Financial Toxicity in Renal Patients (FINTORE) Study: A Cross-Sectional Italian Study on Financial Burden in Kidney Disease-A Project Protocol

Financial toxicity (FT) refers to the negative impact of health-care costs on clinical conditions. In general, social determinants of health, especially poverty, socioenvironmental stressors, and psychological factors, are increasingly recognized as important determinants of non-communicable diseases, such as chronic kidney disease (CKD), and their consequences. We aim to investigate the prevalence of FT in patients at different stages of CKD treated in our universal health-care system and from pediatric nephrology, hemodialysis, peritoneal dialysis and renal transplantation clinics. FT will be assessed with the Patient-Reported Outcome for Fighting Financial Toxicity (PROFFIT) score, which was first developed by Italian oncologists. Our local ethics committee has approved the study. Our population sample will answer the sixteen questions of the PROFFIT questionnaire, seven of which are related to the outcome and nine the determinants of FT. Data will be analyzed in the pediatric and adult populations and by group stratification. We are confident that this study will raise awareness among health-care professionals of the high risk of adverse health outcomes in patients who have both kidney disease and high levels of FT. Strategies to reduce FT should be implemented to improve the standard of care for people with kidney disease and lead to truly patient-centered care.

Residents' satisfaction and suggestions to improve nephrology residency in Italy, and comparison with the organization in other European countries

BACKGROUND

In Italy, nephrology residency is available in twenty-one nephrology schools, each with its own strengths and weaknesses. The present study is aimed at exploring the residents' satisfaction with their training programs.

METHODS

Between April 20th and May 19th, 2021, a questionnaire on residency satisfaction consisting of 49 items was sent to 586 residents and 175 recently certified specialists (qualified to practice as nephrologists in 2019 and 2020), with a response rate of 81% and 51%, respectively. The teaching organization was contextualized with a survey involving 13 European nephrology schools.

RESULTS

Most residency fellowship programs received a good rating with regard to "satisfaction", in particular for the following items: number of hospitalizations followed-up, chronic hemodialysis training, follow-up of transplanted patients, diagnosis and treatment of glomerulonephritis. The teachings that were identified as being of lower quality or insufficient intensity included vascular access management, ultrasound diagnostics and renal nutrition. The need for improvement in formal teaching programs was underlined. Young nephrologists were rather satisfied with their salary and with the quality of the work they were doing, but only few were interested in an academic career since it was generally held that it is "too difficult" to obtain a university position. Many young nephrologists who filled in the questionnaire felt that lack of experience in peritoneal dialysis and vascular access management was a barrier to finding an ideal job. Compared to other European training programs, the Italian program differs with regard to longer exposure to nephrology (as compared to internal medicine), and greater flexibility for internships in different settings, including abroad.

CONCLUSIONS

This first nationwide survey on the satisfaction of residents in nephrology indicates that, despite rather good overall satisfaction, there is room for improvement to make nephrology a more appealing choice and to fulfill the needs of a growing number of renal disease patients.

Food insecurity and kidney disease: a systematic review

BACKGROUND

The risk of developing and worsening chronic kidney disease (CKD) is associated with unhealthy dietary patterns. Food insecurity is defined by a limited or uncertain availability of nutritionally adequate and safe food; it is also associated with several chronic medical conditions. The aim of this systematic review is to investigate the current knowledge about the relationship between food insecurity and renal disease.

METHODS

We selected the pertinent publications by searching on the PubMed, Scopus, and the Web of Science databases, without any temporal limitations being imposed. The searching and selecting processes were carried out through pinpointed inclusion and exclusion criteria and in accordance with the Prisma statement.

RESULTS

Out of the 26,548 items that were first identified, only 9 studies were included in the systemic review. Eight out of the nine investigations were conducted in the US, and one was conducted in Iran. The studies evaluated the relationship between food insecurity and (i) kidney disease in children, (ii) kidney stones, (iii) CKD, (iv) cardiorenal syndrome, and (v) end stage renal disease (ESRD). In total, the different research groups enrolled 49,533 subjects, and food insecurity was reported to be a risk factor for hospitalization, kidney stones, CKD, ESRD, and mortality.

CONCLUSIONS

The relationship between food insecurity and renal disease has been underestimated. Food insecurity is a serious risk factor for health problems in both wealthy and poor populations; however, the true prevalence of the condition is unknown. Healthcare professionals need to take action to prevent the dramatic effect of food insecurity on CKD and on other chronic clinical conditions.

Venous Doppler flow patterns, venous congestion, heart disease and renal dysfunction: A complex liaison

The World Journal of Cardiology published an article written by Kuwahara et al that we take the pleasure to comment on. We focused our attention on venous congestion. In intensive care settings, it is now widely accepted that venous congestion is an important clinical feature worthy of investigation. Evaluating venous Doppler profile abnormalities at multiple sites could suggest adequate treatment and monitor its efficacy. Renal dysfunction could trigger or worsen fluid overload in heart disease, and cardio-renal syndrome is a well-characterized spectrum of disorders describing the complex interactions between heart and kidney diseases. Fluid overload and venous congestion, including renal venous hypertension, are major determinants of acute and chronic renal dysfunction arising in heart disease. Organ congestion from venous hypertension could be involved in the development of organ injury in several clinical situations, such as critical diseases, congestive heart failure, and chronic kidney disease. Ultrasonography and abnormal Doppler flow patterns diagnose clinically significant systemic venous congestion. Cardiologists and nephrologists might use this valuable, non-invasive, bedside diagnostic tool to establish fluid status and guide clinical choices.

Personalized Medicine in Kidney Disease

The Special Issue "Personalized Medicine in Kidney Disease" is focused on the importance of customized medicine in nephrology as it represents one of the main characteristics of successful therapeutic results [...].

