Cristina Gavrilovici

Criteria for and Appropriateness of Renal Transplantation in Elderly Patients with End-Stage Renal Disease: A Literature Review and Position Statement on Behalf of the European Renal Association-European Dialysis and Transplant Association Descartes Working Group and European Renal Best Practice

Abstract During the last 20 years, waiting lists for renal transplantation (RT) have grown significantly older. However, elderly patients (ie ≥65 years of age) are still more rarely referred or accepted to waiting lists and, if enlisted, have less chances of actually receiving a kidney allograft, than younger counterparts. In this review, we looked at evidence for the benefits and risks of RT in the elderly trying to answer the following questions: Should RT be advocated for elderly patients? What should be the criteria to accept elderly patients on the waiting list for RT? What strategies might be used to increase the rate of RT in waitlisted elderly candidates? For selected elderly patients, RT was shown to be superior to dialysis in terms of patient survival. Virtually all guidelines recommend that patients should not be deemed ineligible for RT based on age alone, although a short life expectancy generally might preclude RT. Concerning the assessment of comorbidities in the elderly, special attention should be paid to cardiac evaluation and screening for malignancy. Comorbidity scores and frailty assessment scales might help the decision making on eligibility. Psychosocial issues should also be evaluated. To overcome the scarcity of organ donors, elderly RT candidates should be encouraged to consider expanded criteria donors and living donors, as alternatives to deceased standard criteria donors. It has been demonstrated that expanded criteria donor RT in patients 60 years or older is associated with higher survival rates than remaining on dialysis, whereas living donor RT is superior to all other options.

Overhydration, underhydration, and total body sodium: A tricky “ménage a trois” in dialysis patients

Overhydration is a frequent complication in dialysis patients. It has been linked with hypertension, left ventricular hypertrophy, arterial stiffness, atherosclerosis uremic cardiomyopathy, and all‐cause mortality or cardiovascular morbidity. In addition, predialysis underhydration is also associated with increased risk of death in ESRD patients. In this context, the optimal evaluation of hydration status is a must. However, this mission is not easy or accurate. In the last 10 years, several new methods have been tested in dialysis patients, particularly bioimpedance and lung ultrasonography. The precise clinical value of these techniques in the daily care of hemodialysis patients is not obvious yet. Sodium is also an important piece of this puzzle. Salt intake and/or removal of sodium during dialysis are essential determinants of optimal hydration status. Recent studies have revealed that salt and water homeostasis is also dependent of tissue sodium storage—increased in hemodialysis patients. However, the significance of increased sodium tissue storage as a cardiovascular risk factor and the relationship between tissue sodium content and hard CV endpoint have not yet been elucidated yet.

Modifications in the spectrum of bone mass predictive factors with menopausal status

ABSTRACT Purpose: Fat mass (FM) is a source of adipocytokines, with both positive and negative bone consequences. We aimed to investigate the role of body composition and adipokines as predictive factors for bone mass in women. Methodology: This cross-sectional study included 93 women (38 premenopausal and 55 postmenopausal). Bone mineral density (BMD) and body composition were assessed by dual-energy X-ray absorptiometry. Serum levels of leptin, adiponectin, resistin, and also of the phosphocalcic markers parathormone and vitamin D were measured. Results: Only lean mass (LM) was an independent predictor of BMD in premenopausal women (r2 = 0.381, p < 0.001 for femoral neck BMD, r2 = 0.2, p < 0.01 for whole-body BMD) in both unadjusted and age-adjusted models. The effect of total FM upon BMD became nonsignificant when LM was added to the models assessed. In postmenopausal women, although LM, trunk-to-leg fat ratio, and resistin were initially associated with BMD in unadjusted models, only the trunk-to-leg fat ratio independently predicted BMD at various sites (r2 = 0.171, p < 0.01 for lumbar BMD, r2 = 0.078, p < 0.05 for radius BMD, r2 = 0.094, p < 0.05 for whole-body BMD) after adjusting for age. Conclusions: While in premenopausal women the effect of LM upon bone is prevalent, after menopause, the fat distribution reflected by trunk-to-leg fat ratio is a major determinant of bone mass at different sites. Our study also stresses that the relationship between total FM and BMD is not mediated by adipokines in women irrespective of menopausal status and body composition, but it is largely mediated by LM only in young premenopausal women.

