Dialysis (ISPD).
Materials and methods. The survey concerned the criteria for carrying out nasal swab and exit-site, management of exuberant granulation tissue “Proud Flesh”, treatment of exit-site infection (ESI), use of silver dressings, the role of subcutaneous tunnel ultrasound and cuff shaving.
Results. All PD centers in the North-East Italy area have joined the survey with at least one operator per centre. There was a wide variability between the indications for performing the exit-site swab. In the presence of ESI, the prevalent approach is that of oral systemic empiric therapy associated (20.0%) or less (28.9%) with topical therapy, and then adapting it in a targeted manner to the culture examination.
Discussion. From the discussion of the survey emerged the importance of the ESI as an outcome indicator, which allows us to verify whether our clinical practice is in line with the reference standards. It is essential to know and base our activity on what is indicated in national and international guidelines and to document the events that occur in the patient population of each dialysis unit.

Keywords: Peritoneal Dialysis, Exit-site management, Catheter-related Infections, Survey

Sorry, this entry is only available in Italian.

Introduzione

La dialisi peritoneale (PD) è un importante trattamento dialitico domiciliare cui opta quasi un paziente su cinque fra gli afferenti agli ambulatori specialistici nefrologici [1]. Per i pazienti in PD le infezioni correlate al catetere peritoneale (CP) sono tra i principali fattori di rischio di peritoniti, perdita del CP, drop-out dalla metodica. Queste comprendono l’infezione dell’exit-site (ESI) e del tunnel del CP [2].

Il “Network di Dialisi Peritoneale del Triveneto” ha lo scopo di riunire medici e infermieri che si occupano di PD nel Triveneto per la costruzione di una rete collaborativa all’interno della quale sia possibile diffondere la conoscenza e ottimizzare l’impiego di questa metodica sostitutiva della funzione renale. In questi incontri si parte dall’analisi delle evidenze per quindi verificarne l’attuazione nella real life e confrontarle con l’esperienza e i risultati derivanti dalla pratica clinica dei centri dialisi del Triveneto.

Un argomento di particolare interesse è risultato essere la gestione dell’exit-site infetto del CP, soprattutto in considerazione della recente pubblicazione delle nuove linee guida della Società Internazionale di Dialisi Peritoneale (ISPD) [3]. 

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Executive Dysfunction in Patients Undergoing Chronic Haemodialysis Treatment: A Possible Symptom of Vascular Dementia

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Giulia Belluardo

Giulia Belluardo1, Dario Galeano1, Concetto Sessa1, Luca Zanoli2, Walter Morale1

1 O.C Nefrologia e Dialisi, P.O. “Maggiore” di Modica. Azienda Sanitaria Provinciale di Ragusa, Italia
2 Nefrologia, Dipartimento di Medicina Clinica e Sperimentale, Università di Catania, Catania, Italia

Corresponding author:
Giulia Belluardo
U.O.C di Nefrologia, Ospedale “Maggiore” Via Aldo Moro n°1,
97015 Modica, Italia
E-mail: belluardogiulia12@gmail.com

 

Abstract

Introduction. Patients undergoing chronic haemodialysis (HD) treatment have an 8-10 times higher risk of experiencing stroke events and developing cognitive impairment. The high vascular stress they are subjected to may be the basis for the development of vascular dementia (VaD).
Objective. The aim of the study is to investigate the executive functions, typically impaired in VaD, of patients undergoing chronic haemodialysis treatment.
Method. HD patients were recruited from the U.O.C. of Nephrology and Dialysis (ASP Ragusa). Risk factors for VaD were collected and then the Frontal Assessment Battery (FAB) was administered.
Results. 103 HD patients were included (males = 63%, age 66 ± 14 years). Risk factors for VaD included a high percentage of patients with anaemia (93%), hypertension (64%) and coronary artery disease (68%).  The cognitive data obtained via FAB show a percentage of 55% deficit scores. All risk factors found a significant association with cognitive scores. Anemia, hypertension, intradialytic hypotension, coronary artery disease, and homocysteine are negative predictors of executive function integrity.
Conclusions. More than half of the patients had deficit scores on the FAB. Reduced cognitive flexibility, high sensitivity to interference, poor inhibitory control and impaired motor programming with the dominant hand were evident. In conclusion, a marked impairment of the executive functions, generally located in the frontal lobes of the brain, was detected in the HD patient, which could be a symptom of a dementia of a vascular nature.

