Massimo Testorio

Cardiac, Inflammatory and Metabolic Parameters: Hemodialysis versus Peritoneal Dialysis

Introduction: Mortality in dialysis patients is higher than in the general population, and cardiovascular disease represents the leading cause of death. Hypertension and volume overload are important risk factors for the development of left ventricular hypertrophy (LVH) in hemodialysis (HD) and peritoneal dialysis (PD) patients. Other factors are mainly represented by hyperparathyroidism, vascular calcification, arterial stiffness and inflammation. The aim of this study was to compare blood pressure (BP) and metabolic parameters with cardiovascular changes [cardiothoracic ratio (CTR), aortic arch calcification (AAC) and LV mass index (LVMI)] between PD and HD patients. Materials and Methods: 45 patients (23 HD and 22 PD patients) were enrolled. BP measurements, echocardiography and chest X-ray were performed in each patient to determine the LVMI and to evaluate the CTR and AAC. Inflammatory indexes, intact parathyroid hormone (iPTH) and arterial blood gas analysis were also evaluated. Results: LVMI was higher in PD than HD patients (139 ± 19 vs. 104 ± 22; p = 0.04). In PD patients, a significant correlation between iPTH, C-reactive protein and the presence of LVH was observed (r = 0.70, p = 0.04; r = 0.70, p = 0.03, respectively). The CTR was increased in PD patients as compared to HD patients, while no significant differences in cardiac calcifications were determined. Conclusions: Our data indicate that HD patients present more effective BP control than PD patients. Adequate fluid and metabolic control are necessary to assess the adequacy of BP, which is strongly correlated with the increase in LVMI and with the increased CTR in dialysis patients. PD is a home therapy and allows a better quality of life, but PD patients may present a further increased cardiovascular risk if not adequately monitored.

Neurological, psychological, and cognitive disorders in patients with chronic kidney disease on conservative and replacement therapy

AbstractChronic kidney disease (CKD) is a highly prevalent condition in the world. Neurological, psychological, and cognitive disorders, related to CKD, could contribute to the morbidity, mortality, and poor quality of life of these patients. The aim of this study was to assess the neurological, psychological, and cognitive imbalance in patients with CKD on conservative and replacement therapy.Seventy-four clinically stable patients affected by CKD on conservative therapy, replacement therapy (hemodialysis (HD), peritoneal dialysis (PD)), or with kidney transplantation (KT) and 25 healthy controls (HC), matched for age and sex were enrolled. Clinical, laboratory, and instrumental examinations, as renal function, inflammation and mineral metabolism indexes, electroencephalogram (EEG), psychological (MMPI-2, Sat P), and cognitive tests (neuropsychological tests, NPZ5) were carried out.The results showed a significant differences in the absolute and relative power of delta band and relative power of theta band of EEG (P = 0.008, P < 0.001, P = 0.051), a positive correlation between relative power of delta band and C-reactive protein (CRP) (P < 0.001) and a negative correlation between estimated glomerular filtration rate (eGFR) (P < 0.001) and 1,25-dihydroxyvitamin D3 (1,25-(OH)2D3) (P < 0.001), in all the samples. Qualitative analysis of EEG showed alterations of Grade 2 (according to Parsons–Smith classification) in patients on conservative therapy, and Grade 2–3 in KT patients. The scales of MMPI-2 hysteria and paranoia, are significantly correlated with creatinine, eGFR, serum nitrogen, CRP, 1,25-(OH)2D3, intact parathyroid hormone (iPTH), phosphorus, and cynical and hysterical personality, are correlated with higher relative power of delta (P = 0.016) and theta band (P = 0.016). Moreover, all NPZ5 scores showed a significant difference between the means of nephropathic patients and the means of the HC, and a positive correlation with eGFR, serum nitrogen, CRP, iPTH, and vitamin D.In CKD patients, simple and noninvasive instruments, as EEG, and cognitive-psychological tests, should be performed and careful and constant monitoring of renal risk factors, probably involved in neuropsychological complications (inflammation, disorders of mineral metabolism, electrolyte disorders, etc.), should be carried out. Early identification and adequate therapy of neuropsychological, and cognitive disorders, might enable a better quality of life and a major compliance with a probable reduction in the healthcare costs.

Glomerulonephritis, Pathogenetic Mechanisms and Therapeutic Options: An Overview

Introduction: Most forms of human glomerulonephritis (GN) result from immunologic mechanisms that are mediated by the actions of multiple elements of both the innate and adaptive immune systems, thereby resulting in different clinical manifestations. The treatment of immune-mediated kidney disease is based on steroids and immunosuppressive drugs that interfere with the immune processes. These groups of drugs have led to significant benefits, but severe side effects are still frequent. Monoclonal antibodies directed against molecules of inflammation or several cellular components have emerged in clinical practice. Plasmapheresis and new methods to reduce the risks associated with the procedure with standard therapies may be combined. Moreover new therapeutic options have been proposed, as the use of natural anti-inflammatory cytokines or intracellular signaling reducing inflammation. Materials and Methods: We conducted a systematic review on the pathogenetic mechanisms of glomerulonephritis and their therapies. Results: We analized all RCTs and quasi-RCTs evaluating the current knowledge about pathogenetic mechanisms of glomerulonephritis and related therapy were considered. Conclusion: The pathogenetic mechanisms of glomerulonephritis are complex and strongly influenced by immunogenetic factors. Several clinical trials to identify the best therapeutic options for glomerulonephritis have been conducted, but currently, although significant advancements over the last 10 years have been obtained, important questions are still unanswered. Moreover, we need to consider many and important side effects that have the main therapies for glomerulonephritis. Therefore the development of a web enabled data base to assist nephrologists for the treatment of patients with glomerulonephritis is strongly suggested.

A young man with persistent myalgia and fatigue: an off-label therapeutic approach

A 34-year-old man reported a 16-year history of progressive chronic fatigue, neuromuscular pain in the region of the left shoulder and both knees. The patient presented difficulty in movement especially in the morning with myalgia and fatigue. Moreover, he reported constant headache localized to the parietal region, metallic taste and diarrhea. Central nervous system (CNS) involvement was diagnosed by the presence of cognitive dysfunction, attention and mood disturbances. Physical examination showed numerous flesh-colored to red-brown follicular papules and pustules, 1–3 mm in size all over the face (Fig. 1). Skin biopsy was not performed. The patient had been vaccinated for hepatitis B and tetanus toxoid in 1994 and 1995. No pathological conditions were reported in his clinical history. In 2003 because of the persistence of the symptoms, muscle biopsy was prescribed and autoimmune Macrophagic Myofasciitis (MMF) was finally diagnosed. Further investigations, management and treatment