Carmela Tozzo

Can Pulsatile Cardiopulmonary Bypass Prevent Perioperative Renal Dysfunction during Myocardial Revascularization in Elderly Patients

Backgrounds/Aims: We recently demonstrated that pulsatile cardiopulmonary bypass (CPB) versus standard linear CPB is associated with better perioperative renal function. Since older subjects have a higher risk of acute renal failure, we have extended our study to evaluate the specific impact of pulsatile CPB on the perioperative renal function in elderly patients. Methods: We enrolled 50 patients with normal preoperative renal function: they were stratified by age (65–75 vs. 50–64 years) and randomized to nonpulsatile (group A) or pulsatile CPB (group B). Twenty-seven patients aged ≥50 years and <65 years were randomized to group A (n = 12) or to group B (n = 15) and 23, aged ≥65 years and ≤75 years, to group A (n = 13) or to group B (n = 10). Glomerular filtrate rate (GFR), daily diuresis, lactatemia and other parameters were measured during the pre- and perioperative period. Results: The percent perioperative decrease in GFR was lower in group A than in group B (p < 0.001), without differences between older and younger patients. By contrast, perioperative plasma lactate levels were higher in group A than in group B (p < 0.001), both in older and younger patients. No difference was observed for 24 h urine output and blood urea nitrogen. Conclusions: Pulsatile CPB preserves renal function better than standard CPB even in patients older than 65. CPB could be adopted as the procedure of choice in this subgroup of patients.

Prevalence and Severity of Anaemia in Patients with Type 2 Diabetic Nephropathy and Different Degrees of Chronic Renal Insufficiency

Background/Aim: Type 2 diabetes mellitus is the single most common cause of chronic kidney disease (CKD); however its real impact on renal anaemia has not been established. The aim of this study was to evaluate whether onset, severity, and prevalence of anaemia during the course of CKD is different between type 2 diabetic and non-diabetic patients. Methods: We enrolled 281 patients with: (1) type 2 diabetes and no CKD (n = 75); (2) type 2 diabetes plus CKD (n = 106), and (3) CKD without type 2 diabetes (n = 100). According to K/DOQI guidelines, the patients with renal insufficiency (i.e., those with a glomerular filtration rate <60 ml/min) were subgrouped into three tertiles of CKD: (1) stage 3 (creatinine clearance 60–30 ml/min); (2) stage 4 (creatinine clearance 29–15 ml/min), and (3) stage 5 (creatinine clearance <15 ml/min). Results: Anaemia was observed in 16% of the diabetic patients without CKD; it was more frequent in the diabetic patients with CKD than in the non-diabetic patients with CKD (61.7 vs. 52%, p < 0.05). The comparison among the tertiles showed that the prevalence of anaemia was significantly higher only in diabetic CKD patients of stages 4 and 5. The prevalence was higher in females independently of type 2 diabetes mellitus. In diabetics with a normal renal function, the haemoglobin levels were higher than in diabeticsand non-diabetics with CKD, but the diabetics showed lower levels of haemoglobin than non-diabetics at stage 3 and stage 4 of CKD. Conclusions: Diabetic patients with CKD of stages 4 and 5 have a higher prevalence of anaemia than non-diabetic patients with comparable glomerular filtration rate. A higher awareness of this risk will allow earlier diagnosis and treatment.

A case report of plasma exchange therapy in non-paraneoplastic cerebellar ataxia associated with anti-Yo antibody.

Abstract:  A 71‐year‐old‐woman was admitted to the S. Eugenio Hospital for a history of progressively impaired standing and gait. Anamnesis revealed systemic hypertension, gastric polyposis and juvenile pulmonary tuberculosis. Neurological examination showed a severe truncal and gait ataxia, without any sensory‐motor impairment. Motor and somato‐sensory evoked potentials were normal. Brain Magnetic Resonance Imaging (MRI) showed minimal signs of chronic ischemia only at a supratentorial level. Cerebral Single Photon Emission Computed Tomography, spinal MRI, total body computed tomography, Esophagogastroduodenoscopy, and finally total body Positron Emission Tomography resulted negative for neoplasms. Oncological serum markers were negative. Serum antibody against Purkinjes cells (Anti‐Yo) was detected and titer was 1 : 80, while normally it should be undetectable. Other autoantibodies (Anti‐Hu, Anti‐Ri) were undetectable. Two sessions of plasma exchange (PE) were thus performed, leading to a rapid, marked and durable improvement of standing and gait and to a reduction of the autoantibody, which became undetectable. No serious adverse effect was noted. Although no definite therapy for autoimmune cerebellar ataxia has been established, PE should be considered as one of the main therapeutic choices.

