Unusual Extreme Leukocytosis in Metformin Overdose.

We present the challenging differential diagnosis of an extreme leukocytosis noted at hospital admission of a patient with severe lactic acidosis and acute kidney injury secondary to metformin overdose. Laboratory and imaging work-up ruled out an infectious or malignant cause for severely increased leukocytes count; thus, it was established that the process of leukocyte demargination was the main cause of increased count of leukocytes. Discussion of available literature data is also presented. Our case report highlights the importance for clinicians to be aware of this possible spurious increase of leukocytes in acute non-infectious stressful conditions in order to avoid unnecessary antibiotics.

Chronic Kidney Disease-An Underestimated Risk Factor for Antimicrobial Resistance in Patients with Urinary Tract Infections.

(1) Background: Chronic kidney disease (CKD), as well as antimicrobial resistance (AMR) represent major global health problems, with important social and economic implications. It was reported that CKD is a risk factor for antimicrobial resistance, but evidence is scarce. In addition, CKD is recognized to be a risk factor for complicated urinary tract infections (UTIs). (2) Methods: We conducted an observational study on 564 adult in-hospital patients diagnosed with urinary tract infections. The aim of the study was to identify the risk factors for AMR, as well as multiple drug resistance (MDR) and the implicated resistance patterns. (3) Results: The mean age was 68.63 ± 17.2 years. The most frequently isolated uropathogens were Escherichia coli strains (68.3%) followed by Klebsiella species (spp. (11.2%). In 307 cases (54.4%)), the UTIs were determined by antibiotic-resistant bacteria (ARBs) and 169 cases (30%) were UTIs with MDR strains. Increased age (≥65) OR 2.156 (95% CI: 1.404−3.311), upper urinary tract obstruction OR 1.666 (1.083−2.564), indwelling urinary catheters OR 6.066 (3.919−9.390), chronic kidney disease OR 2.696 (1.832−3.969), chronic hemodialysis OR 4.955 (1.828−13.435) and active malignancies OR 1.962 (1.087−3.540) were independent risk factors for MDR UTIs. In a multivariate logistic regression model, only indwelling urinary catheters (OR 5.388, 95% CI: 3.294−8.814, p < 0.001), CKD (OR 1.779, 95% CI: 1.153−2.745, p = 0.009) and chronic hemodialysis (OR 4.068, 95% 1.413−11.715, p = 0.009) were risk factors for UTIs caused by MDR uropathogens. (4) Conclusions: CKD is an important risk factor for overall antimicrobial resistance, but also for multiple-drug resistance.

Acute kidney injury in moderate and severe COVID-19 patients: Report of two university hospitals.

Acute kidney injury (AKI) is one of the most severe complications of SARS-CoV-2 infection. In a retrospective study, we aimed to describe the influence of COVID-19-related factors on the severity, outcome and timing of AKI in 268 patients admitted in two large COVID-19-designated university hospitals over a period of 6 months. In the univariate analysis, there was a significant relationship between KDIGO stage and the extension of COVID-19 pneumonia on computed tomography (CT), need for oxygen supplementation, serum levels of ferritin, interleukin-6, and procalcitonin, but none of these variables had a value for predicting KDIGO stage in multinomial regression. The odds of recovery of renal function were significantly diminished by d-dimer values. Lack of immunomodulatory treatment was found to be correlated with increased need for renal replacement therapy (RRT). Compared with AKI at admission, hospital-acquired AKI was predicted by the severity of lung damage on CT, evolved more frequently with incomplete recovery of renal function, and was significantly associated with antiviral therapy.

Combination of cranberry extract and D-mannose - possible enhancer of uropathogen sensitivity to antibiotics in acute therapy of urinary tract infections: Results of a pilot study.

