Valentina Consiglio

Pregnancy in dialysis patients: is the evidence strong enough to lead us to change our counseling policy?

BACKGROUND AND OBJECTIVESnAlthough successful pregnancy is rare, results attained with higher dialysis efficiency and the spread of dialysis to different cultural and religious settings are changing the panorama. In this study, we systematically review the recent literature (2000 through 2008) on pregnancy in dialysis.nnnDESIGN, SETTING, PARTICIPANTS, & MEASUREMENTSnMedline on OVID was searched in November 2008, with MESH and free terms on pregnancy and chronic kidney disease or dialysis; limits were human subjects and English-language articles. Case reports were excluded to minimize publication bias. The final selection and extraction of data were performed in duplicate.nnnRESULTSnFrom 2840 references, 241 full-text articles were retrieved; eight fulfilled the selection criteria, and two were added from reference lists. In the 10 studies (nine of 10 monocentric), 90 pregnancies were observed in 78 patients (range of cases five to 15). The studies were heterogeneous for definition of outcomes, duration (2 to 16 yr), period (1988 through 1998 to 2000 through 2006), age (25 to 35 yr), and support and dialysis therapy. Daily dialysis was frequently used; type of treatment, membranes, and flows varied widely. Hypertension and anemia were frequent concerns for the mothers. Intrauterine deaths, hydramnios, and small-for-gestational-age or preterm infants were frequent. The possibility of a healthy offspring ranged from 50 to 100% (overall 76.25%).nnnCONCLUSIONSnEvidence on pregnancy in dialysis is heterogeneous; however, the growing number of reports worldwide and the improving results suggest that we should reconsider our counseling policy, which only rarely includes pregnancy in dialysis patients.

Positron emission tomography as a tool for the ‘tailored’ management of retroperitoneal fibrosis: a nephro-urological experience

BACKGROUNDnRetroperitoneal fibrosis (RF) is a complex clinical entity characterized by a fibro-inflammatory reaction around the abdominal aorta and iliac arteries extended into the retroperitoneum. No biochemical marker correlates with the disease severity and progression, and imaging data fail to discriminate between fibrotic and florid lesions. Positron emission tomography (PET) was recently suggested as a promising tool to detect the disease.nnnMETHODSnWe report on seven consecutive cases of RF managed by tailoring therapeutic interventions to the metabolic activity detected by PET. In 2006-09, seven patients with RF (five new diagnoses) were referred to the same nephro-urological facility. There were six males and one female aged 41-79. RF was associated with autoimmune diseases in three patients, with an aortic aneurysm in another three, and was idiopathic in one. The diagnoses were made by imaging techniques [computed tomography (CT) or nuclear magnetic resonance (NMR)]; PET scan was performed in all patients in the same setting at referral and during follow-up.nnnRESULTSnPatients were followed up with tailored interventions (medical therapy: tamoxifen, steroids, and immunosuppressors according to disease activity, side effects and tolerance). Six patients needed ureteral stenting for obstruction. PET imaging was used as a guide for the tapering of immunosuppressors and for stent removal. In this way, stents were safely removed when a negativization of disease activity was revealed by PET. Only one relapse was recorded over 163 months of follow-up (median 24 months) detected in time by PET.nnnCONCLUSIONnPET is a promising tool for surveillance of disease activity and for planning the removal of ureteral stents in RF.