Different evolution in the treatment of a severe persistent asthma in 2 twins: Case report and review of the literature

Rationale: Asthma is a multifactorial disease with complex genetic inheritance. In children under the age of 5 years, the diagnosis of asthma is a challenge. Patient concern: We present the case of twin sisters under the same treatment for persistent asthma, but with different evolution over the time. Diagnoses: One of the sister is diagnosed with severe persistent bronchial asthma associated with bronchiectasis and dyslipidemia and the other one only with mild persistent asthma. Interventions: At each admission the treatment for the exacerbations and the underlying respiratory infections was represented by antibiotics, short-acting &bgr;2 agonists, and, sometimes, oxygen and systemic corticosteroids. As chronic treatment, they received in the last period inhaled corticosteroids associated with long-acting &bgr;2 agonist. Outcomes: Until the age of 6.5 years, they had similar diagnoses and treatment; from this point one was asymptomatic, with normal pulmonary function tests. The other one had a more complicated evolution which led to a severe crisis by the age of 10 years old. Lessons: Although asthma is a multifactorial disease with complex genetic inheritance, the genetics has its limits. Our twins had a similar onset with the same genetic inheritance, with the same risk factors, with the same comorbidities and with the same treatment. In this context, different evolutions of severe persistent asthma require more extensive genetic investigations. Patient concern: We present the case of twin sisters under the same treatment for persistent asthma, but with different evolution over the time.

Tubular secretion in chronic kidney disease staging: a new proposal

in an accurate, noninvasive and secure way. Since the creatinine excreted in the urine is a combination of the creatinine filtered by the glomerulus and secreted by the proximal tubule, and creatinine proximal tubule secretion can be blocked by high dose of cimetidine, then creatinine clearance aided with cimetidine (CAC) is equivalent to GFR, being the CAC/GFR ratio: 1.1 ± 0.02 [7]. Additionally, there is a classical principle in renal physiology which states that the ratio between creatinine clearance (CC) and CAC (CC/ CAC) can be used for evaluating the magnitude of the tubular secretion activity since a CC/CAC > 1 means the existence of net creatinine secretion, while a CC/CAC = 1 means its deficit [2]. This CC/CAC ratio could be based on 24-h or spot urine samples, in order to simplify the procedure. Besides, the CC/CAC ratio could be useful for establishing different degrees of tubular secretion capability, such as (S1): CC/CAC = 1, (S2): CC/CAC > 1 but <1.5, (S3): CC/CAC ≥ 1.5 and <2, and (S4): CC/CAC ≥ 2 [2, 7, 8]. In addition, CC/CAC ratio constitutes an adequate means for exploring completely the tubular secretion capability since even though cimetidine is mainly secreted by cationic organic transporters, it is also secreted by anionic organic transporters [4]. Thus, it would be very interesting to include the degree of tubular secretion activity in the current CKD staging system, and this categorization could be performed as follows. For instance: if a CKD patient has a GFR: 25 ml/ min/1.73 m2, albuminuria: 500 mg/day, and CC/CAC: > 1.5 but <2, this patient could be classified as stage 4, A2, S3. Even, the documented patient’s tubular secretion capability (e.g., S3) could be registered at the intersection place between his/her GFR and albuminuria–proteinuria level in the CKD stages chart (Table 1). Perhaps, at the same level of proteinuria, a low GFR with a high tubular secretion (Stage 3b-S4) could have a better prognosis than a relatively high GFR without tubular Editor,