Angelo Tralongo

Hepatitis C virus core antigen test in monitoring of dialysis patients.

Hepatitis C virus infection is a persistent worldwide public health concern. The prevalence of HCV infection is much higher in patients on chronic haemodialysis (HD) than in the general population. HCV infection can detrimentally affect patients throughout the spectrum of chronic kidney disease. Despite the control of blood products, hepatitis C virus transmission is still being observed among patients undergoing dialysis. Detection systems for serum HCV antibodies are insensitive in the acute phase because of the long serological window. Direct detection of HCV depends on PCR test but this test is not suitable for routine screening. Recent studies have highlighted the importance of HCV core antigen detection as an alternative to PCR. Few studies exist about the efficacy of HCV core antigen test in dialysis population. We studied the utility of HCV core antigen test in routine monitoring of virological status of dialysis patients. We screened 92 patients on long-term dialysis both by PCR HCV-RNA and HCV core antigen test. The sensitivity of HCVcAg test was 90%, the specificity 100%, the positive predictive power 100%, the negative predictive power 97%, and the accuracy 97%. We think serological detection of HCV core antigen may be an alternative to NAT techniques for routine monitoring of patients on chronic dialysis.

Incidence of hepatitis C virus infection in patients with chronic kidney disease on conservative therapy

Hepatitis C virus (HCV) infection is a never-ending public health problem. Many studies have investigated the incidence of HCV infection among dialysis patients, but there have only been a few epidemiological studies in renal conservative therapy. We studied 320 subjects with pre-dialysis chronic kidney disease living in Sicily, Italy. The incidence of HCV infection was 6.25%. In Europe, incidence ranges from 0.2% to 3.5%. It appears that the incidence of HCV infection is higher in the studied patient population than in the population as a whole.

Acute kidney injury associated with metformin.

designed to record the most relevant details of each handoff patients care. Its method of use promotes interactiveness while incorporating critical details for each patients disposition and care. The incoming physician serves as a scribe on the form while the patient is presented. Empty boxes (easily visualized) prompt a query to complete the data set, ensuring that vital details are always discussed and addressed during handoff. During the pilot phase of this investigation, all EM residents at our institution were asked to use this form after a brief 5-minute training session. These forms were used at 2 urban training sites with an annual census of more than 200,000. There were no exclusions. The residents were subsequently surveyed to gauge its efficacy 1 month after availability. The survey asked 6 questions: their level of residency training, their intent to use this method of handoff after residency, their estimate of effectiveness regarding the potential to reduce medical error, frequency of use, difficulty of use, and whether they believed it improved the care of patients changed over in the ED. A total of 54 (96%) of 56 EM residents responded to the survey. Among those who responded, only 2 had not used the form. Of those that responded and used the form, 69% believed that it was effective in reducing medical error in changeover, whereas 60% believed that this method improved the care of patients changed over in the ED. The majority (80%) found it either easy or very easy to use, whereas only 2% (1 respondent) found it difficult. Fifty-two percent intend to use this tool after completion of residency. In summary, our residents believed that this method improved ED handoff in a positive way. Specifically, they felt that the changeover form is effective in reducing medical error while improving patient care. They also found this form easy to use and portable to their practice beyond residency. We plan on continuing to study the impact of this intervention in a prospective randomized trial comparing relevant patient outcomes. Further exploration into factors such as reduction in reported errors, ED and hospital length of stay, and ED recidivism rates could be studied to help confirm clinical correlation with perceived benefits. Although this method was only implemented at our training institution, it can be easily translated to any ED setting. Its simplicity in design, cost-effectiveness, and ease of use facilitate its application to other centers. It is our belief that this method should be considered for use in any ED without an established effective method of handoff.

Comment on "Haemodialysis using high cut-off dialysers for treating acute renal failure in multiple myeloma"

