Management of Fungal Peritonitis during Continuous Ambulatory Peritoneal Dialysis (CAPD)

A group of 138 patients (pts) on CAPD for a total of 1889 patientmonths had 176 episodes of peritonitis. Eighteen (13%) had fungal peritonitis at one to 20 months after beginning CAPD. The responsible organisms were Candida albicans (nine pts), Candida parapsilosis (five), Candida torulopsis (three), and Trichosporum capitatum (one). These infections were treated by various combinations of antifungal agents using two different strategies: Removal of the Tenckhoff catheter and interruption of CAPD for 10 to 14 days in nine pts (Group A), and continuous peritoneal lavage for four to six days in the remainder -nine pts (Group B). Fourteen of the 18 were cured (seven of nine in each group). In group A, two patients died, one continues on CAPD while the other six (67%) were transferred to hemodialysis because they developed peritoneal adhesions with significant loss in peritoneal space. In group B, only two patients have been transferred to hemodialysis; the other seven continue on CAPD. In our experience, the preferred initial form of treatment is continuous peritoneal lavage in conjunction with antifungal therapy. Catheter removal should be reserved for those who fail to respond to this treatment.

Continuous ambulatory peritoneal dialysis (CAPD) is now accepted as a alternative treatment for end-stage renal disease. However, despite continuous progress in this field, peritonitis still remains a major complication and results in increased morbidity and cost. Although pathogenic fungi account for only 2 7% of peritonitis in patients on CAPD (1–3), the illness is severe and represents a major clinical challenge to these patients. In addition, the therapy of fungal peritonitis is still controversial, especially with regard to the need for removal of the catheter.

This paper presents a retrospective study and describes our experience during the past four years with the management of fungal peritonitis in 18 patients undergoing CAPD at our center.

Frequent COL4 mutations in familial microhematuria accompanied by later-onset Alport nephropathy due to focal segmental glomerulosclerosis

Familial microscopic hematuria (FMH) is associated with a genetically heterogeneous group of conditions including the collagen-IV nephropathies, the heritable C3/CFHR5 nephropathy and the glomerulopathy with fibronectin deposits. The clinical course varies widely, ranging from isolated benign familial hematuria to end-stage renal disease (ESRD) later in life. We investigated 24 families using next generation sequencing (NGS) for 5 genes: COL4A3, COL4A4, COL4A5, CFHR5 and FN1. In 17 families (71%), we found 15 pathogenic mutations in COL4A3/A4/A5, 9 of them novel. In 5 families patients inherited classical AS with hemizygous X-linked COL4A5 mutations. Even more patients developed later-onset Alport-related nephropathy having inherited heterozygous COL4A3/A4 mutations that cause thin basement membranes. Amongst 62 heterozygous or hemizygous patients, 8 (13%) reached ESRD, while 25% of patients with heterozygous COL4A3/A4 mutations, aged >50-years, reached ESRD. In conclusion, COL4A mutations comprise a frequent cause of FMH. Heterozygous COL4A3/A4 mutations predispose to renal function impairment, supporting that thin basement membrane nephropathy is not always benign. The molecular diagnosis is essential for differentiating the X-linked from the autosomal recessive and dominant inheritance. Finally, NGS technology is established as the gold standard for the diagnosis of FMH and associated collagen-IV glomerulopathies, frequently averting the need for invasive renal biopsies.

A randomized controlled trial of exercise training on cardiovascular and autonomic function among renal transplant recipients

BACKGROUND

There are conflicting data regarding the effects of renal transplantation (RT) on uraemic autonomic dysfunction. Moreover, no study has examined the impact of physical training on the cardiac autonomic function in RT patients. Thus, we studied the effects of exercise training on heart rate variability (HRV) and arterial baroreflex sensitivity (BRS), which are sensitive markers of cardiac autonomic outflow, in RT recipients.

METHODS

Eleven patients (Exercise group-aged 52.1 ± 5.6 years) were studied before and after 6 months of exercise training. Twelve age- and sex- matched RT patients (Sedentary) and 12 healthy sedentary individuals (Healthy), who remained untrained, served as controls. At baseline and follow-up, all the subjects underwent cardiopulmonary exercise testing for the evaluation of peak oxygen consumption (VO2peak), a tilt test for the evaluation of BRS and baroreflex effectiveness index (BEI) and an ambulatory 24-h Holter monitoring for time- and frequency-domain measures of HRV.

