International cohort of 382 children with lupus nephritis - presentation, treatment and outcome at 24 months

BACKGROUND

Children with lupus have a higher chance of nephritis and worse kidney outcome than adult patients.

METHODS

We retrospectively analyzed clinical presentation, treatment and 24-month kidney outcome in a cohort of 382 patients (≤ 18 years old) with lupus nephritis (LN) class ≥ III diagnosed and treated in the last 10 years in 23 international centers.

RESULTS

The mean age at onset was 11 years 9 months and 72.8% were females. Fifty-seven percent and 34% achieved complete and partial remission at 24-month follow-up, respectively. Patients with LN class III achieved complete remission more often than those with classes IV or V (mixed and pure). Only 89 of 351 patients maintained stable complete kidney remission from the 6th to 24th months of follow-up. eGFR ≥ 90 ml/min/1.73 m2 at diagnosis and biopsy class III were predictive of stable kidney remission. The youngest and the oldest age quartiles (2y-9y, 5m) (14y, 2m-18y,2m) showed lower rates of stable remission (17% and 20.7%, respectively) compared to the two other age groups (29.9% and 33.7%), while there was no difference in gender. No difference in achieving stable remission was found between children who received mycophenolate or cyclophosphamide as induction treatment.

CONCLUSION

Our data show that the rate of complete remission in patients with LN is still not high enough. Severe kidney involvement at diagnosis was the most important risk factor for not achieving stable remission while different induction treatments did not impact outcome. Randomized treatment trials involving children and adolescents with LN are needed to improve outcome for these children. A higher resolution version of the Graphical abstract is available as Supplementary information.

MO507ROCK STUDY: RESEARCH STUDY OF CANCER ASSOCIATED KIDNEY DISEASES

Background and Aims

The improvement in the survival rates of cancer patients due to the new oncological and biological agents has led to an increase in those who develop kidney diseases.

It is now well known that chronic kidney disease (CKD) and cancer are connected in several ways. Nevertheless, although emerging evidence suggests that the risk of renal impairment in cancer patients is high and increasing, the overall incidence and prevalence of CKD in this population are still uncertain. The purpose of the study is to provide data on the prevalence and incidence of CKD in patients included in the Cancer Registry of the province of Reggio Emilia, Italy, since January, 1st to December, 31st 2016.

Method

single-center, observational and retrospective study. For all patients included, data on sex, age, ethnicity, serum creatinine and related eGFR, type and number of tumors, diagnosis of diabetes mellitus were collected. The main cancer sites considered were breast, colorectal, lung, pancreas, stomach, prostate, lymphomas and leukemias. An eGFR ≥ 60 ml/min1.73m2 was indicative of a normal kidney function, while an eGFR <60 ml/min/1.73m2 as kidney impairment. All the eGFR data were calculated not only with the CKD-EPI formula, now recognized as the reference formula for estimating eGFR in the general population, but also with the Wright formula which seems to provide the best estimate in cancer patients.

Results

4254 patients with a cancer diagnosis were identified between January 1st and December 31st 2016; of these, 171 patients were excluded due to lack of data. Of the remaining 4083 patients, 776 (19%) had at least an eGFR value <60 mL/min/1.73m2 prior to cancer diagnosis and 497 patients (11.7%) were identified as affected by CKD. The incidence of new-onset CKD in the following 24 months since cancer diagnosis was 4.4% (186 patients) [95% CI 3.9-5.3] using CKD-EPI formula; using Wright formula, we identified 140 (3.4%) [95% CI 2.9-4.0] new cases of CKD in the same period. For both cohorts of patients (pre-existing CKD and CKD diagnosed after cancer diagnosis), descriptive analyzes were conducted related to demographic and clinical data. Referring to the CKD-EPI formula, in patients with pre-existing CKD (497 patients, 11.7%), the mean age was 81 years (SD ± 8.4), 53.7% were men, 18.3% had a known diagnosis of type 2 diabetes mellitus, 3.6% of these patients had 2 or more cancer diagnosis in the study period. 44.3% were alive at the end of the follow-up (December 31st, 2018). Using Wright formula, 504 (11.8%) patients with CKD already present at the time of cancer diagnosis were identified; these patients had an average age of 82 years (SD ± 8.4) and in 55.4% of cases were men; 18.8% had type 2 diabetes mellitus and 3.8% had 2 or more cancer diagnosis.