Positron emission tomography: a precious tool in the challenge of the infected cysts in ADPKD

A 68-year-old woman, affected by autosomal dominant polycystic liver and kidney disease (ADPKD), seeks nephrological attention for persistent low-grade fever, with vague abdominal discomfort. She reports a recent gastroenteritis episode, followed by a lower urinary tract infection (Escherichia coli), treated by amoxicillin clavulanate on the basis of the antibiogram. Afterwards, she developed a severe cutaneous allergy, which she linked to amoxicillin clavulanate. On account of the persistence of a low-grade fever, she self-prescribed different antibiotics, without complete clinical remission. n nAt referral, the patient is pale and normotensive with diffuse abdominal tenderness. Her main blood tests are as follows: WBC 9330/mm3, serum creatinine 0.9 mg/dL, GFR 65 mL/min, C-reactive protein 2.38 mg/dL (normal <0.8), ESR 21 mm/h, Hb 10.3 g/dL, serum albumin 2.9 g/dL and 6–8 WBC per high power field at urinalysis. Renal ultrasounds reveal enlarged liver and kidneys with large cysts (maximum 6 cm bilaterally). A complicated cyst, containing dense fluid material (caused by infection or bleeding), is located in the left kidney.

Home dialysis and the Internet: designing an e-learning platform via brainstorming sessions

BACKGROUNDnThe resurgence of home hemodialysis (HHD) underlines the importance of educational programs. Brainstorming is a powerful tool for innovation, widely employed in industry but seldom used in medicine. The aim of this study was to define an e-learning Web platform for HHD patients via a brainstorming approach.nnnMETHODSnFour brainstorming sessions were held 2-6 weeks apart. Twelve people were involved: 2 dialysis physicians, 2 nurses, 2 HHD patients, 2 caregivers, a filmmaker, 2 computer experts (1 with a psychology degree) and a senior engineer. Each session was summarized as the starting point for the following one. The topics discussed were the platform structure and its logo.nnnRESULTSnFor the platform, the following requirements were defined: teaching should be extensive and tailored to different levels of knowledge; all available teaching tools (tutorials, demonstrations, recorded and written materials) should be used; films enhance emotional participation and can be used to reduce fears; the contents should include general information on chronic kidney disease, details of all types of renal replacement therapy (RRT) (how and why), dialysis accidents, blood and imaging tests, laws and reimbursements, direct experiences and history of RRT. Remote monitoring and visual interactions are important for reassurance about HHD and should be provided. The requirements for the logo were that it be innovative, related to daily life, representative of a holistic approach and convey happiness. The logo Hom-e-hem was created, playing on the assonance between the religious term Om and the word home, with the e of electronic linking it with hem, short for hemodialysis.nnnCONCLUSIONnBrainstorming sessions can be used to design patient-tailored educational interventions. The key message, self-care is a bridge from illness back to life, may apply to a wider context.

Weight Loss in Advanced Chronic Kidney Disease: Should We Consider Individualised, Qualitative, ad Libitum Diets? A Narrative Review and Case Study

In advanced chronic kidney disease, obesity may bring a survival advantage, but many transplant centres demand weight loss before wait-listing for kidney graft. The case here described regards a 71-year-old man, with obesity-related glomerulopathy; referral data were: weight 110 kg, Body Mass Index (BMI) 37 kg/m2, serum creatinine (sCr) 5 mg/dL, estimated glomerular filtration rate (eGFR) 23 mL/min, blood urea nitrogen (BUN) 75 mg/dL, proteinuria 2.3 g/day. A moderately restricted, low-protein diet allowed reduction in BUN (45–55 mg/dL) and good metabolic and kidney function stability, with a weight increase of 6 kg. Therefore, he asked to be enrolled in a weight-loss program to be wait-listed (the two nearest transplant centres required a BMI below 30 or 35 kg/m2). Since previous low-calorie diets were not successful and he was against a surgical approach, we chose a qualitative, ad libitum coach-assisted diet, freely available in our unit. In the first phase, the diet is dissociated; he lost 16 kg in 2 months, without need for dialysis. In the second maintenance phase, in which foods are progressively combined, he lost 4 kg in 5 months, allowing wait-listing. Dialysis started one year later, and was followed by weight gain of about 5 kg. He resumed the maintenance diet, and his current body weight, 35 months after the start of the diet, is 94 kg, with a BMI of 31.7 kg/m2, without clinical or biochemical signs of malnutrition. This case suggests that our patients can benefit from the same options available to non-CKD (chronic kidney disease) individuals, provided that strict multidisciplinary surveillance is assured.

