Management of Peritoneal Dialysis-Associated Emergencies during the COVID-19 Pandemic: The Experience of a Center of Excellence.

The COVID-19 pandemic struck unexpectedly; emergency services and chronic care institutions, including dialysis centers, were overloaded. A significant problem was the care of COVID-positive patients alongside the care of chronically dialyzed patients who presented emergencies. In our hospital, which became a COVID support center for dialysis patients with severe forms of the disease, we had to care for PD patients with dialysis-related emergencies. We present two cases of patients managed on an outpatient basis or 1-day hospitalization who were treated successfully without compromising the quality of the care provided. We used remote monitoring, worked in a multidisciplinary team, and shortened the duration of the patients' hospitalization (and implicitly the risk of contact). In pandemic conditions, the advantage of PD was the possibility of patient isolation; in the first 6 months of the pandemic, we recorded no deaths in this category of patients. In hemodialysis patients, infection and mortality rates were high. Although we expected an increase in the number of peritoneal dialysis patients in the post-pandemic period, this did not happen. We continue to plead for the popularization of the PD method among patients and doctors, which has proven advantages in pandemic conditions.

Peritoneal Dialysis-Induced Encapsulating Peritonitis: Diagnostic and Therapeutic Challenges in Women with Benign Gynecological Pathology.

Background: Peritoneal sclerosis (PS) and its most severe form, encapsulating PS (EPS), are rare entities that can occur in various procedures (liver transplantation, intraperitoneal chemotherapy) or secondary to medications (beta-blockers); however, PS or EPS typically occur in patients undergoing peritoneal dialysis as a form of renal function substitution. Medical or surgical treatments can be applied, but morbidity and mortality have high rates. This condition typically presents clinically as an intestinal obstruction caused by the inclusion of the intestinal loops in the peritoneal fibrous membrane. Methods: Herein, we present data from a single tertiary surgery center that has dedicated teams for patients receiving dialysis. Over 12 years, we analyzed a group of 63 patients admitted for catheter replacement/removal or for acute surgical pathology. In five cases (7.9%), we diagnosed EPS. Two patients with EPS presented with atypical abdominal pathologies requiring emergency surgery: one case of hemoperitoneum caused by a ruptured ovarian cyst and one case of uterine fibroids and metrorrhagia. Results: The definitive diagnoses were established intraoperatively and by analyzing the morpho-pathological changes in the peritoneum. The possible intraoperative challenges included laborious dissection, difficulties in restoring the correct anatomical landmarks, an increased duration of the surgical intervention and a high rate of incidents and accidents. Conclusions: The aim of the present study was to emphasize the possibility of other surgical pathologies overlapping with EPS, increasing the complexity of the surgical intervention.

Advantages of total parathyroidectomy in patients with secondary hyperparathyroidism induced by end stage renal disease.

Introduction: Secondary hyperparathyroidism, as a result of chronic kidney disease could be treated medically or surgically. When pharmacotherapy fails, patients undergo surgery - parathyroidectomy, the curative treatment of secondary hyperparathyroidism (SHPT). There are currently 3 accepted surgical techniques, each with supporters or opponents - total parathyroidectomy, subtotal parathyroidectomy and parathyroidectomy with immediate autotransplantation. Methods: In this paper we described our experience on a series of 160 consecutive patients diagnosed with secondary hyperparathyroidism who underwent surgery, in 27 cases it was totalization of the intervention (patients with previously performed subtotal parathyroidectomy or with supernumerary glands and SHPT recurrence). We routinely perform total parathyroidectomy, the method that we believe offers the best results. Results: The group of patients was studied according to demographic criteria, paraclinical balance, clinical symptomatology, pre- and postoperative iPTH (intact parathormone) values, SHPT recurrence, number of reinterventions. In 31 cases we found gland ectopy and in 15 cases we discovered supernumerary parathyroids. A percentage of 96.24% of patients with total parathyroidectomy did not show recurrence. Discussions: After analyzing the obtained results, our conclusion was that total parathyroidectomy is the intervention of choice for patients suffering from secondary hyperparathyroidism when pharmacotherapy fails in order to prevent recurrence of the disease and to correct the metabolic parameters.

Intravenous Iron-Carbohydrate Nanoparticles and Their Similars. What Do We Choose?

