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Hitz P, Pagnamenta A, Pertusini L, Terrot T, Franzosi Y, Bassi J, Silacci-Fregni C, Gaia V, Martinetti G, Keller F, Berwert L, Ogna VF, Lavorato-Hadjeres S, Giunzioni D, D'Ermo A, Valnegri A, Ferrari P, Corti D, Ceschi A, Cippà P, Piccoli L, Giannini O. Prevalence of SARS-CoV-2 infection and impact of vaccination in dialysis patients over two years of the pandemic. J Nephrol 2023; 36:2665-2667. [PMID: 37702913 PMCID: PMC10703959 DOI: 10.1007/s40620-023-01754-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 07/31/2023] [Indexed: 09/14/2023]
Affiliation(s)
- Paolo Hitz
- Faculty of Biomedical Sciences, Università della Svizzera italiana, 6900, Lugano, Switzerland
| | - Alberto Pagnamenta
- Clinical Trial Unit, Ente Ospedaliero Cantonale, 6900, Lugano, Switzerland
- Department of Intensive Care, Ente Ospedaliero Cantonale, 6900, Lugano, Switzerland
- Division of Pneumology, University Hospital of Geneva, 1200, Geneva, Switzerland
| | - Laura Pertusini
- Division of Nephrology, Ente Ospedaliero Cantonale, 6900, Lugano, Switzerland
| | - Tatiana Terrot
- Clinical Trial Unit, Ente Ospedaliero Cantonale, 6900, Lugano, Switzerland
| | - Yves Franzosi
- Clinical Trial Unit, Ente Ospedaliero Cantonale, 6900, Lugano, Switzerland
| | - Jessica Bassi
- Humabs Biomed SA, a subsidiary of Vir Biotechnology, 6500, Bellinzona, Switzerland
| | | | - Valeria Gaia
- Department of Laboratory Medicine, Ente Ospedaliero Cantonale, 6500, Bellinzona, Switzerland
| | - Gladys Martinetti
- Department of Laboratory Medicine, Ente Ospedaliero Cantonale, 6500, Bellinzona, Switzerland
| | - Franco Keller
- Department of Laboratory Medicine, Ente Ospedaliero Cantonale, 6500, Bellinzona, Switzerland
| | - Lorenzo Berwert
- Division of Nephrology, Ente Ospedaliero Cantonale, 6900, Lugano, Switzerland
- Department of Medicine, Ente Ospedaliero Cantonale, 6500, Bellinzona, Switzerland
| | - Valentina Forni Ogna
- Faculty of Biomedical Sciences, Università della Svizzera italiana, 6900, Lugano, Switzerland
- Division of Nephrology, Ente Ospedaliero Cantonale, 6900, Lugano, Switzerland
| | | | - Davide Giunzioni
- Division of Nephrology, Ente Ospedaliero Cantonale, 6900, Lugano, Switzerland
| | - Andrea D'Ermo
- Process Organization and Information Service, Ente Ospedaliero Cantonale, 6500, Bellinzona, Switzerland
| | - Alan Valnegri
- Process Organization and Information Service, Ente Ospedaliero Cantonale, 6500, Bellinzona, Switzerland
| | - Paolo Ferrari
- Faculty of Biomedical Sciences, Università della Svizzera italiana, 6900, Lugano, Switzerland
- Department of Medicine, Ente Ospedaliero Cantonale, 6500, Bellinzona, Switzerland
- Clinical School, University of New South Wales, Sydney, 2052, Australia
| | - Davide Corti
- Humabs Biomed SA, a subsidiary of Vir Biotechnology, 6500, Bellinzona, Switzerland
| | - Alessandro Ceschi
- Faculty of Biomedical Sciences, Università della Svizzera italiana, 6900, Lugano, Switzerland
- Clinical Trial Unit, Ente Ospedaliero Cantonale, 6900, Lugano, Switzerland
- Division of Clinical Pharmacology and Toxicology, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, 6900, Lugano, Switzerland
- Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, 8091, Zurich, Switzerland
| | - Pietro Cippà
- Faculty of Biomedical Sciences, Università della Svizzera italiana, 6900, Lugano, Switzerland
- Division of Nephrology, Ente Ospedaliero Cantonale, 6900, Lugano, Switzerland
- Department of Medicine, Ente Ospedaliero Cantonale, 6500, Bellinzona, Switzerland
| | - Luca Piccoli
- Humabs Biomed SA, a subsidiary of Vir Biotechnology, 6500, Bellinzona, Switzerland
| | - Olivier Giannini
- Faculty of Biomedical Sciences, Università della Svizzera italiana, 6900, Lugano, Switzerland.
- Department of Medicine, Ente Ospedaliero Cantonale, 6500, Bellinzona, Switzerland.
- Ospedale Regionale di Mendrisio, Via Turconi 23, CH-6850, Mendrisio, Switzerland.