RESULTS

In the exercise group, VO2peak increased by 15.8% (P < 0.05) and all depressed HRV and BRS indices were significantly improved after training. Specifically, the standard deviation of all normal-to-normal (NN) intervals (SDNN) significantly increased by 92.5%, the root-mean-square of the differences between consecutive NN intervals by 45.4%, the percentage value of NN50 count by 58.2%, the high-frequency by 74.8% and low-frequency spectral power by 41.6%, BRS by 43.7% and BEI by 57.3%. None of the variables studied was altered over time in either control group.

CONCLUSIONS

The increased cardiorespiratory fitness by exercise training was associated with an improved BRS function and a modification of the sympathovagal control of HRV towards a persistent increase in parasympathetic tone. These alterations may lead to a better cardiovascular prognosis in RT recipients.

P2X(7) receptor at the heart of disease

Purinergic signaling is a crucial component of disease whose pathophysiological basis is now well established. This review focuses on P2X(7), a unique bifunctional purinoreceptor that either opens a non selective cation channel or forms a large, cytolytic pore depending on agonist application and leading to membrane blebbing and to cell death either by necrosis or apoptosis.Activation of P2X(7) receptor has been shown to stimulate the release of multiple proinflammatory cytokines by activated macrophages, with the IL-1b to be the most extensively studied among them. These findings were verified by the use of knockout P2X(7) ((-/-)) mice.Update information coming from all fields of research implicate this receptor at the very heart of diseases such as rheumatoid arthritis, multiple sclerosis, depression, Alzheimer disease, and to kidney damage, in renal fibrosis and experimental nephritis.Clinical studies are currently underway with the newly developed selective antagonists for P2X(7) receptor, the results of which are eagerly anticipated. These studies together with data from in-vivo experiments with the P2X(7) knockout mice and in-vitro experiments will shed light in this exciting area.

Brain dead donor kidneys are immunologically active: is intervention justified?

The improvement in the field of kidney transplantation, during the last decades, has brought kindey transplantation to the top of patient preference as the best kidney replacement therapy. The use of marginal kidney grafts, which are highly immunogenic has become common practice because of lack of kidney donors. Inflammatory activity in the kidneys after brain death is an ongoing phenomenon. The inappropriate treatment of brain dead donor may result to primary non function (PNF) of the graft, delayed graft function (DGF) or to long term graft dysfunction and shortened graft survival. Therefore correct handling of the brain dead donor is of paramount importance. The impact of various pharmacologic agents (catecholamines, glucocorticoids, carbamylated recombinant human erythropoietin, recombinant soluble P-selectin glycoprotein ligant, heme oxygenase-1, carbon monoxide, and mycophenolate mofetil) on the immunogenicity of brain dead donor kidneys is discussed.

Renal fibrosis

Tubulointerstitial renal fibrosis, characterized as a progressive detrimental connective tissue deposition on the kidney parenchyma, appears to be a harmful process leading inevitably to renal function deterioration, independently of the primary renal disease which causes the original kidney injury. Epithelial to Mesenchymal Transition (EMT) of tubular epithelial cells which are transformed to mesenchymal fibroblasts migrating to adjacent interstitial parenchyma constitutes the principal mechanism of renal fibrosis along with local and circulating cells. Proteinuria as well as hypoxia is included among the main mechanisms of EMT stimulation. TGFbeta-1 through the SMAD pathway is considered as the main modulator regulating the EMT molecular mechanism, probably in cooperation with hypoxia inducible factors. Hepatocyte Growth Factor (HGF) and Bone Morphogenetic Factor-7 (BMF-7) are inhibitory to EMT molecules which could prevent in experimental and clinical level the catastrophic process of interstitial fibrosis. Interesting data emerge indicating that HGF and BMF-7 administration prevents the peritoneal fibrosis of mesothelial cells.

Outcomes of kidney transplantation in Greek and Albanian patients: a single centre experience

BACKGROUND AND AIM

It has been reported that racial and ethnic (genetic make up), as well as socioeconomic differences may affect the results of kidney transplantation. Socioeconomic factors are quite difficult to differentiate from genetic factors. It is not surprising that a group with poorer access to health care, less private insurance and less income does less well with serious medical problems. The aim of this study was to compare the outcomes of kidney transplantations in Greek (G) and Albanian (A) patients.

