Unusual presentation of extranodal diffuse large B-cell lymphoma in a solid-organ recipient during long-term immunosuppressive treatment.

INTRODUCTION: Posttransplant lymphoproliferative disorders (PTLDs) refer to a group of diseases, including diffuse large B-cell lymphoma (DLBCL), that develop after solid organ transplantation or hematopoietic stem cell transplantation. Extranodal involvement in PTLDs is common. Reports about exclusive bone marrow involvement are rare. CASE DESCRIPTION: A 70-year-old woman, who had undergone kidney transplantation in 2018, was diagnosed with exclusively extranodal, Epstein-Barr virus-negative DLBCL, with bone marrow and spleen involvement, during long-term immunosuppression. She achieved complete remission with combined immunochemotherapy and temporary hold of immunosuppression. CONCLUSIONS: This case shows an uncommon clinical presentation of DLBCL, which was challenging to diagnose, being entirely extranodal. The favorable clinical course relied on timely diagnosis and a multidisciplinary approach. Long-term consequences of posttransplant immunosuppression require a high level of suspicion for an appropriate management, aimed at preserving the graft while eradicating the lymphoproliferative disorder.

Reliability of bedside ultrasound for measurement of quadriceps muscle thickness in critically ill patients with acute kidney injury.

MAIN PROBLEM: In patients with Acute Kidney Injury there is a lack of nutritional variables that can assess nutritional status, more specifically lean body mass (LBM) and skeletal muscle mass, at the individual level. In this clinical setting, ultrasound (US)) of the quadriceps femoris could represent a widely available, non-invasive, affordable, and reliable tool to evaluate skeletal muscle. METHODS: We performed a cross-sectional observational study in adult critically ill patients with KDIGO stage 3 AKI on dialysis. Quadriceps rectus femoris and vastus intermedius thickness were measured by two assessors. Intra- and interobserver reliability was evaluated using the intraclass correlation coefficient (ICC). The same US measures were obtained before and after dialysis. RESULTS: We enrolled 34 patients, 22 (65%) were male and the mean APACHE II score was 22.7 (±5.6). In the intraobserver reliability study, assessor 1 performed 288 paired measurements and assessor 2 performed 430 paired measurements in 34 patients, with an ICC equal to 0.99 and 1.00, respectively. There were 238 paired measurements (34 patients) in the interobserver reliability study, with an ICC = 0.92. No difference was found in the measurements obtained before and after dialysis (11.5 (4.2) vs 11.4 (4.1) mm, P = 0.2498), independently from acute body weight changes due to fluid removal. CONCLUSION: In patients with AKI, US of quadriceps femoris could represent a simple, accurate, and non-invasive method to evaluate quantitative changes in skeletal muscle.

Urinary ß-trace protein: A unique biomarker to screen early glomerular filtration rate impairment.

The screening for chronic kidney disease (CKD) patients needs the measurement of serum markers like creatinine. Our previous results indicated that urinary excretion of ß-trace protein (BTP), a low-molecular-weight protein (23-29 kDa), is increased in CKD patients from stage 2. The aim of this study was to assess the major determinants of urinary excretion of BTP and to evaluate its feasibility as noninvasive marker of glomerular filtration rate (GFR) impairment.We studied 355 CKD patients (198 males), aged 15 to 83 years, in stable clinical conditions, classified in the different stages of CKD on the basis of GFR (renal clearance of Tc-diethylenetriamine penta-acetic acid). At the same time, we measured serum and urinary creatinine and BTP, and urinary albumin. Urinary excretion of BTP and albumin was expressed as mg/g urinary creatinine. Fractional clearance of BTP was calculated as the ratio of BTP clearance to creatinine clearance (%).Urinary excretion of BTP is mainly determined by its serum concentration and by the level of GFR, and to a lower extent by urinary albumin excretion. In fact, urinary BTP (U-BTP) and fractional clearance of BTP progressively and significantly increased along with the reduction of GFR and the concurrent rise in serum BTP (S-BTP). The relationship of U-BTP with GFR was very similar to that of S-BTP with GFR: U-BTP mirrors S-BTP. The accuracy of U-BTP to screen patients with GFR <90 mL/min/1.73 m was good (area under the curve 0.833), its sensitivity was 76.9%, specificity 80%, and positive predictive value 84.9%. Sensitivity of U-BTP was quite similar to that of S-BTP and serum creatinine.The major determinants of urinary excretion of BTP are S-BTP and GFR. U-BTP may be a suitable noninvasive marker to screen the general population for detection of GFR <90 mL/min/1.73 m.

[The presence of crystals of sodium polystyrene sulfonate in the colonic wall: innocent bystander or pathogenic factor?]. / La presenza di cristalli di sodio polisterene sulfonato nella parete colica: fattore patogenetico o semplice marker di somministrazione?