Anemia is highly prevalent worldwide and iron deficiency is the first cause. Iron deficiency has not only hematologic effects but also non-hematologic effects - immune, metabolic, cognitive dysfunctions and poor cardiovascular and renal outcomes - which generally precede anemia. Iron therapy not only significantly improves the hematological parameters but also has non-hematologic benefits. Given that its efficacy and safety has been revealed over the years, intravenous (IV) iron therapy is frequently used. Intravenous iron products are nanoparticles largely consisting in an iron core surrounded by a carbohydrate shell. They are classified as non-biological complex molecules, being different from small commonly used molecules, with properties and biological behavior impossible to be completely characterized only by physicochemical analysis. To date, there is no appropriate regulatory evaluation system for these medicines and several follow-on versions of the IV iron originators (e.g., iron sucrose) were approved using the same regulatory pathway as for generics. Because of this vulnerability in an adequate pathway for approval, both non-clinical and clinical studies suggested no therapeutic equivalence (thus no interchangeability) between iron sucrose originator (Venofer®), and iron sucrose similars. In this review we aimed to underline the importance of intravenous iron therapy as well as raise awareness regarding the differences between nanomedicines and their intended similar but not identical copies. The potential implications of these differences impact patients (safety, efficacy) but also the medical system (higher costs).

Long-Term Intravenous Iron Therapy and Morbidity in Hemodialysis Patients.

Objective: The aim of this study was to describe long-term intravenous iron therapy-associated morbidity in hemodialysis patients from a single Hemodialysis Center. Material and methods: We conducted an observational retrospective cohort study from 01 January to 31 December 2015. Two hundred and twenty prevalent patients on maintenance hemodialysis therapy for at least 12 months (mean age 53±13 years, 56% males, median hemodialysis vintage 5 (1-26) years) were included. Diabetic nephropathy as primary kidney disease, pregnancy and incomplete data records regarding study aims were exclusion criteria. We compared the frequency, duration and causes of hospitalizations in iron sucrose-treated versus gender and age-matched iron non-treated patients. Differences between groups were assessed using Chi-square and Kruskal-Wallis H tests. A p value µ0.05 was considered statistically significant. Results: From the entire cohort, 68% were iron-treated. One in five patients were treated with higher doses (400 mg monthly), and lower doses were used (100-200 mg monthly) in 80% of patients. There were no differences regarding the rates of admission between the two groups (56/100 patient-years in the iron sucrose-treated vs. 50/100 patient-years in the iron-untreated group, p=0.1). Still, the hospitalization rate significantly increased with the administered iron dose (0.4 vs. 0.7 vs. 0.8/100 patient-years for 100 mg vs. 200 mg vs. 400 mg monthly, respectively, p=0.006). Hospitalization rates due to infectious and cardiovascular diseases were similar for both groups (12/100 patient-years vs. 5.7/100 patient-years, p=0.3 and 11.3/100 patient-years vs. 4.3/100 patient-years, p=0.2, respectively). Conclusion: Higher doses of intravenous iron sucrose appear to be associated with an elevated risk of hospitalization. Nonetheless, long-term intravenous iron therapy seems to have a limited influence in terms of specific cause of morbidity in non-diabetic hemodialysis patients.

Clinical features and outcome of maintenance hemodialysis patients with COVID-19 from a tertiary nephrology care center in Romania.

BACKGROUND: There is limited information about the clinical characteristics, treatment and outcome of maintenance hemodialysis patients with COVID-19. Moreover, regional differences are also conceivable since the extend and severity of outbreaks varied among countries. METHODS: In this retrospective, observational, single-center study, we analyzed the clinical course and outcomes of 37 maintenance hemodialysis patients (median age 64 years, 51% men) hospitalized with COVID-19 from 24 March to 22 May 2020 as confirmed by real-time PCR. RESULTS: The most common symptoms at admission were fatigue (51%), fever (43%), dyspnea (38%) and cough (35%). There were 59% mild/moderate patients and 41% severe/critical patients. Patients in the severe/critical group had a significantly higher atherosclerotic burden since diabetic kidney disease and vascular nephropathies were the most common primary kidney diseases and eighty percent of them had coronary heart disease. Also, Charlson comorbidity score was higher in this group. At admission chest X-ray, 46% had ground-glass abnormalities. Overall, 60% patients received hydroxychloroquine, 22% lopinavir-ritonavir, 11% tocilizumab, 24% systemic glucocorticoids, and 54% received prophylactic anticoagulation. Seven (19%) patients died during hospitalization and 30 were discharged. The main causes of death were cardiovascular (5 patients) and respiratory distress syndrome (2 patients). In Cox regression analysis, lower oxygen saturation, anemia and hypoalbuminemia at admission were associated with increased mortality. CONCLUSIONS: In conclusion, we observed a high mortality rate among maintenance hemodialysis patients hospitalized for COVID-19. Anemia, lower serum albumin and lower basal oxygen saturation at admission were factors associated with poor prognosis.

