Natalia C. V. Melo

Pruritus in hemodialysis patients: The problem remains

Pruritus is still one of the most common and disturbing symptoms of end‐stage renal disease. The objective of this study is to analyze the prevalence of pruritus in hemodialysis patients and the possible factors implicated in its genesis. In a cross‐sectional study, 101 patients on hemodialysis at our center were screened for pruritus. The relationship of various factors with pruritus was evaluated. Of the 101 patients included, 31(30.7%) had pruritus at the time of examination. Patients with pruritus were significantly older than those without pruritus (P=0.0027). Pruritus tended to be more prevalent in patients undergoing dialysis 3 times a week than in those undergoing daily dialysis, but the difference did not reach statistical significance (P=0.0854). Lower transferrin saturation levels were found in patients with pruritus than in those without pruritus (P=0.0144). C‐reactive protein levels were significantly higher in patients with pruritus than in those without pruritus (P=0.0013). There was no significant difference between the groups in the levels of the other inflammatory biomarkers measured. However, there was a tendency toward a correlation between the levels of α‐1‐glycoprotein and the intensity of pruritus (P=0.0834). Our results suggest a possible relationship of the inflammatory response upregulation to pruritus. Additionally, there was a positive relationship between pruritus and iron deficiency, possibly associated with inflammatory elevation of hepcidin. A better understanding of the factors implicated in the genesis of pruritus related to end‐stage renal disease is crucial in the development of more effective treatments for this symptom.

The potential role of C-reactive protein in distinguishing cytomegalovirus from tuberculosis and bacterial infections in renal transplant recipients

Abstract:  Introduction:  The delay in the diagnosis of infections can be deleterious in renal transplant recipients. Thus, laboratory tests leading to an earlier diagnosis are very useful for these patients.

Reprocessing high-flux polysulfone dialyzers does not negatively impact solute removal in short-daily online hemodiafiltration

There are no studies evaluating the impact of dialyzer reprocessing on solute removal in short‐daily online hemodiafiltration (OL‐HDF). Our aim was to evaluate the impact of dialyzer reuse on solute removal in daily OL‐HDF and compare with that in high‐flux short‐daily hemodialysis (SDH). Fourteen patients undergoing a SDH program were included. Pre‐dialysis and post‐dialysis blood samples and effluent dialysate were collected in the 1st, 7th, and 13th dialyzer uses in SDH sessions and in daily OL‐HDF sessions. Directly quantified small solute (urea, phosphorus, creatinine, and uric acid) total mass removal (TMDQ) and clearance (KDQ) were similar when the 1st, 7th, and 13th dialyzer SDH uses were compared with the 1st, 7th, and 13th daily OL‐HDF uses. TMDQ and KDQ of small solutes were similar among analyzed dialyzer uses in SDH sessions and in daily OL‐HDF sessions. β2‐Microglobulin TMDQ and KDQ were statistically higher in daily OL‐HDF dialyzer uses than in the respective SDH uses. There was no difference in β2‐microglobulin TMDQ and KDQ among dialyzer uses in daily OL‐HDF sessions or in SDH sessions. In daily OL‐HDF, albumin loss was significantly different among dialyzer uses (P < 0.001), being lower in the 7th and 13th dialyzer uses than in the first use. Dialyzer reprocessing did not impair solute extraction in daily OL‐HDF. β2‐Microglobulin removal was greater in daily OL‐HDF than in SDH sessions, without significant differences in other solutes extraction. There was a significant reduction in intradialytic albumin loss with dialyzer reprocessing in daily OL‐HDF sessions.

Connecting the dots: hypoxia, pulmonary fibrosis, obstructive sleep apnea, and aging.

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Three cases of hypertension and Renal Arteriovenous fistula with a de novo fistula

Fistula Arteriovenosa Renal (FAVR) e uma causa rara e potencialmente reversivel de hipertensao e insuficiencia renal e/ou cardiaca. O tratamento da FAVR visa preservar o maximo de parenquima renal e, concomitantemente, erradicar os sintomas e efeitos hemodinâmicos decorrentes da FAVR. No presente estudo, serao relatados tres casos de FAVR, incluindo um caso de FAVR idiopatica de novo, que se apresentaram com hipertensao e insuficiencia renal e/ou cardiaca, e descrever a terapeutica adotada e os resultados obtidos.The Renal Arteriovenous Fistula (RAVF) is a rare and potentially reversible cause of hypertension and kidney and/or heart failure. The treatment of RAVF aims at preserving the most of the renal parenchyma and, concomitantly, eradicating the symptoms and hemodynamic effects caused by the RAVF. The present study reports three cases of RAVF, including one case of a de novo idiopathic RAVF, which presented with hypertension and kidney and/or heart failure and describes the therapeutic measures used to treat these patients as well as the outcomes.