Conclusion

The ROCK study is the first large cohort study that allows a clearer estimation of the frequency of CKD in Italian cancer patients. Knowledge of the prevalence of CKD in cancer patients is essential for proper clinical and therapeutic management and implementation of preventive strategies.

[Frail nephropathic patients: maximum conservative therapy or dialysis? Results from a retrospective observational study]

Background and objectives: Chronic dialysis in frail nephropathic patients can worsen the symptom load and their functional autonomy, increasing the risk of early mortality. It is key to evaluate if dialysis treatment represents a real advantage for these patients; Maximum Conservative Therapy (MCT) associated with palliative care, could improve their residual quality of life, avoiding dialysis. The aim of this work is to describe the application and the relative terms of MCT in a complete series of cases followed in our Nephrological Clinic. Study design and setting: This is a retrospective observational study on a cohort of 48 frail nephropathic patients in MCT and 58 on dialysis, in the period between January 2013 and December 2019. The place of death, Incidence Rate (IR) and Incidence Rate Ratio (IRR) related to survival and hospitalization rates were studied. Results: The average duration of MCT was 9.7 months vs 13.5 months of dialysis treatment. One-year probability of survival of dialysis patient was 0.52 [CI 0.38-0.64] vs 0.48 [CI 0.33-0.62] in MCT patients; however, dialysis patients had higher rates of hospitalization (IR 2.780 vs 1.269 in MCT patients), IRR 2.19 [CI 1.66-2.89], according to literature [13]. 67% of dialysis patients died in hospital versus 35% of MCT patients. 34% of MCT patients are still alive at the time of data analysis (January 31, 2020); no dialysis patients are still alive on the same date. Conclusions: The use of dialysis has shown a marginal, even though significant, effect on the average survival of frail nephropathic patients; however, they present a higher hospitalization rate, with consequent impact on the quality of life. The choice of the treatment (MCT vs dialysis) should not be merely based on the presence of comorbidities, but rather on the type of comorbidity found, which represents each time an element in favor of MCT or dialysis.

What volume to choose to assess online Kt/V?

INTRODUCTION

Urea distribution volume (V) can be assessed in different ways, among them the anthropometric Watson Volume (V_W). However, many studies have shown that V_W does not coincide with V and that the latter can be more accurately estimated with other methods. The present multicentre study was designed to answer the question: what V to choose to assess online Kt/V?

MATERIALS AND METHODS

Pre- and postdialysis blood urea nitrogen concentrations and the usual input data set for urea kinetic modelling were obtained for a single dialysis session in 201 Caucasian patients treated in 9 Italian dialysis units. Only dialysis machines measuring ionic dialysance (ID) were utilized. ID reflects very accurately the mean effective dialyser urea clearance (Kd). Six different V values were obtained: the first one was V_W; the second one was computed from the equation established by the HEMO Study to predict the single pool-adjusted modelled V from V_W (V_H) (Daugirdas JT et al. KI 64: 1108, 2003); the others were estimated kinetically as: 1. V_ID, in which ID is direct input in the in the double pool variable volume (dpVV) calculation by means of the Solute-solver software; 2. V_Kd, in which the estimated Kd is direct input in the dpVV calculation by means of the Solute-solver software; 3. V_KTV, in which V is calculated by means of the second generation Daugirdas equation; 4. V_SPEEDY, in which ID is direct input in the dpVV calculation by means of the SPEEDY software able to provide results quite similar to those provided by Solute-solver.

RESULTS

Mean± SD of the main data are reported: measured ID was 190.6 ± 29.6 mL/min, estimated Kd was 211.6 ± 29.0 mL/min. The relationship between paired data was poor (R² = 0.34) and their difference at the Bland-Altman plot was large (21 ± 27 mL/min). V_W was 35.3 ± 6.3 L, V_H 29.5 ± 5.5, V_{_}ID 28.99 ± 7.6 L, V_{_}SPEEDY 29.4 ± 7.6 L, V_KTV 29.7 ± 7.0 L. The mean ratio V_W/V_ID was 1.22, (i.e. V_W overestimated V_ID by about 22%). The mean ratio V_H/V_ID was 1.02 (i.e. V_H overestimated V_ID by only 2%). The relationship between paired data of V_ID and V_W was poor (R² = 0.48) and their mean difference at the Bland-Altman plot was very large (-  6.39 ± 5.59 L). The relationship between paired data of V_ID and V_H was poor (R² = 47) and their mean difference was small but with a large SD (- 0.59 ± 5.53 L). The relationship between paired data of V_ID and V_SPEEDY was excellent (R² = 0.993) and their mean difference at the Bland-Altman plot was very small (- 0.54 ± 0.64 L). The relationship between paired data of V_ID and V_KTV was excellent (R² = 0.985) and their mean difference at the Bland-Altman plot was small (- 0.85 ± 1.06 L).

