[Renal Damage and Obesity: a Silent Pairing].

Obesity is recognized as a true chronic disease and an independent risk factor for kidney disease. In particular, a correlation was observed between obesity and the development of focal segmental glomerulosclerosis. The clinical consequences of obesity on the kidney can include albuminuria, nephrotic syndrome, nephrolithiasis, and increased risk of development and progression of renal failure. Conventional therapy, which includes low-calorie diet, exercise, lifestyle changes, and drug therapy, including GLP1-RA, phentermine, phentermine/topiramate, bupropion/naltrexone, orlistat, is not always able to achieve the desired results and above all does not guarantee stabilization of body weight over time. On the other hand, bariatric surgery is giving excellent results in terms of efficacy and duration. Bariatric surgery techniques that are generally divided into restrictive, malabsorptive, and mixed are not free from possible metabolic complications such as anemia, vitamin deficiency, and stones. However, they are able to ensure a good maintenance of weight loss obtained with disappearance or reduction of the incidence and severity of comorbidities related to obesity.

No additional benefit of prescribing a very low-protein diet in patients with advanced chronic kidney disease under regular nephrology care: a pragmatic, randomized, controlled trial.

BACKGROUND: Whether a very low-protein diet supplemented with ketoanalogues (sVLPD), compared with a standard low-protein diet (LPD), improves outcomes in patients with chronic kidney disease (CKD) under stable nephrology care is undefined. OBJECTIVES: To compare the effectiveness of sVLPD compared with LPD in patients regularly seen in tertiary nephrology care. METHODS: Participants were patients with CKD stages 4-5, followed for at least 6 mo, randomly allocated to receive sVLPD or LPD [0.35 or 0.60 g/kg ideal body weight (IBW)/d, respectively], stratified by center and CKD stage. The primary outcome was time to renal death, defined as the first event between end-stage renal disease (ESRD) and all-cause mortality; secondary outcomes were the single components of the primary outcome, cardiovascular outcome, and nutritional status. RESULTS: We analyzed 223 patients (sVLPD, n = 107; LPD, n = 116). Mean age was 64 y, 61% were male, and 35% had diabetes. Median protein intake (PI), which was 0.8 g/kg IBW/d at baseline in both groups, was 0.83 and 0.60 g/kg IBW/d in LPD and sVLPD, respectively, during the trial with a large decrease only in sVLPD (P = 0.011). During a median of 74.2 mo, we recorded 180 renal deaths (141 dialysis and 39 deaths before dialysis). Risk of renal death did not differ in sVLPD compared with LPD (HR: 1.17; 95% CI: 0.88, 1.57; P = 0.28). No difference was observed for ESRD (HR: 1.12; 95% CI: 0.81, 1.56; P = 0.51), mortality (HR: 0.95; 95% CI: 0.62, 1.45; P = 0.82), or time to fatal/nonfatal cardiovascular events (P = 0.2, log-rank test). After 36 mo, still active patients were 45 in sVLPD and 56 in LPD. No change of nutritional status emerged during the study in any arm. CONCLUSIONS: This long-term pragmatic trial found that in patients with CKD under stable nephrology care, adherence to protein restriction is low. Prescribing sVLPD compared with standard LPD is safe but does not provide additional advantage to the kidney or patient survival.

[Acute HCV-induced hepatitis in a patient affected by atypical hemolytic uremic syndrome (aHUS) treated with Eculizumab - case report].

Atypical hemolytic uremic syndrome (aHUS) is a rare and heterogenous disease caused by a disregulation of the alternative pathway of the complement cascade. Specifically, microvascular damage is produced that can lead to acute kidney disease, hemolytic anemia and thrombocytopenia. It accounts for 10% of all hemolytic uremic syndromes and can result in death or in end stage renal disease since the first episode. We can differentiate two forms of aHUS: a sporadic form (80%), affecting adult people, and a familial form (20%) that usually became manifest during infancy. In the acute phase of the disease, frequent and severe anemia requires multiple blood transfusions, exposing patients to the risk of catching an infective disease. HCV hepatitis is the most prevalent chronic hepatitis worldwide, with approximately 170 million chronically infected individuals - many of which are unaware of their condition. The evolution of the HCV infection is variable: almost 20% of patients spontaneously clear the infection over time (Anti HCV positive, HCV RNA negative patients); 80% of patients cannot control the virus and develop chronic infection (Anti HCV positive; HCV RNA positive patients) that can evolve into liver cirrhosis and hepatocellular carcinoma. The aim of this paper is to describe a clinical case of acute HCV hepatitis in a patient with aHUS treated with Eculizumab.