Keywords: hemodialysis, cognitive, impairment, vascular, dementia

Sorry, this entry is only available in Italian.

Introduzione

I pazienti affetti da malattia renale cronica (CKD) sono solitamente più a rischio della popolazione generale di sviluppare deterioramento cognitivo [1], con una prevalenza che varia dal 13% al 58% [2-4]. L’associazione tra malattia renale cronica e funzioni cognitive è stata recentemente indagata e prove collettive dimostrano che una diminuzione del tasso di filtrazione glomerulare stimato (eGFR) aumenta la probabilità di incorrere in deterioramento cognitivo [5, 6]. Sono molti i meccanismi eziopatogenetici sottostanti questo fenomeno, come la disfunzione vascolare, l’infiammazione, l’accumulo di tossine uremiche, l’anemia e le anomalie elettrolitiche [7]. I pazienti in End Stage Renal Disease (ESRD) hanno un rischio maggiore di sviluppare patologie cerebrovascolari e cardiovascolari [8]. In particolare, studi hanno dimostrato che i pazienti allo stadio terminale della malattia e in trattamento emodialitico cronico (HD) hanno un’incidenza di ictus 8-10 volte maggiore rispetto alla popolazione generale, con una prevalenza di ictus emorragico rappresentante il 20% di tutti gli eventi ictali nel dializzato, e presentano una autoregolazione cerebrale alterata [9–12]. Nello specifico, l’emodialisi induce una significativa riduzione del flusso sanguigno cerebrale (CBF) in tutti i lobi durante le sedute emodialitiche [10]. Dunque, l’ingente stress vascolare a cui sono sottoposti questi pazienti potrebbe costituire la base per lo sviluppo del deterioramento cognitivo constatato in questa popolazione e, in particolare, per quadri di demenza vascolare [13].  

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Clinical implications of serum anti-PLA2R levels and glomerular PLA2R deposits in primary membranous nephropathy

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Krishna Chaitanya Gunda

Krishna Chaitanya Gunda1, Gerry George Mathew2, S Balasubramanian3, K S Sunil Kumar4

1 MD, DNB(Nephrology) Consultant Nephrologist, Department of Nephrology, Asian institute of Nephrology and Urology, Nungambakkam, Chennai, Tamil Nadu, India-600034
2 MD, DNB(Nephrology) Associate Professor, Department of Nephrology, SRM Medical College Hospital and Research Centre, Kattankulathur, Tamil Nadu, India-603203
3 MD, DNB(Nephrology) Senior Consultant Nephrologist, Department of Nephrology, Apollo hospital, Greams lane, 21, Greams road, Thousand lights, Chennai, Tamil Nadu, India-600006
4 MD, Consultant Pathologist, Department of Pathology, Apollo hospital , Greams lane, 21, Greams road, Thousand lights, Chennai, Tamil Nadu, India-600006

Corresponding author:
Gerry George Mathew
Department of Nephrology,
SRM Medical College Hospital and Research Centre, Kattankulathur, Tamil Nadu, India-603203
Mobile number: +91-8291077361
Email: gerrygeorge007@gmail.com

 

Abstract

Introduction. The clinical implications of serum anti-PLA2R with glomerular PLA2R deposits in primary membranous nephropathy (PMN) is scarcely reported. Hence the study was designed to demonstrate the prevalence of serum anti-PLA2R levels and PLA2R staining in glomeruli in PMN and the clinical implications of the two parameters.
Objectives.

  1. Investigate the prevalence of anti PLA2R positivity in PMN.
  2. Ascertain correlation between serum anti-PLA2R levels and glomerular staining for PLA2R with clinical and lab parameters in PMN.

