Difficulties in the differential diagnosis of proteinuria during pregnancy / A várandósság során jelentkezo proteinuria differenciáldiagnosztikájának nehézségei

Even during normal pregnancy, significant morphological, functional and hemodynamic changes take place in the kidneys, resulting in a slightly increased proteinuria. However, an abnormal increase, especially if accompanied by hypertension or impaired renal function, requires close maternal and fetal follow-up, as it may predict severe perina-tal complications. Differential diagnosis of proteinuria is diverse, and the primary consideration in clarifying the etiol-ogy is to differentiate between preeclampsia and other possible primary kidney disease. We list all the diseases on the etiological palette that may even mimic the symptoms of preeclampsia, making it difficult to make an accurate diag-nosis. In the case of a 31-year-old gravida, we review the differential diagnosis of progressive proteinuria observed during pregnancy. In addition to the diagnosis of postpartum preeclampsia, renal malignancy was confirmed. We are also looking for the answer whether malignant kidney cancer can be blamed for the clinical presentation that includes hypertension, progressive proteinuria.

Type of Referral, Dialysis Start and Choice of Renal Replacement Therapy Modality in an International Integrated Care Setting.

INTRODUCTION: Integrated Care Settings (ICS) provide a holistic approach to the transition from chronic kidney disease into renal replacement therapy (RRT), offering at least both types of dialysis. OBJECTIVES: To analyze which factors determine type of referral, modality provision and dialysis start on final RRT in ICS clinics. METHODS: Retrospective analysis of 626 patients starting dialysis in 25 ICS clinics in Poland, Hungary and Romania during 2012. Scheduled initiation of dialysis with a permanent access was considered as planned RRT start. RESULTS: Modality information (80% of patients) and renal education (87%) were more frequent (p<0.001) in Planned (P) than in Non-Planned (NP) start. Median time from information to dialysis start was 2 months. 89% of patients started on hemodialysis, 49% were referred late to ICS (<3 months from referral to RRT) and 58% were NP start. Late referral, non-vascular renal etiology, worse clinical status, shorter time from information to RRT and less peritoneal dialysis (PD) were associated with NP start (p<0.05). In multivariate logistic regression analysis, P start (p≤0.05) was associated with early referral, eGFR >8.2 ml/min, >2 months between information and RRT initiation and with vascular etiology after adjustment for age and gender. "Optimal care," defined as ICS follow-up >12 months plus modality information and P start, occurred in 23%. CONCLUSIONS: Despite the high rate of late referrals, information and education were widely provided. However, NP start was high and related to late referral and may explain the low frequency of PD.

Immunogenicity and safety of an investigational AS02(v)-adjuvanted hepatitis B vaccine in patients with renal insufficiency who failed to respond or to maintain antibody levels after prior vaccination: results of two open, randomized, comparative trials.

An investigational AS02(v)-adjuvanted hepatitis B (HB-AS02) was compared with a licensed conventional recombinant hepatitis B vaccine (HBVAXPRO™; Sanofi Pasteur MSD, Lyon, France) in pre-dialysis, peritoneal dialysis and hemodialysis patients aged ≥18 years who had failed either to respond to prior vaccination with a conventional hepatitis B vaccine (Study A; n=251) or to maintain protective antibody concentrations after prior hepatitis B vaccination (Study B; n=181). These were open, randomized, comparative trials. Mean (range) age was 65.9 (31-92) and 64.6 (29-92) years in the two studies, respectively. In Study A, two doses of HB-AS02 given one month apart were found to be superior to two doses of the licensed vaccine in terms of seroprotection rate (76.9% versus 37.6%) and anti-HBs geometric mean antibody concentration (GMC; 139.3 versus 6.9mIU/ml), with antibody concentrations ≥100mIU/ml in 61.1% and 15.4% of subjects in the two groups, respectively. In Study B, one month after administration of a single booster dose, seroprotection rates were 89.0% in the HB-AS02 group and 90.8% in the licensed vaccine group, 81.3% and 60.9% of subjects had antibody concentrations ≥100mIU/ml, and anti-HBs GMCs were 1726.8 and 189.5mIU/ml. HB-AS02 was found to be more reactogenic than the licensed vaccine. In summary, the investigational HB-AS02 vaccine induced higher seroprotection rates and anti-HBs GMCs than a licensed conventional hepatitis B vaccine in uremic patients who had failed to respond or to maintain protective antibody titers after prior hepatitis B vaccination.