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Bassi J, Giannini O, Silacci-Fregni C, Pertusini L, Hitz P, Terrot T, Franzosi Y, Muoio F, Saliba C, Meury M, Dellota EA, Dillen JR, Hernandez P, Czudnochowski N, Cameroni E, Beria N, Ventresca M, Badellino A, Lavorato-Hadjeres S, Lecchi E, Bonora T, Mattiolo M, Trinci G, Garzoni D, Bonforte G, Forni-Ogna V, Giunzioni D, Berwert L, Gupta RK, Ferrari P, Ceschi A, Cippà P, Corti D, Lanzavecchia A, Piccoli L. Poor neutralization and rapid decay of antibodies to SARS-CoV-2 variants in vaccinated dialysis patients. PLoS One 2022; 17:e0263328. [PMID: 35143540 PMCID: PMC8830698 DOI: 10.1371/journal.pone.0263328] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 01/14/2022] [Indexed: 12/11/2022] Open
Abstract
Patients on dialysis are at risk of severe course of SARS-CoV-2 infection. Understanding the neutralizing activity and coverage of SARS-CoV-2 variants of vaccine-elicited antibodies is required to guide prophylactic and therapeutic COVID-19 interventions in this frail population. By analyzing plasma samples from 130 hemodialysis and 13 peritoneal dialysis patients after two doses of BNT162b2 or mRNA-1273 vaccines, we found that 35% of the patients had low-level or undetectable IgG antibodies to SARS-CoV-2 Spike (S). Neutralizing antibodies against the vaccine-matched SARS-CoV-2 and Delta variant were low or undetectable in 49% and 77% of patients, respectively, and were further reduced against other emerging variants. The fraction of non-responding patients was higher in SARS-CoV-2-naïve hemodialysis patients immunized with BNT162b2 (66%) than those immunized with mRNA-1273 (23%). The reduced neutralizing activity correlated with low antibody avidity. Patients followed up to 7 months after vaccination showed a rapid decay of the antibody response with an average 21- and 10-fold reduction of neutralizing antibodies to vaccine-matched SARS-CoV-2 and Delta variant, which increased the fraction of non-responders to 84% and 90%, respectively. These data indicate that dialysis patients should be prioritized for additional vaccination boosts. Nevertheless, their antibody response to SARS-CoV-2 must be continuously monitored to adopt the best prophylactic and therapeutic strategy.
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Affiliation(s)
- Jessica Bassi
- Humabs BioMed SA, A Subsidiary of Vir Biotechnology, Bellinzona, Switzerland
| | - Olivier Giannini
- Faculty of Biomedical Sciences, Università della Svizzera italiana, Lugano, Switzerland
- Department of Medicine, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | | | - Laura Pertusini
- Division of Nephrology, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Paolo Hitz
- Faculty of Biomedical Sciences, Università della Svizzera italiana, Lugano, Switzerland
| | - Tatiana Terrot
- Clinical Trial Unit, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Yves Franzosi
- Clinical Trial Unit, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Francesco Muoio
- Humabs BioMed SA, A Subsidiary of Vir Biotechnology, Bellinzona, Switzerland
| | - Christian Saliba
- Humabs BioMed SA, A Subsidiary of Vir Biotechnology, Bellinzona, Switzerland
| | - Marcel Meury
- Vir Biotechnology, San Francisco, California, United States of America
| | | | - Josh R. Dillen
- Vir Biotechnology, San Francisco, California, United States of America
| | - Patrick Hernandez
- Vir Biotechnology, San Francisco, California, United States of America
| | | | - Elisabetta Cameroni
- Humabs BioMed SA, A Subsidiary of Vir Biotechnology, Bellinzona, Switzerland
| | - Nicola Beria
- Division of Nephrology, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | | | - Alberto Badellino
- Division of Nephrology, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | | | - Elisabetta Lecchi
- Division of Nephrology, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Tecla Bonora
- Division of Nephrology, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Matteo Mattiolo
- Division of Nephrology, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Guido Trinci
- Division of Nephrology, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Daniela Garzoni
- Division of Nephrology, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Giuseppe Bonforte
- Division of Nephrology, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | | | - Davide Giunzioni
- Division of Nephrology, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Lorenzo Berwert
- Division of Nephrology, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Ravindra K. Gupta
- Cambridge Institute of Therapeutic Immunology & Infectious Disease (CITIID), Cambridge, United Kingdom
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Paolo Ferrari
- Faculty of Biomedical Sciences, Università della Svizzera italiana, Lugano, Switzerland
- Division of Nephrology, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Clinical School, University of New South Wales, Sydney, Australia
| | - Alessandro Ceschi
- Faculty of Biomedical Sciences, Università della Svizzera italiana, Lugano, Switzerland
- Clinical Trial Unit, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Division of Clinical Pharmacology and Toxicology, Institute of Pharmacological Science of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, Zurich, Switzerland
| | - Pietro Cippà
- Department of Medicine, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
- Division of Nephrology, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | - Davide Corti
- Humabs BioMed SA, A Subsidiary of Vir Biotechnology, Bellinzona, Switzerland
| | | | - Luca Piccoli
- Humabs BioMed SA, A Subsidiary of Vir Biotechnology, Bellinzona, Switzerland
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Zemp DD, Giannini O, Quadri P, Tettamanti M, Berwert L, Lavorato S, Pianca S, Solcà C, de Bruin ED. A Pilot Observational Study Assessing Long-Term Changes in Clinical Parameters, Functional Capacity and Fall Risk of Patients With Chronic Renal Disease Scheduled for Hemodialysis. Front Med (Lausanne) 2022; 9:682198. [PMID: 35186984 PMCID: PMC8854975 DOI: 10.3389/fmed.2022.682198] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 01/05/2022] [Indexed: 12/19/2022] Open
Abstract
BackgroundPatients with end-stage renal disease are known to be particularly frail, and the cause is still widely seen as being directly related to specific factors in renal replacement therapy. However, a closer examination of the transitional phase from predialysis to long-term hemodialysis leads to controversial explanations, considering that the frailty process is already well-described in the early stages of renal insufficiency. This study aims to describe longitudinally and multifactorially changes in the period extending from the decision to start the replacement therapy through to the end of 2 years of hemodialysis. We hypothesized that frailty is pre-existent in the predialysis phase and does not worsen with the beginning of the replacement therapy. Between 2015 and 2018 we recruited 25 patients (72.3 ± 5.7 years old) in a predialysis program, with the expectation that replacement therapy would begin within the coming few months.MethodsThe patients underwent a baseline visit before starting hemodialysis, with 4 follow-up visits in the first 2 years of treatment. Health status, physical performance, cognitive functioning, hematology parameters, and adverse events were monitored during the study period.ResultsAt baseline, our sample had a high variability with patients ranging from extremely frail to very fit. In the 14 participants that did not drop out of the study, out of 32 clinical and functional measures, a statistically significant worsening was only observed in the Short Physical Performance Battery (SPPB) score (p < 0.01, F = 8.50) and the number of comorbidities (p = 0.01, F = 3.94). A careful analysis, however, reveals a quite stable situation in the first year of replacement therapy, for both frail and fit participants and a deterioration in the second year that in frail participants could lead to death.ConclusionOur results should stimulate a reassessment about the role of a predialysis program in reducing complications during the transitional phase, but also about frailty prevention programs once hemodialysis has begun, for both frail and fit patients, to maintain satisfactory health status.
