Pier Luigi Bedani

Destructive spondyloarthropathy and radiographic follow-up in hemodialysis patients

Nine patients undergoing regular dialytic treatment for more than 60 months showed clinical and radiologic features of a noninfective and destructive spondyloarthropathy. The cervical spine was most affected (100%), followed by the dorsal (three patients, 33.3%) and the lumbar spine (two patients, 22.2%). Typically, radiographs and CT scans revealed narrowing of intervertebral spaces, with destruction or sclerosis of the subchondral bone of the vertebral plate.Autopsy was performed on three patients; histologic study demonstrated the presence of large amyloid deposits containing β2-microglobulin (β2-m) in the discs and peridiscal ligaments.A radiographic follow-up of the cervical spine was performed in seven patients after a period of 12 months and showed that the bone destruction in DSA is very rapid and progressive. The lower biocompatibility of the cuprophan membranes of dialyzers is probably the factor most responsible for hyperproduction of β2-m and subsequently osteoarticular deposition of a new type of amyloidosis.

Benign nodular calcification and calciphylaxis in a haemodialysed patient

Several types of soft tissue calcification can be detected from radiographic evaluation of patients with end‐stage renal failure. The factors that predispose to such calcification include an increase in CaxP product in serum, the degree of secondary hyperparathyroidism, the level of blood magnesium, the degree of alkalosis, and the presence of local tissue injury. Three major varieties include calcification of medium‐sized arteries, periarticular or tumoral calcification and visceral calcification. Calciphylaxis is a phenomenon consisting of acute ischemic necrosis in presence of calcification of dermohypodermic arterioles. It occurs mostly in chronic renal failure patients with secondary or tertiary hyperparathyroidism with a persistently elevated calcium‐phosphorus product. There are few options in treating calciphylaxis and the outcome is generally poor. The authors report the case of a haemodialised patient with benign nodular calcification and calciphylaxis. The coexistence of both entities in the same patient has never been described.

Erythropoietin and Cardiocirculatory Condition in Aged Patients with Chronic Rena l Failure

Background/Aim: The clearest benefit of recombinant human erythropoietin (rHuEPO) in end-stage renal disease is a substantial reduction in transfusion dependency and an improved quality of life. In this report, we describe the efficacy of weekly subcutaneous administration of rHuEPO in 11 elderly patients with anemia secondary to chronic renal failure. Methods: The role of rHuEPO therapy in increasing the patient’s quality of life and in decreasing the hospitalization rates secondary to cardiac morbidity was verified in 11 elderly patients (age range between 66 and 85 years) with anemia due to chronic renal failure. The mean hemoglobin level at the beginning of the study was 8.2 ± (SD) 0.7 g/dl, and the serum creatinine concentration was 4.8 ± 1.36 mg/dl. The patients underwent baseline and annual echocardiography, in addition to an electrocardiogram. Results: Most patients experienced a partial regression of left ventricular hypertrophy, and no congestive heart failure was documented. The mean hemoglobin level during rHuEPO therapy increased to 11.3 ± 1.2 g/dl, while the mean serum creatinine concentration did not change significantly. Conclusions: Our results confirm that early anemia correction in aged chronic renal failure patients permits improvement of the quality of life, of exercise performance, and of cognitive functions. Reduced transfusion need and regression of left ventricular hypertrophy favor a minor incidence of cardiac morbidity and contribute to reduce health costs.

Acute Rhabdomyolysis and Hemoglobin Reduction after Bezafibrate Overdose in Hyperlipidemic Patients on Hemodialysis