[Tic douloureux sustained by an eye tumor]

Cancer is a major cause of morbidity and mortality in solid organ transplantation. Nonmelanoma skin cancer (NMSC) such as basocellular (BCC) and spinocellular (SCC) carcinoma, are common in renal transplant recipients. We report a case of an SCC affecting a lacrimal gland in a subject with kidney transplantation. A man aged 75 years who had suffered from glomerulopathy since 1967 and subsequently started haemodialysis, in 1989 was transplanted from a living donor. In 2019, he suffered paresthesia and pain in his right eyebrow arch and he was diagnosed to have neuralgia of the fifth cranial nerve. The failure of medical treatment and the development of a mass in his eyelid plus exophthalmos induced healthcare professionals to perform a magnetic resonance. The latter showed a retrobulbar mass measuring 39×22×16 mm3. Biopsy revealed an SCC and the patient underwent eye exenteration. Although NMSC of the eye is an extremely rare condition, risk factors such as male sex, history of glomerulopathy, and duration of immunosuppression should be taken into consideration at the time of the onset of eye symptoms.

The Hypertensive Disorders of Pregnancy: A Focus on Definitions for Clinical Nephrologists

About 5-10% of pregnancies are complicated by one of the hypertensive disorders of pregnancy. The women who experience these disorders have a greater risk of having or developing kidney diseases than women with normotensive pregnancies. While international guidelines do not provide clear indications for a nephrology work-up after pregnancy, this is increasingly being advised by nephrology societies. The definitions of the hypertensive disorders of pregnancy have changed greatly in recent years. The objective of this short review is to gather and comment upon the main definitions of the hypertensive disorders of pregnancy as a support for nephrologists, who are increasingly involved in the short- and long-term management of women with these disorders.

MO577: The Role of Nutritional Therapy in CKD: Low Protein Diet VS Mediterranean Diet, A Multicentric Study

BACKGROUND AND AIMS

Nutritional therapy exerts a positive role for the prevention, progression and treatment of chronic kidney disease (CKD) and cardiovascular diseases. An individualized, stepwise approach is essential to guarantee high adherence to nutritional patterns and to reach therapeutical goals. Which is the best dietary regimen is still a matter of discussion.

METHOD

We performed an observational, multicentric study on 75 non-diabetic patients with CKD stage III-IV with a one-year follow-up (Table 1). We compared two of the most used dietary regimens for CKD patients: low protein diet (LPD) and the Mediterranean diet (MD).

RESULTS

Our results showed a significant renal function preservation in LPD compared with the MD cohort patients. An unadjusted model with a general linear model for repeated measures demonstrated a MD significant effect on creatinine clearance compared with LPD with an estimate marginal mean of −9.98 mL/min (95% CI: −15.6 to −4.3). Adjusted model for age, BMI and sex confirmed this significance in between-group in the joint mean difference (9.34, 95%CI: −15.44 to −3.24) (Fig. 1).

CONCLUSION

An adequate dietary strategy is of pivotal importance in the treatment of chronic diseases like CKD. Our study aimed to bring more evidence in the contest of nutritional therapy, demonstrating that beside the central importance of the MD for selected patients, LPD seems to have superior therapeutical benefits on kidney function preservation.

MO912: Different Immunogenicity of Previous SARS-COV-2 Infection or Comirnaty Vaccine (BNT162B2, BioNTech/Pfizer) in Haemodialysis Patients

BACKGROUND AND AIMS

The pandemic emergency deriving from the SARS-CoV-2 infection has made it necessary to find effective strategies to preserve high-risk populations with severe comorbidities like haemodialysis patients. Adequate vaccination coverage is of vital importance, representing the main weapon to counter the spread of the virus.

The purpose of our study was to evaluate the antibody response of our dialysis patients vaccinated with the Comirnaty-BioNTech/Pfizer vaccine in comparison with those with previous infection.

METHOD

We retrospectively analysed 52 patients referried to the Dialysis Unit of University Hospital G. Martino, Messina, from 2020 to 2021. Of these, 41 patients had never contracted SARS-CoV-2 (group A), while 11 patients had contracted the infection (group B). Serum samples were taken before vaccine administration, 3 months and 6 months after administration. A linear mixed model was performed on the measurements to analyse the difference in antibody response, comparing the values ​​of neutralizing IgG and anti-COVID-19 antibodies during time (Fig. 1).

RESULTS

The results showed a statistically significant higher titre of anti-spike antibodies in patients with a previous infection (P = 0.003), with a stronger association at 6 months after infection. The linear mixed model showed a significant association over time between infection and antispike (ln U/L) in the univariate model, which was confirmed in the multivariate model {adjSlope: 2.9, [95% confidence interval (95% CI) 1.3–4.6]; P =.001}. No other variables were related to antispike.

CONCLUSION

These findings can raise novel questions on the role of natural immunity and antibody titre in the haemodialysis population.

MO217: Proteinuria/BMI Ratio in Primary Membranous Nephropathy as a Possible Predictive Factor of Therapeutic Efficacy

BACKGROUND AND AIMS

The attempt to identify the most suitable therapies and their appropriate dose is at the base of tailored medicine approach. We decided to analyze the renal outcomes of patients affected by primary membranous nephropathy (MN) referring to our unit from January 2005 to December 2020, treated with conservative or immunosuppressive therapy, searching for any predictive factor of therapeutic response.

METHOD

We performed a retrospective analysis of 31 MN patients (M 20, F 11), checking anti-PLA2R status, kidney biopsy and comorbidities. All patients underwent a quarterly control for 1 year, evaluating blood pressure, body mass index (BMI), biochemistry, urinalysis and 24-h proteinuria. Variable distribution was evaluated with Kolgomorov–Smirnov test and data expressed as median [interquartile range (IQR) range] or mean ± SD. Basal features were analyzed with student's t- test for independent variables, Mann–Whitney test for continuous variables and Pearson's chi-squared analysis for dummy variables. Trend analysis was computed with a linear mixed model for repeated analysis.

