[Renal stone ileus in xanthogranulomatous pyelonephritis. A case report]. / Occlusione intestinale da calcolo renale in pielonefrite xantogranulomatosa. Descrizione di un caso.

A peculiar case of intestinal occlusion caused by a renal stone in a patient with nephroduodenal fistula due to previous xanthogranulomatous pyelonephritis is reported. Only few cases of nephroduodenal fistula are described in the literature, generally as a single case report or in small series. A nephroduodenal fistula as a result of chronic renal inflammatory disease such as xanthogranulomatous pyelonephritis, is usually associated with renal stones, recurrent urinary tract infections or endocrine disorders. Finally, renal stone as a cause of ileus is an event rarely described in the literature. In the case described, a correct preoperative diagnosis was possible with computerized tomography. During the operation a big renal stone was found and removed from the small bowel, but a limited resection was necessary because of the vascular impairment of the tract. At 8-month follow-up from operation, the patient was in good health, and no symptoms of renal or intestinal diseases were found.

[Scabies in a dalysis unit. Mystery and prejudice]. / La scabbia in un centro dialisi. Mistero e pregiudizio.

BACKGROUND: Pruritus is one of the most common symptoms of uremia. The etiology of uremic pruritus is steel incompletely known. Scabies may be a cause of itching in these patients. METHODS: Retrospective analysis of beginning and developing of a scabies outbreak in a Dialysis Unit with 160 patients. RESULTS: Sixteen cases of scabies were observed in the Dialysis Unit from April 1998 and January 1999: in 6 of them the scarification was positive. In 10 the scarification was negative, but itching disappeared after treatment with benzyl benzoate 20%. Many courses were necessary (max 6). Prophylaxis (treatment with benzyl benzoate 20% for 3 days and lingery cleaning) was applied to approximately 400 people. No cases were observed among health care workers of the Dialysis Unit. CONCLUSIONS: In a Dialysis Unit the diagnosis of scabies is difficult because the patients often have generalized itching; moreover some of them are affected by neuropathy that may make the infestation of scabies more difficult to identify. The most important factor to limitate the outbreak seems to be the prophylaxis of people who take care of patients (health-care workers, family members and car-drivers). It seems also necessary to repeat the treatments many times. The most exposed patients seemed to be those with diminished independence, diabetes and malnutrition.

[Bright disease in Turin and Italy from the middle of the 19th century to the middle of the 20th century]. / La "malattia di Bright" a Torino e in Italia dalla metà dell'Ottocento alla metà del Novecento.

For many years the term nephritis was used to indicate renal diseases (in the sense of Bright s disease) in a larger sense. This review summarizes the history of the concept of glolomerulonephritis from Egyptian Medicine up to the Post-Biopsy Era, in particularly in Turin and in Italy. This study reports an epidemiology survey of Bright s disease in Italy from 1880 up to 1960. Towards the end of the 19th century Bright s disease accounted for 26 deaths/year/105 population (in comparison with more than 200 from tubercolosis) in Italy. At the beginning of the 20th century, Bright s disease was the seventh cause of death in Italy. Moreover, in Italy autopsy studies showed a higher percentage of deaths attributed to Bright s disease (5-7%) in comparison with those obtained from vital studies. In 1960, just before the beginning of renal replacement therapy, Bright s disease accounted for 15.7 deaths/year/105 population. Probably it was difficult to recognize in the real incidence of chronic renal diseases leading to death in the 1960s, and vital studies were able to furnish only approximate estimates. However, noteworthy is the fact that these values were very close to those estimated as being the annual need for renal replacement therapy (10-20/year/105 population).

[Acute renal failure. Epidemiologic observations in the Piedmont region]. / Insufficienza renale acuta. Osservazioni epidemiologiche nella Regione Piemonte.

BACKGROUND: The use of ICD9-CM for the classification of disease has been introduced in Italy. A retrospective study has been performed to evaluate the incidence of Acute Renal Failure Dialysis treated (ARFD) in Piedmont (4,500,000 inhabitants) and to evaluate the use of ICD9-CM for the classification of Acute Renal Failure (ARF) in the compilation of Hospital Discharge Sheets (SDOs). METHODS: The Piedmont Renal Transplant Registry was used to look for episodes of ARFD in the Region in 1997. All cases of ARF (584,5,6,7,8,9- 997.5- 958.5- 788.9- 634.3-639,3-669.3) were looked for in SDOs of all admissions to hospitals in the Region in the same period. RESULTS: 646 episodes of ARFD were found in the Piedmont Registry, that is an incidence of 142 episodes/million/year. 830 episodes of ARF (184 episodes/million/year) were found in an analysis of SDOs. It is impossible to find cases of ARFD from an analysis of SDO data. CONCLUSIONS: The ICD9-CM system, in Piedmont, in 1997, wasn't well utilized and the data are not useful for epidemiological studies unless further education in their use has been carried out. The analysis of the Piedmont Registry evidences that in the Region all the cases of advanced ARF (creatinine > 5 mg%) are treated by Dialysis. This may indicate a good performance of nephrological care, but the data have to be confirmed, because the incidence of ARFD is higher than in other European countries.

