Placental and Renal Pathways Underlying Pre-Eclampsia

Pre-eclampsia is a serious complication of pregnancy characterized by a state of multiorgan hypertensive disorders, with or without proteinuria and possible multiorgan dysfunction. Chronic kidney disease is an established risk factor for the development of pre-eclampsia, as angiogenic homeostasis is altered and the maternal circulation is already hypertensive. Facing pre-eclampsia in the context of chronic kidney disease is a challenging emergency for both the mother and the fetus. The clinical features and the management of this multi-organ disorder are clearly defined in the modern literature but the underlying pathophysiologic mechanisms remain not fully elucidated. Understanding the pathophysiology that mediates the onset of pre-eclampsia itself and in synergy with chronic kidney disease is fundamental for developing prompt prevention strategies, treatment planning, and patient counseling. This review aims to summarize the main molecular mechanisms involved in the process of pre-eclampsia, with a particular focus on the role of the kidneys and hormonal pathways related to renal function in normal pregnancy and pre-eclamptic syndromes.

Perceptions of Teamwork and Knowledge Attitudes of Hemodialysis Unit Nurses on Infection Prevention

INTRODUCTION

The Nurses of Hemodialysis Units: it is necessary to face HAIs (hospital-acquired infections) as a "well-tuned" teamwork. The aim of this study was to investigate the perceptions of the teamwork as well as the knowledge attitudes of the nurses of hemodialysis units on infection prevention in Greece.

METHODOLOGY

A cross-sectional survey was conducted with a sample of 1018 HCWs (health care workers) of hemodialysis units in Greece. The questionnaires used were: Teamwork Perceptions Questionnaire (T-TPQ) TeamSTEPPS®-Instructor Manual, and questionnaire APPENDIX A.

RESULTS

The majority of them were nurses (69.45%) and nurse assistants (23.87%). About teamwork perceptions per factor, we observed uniformity in their responses with very high rates of agreement. The attitudes of nurses of hemodialysis units on the prevention of infections were distinguished in particularly high rates of compliance with a high perception of the risk of transmission of infections with better compliance being that of women. Also, women seem to be more knowledgeable about diseases that mostly affect the pediatric population. It seemed that level of knowledge between the two sexes did not differ regarding HBV (63.16% vs. 66.71%, p = 0.430), HCV (63.91% vs. 66.71%, p = 0.553), HIV infection (78.95% vs. 81.76%, p = 0.471), and influenza (55.64% vs. 59.61%, p = 0.394).

CONCLUSIONS

This study highlighted for the first time the high level of perceptions of teamwork of the HCWs of the hemodialysis units in Greece. It is recommended to investigate the correct application of prevention measures and to detect the causes of deviation from good practices with subsequent investigations on hemodialysis units of Greece.

The Role of Heme Oxygenase-1 as an Immunomodulator in Kidney Disease

The protein heme oxygenase (HO)-1 has been implicated in the regulations of multiple immunological processes. It is well known that kidney injury is affected by immune mechanisms and that various kidney-disease forms may be a result of autoimmune disease. The current study describes in detail the role of HO-1 in kidney disease and provides the most recent observations of the effect of HO-1 on immune pathways and responses both in animal models of immune-mediated disease forms and in patient studies.

Association Between Vaccination Status and Mortality Among Intubated Patients With COVID-19-Related Acute Respiratory Distress Syndrome

IMPORTANCE

Although vaccination substantially reduces the risk of severe COVID-19, it is yet unknown whether vaccinated patients who develop COVID-19 and require invasive mechanical ventilation have lower mortality than controls.

OBJECTIVE

To examine the association between COVID-19 vaccination status and mortality among critically ill patients who require invasive mechanical ventilation owing to acute respiratory distress syndrome (ARDS) related to COVID-19.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter cohort study was performed between June 7, 2021, and February 1, 2022, among 265 consecutive adult patients with COVID-19 in academic intensive care units who underwent invasive mechanical ventilation owing to ARDS.

EXPOSURES

Patients in the full vaccination group had completed the primary COVID-19 vaccination series more than 14 days but less than 5 months prior to intubation. This time threshold was chosen because guidelines from the US Centers for Disease Control and Prevention recommend a booster dose beyond that time. The remaining patients (ie, those who were unvaccinated, partially vaccinated, or fully vaccinated <14 days or >5 months before intubation) comprised the control group.

MAIN OUTCOMES AND MEASURES

The primary outcome was time from intubation to all-cause intensive care unit mortality. A Cox proportional hazards regression model including vaccination status, age, comorbid conditions, and baseline Sequential Organ Failure Assessment score on the day of intubation was used.

RESULTS

A total of 265 intubated patients (170 men [64.2%]; median age, 66.0 years [IQR, 58.0-76.0 years]; 26 [9.8%] in the full vaccination group) were included in the study. A total of 20 patients (76.9%) in the full vaccination group received the BNT162b2 vaccine, and the remaining 6 (23.1%) received the ChAdOx1 nCoV-19 vaccine. Patients in the full vaccination group were older (median age, 72.5 years [IQR, 62.8-80.0 years] vs 66.0 years [IQR, 57.0-75.0 years]) and more likely to have comorbid conditions (24 of 26 [92.3%] vs 160 of 239 [66.9%]), including malignant neoplasm (6 of 26 [23.1%] vs 18 of 239 [7.5%]), than those in the control group. Full vaccination status was significantly associated with lower mortality compared with controls (16 of 26 patients [61.5%] died in the full vaccination group vs 163 of 239 [68.2%] in the control group; hazard ratio, 0.55 [95% CI, 0.32-0.94]; P = .03).