RESULTS

We performed 186 repeated measurements, with median age at diagnosis of 52 years old (43.7–68) and eGFR of 72.8 ± 31.6 mL/min. Median reduction of proteinuria was 3.732 g/24 h (7.63–1.77). We first found a direct association of proteinuria/BMI ratio at diagnosis with proteinuria remission at last follow-up (r −.7506; P < .0001), irrespective of the specific therapy.

We divided the patients according to their basal proteinuria/BMI ratio being lower or higher than the whole cohort median value. Significant differences between the two groups were found in serum albumin (3.5 ± 0.68 versus 2.52 ± 0.62 g/dL, P = .001) and LDL (132 ± 17 versus 179 ± 66 mg/dL, P = .034), but the latter was rather an effect of proteinuria, as proved by the adjusted model. Also hypertension prevalence in the higher proteinuria/BMI ratio group lacked any statistical significance.

The adjusted model proved an association in longitudinal follow-up between eGFR and both proteinuria/BMI ratio (β: 29.28, P = .037, 95% CI 1.75–56.80) and age [β = −1.27, P = .001, 95% CI −1.75–(−0.79)].

At biopsy time, almost half of the patients were anti-PLA2R positive (15), while the other were screened for secondary causes of MN (16). Irrespective of their anti-PLA2R status or the administration of Ponticelli regimen or Rituximab, complete remission was achieved in 31% of patients, while 34.5% experienced a partial remission and 34.5% did not respond to at least a therapeutic protocol.

CONCLUSION

As previously reported by Yonekura in a cross-sectional registry study, larger physical constitution defined by both BMI >25 kg/m2 and body surface area (BSA) >1.73 m2 was associated with higher proteinuria in glomerulonephritis such as MN and minimal change disease (MCD) [1], compared with other primary glomerulopathies. Their hypothesis was based mainly in the different distribution of lesions in podocytes, capillary walls and glomerular basement membrane, whose permeability may be worsened by both hyperfiltration associated with obesity and the overfilling of nephrotic syndrome.

In our patients, BMI was also a surrogate marker to quantify the edema amount and to attempt a clinical evaluation of therapy efficacy, along with biochemistry. Patients with higher proteinuria/BMI ratio were typically affected by nephrotic syndrome and less responsive to at least a line of RAAS inhibitors and/or immunosuppressants such as Ponticelli regimen or Rituximab treatment as demonstrated by serum albumin variations.

Albeit remission is not directly correlated with basal BMI, our results appear to confirm that patients’ body mass and extracellular fluid volume may result in more effective individualized therapies in MN but this recorded association must be confirmed by larger scale clinical trials.

Role of Zinc in Diabetic Kidney Disease

Diabetic Kidney Disease (DKD) represents the most common cause of Chronic Kidney Disease (CKD) in developed countries. Approximately 30% to 40% of diabetes mellitus (DM) subjects develop DKD, and its presence significantly increases the risk for morbidity and mortality. In this context, Zinc seems to have a potential role in kidney and body homeostasis in diabetic individuals as well as in patients at a high risk of developing this condition. This essential element has functions that may counteract diabetes-related risk factors and complications, which include stabilization of insulin hexamers and pancreatic insulin storage and improved glycemic control. In our review, we analyzed the current knowledge on the role of zinc in the management of renal impairment in course of DM. Several studies underline the critical role of zinc in reducing oxidative stress levels, which is considered the common denominator of the mechanisms responsible for the progression of kidney disease. Reaching and maintaining a proper serum zinc level could represent a valuable target to reduce symptoms related to DM complications and contrast the progression of kidney impairment in patients with the high risk of developing end-stage renal disease. In conclusion, analyzing the beneficial role of zinc in this review would advance our knowledge on the possible strategies of DM and DKD treatment.

Gender differences in new hypoglycemic drug effects on renal outcomes: a systematic review

INTRODUCTION

Lifetime diabetes risk is greater in women than in men. Women with diabetes mellitus (DM) have a greater prevalence of diabetic kidney disease (DKD) risk factors. The diagnosis of DM is often delayed in women, with poorer outcomes and with expected therapeutic goals missed.

AREA COVERED

A systematic literature review following PRISMA guidelines was conducted in the PubMed gateway of the MEDLINE database and Clinicaltrials.gov. The purpose of our research was to establish the sex differences on renal outcomes in users of the new hypoglycemic drugs: sodium-glucose transport protein 2 inhibitors (SGLT-2i), dipeptidyl peptidase-IV Inhibitors (DPP-IVi) and glucagon-like peptide-1 inhibitors (GLP-1i).

EXPERT OPINION

New hypoglycemic drugs represent promising tools in the treatment and prevention of severe complications of diabetes, cardiovascular diseases and chronic kidney disease. Even if renal outcomes are investigated in both randomized controlled trials and cardiovascular outcome trials, gender-based analysis is not always performed. This may lead to relevant information for risk-benefit evaluation and therapeutic choices being missed, with gender-based equality in outcomes lacking. Our systematic review demonstrated that the gap among sexes in DKD can be partially filled using new hypoglycemic drugs. Sexual dimorphism analysis could represent a keystone for the development of adequate gender-specific therapies.