We read with interest the article of Dr. Martín-Reyes et al. We agree with the motivation of their study: 1. the survival of the patients suffering from Multiple Myeloma (MM) depend on whether or not they recover renal function, not only due to the complications derived from the renal failure itself, but also from the reduced possibility of access to more effective treatments; . the importance of rapid reduction of free light chains blood levels in order to facilitate the recovery of renal function. We wish to report our experience in this topic In April 2011 a 43-year-old man, with a previously normal renal function, was admitted to our hospital for severe acute renal failure (ARF) of an unknown cause. The review of the clinical history didn’t revealed any previous disease. For 2 months he was suffering from lumbar pain. We started haemodialysis treatment three times a week. Laboratory investigations and bone marrow biopsy detected a lambda IgG MM. We performed kidney biopsy and we observed glomerular deposition of lambda chains, without histological signs of chronic renal damage, and a negative Congo red stain test. In 2 weeks the patient received 10 haemodialysis (HD) treatment with high cut-off (HCO) dialyzer (Theralite, Gambro Henchingen, Germany). We performed on alternating days HCO HD sessions with standard monitors; they lasted for 5 hours, involved a blood flow of 300ml/min and had an ultrapure dialysate flow rate of 500ml/min. Sodium Reviparine (Clivarina) was applied at 2400 IU in single dose priming. The values of Platelets (60.000/mmc) motivated the prescription on the duration of HCO HD and on the dose of heparin. At the end of each session we didn’t administer albumin. Ultrafiltration was programmed according to the clinical need. Before and after each session, mean free light chain levels were measured in terms of mg/l using nephelometry (N latex test, Siemens) Initially λ FLC concentration was 5500mg/L. At the end of HCO dialyzer HD end of HCO dialyzer HD cycle, the concentration was 94.80mg/L. The concentrations and ratios of light chain levels from the start to the end of treatment are summarised in Table 1.

The Prevalence of Hepatitis B Virus Infection in a Population on Long-Term Hemodialysis

Dear Editor, Although the prevalence and incidence rates among hemodialysis (HD) patients in developed countries have declined over the last 3 decades, Hepatitis B virus (HBV) infection remains a major issue in the HD setting [1]. The isolated finding of HBcAb in HBsAg-negative subjects is considered an indication of past exposure to HBV and resolved infection, but the use of sensitive techniques to detect HBV-DNA has shown that low levels of viremia are detectable in HBsAg-negative/HBcAb-positive subjects. Today, vaccination programs offer the promise of eliminating HBV infection from developed areas, but emigration from countries of the world where HBV is highly prevalent will result in HBsAg-negative patients with past exposure to HBV, with the likelihood of them developing ESRD and entering the dialysis pool. We investigated the prevalence of HBV infection in HD patients by analyzing the HBV serological markers of 322 HD patients from January 2016 to June 2017 in Palermo Italy. Among the 322 screened patients, we found 6 were HBsAg-positive (1.8%); among these patients, 2 had coinfection with HCV and 1 with HIV; 2 patients were migrant from Africa; all HBsAg-positive patients had history of transfusion but not of illicit drugs abuse. Among the remaining 316 HBsAg-negative patients, we found that 56 were HBcAb-positive (18%) and 59 were HBsAbpositive (19%) patients; 32 patients (10%) had mixed HbsAb/HBcAb-positivity; no positive case of IgM-HBcAb-, HBeAg-, or HBeAb-positive was detected; 311 patients were Caucasian; 3 patients had migrated from Africa and 2 patients had migrated from Bangladesh. All serological markers of the HBsAg-negative patients are summarized in Table 1. Despite the decline of HBV infection worldwide in the general population, the most recent reports show a persistent presence of HBV in HD setting. Data from Regional Italian Registries on HBsAg-positivity in HD patients range from 0.6 to 2.2% [2]. In the general population, HBcAb is a long-life serological marker of previous HBV infection and it is found in persons with chronic infection as well as in those who recover from infection. In Italy, the prevalence of HBsAgnegative/HBcAb-positive subjects among first-time blood donors ranges from 4.85 to 8.3% [3–4]. In clinical practice, the presence of HBcAb in HBsAg-negative/ HBsAb-negative subjects is considered an important key for occult HBV infection Table 1. Serological HBV-HCV-HIV markers in 316 Sicilian HBsAg-negative hemodialysis patients

A case of acute EPS with local cocoon formation in a patient on peritoneal dialysis

Encapsulating peritoneal sclerosis is a rare and life-threatening complication of long-term peritoneal dialysis and until now there is no established medical treatment. Many factors have been incriminated in its pathogenesis but they do not explain all risk conditions. We report our experience and we investigate the predisposing factors. Probably unidentified factors make some patients more susceptible to developing encapsulating peritoneal sclerosis.

