Emanuela Rizzioli

Risk Factors for Renal Disease and Urinary Abnormalities in Men and Women: Data from The World Kidney Day in The Province of Ferrara, Italy

Background: Chronic kidney disease (CKD) is a worldwide health problem due to its morbidity and mortality, and cost. World Kidney Day (WKD) has been planned to improve disease prevention. The aim of this study was to evaluate CKD risk factors and urinary abnormalities, collected on WKD along several years, in men and women. Patients and methods: Between 2006 and 2012, 1980 subjects, of whom 1012 women, from general population living in Ferrara area, a town in the north-east of Italy, were investigated. For each participant age, sex, smoking, hypertensive and diabetic status, body mass index (BMI), waist circumference (WC), and blood pressure (BP) were obtained. Moreover, body shape index (BSI) was calculated. All subjects underwent dipstick urinalysis. Results: Men had higher BMI, WC, and BP than women. Women had higher prevalence of abdominal obesity and higher BSI (0.0951 ± 0.0105 vs. 0.0920 ± 0.0071 m11/6kg−2/3), while men had higher prevalence of overweight. In women, hematuria and leukocyturia were more prevalent (16.9% vs. 12.8%; OR 95%CI 1.161 (1.042–1.294); p = 0.012; 18.5% vs. 7% OR 95%CI 1.538 (1.403–1.676); p < 0.001, respectively), while glycosuria was less frequent (4.2% vs. 8.8% OR 95%CI 0.642 (0.501–0.822); p < 0.001) than in men. Frequency of proteinuria was similar in the two sexes. Venn diagrams indicate a different overlap of urinary abnormalities in the two sexes. Conclusions: Risk factors for CKD collected during the WKD appear to be different in the two sexes, and urinary abnormalities overlap differently. Data collected during the WKD are related to sex, and women deserve greater attention.

Acute Renal Failure due to a Calculus Obstructing a Transplanted Kidney

Nephrolithiasis is a rare finding in kidney transplantation and anuria could be the only clinical sign. We report the case of a 52-year-old Caucasian male renal transplant recipient admitted due to acute renal failure (ARF) and anuria. He reported no symptoms and a palpable bulge in the right iliac fossa corresponding to the graft was present. Ultrasonography showed hydronephrosis of the graft. A double-J ureteral stent was inserted with resolution of ARF. ARF with anuria and the presence of a palpable non-tender, elastic mass over the graft could be the clinical picture of obstructive ARF in a transplanted kidney.

Management of intradialytic hypertension: old problem, old drug?

Of the patients beginning with dialysis, 60–85% of them may account for hypertension, and dialysis alone is capable of controlling hypertension in over 50% of these patients [1]; resistant hypertension and paradoxical blood pressure (BP) elevation during dialysis are possible but relatively infrequent complications [1]. Nevertheless, there is no widely accepted definition of intradialytic hypertension [2]. Several definitions, mostly arbitrary, have been used such as any increase in mean arterial BP of 15 mmHg or more during or immediately after hemodialysis, hypertension during the second or third hour of dialysis after significant ultrafiltration has taken place, or an increase in BP that is resistant to ultrafiltration, with post-ultrafiltration BP exceeding the pre-ultrafiltration BP in more than half of the sessions [2]. Thus, the prevalence of intradialytic hypertension, in consideration with the different definitions, has shown wide variations, from 5 to 15% [2]. We report a case of a 70-year-old woman with a personal medical history including a long-standing smoking habit, type-2 diabetes mellitus with diabetic nephropathy, cerebral vascular disease, coronary artery disease, previous myocardial infarction treated with PTCA and stenting. Forty-one weeks before, she had started chronic dialysis therapy three times a week, performed by artero-venous fistula on an afternoon shift (13:00–18:00 hours). Some of the details of the dialysis treatment are bicarbonate dialysis, duration 3.5 h, average weekly body weight gain 3.3 kg, hourly decrease 9 mm Hg, blood flow 300 ml/min. Pharmacologic therapy included clopidogrel 75 mg/day, metoprolol 50 mg b.i.d., sustained-release isosorbide-5mononitrate 50 mg/day, nifedipine gastrointestinal therapeutic system (GITS) 60 mg/day, ramipril 10 mg/day, and clonidine transdermal (1 TTS1 system/week). The patient showed significant increase in BP levels, especially during the second hour of dialysis, not responding to several drug schedules, e.g., extradoses of nifedipine, amlodipine, and clonidine. Only the introduction in therapy of the vasodilatator minoxidil (Loniten , Pharmacia & Upjohn SpA) allowed a successful control and stabilization of the paradoxical BP increase (Table 1). A first point of discussion could be the lack of use of diuretics. In advanced renal failure, sodium imbalance is becoming positive, and the extracellular volume (ECV) expands. In patients with chronic kidney disease, especially in the case of poor adherence to salt restriction, diuretics play an important role [3]. However, this is not always the case for dialysis patients. The concept of controlling BP by achieving the lowest possible ECV has been termed as ‘‘dry weight’’, the post-dialysis weight at which the patient is and remains normotensive until the next dialysis despite the interdialytic fluid retention without anti-hypertensive medication [4]. Dry weight is usually assessed using the clinical method [4]. Useful information include: (1) medical history (dietary habits, salt excess) and presence/ absence of symptoms of volume overload; (2) clinical signs: blood pressure (measured lying, sitting, and standing), weight, central venous pressure, presence of edema; E. Rizzioli Modulo di Nefrologia, Unità Operativa di Medicina Interna, Ospedale del Delta, Azienda U.S.L. di Ferrara, Ferrara, Italy