Amyloidosis and Glomerular Diseases in Familial Mediterranean Fever

Familial Mediterranean fever (FMF) is a genetic autoinflammatory disease with autosomal recessive transmission, characterized by periodic fever attacks with self-limited serositis. Secondary amyloidosis due to amyloid A renal deposition represents the most fearsome complication in up to 8.6% of patients. Amyloidosis A typically reveals a nephrotic syndrome with a rapid progression to end-stage kidney disease still. It may also involve the cardiovascular system, the gastrointestinal tract and the central nervous system. Other glomerulonephritis may equally affect FMF patients, including vasculitis such as IgA vasculitis and polyarteritis nodosa. A differential diagnosis among different primary and secondary causes of nephrotic syndrome is mandatory to determine the right therapeutic choice for the patients. Early detection of microalbuminuria is the first signal of kidney impairment in FMF, but new markers such as Neutrophil Gelatinase-Associated Lipocalin (NGAL) may radically change renal outcomes. Serum amyloid A protein (SAA) is currently considered a reliable indicator of subclinical inflammation and compliance to therapy. According to new evidence, SAA may also have an active pathogenic role in the regulation of NALP3 inflammasome activity as well as being a predictor of the clinical course of AA amyloidosis. Beyond colchicine, new monoclonal antibodies such as IL-1 inhibitors anakinra and canakinumab, and anti-IL-6 tocilizumab may represent a key in optimizing FMF treatment and prevention or control of AA amyloidosis.

Monocyte to HDL ratio: a novel marker of resistant hypertension in CKD patients

BACKGROUND

Inflammation, oxidative stress (OS), atherosclerosis and resistant hypertension (RH) are common features of chronic kidney disease (CKD) leading to a higher risk of death from cardiovascular disease. These effects seem to be modulated by impaired anti-oxidant, anti-inflammatory and reverse cholesterol transport actions of high-density lipoprotein cholesterol (HDL). HDL prevents and reverses monocyte recruitment and activation into the arterial wall and impairs endothelial adhesion molecule expression. Recently, monocyte count to HDL-cholesterol ratio (MHR) has emerged as a potential marker of inflammation and OS, demonstrating to be relevant in CKD. Our research was aimed to assess, for the first time, its reliability in RH.

METHODS

We performed a retrospective study on 214 patients with CKD and arterial hypertension who were admitted between January and June 2019 to our Department, 72 of whom were diagnosed with RH.

RESULTS

MHR appeared inversely related to eGFR (ρ = - 0.163; P = 0.0172). MHR was significantly higher among RH patients compared to non-RH ones (12.39 [IQR 10.67-16.05] versus 7.30 [5.49-9.06]; P < 0.0001). Moreover, MHR was significantly different according to the number of anti-hypertensive drugs per patient in the whole study cohort (F = 46.723; P < 0.001) as well as in the non-RH group (F = 14.191; P < 0.001). Moreover, MHR positively correlates with diabetes mellitus (ρ = 0.253; P = 0.0002), white blood cells (ρ = 0.664; P < 0.0001) and C-reactive protein (ρ = 0.563; P < 0.0001).

CONCLUSIONS

MHR may be a reliable biomarker due to the connection between HDL and monocytes. Our study suggests that MHR is linked with the use of multiple anti-hypertensive therapy and resistant hypertension in CKD patients, and can be a useful ratio to implement appropriate treatment strategies.

MO466A NOVEL PREDICTION MARKER OF 10-YEAR RISK AND LIFETIME RISK OF RECURRENT CARDIOVASCULAR EVENTS IN PATIENTS WITH CKD AND DIABETES MELLITUS

Background and Aims

Chronic kidney disease (CKD) is one of the most prevalent complication of Diabetes Mellitus and patients with both diseases are more exposed to atherosclerosis injury and premature death from cardiovascular disease (CVD).

CVD is worsened by inflammation, oxidative stress, lipid accumulation and high-density lipoprotein cholesterol (HDL) reduction: patients with altered lipid metabolism more often present monocyte profile changes, with an altered pro-inflammatory phenotype leading to a significant risk of plaque formation and atherosclerosis. The alteration of the balance between monocyte and HDL, represented by the Monocyte/HDL ratio (MHR), is an easy way to evaluate the inflammatory status and to study appropriate strategies to treat high-risk patients.

Method

We evaluated 150 consecutive diabetic patients with CKD hospitalized in the Unit of Nephrology and Dialysis of the Policlinic G. Martino of Messina, Italy, with a history of CVD. We used the SMART-REACH SCORE, a model created to estimate life expectancy without recurrent cardiovascular events for individuals with a history of CVD. We performed a retrospective analysis of the MHR status of our patients to study its correlations with the 10-year risk and lifetime risk for myocardial infarction, stroke or vascular death, recurrent CVD events and free life-expectancy if standard care is provided.

Results

In the entire cohort of patients, MHR appeared to be positively correlated with ten-year risk (ρ=0.469; P &lt;0.0001) (Figure 1) and lifetime risk of myocardial infarction, stroke, or CV death (ρ=0.428; P &lt;0.0001) (Figure 2). Furthermore, patients with higher MHR levels had a significantly smaller number of years of CVD-free life expectancy (ρ=-0.364; P &lt;0.0001) (Figure 3).

Conclusion

MHR can represent a valid tool to predict the recurrence of CVD in CKD patients with diabetes. This easy-to-perform marker of oxidative stress and CVD risk can be used alone or in a multiple biomarker panel, improving the stratification and management of patients with comorbidities and risk of life- threatening conditions.

Kidney Biopsy in Type 2 Diabetic Patients: Critical Reflections on Present Indications and Diagnostic Alternatives

Roughly 3% of patients worldwide with a new diagnosis of type 2 diabetes mellitus (T2DM) already have an overt nephropathy at diagnosis and about 20-30% of the remaining ones develop a complication of this kind later in life. The early identification of kidney disease in diabetic patients is important as it slows its progression, which is important not only because this reduces the need for renal replacement therapy, but also because it decreases the high rate of mortality and morbidity associated with a reduction in kidney function. The increasing prevalence of type 2 diabetes and the consequent greater probability of finding different types of kidney diseases in diabetic patients frequently gives rise to overlapping diagnoses, a definition encompassing the differential diagnosis between diabetic and non-diabetic kidney disease. The issue is made more complex by the acknowledgement of the increasing frequency of presentations of what is termed "diabetic kidney disease" without relevant proteinuria, in particular in T2DM patients. Distinguishing between diabetes related and non-diabetes related forms of kidney disease in diabetic patients is not only a semantic question, as different diseases require different clinical management. However, while the urologic and macrovascular complications of diabetes, as well as overlapping parenchymal damage, can be diagnosed by means of imaging studies, often only a kidney biopsy will make a differential diagnosis possible. In fact, the coexistence of typical diabetic lesions, such as nodular glomerulopathy or glomerulosclerosis, with different glomerular, vascular and tubulo-interstitial alterations has been extensively described, and an analysis of the dominant histological pattern can contribute to determining what therapeutic approach should be adopted. However, due to the high frequency of kidney diseases, and to the fact that T2DM patients are often affected by multiple comorbidities, a kidney biopsy is not generally performed in T2DM patients. What follows is a review aiming to discuss the diagnostic work-up, on the base of clinical, laboratory and imaging criteria, and evaluate the present indications and alternatives to renal biopsy.