Dr. Pier Luigi Bedani, Division of Nephrology, S. Anna Hospital, Corso Giovecca 203, I-44100 Ferrara (Italy) Dear Sir, Many patients with chronic renal failure (CRF) develop hyperlipidemia. Frequently, to correct this abnormality some form of pharmacological intervention is necessary. In clinical trials bezafibrate was administered to hyperlipidemic patients with CRF [1] or in regular dialytic treatment (RDT) [2]. Severe adverse reactions were reported infrequently but in some patients suffering from CRF [3] bezafibrate therapy induced rhabdomyolysis. We present 2 cases of bezafibrate overdose complicated with rhabdomyolysis and acute hemoglobin reduction in patients on RDT. Case 1: A 63-year-old man on RDT for 5 months owing to diabetic nephropathy was treated with bezafibrate at the dosage of 400 mg every second day. Four weeks later he experienced diffuse muscle weakness and nocturnal cramps. Laboratory studies showed a slight increase in serum creatine phosphokinase (CPK) and lactic dehydroge-nase (LDH) with a small reduction in Hb concentration (from 8.1 to 7.4 g/dl). Because of the persistence of hypertriglyceridemia, we recommended that the patient continue the bezafibrate therapy with a more appropriate dosage (i.e. 200 mg every third day). The erroneous understanding of our prescription made the patient carry on with the same dosage of the drug. After a further 4 weeks he experienced aching of his muscles, which gradually worsened, leading to generalized weakness and severe fatigue in walking. The most significant laboratory data are shown in figure 1. There was also a light increase of serum and urine concentrations of myoglobin without reduction of daily diuresis. The drug

Periosteal new bone in uraemic osteodystrophy

Out of 54 patients requiring haemodialysis approximately one quarter were found to have periosteal new bone associated with severe renal osteodystrophy. This feature has been analysed and correlated with biochemical, clinical, and histological parameters. No direct correlation was found with the duration of haemodialysis, but there is a good correlation with histological indices of osteitis fibrosa and serum parathormone levels. Periosteal new bone regressed or totally disappeared in eight patients after parathyroidectomy and renal transplantation. It is suggested that periosteal new bone may be a useful indicator of hyperparathyroidism in this type of patient.

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.

Effectiveness of subcutaneous low-dose erythropoietin in patients with chronic renal failure despite functional iron deficiency.

Dr. Pier Luigi Bedani, Division of Nephrology, S. Anna Hospital, I-44 100 Ferrara (Italy) Dear Sir, There are many causes of decreased responsiveness to erythropoietin (EPO) in patients with chronic renal failure. The commonest is insufficient iron to meet the demands of increased erythrocyte production [1]· However, there are patients who respond to EPO with a rapid increment of haemoglobin despite the lowest ferritin levels [2]. We report on 4 patients with anaemia due to chronic renal failure, who responded favourably to weekly subcutaneous low-dose EPO despite functional iron deficiency. The patients (4 females; mean age: 47 ± 21 years; serum basal creatinine ranged between 476 and 724 μmol/l) participated in a study made in various hospitals assessing the effect of EPO on anaemia due to progressive renal failure. Inclusion criteria for the study were a minimum age of 18 years irrespective of sex, a serum creatinine level between 200 and 800 μmol/l and serum haemoglobin concentration of less than 90 g/l. After 2 weeks of prophylactic oral iron supplementation (40 mg/day of elemental iron), all patients were treated with EPO (Eprex, Cilag) 100 U/ kg/week by the subcutaneous route. The target haemoglobin concentration for this study was set at 110 g/l, and after having arrived at this level the EPO dose was adjusted to maintain it at a stable value. Before treatment, all but 1 patient had normal serum ferritin concentrations (54, 61, 55 and 8 ng/ml, respectively; normal range 15-300 ng/ml), while calculated percentage saturation of Transferrin saturation Ferritin Haemoglobin Fig. 1. Behaviour of serum ferritin levels, percentage of transferrin saturation and haemoglobin concentrations in 4 patients treated over 24 weeks with EPO.

Acute Hypoparathyroidism after Percutaneous Fine-Needle Ethanol Injection (PFNEI) in a Patient on Haemodialysis