Supine Systolic Blood Pressure and 1-Year Mortality in Patients With Acute Chest Pain

To the Editor: Dr Stenestrand and colleagues analyzed data from 119 151 participants in the Registry of Information and Knowledge About Swedish Heart Intensive Care Admissions (RIKS-HIA) who were treated for chest pain in the intensive care unit from 1997 to 2007. The study reported that absolute 1-year mortality was 40.3% higher in quartile 1 (Q1, supine systolic blood pressure 128 mm Hg) compared with quartile 2 (Q2, supine systolic blood pressure 128-144 mm Hg), adjusted for age; sex; smoking status; diastolic blood pressure; use of antihypertensive medication and nitroglycerin at admission; and use at discharge of antihypertensive, statin, antiplatelet, and anticoagulant drugs and other lipid-lowering medication. As a study limitation, the authors said that “it is possible that factors not present in the RIKS-HIA database, such as malnutrition or anemia, might explain part of the relatively poor prognosis associated with low admission systolic BP.” However, another possible confounder is sleep apnea, an important pathophysiological and prognostic factor in cardiovascular disease. Sleep apnea may have been more prevalent in Q1 than in Q2: individuals in Q1 were older and had higher heart rate than those in Q2, and sleep apnea is generally more prevalent among older individuals and is associated with higher heart rate. Despite a greater prevalence of -blocker use in Q1 than in Q2, Q1 participants had higher heart rate, possibly due to a more intense sympathetic activation in Q1, consistent with associated sleep apnea. Relative to Q2, Q1 participants had greater prevalence of aspirin and statin use and lower total cholesterol levels and diastolic blood pressure, traditionally associated with better prognosis in chest pain. Consequently, it is possible that a negative prognostic factor in chest pain such as sleep apnea was not evaluated. In previous studies, sleep apnea was present in up to 57% of patients with acute coronary syndrome, being associated with increased coronary restenosis, major adverse cardiac events, and cardiac death. Based on these data, undiagnosed or untreated sleep apnea might explain, at least in part, the poor prognosis associated with low admission supine systolic blood pressure in acute chest pain in the study by Stenestrand et al. However, this hypothesis would have to be addressed by a prospective clinical study.

Brainstem tumour mimicking pheochromocytoma.

The diagnosis of a catecholamine-secreting pheochromocytoma is always suggested by occurrence of severe and symptomatic paroxysmal hypertension. However, in most patients this diagnosis is not confirmed, despite extensive investigation. 1 Traditionally, besides pheochromocytoma, the differential diagnosis in cases of paroxysmal hypertension associated with catecholamine excess should include cocaine use, antiparkinsonian drugs, obstructive sleep apnoea and baroreflex failure. 2 Nonetheless, when the paroxysmal hypertension is associated not only with catecholamine excess, but also with neurologic signs, a very rare differential diagnosis should also be considered: a brainstem tumour mimicking pheochromocytoma. 3―5 .

Três casos de hipertensão e Fístula Arteriovenosa Renal: com uma fístula de novo

Fistula Arteriovenosa Renal (FAVR) e uma causa rara e potencialmente reversivel de hipertensao e insuficiencia renal e/ou cardiaca. O tratamento da FAVR visa preservar o maximo de parenquima renal e, concomitantemente, erradicar os sintomas e efeitos hemodinâmicos decorrentes da FAVR. No presente estudo, serao relatados tres casos de FAVR, incluindo um caso de FAVR idiopatica de novo, que se apresentaram com hipertensao e insuficiencia renal e/ou cardiaca, e descrever a terapeutica adotada e os resultados obtidos.The Renal Arteriovenous Fistula (RAVF) is a rare and potentially reversible cause of hypertension and kidney and/or heart failure. The treatment of RAVF aims at preserving the most of the renal parenchyma and, concomitantly, eradicating the symptoms and hemodynamic effects caused by the RAVF. The present study reports three cases of RAVF, including one case of a de novo idiopathic RAVF, which presented with hypertension and kidney and/or heart failure and describes the therapeutic measures used to treat these patients as well as the outcomes.

Tres casos de hipertención y Fístula Arteriovenosa Renal: con una fístula de novo

Fistula Arteriovenosa Renal (FAVR) e uma causa rara e potencialmente reversivel de hipertensao e insuficiencia renal e/ou cardiaca. O tratamento da FAVR visa preservar o maximo de parenquima renal e, concomitantemente, erradicar os sintomas e efeitos hemodinâmicos decorrentes da FAVR. No presente estudo, serao relatados tres casos de FAVR, incluindo um caso de FAVR idiopatica de novo, que se apresentaram com hipertensao e insuficiencia renal e/ou cardiaca, e descrever a terapeutica adotada e os resultados obtidos.The Renal Arteriovenous Fistula (RAVF) is a rare and potentially reversible cause of hypertension and kidney and/or heart failure. The treatment of RAVF aims at preserving the most of the renal parenchyma and, concomitantly, eradicating the symptoms and hemodynamic effects caused by the RAVF. The present study reports three cases of RAVF, including one case of a de novo idiopathic RAVF, which presented with hypertension and kidney and/or heart failure and describes the therapeutic measures used to treat these patients as well as the outcomes.