Kidney Disease in Diabetic Patients: From Pathophysiology to Pharmacological Aspects with a Focus on Therapeutic Inertia

Diabetes mellitus represents a growing concern, both for public economy and global health. In fact, it can lead to insidious macrovascular and microvascular complications, impacting negatively on patients' quality of life. Diabetic patients often present diabetic kidney disease (DKD), a burdensome complication that can be silent for years. The average time of onset of kidney impairment in diabetic patients is about 7-10 years. The clinical impact of DKD is dangerous not only for the risk of progression to end-stage renal disease and therefore to renal replacement therapies, but also because of the associated increase in cardiovascular events. An early recognition of risk factors for DKD progression can be decisive in decreasing morbidity and mortality. DKD presents patient-related, clinician-related, and system-related issues. All these problems are translated into therapeutic inertia, which is defined as the failure to initiate or intensify therapy on time according to evidence-based clinical guidelines. Therapeutic inertia can be resolved by a multidisciplinary pool of healthcare experts. The timing of intensification of treatment, the transition to the best therapy, and dietetic strategies must be provided by a multidisciplinary team, driving the patients to the glycemic target and delaying or overcoming DKD-related complications. A timely nephrological evaluation can also guarantee adequate information to choose the right renal replacement therapy at the right time in case of renal impairment progression.

Maternal and Fetal Outcomes of Pregnancy in Nephrotic Syndrome Due to Primary Glomerulonephritis

Chronic kidney disease (CKD) affects 3% of pregnancies, impacting on maternal and fetal outcomes, and at the same time, a recurrent question in nephrology regards gestation impact on kidney function. Observational studies stated that CKD stage, pre-existent hypertension, and proteinuria are the main predictors of possible complications, such as maternal CKD progression, maternal or fetal death, prematurity, small for gestational age (SGA) newborn, or admission to the neonatal intensive care unit. In this regard, given the prominence of proteinuria among other risk factors, we focused on primary nephrotic syndrome in pregnancy, which accounts for 0.028% of cases, and its impact on materno-fetal outcomes and kidney survival. Data extracted from literature are scattered because of the small cohorts investigated in each trial. However, they showed different outcomes for each glomerular disease, with membranous nephropathy (MN) having a better maternal and fetal prognosis than focal and segmental glomerulosclerosis (FSGS), membranoproliferative glomerulonephritis (MPGN), or minimal change disease (MCD). Nephrotic syndrome does not have to discourage women to undertake a pregnancy, but the correct management may include a specific evaluation of risk factors and follow-up for adverse materno-fetal events and/or maternal kidney disease progression.

SO034A NEW MARKER OF RESISTANT HYPERTENSION IN CKD PATIENTS

Background and Aims

Monocytes -HDL ratio (MHR), has emerged as a possible marker of inflammation and oxidative stress (OS), demonstrating its possible use in the population with Chronic Kidney Disease (CKD). These effects seem to be modulated by an increased lipid production, by reduced cellular catabolism of fatty acids and by the alteration of the antioxidant, anti-inflammatory mechanisms and the reverse cholesterol transport of HDL. The latter to exert favorable effects on inflammatory and oxidative pathway. The purpose of our research is to evaluate the link between MHR and resistant hypertension (RH) which, together with inflammation, OS and atherosclerosis, represents a widespread feature in the population with CKD and carries a greater risk of premature death due to cardiovascular disease.

Method

A retrospective study has been performed on 251 hypertensive patients, admitted in the last 6 months to the Unit of Nephrology and Dialysis of the Policlinic G. Martino of Messina, Italy. 80 patients were diagnosed with RH, defined as blood pressure that remains above 140/90 mmHg despite use of three different classes of antihypertensive medications (one of which must be a diuretic) at the maximum tolerated doses.

We evaluated the distribution of data with Kolmogorov-Smirnov test and, considering that MHR had a non-normal distribution, we expressed the values as medians and interquartile ranges (IQR). Moreover, differences between groups with Mann-Whitney test, correlations with Rank Correlation and Spearman's Rho coefficient were also considered in the analysis. Finally, we assessed the differences of variables between the means of different groups with ANOVA test using multiple regression to valuate independent relations between variables.

Results

MHR appeared to be positively correlated with serum creatinine levels (ρ=0.24; P=0.0001) (Figure 1). MHR correlated with the number of antihypertensive drugs per patient in the entire cohort of patients (F = 18.23; P &lt;0.001) (Figure 2). Patients with RH had a significantly higher MHR than patients without resistant hypertension (0.1493 [IQR 0.12 - 0.18] versus 0.11 [IQR 0.0 - 0.13], P &lt;0.0001) (Figure 3).

Conclusion

MHR has proven to be an accurate tool in quantifying inflammatory status and OS, whose effectiveness lies in the close correlation that exists between HDL and monocytes. HDL prevent and reverse the recruitment of monocytes in the arterial wall and their activation through a decrease in their F-actin content, thereby reducing the expression of CD11b on monocytes, and modulating their adhesion to the endothelium. Our study showed that MHR could be a useful and immediate tool to evaluate OS and inflammatory status in order to select high-risk patients and identify earlier and appropriate treatment strategies.