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Affiliation(s)
- Damiano D. Zemp
- Department of Health Sciences and Technology, Institute of Human Movement Sciences and Sport, ETH Zurich, Zurich, Switzerland
- Service of Geriatrics, EOC, Ospedale Regionale di Mendrisio EOC, Mendrisio, Switzerland
| | - Olivier Giannini
- Department of Medicine, EOC, Bellinzona, Switzerland
- Division of Nephrology, EOC, Lugano, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera italiana, Lugano, Switzerland
| | - Pierluigi Quadri
- Service of Geriatrics, EOC, Ospedale Regionale di Mendrisio EOC, Mendrisio, Switzerland
- Department of Medicine, EOC, Bellinzona, Switzerland
| | - Mauro Tettamanti
- Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy
| | - Lorenzo Berwert
- Department of Medicine, EOC, Bellinzona, Switzerland
- Division of Nephrology, EOC, Lugano, Switzerland
| | | | | | - Curzio Solcà
- Service of Nephrology, Centro Dialisi Nefrocure e Clinica Luganese Moncucco, Lugano, Switzerland
| | - Eling D. de Bruin
- Department of Health Sciences and Technology, Institute of Human Movement Sciences and Sport, ETH Zurich, Zurich, Switzerland
- Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden
- Department of Health, OST - Eastern Swiss University of Applied Sciences, St. Gallen, Switzerland
- *Correspondence: Eling D. de Bruin
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Bassi J, Giannini O, Silacci-Fregni C, Pertusini L, Hitz P, Terrot T, Franzosi Y, Muoio F, Saliba C, Meury M, Dellota EA, Dillen JR, Hernandez P, Czudnochowski N, Cameroni E, Beria N, Ventresca M, Badellino A, Lavorato-Hadjeres S, Lecchi E, Bonora T, Mattiolo M, Trinci G, Garzoni D, Bonforte G, Forni-Ogna V, Giunzioni D, Berwert L, Gupta RK, Ferrari P, Ceschi A, Cippà P, Corti D, Lanzavecchia A, Piccoli L. Poor neutralization and rapid decay of antibodies to SARS-CoV-2 variants in vaccinated dialysis patients. PLoS One 2022. [PMID: 35143540 DOI: 10.1101/2021.10.05.21264054v2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2023] Open
Abstract
Patients on dialysis are at risk of severe course of SARS-CoV-2 infection. Understanding the neutralizing activity and coverage of SARS-CoV-2 variants of vaccine-elicited antibodies is required to guide prophylactic and therapeutic COVID-19 interventions in this frail population. By analyzing plasma samples from 130 hemodialysis and 13 peritoneal dialysis patients after two doses of BNT162b2 or mRNA-1273 vaccines, we found that 35% of the patients had low-level or undetectable IgG antibodies to SARS-CoV-2 Spike (S). Neutralizing antibodies against the vaccine-matched SARS-CoV-2 and Delta variant were low or undetectable in 49% and 77% of patients, respectively, and were further reduced against other emerging variants. The fraction of non-responding patients was higher in SARS-CoV-2-naïve hemodialysis patients immunized with BNT162b2 (66%) than those immunized with mRNA-1273 (23%). The reduced neutralizing activity correlated with low antibody avidity. Patients followed up to 7 months after vaccination showed a rapid decay of the antibody response with an average 21- and 10-fold reduction of neutralizing antibodies to vaccine-matched SARS-CoV-2 and Delta variant, which increased the fraction of non-responders to 84% and 90%, respectively. These data indicate that dialysis patients should be prioritized for additional vaccination boosts. Nevertheless, their antibody response to SARS-CoV-2 must be continuously monitored to adopt the best prophylactic and therapeutic strategy.