Patients and Methods. Fifty PMN patients during the period from October 2017 to December 2018 were included. Labs were done and eGFR was calculated as per MDRD 6. Anti-PLA2R titres were done in all patients. Titres more than 20 RU/ml were considered positive. Glomerular staining for PLA2R was graded on fresh frozen tissue by immunofluorescence technique.
Results. Anti-PLA2R antibody positivity and glomerular PLA2R deposition was observed in 42% (21/50) and 86% (43/50) patients respectively. 79.3% (23/29) had positive glomerular PLA2R deposition with negative serum anti PLA2R. Positive correlation were observed between serum PLA2R antibody and serum creatinine (p = 0.0001) and urine protein-creatinine ratio levels with tissue PLA2R staining grades (p = 0.04). Negative association was found between serum albumin (p = 0.026) and tissue PLA2R staining grades.
Conclusion. Serum anti-PLA2R wasn’t a sensitive marker of primary membranous nephropathy in our study group emphasising the need to consider a compendium of serological markers for diagnosis of primary membranous nephropathy and to rely more on glomerular deposition of PLA2R as a better clinical indicator for PMN.

Keywords: anti-PLA2R, Membranous Nephropathy, Glomerular PLA2R deposits, Tissue PLA2R staining, Nephrotic Syndrome

Introduction

Membranous nephropathy (MN) is an important aetiology of adult onset nephrotic syndrome which is subclassified into primary (PMN) and secondary membranous nephropathy. Secondary membranous nephropathy is implicated in clinical scenarios such as cancer, autoimmune diseases and infections [1, 2]. PMN can be diagnosed on the basis of biomarkers like Anti PLA2R levels which can be useful in adjusting the therapeutic initiatives for management of the disease process. These biomarkers may be used to predict clinical consequences like decreased eGFR or proteinuria [3]. The discovery of phospholipase A2 receptor (PLA2R) antibody has contributed to an improvised understanding of the pathophysiology of PMN [4]. The specificity and sensitivity of PLA2R antibody for the PMN has been approximated to be around 100% [5] and 50% to 80% respectively [6]. Previous studies have tried to assess the utility of antibodies to PLA2R in clinical practice. However, there is a definite need for more studies to study the prevalence of glomerular PLA2R deposits, so that it can be applied as a diagnostic and prognostic test in the patients with PMN. 

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Factors Associated with Neonatal Arterial Hypertension: Case and Control Study

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Carolina Gutiérrez-Cortés

Carolina Gutiérrez-Cortés1, Catalina Lince-Rivera2, Adriana P. Bohórquez-Peñaranda3, Mariangel Castillo-Arteaga4, Ingrid Mayerly Gómez5, Juan Guillermo Cárdenas-Aguilera 6

1 Specialist in pediatric, Pontificia Universidad Javeriana, Bogotá, Colombia
2 Specialist in pediatric and neonatology, Pontificia Universidad Javeriana, Bogotá, Colombia
3 MSc Clinical Epidemiology, Pontificia Universidad Javeriana, Bogotá, Colombia
4 Specialist in pediatric nephrology, Hospital Universitario San Ignacio, Bogotá, Colombia
5 Specialist in pediatric and neonatology, Pontificia Universidad Javeriana, Bogotá, Colombia
6 Specialist in pediatric nephrology, Subred Integrada de Servicios de Salud Sur Occidente, Bogotá, Colombia

Corresponding author:
Juan Guillermo Cárdenas Aguilera
Pontificia Universidad Javeriana
Bogotá, Colombia
Tel (+57) 601 320 8320
Cra 7 No 40 - 62
Email: cardenasjg@javeriana.edu.co

 

Abstract

Background. Neonatal high blood pressure has been diagnosed more frequently in recent years, and its impact extends to adulthood. However, the knowledge gaps on associated factors, diagnosis, and treatment are challenging for medical personnel. The incidence of this condition varies depending on neonatal conditions. Patients in the Newborn Unit are at increased risk of developing high blood pressure. The persistence of this condition beyond the neonatal stage increases the risk of cardiovascular disease and chronic kidney disease in childhood and adulthood.
Methodology. A case-control study was carried out. It included hospitalized patients with neonatal hypertension as cases. Three controls were randomly selected for each case and matched by gestational age. The variables were analyzed based on their nature. Multivariate analysis was performed using a multivariate conditional regression model to identify variables associated with the outcome. Finally, the model was adjusted for possible confounders.
Results. 37 cases were obtained and matched with 111 controls. In the univariate analysis, heart disease (OR 2.86; 95% CI 1.22-6.71), kidney disease (OR 7.24; 95% CI 1.92-28.28), bronchopulmonary dysplasia (OR 6.62; 95% CI 1.42-50.82) and major surgical procedures (OR 3.71; 95% CI 1.64-8.39) had an association with neonatal arterial hypertension. Only the latter maintained this finding in the multivariate analysis (adjusted OR 2.88; 95% CI 1.14-7.30). A significant association of two or more comorbidities with neonatal arterial hypertension was also found (OR 3.81; 95% CI 1.53-9.49).
Conclusions. The study analyzed the factors related to high blood pressure in hospitalized neonates, finding relevant associations in the said population. The importance of meticulous neonatal care and monitoring of risk factors such as birth weight and major surgeries is highlighted.