[Immune response to influenza vaccination among peritoneal dialysis patients]. / Risposta immune alla vaccinazione antiinfluenzale nei pazienti in dialisi peritoneale.

The influenza vaccination is considered useful in preventing influenza and its complications, but its efficacy is variable especially in uremia. The humoral efficacy in a group of 15 patients in peritoneal dialysis treatment has been evaluated. Antibody responses were measured before vaccination and at time intervals of 1-4 months after vaccination. A good response to viruses A (A/H3N2/Johannesburg 33/94, A/H1N1/Singapore 6/86), respectively 80% and 66.7% and an attenuated response (20%) to virus B (B/Beijing 184/93) was observed. For viruses A, the "non responders" were elder patients with a low count of lymphocytes. For virus B it is suggested that the low response is perhaps related to variable effectiveness of vaccine.

[Effectiveness of influenza vaccination in patients undergoing regular dialysis treatments]. / Efficacia della vaccinazione antifluenzale nei pazienti in trattamento dialitico regolare.

BACKGROUND: The influenza vaccination is considered useful in preventing influenza and its complications, but its efficacy is variable. Recent data on clinical effectiveness of influenza vaccination in renal patients are lacking. MATERIALS AND METHODS: The clinical efficacy in our Hemodialysis Unit during the last three years has been evaluated: 287 patients have been vaccinated. The rate of vaccination achieved has been of 81.3%. RESULTS: The efficacy has been of 46.7%. The difference of efficacy noted among young people (< 60 years) and elderly (> 60 years) in general population is not observed among our hemodialyzed patients. Bronchopulmonary complications (radiographically proven) have been low: 1.7%. No mortality increase has been observed. CONCLUSIONS: These findings suggest that influenza vaccine can reduce the incidence and severity of influenza virus infections also among hemodialyzed patients.

Vitamin E supplementation in preeclampsia.

An oxidant/antioxidant imbalance has been suggested among the pathogenetic factors involved in preeclampsia. As vitamin E is one of the most important antioxidant body components, a nonrandomized controlled trial was undertaken in 36 preeclamptic patients in order to evaluate the effect of vitamin E supplementation (100-300 mg/day per os) on fetal and maternal outcome. Fetal mortality was similar in 14 patients treated with conventional therapy plus oral vitamin E supplementation (35%) and in 22 patients treated with conventional therapy only (36%). Furthermore, in both groups of patients proteinuria increased, and increased dosages of antihypertensive drugs were called for in order to control blood pressure. We conclude that, with these dosages and in case of an already established disease, vitamin E does not improve fetal outcome in severe preeclampsia. Furthermore, it does not show favorable effects on maternal hypertension and proteinuria.

Oxygen free radicals are not the main factor in experimental gentamicin nephrotoxicity.

As a role for oxygen free radicals has been suggested in gentamicin (G) nephrotoxicity, we tested the hypothesis that exogenously administered glutathione (GSH), able to restore intracellular antioxidant potential, could be useful in reducing damage. Adult Sprague-Dawley rats were injected with saline (n = 30), subcutaneous (s.c.) G 100 (n = 23) and 150 mg/kg/day (n = 14), or s.c. G at the same dosages plus intraperitoneal (i.p.) GSH 1200 mg/kg/day (n = 24 and 14, respectively) for 7 days. In the G-100-day protocol, GSH-treated rats showed significantly lower renal G content (2.79 +/- 0.8 vs. 3.61 +/- 1.4 micrograms/mg prot) coupled with lower plasma urea (153 +/- 79 vs. 188 +/- 61 mg/dL) and creatinine levels (1.63 +/- 1 vs. 2.45 +/- 1 mg/dL). As to renal oxidant/antioxidant balance, local GSH was increased (0.32 +/- 0.01 vs. 0.19 +/- 0.01 microgram/mg prot) while lipid peroxidation, determined by production of thiobarbituric acid reactive substances (TBARS), was decreased (0.35 +/- 0.02 vs. 0.52 +/- 0.02 nmol/mg prot). In the G-150-mg protocol, GSH-treated rats showed no differences in renal gentamicin content or in blood urea and creatinine levels, in spite of a significantly lower renal TBARS production and a significantly higher GSH content. Urine enzyme excretion did not significantly change in GSH-treated vs. not-GSH-treated rats in both protocols. We conclude that: (a) GSH interferes with G nephrotoxicity mainly via a reduction in G uptake; (b) the oxidative renal stress is not crucial in inducing renal damage. In fact, when increased G dosages blunt the ability of GSH in reducing G uptake, no substantial protection is demonstrated.

Hemolytic-uremic syndrome during recombinant alpha-interferon treatment for hairy cell leukemia.

We report a case of hemolytic uremic syndrome in a patient suffering from hairy cell leukemia during recombinant alpha-interferon treatment. We believe that this is the first report of the occurrence of this peculiar kind of acute renal failure following alpha-interferon therapy. This association may suggest possible speculations regarding side effects of interferon treatment and pathogenesis of hemolytic uremic syndrome.

Repeated albumin infusions do not lower blood pressure in preeclampsia.