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Affiliation(s)
- Jessica Bassi
- Humabs BioMed SA, A Subsidiary of Vir Biotechnology, Bellinzona, Switzerland
| | - Olivier Giannini
- Faculty of Biomedical Sciences, Università della Svizzera italiana, Lugano, Switzerland
- Department of Medicine, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | | | - Laura Pertusini
- Division of Nephrology, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Paolo Hitz
- Faculty of Biomedical Sciences, Università della Svizzera italiana, Lugano, Switzerland
| | - Tatiana Terrot
- Clinical Trial Unit, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Yves Franzosi
- Clinical Trial Unit, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Francesco Muoio
- Humabs BioMed SA, A Subsidiary of Vir Biotechnology, Bellinzona, Switzerland
| | - Christian Saliba
- Humabs BioMed SA, A Subsidiary of Vir Biotechnology, Bellinzona, Switzerland
| | - Marcel Meury
- Vir Biotechnology, San Francisco, California, United States of America
| | | | - Josh R Dillen
- Vir Biotechnology, San Francisco, California, United States of America
| | - Patrick Hernandez
- Vir Biotechnology, San Francisco, California, United States of America
| | | | - Elisabetta Cameroni
- Humabs BioMed SA, A Subsidiary of Vir Biotechnology, Bellinzona, Switzerland
| | - Nicola Beria
- Division of Nephrology, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | | | - Alberto Badellino
- Division of Nephrology, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | | | - Elisabetta Lecchi
- Division of Nephrology, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Tecla Bonora
- Division of Nephrology, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Matteo Mattiolo
- Division of Nephrology, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Guido Trinci
- Division of Nephrology, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Daniela Garzoni
- Division of Nephrology, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Giuseppe Bonforte
- Division of Nephrology, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | | | - Davide Giunzioni
- Division of Nephrology, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Lorenzo Berwert
- Division of Nephrology, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Ravindra K Gupta
- Cambridge Institute of Therapeutic Immunology & Infectious Disease (CITIID), Cambridge, United Kingdom
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Paolo Ferrari
- Faculty of Biomedical Sciences, Università della Svizzera italiana, Lugano, Switzerland
- Division of Nephrology, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Clinical School, University of New South Wales, Sydney, Australia
| | - Alessandro Ceschi
- Faculty of Biomedical Sciences, Università della Svizzera italiana, Lugano, Switzerland
- Clinical Trial Unit, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Division of Clinical Pharmacology and Toxicology, Institute of Pharmacological Science of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, Zurich, Switzerland
| | - Pietro Cippà
- Department of Medicine, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
- Division of Nephrology, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | - Davide Corti
- Humabs BioMed SA, A Subsidiary of Vir Biotechnology, Bellinzona, Switzerland
| | | | - Luca Piccoli
- Humabs BioMed SA, A Subsidiary of Vir Biotechnology, Bellinzona, Switzerland
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Del Giorno R, Lavorato Hadjeres S, Stefanelli K, Allegra G, Zapparoli C, Predrag L, Berwert L, Gabutti L. Consequences of Supraphysiological Dialysate Magnesium on Arterial Stiffness, Hemodynamic Profile, and Endothelial Function in Hemodialysis: A Randomized Crossover Study Followed by a Non-Controlled Follow-Up Phase. Adv Ther 2020; 37:4848-4865. [PMID: 32996010 PMCID: PMC7595984 DOI: 10.1007/s12325-020-01505-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 09/12/2020] [Indexed: 11/28/2022]
Abstract
Introduction Increasing dialysate magnesium (D-Mg2+) appears to be an intriguing strategy to obtain cardiovascular benefits in subjects with end-stage kidney disease (ESKD) on hemodialysis. To date, however, hemodialysis guidelines do not suggest to increase D-Mg2+ routinely set at 0.50 mmol/L. Methods A randomized 4-week crossover study aimed at investigating the consequences of increasing D-Mg2+ from 0.50 to 0.75 mmol/L on arterial stiffness, hemodynamic profile, and endothelial function in subjects undergoing hemodialysis. The long-term effect of higher D-Mg2+ on mineral metabolism markers was investigated in a 6-month follow-up. Data were analyzed by linear mixed models for repeated measures. Results Data of 39 patients were analyzed. Pulse wave velocity and pulse pressure significantly decreased on the higher D-Mg2+ compared with the standard one by − 0.91 m/s (95% confidence interval − 1.52 to − 0.29; p = 0.01) and − 9.61 mmHg (− 18.89 to − 0.33, p = 0.04), respectively. A significant reduction in systolic blood pressure of − 12.96 mmHg (− 24.71 to − 1.22, p = 0.03) was also observed. No period or carryover effects were observed. During the long-term follow-up phase the higher D-Mg2+ significantly increased ionized and total serum Mg (respectively from 0.54 to 0.64 and from 0.84 to 1.07 mmol/L; mean percentage change from baseline to follow-up + 21% and + 27%; p ≤ 0.001), while parathormone (PTH) decreased significantly (from 36.6 to 34.4 pmol/L; % change − 11%, p = 0.03). Conclusions Increasing dialysate magnesium improves vascular stiffness in subjects undergoing maintenance hemodialysis. The present findings merit a larger trial to evaluate the effects of 0.75 mmol/L D-Mg2+ on major clinical outcomes. Trial Registration The study was retrospectively registered on the ISRCTN registry (ISRCTN 74139255) on 18 June 2020.
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Affiliation(s)
- Rosaria Del Giorno
- Department of Internal Medicine, Clinical Research Unit, Regional Hospital of Bellinzona and Valli, Ente Ospedaliero Cantonale, Bellinzona, Switzerland.
