Parotid metastasis from renal cell carcinoma: a case report and review of the literature.

Renal cell carcinoma metastasis to the parotid gland after tumour nephrectomy is extremely rare. Herewith a review of the literature on this topic is discussed and a case report is presented of a 69-year-old man affected by parotid localization of renal clear cell carcinoma with neck lymph node metastases and involvement of the masseter muscle 2 years after nephrectomy. When an otolaryngologist encounters a parotid mass, diverse differential diagnoses have to be considered. A high level of suspicion of metastatic disease from the specific primary site will help in achieving correct diagnosis and evaluation of the extension of the disease. Surgical resection, even enlarged parotidectomy with neck dissection, should be considered as a therapeutic option for exclusive location of the disease in the head and neck.

Imaging work-up for peritoneal access care and peritoneal dialysis complications.

Peritoneal dialysis (PD) represents a treatment opportunity for patients with end-stage renal failure, but it has particular complications that sometimes force cessation of this procedure (1- 9). These complications are due to the presence of the peritoneal catheter and of dialysis solution within the peritoneal cavity. Infections are the most common complications of PD, followed by mechanical complications. Diagnostic imaging of the complications of PD is important because such an evaluation can aid in the diagnosis and in the decision making process about the treatment. In this review we present the main radiologic investigations employed: plain radiograph, US, peritoneography, computed tomography peritoneography, magnetic resonance peritoneography, peritoneal scintigraphy. To diagnose catheter-related problems plain radiograph, ultrasonography and peritoneography can be useful. US is useful in diagnosing and following-up exit-site and tunnel infections. Peritoneography and CT-peritoneography, alone or in combination, can be recommended as gold standard investigation to assess mechanical peritoneal dialysis complications, such as catheter malfunction, leaks, hernias and sclerosing peritonitis. Newer methods, such as MR peritoneography or scintigraphy could be useful in selected patients, on center-based experience. An appropriate use of radiology may significantly improve technique survival, morbidity and mortality of patients treated with PD.

[Characterisation of an HBsAg mutant of hepatitis B virus (HBV) isolated from a dialysed patient involved in an occupational accident]. / Caratterizzazione di un mutante dell'HBsAg del virus dell'epatite B (HBV) in un paziente dializzato coinvolto in un infortunio professionale.

BACKGROUND: Mutants of the hepatitis B virus (HBV) following vaccination (escape mutants) have been isolated over the course of the last decade. They consist most commonly of an aminoacid change from glycine to arginine at position 145 of the highly antigenic a determinant of the surface antigen (HBsAg). OBJECTIVE: Description of an escape mutant of HBV identified in the course of the post-exposure follow-up of a percutaneous exposure. METHODS: The viral DNA was extracted from serum samples of a dialysed patient vaccinated against hepatitis B, who developed an acute infection. A direct sequencing was performed on the amplified DNA followed by a sequence analysis. RESULTS AND CONCLUSIONS: A threonine to lysine substitution at position 118 of HBsAg (Thrll8Lys) was observed in the analysed viral aminoacid sequence. Such mutation could have significantly changed the antigenic profile of the HBsAg compared to that of the wild type.

Hemoperitoneum in a continuous ambulatory peritoneal dialysis patient caused by a hepatocarcinoma treated with percutaneous embolization.

Hemoperitoneum is an infrequent but normally benign complication in continuous ambulatory peritoneal dialysis (CAPD) patients. It can occur at any time during peritoneal dialytic treatment. Hemoperitoneum is not associated with a specific disease and usually disappears spontaneously. In 20% of cases, however, hemoperitoneum is severe and requires specific investigation and emergency therapy. We report a case of hemoperitoneum in a 70-year-old, anti-hepatitic C virus-positive woman. After 48 months of CAPD treatment, a bloody peritoneal effluent developed, with severe anemia (hematocrit decreased from 30% to 20%). An abdominal computed tomography scan showed three hepatic lesions with signs of hepatic neoplasms; selective hepatic arteriography confirmed the diagnosis. Chemoembolization of the three lesions was performed, and hemoperitoneum disappeared within a few hours.