CONCLUSIONS AND RELEVANCE

In this cohort study, full vaccination status was associated with lower mortality compared with controls, which suggests that vaccination might be beneficial even among patients who were intubated owing to COVID-19-related ARDS. These results may inform discussions with families about prognosis.

Evaluation of Pupils' Knowledge about Kidney Health

The purpose of this study was to investigate the level of renal function knowledge of primary school pupils in Greece. We conducted a cross-sectional study with a convenience sample of 220 pupils, coming from the 5th and 6th grades of general education schools. A questionnaire consisting of 11 questions was developed from scratch. However, based on an analysis of Cronbach's alpha values obtained when individual questions were deleted, two questions were removed from the analysis, and only nine remained for analysis and participated in the calculation of the knowledge score. Moreover, the gender and daily habits of pupils regarding water consumption and frequency of urination were recorded. Pupils had a high percentage of correct knowledge about the number of kidneys (95.2%), whether a child may have problems with the kidneys (85.5%) and whether a person can survive with one kidney (68.5%). Low levels of knowledge were observed in the function and role of the kidneys (36.4%), as well as the part of the body where the kidneys are located (30.9%). The median (interquartile range (IQR)) total knowledge score was 6 (5-7), with no difference detected between genders (p = 0.135). A statistically significant difference between pupils of 5th and 6th grades was found but the difference did not seem to be clinically significant (p = 0.035). The present research demonstrates that pupils' knowledge of renal function and the protection of their kidneys needs improvement.

Generation of a novel decay accelerating factor (DAF) knock-out rat model using clustered regularly-interspaced short palindromic repeats, (CRISPR)/associated protein 9 (Cas9), genome editing

Decay accelerating factor (DAF), a key complement activation control protein, is a 70 kDa membrane bound glycoprotein which controls extent of formation of the C3 and C5 convertases by accelerating their decay. Using clustered regularly-interspaced short palindromic repeats, (CRISPR)/associated protein 9 (Cas9) genome editing we generated a novel DAF deficient (Daf^-/-) rat model. The present study describes the renal and extrarenal phenotype of this model and assesses renal response to complement-dependent injury induced by administration of a complement-fixing antibody (anti-Fx1A) against the glomerular epithelial cell (podocyte). Rats generated were healthy, viable and able to reproduce normally. Complete absence of DAF was documented in renal as well as extra-renal tissues at both protein and mRNA level compared to Daf^+/+ rats. Renal histology in Daf^-/- rats showed no differences regarding glomerular or tubulointerstitial pathology compared to Daf^+/+ rats. Moreover, there was no difference in urine protein excretion (ratio of urine albumin to creatinine) or in serum creatinine and urea levels. In Daf^-/- rats, proteinuria was significantly increased following binding of anti-Fx1A antibody to podocytes while increased C3b deposition was observed. The DAF knock-out rat model developed validates the role of this complement cascade regulator in immune-mediated podocyte injury. Given the increasing role of dysregulated complement activation in various forms of kidney disease and the fact that the rat is the preferred animal for renal pathophysiology studies, the rat DAF deficient model may serve as a useful tool to study the role of this complement activation regulator in complement-dependent forms of kidney injury.

Primary adrenal leiomyosarcoma: A case report

Adrenal leiomyosarcomas are rare mesenchymal tumors of the suprarenal region that are usually diagnosed after they have reached a large size. We report the case of a 62-year-old male with an incidentally found left adrenal mass. Magnetic resonance imaging of the retroperitoneal space showed a heterogeneously enhanced mass, measuring 10x8.2 cm, with characteristics suspicious of malignancy. The patient underwent left radical adrenalectomy after the hormonal evaluation of the tumor due to the high probability of adrenocortical carcinoma. However, microscopic examination of the tumor showed a spindle cell sarcoma. Immunohistochemically the neoplastic cells were found positive for desmin and smooth muscle actin and the diagnosis of a well differentiated adrenal leiomyosarcoma was established. During follow-up the patient presented an aggressive course as he developed bone, liver and pulmonary metastases early postoperatively, which were treated with radiation therapy and chemotherapy. The patient has progressive metastatic disease while on chemotherapy 31 months after surgery.

Immunosuppressive regimens based on Cyclophospamide or Calcineurin inhibitors: Comparison of their effect in the long term outcome of Primary Membranous Nephropathy

INTRODUCTION

Management of the Primary Membranous Nephropathy (PMN) usually involves administration of immunosuppressives. Cyclophosphamide (Cyclo) and Calcineurin Inhibitors (CNIs) are both widely used but only limited data exist to compare their efficacy in long term follow-up.

AIM

The aim of the present study was to estimate and compare long term effects of Cyclo and CNIs in patients with PMN.

PATIENTS-METHODS

Clinical data, histologic findings and long term outcome were retrospectively studied. The response to treatment and rate of relapse was compared between patients treated with CNIs or Cyclo based immunosuppressive regimens.