- Institute of Biomedicine, University of Southern Switzerland, Lugano, Switzerland.
| | - Soraya Lavorato Hadjeres
- Nephrology and Dialysis Service, Regional Hospital of Bellinzona and Valli, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Kevyn Stefanelli
- Department of Social Sciences and Economics, Sapienza University of Rome, Rome, Italy
| | - Giampiero Allegra
- Department of Internal Medicine, Clinical Research Unit, Regional Hospital of Bellinzona and Valli, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Claudia Zapparoli
- Department of Internal Medicine, Clinical Research Unit, Regional Hospital of Bellinzona and Valli, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Lazarevic Predrag
- Nephrology and Dialysis Service, Regional Hospital of Bellinzona and Valli, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Lorenzo Berwert
- Nephrology and Dialysis Service, Regional Hospital of Bellinzona and Valli, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Luca Gabutti
- Department of Internal Medicine, Clinical Research Unit, Regional Hospital of Bellinzona and Valli, Ente Ospedaliero Cantonale, Bellinzona, Switzerland.
- Nephrology and Dialysis Service, Regional Hospital of Bellinzona and Valli, Ente Ospedaliero Cantonale, Bellinzona, Switzerland.
- Institute of Biomedicine, University of Southern Switzerland, Lugano, Switzerland.
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6
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Del Giorno R, Lavorato S, Stefanelli K, Allegra G, Zapparoli C, Lazarevic P, Berwert L, Gabutti L. P0226CONSEQUENCES OF SUPRAPHYSIOLOGICAL DYALYSATE MAGNESIUM CONCENTRATION ON ARTERIAL STIFFNESS, HEMODYNAMIC PROFILE AND ENDOTHELIAL FUNCTION IN HEMODIALYSIS: A RANDOMIZED CROSS-OVER STUDY AND FOLLOW-UP. Nephrol Dial Transplant 2020. [DOI: 10.1093/ndt/gfaa142.p0226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background and Aims
Increasing dialysate magnesium improves vascular stiffness in subjects undergoing maintenance hemodialysis. The present findings merit a larger trial to evaluate the effects of a 0.75 mmol/L D-Mg2+ on major clinical outcomes.
Method
A randomized 4-week cross-over study aimed at investigating the consequences of increasing D-Mg2+ from 0.50 to 0.75 mmol/L on arterial stiffness, hemodynamic profile, and endothelial function in subjects undergoing hemodialysis. The long-term effect of higher D-Mg2+ on mineral metabolism markers was investigated in a six-month follow-up. Data were analysed by linear mixed models for repeated measures.
Results
Pulse wave velocity and pulse pressure significantly decreased on the higher D-Mg2+ compared with the standard one by -0.91 m/sec (95% confidence interval: -1.52 to -0.29; p=0.01) and -9.61 mmHg (-18.89 to -0.33, p=0.04), respectively. A significant reduction in systolic blood pressure of -12.96 mmHg (-24.71 to -1.22, p=0.03) was also observed. No period or carryover effects were observed. During the long-term follow-up the higher D-Mg2+ significantly increased total serum and ionized Mg (mean percentage change from baseline to follow-up +21%; and + 27%; p≤0.001 for both), while parathormone (PTH) decreased significantly (-11%, p=0.03).
Conclusion
Increasing dialysate magnesium improves vascular stiffness in subjects undergoing maintenance hemodialysis. The present findings merit a larger trial to evaluate the effects of a 0.75 mmol/L D-Mg2+ on major clinical outcomes.
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Affiliation(s)
- Rosaria Del Giorno
- EOC Ente Ospedaliero Cantonale, Department of Internal Medicine, Clinical Research Unit, Regional Hospital of Bellinzona and Valli, Ente Ospedaliero Cantonale, Bellinzona, Switzerland, Bellinzona, Switzerland
| | - Soraya Lavorato
- EOC Ente Ospedaliero Cantonale, Department of Internal Medicine, Clinical Research Unit, Regional Hospital of Bellinzona and Valli, Ente Ospedaliero Cantonale, Bellinzona, Switzerland, Bellinzona, Switzerland
- EOC Ente Ospedaliero Cantonale, Nephrology and Dialysis Service, Regional Hospital of Bellinzona and Valli, Ente Ospedaliero Cantonale, Bellinzona, Switzerland, Bellinzona, Switzerland
| | | | - Giampiero Allegra
- EOC Ente Ospedaliero Cantonale, Department of Internal Medicine, Clinical Research Unit, Regional Hospital of Bellinzona and Valli, Ente Ospedaliero Cantonale, Bellinzona, Switzerland, Bellinzona, Switzerland
| | - Claudia Zapparoli
- EOC Ente Ospedaliero Cantonale, Department of Internal Medicine, Clinical Research Unit, Regional Hospital of Bellinzona and Valli, Ente Ospedaliero Cantonale, Bellinzona, Switzerland, Bellinzona, Switzerland
| | - Pedrag Lazarevic
- EOC Ente Ospedaliero Cantonale, Nephrology and Dialysis Service, Regional Hospital of Bellinzona and Valli, Ente Ospedaliero Cantonale, Bellinzona, Switzerland, Bellinzona, Switzerland
| | - Lorenzo Berwert
- EOC Ente Ospedaliero Cantonale, Nephrology and Dialysis Service, Regional Hospital of Bellinzona and Valli, Ente Ospedaliero Cantonale, Bellinzona, Switzerland, Bellinzona, Switzerland
| | - Luca Gabutti
- EOC Ente Ospedaliero Cantonale, Department of Internal Medicine, Clinical Research Unit, Regional Hospital of Bellinzona and Valli, Ente Ospedaliero Cantonale, Bellinzona, Switzerland, Bellinzona, Switzerland
- Università della Svizzera italiana, Institute of Biomedicine, Lugano, Switzerland
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7