A Case Report of Generalized Pustular Psoriasis Associated With IgA Nephropathy.

Psoriasis vulgaris is a complex immune-mediated disorder that manifests as a chronic skin disorder, characterized by well-circumscribed inflammatory, erythematous plaques. In this case report, we present a patient with generalized pustular psoriasis (GPP) who presented to the nephrology department with rapidly progressive decline in renal function. The diagnosis of GPP was made a month ago, secondary to a coagulase-negative staphylococcal superinfection. Intrinsically, this introduced a diagnostic challenge as the presumed diagnosis of immunoglobulin A (IgA) nephropathy had to be distinguished from IgA-dominant infection-related glomerulonephritis. We further discuss the current evidence and immunohistological profiles of IgA nephropathy in psoriasis and detail the evolution of renal function of our patient over 25 months after he presented to our department.

Acute Kidney Injury in a Patient With Cryoglobulinemia Secondary to Hepatic Mucosa-Associated Lymphoid Tissue Lymphoma: Case Report and Literature Review.

We report a patient with IgM-predominant type I cryoglobulinemia (CG), who presented to our nephrology department with acute kidney injury. He was previously diagnosed with sensorimotor neuropathy, which was in remission with maintenance dose of corticosteroids. Upon admission, there were ulcerated, necrotic cutaneous lesions localized to the inner aspect of the thighs bilaterally. Further workup revealed a mucosa-associated lymphoid tissue lymphoma, causing type I CG. Screening tests for hepatitis viruses were negative at this time. Under treatment with diuretics and high-potency glucocorticoids, the patient had an acceptable recovery of renal function and was referred to oncology for treatment. Unfortunately, three months later the patient succumbed to fulminant hepatitis, presumably secondary to reactivation of an occult hepatitis B/D co-infection. We further conducted a literature review to better describe patient characteristics and renal involvement in type I CG.

ANCA positive crescentic glomerulonephritis outcome in a Central East European cohort: a retrospective study.

BACKGROUND: The recently suggested distinct pathogenic pathways for myeloperoxidase (MPO) and proteinase 3 (PR3) anti-neutrophilic cytoplasmic antibodies (ANCA) associated vasculitis could result in different modes of presentation and outcome. Moreover, kidney outcome was related to a new histopathologic classification of pauci-immune glomerulonephritis. As reports were not always concordant, possible because differences in severity of organ lesions and ethnicity, we evaluated the outcome of a cohort of Central-East European patients with crescentic glomerulonephritis in relation with ANCA specificity and histopathological classification. METHODS: Seventy-five patients were consecutively diagnosed by kidney biopsy (76 % MPO-ANCA specificity, 52 % crescentic) and followed for a median period of 3.2 years. Study end-points were response to therapy, end stage renal disease (ESRD) and death. RESULTS: PR3-ANCA patients were younger, in higher proportion male and had higher Birmingham Vasculitis Activity Scores (BVAS). The kidney disease was severe at presentation (median creatinine 5 mg/dL; 27 % required temporary dialysis) and worst in PR3-ANCA positive patients (50 % patients needed temporary dialysis vs. 19 %). The lung was the second most affected organ (31 % severe lung hemorrhage). Lung and kidney damage were related; the odds of hemorrhagic alveolitis in patients needing dialysis at presentation were 4 (95 % CI 1-13; p = 0.006) times higher than in those who did not. The rate of response to therapy (without signs of active vasculitis and stable or declining serum creatinine) was 60 % and was associated with dialysis independency, older age and higher platelet number at presentation. The probabilities to survival 1 and 5 years for kidney and patient were 93 and 64 %, and respectively 88 and 67 %. Kidney survival was predicted by response to therapy and dialysis independency at presentation. Patients with BVAS < 15 and responding to induction therapy had better chances of survival. Neither response to therapy nor outcome was influenced by ANCA specificity or by the histopathological class. CONCLUSIONS: When kidney damage is severe in ANCA vasculitis, the need of dialysis at presentation and the response to induction therapy overcome the prognostic utility of both ANCA specificity and histopathological class.

