Yuri Battaglia

Progression of coronary artery calcification and cardiac events in patients with chronic renal disease not receiving dialysis

We tested for the presence of coronary calcifications in patients with chronic renal disease not on dialysis and studied its progression in 181 consecutive non-dialyzed patients who were followed for a median of 745 days. Coronary calcifications (calcium score) were tallied in Agatston units by computed tomography, and the patients were stratified into two groups by their baseline calcium score (100 U or less and over 100 U). Survival was measured by baseline calcium score and its progression. Cardiac death and myocardial infarction occurred in 29 patients and were significantly more frequent in those patients with calcium scores over 100 U (hazard ratio of 4.11). With a calcium score of 100 U or less, the hazard ratio for cardiac events was 0.41 and 3.26 in patients with absent and accelerated progression, respectively. Thus, in non-dialyzed patients, the extent of coronary calcifications was associated to cardiac events, and progression was an independent predictive factor of cardiac events mainly in less calcified patients. Hence, assessment of coronary calcifications and progression might be useful for earlier management of risk factors and guiding decisions for prevention of cardiac events in this patient population.

Clinical Significance of FGF-23 in Patients with CKD

FGF23 is a bone-derived hormone that plays an important role in the regulation of phosphate and 1,25-dihydroxy vitamin D metabolism. FGF23 principally acts in the kidney to induce urinary phosphate excretion and suppress 1,25-dihydroxyvitamin D synthesis in the presence of FGF receptor 1 (FGFR1) and its coreceptor Klotho. In patients with chronic kidney disease (CKD), circulating FGF23 levels are progressively increased to compensate for persistent phosphate retention, but this results in reduced renal production of 1,25-dihydroxyvitamin D and leads to hypersecretion of parathyroid hormone. Furthermore, FGF23 is associated with vascular dysfunction, atherosclerosis, and left ventricular hypertrophy. This paper summarizes the role of FGF23 in the pathogenesis of mineral, bone, and cadiovascular disorders in CKD.

Correction: Interaction of healthcare staff’s attitude with barriers to physical activity in hemodialysis patients: A quantitative assessment

Background and aim of the study In hemodialysis patients, sedentarism is a potentially modifiable mortality risk factor. We explored whether healthcare staff’s attitude towards exercise interacts with patient-perceived barriers in modifying the level of physical activity in this population. Methods In this prospective, cross-sectional, multicenter study we recruited 608 adult patients and 330 members of the healthcare staff in 16 hemodialysis units in Italy. We assessed patient-perceived barriers to, and healthcare staff’s attitude towards, exercise by specific questionnaires. We fitted multilevel linear models to analyze the relationships of either barriers or staff’s attitude, and their interaction, with a measure of patient self-reported physical activity (the Human Activity Profile–Adjusted Activity Score [HAP-AAS]), adjusting for multiple confounders. We also employed latent class analysis to dichotomize patients into those endorsing or not endorsing barriers. Results Most barriers were negatively associated with the HAP-AAS (adjusted change attributable to a given barrier ranging between -5.1 [“Feeling too old”, 95% Confidence Interval: -9.4 to -0.8] and -15.6 [“Ulcers on legs and feet”, 95%CI: -24.8 to -6.5]. We found a significant interaction between staff’s attitude and barriers (adjusted P values ranging between 0.03 [“I do not believe that it is physician’s or nurse’s role providing advice on exercise to patients on dialysis”] and 0.001 [“I do not often ask patients about exercise”]). A beneficial effect of a proactive staff’s attitude was evident only in patients not endorsing barriers. Conclusions Barriers and non-proactive staff’s attitude reduce physical activity in hemodialysis patients. Patients not endorsing barriers benefit the most from a proactive staff’s attitude.

