Onofrio Schillaci

Hepatitis C virus core antigen test in monitoring of dialysis patients.

Hepatitis C virus infection is a persistent worldwide public health concern. The prevalence of HCV infection is much higher in patients on chronic haemodialysis (HD) than in the general population. HCV infection can detrimentally affect patients throughout the spectrum of chronic kidney disease. Despite the control of blood products, hepatitis C virus transmission is still being observed among patients undergoing dialysis. Detection systems for serum HCV antibodies are insensitive in the acute phase because of the long serological window. Direct detection of HCV depends on PCR test but this test is not suitable for routine screening. Recent studies have highlighted the importance of HCV core antigen detection as an alternative to PCR. Few studies exist about the efficacy of HCV core antigen test in dialysis population. We studied the utility of HCV core antigen test in routine monitoring of virological status of dialysis patients. We screened 92 patients on long-term dialysis both by PCR HCV-RNA and HCV core antigen test. The sensitivity of HCVcAg test was 90%, the specificity 100%, the positive predictive power 100%, the negative predictive power 97%, and the accuracy 97%. We think serological detection of HCV core antigen may be an alternative to NAT techniques for routine monitoring of patients on chronic dialysis.

Incidence of hepatitis C virus infection in patients with chronic kidney disease on conservative therapy

Hepatitis C virus (HCV) infection is a never-ending public health problem. Many studies have investigated the incidence of HCV infection among dialysis patients, but there have only been a few epidemiological studies in renal conservative therapy. We studied 320 subjects with pre-dialysis chronic kidney disease living in Sicily, Italy. The incidence of HCV infection was 6.25%. In Europe, incidence ranges from 0.2% to 3.5%. It appears that the incidence of HCV infection is higher in the studied patient population than in the population as a whole.

Acute kidney injury associated with metformin.

designed to record the most relevant details of each handoff patients care. Its method of use promotes interactiveness while incorporating critical details for each patients disposition and care. The incoming physician serves as a scribe on the form while the patient is presented. Empty boxes (easily visualized) prompt a query to complete the data set, ensuring that vital details are always discussed and addressed during handoff. During the pilot phase of this investigation, all EM residents at our institution were asked to use this form after a brief 5-minute training session. These forms were used at 2 urban training sites with an annual census of more than 200,000. There were no exclusions. The residents were subsequently surveyed to gauge its efficacy 1 month after availability. The survey asked 6 questions: their level of residency training, their intent to use this method of handoff after residency, their estimate of effectiveness regarding the potential to reduce medical error, frequency of use, difficulty of use, and whether they believed it improved the care of patients changed over in the ED. A total of 54 (96%) of 56 EM residents responded to the survey. Among those who responded, only 2 had not used the form. Of those that responded and used the form, 69% believed that it was effective in reducing medical error in changeover, whereas 60% believed that this method improved the care of patients changed over in the ED. The majority (80%) found it either easy or very easy to use, whereas only 2% (1 respondent) found it difficult. Fifty-two percent intend to use this tool after completion of residency. In summary, our residents believed that this method improved ED handoff in a positive way. Specifically, they felt that the changeover form is effective in reducing medical error while improving patient care. They also found this form easy to use and portable to their practice beyond residency. We plan on continuing to study the impact of this intervention in a prospective randomized trial comparing relevant patient outcomes. Further exploration into factors such as reduction in reported errors, ED and hospital length of stay, and ED recidivism rates could be studied to help confirm clinical correlation with perceived benefits. Although this method was only implemented at our training institution, it can be easily translated to any ED setting. Its simplicity in design, cost-effectiveness, and ease of use facilitate its application to other centers. It is our belief that this method should be considered for use in any ED without an established effective method of handoff.

The urokinase lock-therapy for hemodialysis occluded central venous catheters.