CONCLUSIONS

V_ID can be considered the reference method to estimate the modelled V and then the first choice to assess Kt/V. V_SPEEDY is a valuable alternative to V_ID. V_KTV can be utilized in the daily practice, taking also into account its simple way of calculation. V_W is not advisable because it leads to underestimation of Kt/V by about 20%.

Severe Milk-Alkali Syndrome in a Patient with Hypoparathyroidism Associated with 1,25(OH)2D, Hydrochlorothiazide and Anthranoid Laxative Consumption

Background

Milk-alkali syndrome is a life-threatening condition defined by the triad of hypercalcaemia, metabolic alkalosis and acute renal failure, and is associated with consumption of calcium and absorbable alkali.

Methods

We report the case of a patient admitted to a step-down unit of a large hospital in Italy.

Results

The patient was a 59-year-old woman with hypoparathyroidism and mild chronic kidney insufficiency, treated for a preceding episode of hypocalcaemia with high doses of calcitriol and calcium carbonate, who was also taking hydrochlorothiazide and unreported herbal anthranoid laxatives. The patient was admitted to hospital with severe hypercalcaemia, severe metabolic alkalosis and acute renal insufficiency. The patient was successfully treated with urgent dialysis, loop diuretics and calcitonin administration.

Conclusions

This case underlines the need for caution when treating patients with impaired calcium metabolism regulation, and suggests that herbal anthranoid laxatives might act as triggers for milk-alkali syndrome.

LEARNING POINTS

The Evolution of the Journal Club: From Osler to Twitter

Journal clubs have typically been held within the walls of academic institutions and in medicine have served the dual purpose of fostering critical appraisal of literature and disseminating new findings. In the last decade and especially the last few years, online and virtual journal clubs have been started and are flourishing, especially those harnessing the advantages of social media tools and customs. This article reviews the history and recent innovations of journal clubs. In addition, the authors describe their experience developing and implementing NephJC, an online nephrology journal club conducted on Twitter.

[Smart, Social, and Mobile: the future of Nephrology in the Era of Digital Health]

Healthcare is in the middle of a digital revolution. Physicians are adopting mobile apps that make them more effective and patients are taking to ones that give them more control over their healthcare. Mobile technology is changing Medicine. A new movement for free open access medical education (FOAMed) is growing through Social Media. E-learning is increasing access to new and exciting learning opportunities, deeply changing the traditional concept of continuous medical education. What will be the future of Nephrology in the era of Digital Health?

Kidney involvement in medium- and large-vessel vasculitis

Medium- and large-vessel vasculitides (MVV and LVV, respectively) comprise a heterogeneous group of disorders whose common denominator is the inflammatory involvement of vessels of medium and large size. This disease spectrum includes giant-cell arteritis and Takayasu's arteritis, which typically affect the aorta and its main branches, and Kawasaki's disease and polyarteritis nodosa, which involve medium-sized arteries. Chronic periaortitis, characterized by a perivascular fibro-inflammatory reaction affecting the abdominal aorta and the periaortic tissue, frequently has a systemic distribution, involving other segments of the aorta and its major branches, and could thus be included in this group. Unlike small-vessel vasculitides, MVV and LVV do not cause glomerulonephritis, although glomerular immune-mediated lesions and tubulo-interstitial nephritis occur with varying frequency. However, MVV and LVV can often involve the renal artery and its branches, causing a wide array of lesions that range from renal artery stenosis to intra-renal vasculitis causing renal ischaemia/infarction, microaneurysms and haemorrhage. This review focuses on renal involvement in MVV and LVV and underlines why renal abnormalities in these syndromes should not be overlooked.