Prevalence of hypertension in patients on peritoneal dialysis: results of an Italian multicentre study.

BACKGROUND: The tenet that peritoneal dialysis is capable of either normalizing or improving blood pressure control in uraemic patients is based on outdated or monocentric experiences. Therefore, we assessed the prevalence of hypertension and the efficacy of antihypertensive therapy in a large, multicentric cohort of patients on peritoneal dialysis. METHODS: Twenty seven out of the 50 centres belonging to the Italian Co-operative Peritoneal Dialysis Study Group took part in the study. The main patient selection criteria were: peritoneal dialysis therapy for at least 3 months and no peritonitis or changes in dialysis technique for at least 1 month. Clinical blood pressure was measured according to WHO/ISH guidelines. Ambulatory blood pressure monitoring was carried out using a SpaceLabs 90207 recorder. Hypertension was defined according to WHO/ISH criteria and staged according to the criteria of the Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure (JNC), 5th Report. Ambulatory blood pressure monitoring recordings were used to evaluate white-coat hypertension, blood pressure load and the dipping phenomenon. RESULTS: Five hundred and four subjects were evaluated. Hypertension was prevalent in 88.1% of the population, and 362 out of 444 hypertensive patients were on antihypertensive therapy. JNC staging revealed that 188 patients had moderate to severe hypertension. Blood pressure load was pathological in 77.3% of the patients receiving antihypertensive treatment. White-coat hypertension was identified in 9.1% of the hypertensive patients not on antihypertensive therapy, and 53.1% of the patients were non-dippers. CONCLUSIONS: The study demonstrates that hypertension is a dramatic, unsolved problem in uraemic patients treated with peritoneal dialysis, and casts doubts on the effectiveness of our current peritoneal dialysis strategies and pharmacological management of hypertension.

Trace elements and micropollutant anions in the dialysis and reinfusion fluid prepared on-line for haemodiafiltration.

Exposure to the trace elements and micropollutions of tap water may be very considerable in dialysis patients. As few data on trace elements in reinfusion and dialysis fluid for haemodiafiltration (HDF) have been reported, we studied nine trace elements (microg/l; Al, As, Cd, Cr, Cu, Hg, Pb, Se, Zn) and five anions (mg/l; F-, NO2-, NO3-, PO4(3-), SO4(2-)) in tap water, in water after two passages of reverse osmosis (2RO), in dialysate and in on-line prepared reinfusate. NO3- and SO4(2-) were somewhat elevated in our tap water (22.2+/-7.6 and 21.8+/-11.3 mg/l) but decreased (P<0.001) after 2RO (1.4+/-1.5 and 0.9+/-1.1 mg/l); the other anions, which were at a very low level, remained unchanged. All trace elements decreased, with statistical significance only for Al, Cr and Zn from 14.9+/-19.9, 2.6+/-0.6 and 35.1+/-41.1 microg/ to 3.2+/-2.1, 0.2+/-0.2 and 3.5+/-4.8 microg/l, respectively. Due to impurities in concentrate salts for Al (5.4+/-3.1), Cr (0.5+/-0.4) and SO4(2-) (2.4+/-1.8), greater concentrations were found in dialysate and reinfusate than in tap water after 2RO (P<0.03). For all measurements, trace elements and anions were at acceptable levels according to international standards. Simultaneous determinations of trace elements at inflow (Din) and outflow (Dout) of the dialysate as well as in plasma or in whole blood at the beginning of on-line HDF documented Dout/Din>1 for Al, Cu and Zn and a positive gradient between the concentration in blood and dialysate inlet. In conclusion, our dialysate and reinfusate can be considered safe regarding trace elements and micropollution: two passages through reverse osmosis reduces the concentrations of trace elements and anions. The impurities of concentrates are acceptable. Accumulation or depletion of trace elements should be evaluated after longitudinal studies of plasma concentrations.

Plasma or whole blood concentrations of trace elements in patients treated by haemodiafiltration with on-line prepared substitution fluid.