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Del Giorno R, Berwert L, Pianca S, Bianchi G, Giannini O, Gabutti L. Comparative analysis of the long-term effect of two families of high-flux polysulfone dialysers on platelet count: a retrospective cross-sectional study. Ther Clin Risk Manag 2017; 13:1415-1422. [PMID: 29081657 PMCID: PMC5652913 DOI: 10.2147/tcrm.s143708] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Introduction Thrombocytopenia is a potential complication of hemodialysis (HD), and its occurrence has been described even with highly biocompatible polysulfone (PSf) membranes. Dialysis units routinely monitor platelet (PLT) count at the beginning of HD sessions. However, considering that the long-term effects on PLT count could easily be missed, the prevalence of HD-related thrombocytopenia could be underestimated. In the present study, we aimed to investigate the following: 1) the long-term impact of HD treatment on PLT count, comparing two families of dialysis membranes made up of similar PSfs; 2) whether the switch between the dialysis membranes studied significantly affects PLT count; and 3) the prevalence and the risk of HD-induced thrombocytopenia according to the dialysis membranes used. Methods A cross-sectional retrospective study was performed comprising 157 adult chronic HD patients. The HD membranes under investigation were of the series FX, Helixone® Fresenius (Filters A), and Polyflux® Gambro (Filters B). Patients were treated in 4 dialysis units in Southern Switzerland. Data were collected from a centralized computing platform. Findings PLT count significantly differs between Filters A and B with, respectively, 188 (153–243) ×10E9/L versus 214 (179–255) ×10E9/L (p=0.036). The prevalence of thrombocytopenia was higher for Filter A compared with Filter B (28.4% versus 12.8%; p<0.001). The switch from Filter A to Filter B significantly affected PLT count: from 189 (146–217) ×10E9/L to 217 (163–253) ×10E9/L (p<0.001; analysis on 26 patients). A linear random-intercept model confirmed the results (β coefficient =35.214; SE =5.956; p<0.001). In a mixed-effects logistic regression model, the risk of thrombocytopenia for Filter B was 0.157 (CI =0.056–0.442). Discussion Our data suggest that among the PSf membranes studied, the FX membrane induced a lasting decrease in PLT count and caused significantly more thrombocytopenia. Prospective studies are warranted to verify our findings.
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Affiliation(s)
- Rosaria Del Giorno
- Department of Internal Medicine, Nephrology and Dialysis Unit, Regional Hospital of Bellinzona and Valli, Ente Ospedaliero Cantonale, Bellinzona
| | - Lorenzo Berwert
- Department of Internal Medicine, Nephrology and Dialysis Unit, Regional Hospital of Bellinzona and Valli, Ente Ospedaliero Cantonale, Bellinzona
| | - Silvio Pianca
- Nephrology Unit, Civico Hospital, Ente Ospedaliero Cantonale, Lugano
| | - Giorgia Bianchi
- Nephrology Unit, La Carità Hospital, Ente Ospedaliero Cantonale, Locarno
| | - Olivier Giannini
- Nephrology Unit, Beata Vergine Hospital, Ente Ospedaliero Cantonale, Mendrisio, Switzerland
| | - Luca Gabutti
- Department of Internal Medicine, Nephrology and Dialysis Unit, Regional Hospital of Bellinzona and Valli, Ente Ospedaliero Cantonale, Bellinzona
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8
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Salvadé I, Schätti-Stählin S, Violetti E, Schönholzer C, Cereghetti C, Zwahlen H, Berwert L, Burnier M, Gabutti L. A prospective observational study comparing a non-operator dependent automatic PWV analyser to pulse pressure, in assessing arterial stiffness in hemodialysis. BMC Nephrol 2015; 16:62. [PMID: 25904000 PMCID: PMC4410461 DOI: 10.1186/s12882-015-0058-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Accepted: 04/15/2015] [Indexed: 11/28/2022] Open
Abstract
Background Chronic kidney disease (CKD) accelerates vascular stiffening related to age. Arterial stiffness may be evaluated measuring the carotid-femoral pulse wave velocity (PWV) or more simply, as recommended by KDOQI, monitoring pulse pressure (PP). Both correlate to survival and incidence of cardiovascular disease. PWV can also be estimated on the brachial artery using a Mobil-O-Graph; a non-operator dependent automatic device. The aim was to analyse whether, in a dialysis population, PWV obtained by Mobil-O-Graph (MogPWV) is more sensitive for vascular aging than PP. Methods A cohort of 143 patients from 4 dialysis units has been followed measuring MogPWV and PP every 3 to 6 months and compared to a control group with the same risk factors but an eGFR > 30 ml/min. Results MogPWV contrarily to PP did discriminate the dialysis population from the control group. The mean difference translated in age between the two populations was 8.4 years. The increase in MogPWV, as a function of age, was more rapid in the dialysis group. 13.3% of the dialysis patients but only 3.0% of the control group were outliers for MogPWV. The mortality rate (16 out of 143) was similar in outliers and inliers (7.4 and 8.0%/year). Stratifying patients according to MogPWV, a significant difference in survival was seen. A high parathormone (PTH) and to be dialysed for a hypertensive nephropathy were associated to a higher baseline MogPWV. Conclusions Assessing PWV on the brachial artery using a Mobil-O-Graph is a valid and simple alternative, which, in the dialysis population, is more sensitive for vascular aging than PP. As demonstrated in previous studies PWV correlates to mortality. Among specific CKD risk factors only PTH is associated with a higher baseline PWV. Trial registration ClinicalTrials.gov Identifier: NCT02327962.