Dr. Pier Luigi Bedani, Division of Nephrology, S. Anna Hospital, Corso Giovecca 203, I-44100 Ferrara (Italy) Dear Sir, Percutaneous fine-needle ethanol injection (PFNEI) is a valid procedure for the treatment of secondary hyperparathyroidism (sHPT) in uraemic patients undergoing chronic dialysis, particularly when parathyroid hyperactivity recurs after subtotal para-thyroidectomy (PTX) [13]. The side-effects of PFNEI are limited (remitting local pain, transient dysphonia, light parathyroid swelling owing to oedema or haematoma) and usually do not promote acute changes in serum calcium and phosphorus concentrations, because the correction of sHPT is slow and progressive [2, 3]. We report a case of acute hypoparathyroidism after PFNEI of an enlarged parathyroid gland in a haemodialyzed patient who had been previously submitted to subtotal PTX. Case Report A 38-year-old woman on RDT for 35 months because of chronic glomerulonephri-tis had been submitted to PTX for severe sHPT. Histological study had confirmed the removal of three parathyroid glands, i.e. the two apical and the lower left. The day after the operation, the patient had a transient light hypocalcaemia favourably corrected by oral calcium and calcitriol administration. A few months later, the patient experienced muscu-loskeletal pains, symptoms of polyneuropa-thy, persistent hyperphosphataemia, which could not be corrected by overdoses of aluminium-containing phosphate binders, and very elevated serum alkaline phosphatase (1,280 U/l; reference interval 99-310 U/l). Fig. 1. Acute changes in the serum PTH (•), calcium (Ca, ¤), phosphorus (P, ■) and alkaline phosphatase (ALP, O) after the second percutaneous ethanol injection. Sonographic study of the anterior region of the neck showed an enlarged gland on the right basal side. An ultrasonically guided fine-needle aspiration biopsy was performed, but histological study indicated, erroneously, the presence of thyroid tissue. Some months later, with persisting bone pain and intractable pruritus, due to hyperphosphataemia (7.5-8.2 mg/dl, 2.5-2.7 mmol/l; reference intervals 2-5 mg/ dl, 0.7-1.7 mmol/l) and elevated Ca × P product (75-80 mg/dl), the patient underwent an MNR of the neck which showed the presence ofa lower right enlarged parathyroid gland. A further fine-needle aspiration biopsy was performed. The cytological examination confirmed

Favorable Effects of Prostacyclin Infusion in a Patient Given a Renal Transplant and with Severe Vascular Disease Secondary to Diabetes—A Case Report

Microangiopathy is one of the most frequent diseases in diabetic patients. A diabetic man with a kidney transplant and with severe and progressive vasculo pathy with early necrosis of the fingers and toes was submitted to three prosta cyclin (PGI2) intravenous infusions (5 ng/kg/min for forty-eight hours) during a period of two months. Three months after the last infusion, radiographs of the hands and feet showed a marked reduction in the extent of the vascular calcifi cations and healing of the ischemic-necrotic areas. The authors discuss the im mediate and later effects of PGI2 infusion in a case of diabetic vascular disease.

Effect of Ciclosporin on Triglyceridemia in Long-Term Renal Transplant Recipients

Accessible online at: http://BioMedNet.com/karger Dear Sir, Hyperlipidemia is one of the most frequent complications in renal transplant recipients (RTR) [1]. Immunosuppressive treatment with corticosteroids and ciclosporin A (CS-A) and impairment of the renal function represent the pivotal etiological factors [1, 2]. The data presented in the literature mostly show short-term posttransplant hyperlipidemia. In this study, we evaluated the differences in the lipid profile of two groups of RTR in relation to immunosuppressive therapy several years after transplantation. Twenty-eight RTR (mean age 52.8 B 7.8, range 36–65 years) were examined. Eligibility criteria were: (1) a time interval since transplantation of at least 100 months, and (2) serum creatinine values ^1.9 mg/dl. On the basis of immunosuppressive therapy, the patients were classified into two groups, homogeneous in number, age, and clearance of creatinine. The first group (mean age 54 B 6.4 years) was treated with corticosteroids and azathioprine; the second group (mean age 51.7 B 9.1 years) received corticosteroids, azathioprine, and CS-A. Both groups were submitted to ultrasonographic scanning of the right and left common carotid artery, the carotid bifurcation and the internal and external carotid. A specific score was applied to classify the results. All patients were on a free diet, did not receive antilipidemic drugs for at least 3 months, and were not affected by hypertension. Statistical analysis was performed using the Wilcoxon test for unpaired data. In spite of a shorter time since transplant, the CS-A group showed significantly higher serum triglyceride concentrations (p ! 0.05, table 1). There were no significant differences in renal function, body mass index and high-density, low-density, and total cholesterolemia, even if the total cholesterol content was high in both groups. Echo color Doppler showed atherosclerotic alterations with a similar score in both groups. Our study brings a further contribution to discussion on etiopathogenetic factors of