Tenofovir and kidney transplantation: case report

Background: Hepatitis B viral infection (HBV) has been regarded as a contraindication for kidney transplantation because of the high risk of viral activation induced by immunosuppressive therapy. Anti-retroviral drugs have changed the prognosis of patients with hepatitis B viral infection (HBV+) who are candidates for renal transplant; indeed, therapy with antiretroviral drugs may ensure lower rates of morbidity and mortality compared to traditional therapies. Entecavir is the first-line antiviral therapy recommended for the treatment of HBV+ kidney-transplanted patients. In case of resistance to entecavir, tenofovir may be an alternative drug, either alone or in combination with entecavir. However, the best strategy of treatment is still unknown. In this case-report, a HBV+ kidney-transplanted patient who presented resistance to entecavir was initially treated by associating tenofovir to entecavir and with tenofovir alone afterward. This strategy induced complete remission of viral replication. Case presentation: In a HBV+ kidney-transplanted patient under monotherapy with entecavir, HBV flare (HBV DNA > 170.000 × 103 UI/mL, HBeAg+, HbeAb–) occurred 9 months after transplantation; at that time, blood chemistry highlighted: creatinine 1.46 mg/dL, blood urea 65 mg/dL, e-GFR 50 mL/min, proteinuria 300 mg/24 h, calciuria 2,12 mmol/24 h, phosphaturia 0.56 g/24 h, vitamin D 11.5 ng/mL, PTH 130 pg/mL, calcemia 2.3 mmol/L, and phosphoremia 2 mg/dL. Liver elastometry (FibroScan) showed moderate fibrosis. Tenofovir was associated to entecavir. Three months after the combination therapy, reduction in HBV DNA replication (351 × 103 UI/mL) was obtained. Creatinine and e-GFR were 1.48 mg/dL and 52 mL/min, respectively. At this point, entecavir was discontinued. After 13 months of tenofovir monotherapy, complete remission of viral replication was achieved but renal function deteriorated and proteinuria increased. Conclusion: This case-report indicates that tenofovir is effective in reducing viral replication of hepatitis B virus in a kidney-transplanted patient who presented resistance to previous treatment with entecavir. However, it should be taken into account that tenofovir could affect renal function.

Pseudoxantoma elasticum with kidney calcifications: a case report

Pseudoxantoma elasticum (PXE) is an autosomal recessive disease caused by mutations in the ABCC6 gene. It is characterized by elastic fiber mineralization and fragmentation of connective tissue mostly within the dermis of the skin, Bruchs membrane of the retina, and the mid layers of the arterial blood vessels. Rarely, multiple calcifications have also been reported in PXE patients’ kidneys. We here report the case of a 40-year-old man who came to our observation for microhematuria, proteinuria, and multiple calcifications in the kidneys detected by ultrasound examination, in the absence of PXE skin lesions. Fundoscopic examination was positive for angioid streaks, and the genetic test confirmed ABCC6 mutation. Fundoscopy can thus be useful for excluding the diagnosis of PXE in patients with isolated multiple calcifications of the kidneys.

Peritoneal dialysis: a look at the future

Several factors may be responsible for the insufficient diffusion of peritoneal dialysis (PD) in Italy, including the lack of cultural understanding, organizational problems, and inappropriate health policies. Therefore, different approaches have been proposed to face these issues leading to a wider use of this technique. Among these strategies we think that a key role should be played by the promotion of educational initiatives mostly addressed to young nephrologists. At the same time, development of new technologies, such as domotics and web-based applications, might help to make PD more acceptable and suitable for both patients and physicians. These are some of the most important challenges to promote PD growth in the future.

Onset of systemic lupus erythematous complicated by severe multiorgan involvement

The authors report the case of a 51-year-old man with a 1-month history of mild gastroenteritic symptoms, daily fever and malaise. The patient was febrile (38.5°C) and laboratory data showed renal failure (creatinine 2.5 mg/dL), proteinuria and hemoglobinuria. A 10-day antibiotic therapy was started since an infective gastrointestinal process was initially suspected. When autoimmune immunologic patterns, associated with renal, neurologic and hematologic signs, confirmed the diagnosis of systemic lupus erythematous the patient was infused with high-dose intravenous corticosteroids. Despite the treatment, the patient developed rhabdomyolysis, acute pancreatitis, worsening of renal function (creatinine 5.5 mg/dL) to oliguria, and marked cognitive impairment. Our case focuses on the importance of an early recognition of laboratory and anamnestic data that may suggest a systemic autoimmune involvement, so as to rapidly undertake an aggressive immunosuppressive therapy.

World Kidney Day “do-it-yourself”

Since more than 5 years, the World Kidney Day (WKD) is held in Italy in March. It represents an important event to stimulate kidney disease prevention among the population. We asked dr. Luca Apicella, a young nephrologist, to tell us about his experience organizing, for the first time, the WKD in his hometown, Salerno. In his report, Dr. Apicella outlines the main steps followed to organize the event and the difficulties that he faced in the preceding months. His account results in a practical checklist to be adopted by every young nephrologist who wishes to follow his example and successfully organize the WKD in his/her area.

Extracapillary glomerulonephritis overlaid on primary amyloidosis AL: case report

Amyloidosis is a disease characterized by the deposition of extracellular protein called amyloid. There are two types of amiloidosis: primary AL and secondary AA. Renal involvement is frequent and it occasionally presents as renal failure progressive sustained by extracapillary glomerulonephritis. The rare cases reported in the literature are related to amyloidosis secondary to rheumatoid arthritis. We report case of a 46 year old woman, smoker with autoimmune hypothyroidism, came to our observation for nephrotic syndrome, hypertension, anemia, acute renal failure. Renal biopsy showed extracapillary glomerulonephritis overlaid on primary amyloidosis AL. Despite the early start of drug therapy, the patient died after about six months.