Large membrane pores and large quantities of reinfusion fluids can influence the dialytic balance of trace elements in haemodiafiltration (HDF). As there are no studies in HDF with on-line produced reinfusate, we studied plasma or whole blood (*) concentrations of trace elements (Al, Cd*, Cr* and Se: microg/l; Cu, Pb* and Zn*: microg/dl) of 24 on-line HDF, 20 haemodialysis (HD) patients and 66 490 normal subjects (N). The concentrations of Al (11.7+/-9.5), Cd (0.73+/-0.59) and Cr (6.5+/-6.9) were significantly greater in on-line HDF patients than in normal subjects (6+/-0.4; 0.6+/-0.2; 0.5+/-0.02), but similar to those of HD patients. In on-line HDF patients, Cu (85.3+/-17.7), Pb (8+/-4.6), Se (68+/-27) and Zn (546+/-103) concentrations were less than in normal subjects (108+/-3.4; 11+/-0.8; 95+/-1.8; 673+/-23), and those of Cu and Zn were also less than in HD patients (99.5+/-16.8; 670+/-65). At the end of an on-line HDF treatment (42-69 studies), there was a significant increase in Al (from 12.8+/-9.1 to 15.4+/-8.3), Cr (from 7.2+/-6.4 to 9.5+/-7), Cu (from 97.3+/-21.5 to 109.4+/-27.2) and Zn (from 577+/-108 to 619+/-117). A longitudinal study (n = 16-18) for 12-30 months documented stable concentrations of Al, Cd, Cr, Se and Zn and a significant increase of Cu and Pb to normal concentrations. In conclusion, our on-line HDF patients have elevated Al, Cd, Cr and decreased Cu, Pb, Se, Zn concentrations in plasma or whole blood determinations. Cu and Pb normalize with time; the other trace elements remain stable as documented by numerous determinations. As the values for on-line HDF patients are similar to those of HD patients, the level of accumulation or depletion of trace elements in on-line HDF can be considered as safe as in HD; the increase in Al, Cd, Cu and Zn at the end of treatment may be an expression of the increase of those trace elements linked to proteins.

Myths and reality concerning hypertension in peritoneal dialysis patients: results of a multicenter study.

OBJECTIVES: To evaluate the prevalence of hypertension, the average blood pressure level, the 24 h blood pressure profile, and the efficacy of antihypertensive therapy for a large population of peritoneal dialysis patients.DESIGN: A cross-sectional, observational multicenter study. METHODS: From 504 peritoneal dialysis patients (18% of the Italian peritoneal dialysis population) involved in a multicenter observational study, we selected 414 who had undergone successful ambulatory blood pressure monitoring (i.e. no hours with data absent, >/= 75% successful readings and monitoring duration >/= 24 h). Office blood pressure measurements and ambulatory blood pressure monitoring were performed for each patient on the same day with a standard mercury sphygmomanometer and a SpaceLabs 90207 device, respectively.RESULTS: According to World Health Organization/International Society of Hypertension criteria, 44 peritoneal dialysis patients (10.6%) were normotensive and 370 patients (89.4%) were hypertensive, 304 (82.1%) of whom were being administered antihypertensive therapy. Daytime systolic and diastolic blood pressures were both significantly lower than office systolic and diastolic blood pressures (140.7 +/- 19.7/72.1 +/-11.1 versus 148.3 +/- 23.6/85.6 +/- 12 mmHg; P < 0.001). The difference between office blood pressure and daytime blood pressure was significantly correlated to office blood pressure (P < 0.001 for systolic and P < 0.001 for diastolic). The diurnal blood pressure rhythm evaluated by visual inspection of hourly mean plots was not influenced by sex, age, antihypertensive treatment, and peritoneal dialysis modality. Systolic and diastolic blood pressures exhibited a day-night mean decreases of 8.6 +/- 11.7 and 7.7 +/- 6.9 mmHg, respectively, and daytime blood pressure values were significantly higher than night-time ones (P < 0.001). Two hundred and twenty patients (53.1%) were nondippers according to O'Brien's criteria, 247 patients (59.7%) were nondippers according to Verdecchia's criteria, and 269 patients (65.0%) were nondippers according to Staessen's criteria. Only 39 patients (9.4%) had a reversed circadian rhythm. The day-night differences of systolic and diastolic blood pressures were in a unimodal distribution. Among hypertensive patients not being administered antihypertensive therapy, only six patients ( five women and one man) had white-coat hypertension. Among hypertensive patients being administered antihypertensive therapy, 235 patients (77.3%) had 24 h blood pressure loads > 30%.CONCLUSION: There is a high prevalence of hypertension among peritoneal dialysis patients. White-coat hypertension is very rare in this population. Despite the extensive use of antihypertensive therapy, control of blood pressure is maintained in a large number of our peritoneal dialysis patients. Any classification of patients into dipers and nondippers must be interpreted cautiously.