P0443ONE YEAR AFTER PROTEINURIA IN LUPUS NEPHRITIS: EURO LUPUS VS MYCOPHENOLATE, A SINGLE-CENTER EXPERIENCE

Background and Aims

Lupus nephritis (LN) develops in about 50% of patients affected by Systemic Lupus Erythematosus (SLE) and it is associated with higher morbidity and mortality risk. Approximately 10 % of LN patients is expected to reach end stage renal disease (ESRD). Proteinuria at 1 year has been demonstrated as the best predictor factor of long-term renal outcome. We compared the effects of two different induction therapies (Euro Lupus protocol [EL] vs Mycophenolate [MMF]) in terms of eGFR, proteinuria, serum albumin and complement activation in LN patients related to our centre.

Method

We retrospectively reviewed the records of 34 adult patients with LN from 2011 to 2019. Patients were divided in two groups according to therapeutic strategy chosen: EL (n=21 patients, group 1) and MMF (n=13, group 2). Data with normal distribution are expressed as average ± standard deviation, while data with non normal distribution are referred to as median and interquartile range [IQR]. Basal values of eGFR, proteinuria, albumin and complement were compared to 1 year values with Student t-test for normal variables or with Wilcoxon test for non normal variables.

Results

The mean age of the patients was 41.27±17.43 years, there was a predominance of female (85,3%) LN was diagnosed at 32±16 years old. According to LN classification, 88.2% of them was affected by III, IV, V and mixed LN class Basal values of eGFR (estimated with CKD-EPI method) were similar between groups 1 and 2 (86.12±52.86 vs 73.75±30.35, P=0.4890) as well as proteinuria (2.00 [0.48-4.57] vs 0.71 [0.28-1.39] g/24h, P=0.3284). After one year of follow up, eGFR did not show significant differences between two groups, while proteinuria was significantly lower in group 1 (2.)). 00 [0.48-4.57] vs 0.44 [0.19-0.91] g/24h, P=0.0034) than in group 2 (0.71 [0.28-1.39] vs 0.15 [0.08-0.77] g/24h, P=0.4687) (fig.1). Moreover, we recorded in group 1 higher values of albumin after one year of follow up (3.20 [2.52-3.94] vs 4.33 [3.99-4.57] g/dl, P=0.0195) (fig.2) and C3 consumption (35.00 [1.00-81.25] vs 89.00 [2.00-112.50] mg/dl, P=0.0067) (fig.3), while group 2 did not show any statistically significant differences.

Conclusion

In patients affected by LN, EL protocol demonstrated to be more effective than MMF in reducing one year after proteinuria, thus improving albumin and C3 serum titer.

P0491THE ROUTE TO INDIVIDUALIZED THERAPIES IN PRIMARY MEMBRANOUS NEPHROPATHY: BMI AND KIDNEY OUTCOMES

Background and Aims

A real progress in treating patients more than diseases, would rest on tailored medicine and go beyond the hypothesis that “one size fits all”. Glomerular diseases are not an exception to this consideration, and deserve case-by-case evaluation for choosing both the most suitable therapeutic agent and its appropriate dose, because a standardized treatment may result in worse prognosis.

We analyzed the role of body mass index (BMI) in modifying renal outcomes of patients with nephrotic syndrome due to membranous nephropathy (MN) treated with immunosuppressive drugs.

Method

We performed a retrospective analysis of 29 MN patients related to our center (M 19, F 10), checking their anti PLA2R status at kidney biopsy time and any change in proteinuria, serum creatinine (SCr) and body mass index (BMI) between diagnosis and at last follow-up visit, in search of a correlation with their response to immunosuppressive treatment. Data with non normal distribution are expressed as median and interquartile range [IQR].

Results

The median follow-up of our patients lasted 49 months [IQR 14-80]. At biopsy time, almost half of them was anti-PLA2R positive (n=14 subjects) while the other resulted to be negative and were thus screened for secondary causes of MN (n=15). Irrespective either of anti-PLA2R status or the administration of Ponticelli regimen or Rituximab, complete remission was achieved in 31% of patients, while 34.5% experienced a partial remission and 34.5% resulted non responder to at least a therapeutic protocol. Median proteinuria reduction was of 3.732g/24h [IQR 7.636-1.77 g/24h]. Median rise in SCr was 0.140 mg/dl [IQR -0.11 – 0.4 mg/dl]. Direct association between the proteinuria/BMI ratio at diagnosis and remission of proteinuria at last follow up was statistically significant (r=-0.7506; P&lt;0.0001) (Fig.1).

Conclusion

Albeit remission is not directly correlated with basal BMI, our results appear to confirm that an appropriate drug posology, not only according to patients’ renal or hepatic function but also to their body mass, may result in more effective individualized therapies in MN; nevertheless, this recorded association must be confirmed by large scale randomized clinical trials.

P1845HISTORY AND FUTURE PERSPECTIVES OF PAROXYSMAL NOCTURNAL HEMOGLOBINURIA

Background and Aims

Paroxysmal nocturnal hemoglobinuria (PNH) is a rare clonal disorder that affects about 1-1,5 cases per million individuals, characterized by hemolysis, peripheral blood cytopenia, bone marrow dysfunction, thrombosis, renal impairment and arterial and pulmonary hypertension.

The first case of PNH was probably described in 1793 by a surgeon, Dr Charles Stewart, in the medical commentaries “Account of a singular periodical discharge of blood from the urethra”. In the following decades several cases have been reported by the most eminent physicians and scientists of the time.

Method

In 1882 Paul Strübing was the first to identify PNH as a new disease entity. Hijmans in 1911 considered the possibility that the complement system mediated the hemolysis of PNH erythrocytes and in the same year, Italian scientists Ettore Marchiafava and Nazari scrupulously described the pathogenesis of the affection.