RESULTS

Twenty three centers participated in the study, with 752 PMN patients (Mean age 53.4(14-87) yrs, M/F 467/285), followed for 10.1±5.7 years. All patients were initially treated with Renin Angiotensin Aldosterone System inhibitors (RAASi) for at least 6 months. Based on their response and tolerance to initial treatment, patients were divided into 3 groups, group I with spontaneous remission, who had no further treatment, group II, continued on RAASi only, and group III on RAASi+immunosuppression. Immunosuppressive regimes were mainly based on CNIs or Cyclo. Frequent relapses and failure to treatment were more common between patients who had started on CNIs (n = 381) compared to those initially treated with Cyclo (n = 110), relapse rate: 25.2% vs. 6.4%, p<0.0001, and no response rate: 22.5% vs. 13.6%, p = 0.04, respectively.

CONCLUSIONS

Long term follow up showed that administration of Cyclo in PMN is followed by better preservation of renal function, increased response rate and less frequent relapses, compared to CNIs.

Swift Cure of a Chronic Wound Infected With Multiresistant Staphylococcus aureus in an Elderly Patient With Stage 5 Renal Disease

We present a case of a 91-year-old female with stage 5 renal disease, diabetes type 2, and considerable weakness, suffering from a 2-month-old wound infected by a multiresistant Staphylococcus aureus. The wound measured 7 cm in length, 5 cm in width, and 1.5 cm in depth, having purulent white edges and exudates exceeding the size of the wound. The systemic antibiotic use was opposing to improve the patient's clinical condition due to underlying nephrotoxicity that may have deteriorated renal failure and resistance of the infecting pathogen. The halogenated taurine (Tau) derivatives N-chlorotaurine (NCT) and N-bromotaurine (NBrT) with potent anti-inflammatory and antimicrobial efficacy were alternatively employed as combination topical treatment to provide a therapeutic solution. Each agent was applied separately with an interval of 5 minutes as a 1% spray in aqueous solution every 30 minutes during the day for 3 days. This treatment was very well tolerated and led to rapid disappearance of the purulent exudate, rapid epithelialization, and complete healing. To avoid relapse, the application was continued 4 times daily for a further 4 days. No complications occurred in the course of treatment. This case report confirms the therapeutic efficacy of NCT in chronic purulent wounds. NBrT is well tolerated, too, and can be used in combination with NCT in emergency clinical settings. Its potential as a single agent should be investigated in further studies. Advancement of wound closure by these agents proved to be life-saving for this patient. Further molecular research is needed to identify mechanisms that promote wound healing.

Serum Endocan Levels are Associated With Paraoxonase 1 Concentration in Patients With Chronic Kidney Disease

Endocan is a soluble proteoglycan released by the vascular endothelium. The increase of its serum levels is associated with inflammation, endothelial dysfunction and cardiovascular events in patients with chronic kidney disease (CKD). We studied the association of serum endocan with the lipid profile of 105 CKD patients with dyslipidemia, divided in two groups, non-dialyzed (CKD, N = 57) and hemodialysis (HD, N = 48) in comparison with 30 normal controls (NC). We also analyzed endocan in relation with the concentration of two serum HDL-linked members of the paraoxonase (PON) family, PON1 and PON3, which have been previously found to have antiatherogenic properties. The results showed that endocan levels were significantly higher in HD patients than in CKD patients (P < 0.001) and NC (P < 0.001). PON1 was significantly decreased only in HD patients compared to NC (P < 0.001), whereas PON3 was significantly increased in both patient groups (P < 0.001). Endocan levels were significantly and positively correlated with total cholesterol and LDL-C in CKD and additionally were negatively correlated with HDL-C in HD group. PON1 levels were significantly correlated with endocan in both groups, while no correlation was observed for PON3 in either group. Multiple regression analysis between endocan and the above lipid parameters in the total of patients revealed that endocan was independently associated only with PON1 (β = -0.513, P = 0.002). It is concluded that the increase of serum endocan levels in patients with CKD may be associated with the decrease of PON1 concentration, irrespective of lipid alterations produced by atherosclerosis development.

Factors influencing first vascular access placement in patients starting hemodialysis

BACKGROUND

The aim of the study was to assess whether age, gender and the primary renal disease are associated with differences in the type of first vascular access placement.

METHODS

We reviewed the records of 145 patients on hemodialysis (HD) 44 females and 101 males with a mean age of 64±14.5 years, on HD for 46.9±41.2 months (range 1-252).

RESULTS

The primary renal diseases were diabetes (23.4%), hypertension (17.2%), glomerulonephritis (25.7%), cardiac failure (6.9%) and others (26.8%). Double lumen catheter and arteriovenous fistula was the first vascular access in 109 (75%) and 35 patients (24%) patients, respectively. Graft was the first vascular access in 1 patient (0.5%). Arteriovenous fistula was the first choice for 29.7% of the male patients and 9% of the female. Double lumen catheter was the first choice for 70.3% of the male (subclavian 50.5%, femoral 4.95%, and jugular 14.85%) and 86.4% of the female (subclavian 75%, femoral 2.3%, and jugular 9.1%) (P=0.04). Double lumen catheter was the first choice for 79.7% of the patients older than 65 years and 70.4% for the patients younger than 65 years (P=0.19). Double lumen catheter was the first choice for all the patients with cardiac failure as the primary cause of renal disease.