Hyperkalemia is a frequent electrolyte disturbance in patients on dialysis or non-dialysis CKD patients, including those using renin-angiotensin system inhibitor drugs. Sodium polystyrene sulfonate (SPS; Kayexalate) is a resin widely used for hyperkalemia treatment. Unfortunately, its use entails some serious unwanted gastrointestinal side effects. We report the case of a 64-year-old male diabetic patient, suffering from ESRD on hemodialysis, who was treated with 30 g of Kayexalate twice a week (long interdialytic interval). This is a quite common case in the clinical practice. The patient experienced an episode of rectal bleeding followed by the diagnosis of non-specific colitis through colonoscopy. Histological examination, showed the presence of crystals of Kayexalate in the colonic mucosa leading to the suspect of iatrogenic intestinal damage caused by Kayexalate administration. Treatment with SPS was stopped. Nevertheless crystals remain evident in the intestinal mucosa in a colonoscopy performed 14 months later due to a new episode of rectal bleeding. Two years after the first episode the patient died because of intestinal infarction. The review of the literature highlights the risk of serious side effects such as necrotizing colitis with perforation both for the drug in sodium phase and in calcium phase. New intestinal potassium-binger agents, apparently without intestinal severe side effects, are under clinical evaluation. This case does not assess if the crystals deposited in the colonic mucosa are inert or have contributed to the final event, but it shows that Kayexalate is a drug with potential harmful effect even when used orally, at very low dosage and without sorbitol. In our opinion, the SPS should be prescribed carefully, especially as chronic administration, and the prescription should be limited to real and pressing requirements.

[Protein-energy wasting and nutritional supplementation in chronic hemodialysis]. / Deplezione proteico-energetica e supplementazione nutrizionale nei pazienti in emodialisi cronica.

Protein Energy Wasting (PEW) is a pathological condition characterized by a progressive reduction of protein and energy stores. PEW has a high prevalence among patients with CKD/ESRD (Chronic Kidney Disease/End Stage Renal Disease) and is closely associated with adverse clinical outcomes and increased rate of hospitalization, complications and mortality. The multifactorial pathogenesis of PEW is complex. A key role is played both by the reduced intake of nutrients and the condition of hypercatabolism/reduced anabolism typical of renal patients. The approach to prevent or treat PEW has several milestones such as reduction of potential risk factors, improvement in lifestyle and correction of any factor related to dialysis. It also needs a periodic assessment of nutritional status by using biochemical markers, body and muscle mass variables, nutritional scores and instrumental methods, aiming for an early diagnosis. In case of reduced protein and energy intake, the administration of nutrients during dialysis, or the use of oral supplements specific for renal patients are the first nutritional interventions recommended. In fact, oral nutritional supplementation represents the most effective nutritional approach to PEW prevention and treatment. It is simple and safe and it has a positive impact on quality of life and survival of haemodialysis patients. In the case of failure of oral supplementation, nutritional support should be enhanced by using intradialytic parenteral nutrition (IDPN). If the patient has difficulty in swallowing or IDPN is insufficient, total enteral nutrition should be considered.

[Hyponatremia: from guidelines to clinical practice]. / Iponatremia: dalle Linee Guida alla pratica clinica.

The publication, within a short time interval, of a consensus statement on the pathophysiology, diagnosis and treatment of hyponatremia by a panel of experts mainly from the US and of the European Guidelines on the same topic has marked an important step towards reducing the differences in the treatment of this frequent, and potentially fatal, electrolyte disorder. Within this framework, the European Society of Intensive Care Medicine (ESICM), the European Society of Endocrinology (ESE), and the European Dialysis and Transplantation Association-European Renal Association, represented by the European Renal Best Practice (ERBP), have developed these Guidelines for clinical practice, that are focused mainly on the diagnosis and the treatment of hyponatremia. In fact, they are the result of a tight collaboration between the three scientific societies involving those specialists with an elective interest for this electrolyte disorder. In addition to a rigorous methodological approach, a choice was made to provide a document focused on clinically relevant outcomes and useful for everyday practice. With respect to the original paper, this version of the Guidelines has been shortened and translated with a special view to the recommendations concerning the diagnosis and treatment of hyponatremia. It is preceded by an introduction underscoring the main targets of non-pharmacological treatment in acute severely symptomatic cases, specifically as regards the rate of correction of hyponatremia; subsequently, potential explanations for the discrepancies between the European Guidelines and the consensus statement by US experts concerning the use of vaptans are briefly discussed; the rationale and practical limitations in the clinical use of urea are analyzed in more detail.

Effective and timely evaluation of pulmonary congestion: qualitative comparison between lung ultrasound and thoracic bioelectrical impedance in maintenance hemodialysis patients.