Nutritional parameters in diabetic patients on CAPD.

In diabetic patients treated with dialysis, morbidity and mortality are more elevated than in nondiabetic patients. For the high dropout of diabetic patients between the first and the second year of treatment not much data are available on their nutritional parameters. For this reason, after excluding patients who had not had a two-years follow-up, we compared two groups of patients, 8 diabetics and 10 nondiabetics, similar in age (66.0 +/- 8.1 vs 65.0 +/- 8.3 years) and weight (61.8 +/- 11.9 vs 62.1 +/- 5.5 kg), measuring their nutritional parameters [body mass index (BMI), normalized protein catabolic rate (PCRN), albumin, transferrin, cholesterol], dialytic dose (Kt/V), renal residual function (RRF) and peritoneal urea (Kdu) and creatinine clearances (Kdcr) after one and 24 months of continuous ambulatory peritoneal dialysis (CAPD). At the start of CAPD, diabetics had greater weekly Kt/V (2.77 +/- 0.68 vs 2.19 +/- 0.35, p < 0.03) for a better residual renal function (5.0 +/- 2.0 vs 2.6 +/- 1.6 mL/min, p < 0.01) and greater loss of proteins in dialysate (7.8 +/- 2.3 vs 5.2 +/- 2.1 g/day, p < 0.05). After 24 months diabetic patients showed a significant decrease in albumin (3.44 +/- 0.34 vs 2.92 +/- 0.33 g/dL, p > 0.01), PCRN (1.21 +/- 0.20 vs 0.92 +/- 0.10 g/kg/day, p < 0.02), and weekly Kt/V (2.77 +/- 0.68 vs 2.25 +/- 0.38, p < 0.05), and a reduction, even if not as significant as with nondiabetic patients, in residual renal function (5.0 +/- 2.0 vs 3.0 +/- 2.3, p = NS). BMI (p < 0.01) was significantly increased in both groups, and this increase is higher in diabetic patients, while transferrin and cholesterol had no significant variations in both groups of patients. Peritoneal clearances did not change in 24 months, whereas the daily protein loss into dialysate was constantly higher in diabetic patients. In conclusion, diabetic patients have, over time, a decrease of total (renal and peritoneal) clearances of urea and creatinine (primarily because of loss of residual renal function, a reduced protein intake (evaluated as PCRN), and an increased loss of proteins from the peritoneum, which bring about a decrease in albuminemia, a possible concomitant cause of the greater morbidity and mortality in diabetic patients.

Continuous on-line determination of recirculation by thermodilution in hemodialysis patients.

The consistency of the determination of A-V fistula recirculation (R) using the thermodilution method (T) with a new probe (blood temperature monitor, BTM Fresenius A.G.) was studied in 32 patients (AVF: proximal 34%, distal 63%, graft 3%). We compared R calculated by T with both the traditional three-sample method (C) and the low-flow three-sample method (L); both BUN and creatinine (CR) were measured in all samples at the beginning and at the end of the session. T was also determined at the 2nd and 3rd hour. There was a significant correlation between T and either C or L at the start of the session (BUN and CR) as well as at the end (only CR). R was higher (11.9 +/- 10) in proximal AVF than in the distal (5 +/- 3.1%; p0.01) when measured by T at the same blood flow (QB: 313 +/- 45 vs 343 +/- 52 mls/min, p = ns). T increased but not significantly by increasing Qb from 150 to 300 mls/min in ten patients. No correlation was found during the session between blood pressure and T variations. In conclusion, T and L give very similar results while C overestimates recirculation. R is easy to perform repeteadly by T with results available online.