CONCLUSION

Double lumen catheter was the first vascular access for the majority of our patients, probably due to late Nephrologist's referral. Cardiac failure being the primary cause of renal disease and female gender influence also this choice, but not the age of the patients.

Comparison of creatinine clearance estimates in subgroups based on Body Mass Index and albumin

BACKGROUND

The establishment of accurate equations for glomerular filtration rate (GFR) estimations is still far from the realization. Factors such as age, diabetes, stage of CKD, pregnancy, muscle mass and ethic nation are associated with less reliance upon commonly utilized estimation equations. We aimed to compare the routine use of 24-hour creatinine clearance (CrCl) and GFR estimates calculated by Crockoft-Gault (CG) and modification of diet in renal disease (MDRD) formulas in patients with different levels of renal dysfunction in subgroups, based on Body Mass Index (BMI) and serum albumin (Alb) levels.

METHODS

Two hundred and seventy-nine non diabetic patients (172 men and 107 women), aged 54±23 years, with BMI 27.3±4.4 were enrolled in the study. All patients presented creatinine 1.8±1.2 (mg/dL) and Alb 3.5±1.3g/dL. The comparison of CrCl versus CG had bias 3.1 while the comparison of CrCl versus MDRD had a bias of 6.6.

RESULTS

Univariate analysis showed that age, sex and BMI were not significant biases related to the CG, MDRD and CrCl. Indeed, the bias related to the CG was significantly lower than that related to MDRD in patients with either low or high serum albumin. Interestingly, the bias associated with CG was 1.3 in non-diabetic patients with Alb ≤3.5 mg /dL suggesting that CG equation could be used interchangeable to CrCl in these patients.

CONCLUSION

CG gave a better prediction of measured CrCl than MDRD in Mediterranean, non-diabetic, non-hospitalized patients although misclassification of patients with regard to renal impairment stage was not present.

Untreated newly diagnosed essential hypertension is associated with nonalcoholic fatty liver disease in a population of a hypertensive center

Purpose

Recent studies have demonstrated that hypertension (HTN) is associated with nonalcoholic fatty liver disease (NAFLD) in treated hypertensive patients. The aim of this study was to investigate the association between newly diagnosed essential HTN and NAFLD in untreated hypertensive patients.

Patients and methods

A consecutive series of 240 subjects (143 hypertensives and 97 normotensives), aged 30–80 years, without diabetes mellitus were enrolled in the study. Subjects with 24-hour systolic blood pressure (SBP) values ≥130 mmHg and/or diastolic BP values ≥80 mmHg were defined as hypertensives. NAFLD was defined as the presence of liver hyperechogenicity on ultrasound.

Results

Body mass index (P=0.002) and essential HTN (P=0.016) were independently associated with NAFLD in the multivariate logistic regression model. Furthermore, the multivariate analysis revealed that morning SBP (P=0.044) was independently associated with NAFLD.

Conclusion

Untreated, newly diagnosed essential HTN is independently associated with NAFLD. Ambulatory BP monitoring could be used for the diagnosis of essential HTN in patients with NAFLD.

Microcirculatory alterations during continuous renal replacement therapy in ICU: A novel view on the 'dialysis trauma' concept

OBJECTIVE

The purpose of this study was to evaluate microcirculation over 24 h renal replacement therapy (CRRT) in critically ill patients.

METHODS

We conducted a single-center, prospective, observational study, measuring microcirculation parameters, monitored by near infrared spectroscopy (NIRS) before hemodiafiltration onset (H0), and at six (H6) and 24 h (H24) during CRRT in critically ill patients. Serum Cystatin C (sCysC) and soluble (s)E-selectin levels were measured at the same time points. Twenty-eight patients [19 men (68%)] were included in the study.

RESULTS

Tissue oxygen saturation (StO2, %) [76.5 ± 12.5 (H0) vs 75 ± 11 (H6) vs 70 ± 16 (H24), p = 0.04], reperfusion rate, indicating endothelial function (EF, %/sec) [2.25 ± 1.44 (H0) vs 2.1 ± 1.8 (H6) vs 1.6 ± 1.4 (H24), p = 0.02] and sCysC (mg/L) [2.7 ± 0.8 (H0) vs 2.2 ± 0.6 (H6) vs 1.8 ± 0.8 (H24), p < 0.0001] significantly decreased within the 24 h CRRT. Change of EF positively correlated with changes of sCysC within 24 h CRRT (r = 0.464, p = 0.013) while in patients with diabetes the change of StO2 correlated with dose (r = − 0.8, p = 0.01). No correlation existed between hemoglobin and temperature changes with the deteriorated microcirculation indices. sE-Selectin levels in serum were elevated; no difference was established over the 24 h CRRT period. A strong correlation existed between the sE-Selectin concentration change at H6 and H24 and the mean arterial pressure change in the same period (r = 0.77, p < 0.001).

CONCLUSIONS

During the first 24 h of CRRT implementation in critically ill patients, deterioration of microcirculation parameters was noted. Microcirculatory alterations correlated with sCysC changes and with dose in patients with diabetes.