Keywords: Hypertension, Prematurity, Bronchopulmonary Dysplasia, Epigenetics, Neonate, Prematurity, Kidney Disease, Blood Pressure

Introduction

With technological advances in neonatal care, Newborn Units (NU) have undergone significant changes, increasing survival in low-weight patients due to prematurity or intrauterine growth retardation. Low birth weight (LBW) is determined to correspond to weights less than 2500 grams (Table 1).

Birth Weight
Less than 2500 g Low birth weight
Less than 1500 g Very low birth weight
Less than 1000 g Extremely low birth weight
Table 1. Low birth weight classifications. Adapted and translated from Atehortua et al. [1].

 

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Advanced Care Planning (ACP) and Hemodialysis: a Pilot Project for the Application of Italian Law 219/2017 in Dialysis Units

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Cristina Tantardini

Cristina Tantardini1, Clara Pelizzari2

1 UO Nefrologia e Dialisi, ASST Crema, Crema (CR), Italia
2 UO Psicologia Clinica, ASST Crema, Crema (CR), Italia

Corresponding author:
Cristina Tantardini
UO Nefrologia e Dialisi
ASST Crema l.go U. Dossena 2, 26013 Crema (CR), Italia
TEL. 0373-280417
e-mail: cristinatantardini@hotmail.com

 

Abstract

The law 219/2017 is the first Italian law about advanced care planning (ACP). ACP is an important part of the therapeutic relationship between patients and doctors: thanks to ACP patients can think and discuss about end of life decisions, considering clinical aspects, but also psychological, cultural, social and ethical issues. Patients prepare themselves in advance because of the possibility of future cognitive impairment, can identify a surrogate decision maker and make end-life decisions according to their goals and values.

End-stage kidney disease (ESRD) is often characterized by important symptoms, psychological suffering and social disadvantage, and patients affected by ESRD often have slow physical and cognitive decline. Despite this, access to palliative care is reduced for these patients as compared to patients affected by other end-stage organ failures. This is the reason why we want to explore the possibility of applying APC to ESRD patients.

This pilot study, regarding three patients from the Dialysis Unit of ASST Crema in Italy, has been conducted to verify the applicability of the law 219/2017 in Dialysis Units. It shows that we have to deeply investigate this issue from both sanitary workers’ and patients’ and families’ points of view. We need more studies with a larger number of patients and a longer period of follow-up, but we also need to teach sanitary workers how to approach APC and to teach people what APC is and why it’s so important for everyone.

Keywords: advanced care planning, end-stage kidney disease, dialysis

Sorry, this entry is only available in Italian.

Introduzione

Che cos’è la pianificazione condivisa delle cure (PCC)?

Per “pianificazione condivisa delle cure” si intende un processo che si svolge all’interno di una relazione di fiducia tra il paziente e il personale sanitario, in cui si illustrano al paziente e alle persone a lui vicine la situazione attuale di malattia, le possibilità di cura e la prognosi e si riflette in anticipo in merito alle decisioni relative al fine vita tenendo inevitabilmente conto, oltre che degli aspetti clinici, di quelli psicologici e della dimensione culturale, sociale, spirituale ed etica del paziente [1].

Nel corso di questo processo il paziente si prepara alla propria eventuale, futura, incapacità di autodeterminarsi (e quindi di acconsentire o meno alle cure proposte), può identificare un fiduciario ed esplicita ai curanti le proprie indicazioni per le fasi di incapacità e/o per il fine vita in linea con i propri valori ed i propri obbiettivi [2].