From October 2000 until September 2014, we used the following protocol of CVC declotting through urokinase lock-therapy: we filled each lumen of CVC with 10,000 UI of urokinase + 1,000 UI of sodium heparin (total volume 2 ml); after 30 min this solution was drawn off. According to protocol we performed this instillation 5 times (at 0, 30, 60, 90 and 120 min); after 30 min the last dose was drawn off. We then started the HD treatment. We treated 94 patients with thrombosis-related malfunction of CVC; catheter function was restored in 90% of patients with no side effects, during the observed period. Hemodialysis treatment was performed immediately after urokinase therapy with blood speed >150 ml/min in all patients. We did not practice the ‘pushprotocol’ to avoid the systemic administration of the drug. To avoid the systemic anticoagulation in uremic patients, who are often found with hemorrhagic pathology, we filled each lumen of CVC with urokiDear Editor, The recent trend among an increasing number of patients is the use of Central Venous Catheters (CVC) to perform hemodialysis (HD) [1] . The thrombosis-related malfunction of CVC is a frequent event with a significant impact on both the patient and the Nephrology Departments. The malfunction of the CVC is directly proportional to the time of existence and the vessel wall-related rheological factors [2] . Thrombolytic drugs are commonly used as a first-line treatment for clotted hemodialysis catheters. No thrombolytic agent has so far been specifically indicated for the management of occluded hemodialysis catheters. The reported efficacy of urokinase for restoring patency of occluded hemodialysis catheters has ranged from 14 to 100% [3] . The review of recent literature shows that declotting can be done with ‘high-dose’ or ‘low-dose’ lock urokinase therapy, but no consensus exists on the adequate dose to obtain thrombolysis [4–6] . Received: October 17, 2014 Accepted after revision: February 13, 2015 Published online: March 19, 2015

Comment on "Haemodialysis using high cut-off dialysers for treating acute renal failure in multiple myeloma"

We read with interest the article of Dr. Martín-Reyes et al. We agree with the motivation of their study: 1. the survival of the patients suffering from Multiple Myeloma (MM) depend on whether or not they recover renal function, not only due to the complications derived from the renal failure itself, but also from the reduced possibility of access to more effective treatments; . the importance of rapid reduction of free light chains blood levels in order to facilitate the recovery of renal function. We wish to report our experience in this topic In April 2011 a 43-year-old man, with a previously normal renal function, was admitted to our hospital for severe acute renal failure (ARF) of an unknown cause. The review of the clinical history didn’t revealed any previous disease. For 2 months he was suffering from lumbar pain. We started haemodialysis treatment three times a week. Laboratory investigations and bone marrow biopsy detected a lambda IgG MM. We performed kidney biopsy and we observed glomerular deposition of lambda chains, without histological signs of chronic renal damage, and a negative Congo red stain test. In 2 weeks the patient received 10 haemodialysis (HD) treatment with high cut-off (HCO) dialyzer (Theralite, Gambro Henchingen, Germany). We performed on alternating days HCO HD sessions with standard monitors; they lasted for 5 hours, involved a blood flow of 300ml/min and had an ultrapure dialysate flow rate of 500ml/min. Sodium Reviparine (Clivarina) was applied at 2400 IU in single dose priming. The values of Platelets (60.000/mmc) motivated the prescription on the duration of HCO HD and on the dose of heparin. At the end of each session we didn’t administer albumin. Ultrafiltration was programmed according to the clinical need. Before and after each session, mean free light chain levels were measured in terms of mg/l using nephelometry (N latex test, Siemens) Initially λ FLC concentration was 5500mg/L. At the end of HCO dialyzer HD end of HCO dialyzer HD cycle, the concentration was 94.80mg/L. The concentrations and ratios of light chain levels from the start to the end of treatment are summarised in Table 1.

The Prevalence of Hepatitis B Virus Infection in a Population on Long-Term Hemodialysis