Changes in skeletal muscle microcirculation after a hemodialysis session correlates with adequacy of dialysis

Background

Monitoring of the microcirculation may add additional information in terms of improving the adequacy of hemodialysis (HD) for patients. Withdrawal of liquid and complement activation during a HD session reduces the external pressure on the microcirculation and leads to an increased dilatation of the peripheral capillaries. The purposes of this study were to assess the effect of a single HD or hemodiafiltration session on the thenar microcirculation in patients with end-stage renal disease (ESRD) with or without diabetes, investigate the possible relationship between changes in the microcirculation and adequacy of dialysis (including Kt/V and parameters indicating secondary hyperparathyroidism), and compare microcirculation measurements obtained from patients with ESRD and those from healthy controls.

Methods

This pilot prospective observational study including eleven patients with ESRD on maintenance HD (nine men of mean age 73±10.5 years, ten [91%] with hypertension), nine patients with ESRD on maintenance hemodiafiltration (six men of mean age 65.5±13.2 years, five [55.5%] with diabetes and four [44.5%] with hypertension), and eight healthy volunteers. Two paired microcirculation assessments were recorded for each HD patient before and after a dialysis session. Near infrared spectroscopy and the vascular occlusion test were used to assess the microcirculation, and blood work samples were collected before and after dialysis when the pump slowed down.

Results

Patients with ESRD showed an increase in thenar cell metabolism at rest after a 4-hour HD session, and changes in cell metabolism correlated with the Kt/V of the session. Pre-dialysis tissue oxygen saturation over the 4-hour HD session correlated with pre-dialysis serum calcium and parathyroid hormones. Vascular reactivity was lower in ESRD patients receiving HD or hemodiafiltration than in healthy controls.

Conclusion

Improvement in skeletal muscle microcirculation noted after a HD session was related to adequacy of dialysis. Evaluation of the microcirculation may provide additional information for management of patients on HD and identify novel targets for treatment. These preliminary findings need to be tested using a larger data set.

The role of an out-patient renal clinic in renal disease management

The out-patient renal clinic (ORC) represents an important part of the nephrology service in general hospitals. The majority of renal diseases are chronic and patients need a systematic follow-up according to the severity and progression of kidney failure. The most important clinical manifestation is chronic renal failure (CRF) or chronic renal disease (CKD) The management of CKD, apart from medical and nursing services, also involves a number of community structures and financial resources. CRF treatment is costly and is a serious problem for the health systems in the western world. Effective treatment in the early stages aims to decrease the progression of kidney damage and, therefore, to prolong kidney function. Patients with renal failure can be managed as out-patients. The increased number of patients and the complexity of kidney diseases demand the collaboration of other out-patient clinics. The ORC may play an important role in this process. In this article. we present a literature review of the role of ORCs in the management of renal diseases around the world and we also present data based on our experience in our ORC.

Caregivers' experience in patients with chronic diseases

The aim of this study was to describe the characteristics of caregivers of patients with chronic diseases, assess their perceived burden, and investigate factors influencing this burden. Seventy-three patient-attendants (43 men and 30 women) participated in the pilot-research conducted by two clinics. Of them, 68% attended patients with a malignant disease and 32% attended patients in the end stage of renal disease. Based on questionnaire data, the influence of the social support was studied, in particular that of family members or through state programmers. Family members are the primary caregivers (spouses 51%, children 29%, and others 20%). Psychological support is the main important help that they need and there are a small number of caregivers who have access to a network of medical and social support. It is found that the family still remains the main supporting mechanism for attendants and patients in our population.

Scale up and safety parameters of antigen specific immunoadsorption of human anti-acetylcholine receptor antibodies

Myasthenia gravis is an autoimmune disease usually caused by autoantibodies against the muscle nicotinic acetylcholine receptor (nAChR). Current treatments are not specific, and thus often cause side effects. Here, we elaborate on our previous findings on antigen specific immunoadsorption towards scaling up the method as well as testing whole blood apheresis. The average percent of plasma or whole blood immunoadsorption was up to 79.5%±2.9. Moreover, neither pyrogens were co-administered nor did complement activation occur after immunoadsorption. Thus, antigen-specific apheresis of anti-AChR autoantibodies seems a safe and effective treatment for myasthenia gravis that can be scaled up for clinical testing.

Does the extracorporeal circulation worsen anemia in hemodialysis patients? Investigation with advanced microscopes of red blood cells drawn at the beginning and end of dialysis

BACKGROUND

In hemodialysis (HD) patients, anemia relates to three main factors: insufficient production of erythropoietin; impaired management of iron; and decreased lifespan of red blood cells (RBCs). The third factor can relate to structural deterioration of RBCs due to extrinsic (extracorporeal circuit; biochemical activation and/or mechanical stress during dialysis) and intrinsic (uremic milieu; biochemical interference of the RBC membrane constituents with toxins) mechanisms. Herein, we evaluate information accessed with advanced imaging techniques at the cellular level.

METHODS

Atomic force and scanning electron microscopes were employed to survey intact RBCs (iRBCs) of seven HD patients in comparison to seven healthy donors. The extrinsic factor was investigated by contrasting pre- and post-HD samples. The intrinsic environment was investigated by comparing the microscopy data with the clinical ones.