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Affiliation(s)
- Igor Salvadé
- Division of Nephrology, Ospedale la Carità, Via Ospedale 1, 6600, Locarno, Switzerland.
| | | | | | | | | | - Hugo Zwahlen
- Division of Nephrology, Ospedale San Giovanni, Bellinzona, Switzerland.
| | - Lorenzo Berwert
- Division of Nephrology, Ospedale San Giovanni, Bellinzona, Switzerland.
| | - Michel Burnier
- Division of Nephrology, University Hospital of Lausanne, Lausanne, Switzerland.
| | - Luca Gabutti
- Division of Nephrology, Ospedale la Carità, Via Ospedale 1, 6600, Locarno, Switzerland.
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9
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Berwert L, Vogt B, Burnier M. [Hypernatremia: a matter of water]. Rev Med Suisse 2010; 6:444-447. [PMID: 20344994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Hypernatremia is defined as a serum sodium concentration above the upper laboratory reference range, usually > 145 mmol/l. It is a common electrolyte disorder in the very young and the very old patient. Hospitalization itself is a risk factor for developing hypernatremia. Free water deficit is the main cause of this condition. It induces hyperosmolality and an intracellular dehydration. Clinical manifestations are mostly neurological but non-specific. A blood sample analysis is needed to establish the diagnosis. Hypernatremia is associated with a high mortality and morbidity. Treatment consists of correcting the underlying cause and the volume deficit. A brief review of this condition is proposed.
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Affiliation(s)
- Lorenzo Berwert
- Service de néphrologie et consultation d'hypertension, Département de médecine interne, CHUV, 1011 Lausanne.
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10
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Simon R, Berwert L, Burnier M, Teta D. [Severe renal insufficiency secondary to renal cholesterol emboli: therapeutical options revisited]. Rev Med Suisse 2010; 6:432-437. [PMID: 20344992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Disseminated cholesterol crystal embolism is observed in elderly men with severe atherosclerosis. This syndrome may be triggered by arterial catheterizations, major vascular surgery, thrombolytic and/or anticoagulation treatment. Cutaneous signs, subacute renal insufficiency, a marked inflammatory syndrome and eosinophilia are common. Immunologic testing is normal except for hypocomplementaemia. The diagnosis may be confirmed by biopsy (skin, gastrointestinal or renal), and/or by a fundoscopic examination. The treatment consists in withdrawing all form of anticoagulation, proscribing vascular surgery and arterial catheterization, prescribing aspirin and statins, and controlling arterial blood pressure. Corticosteroids may be given in refractory cases. The prognosis of cholesterol crystal embolism is poor but may be improved by statins.
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Affiliation(s)
- Raphaël Simon
- Service de néphrologie et consultation d'hypertension, Département de médecine interne, CHUV, 1011 Lausanne
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11
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Abstract
Hypernatriämie bezeichnet eine über die Norm erhöhte Natriumkonzentration im Serum. Die Ursache einer Hypernatriämie ist häufig ein Wassermangel bei vermindertem Durstgefühl oder mangelnder exogener Wasserzufuhr. In seltenen Fällen kann eine Hypernatriämie durch eine erhöhte Natriumzufuhr entstehen. Schwere Hypernatriämien sind gefährlich und können bleibende Schäden hervorrufen. Bedrohliche Hypernatriämien können schon im frühen Kindesalter auftreten. Bei Erwachsenen und sehr alten Patienten ist besonders auf Medikamente zu achten, welche das Durstgefühl beeinflussen und somit Ursache einer Hypernatriämie sein können. Der Spitalaufenthalt selbst ist ein begünstigender Faktor für das Auftreten einer Hypernatriämie. Die Therapie besteht in der Korrektur der Ursache und im gezielten Volumen- und Elektrolyt- Management.
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Affiliation(s)
- Bruno Vogt
- Service de Néphrologie et d’Hypertension, Département de Médecine, Centre Hospitalier Universitaire Vaudois CHUV, Université de Lausanne, Lausanne
| | - Lorenzo Berwert
- Service de Néphrologie et d’Hypertension, Département de Médecine, Centre Hospitalier Universitaire Vaudois CHUV, Université de Lausanne, Lausanne
| | - Michel Burnier
- Service de Néphrologie et d’Hypertension, Département de Médecine, Centre Hospitalier Universitaire Vaudois CHUV, Université de Lausanne, Lausanne
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12
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Schneiter S, Berwert L, Bonny O, Teta D, Burnier M, Vogt B. [Anorexia nervosa and the kidney]. Rev Med Suisse 2009; 5:440-444. [PMID: 19317309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Anorexia nervosa (AN) is a severe and potentially lethal disease of the young woman. It is defined as an anxious disorder not to gain weight, and an obsessive behavior regarding body weight and physical appearance. Different and variable patterns of behaviour are observed. This article focuses on the renal problems observed in anorexic patients. Anorexia is often associated with severe electrolyte disturbances, such as hypokalemia and hypophosphatemia, and alterations of water metabolism with hyponatremia and edema. Hypokalemia and chronic dehydration may contribute to the development of renal failure. Even end stage renal disease can be observed in these patients. A better understanding of the pathophysiology might improve treatment of patients suffering from AN.