Pneumo-Renal Syndrome in Anti- Neutrophil Cytoplasm Antibody (ANCA)-Associated Small-Vessel Vasculitis.

OBJECTIVES: We aimed to evaluate the prevalence of lung hemorrhage, its determinants and its prognostic significance in adults patients with severe kidney involvement due to ANCA-associated vasculitis diagnosed and treated in a nephrology department. MATERIAL AND METHODS: Seventy-five patients consecutively diagnosed by kidney biopsy with crescentic pauci-immune glomerulonephritis entered this cohort study and were grouped according to the presence of diffuse alveolar hemorrhage (DAH - diagnosed as diffuse alveolar pattern on chest radiographs and anemia without evidence of another external bleeding). ANCAs were assessed by capture PR3-ANCA and MPO-ANCA ELISA or by indirect immunofluorescence. OUTCOMES: Patients were followed for a median period of 38 (11.7; 65.8) months. The median age was 61.6 years. Median creatinine was 5.7 mg/dL and 17% of the patients needed temporary dialysis. Most of the patients (76%) had MPO-ANCA; 31% had pneumo-renal syndrome. DAH patients had more severe and active kidney disease, as reflected by higher serum creatinine (7.1 mg/dL vs 4.45 mg/dL; p=0.006) and higher hematuria (610/mm3 vs 230/mm3, p=0.003). The risk of DAH was not influenced by gender, age or ANCA specificity, but by smoking (smokers had a 4 (95%CI 1.18-14.2; p=0.002) times higher the risk of lung hemorrhage) and by season (patients diagnosed in winter and autumn had a 6 (95% CI 1.6-20.9; p=0.005) times higher the risk of lung hemorrhage). The proportion of responders and of patients with relapses, and time to maintenance dialysis or to death were similar irrespective to the occurrence of DAH at presentation. CONCLUSION: In patients with ANCA associated pauci-immune glomerulonephritis, cold season, smoking and active kidney disease, but not ANCA specificity or inflammation were associated with lung hemorrhage. Although diffuse alveolar hemorrhage was the main cause of death, it was not related to short- or long-term outcome.

Abdominal aortic calcification and renal resistive index in patients with chronic kidney disease: is there a connection?

BACKGROUND: We aimed to evaluate the relationship between abdominal aortic calcification (AAC) and renal resistive index (RRI), parameters associated with cardiovascular outcome, in non-dialysis chronic kidney disease (CKD) patients. METHODS: Seventy-seven stable patients mainly in CKD stages 3B and 4 (44 and 28%), median age 69 years, with a positive history of systemic atherosclerosis were prospectively enrolled. RRI, carotid intima-media thickness (IMT), Kauppila score for AAC (AACs), cardio-ankle vascular index (CAVI) and ankle-brachial index (ABI) were assessed. Traditional and non-traditional atherosclerosis risk factors were also evaluated. RESULTS: Vascular (50%), diabetic (26%) and primary glomerular nephropathies (8 %) were the main causes of CKD. AAC was highly prevalent (77%). In the whole cohort, RRI was directly related to AACs (rs = 0.35, p < 0.001). AACs correctly identified patients with RRI >0.7 in 69% (56-81%) of cases, a cut-off of 5 resulting the best combination of sensitivity (65%) and specificity (68%). Compared to those with AACs <5, patients with AACs >5 were older, had higher serum cholesterol, C-reactive protein and IMT, lower ABI, but similar CAVI, estimated glomerular filtration rate, serum calcium and phosphate. In the whole cohort, AACs was negatively correlated with ABI (rs = -0.51, p < 0.001) and positively with IMT (rs = 0.27, p = 0.01), supporting a role for Kauppila score in integrating information on both intra- and extrarenal atherosclerosis. CONCLUSIONS: As Kauppila score correlates with RRI in non-dialysis CKD patients, it could be a fast, convenient and relatively inexpensive tool for estimating RRI, and consequently the intrarenal vascular status, but further research is warranted.