Diagnosis of rare entity CD138 negative plasma cell multiple myeloma: the synergy between laboratory and clinician makes the difference.

Plasma cell multiple myeloma (MM) is a multiform clinical entity characterized by different laboratory hallmarks. This case shows a rare entity of plasma cell myeloma: the entire plasma cell population lack the CD138 expression. In this case, a careful analysis of laboratory finding, particular flow cytometry gating strategies and the use of other ancillary laboratory tests, guide the clinicians to correct diagnosis. The correct evaluation of pre-analytical phase and the correct gating strategy are the necessary conditions to produce robust and solid flow cytometric results. The diagnostic implications of CD138-negative plasma cell are strictly linked to stem cell-like clonogenic features, such as possible more aggressive clinical behaviour and increasing probability of chemotherapy resistance. At this time, clinical laboratory remains the main reference point to MM diagnosis.

Peritoneal videodialysis: first Italian audit.

Conceived and developed since 2001 at the Alba Center, Videodialysis (VD) was used initially to prevent dropout in prevalent PD patients by guiding them in performing dialysis (VD-Caregiver). Subsequently, its use was extended to the clinical follow-up of critical patients (VD-Clinical), problems relating to transport to the Center (VD-Transport), and since 2016 for training/retraining all patients (VD-Training). Since 2017 other Centers have employed VD using modalities analyzed in this paper. Methods: the paper reports the findings of an Audit (February 2021) of the Centers using VD on 31-12-2020. The Centers provided the following information: the characteristics of the patients using VD; the main and secondary reasons for using VD, considering nursing home (VD-NH) patients separately; VD outcomes: duration, drop-out, peritonitis, patient/caregiver satisfaction (minimum: 1 - maximum: 10). Results: VD, which began between 09-2017 and 12-2019, has been used in 6 Centers for 54 patients at 31-12-2020 (age:71.8±12.6 years - M:53.7% - CAPD:61.1% - Assisted PD:70.3%). The most frequent reason has been VD-Training (70.4%), followed by VD-Caregiver (16.7%), VD-NH (7.4%), VD-Clinical (3.7%), and VD-Transport (1.9%), with differences between Centers. VD-Training is used most with self-care patients (93.8% - p<0.05), while with patients on Assisted PD it is associated with secondary reasons (95.7% - p<0.02). VD-Training (duration: 1-4 weeks) has always been completed successfully. No peritonitis was reported; satisfaction was 8.4±1.4. Conclusion: videodialysis is a flexible, effective, safe, and valued tool that can be employed using various modalities depending on the choice of the Center and the complexity of the patient.

Acute kidney injury, a common and severe complication in hospitalized patients during the COVID-19 pandemic.

INTRODUCTION: Acute respiratory failure (ARF) is the main clinical sign of coronavirus disease-2019 (COVID-19), but little is known about the outcome of acute kidney injury (AKI) associated with ARF. STUDY DESIGN: Retrospective cohort study on clinical features of adult patients hospitalized with COVID-19 between March 1st and April 30th, 2020 in the district of Piacenza (Italy). RESULTS: Among 1894 hospitalized patients, 1701 affected by COVID-19 underwent at least two serum creatinine evaluations. According to KDIGO definitions, 233 of 1,701 patients (13.7%) developed AKI: 159, 34, and 40 had stage 1, 2 and 3 AKI, respectively. Patients with AKI were older (mean age 73.5 ± 14 years, range 24-95) than those without AKI (72 ± 14 years, range 20-102). In-hospital mortality was high in COVID patients (567/1701 patients, 33%), which almost doubled among AKI patients (132/233 patients, 57%), compared with those without AKI (p < 0.01). Risk factors for AKI included older age, male gender, diabetes and need for ventilation. Fourteen patients with stage 3 AKI underwent renal replacement therapy (RRT). CONCLUSIONS: Hospitalized COVID-19 patients with AKI associated with ARF have poor chances of survival. Diagnosing and preventing the progression of renal damage is fundamental in order to delay initiating RRT, especially when resources are limited.

What can a home hemodialysis program offer to patients in a nursing home setting? A case series and feasibility analysis.