[Development of mesangial immunoglobulin IgA glomerulonephritis and p-ANCA positivity in a patient with psoriatic arthritis]. / Insorgenza di glomerulonefrite a depositi mesangiali di IgA e positività di p-ANCA in un paziente affetto da artrite psoriasica in trattamento con etanercept.

Tumor necrosis factor (TNF) inhibitors are widely used for the treatment of various rheumatic diseases. These agents may lead to development of systemic autoimmune diseases and renal complications. We report a patient with psoriatic arthritis and renal failure treated with two TNF inhibitors (Etanercept and then Adalimumab). After this treatment he developed proteinuria with nephrotic syndrome. A renal biopsy was performed highlighting GN with mesangial IgA deposits. Then he developed p-ANCA positivity. Following that, etanercept and adalimumab were stopped and a treatment by corticosteroids was initiated, but renal function decreased. Currently the patient is treated by haemodialysis. In our patient, the pathogenic role for anti-TNF therapy is suggested by the close temporal relationship with development of glomerular disease and by the improvement in proteinuria after drug withdrawal. However, the patient was treated once more with TNF agents, so he developed end stage renal disease.

[Iodide mumps following low-osmolarity contrast medium use in haemodialysis patients]. / Iodide mumps dopo somministrazione di mezzo di contrasto a bassa osmolarità in pazienti sottoposti ad emodialisi.

Sialadenitis (Iodide Mumps) is a rare complication following the administration of iodinated contrast media. It is characterized by the painless bilateral enlargement of the submandibular salivary glands. The pathogenesis of this adverse reaction remains unclear. It may be due to an idiosyncratic reaction or related to toxic accumulation of iodide in the ductal systems of the salivary glands. Iodide mumps may occur after administration of any iodinated contrast agent: 98% of injected iodide is eliminated by the kidneys and only 2% is excreted from other organs such as salivary, sweat and lacrimal glands. Normally, the injected dose of contrast medium does not provide a sufficiently high iodide concentration to cause iodide mumps, but impaired renal excretion of contrast medium results in liberation of iodide and enables the salivary glands to concentrate inorganic iodide. This condition is rare and self-limiting. The current management is supportive therapy using analgesics and dialysis. We report two cases of iodide mumps in end-stage renal disease (ESRD) patients treated with haemodialysis after administration of iodinated contrast media. The cases were characterized by rapid onset and resolution of the symptoms in the absence of specific treatment.

[Liposomial iron: a new proposal for the treatment of anaemia in chronic kidney disease]. / Il ferro liposomiale: una nuova proposta per il trattamento dell'anemia nei pazienti affetti da insufficenza renale cronica.

Iron supplementation is essential for the treatment of anemia in the chronic kidney disease (CKD) population. Liposomial iron is a preparation of ferric pyrophosphate carried within a phospholipidic membrane. Compared to other oral formulations, it is well absorbed from the gut and demonstrates high bioavailability together with a lower incidence of side effects. The aim of our study was to evaluate the effectiveness of treatment with liposomial iron compared to intravenous iron in a CKD population with anemia and iron deficiency. Our study is a single-center, prospective, randomized, fourth-phase study. Enrollment for the study began in October 2011 and CKD 3, 4 and 5 patients were randomized to receive either intravenous iron or liposomial iron in a 1:2 ratio. The primary outcome was set as the increase of hemoglobin from baseline. The secondary outcomes were the reduction of erythropoietin dosage by at least 25% in patients treated with erythropoiesis-stimulating agents and an increase in serum ferritin of 100 ng/ml from baseline values. In the preliminary study, 21 patients were analyzed, 14 of whom were treated with oral liposomial iron and 7 with intravenous iron. The observed increase of hemoglobin at 8 weeks compared to baseline was similar in both groups but was significant in the liposomial group only.

