Ugo Rotolo

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.

Renal Involvement in Psychological Eating Disorders

Psychological eating disorders – anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder – are an increasing public health problem with severe clinical manifestations: hypothermia, hypotension, electrolyte imbalance, endocrine disorders and kidney failure; they are of interest to nephrologists, but pathophysiological mechanisms in determining the renal involvement are still unclear. We describe pathophysiology, histological features and clinical manifestations of the most frequent psychological eating disorders: AN and BN. Regarding AN, we analyze the recent literature, and identify 3 principal pathways towards renal involvement: chronic dehydration-hypokalemia, nephrocalcinosis and chronic rhabdomyolysis. Regarding BN, we describe the correlation between obesity and many proinflammatory cytokines, chemokines, growth factors and adipokines, having potential metabolic and hemodynamic effects on the kidney and an important role in the pathogenesis of obesity-related renal injury, independently of hypertension and diabetes.

Renal amyloidosis due to hyper-IgD syndrome

865 Nefrologia 2012;32(6):836-66 amination showed normal findings and no symptoms suggestive of respiratory, abdominal or urinary infection were apparent. Chest radiography and abdominal ultrasonography scan revealed no abnormalities. Laboratory investigations showed proteinuria 9.17g/day, a M. Carmen Ruiz-Fuentes, Agustina Rubert-Gómez De Quero, Carmen De Gracia-Guindo, Pilar Galindo-Sacristán, Antonio Osuna-Ortega Unidad de Nefrología. Hospital Universitario Virgen de las Nieves. Granada. Correspondencia: M. Carmen Ruiz Fuentes Unidad de Nefrología. Hospital Universitario Virgen de las Nieves. Avda. Fuerzas Armadas, 2. 18012 Granada. mamenruizfuentes@telefonica.net

Renal thrombotic microangiopathy induced by β-interferon

Sir, We read with interest the recent case report ‘Minimal change disease with interferon-β therapy for relapsing remitting multiple sclerosis’ [1]. In this paper, the authors include renal thrombotic microangiopathy (TMA) among rare side effects of interferon (IFN) therapy, more frequently described with IFN-α [2]. We report here our experience about this topic. A 36-year-old white female with a 3-year history of multiple sclerosis and normal blood pressure and renal function was admitted for acute renal failure and pulmonary oedema. Three months previously, she started subcutaneous IFN-β-1a treatment of 22 μg thrice weekly. On admission, physical examination showed high blood pressure and severe pleuropericarditis without neurological or dermatological findings. Laboratory tests revealed microangiopathic haemolytic anaemia. Other immunological and microbiological laboratory tests were unremarkable. A renal biopsy disclosed signs of TMA; among 43 glomeruli, light microscopy revealed focal ischaemic signs and mild mesangial cell proliferation; vessel narrowing with thrombi and thickening of arteriolar walls and intimal onion skin-like swelling; light interstitial lymphomonocytic infiltration and focal tubular atrophy. Immunofluorescence showed mesangial IgM, C1q and fibrinogen staining. A diagnosis of haemolytic–uraemic syndrome was made. She was treated with transfusions, haemodialysis, plasma exchange and methylprednisolone i.v. followed by oral prednisone. Her cardiac function improved, and haematological signs progressively disappeared, but renal function did not recover. IFN-β treatment was discontinued. She is now receiving peritoneal dialysis treatment. IFN-α is known to cause a variety of renal lesions, including TMA [3,4], but to our knowledge, our observation is the first report of TMA induced by INF-β. Editorial note: This letter had been sent to Aravindan A. et al., but we did not receive a response. Conflict of interest statement. None declared.

Spontaneous kidney rupture in a patient on chronic hemodialysis

■■ Non-traumatic spontaneous rupture of the kidney in subjects on chronic hemodialysis is a rare event. In most cases it is associated with acquired cystic kidney disease (ACKD) [1] or the presence of kidney cancer. [2] There are few reports on this topic. Until 2009 Goto identified in the Japanese literature only five reports of renal cell carcinoma in patients with end-stage renal disease (ESRD) manifesting with spontaneous rupture. [3] In the general population primary neoplasms of the renal pelvis are uncommon and most are malignant. The majority of these cases consist of transitional cell carcinoma. Squamous cell carcinoma (SCC) and adenocarcinoma (AC) of the renal pelvis are highly uncommon tumors and constitute less than 1% of upper urinary tract neoplasms. [4] SCC and AC are known to be associated with chronic renal calculi and infection. The incidence of coexisting urinary stone disease varies from 18% in the United States to 100% in Hong Kong. [5,6] The

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.

Does Systematic Preliminar Colour Doppler Study Reduce Kidney Biopsy Complication Incidence

While ultrasonography is widely performed prior to biopsy, colour Doppler examination is often used only to discover post-biopsy complications. Aim of this paper was to evaluate the usefulness of colour Doppler examination in planning the optimal site of puncture for renal biopsy. Present analysis includes 561 consecutive percutaneous renal biopsies performed from the same operator. Until August 2000 332 biopsies were performed after a preliminary ultrasonography (Group A). From September 2000, 229 patients underwent even a preliminary colour Doppler study (Group B). Postbioptic bleeding were categorized as minor (gross hematuria or subcapsular perinephric hematoma < 4 cmq of greater diameter) or major (hematoma >4 cmq of greater diameter; requiring blood transfusion or invasive procedures; leading to acute renal failure, urine tract obstruction, septicaemia, or death). Major complications were seen in 2.1% in Group A while in Group B only one case was reported (0.43%). Minor clinically significant complications occur in 7.8% in Group A and in 3.4% of cases of Group B. Colour Doppler reduced drastically the incidence of complications observed before the introduction of routine colour Doppler examination prior to biopsy. In our opinion, these data support the use of preliminary colour Doppler study when a biopsy is planned.

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