Dear Editor, Although the prevalence and incidence rates among hemodialysis (HD) patients in developed countries have declined over the last 3 decades, Hepatitis B virus (HBV) infection remains a major issue in the HD setting [1]. The isolated finding of HBcAb in HBsAg-negative subjects is considered an indication of past exposure to HBV and resolved infection, but the use of sensitive techniques to detect HBV-DNA has shown that low levels of viremia are detectable in HBsAg-negative/HBcAb-positive subjects. Today, vaccination programs offer the promise of eliminating HBV infection from developed areas, but emigration from countries of the world where HBV is highly prevalent will result in HBsAg-negative patients with past exposure to HBV, with the likelihood of them developing ESRD and entering the dialysis pool. We investigated the prevalence of HBV infection in HD patients by analyzing the HBV serological markers of 322 HD patients from January 2016 to June 2017 in Palermo Italy. Among the 322 screened patients, we found 6 were HBsAg-positive (1.8%); among these patients, 2 had coinfection with HCV and 1 with HIV; 2 patients were migrant from Africa; all HBsAg-positive patients had history of transfusion but not of illicit drugs abuse. Among the remaining 316 HBsAg-negative patients, we found that 56 were HBcAb-positive (18%) and 59 were HBsAbpositive (19%) patients; 32 patients (10%) had mixed HbsAb/HBcAb-positivity; no positive case of IgM-HBcAb-, HBeAg-, or HBeAb-positive was detected; 311 patients were Caucasian; 3 patients had migrated from Africa and 2 patients had migrated from Bangladesh. All serological markers of the HBsAg-negative patients are summarized in Table 1. Despite the decline of HBV infection worldwide in the general population, the most recent reports show a persistent presence of HBV in HD setting. Data from Regional Italian Registries on HBsAg-positivity in HD patients range from 0.6 to 2.2% [2]. In the general population, HBcAb is a long-life serological marker of previous HBV infection and it is found in persons with chronic infection as well as in those who recover from infection. In Italy, the prevalence of HBsAgnegative/HBcAb-positive subjects among first-time blood donors ranges from 4.85 to 8.3% [3–4]. In clinical practice, the presence of HBcAb in HBsAg-negative/ HBsAb-negative subjects is considered an important key for occult HBV infection Table 1. Serological HBV-HCV-HIV markers in 316 Sicilian HBsAg-negative hemodialysis patients

Haemodiafiltration with ultrafiltrate regeneration in the removal of free light chains in multiple myeloma and acute kidney injury

enal function is frequently impaired in plasma cell yscrasias. In patients suffering from multiple myieloma MM), the acute kidney injury (AKI) is a serious prognostic actor. The nephrologists are interested in the fast reduction f free light chains (FLC) blood levels through extracorporeal reatments in order to facilitate the recovery of renal funcion, to offer more effective chemotherapy and to improve enal and patient outcomes. Extended haemodialysis with igh-molecular weight cut-off (HCO) membranes are effective n the removal of FLC but they have high cost and produce substantial loss of albumin.1 Recent studies reported the ffectiveness of haemodiafiltration with ultrafiltrate regenration in the reduction of FLC in MM with renal failure.2–4 he haemodiafiltration with ultrafiltrate regeneration by dsorption in resin and endogenous reinfusion (HFR) is an xtracorporeal clearance technique that combines convecion, adsorption and diffusion without albumin removal. We eport our experience. We studied the effects of HFR on

The efficacy and safety of Sofosbuvir/Ledipasvir therapy in patients on long-term hemodialysis with hepatitis C virus infection

© 2018 Indian Journal of Nephrology | Published by Wolters Kluwer Medknow Sir, The Hepatitis C virus (HCV) infection is a serious health problem in hemodialysis (HD) patients worldwide. Among these patients, the prognosis of patients with HCV‐infection is significantly worse than in patients without HCV infection; the survival of renal allograft is also worsened in HCV‐infected than in non HCV‐infected patients.[1] The Kidney Disease Improvement Global Outcome guidelines recommend anti‐HCV therapy for HD patients with HCV infection on renal transplant waiting list.[2] The treatment of HCV‐ infection has progressed markedly over the last two decades, but HCV‐infected patients on long‐term HD rarely receive antiviral treatment because of adverse events of interferon (IFN)‐based therapy. Although some studies highlight the effectiveness of more recent IFN‐free anti‐HCV therapy in patients with end‐stage renal disease (ESRD), without relevant adverse events, there are limited data on the experience with new direct‐acting antiviral drugs in patients on long‐term HD.[3] Since 2014, in the European Union, Sofosbuvir (SOF) 400 mg/Ledipasvir (LDV) 90 mg (Harvoni®) is licensed for chronic HCV infection therapy. Approximately 80% of SOF is excreted by kidneys, whereas 15% is excreted in feces. Biliary excretion is the major route of elimination of unchanged LDV with renal excretion being a minor pathway (approximately 1%). Concerns have been raised because of the higher concentrations of SOF and its metabolites in patients with ESRD on dialysis as compared with patients with normal renal function. According to the latest EASL Guidelines (September 2016), no dose adjustment of SOF/LDV is required for patients with mild or moderate renal impairment (estimated glomerular filtration rate [GFR] >30 ml/min/1.73 m2), and a full‐dose SOF is recommended in patients with stage 5 chronic kidney disease CKD on dialysis; however, the safety has not been assessed in patients with stage 4 or 5 CKD not on dialysis.[4] In the experience of Saxena et al., a progressive deterioration of renal function and renal symptoms was reported in patients with eGFR ≤45 ml/min/1.73 m2 receiving an SOF‐based regimen, although efficacy was comparable to that observed in patients without renal impairment.[5] We report our experience in a patient on long‐term HD with HCV infection. A 58‐year‐old male, born in Sicily (Southern Italy), was receiving HD. From 1989, he had been suffering from chronic kidney disease due to congenital renal hypoplasia. He was infected with HCV of genotype 1b. Blood transfusions, carried out before 1990 (beginning of the routine screening for HCV in Italy), were probably the transmission source of HCV‐infection. He had not received IFN‐based therapy. The Efficacy and Safety of Sofosbuvir/Ledipasvir Therapy in Patients on Long-term Hemodialysis with Hepatitis C Virus Infection Letters to Editor