In the 1925 Enneking introduced for the first time the name “paroxysmal nocturnal hemoglobinuria”, to define this pathology.

Results

Despite the increased knowledge of this syndrome, therapies for PNH were still only experimental and symptomatic, with the use of antimicrobial agents, corticosteroids and blood transfusions. The natural history of PNH changed remarkably only in the 2007, with the introduction of Eculizumab complement blockade agent. The Ravulizumab, a long-acting C5 complement inhibitor approved on December 2018 by the U.S. food and drug Administration (FDA), and on July 2019 by the European Commission, represent a new promising instrument for PNH treatment.

Conclusion

Second generation of anti-complement agents are currently under investigation, representing future promising instruments for the treatment of PNH.

Complement Inhibition Therapy and Dialytic Strategies in Paroxysmal Nocturnal Hemoglobinuria: The Nephrologist's Opinion

Paroxysmal nocturnal hemoglobinuria (PNH) is a rare clonal disease that presents an estimated incidence of 1.3 cases per million per year, with a prevalence of 15.9 cases per million. It is characterized by hemolysis, bone marrow dysfunction with peripheral blood cytopenia, hypercoagulability, thrombosis, renal impairment and arterial and pulmonary hypertension. Hemolysis and subsequent hemosiderin accumulation in tubular epithelium cells induce tubular atrophy and interstitial fibrosis. The origin of PNH is the somatic mutation in the X-linked phosphatidylinositol glycan class A (PIG-A) gene located on Xp22: this condition leads to the production of clonal blood cells with a deficiency in those surface proteins that protect against the lytic action of the activated complement system. Despite the increased knowledge of this syndrome, therapies for PNH were still only experimental and symptomatic, until the introduction of the C5 complement blockade agent Eculizumab. A second generation of anti-complement agents is currently under investigation, representing future promising therapeutic strategies for patients affected by PNH. In the case of chronic hemolysis and renal iron deposition, a multidisciplinary approach should be considered to avoid or treat acute tubular injury or acute kidney injury (AKI). New promising perspectives derive from complement inhibitors and iron chelators, as well as more invasive treatments such as immunoadsorption or the use of dedicated hemodialysis filters in the presence of AKI.

Association of Higher Advanced Oxidation Protein Products (AOPPs) Levels in Patients with Diabetic and Hypertensive Nephropathy

Background and Objectives: Diabetes mellitus (DM) and hypertension (HT) are characterized by cell damage caused by inflammatory and metabolic mechanisms induced by alteration in reduction-oxidative status. Serum advanced oxidation protein products (AOPP) are new markers of protein damage induced by oxidative stress. We evaluated serum levels of AOPP in a cohort of patients with DM and HT, with or without renal complications, compared with a control healthy population. Materials and Methods: The study group comprised of 62 patients with type 2 DM and 56 with HT. The 62 patients affected by DM were further distinguished in 24 subjects without renal impairment, 18 with diabetic nephropathy (DN), 20 with chronic kidney disease (CKD) stage 2–3 secondary to DN. The subgroup of 56 patients with primary HT comprised 26 subjects without renal complications and 30 with CKD (stage 2–3) secondary to HT. Thirty healthy controls, matched for age and sex, were recruited among blood donors. Results: Increased AOPP levels were found in DM patients compared with healthy subjects, although not significantly. This index was higher and more significant in patients with DN and CKD secondary to DN than in DM patients without nephropathy (p < 0.05) or controls (p < 0.0001). Patients with HT and with kidney impairment secondary to HT also had significantly higher AOPP serum levels than controls (p < 0.01 and p < 0.0001, respectively). There were no significant differences in mean AOPP levels among DM and HT patients. Conclusion: Our study showed that oxidative stress was higher in diabetic or hypertensive subjects than in healthy controls and, in particular, it appeared to be more severe in patients with renal complications. We suggest that the assessment of AOPP in diabetic and hypertensive patients may be important to predict the onset of renal failure and to open a new perspective on the adoption of antioxidant molecules to prevent CKD in those settings.

Role of Vitamin D Status in Diabetic Patients with Renal Disease

Diabetes mellitus (DM) poses a major public health problem worldwide, with ever-increasing incidence and prevalence in recent years. The Institute for Alternative Futures (IAF) expects that the total number of people with type 1 and type 2 DM in the United States will increase by 54%, from 19,629,000 to 54,913,000 people, between 2015 and 2030. Diabetic Nephropathy (DN) affects about one-third of patients with DM and currently ranks as the first cause of end-stage kidney disease in the Western world. The complexity of interactions of Vitamin D is directly related with progressive long-term changes implicated in the worsening of renal function. These changes result in a dysregulation of the vitamin D-dependent pathways. Various studies demonstrated a pivotal role of Vitamin D supplementation in regression of albuminuria and glomerulosclerosis, contrasting the increase of glomerular basement membrane thickening and podocyte effacement, with better renal and cardiovascular outcomes. The homeostasis and regulation of the nephron’s function are absolutely dependent from the cross-talk between endothelium and podocytes. Even if growing evidence proves that vitamin D may have antiproteinuric, anti-inflammatory and renoprotective effects in patients with DN, it is still worth investigating these aspects with both more in vitro studies and randomized controlled trials in larger patient series and with adequate follow-up to confirm the effects of long-term vitamin D analogue supplementation in DN and to evaluate the effectiveness of this therapy and the appropriate dosage.

Emerging therapeutic strategies for minimal change disease and focal and segmental glomerulosclerosis

INTRODUCTION

Minimal change disease (MCD) and Focal and segmental glomerulosclerosis (FSGS) are two of the major causes of nephrotic syndrome (NS) in children and adults. According to KDIGO (Kidney Disease: Improving Global Outcomes) guidelines, the treatment of adult primary MCD and FSGS should be based on immunosuppressants and antiproteinuric drugs. Recently, Rituximab, a humanized monoclonal antibody (mAb) has emerged as a potential treatment for steroid or calcineurin inhibitor-dependent patients; it has however demonstrated lower efficacy in those with nephrotic syndrome that is resistant to the above indicated drugs.