RESULTS

The iRBC membranes of the enrolled HD patients were overpopulated with orifice-like (high incidence; typical size within 100-1,000 nm) and crevice-like (low incidence; typical size within 500-4,000 nm) defects that exhibited a statistically significant (P < 0.05) relative increase (+55% and +350%, respectively) in respect to healthy donors. The relative variation of the orifice and crevice indices (mean population of orifices and crevices per top membrane surface) between pre- and post-HD was not statistically significant (-3.3% and +4.5%, respectively). The orifice index correlates with the concentrations of urea, calcium, and phosphorus, but not, however, with that of creatinine.

CONCLUSION

Extracorporeal circulation is not detrimental to the structural integrity of RBC membranes. Uremic milieu is a candidate cause of RBC membrane deterioration, which possibly worsens anemia.

Serum hepcidin levels are associated with serum triglycerides and interleukin-6 concentrations in patients with end-stage renal disease

Hepcidin has emerged as a peptide with a key role in the regulation of iron homeostasis in patients with chronic kidney disease (CKD), having a strong dependence on inflammation. Recent studies reveal that hepcidin may be also associated with the progression of atherosclerosis. This study was performed to analyze the relation of hepcidin to markers of atherosclerosis and inflammation in patients on dialysis. A total of 90 individuals were enrolled. Sixty patients with end-stage renal disease, who were on hemodialysis (HD) (N = 30) and peritoneal dialysis (N = 30) were compared with 30 normal controls (NC). Age, body mass index, time on dialysis, serum lipids, C-reactive protein (CRP) and interleukin-6 (IL-6) were measured and analyzed in correlation with hepcidin concentration. It was found that patients on HD and peritoneal dialysis have significantly higher (P < 0.0001) levels of hepcidin, CRP and IL-6 than NC. Hepcidin in dialysis patients is significantly related to age (r = 0.373, P = 0.012), serum triglycerides (r = 0.401, P = 0.005), HDL-C (r = -0.268, P = 0.048), CRP (r = 0.436, P = 0.0007) and IL-6 (r = 0.569, P < 0.0001). In multiple regression analysis, hepcidin correlated independently with triglycerides (β = 0.402, P = 0.041) and IL-6 (β = 0.559, P = 0.006). Moreover, patients with high triglycerides in combination with high IL-6 levels have significantly increased concentrations of hepcidin than those with low triglycerides and low IL-6 levels (P < 0.0001). Elevated levels of hepcidin in patients with CKD on dialysis may be related to the occurrence of high triglycerides and high IL-6 serum concentrations. This probably suggests that hepcidin may play a role to the progression of atherosclerosis and inflammation, but this hypothesis should be further evaluated.

Novel biomarkers of acute kidney injury in the general adult ICU: a review

Acute kidney injury is one of the most frequent problems occurring in the critically ill patients of the intensive care units and it is well established that it increases both morbidity and mortality in these patients. Moreover, despite technological and pharmaceutical advances during the last decades, the incidence as well as the mortality associated with acute kidney injury in these patients remains unchanged. Creatinine, the most common renal dysfunction biomarker in use, has many disadvantages, such as time delay in its increase and the influence by other factors on its serum concentration, such as age, gender, muscle mass, etc. Hence, the need for better renal biomarkers in order to timely intervene for acute kidney injury prevention is imperative. The lack of an early biomarker is an obstacle for the development of new acute kidney injury prevention strategies. With the incidence of acute kidney injury reaching epidemic dimensions, the need for novel markers is urgent. During the last years, the research for finding such biomarkers has been intense. The purpose of the present article is to review the studies which have tested the predictive ability of those markers (in urine and/or plasma) for early detection of acute kidney injury in the mixed adult intensive care unit population and underline the potential limitations encountered in the various studies.

Antigen-specific apheresis of autoantibodies in myasthenia gravis

Myasthenia gravis (MG) is an autoimmune disorder affecting the neuromuscular junction, usually caused by autoantibodies against the acetylcholine receptor (AChR) or the muscle-specific kinase (MuSK). Our aim is the development of a therapy based on the selective extracorporeal elimination of anti-AChR or anti-MuSK antibodies. To this end, the extracellular domains of the AChR subunits and MuSK have been expressed in yeast to be used as adsorbents, after optimization, and to obtain large quantities of proteins with near-native structure. We have characterized these proteins with respect to their use as specific immunoadsorbents for MG autoantibodies, and have begun large-scale experiments in order to verify the feasibility of application of the method for therapy. Furthermore, we have initiated animal studies to test possible toxicity and safety issues of the adsorbents or the procedure itself. The successful completion of the scale-up and safety tests will allow the initiation of clinical trials.

Defected red blood cell membranes and direct correlation with the uraemic milieu: the connection with the decreased red blood cell lifespan observed in haemodialysis patients

Together with impaired production of erythropoietin and iron deficiency, the decreased lifespan of red blood cells (RBCs) is a main factor contributing to the chronic anaemia observed in haemodialysis (HD) patients. Atomic force microscopy is employed in this work to thoroughly survey the membrane of intact RBCs (iRBCs) of HD patients in comparison to those of healthy donors, aiming to obtain direct information on the structural status of RBCs that can be related to their decreased lifespan. We observed that the iRBC membrane of the HD patients is overpopulated with extended circular defects, termed 'orifices', that have typical dimension ranging between 0.2 and 1.0 μm. The 'orifice' index-that is, the mean population of 'orifices' per top membrane surface-exhibits a pronounced relative increase of order 54 ± 12% for the HD patients as compared to healthy donors. Interestingly, for the HD patients, the 'orifice' index, which relates to the structural status of the RBC membrane, correlates strongly with urea concentration, which is a basic index of the uraemic milieu. Thus, these results indicate that the uraemic milieu downgrades the structural status of the RBC membrane, possibly triggering biochemical processes that result in their premature elimination from the circulation. This process could decrease the lifespan of RBCs, as observed in HD patients.