Selected Abstracts from the 35th Vicenza Course onAKI & CRRT, Vicenza, June 13-16, 2017: Abstracts

Purpose We analyzed the relationship between a positive fluid balance and its persistence over time on acute kidney injury (AKI) development, severity and resolution among ST elevation myocardial infarction (STEMI) patients complicated by cardiogenic shock. Methods We retrospectively studied the cumulative fluid balance intake and output at 96 h following hospital admission in 84 consecutive adult patients with STEMI complicated by cardiogenic shock. The cohort was stratified into two groups, based on the presence or absence of positive fluid balance on day 4. Patients’ records were assessed for the development of AKI, AKI severity and recovery. Results Patients having positive fluid balance were more likely to develop a more severe AKI stage (52% vs. 13%; p < 0.001), were less likely to have recovery of their renal function (29% vs. 75%, p = 0.001), and demonstrated positive correlation between the amount of fluid accumulated and the rise in serum creatinine (R = 0.42, p = 0.004). For every 1 l increase in positive fluid balance, the adjusted possibility for recovery of renal function decreased by 21% (OR = 0.796, 95% CI 0.67–0.93; p = 0.006). Conclusions A positive fluid balance was strongly associated with higher stage AKI and lower rate of AKI recovery in STEMI complicated by cardiogenic shock. Graphical abstract Figure. No Caption available. HighlightsPatients having positive fluid balance were more likely to develop a more severe renal injury.Patients having positive fluid balance were less likely to have recovery of their renal function.Positive correlation between the amount of fluid accumulated and the rise in serum creatinine

Metformin-Associated Lactic Acidosis Undergoing Renal Replacement Therapy in Intensive Care Units: A Five-Million Population-Based Study in the North-West of Italy

Background: Metformin-associated lactic acidosis (MALA) is a severe complication of drug administration with significant morbidity and mortality. So far no study in large population areas have examined the incidence, clinical profile and outcome of acute kidney injury (AKI)-MALA patients admitted in intensive care units (ICUs) and treated by renal replacement therapy (MALA-RRT). Methods: Retrospective analysis over a 6-year period (2010-2015) in Piedmont and Aosta Valley regions (5,305,940 inhabitants, 141,174 diabetics treated with metformin) of all MALA-RRT cases. Results: One hundred and seventeen cases of AKI-MALA-RRT were observed (12.04/100,000 metformin treated diabetics, 1.45% of all RRT-ICU patients). Survival rate was 78.3%. The average duration of RRT was 4.0 days at mean dialysis effluent of 977 mL/kg/day. At admission most patients were dehydrated, and experienced shock and oliguria. Conclusion: Our data showed that MALA-RRT is a common complication, needing more prevention. Adopted policy of early, extended, continuous and high efficiency dialysis could contribute to an observed high survival rate. Video Journal Club “Cappuccino with Claudio Ronco” at http://www.karger.com/?doi=471917.

Acute renal failure, severe sodium and potassium imbalance and sudden tetraplegia

Eating disorders with severe electrolyte abnormalities are serious diseases often encountered in the clinical practice [1]. Their association with chronic kidney disease has been defined as a prescription for disaster, thus underlining the mutual interactions between salt-losing interstitial nephropathies, most commonly encountered in this setting, and the combination of malnutrition and diuretic abuse [2]. There are several life-threatening complications of electrolyte imbalance, including cardiac arrhythmia and involvement of the peripheral and central nervous systems [1–5]. The presence of renal failure and of contracted vascular volume may enhance the risks and render the correction of the complex electrolyte alterations particularly difficult. Furthermore, the differential diagnosis of the complications may be difficult and the clinical nephrologist should be aware of the main features of the life-threatening neurological diseases, as exemplified by the present case [6–9].