Extended spectrum beta lactamase peritonitis: Our experience

Sir, We read with interest the article of Dr. Sinha and Coll[1] on extended spectrum beta‐lactamase (ESBL) peritonitis in patient on chronic peritoneal dialysis (PD). The guidelines of International Society for PD[2] state that the selection of empiric antibiotics must cover all serious pathogens that are likely to be present, through a first‐generation cephalosporin, such as cefazolin or cephalothin, with a second drug for broader Gram‐negative coverage (including coverage for Pseudomonas) such as aminoglycoside, ceftazidime, cefepime, or carbapenem.

Is There a Correlation Between Immunologic and Psychological Parameters in Peritoneal dialysis Patients

chills, and rigor, and was started on empirical amoxicillin clavulanate. However, her illness was further complicated by PD-associated peritonitis and septic shock. She was then started on intraperitoneal cefazolin and amikacin. A dose of intravenous vancomycin was also given empirically. Despite those efforts, the patient’s condition deteriorated rapidly, and she succumbed 2 days after the onset of fever. Blood and PD effluent cultures subsequently grew MRSA.

High cut-off dialyser haemodialysis in cast nephropathy

Sir, The importance of renal function in the prognosis of patients with multiple myeloma (MM) has been well established and rapid reversal of renal failure may offer the best long-term outcome. The use of extracorporeal means of removing immunoglobulin free light chains (FLCs) responsible for cast nephropathy in patients with MM is controversial. Nephrologists are interested in a treatment strategy combining chemotherapy and extracorporeal treatments in patients with biopsy-proven cast nephropathy or a high probability of cast nephropathy (defined as >200 mg/dL on the FLC assay). Some previous studies have shown that the plasma exchange is unable to remove sufficient FLCs for clinical benefits. The issue of whether an extended duration of dialysis with high cut-off (HCO) dialysers is more effective than plasma exchange at removing FLC or reversing renal failure is not settled [1]. Hutchison and Leung reported that a 60% reduction in FLCs by Day 21 is associated with recovery of renal function for 80% of the studied patients [2]. Our experience: a 43-year-old man, who was not complaining of any previous disease and with a previously normal renal function, suffering from biopsy proven lambda myeloma kidney, without any histological sign of chronic renal damage, and renal failure dialysis dependant, in 2 weeks received 10 haemodialysis (HD) treatments with HCO-dialyser (Theralite Gambro). We quantified the concentration of FLCs by nephelometry (Biocite, N latex test; Siemens). Initially, λ FLC concentration was 5500 mg/L. At the end of HCO dialyser HD cycle, the concentration was 94.80 mg/L (Table 1). Table 1. Concentrations and ratios of FLC before and after HCO-dialyser HDa We did not observe any adverse effects. We observed by Day 7 a sustained and >50% reduction of FLCs with dialysis alone before the chemotherapy was initiated. After the third HCO-dialyser HD, the patient started PAD Orlowsky chemotherapy (Bortezomib–Doxorubicin–Dexamethasone) with successful haematological result but with partial renal function recovery. Currently (5 months after HCO-dialyser treatment), the patient is on maintenance HD two times a week. Some reports show a recovery of renal function after several months. If the patient does not recover normal renal function, we think that a new kidney biopsy can help his management.

Hepatitis C virus core antigen test in virological monitoring of patients on long-term dialysis

normal. Therefore, the high RI could not be explained by intrarenal abnormalities, pointing to an extrarenal cause. One such cause could be stiffness of the pre-renal arterial vessels. Our patient had suffered from coronary heart disease, insufficiency of the aortic valve and an aneurysm of the ascending aorta. Therefore, 7 years before transplantation, she had undergone to aerotocoronary bypass grafting and implantation of a prosthetic aortic valve, and a vascular graft (Hemashield Vantage) of the ascending aorta. Dacron grafts are extremely stiff compared to the healthy aorta [3]. Therefore, they cannot expand during systole, and contraction during diastole, the main determinant of diastolic aortic flow, is absent. We suggest that this phenomenon explains the missing diastolic perfusion in the patients renal allograft. In addition, Doppler ultrasound of the abdominal aorta and the superior mesenteric artery also showed a complete absence of diastolic perfusion. In conclusion, this case demonstrates that an increased RI in a renal allograft may not always be a consequence of intrarenal pathology, but may also be caused by impairment of the function of pre-renal arterial vessels. Whether the absence of diastolic blood flow in the transplanted kidney will have a negative impact on long-term graft function is, at present, unknown. Eighteen months after transplantation, the patients allograft function is excellent with an actual serum creatinine of 120 μmol/L.