PATIENTS AND METHODS

Twenty nine transplanted patients of Albanian ancestry were matched with 29 Greek patients retrospectively. Their mean age was 34 (G) and 31 (A) years, there were 21 men and 8 women in each group (G, A) and they received 26 kidneys from living related donors and 3 kidneys from cadaveric donors respectively. Arterial blood pressure (ABP), body weight (BW), serum creatinine, serum total protein and albumin, total cholesterol, HDL-cholesterol and triglycerides, 24 hour proteinuria were measured on 7th, 15th postoperative day, 1st , 3rd , 6th month and 1st year after transplant. BMI was calculated before and 1 year after transplantation and acute rejection episodes were recorded too. Methylprednizolone (MP), cyclosporine (CsA) dose /kg BW were calculated at baseline, 1, 3, 6, 12 months after transplant. Cumulative patient and graft survival at 1 and 5 years were calculated too.

RESULTS

Patient survival at 1 and 5 years was 100% / 93.1% and 100% /93.1% respectively (p: NS). Graft survival at 1 and 5 years was 100% / 93.10% and 93.75% / 86.45% respectively (p: NS). BW (but not BMI) and total cholesterol levels in Greek patients were higher compared to those of Albanian patients during the 1st post transplant year (p: 0.044 and p: 0.021 respectively). MP dose in A patients was higher during the first year (p: 0.05).

CONCLUSION

Patients and graft survival do not present difference between G and A patients. There is significant difference on cholesterol profile between G and A patients. A larger number of transplants are possibly needed to allow us to draw firm conclusions.

Cardio-renal anemia syndrome

The interaction between chronic heart failure, chronic kidney insufficiency and anemia, form a vicious cycle, termed as the cardio-renal anemia syndrome. The interaction between these three conditions causes deterioration of the cardiac and renal function and increases anemia. Each of the three can cause or be caused by the others.We herein analyze and speculate the mechanisms involved in the pathophysiology of this new syndrome highlighting the main points of interest that seem to expand upon more than one specialty. The cardio-renal anemia syndrome is emerging in the area of clinical investigation with progressively elevated significance. Additionaly we report the data related to anemia treatment as part of therapeutic perspective concerning the management of patients manifesting the profile of this syndrome.

Leptin as a cardiovascular risk factor

The role of leptin in humans is not yet precisely established. Nevertheless there is increasing evidence revealing that this molecule is involved in the pathogenesis of atherosclerosis as an independent risk factor. From another point of view, however, leptin is already related to known traditional risk factors for accelerated atherogenesis, like obesity. We herein provide the experimental and clinical data concerning the association between leptin and atherosclerotic disease. Vascular stiffness and calcification, immune response regulation, fibrinolysis, and oxidative stress, are the main fields to be investigated in relation to leptin in the present study. Additionally the description of the main characteristics of leptin and its receptors is included in the introduction of this article, whereas in the end the main clinical data suggesting that this molecule represents an interesting risk factor for atherosclerotic disease are provided.

Rhabdomyolysis updated

Rhabdomyolysis constitutes a common cause of acute renal failure and presents paramount interest. A large variety of causes with different pathogenetic mechanisms can involve skeletal muscles resulting in rhabdomyolysis with or without acute renal failure. Crush syndrome, one of the most common causes of rhabdomyolysis presents increased clinical interest, particularly in areas often involved by earthquakes, such as Greece and Turkey. Drug abusers are another sensitive group of young patients prone to rhabdomyolysis, which attracts the clinical interest of a variety of medical specialties. We herein review the evidence extracted from updated literature concerning the data related to pathogenetic mechanisms and pathophysiology as well as the management of this interesting syndrome.

Interventional nephrology: a new subspecialty of nephrology

Interventional Nephrology is a new and emerging subspecialty of Nephrology that mainly deals with ultrasonography of kidneys and ultrasound-guided renal biopsy, insertion of peritoneal dialysis catheters, tunneled dialysis catheters as a vascular access for patients undergoing hemodialysis as well as percutaneous endovascular procedures performed to manage dysfunction of arteriovenous fistulas or grafts in end stage renal disease patients. Traditionally, these procedures have been delegated to a variety of specialists with resultant delays in diagnosis and initiation of therapy. To avoid the delays nephrologists have taken the initiative to perform these procedures themselves. Indeed, recent data have emphasized that nephrologists can safely and successfully perform these procedures with excellent results. The success of nephrologist's role in Interventional Nephrology insures the ideal management of renal patients with effectiveness, safety and lower cost for Public Health System. Certainly nephrologists must have adequate training and develop the necessary skills in the new fields as a prerequisite for the success of the concept.