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Affiliation(s)
- Sabine Schneiter
- Service nephrologie et Consultation d'hypertension, Département de médecine interne, CHUV, 1011 Lausanne
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13
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Berwert L, Teta D, Zanchi A. [Chronic kidney disease and antidiabetic treatment]. Rev Med Suisse 2007; 3:598-604. [PMID: 17436798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
Diabetic nephropathy is the leading cause of chronic renal failure (CRF) in Europe. About fifty percent of diabetic subjects develop microalbuminuria, which progresses towards established diabetic nephropathy in one third of patients. The treatment of type 2 diabetes in a patient with CRF is a challenge for the general practitioner, because of the accumulation of drugs and/or specific metabolites. Sulfonylureas are associated with an increased risk of hypoglycaemia. Biguanides may exceptionally cause life-threatening lactic acidosis. Glitazones have an interesting profile since they decrease microalbuminuria and blood pressure. However, their safety is not well defined in the context of CRF In the case of severe CRF, only insulin and repaglinide can be recommended.
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Affiliation(s)
- L Berwert
- Service de néphrologie et consultation d'hypertension, CHUV, 1011 Lausanne.
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14
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Berwert L, Kaeser P, Livio F, Vollenweider P, Waeber G. [Hyponatremia: an unusual case report]. Praxis (Bern 1994) 2003; 92:1727-1732. [PMID: 14587366 DOI: 10.1024/0369-8394.92.41.1727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Hyponatremia is a frequent finding and asks for a rapid diagnostic evaluation. We report a case of recurrent hyponatremia secondary to an adrenal insufficiency of medicamentous and tuberculous origin. This case illustrates the importance of a rapid etiologic diagnosis of hyponatremia and allows us to review adrenal insufficiency of tuberculous origin. It also stresses the danger of potential drug interactions in case of corticosteroid substitution.
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MESH Headings
- Addison Disease/complications
- Addison Disease/diagnosis
- Adrenal Insufficiency/complications
- Adrenal Insufficiency/diagnosis
- Adult
- Anti-Inflammatory Agents/administration & dosage
- Anti-Inflammatory Agents/pharmacology
- Anti-Inflammatory Agents/therapeutic use
- Anti-Ulcer Agents/administration & dosage
- Anti-Ulcer Agents/pharmacology
- Anti-Ulcer Agents/therapeutic use
- Antitubercular Agents/administration & dosage
- Antitubercular Agents/pharmacology
- Antitubercular Agents/therapeutic use
- Diagnosis, Differential
- Drug Interactions
- Elbow Joint
- Enzyme Inhibitors/administration & dosage
- Enzyme Inhibitors/pharmacology
- Enzyme Inhibitors/therapeutic use
- Helicobacter Infections/diagnosis
- Helicobacter Infections/drug therapy
- Helicobacter pylori
- Humans
- Hydrocortisone/administration & dosage
- Hydrocortisone/pharmacology
- Hydrocortisone/therapeutic use
- Hyponatremia/diagnosis
- Hyponatremia/etiology
- Male
- Omeprazole/administration & dosage
- Omeprazole/pharmacology
- Omeprazole/therapeutic use
- Proton Pump Inhibitors
- Time Factors
- Tuberculosis, Endocrine/complications
- Tuberculosis, Endocrine/diagnosis
- Tuberculosis, Endocrine/drug therapy
- Tuberculosis, Osteoarticular/complications
- Tuberculosis, Osteoarticular/diagnosis
- Tuberculosis, Osteoarticular/drug therapy
- Tuberculosis, Pulmonary/complications
- Tuberculosis, Pulmonary/diagnosis
- Tuberculosis, Pulmonary/drug therapy
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Affiliation(s)
- L Berwert
- Service de médecine Interne B, Division de pharmacologie clinique, Département de médecine, CHUV, Lausanne
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15
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Abstract
The ontogeny of the endocrine pancreas of a teleost, the turbot (Scophthalmus maximus), was investigated by the use of double immunofluorescence. Clustered insulin (INS)-immunoreactive (IR) cells were observed on the first day after hatching. During the following days, the islet largely increased in size and some smaller islets appeared. All islets consisted only of INS-IR cells. Between day 5 (onset of exogenous feeding) and 7, somatostatin (SOM) and glucagon (GLUC) cells appeared. In the large (principal) islet, the SOM-IR cells intermingled with the INS-IR cells. In the secondary islets, they occurred at the periphery. The GLUC-IR cells were located at the periphery in all islets. Subsequently, two-four additional small principal islets appeared. At day 11, pancreatic polypeptide (PP)-IR cells were present in principal islets and secondary islets. Starting with day 11, in all islets, insulin-like growth factor 1 (IGF-1) immunoreactivity was localized in numerous PP-IR cells and GLUC-IR and some SOM-IR cells. It also occurred in enteroendocrine cells that seemed to contain none of the classical islet hormones. The early appearance of INS correlates with its key role in the regulation of fish protein and lipid metabolism. Islet-derived IGF-1 might inhibit the regulation of INS secretion in a paracrine manner and may be highly involved in growth-promoting processes.
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Affiliation(s)
- L Berwert
- Institute of Anatomy, University of Zürich, Switzerland
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