AREAS COVERED

Analysis of ongoing and already completed clinical trials, retrieved from clinicaltrials.gov, clinicaltrialsregister.eu and PubMed involving new therapies for nephrotic syndrome secondary to MCD and FSGS.

EXPERT OPINION

The most promising drugs under investigation for MCD and FSGS are mAbs. We are hopeful that new therapeutic options to treat multi-drug resistant MCD and FSGS will emerge from currently ongoing studies. What appears certain is the difficulty in enrolling patients affected by orphan renal diseases and the selection of valid endpoints in clinical trials, such as kidney failure.

Transcription factors PRE3 and WOX11 are involved in the formation of new lateral roots from secondary growth taproot in A. thaliana

The spatial deployment of lateral roots determines the ability of a plant to interact with the surrounding environment for nutrition and anchorage. This paper shows that besides the pericycle, the vascular cambium becomes active in Arabidopsis thaliana taproot at a later stage of development and is also able to form new lateral roots. To demonstrate the above, we implemented a two-step approach in which the first step leads to development of a secondary structure in A. thaliana taproot, and the second applies a mechanical stress on the vascular cambium to initiate formation of a new lateral root primordium. GUS staining showed PRE3, DR5 and WOX11 signals in the cambial zone of the root during new lateral root formation. An advanced level of wood formation, characterized by the presence of medullar rays, was achieved. Preliminary investigations suggest the involvement of auxin and two transcription factors (PRE3/ATBS1/bHLH135/TMO7 and WOX11) in the transition of some vascular cambium initials from a role as producers of xylem/phloem mother cells to founder cells of a new lateral root primordium.

C3 glomerulopathy in cystic fibrosis: a case report

Background

C3 glomerulonephritis is a rare glomerulopathy characterized at renal biopsy by C3 deposition, alone or with scanty immunoglobulins, as well as by an electron-dense material in mesangium, subendothelial and subepithelial space. An abnormal systemic activation of the alternative pathway of the complement cascade is responsible for the development of the disease if triggered by several possible environmental conditions. We report the first case in literature of a patient affected by cystic fibrosis and C3GN.

Case presentation

Our case involves a young woman with cystic fibrosis, who had persistent microscopic hematuria, proteinuria and hypocomplementemia C3 for over three months. Renal biopsy confirmed the diagnosis of C3 glomerulopathy. Complement system dysregulation was tested and resulted in a strong terminal pathway activation proved by high levels of sC5b-9 complex, amounting to 1588 ng/ml (normal value < 400 ng/ml). Next generation sequencing (NGS) showed polymorphism in CFH (p.V62I in SCR1) and THBD (p.A473V), already known as pathogenic for C3GN, as well as a mutation in C3 (p.R102G) associated only with age-related macular degeneration (AMD) so far. Treatment was based on ACE inhibitors and kidney function is currently stable (GFR 50 ml/min, serum creatinine 1.7).

Conclusions

The co-existence of C3 glomerulopathy in a patient with CF, which is characterized by chronic infection/inflammation, makes this case an interesting model of chronic altered systemic activation of the alternative pathway of the complement cascade.

[Long-term outcome of renal function in women with preeclampia and pregestational diabetes]

Pre-eclampsia (PE) is an important cause of acute renal failure and an important risk marker for subsequent chronic kidney disease. In normal pregnancy, there are marked changes in the renin-angiotensin system (RAS) including considerably elevated angiotensin II (ang II) levels. However, vascular resistance decreases markedly during normal pregnancy, suggesting that pregnant individuals are less sensitive to ang II than non-pregnant individuals. In contrast, during PE decreased circulating components of the RAS with enhanced sensitivity of ang II infusion have been reported. Patients with a history of PE have an increased risk of microalbuminuria with a prevalence similar to subjects with type 1 diabetes mellitus. Women with gestational or chronic hypertension were at a high risk of end-stage renal disease (ESRD) vs. normotensive ones, but the risk is much greater for women who had PE or eclampsia than those who had gestational hypertension only. A previous episode of PE should suggest long-term follow-up, especially with respect to hypertension and microalbuminuria within 6-8 weeks of delivery, and should require a nephrological consult if these disorders do not resolve. Pregestational diabetes was also associated with long-term increased risk of ESRD and death. Lastly, women who have PE and give birth to offspring with low birth weight and short gestation have a substantially increased risk for having a later kidney biopsy. For all these reasons, short and long-term evaluation of kidney function should be suggested in women with previous complicated pregnancy.

Autoimmune Thyroiditis and Glomerulopathies

Autoimmune thyroiditis (AIT) is generally associated with hypothyroidism. It affects ~2% of the female population and 0.2% of the male population. The evidence of thyroid function- and thyroid autoantibody-unrelated microproteinuria in almost half of patients with AIT and sometimes heavy proteinuria as in the nephrotic syndrome point to a link of AIT with renal disease. The most common renal diseases observed in AIT are membranous nephropathy, membranoproliferative glomerulonephritis, minimal change disease, IgA nephropathy, focal segmental glomerulosclerosis, antineutrophil cytoplasmic autoantibody (ANCA) vasculitis, and amyloidosis. Different hypotheses have been put forward regarding the relationship between AIT and glomerulopathies, and several potential mechanisms for this association have been considered. Glomerular deposition of immunocomplexes of thyroglobulin and autoantibodies as well as the impaired immune tolerance for megalin (a thyrotropin-regulated glycoprotein expressed on thyroid cells) are the most probable mechanisms. Cross-reactivity between antigens in the setting of genetic predisposition has been considered as a potential mechanism that links the described association between ANCA vasculitis and AIT.