Uncomplicated lower urinary tract infections are extremely common in women. Antibiotic treatment for acute episodes and for recurrence prophylaxis has its drawbacks and alternative therapies are sought in order to reduce the antimicrobial resistance phenomenon and the intestinal dismicrobism expansion. There are few studies on the effect of combination of cranberry extract with D-mannose in acute urinary tract infection management. In a pilot, randomized study 93 non-pregnant, otherwise healthy women, were enrolled with mean age of 39.77±10.36, diagnosed with uncomplicated lower urinary tract infection. Medical history, clinical examination, urine culture and a list of complaints were noted at the baseline visit. In a first phase of the study, treatment with either guideline recommended antibiotic alone or in association with the investigated product (cranberry extract plus D-mannose) was prescribed and all patients were clinically examined at day 7. All ameliorated and cured patients received in a second phase of the study, in a double-blind manner, prophylaxis with the investigated product or placebo for another 21 days, then a second clinical examination and a check of the list of complaints were performed. The cure rates were higher at day 7 when investigated product was added to antibiotic (91.6 vs. 84.4%). In resistant strains, a significantly higher cure rate was shown when the investigated product was added to antibiotic prescribed (88.8 vs. 37.5%, P<0.0001). The effect of cranberry extract plus D-mannose combination in acute urinary tract infection episodes seems to be promising. The significant cure rate registered in the patients with antibiotic-resistant urine cultures may be explained by a beneficial influence of the product on the antimicrobial sensitivity. Further studies are needed on this subject.

Supersonic Shear Wave Ultrasonography for Assessing Tissue Stiffness in Native Kidney.

Recent years have brought shear wave elastography to the attention of nephrologists as a non-invasive method for detecting kidney fibrosis and, therefore, as a potential tool for reducing the need for kidney biopsy. Few studies are performed on native kidney. We aimed to compare cortical stiffness, assessed by measuring Young's modulus (YM, kPa) with SuperSonic Imaging technology, in patients with various degrees of chronic kidney disease (CKD) compared with healthy individuals. Cortical stiffness was measured by two operators, in different sessions, in 32 patients with CKD stages 3-5 and 20 healthy individuals. Comparison between mean YM values in CKD and those in controls and also between the different stages of CKD was our primary objective. The influence of other possible confounders on YM readings was also investigated and analyzed. Mean YM was significantly greater in CKD patients than in controls. Estimated YM was not able to differentiate the stages of CKD, except stage 5. Intra-subject variability was greater in CKD than in controls. Body mass index was the most important confounder in multiple analyses, in both the CKD and control groups. Our results highlight a positive correlation between increased cortical stiffness and presence of CKD. Further studies are needed to validate this method for implementation in daily clinical practice.

Nephrotic syndrome secondary to amyloidosis in a patient with monoclonal gammopathy with renal significance (MGRS).

Monoclonal gammopathy with renal significance (MGRS) is a relative new-described entity, diagnosed especially in older patients and deriving from the group with monoclonal gammopathy of undetermined significance (MGUS). Various renal lesions may arise in MGRS, according to the ultrastructural characteristics of the monoclonal immunoglobulin deposition in the kidney, from proliferative glomerulopathies and amyloidosis to light chain proximal tubulopathy and crystal-storing histiocytosis. Although both are considered premalign or non-malignant hematological conditions, kidney involvement in MGRS aggravates the prognosis of the patients and need to be treated aggressively. We discuss the case of a 44-year-old female patient admitted in our Department of Nephrology for clinical picture of impure nephrotic syndrome and decreased renal function associated with Bence-Jones proteinuria. Renal biopsy was performed, and fibrillar amyloid deposits were demonstrated both in glomerular and tubular basement membranes; the immunofluorescence identified the presence of κ chains. Bone marrow aspiration and biopsy showed <10% plasmocytic proliferation confirming the diagnosis of MGRS.

Value of ultrasound elastography in the diagnosis of native kidney fibrosis.

In the last decade, ultrasound elastography, an already widely used technique in the diagnosis of hepatic fibrosis, has raised the attention of nephrologists as a potential valuable noninvasive tool for the diagnosis of renal fibrosis. Due to renal deep location and anatomic complexity, the shear wave techniques are the most appropriate elastography methods for exploring native kidneys. Recent research offers promising results, but further larger studies are required for a better standardization of this method and also for establishing reference values of normal kidney elasticity. This article reviews the studies conducted for exploring the native kidney, highlighting the advantages and limitations of ultrasound elastography for assessing fibrosis development in chronic kidney diseases.

Vascular calcification in continuous ambulatory peritoneal dialysis patients.

Vascular calcifications represent a severe complication of secondary hyperparathyroidism in patients with chronic kidney disease (CKD) stage 5. The factors influencing the development of this complication are in close relation with the pathology of chronic dialysis premorbid condition, and with therapy as well. The present article highlights the association between several factors and the development or the aggravation of vascular calcifications in continuous ambulatory peritoneal dialysis (CAPD) patients. The results are not always in accordance with similar literature data, but there is a lack of researches regarding mineral metabolism in peritoneal dialysis patients versus those on chronic hemodialysis.