INTRODUCTION: Over the last decades, the number of elderly patients on dialysis has rapidly grown on account of increased life expectancy, improved care and reduced mortality rate. Therefore, cooperation between geriatricians and nephrologists has become mandatory for co-managing kidney disease in these patients. Based on renewed interest in home hemodialysis (HHD), elderly patients may benefit from not being transported from their home for therapy. METHODS: Here, we report our experience with HHD involving three elderly patients who were followed-up over a 15-months period in a nursing home. FINDINGS: Our experience demonstrates that hospitalization abruptly dropped from 40 days to zero days, the need for erythropoietin stimulating agents (ESAs) diminished, transportation-related costs for home treatments decreased, and quality of life (QoL) improved. This was confirmed by a questionnaire administered to our patients at the start and again after 6 months of HHD which evaluated the Physical Health Component Score (PCS) and the Mental Health Component Score (MCS). DISCUSSION: Home hemodialysis may represent an important way to improve social, mental, and physical recovery, while also eliminating the cost of transportation and the discomfort of abandoning their "homes" and daily habits. Home hemodialysis is an effective alternative to in-center HD or peritoneal dialysis (PD) that should be offered to elderly patients when a home caregiver is not available, nonetheless, nursing assistance is required. Moreover, HHD allows patients to stay at home, thereby avoiding several weekly trips to the dialysis center, and may be useful in reducing infections, especially in times of the COVID-19 pandemic, as demonstrated by our experience.

Covid-19 and its impact on nephropathic patients: the experience at Ospedale "Guglielmo da Saliceto" in Piacenza.

Roberto Scarpioni and colleagues recount their experience with the Covid-19 epidemic at the Nephrology and Dialysis Center of the "Guglielmo da Saliceto" Hospital in Piacenza, where everybody is still fighting to this moment to contain the spread of the disease and face an increasingly unsustainable clinical situation. Piacenza is only 15 km away from the main cluster of cases in the country (Codogno, in the Lodi province) and, after the closure of the Hospital in Codogno, saw an escalation in the number of patients testing positive to Covid-19. The authors describe their efforts and the practices they adopted to contain the spread of the disease among inpatients visiting the hospital's Hemodialysis Clinic. They also reflect on some of the data available on the 25/03/2020, such as the number of patients testing positive and the mortality rate, unfortunately very high. Their aim is to help all colleagues that have yet to face this epidemic in its full force.

Hemodialysis vascular access: everything you always wanted to know about it (but were afraid to ask).

Vascular accesses are essential for effective dialysis treatment. Arteriovenous fistulas, grafts and central venous catheters are the options available to the nephrologist, but they all have their pros and cons. All of the 3 types of vascular access share the same complications but at different rates, and their costs vary enormously, with on balance the arteriovenous fistula being the best choice. Nevertheless, recently the number of incident patients starting dialysis treatment with a venous catheter as vascular access has been steadily increasing. This is true even for more advanced countries such as the United States, where despite the efforts made to promote the use of fistulas, their prevalence is still low compared with Europe. Moreover, nowadays nephrologists are required to master technical skills that once were those of surgeons and to perform interventions to preserve the patency of the access. The aim of this paper is to review the prevalence, benefits and complications of the different vascular accesses in light of the most recent findings.

Loss of renal function in the elderly Italians: a physiologic or pathologic process?

BACKGROUND: Nowadays it seems that chronic kidney disease (CKD) is outbreaking, mostly in the elderly participants. The aim of this study was to assess the progression of CKD in different ages. METHODS: We conducted a monocentric, retrospective, observational study enrolling 116 patients afferent to our outpatient clinic. INCLUSION CRITERIA: age >18 years, follow-up ≥5 years, estimated glomerular filtration rate (eGFR) <60mL/min/1.73 m(2), and/or diagnosed renal disease and/or presence of renal damage. Patients were divided into four groups according to their age: 25-55 years (n = 27), 56-65 (25), 66-75 (42), and 76-87 (22). eGFR was calculated using the modification of diet in renal disease and the CKD-epidemiology collaboration formulas. RESULTS: Younger patients had a significantly longer follow-up and less comorbidities, evaluated by the cumulative illness rating scale score, compared with the other groups. There was no difference between creatinine at baseline and at the end-of-follow-up period among the groups. Even though renal function significantly decreased in all groups, we noticed a slower progression as the age increased, and the difference between basal and end-of-follow-up eGFR was minimal in the group of patients aged 76-87 years. Analyzing the eGFR of every ambulatory control plotted against the year of follow-up, we showed a more rapid loss of filtrate in the younger group. Instead, loss of renal function decreased as the age of patients increased. CONCLUSIONS: This study demonstrates that, in elderly Italian participants, progression of CKD occurs more slowly than in younger patients. This implies that we may probably face an epidemic of CKD but that most of elderly patients diagnosed with CKD may not evolve to end-stage renal disease and require renal replacement therapy.