Comment on "Prevalence of Occult Hepatitis B Virus Infection in Hemodialysis Patients in Isfahan, Iran"

© 2017 Advanced Biomedical Research | Published by Wolters Kluwer Medknow Sir, We read with attention the article of Kalantari et al. titled, “Prevalence of occult hepatitis B virus infection in hemodialysis patients in Isfahan, Iran.”[1] We agree the need for a careful surveillance of hepatitis B virus (HBV) infection in hemodialysis (HD) patients because the extracorporeal blood circulation predisposes the patients undergoing HD to nosocomial transmission of blood-borne viruses. These patients are at a high risk of exposure to HBV within HD units, with a wide variation in endemicity between the countries and the immunodefi cient state associated with end-stage renal disease that can increase the susceptibility to infection. We would like to report our experience on occult HBV infection in patients on long-term HD in Palermo, Italy. According to the European Centre for Disease Prevention and Control, Italy is an area of low endemicity.[2] In January 2017, we performed the routinary monitoring of HIV, HBV, and hepatitis C virus (HCV) serology in 48 patients undergoing chronic HD. All patients were hepatitis B surface antigen negative, 2 HIV positive, and 2 HCV positive. No patient previously received the HBV vaccination. Regarding the HBV serology, we found thirty hepatitis B surface antibody (HbsAb)/hepatitis B core antibody (HBcAb) negative, nine HBsAb positive, one HBcAb po sitive, and eight patients with HBsAb + HBcAb positivity. Among the 48 HD patients, we assessed HBV DNA. All patients were negative for HBV DNA. In addition, in our experience, the prevalence of occult HBV infection in HD patients was 0%.

Malposition of the Central Venous Catheter in the Hemiazygos Vein.

DOPPS I (1996–1999) and DOPPS III (2005–2007). CVC misplacement, defined as any catheter position outside the superior vena cava (SVC), may be associated with catheter insertion [2–4] . We report a teaching case with a rare complication associated with the insertion of a temporary CVC for HD. A 48-year-old man for 2 years on longterm HD was admitted to the hospital for thrombosis of artero-venous fistula. A tunnelled double-lumen CVC to achieve emergency vascular access for HD was inserted through the right internal jugular vein without imaging guidance. The procedure was performed without any signifDear Editor, The central venous catheter (CVC) is widely used to achieve vascular access for the hemodialysis (HD) treatment. The Dialysis Outcomes and Practice Patterns Study (DOPPS) study indicates that 25% of HD patients in the United States, 41% in Belgium and 28% in the United Kingdom are dialyzed with catheters [1] . The temporary insertion of CVCs is increasing in patients on long-term HD and several complications (pneumothorax, hemothorax, arrhythmia) have been described both during its placement and in its maintenance in these subjects. Despite these risks, the catheter use increased twoto threefold in Italy, Germany, France and Spain between Received: April 19, 2016 Accepted: May 17, 2016 Published online: June 10, 2016