Comparative evolution of hemodialysis vs. peritoneal dialysis in elderly.

UNLABELLED: The prevalence of treated patients with end-stage renal disease (ESRD) has considerably increased in the last decade mainly in the elderly age groups. The type of optimal mode of dialysis therapy in elderly is difficult to establish and most studies comparing hemodialysis and peritoneal dialysis in elderly failed to demonstrate the superiority of one therapy versus the other. The present article uses Charlson Co morbidity Index to compare evolution of an elderly population in HD versus PD. MATERIAL AND METHODS: Nondiabetic patients (> 65 years) who initiated dialysis therapy for ESRD during January 2006-December 2007. RESULTS: In HD group, the median CCI calculated 6 month before initiating dialysis therapy was 5.87, with limits between 3 and 11. At the time of initiating dialysis, the median CCI was 6.55 (limits 3-11). In peritoneal dialysis group, CCI evaluated 6 months before initiating dialysis had a median value of 7.38, with limits between 3 and 11. At the time of initiating dialysis procedure, the median CCI was 7.72. CONCLUSIONS: This study demonstrates that PD is, in the majority of situations, a better option for dialysis in elderly.

Functional status of chronic renal replacement therapy in elderly patients--comparison between hemodialysis and peritoneal dialysis.

UNLABELLED: Nowadays, nephrologists are confronted with an increasing number of elderly patients diagnosed with end-stage renal disease (ESRD) in need of dialysis. The benefits of renal replacement therapy are uncertain in this group of patients. Most studies show that the quality of life and survival of elderly dialyzed patients are worse than in younger patients because of multiple comorbidities. Functional status is an important aspect of the quality of life, a strong predictor of survival and a determinant of the health care systems costs. METHOD: In the present research, we compare the change in the functional status--appreciated with the MDS-ADL score--in a cohort of hemodialyzed versus peritoneal dialyzed elderly patients (> 65 years) during a period of 3 years after starting dialysis treatment. RESULTS: At the time of initiating dialysis, the median minimum data set of activities of daily living (MDS-ADL) score in hemodialysis (HD) elderly patients was 4.04 and in continuous ambulatory peritoneal dialysis (CAPD) group was 6.27 (the median MDS-ADL score at the moment of starting dialysis was statistically significant higher in peritoneal group than in hemodialysis elderly group). CONCLUSIONS: The results conclude that elderly treated with peritoneal dialysis have a better evolution of functional status than hemodialyzed elderly patients do.

Hyperhomocysteinemia in renal diseases.

Homocysteine is a sulfurated amino acid used for the synthesis of methionine. The last decade's researches proved that hyperhomocysteinemia is an independent risk factor for atherosclerotic vascular disease. The vascular injury induced by several mechanisms of hyperhomocysteinemia is the hallmark of homocysteine's atherogenic properties. Hyperhomocysteinemia is present in 85% of the patients with chronic renal failure (cardiovascular diseases are the main cause of mortality) and persists after initiating dialysis or after renal transplantation. Although folic therapy or folinic acid therapy reduce homocysteine levels with 20-40% in hemodialysis patients, the effects on cardiovascular morbidity have yet to be proven in future studies.

The importance of residual renal function in chronic dialysed patients.

In the last decade, many researches have reached to the conclusion that preservation of residual renal function (RRF) is important after initiating dialysis, as well as in the predialysis period. RRF has been proven to contribue to the quality of life of dialysis patients. Longer preservation of RRF provides a better small and middle molecule removal, improved volemic status and arterial pressure control, diminished risk of vascular and valvular calcification due to better phosphate removal. Deterioration of RRF results in worsening of anemia, inflammation and malnutrition. It is now proven a direct relationship between RRF value and survival in dialysis patient. Several therapeutical intervention have been proven to ameliorate the decline of RRF in dialysis patients. Some of them are identical with those before initiating dialysis: ACE-inhibitors and/or angiotensin-receptor blockers, limiting the use of nephrotoxic drugs, avoiding contrast media procedures, adequate control of blood pressure. Others are specific for dialysis period: adequate dialysis dose, avoiding excessive ultrafiltration, preventing arterial hypotension during dialysis sessions, using biocompatible dialysis membranes, ultrapure water for dialysis, dietary interventions.