Since intravascular volume contraction is regarded as an important pathological feature in preeclampsia, it has been proposed that plasma volume expansion could be a therapeutic manoeuver that interrupts the pathogenetic chain of hypovolemia inducing increased vascular resistance. Furthermore, tissue perfusion should be improved and, if albumin is used as plasma expander agent, interstitial edema should also be reduced. We report the results observed in an open pilot study in ten preeclamptic patients treated with daily albumin infusions (0.4 to 1 g/kg) from 7 to 36 days. No acute effects were shown on blood pressure, and the need for antihypertensive therapies did not decrease in the following days. Serial evaluation after at least five or ten days of repeated albumin infusions did not show stable changes in electrolytes excretion, renal clearances, serum protein concentration and hematocrit value, nor in aldosterone, renin and atrial natriuretic peptide basal levels, while proteinuria tended to increase. Uteroplacental and fetoplacental blood flow acutely ameliorated in 3 cases only after albumin 1 g/Kg, but reached basal values again on the next day. The clinical implications are that daily albumin infusions with this schedule dosage do not lower blood pressure and that they are unable to induce stable changes in renal function, uteroplacental and fetoplacental resistance. No maternal complications were observed during the conservative management, but fetal mortality was high (6/10). Given the uncontrolled study, we cannot know whether similar results had been achieved by conventional therapy only.

Concomitant iron and aluminum mass transfer following deferoxamine infusion during hemofiltration.

Variable tissue overloading can alter the removal rate of iron and aluminum from uremics. Owing to its higher affinity to deferoxamine (DFO) and higher plasma concentrations, Fe could impair Al removal in cases of simultaneous body burden. Fe and Al plasma kinetics and mass transfer were therefore studied in 12 uremic patients with different Fe and Al status: six with normal ferritin levels (less than 400 micrograms/L [ng/mL]), and Al 1.4 to 4.7 mumol/L (40 to 131 micrograms/L) (group A); six with increased ferritin (greater than 2,000 micrograms/L), and Al 1.7 to 17 mumol/L (47 to 476 micrograms/L) (group B). DFO (40 and 80 mg/kg in a random sequence) was administered once a week during the first hour of the first hemofiltration (HF). The results show that in both groups and with both DFO doses, maximum Fe and Al mass transfer was achieved in the first and second HF, respectively. The 80-mg/kg dose of DFO significantly raised Al mass transfer in both groups, whereas Fe mass transfer was only slightly affected. Even though plasma Fe levels were almost always higher than Al, Al mass transfer eventually exceeded that of Fe, in both Fe-normal and Fe-overload patients. The bias towards Al in mass transfer was enhanced in both groups in the second HF, and at the higher DFO doses. Thus, DFO once a week reduced Fe loss to less than 30 mumol/wk in patients with normal ferritin levels. In both Fe and Al overloaded patients, Al can be removed, and Al mass transfer may often exceed Fe mass transfer, depending on the degree of tissue burden, the time from DFO infusion, and the DFO dose.

Pregnancy-related acute renal failure.

From 1958 to 1987, 81 cases of pregnancy-related acute renal failure (PR-ARF) were observed (9% of the total number of acute renal failure [ARF] needing dialysis). In the three successive ten-year periods (1958-67, 1968-77, 1978-87) the incidence of PR-ARF fell from 43% to 2.8% with respect to the total number of ARF, and from 1/3,000 to 1/15,000 with respect to the total number of pregnancies. Maternal mortality was high (32%), with 5 cases of death in the last ten years. Irreversible renal damage was recorded in 11.6% of PR-ARF, and, in particular, in 26.3% of cases in preeclampsia-eclampsia (PE-E). Worse maternal and renal prognosis occurred in PE-E complicated by abruptio placentae. Neither disseminated intravascular coagulation (DIC), microangiopathic hemolytic anemia nor prostacyclin imbalance were significantly related to the severity of renal damage. Heparin therapy did not modify DIC evolution and renal outcome and was aggravated by severe hemorrhagic complications. In conclusion, PR-ARF has become a rare, but still critical occurrence, and the most effective measures would be a program of careful prevention.

The role of intravascular coagulation in pregnancy related acute renal failure.

Pregnancy-related acute renal failure (ARF) can include reversible tubular necrosis as well as irreversible cortical necrosis. Though pathogenetic mechanism are not fully understood, disseminated intravascular coagulation (DIC) probably plays a primary role. We report 25 cases of pregnancy-related ARF: 13 were associated with preeclampsia or eclampsia and 12 with obstetric complications. The following parameters were studied: partial thromboplastin, prothrombin and thrombin time, fibrinogen, anti-thrombin III and FDP levels, platelet count, whole blood clot lysis time and area, fragmented red cells (schistocytes) in the blood smear, hemoglobin, aptoglobin and LDH concentrations. DIC was scored in arbitrary units ranging from 12 to 36 and related to the clinical picture, renal outcome and the treatment employed. Five patients had irreversible renal damage, while 19 recovered fully; one patient died and no renal histology was available. The DIC score did not seem to have a significant relation to the severity of renal damage.