Acute renal failure caused by nontraumatic rhabdomyolysis

Nontraumatic rhabdomyolysis may be associated with severe metabolic disturbances. In particular, previous literature has described a 8-20% incidence of acute renal failure in rhabdomyolysis. The aim of this study was to evaluate our experience on 11 patients with acute renal failure treated by high-efficiency daily hemodialysis.

Acute Leukemia in a Uremic Patient Undergoing Erythropoietin Treatment

Dr. Valentina Mazzarella, Ospedale S. Eugenio, Clinica Chirurgica II Università, Piazzale dell’Umanesimo 10, I-00144 Roma (Italia) Dear Sir, Erythropoietin (EPO) has been shown to be an excellent drug to reverse anemia in uremia with few adverse effects. We describe 1 case of leukemia developing during EPO treatment in a uremic patient. In July 1995, we observed a 74-year-old man affected by end-stage renal failure following nephroangiosclerosis on maintenance hemodialysis since January 1993. The patient had a good clinical status except for a persistent anemia: hemoglobin was 7.1 g/dl, hematocrit 20.9%, white blood cell count 6.1 × lOVμl, platelet count 221.0 × 103/μl. EPO treatment (4,000 IU s.c. twice weekly) was started. The hemoglobin value improved after 18 days and became stable, at 8.2 g/dl. Seven weeks after EPO therapy, the patient complained of fever, dyspnea, weakness and leukocytosis. Subsequent laboratory and clinical features showed a picture of acute lymphocytic leukemia (ALL). One month later the patient died during chemotherapy. Campistrus et al. [1] observed acute non-lymphocytic leukemia (ANLL) in a uremic patient in hemodialysis treated with EPO. Uyttebroeck et al. [2] described a transformation to acute myelomonocytic leukemia in a child affected by 5q-syndrome after EPO treatment. Both authors did not exclude that extramedullary hematopoiesis with secondary transformation to leukemia stimulated by EPO occurred. Furthermore the development of acute leukemia was observed in 3/14 patients with myelodysplastic syndromes while on EPO therapy [3]. There is evidence that EPO in vitro can stimulate ANLL blast cells [4]. At present, EPO is employed in anemia associated with all hematologic malignancies and solid tumors except acute myeloid leukemia. An interesting study suggests that in both murine and human systems genetic alterations of the EPO receptor gene are not rare events and could be involved in the occurrence of the erythroleukemic process [5]. We observed 1 case of ALL in a uremic patient and no references have been found on ALL after EPO treatment. It is possible that the anemia was a symptom of a preleu-kemic state. Further investigations are needed in order to clarify whether EPO increases the potential risk of transformation to acute leukemia. Careful use of EPO is important in particular in uremic patients, because the anemia is not always a renal symptom.

RHEOPHERESIS IN VASCULAR DISEASES

BACKGROUND Endothelial dysfunction is a common condition in many microvascular diseases, such as Age-related Macular Degeneration (AMD) and Peripheral Arterial Occlusive Disease (PAOD). Rheopheresis therapy improves ematic viscosity, shear stress and endothelial function while decreasing fibrinogen, LDL-cholesterol and alpha-2-macroglobulin levels. OBJECTIVE To evaluate the therapeutic efficacy of rheopheresis in patients with microcirculatory diseases. MATERIALS AND METHODS Eight patients (7 male and 1 female) were treated with rheopheresis: 3 males were affected by AMD, 4 male and 1 female by uremia and PAOD. We used Membrane Differential Filtration (MDF) with an ethinylvinyl alcohol copolymer membrane as plasmafiltrator. Patients with AMD were treated once a week for ten weeks. Patients affected with PAOD were treated twice weekly for 3 weeks and then were placed on a once-a-week program. RESULTS In all treated patients with AMD, visual acuity improved. In all patients affected with PAOD, we observed a complete resolution of pain; 3 out of 5 had a complete remission of ulcers. There was partial reduction of ulcers in the other patients and no adverse effects were observed. CONCLUSION Rheopheresis is a safe, effective form of hemorheotherapy.

Renal function in patients with orthotopic liver transplantation

Since 1980 the introduction of Cyclosporine (CyA) into clinical practice has broadened the indications for orthotopic liver transplantation (OLT), because of improved patient and graft survival.