Influence of haemodialysis on variability of pulse wave velocity in chronic haemodialysis patients.

BACKGROUND: The major determinants of pulse wave velocity (PWV) in haemodialysis (HD) patients are not fully known. We studied chronic HD patients to assess the effect of cyclic variations in both hydration status and blood pressure on PWV. METHODS: Twenty patients were examined along three consecutive HD sessions and interdialysis periods during a week-long period. Twenty healthy subjects and 20 chronic kidney disease (CKD) patients (stage 5) were evaluated as controls. RESULTS: In contrast to controls, HD patients showed cyclic changes in PWV. Specifically, PWV values in HD patients were significantly higher prior to the first HD session of the week compared with values measured prior to the other two HD sessions during the week. In addition, PWV showed significant reductions during each dialysis session (15.6 +/- 5.2 to 9.3 +/- 2.3, 13.4 +/- 4.0 to 8.7 +/- 2.4, and 12.4 +/- 2.6 to 9.2 +/- 2.2 m/sec, before and after the first, second and third weekly dialysis sessions, respectively). Nevertheless, the weighted weekly values of PWV in HD patients (10.8 +/- 5.7 m/sec) were similar to those in CKD patients (9.9 +/- 4.2 m/sec). The HD ultrafiltration rate (UF) was significantly correlated with intradialysis PWV changes (r = 0.465; P < 0.001) and with after dialysis PWV values (r = -0.654; P < 0.0001). Blood pressure changes during dialysis were weakly correlated with post-dialysis PWV (r = -0.267; P < 0.05), but not with PWV changes during dialysis. CONCLUSIONS: In chronic HD patients, single PWV values varied widely during 1 week of HD sessions, whereas the weighted level showed only a slight increase. The major determinant of changes in PWV during HD appears to be the alterations in hydration status; the most representative time point for PWV measurements during HD corresponds to the interdialysis days.

Metabolic effects of two low protein diets in chronic kidney disease stage 4-5--a randomized controlled trial.

BACKGROUND: International guidelines have not reached a complete agreement about the optimal amount of dietary proteins in chronic kidney disease(CKD). The aim of this study was to compare, with a randomized-controlled design, the metabolic effects of two diets with different protein content (0.55 vs 0.80 g/kg/day) in patients with CKD stages 4-5. METHODS: Study design and sample size calculations were based on previously published experience of our group with low protein diet. The primary outcome of the study was the modification of serum urea nitrogen concentration. From 423 patients randomly assigned to the two diets 392 were analysed: 200 for the 0.55-Group and 192 for the 0.8-Group. The follow-up ranged 6-18 months. RESULTS: Mean age was 61+/-18 years, 44% were women, mean eGFR was 18+/-7 ml/min/month. Three months after the dietary assignment and throughout the study period the two groups had a significantly different protein intake (0.72 vs 0.92 g/kg/day). The intention-to-treat analysis did not show any difference between the two groups. Compliance to the two test diets was significantly different (P < 0.05): 27% in the 0.55-Group and 53% in the 0.8-Group, with male gender and protein content (0.8 g/kg/day) predicting adherence to the assigned diet. The per protocol analysis, conversely, showed that serum urea nitrogen, similar at the time of randomization, significantly increased in the 0.8-Group vs 0.55-Group by 15% (P < 0.05). Serum phosphate, PTH and bicarbonate resulted similar in the two groups throughout the study. The 24 h urinary urea nitrogen significantly decreased after the first 3 months in 0.55-Group (P < 0.05), as well as the excretion of creatinine, sodium and phosphate (P < 0.05 vs baseline) and were significantly lower than the 0.8-Group. The prescription of phosphate binders, allopurinol, bicarbonate supplements and diuretics resulted significantly less frequent in the 0.55-Group (P < 0.05). CONCLUSIONS: This study represents the first evidence that in CKD patients a protein intake of 0.55 g/kg/day, compared with a 0.8 g/kg/day, guarantees a better metabolic control and a reduced need of drugs, without a substantial risk of malnutrition.