Intensification of peritoneal dialysis improves valacyclovir neurotoxicity

Valacyclovir induced neurotoxicity is a life-threatening complication, usually starting 24-48 h after drug-peak serum concentrations. The elderly with impaired renal function seem to be the most susceptible group to valacyclovir neurotoxicity. Although hemodialysis is considered the best method for rapid drug removal, our case showed that intensive peritoneal dialysis regimen leads to the recovery of neurotoxicity after 3 days.

Vascular access today

The number of patients with chronic kidney disease requiring renal replacement therapy has increased worldwide. The most common replacement therapy is hemodialysis (HD). Vascular access (VA) has a key role for successful treatment. Despite the advances that have taken place in the field of the HD procedure, few things have changed with regards to VA in recent years. Arteriovenous fistula (AVF), polytetrafluoroethylene graft and the cuffed double lumen silicone catheter are the most common used for VA. In the long term, a number of complications may present and more than one VA is needed during the HD life. The most common complications for all of VA types are thrombosis, bleeding and infection, the most common cause of morbidity in these patients. It has been estimated that VA dysfunction is responsible for 20% of all hospitalizations. The annual cost of placing and looking after dialysis VA in the United States exceeds 1 billion dollars per year. A good functional access is also vital in order to deliver adequate HD therapy. It seems that the native AVF that Brescia and Cimino described in 1966 still remains the first choice for VA. The native forearm AVFs have the longest survival and require the fewest interventions. For this reason, the forearm AVF is the first choice, followed by the upper-arm AVF, the arteriovenous graft and the cuffed central venous catheter is the final choice. In conclusion, VA remains the most important issue for patients on HD and despite the technical improvements, a number of problems and complications have to be resolved.

Successful non-surgical treatment of perirenal haematoma after percutaneous renal artery angioplasty in a solitary kidney

Renal artery angioplasty with stent placement represents an effective choice for correcting renal artery stenosis. However, if iatrogenic renal artery injury occurs, as in the case of solitary kidney, the risk of requiring chronic dialysis increases. This article reports the case of a patient with a solitary kidney, who underwent renal stenting and developed a retroperitoneal haematoma. The patient was managed conservatively and the perirenal haematoma resolved. Within the period of follow-up, the patient had maintained stable renal function with adequate blood pressure control.

Is there any association between IgA nephropathy, Crohn's disease and Helicobacter pylori infection?

A case of IgA nephropathy (IgAN) associated with Crohn's disease (CD) and preceded Helicobacter pylori (Hp) infection is described. Therapy with corticosteroids and azathioprine resulted in clinical improvement. The connection between IgAN and CD is well established, while tonsillar Hp is a potential antigen causative of IgAN. The three entities may reflect a common immunopathogenetic mechanism involving an IgA response to mucosal challenge.

Multiple histopathological skin alterations in a hemodialysis patient with severe pruritus

Pruritus is an alarming symptom in patients with end-stage renal disease (ESRD) accompanied by sleep disturbances and physical and mental disorders. Although its prevalence is very high among hemodialysis patients (90%), its etiology and its successful treatment have been unconfirmed (Melo N, Elias R, Castro M, Romao G, Abensur H. Pruritus in hemodialysis patients: The problem still remains. Hemodial Int. 2009;13:38-42.). Common pruritus etiologies, such as high parathyroid hormone levels, dialysis inadequacy, and iron deficiency are matters of conflict. The case of a hemodialysis patient with consistent itching and a variety of cutaneous eruptions, which after performing skin biopsy were explored and cured, is described. This article addresses the possibility of other causes of pruritus in ESRD and encourages watchful waiting with simple medical interventions, which would relieve patients' symptoms.

Erythrocyte Na+-Li+ counter-transport activity and digoxin-like substances in insulin dependent diabetic women with preexisting preeclampsia

AIM OF THE STUDY

To determine whether there is pathogenetic link between red cells sodium-lithium counter-transport activity and digoxin-like immunoreactive substances (DLIS) in plasma of insulin-dependent diabetic (IDDM) and non-diabetic women with preexisting preeclampsia (PE).

SUBJECTS AND METHODS

We studied Na(+)/Li(+) CT activity in red cells and plasma levels of DLIS in 11 IDDM women with preexisting PE (Group 1), 13 IDDM without preexisting PE (Group 2) 23 non-diabetic women with preexisting PE (Group 3) and 12 non-diabetic women with normal pregnancy (Group 4) at least 4 months after delivery.