In sintesi, la PCC permette al paziente di esprimere che cosa significhi per lui vivere e morire bene [2, 3]. 

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Apheresis Techniques for the Treatment of Hyperbilirubinemia in the Nephrology Unit

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Corrado Pluvio

Emanuela de Pascale1, Gaia Marinelli1, Pietro Iulianiello2, Rossana Matrisciano2, Davide Viggiano2, Corrado Pluvio1

1 AORN dei Colli, “D. Cotugno” Hospital, Department of Dialysis with Hepatic-Infective Complications, via L. Bianchi, 80131, Naples, Italy
2 Department of Translational Medical Sciences, University of Campania “L. Vanvitelli”, Naples

Corresponding author:
Prof. Davide Viggiano
UON Nefrologia e dialisi
Dip. Scienze mediche traslazionali
Università della Campania, Napoli
Email: davide.viggiano@unicampania.it

 

Abstract

Therapeutic apheresis is an important hematological and nephrological method for conditions with altered plasma composition. It is also indicated for the removal of protein-bound molecules, such as bilirubin. Several techniques can remove these compounds, such as the extracorporeal circulation molecular adsorption system (MARS), plasma exchange (PEX), and plasma adsorption and perfusion (PAP). Here we report our experience in the comparison between MARS, PEX and PAP, since current guidelines do not specify which method is the most appropriate and under which circumstances it should be used.

The choice of technique cannot be based on the desired plasma bilirubin concentration, since these three techniques show similar results with a similar final outcome (exitus). In fact, PAP, PEX and MARS significantly reduce bilirubin levels, but the degree of reduction is not different among the three. Furthermore, the three techniques do not differ in the rate of cholinesterase change, while less reduction of liver transaminases was found by using PAP.

MARS should be preferred in the case of renal involvement (hepatorenal syndrome with hyperbilirubinemia). PAP has the advantage of being simple and inexpensive. PEX remains an option when emergency PAP is not available, but the risk of using blood products (plasma and albumin) must be considered.

Keywords: Molecular Adsorbent Recirculating System, MARS, Plasma Adsorption Perfusion, plasma exchange

Sorry, this entry is only available in Italian.

Introduzione: inquadramento storico

La gialla discolorazione della pelle e occhi, lo yearkon ebraico, è una dei mali che la Bibbia riporta qualora non si ascolti la voce di Dio (Deuteronomio 28, 21). Già nel 500 a.C. se ne riconosce la causa nella ostruzione o costipazione del fegato, come riportato dal medico bizantino Alessandro di Tralles, e, infatti, la bile gialla è uno dei quattro umori identificati da Ippocrate di Cos (morto nel 377 a.C.).

Verso la fine del 1800 lo sviluppo di tecniche biochimiche applicate alla clinica porta alla identificazione della bilirubina (fra gli altri anche Virchow diede importanti contributi).

Nel 1933 Zimmermann e Yannet scoprono che il Kernicterus (una degenerazione dei gangli della base in corso di ittero, descritta da Christian Georg Schmorl nel 1904 e prima da Johannes Orth nel 1875) è causato dalla deposizione di bilirubina a livello cerebrale [1].

La bilirubina è lipofila, può attraversare la barriera emato-cerebrale. Gerard Odell nel 1959 [2] e poi il celebre Gilbert nel 1973 [3] dimostrano allora che l’albumina plasmatica riduce i livelli plasmatici di bilirubina grazie a un potente legame fra i due.

Nonostante la coeva introduzione della emodialisi, queste tecniche non si presentano come utili a rimuovere la bilirubina, proprio a causa del forte legame con la albumina, e solo la dialisi peritoneale presenta di una qualche utilità al proposito nei lontani anni ’60 [4].

Nei primi anni ’50 un biochimico dell’Università di Harvard (Boston), Edwin Cohn, usando un pool di plasma umano, sviluppò una procedura su larga scala per la purificazione dell’albumina come alternativa al plasma liofilizzato per i soldati feriti. La “centrifuga di Cohn” fu, di fatto, un antenato della plasmaferesi [5]. 

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