The assessment of pulmonary congestion in maintenance hemodialysis (MHD) patients is challenging. Bioelectrical impedance analysis (BIA) can estimate body water compartments. Natriuretic peptides are markers of hemodynamic stress, neurohormonal activation and extracellular volume overload. Lung ultrasound (LUS) has been proposed for the non-invasive estimation of extravascular lung water through B-lines assessment. Up to now, no study evaluated the correlation between B-lines, segmental thoracic BIA, and natriuretic peptides in MHD patients. The aims of this study were: (1) To validate LUS as a tool for an effective and timely evaluation of pulmonary congestion in MHD patients, in comparison with segmental thoracic BIA, and with natriuretic peptides; (2) To compare a comprehensive whole chest ultrasound scanning with a simplified and timely scanning scheme limited to the lateral chest regions.Thirty-one MHD adult patients were examined. LUS, total body and thoracic BIA, and natriuretic peptides were performed immediately before and after a mid-week dialysis session. The number of B-lines assessed by LUS was compared with total body and thoracic impedance data and with natriuretic peptides.Pre-HD B-lines ranged 0-147 (mean 31) and decreased significantly post-HD (mean 16, P < 0.001). A significant correlation was found between the number of B-lines and extra-cellular water index (ECWI, r = 0.45, P < 0.001), with thoracic impedance (r = 0.30, P < 0.05), and with BNP (r = 0.57, P < 0.01). The dynamic changes in B-lines correlated better with thoracic impedance than with total body impedance, and correlated with extra-cellular but not with intra-cellular water index. The correlation between B-lines and ECWI was similar when LUS was limited to the lateral chest regions or performed on the whole chest. Multivariate analysis showed that only segmental thoracic impedance was an independent predictor of residual pulmonary congestion.The dynamic changes in B-lines after hemodialysis are correlated to the changes in total body and extra-cellular water, and particularly to lung fluids removal. B-line assessment in MHD patients is highly feasible with a simplified and timely scanning scheme limited to the lateral chest regions. These premises make B-lines a promising biomarker for a bedside assessment of pulmonary congestion in MHD patients.

Geriatric nutritional risk index is a strong predictor of mortality in hemodialysis patients: data from the Riscavid cohort.

INTRODUCTION: Malnutrition is a common complication in hemodialysis (HD) patients and it is related to morbidity and mortality. Although a gold standard method for diagnosis of malnutrition is not available, serum albumin, body weight and height are commonly used and are included in the calculation of the Geriatric nutritional risk index (GNRI). Recently the association between GNRI and mortality in chronic HD patients has been documented in Asian populations. Our aim was to examine the relative reliability of the GNRI as a mortality and morbidity predictor in an Italian HD cohort. METHODS: We prospectively examined the GNRI of 753 maintenance HD patients aged 65.7 ± 14.1 years, 457 males, included in the Riscavid cohort, and followed them up for 84 months. Predictors for all-cause death were examined using Kaplan-Meier and Cox proportional-hazards analyses. RESULTS: Low GNRI was significantly associated with signs of wasting, i.e. low Body mass index, hypoalbuminemia, low normalized protein catabolic rate. Patients within the lowest GNRI quartile had a significantly lower survival rate than those in the 2nd to 4th quartile (p < 0.001). Multivariate Cox proportional-hazards analysis demonstrated that the lowest quartile of GNRI was a significant predictor of case mix adjusted all-cause mortality (HR 1.72; CI 1.35-2.18, p < 0.001). CONCLUSIONS: These results demonstrate that low GNRI (<92) is associated with malnutrition and is a strong predictor of overall mortality in HD patients. However, cardiovascular events did not differ among the GNRI quartiles. A low GNRI score can be considered a simple and reliable marker of malnutrition and predictor for mortality risk in Caucasian HD patients.

Dietary protein restriction for renal patients: don't forget protein-free foods.

OBJECTIVE: The treatment of chronic kidney disease (CKD) consists of pharmacological, nutritional, and psychological-social approaches. The dietary therapy of CKD, namely a low-protein low-phosphorus diet, plays a crucial role in contributing to delay the onset of end-stage renal disease (ESRD) and to protect cardiovascular and nutritional status. The protein-free food products represent a very important tool for the implementation of a low-protein diet to ensure adequate energy supply, reducing the production of nitrogenous waste products. METHODS: This survey included 100 consecutive CKD patients who were asked their opinion about the use of protein-free foods. RESULTS: Ninety-eight patients (98%) reported a regular daily intake of protein-free pasta (as macaroni, spaghetti, etc.), which was the preferred product consumed. Actually, the taste and texture of protein-free pasta were considered as "good" or "very good" by 70% of patients. Conversely, 43% of CKD patients perceived the taste and texture of protein-free bread as "bad" or "very bad", and 30% found it "acceptable". Therefore, the main concern for the implementation of low-protein diets is the use and palatability of the protein-free products, bread in particular. CONCLUSIONS: The use of these products may help in reducing protein, phosphorus, and sodium intake while supplying an adequate energy intake, which represents the basis for a nutritionally safe and successful dietary treatment of advanced CKD patients. Manufacturers and food technology should make more efforts to finding new solutions to improve the taste and texture of protein-free products.