[Plasma cell dyscrasias and renal damage]

Kidney damage caused by immunoglobulin free light chains in the setting of plasma cell dyscrasias is common and may involve all renal compartments, from the glomerulus to the tubulointerstitium, in a wide variety of histomorphological and clinical patterns. The knowledge of how free light chains can promote kidney injury is growing: they can cause functional changes, be processed and deposited, mediate inflammation, apoptosis and fibrosis, and obstruct nephrons. Each clone of the free light chain is unique and its primary structure and post-translation modification can determine the type of renal disease. Measurement of serum free light chain concentrations and calculation of the serum kappa/lambda ratio, together with renal biopsy, represent essential diagnostic tools. An early and correct diagnosis of renal lesions due to plasma cell dyscrasias will allow early initiation of disease-specific treatment strategies. The treatment of free light chain nephropathies is evolving and knowledge of the pathways that promote renal damage should lead to further therapeutic developments.

[Pathophysiology of portal hypertension and mechanisms of sodium and water retention in cirrhosis]

Portal hypertension is caused by an increased resistance to portal outflow and an increased portal blood inflow. Portal hypertension is associated with an abnormal distribution of the blood volume, which is increased in the splanchnic territory and reduced in the non-splanchnic compartments. The relative underfilling of the arterial circulation is responsible for the sodium and water retention, which is a consequence of the baroceptor-mediated activation of vasoconstrictor and antinatriuretic factors triggered to restore circulatory integrity.

[Current therapeutic strategies for HCV-associated cryoglobulinemia]

Cryoglobulinemia refers to the presence in serum of immunoglobulins, that reversibly precipitate at low temperatures. Cryoglobulins are classified according to their immunochemical properties as type I, composed of a single monoclonal immunoglobulin, and types II and III, referred as mixed cryoglobulinemia (MC), composed by a mixture of monoclonal (type II) and polyclonal (type III) IgM that have rheumatoid factor activity and bind to polyclonal IgGs. MC is a systemic vasculitis with cutaneous and multiple organ involvement including chronic hepatitis, membrano-proliferative glomerulonephritis, and peripheral neuropathy. In more than 90% of patients, MC is associated with chronic hepatitis C virus (HCV) infection, which is considered the triggering factor of the disease. Patients with HCV-related MC may be managed by means of etiological, pathogenetic or symptomatic therapeutic modalities. The choice of the more appropriate treatment is strictly related to the assessment of disease activity, and to the extent and severity of organ involvement. This paper reviews the currently available therapeutic strategies for MC syndrome, emphasizing the importance of HCV eradication, and the safety/efficacy of new biologic therapies for selective control of cryoglobulin-producing B-cells.

Cryoglobulinemic glomerulonephritis: an extrahepatic manifestation of hepatitis C virus (HCV) infection

A 66-year-old woman was admitted to our Department for evaluation of a nephrotic syndrome. Physical examination revealed ankle edema, palpable purpura of the legs and hypertension. There was no hepatosplenomegaly. The main laboratory findings were haemoglobin 11.4 g/dl, serum creatinine 1.4 mg/dl, proteinuria 3.5 g/day with reduced serum albumin (3.1 g/dl), rheumatoid factor (RF) activity 125 IU/ml, and serum C4 levels 2.3 mg/dl. Cryocrit was 24%, with type II (IgG-IgM-κ) cryoglobulins. The patient was positive for HCV antibodies and serum HCV RNA; the genotype was 1b. A percutaneous renal biopsy showed a cryoglobulinemic membranoproliferative glomerulonephritis with moderate histologic severity. The primary goal in patients with mild-to-moderate disease is viral clearance, so combination therapy with interferon-α (3 MU thrice weekly) and ribavirin (800 mg/day) was started. Twelve weeks later, serum HCV RNA had disappeared, a result that was confirmed at the end of antiviral therapy in week 48, and during the post-treatment follow-up. Proteinuria returned to the normal range, cryoglobulins decreased to undetectable levels and serum C4 levels normalized. RF activity decreased, but remained above normal. The message provided by this illustrative case is that antiviral therapy represents the first-line treatment for HCV-related cryoglobulinemic patients with mild-to-moderate kidney involvement, because it provides the best chance of viral clearance and subsequent disease improvement.