RESULTS

Na(+)/Li(+) CT activity was higher in Group 1 compared to Group 2 (mean ± SEM 0.316 ± 0.05 vs 0.190 ± 0.02 mmol/LRBC/hr p < 0.05) and in Group 3 compared to Group 4 (0.365 ± 0.004 vs 0.168 ± 0.01 mmol/LRBC/hr, p < 0.01). Plasma levels of DLIS were higher in Group 3 compared to Group 4 (0.727 ± 0.189 vs 0.295 ± 0.066 ng/ml; p<0.05); there was no statistically significant difference between the two diabetic groups. In Groups 1 and 3, Na(+)/Li(+) CT activity was correlated to the plasma levels of DLIS (r = 0.927; p < 0.001 and r = 0.485; p<0.05 respectively).

CONCLUSION

Increased Na(+)/Li(+) CT activity and increased plasma levels of DLIS may contribute to PE in IDDM and non-diabetic women.

Is the underutilization of peritoneal dialysis in relation to hemodialysis, as renal replacement therapy, justifiable worldwide? Yes or No

Peritoneal dialysis is the most important home dialysis treatment for end stage renal diseases and needs personal involvement, and support from the family . Peritoneal dialysis presented a number of discouraging technical problems and led to the belief that PD was not an appropriate renal replacement therapy, for patients with end stage renal disease. Despite the improvement of the method its rate remain low (11%) worldwide. The factors affecting the choice of PD are multiple and explain the disparity in the use of peritoneal dialysis in different countries and different parts of the same country. Dialysis costs and reimbursement structures are significant in decisions about the rates and modalities of renal replacement therapy. Late referral and the health care system seems to be very important factors that influence the dialysis modality choice. After the initiation of peritoneal dialysis we can see other factors that influence the survival of the method. The rate of peritonitis and the peritoneum function seems to be important issues.

Correlation of depressive symptoms and olfactory dysfunction in patients on hemodialysis

BACKGROUND AND AIM

A possible link between depression and olfactory dysfunction has been suggested in the literature, in research projects using the olfactory bulbectomy model. In human studies using a syndrome-oriented approach, such an association has not been reported consistently. The aim of the study was to test the association of olfactory dysfunction with depression using a symptom-oriented approach.Paients and methods: Twenty eight end-stage renal failure patients took part in this project. The patients olfactory identification ability was tested with the University of Pennsylvania Smell Identification Test (UPSIT). Immediately before olfactory testing, the subjects completed the Zung self-rating scale, which provides data on symptoms of depression in this group of patients.

RESULTS

The mean value of the number of mistakes made in the olfactory identification ability (UPSIT test) by the total sample was 14.0±4.5, with a range 6-22. Half of the symptoms seem to bear an influence on the olfactory identification performance. Patients experiencing decreased libido and dissatisfaction exhibited significantly reduced olfactory function, as contrasted to those not experiencing these symptoms. The above results remain practically unaltered even after taking into account such probable confounding factors as age, sex, olfactory detection threshold and duration of illness.

CONCLUSION

These findings support previous evidence indicating that olfactory dysfunction may be related to specific depressive symptoms in humans. The present findings also suggest that the symptom-oriented approach is an effective research tool for the elucidation of such clinical issues. The need for further research in this field is pointed out.

Correlations of Sialic Acid with Markers of Inflammation, Atherosclerosis and Cardiovascular Events in Hemodialysis Patients

<i>Background:</i> Serum total sialic acid (S-TSA) is associated with atherosclerotic process in general population. The aim of our study was to evaluate possible correlations of S-TSA with markers of inflammation and atherosclerosis in hemodialysis (HD) patients. <i>Methods:</i> We involved 53 asymptomatic, nondiabetic HD patients and 28 healthy controls. Atherosclerosis was evaluated by carotid ultrasonography, estimating intima media wall thickness and wall to lumen ratio bilaterally. To confirm our findings, we performed a 32-month cohort study, during which cardiovascular (CV) events were analyzed in relation to S-TSA concentration. <i>Results:</i> HD patients had higher S-TSA compared to controls (adjusted OR: 1.04, p = 0.026). In HD patients, S-TSA independently correlated with hs-CRP (p < 0.0001), lipoprotein(a) (p = 0.02), intima media wall thickness (p = 0.023) and wall to lumen ratio (p = 0.028). Increased S-TSA concentration was associated with more CV events (p = 0.03). <i>Conclusions:</i> Serum TSA seems to correlate with inflammation, accelerated atherosclerosis and CV events in nondiabetic HD patients, but more studies need to confirm our findings.

Reactive Oxygen Metabolites: A Link between Oxidative Stress and Inflammation in Patients on Hemodialysis

Oxidative stress plays a significant role in the development of inflammation in patients undergoing hemodialysis (HD). This study intends to evaluate the relationship between C-reactive protein (CRP) and the newly established marker of lipid peroxidation, d-ROMs (reactive oxygen metabolites), in comparison with different indicators of oxidative stress. Plasma total antioxidant capacity (TAC), lipid peroxidation products malonaldehyde (MDA) and 4-hydroxyalkenals, as well as d-ROMs, were determined in 24 patients before HD and in 21 normal controls (NC). It was found that HD patients had higher levels of d-ROMs than NC (p = 0.033). A highly significant positive correlation was observed between logCRP and d-ROMs concentrations (p < 0.0001, r = 0.85) in patients, but not in NC. The concentrations of TAC and MDA were not associated with CRP in HD or in NC individuals. It is concluded that d-ROMs concentration is a potent marker of oxidative injury that is strongly indicative of the inflammatory status in HD patients.