Antihypertensive agents and renal transplantation

Advances in the field of kidney transplantation have led to a significant increase in the life of renal allograft with 1-year graft survival rates of 93% to 99%. This increase in early graft survival has made it possible to observe the long-term morbidities that accompany renal transplantation. Studies correlating the reduction of arterial blood pressure with patient and graft survival as well as the risk of cardiovascular disease do not exist. The recommendations come from the general population and from comparative studies of hypertensive and normotensive kidney graft recipients. It is known that in the general population hypertension is a risk factor for chronic kidney disease but at the same time a risk factor for death, ischaemic heart disease, chronic heart failure and left ventricular hypertrophy. We must always have in mind that there are many similarities between a kidney graft recipient and a patient with chronic kidney disease. Renal transplant recipients represent a patient population with a very high risk for development of cardiovascular disease which has been identified as the leading cause of death in these patients. Of 18,482 deaths among renal allograft recipients, 38% had functioning renal allografts. Successful renal transplantation (Rt) can result in partial regression of left ventricular hypertrophy (LVH) if it is associated with hypertension (HTN) remission or if HTN is controlled by medications. Frequently post transplant HTN is associated with failure of LVH to regress. Transplant clinicians must choose antihypertensive agents that will provide their patients with maximum benefit from renal allograft and cardiovascular perspective. The target must always be long term patient and graft survival and acceptable quality of life. The antihypertensive drugs usually used after kidney transplantation are diuretics, calcium channel blockers, angiotensin converting enzyme inhibitors, angiotensin II receptor blockers and beta-blockers. Most emphasis is given lately to ACEIs/ARBs and beta-blockers because of their cardioprotecive effect.

Quality of life survey and palliative care in lung cancer patients

Aim. In patients with advanced and/or inoperable bronchial tumors, methods of palliative care such as radiotherapy, chemotherapy, brachytherapy and cryotherapy, singly and/or in combination, aiming at extending the survival time and improving the quality of life, were examined. Methods. One hundred and sixty three (163) patients, with mean age 67.9 yrs (range 22-25) and a male/female ratio at 1.34/1, treated between 2000-2004 were studied. Eighty one (81) patients receiving only cryotherapy presented a two-year survival rate at 19.3%, whilst eighty three (83) patients treated with radiotherapy or brachytherapy and/or chemotherapy showed a two-year survival rate at 25%. Sixty-five percent (65%) of patients only cryotreated had improvement in at least one or more Karnofsky and WHO indices. Results. Eighty percent (80%) of patients who received cryotherapy accompanied with supplementary palliative treatment showed amelioration of their clinical status. Conclusion. It seems that for patients with advanced or inoperable lung tumors, cryotherapy associated with additional palliative care may influence the survival time and improve their quality of life.

Combined treatment of hypercholesterolemia of renal transplant allograft recipients with fluvastatin and gemfibrozil

The aim of this study was to investigate the safety and efficacy of combined treatment with fluvastatin (F) and gemfibrozil (G) in hypercholesterolemic renal transplant recipients (RTR). Ten hypercholesterolemic (total cholesterol [TC] > 220 mg/dl) RTR (7 men) with mean age 44 years (range 25-56 years) who remained hypercholesterolemic after 3 months of treatment (period A) with fluvastatin (40 mg/d) continued taking the same dose of F plus G (600 mg/dl) for another 3-month period (B). Serum total cholesterol, high density lipoprotein cholesterol (HDL-C), LDL cholesterol (LDL-C), triglyceride, serum creatinine (creatinine phosphokinase (CPK), serum glutamic-oxaloacetic transaminase (SGOT), and serum glutamate pyruvate transaminase (SGPT) were measured before treatment and at the end of periods A and B. Mean TC levels were 360.30 +/- 62.42 mg/dl, 324.10 +/- 100.53 mg/dl, 270.80 +/- 67.77 mg/dl; mean LDL-C levels were 259.33 +/- 71.43 mg/dl, 219.60 +/- 81.31 mg/dl, 189.70 +/- 65.51 mg/dl; mean HDL-C levels were 37.10 +/- 11.68 mg/dl, 39.80 +/- 13.21 mg/dl, 41.00 +/- 12.94 mg/dl; mean triglyceride levels were 354.60 +/- 183.29 mg/dl, 349.30 +/- 242.94 mg/dl, 207.00 +/- 85.35 mg/dl before treatment and at the end of periods A and B, respectively. There was a statistically significant fall of serum TC (P = 0.002), LDL-C (P = 0.016), and triglyceride (P = 0.029) levels at the end of periods A and B. Kidney and liver function did not change. F and G combined treatment is safe and useful in patients who do not respond satisfactorily to monotherapy with F. Gemfibrozil augments the effect of F on TC, LDL-C, and triglyceride levels.