Residual renal function and nutritional parameters in CAPD.

In continuous ambulatory peritoneal dialysis (CAPD) residual renal function (RRF) plays an important role in the total amount of weekly clearances of small molecules. The purpose of this study was to determine if there were any differences in certain nutritional parameters between patients with and without RRF, total weekly clearance (KT/V) being equal. Therefore, we compared two groups of patients with equal weekly KT/V: group A without RRF [n = 7, KT/V 2.07 +/- 0.2) and group B with RRF (n = 7, KT/V 2.11 +/- 0.1, urea clearance 1.13 +/- 0.8, creatinine clearance 2.01 +/- 1.5 mL/min, contributing on the average of 15% (range 5.5%-28%) to the determination of KT/V]. The two groups were selected from 52 patients on CAPD for more than 9 months and they were comparable in age (A = 64.6 +/- 7 years, B = 64.1 +/- 7 years), duration of dialysis (A = 39.8 +/- 25 months, B = 36.3 +/- 31 months), body weight (A = 64 +/- 3.9 kg, B = 64.7 +/- 7.4 kg), and body mass index (A = 26.6 +/- 2.9, B = 25.8 +/- 3.6). The two groups turned out to be different in transferrin (A = 209 +/- 51, B = 278 +/- 24 mg/dL, p < 0.006), normalized protein catabolic rate (PCRN) (A = 0.87 +/- 0.07, B = 1.11 +/- 0.07 g/kg/day, p = 0.00), and albumin (A = 3.31 +/- 0.1, B = 3.55 +/- 0.2, p < 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)

High-dose oral calcitriol and zero calcium peritoneal solutions in CAPD patients with refractory secondary hyperparathyroidism.

We evaluated the effect of pulse oral calcitriol (4 micrograms three times weekly for 6 months) on parathyroid function in nine CAPD patients with hyperparathyroidism refractory to conventional low-dose oral calcitriol. Zero calcium peritoneal solutions were used to prevent the development of hypercalcaemia. The peritoneal loss of calcium increased from 168 +/- 40 to 417 +/- 48 mg/day using zero calcium solutions. Pulse oral calcitriol resulted in a significant decrease in PTH (from 617 +/- 272 to 382 +/- 299 pg/ml) by the 15th day of therapy, while serum iCa did not change from baseline. During the first month of therapy the mean PTH levels remained significantly reduced compared to baseline, thereafter PTH increased in four of nine patients. Hyperphosphataemia was not satisfactorily controlled in four patients, despite large amounts of binders used; seven of nine patients developed hypercalcaemia and required either the substitution of calcium acetate for calcium carbonate or reduction of calcitriol dose. Three patients showed a progressive increase in PTH. In conclusion our data suggest that in most CAPD patients with severe hyperparathyroidism oral calcitriol pulse therapy is not effective in maintaining a permanent suppression in PTH levels.

Effects of calcitriol pulse therapy per os in CAPD patients.

Pulse calcitriol therapy (IV or per os) has been efficacious in hemodialysis (HD) patients to inhibit parathyroid hormone (PTH) levels, but there are very poor data for continuous ambulatory peritoneal dialysis (CAPD) patients. For this reason, we used calcitriol (C) per os (0.75-1.5 micrograms three times weekly) in 19/54 patients who had PTH > 150 pg/mL (on peritoneal dialytic treatment for 6-114 months, weekly KT/V 2.01 +/- 0.43); 16% were in therapy with calcium (Ca) carbonate, 26% with calcium acetate alone, and 58% with calcium acetate associated with magnesium (Mg) carbonate and reduction of dialysate Ca (CaD) and dialysate Mg (MgD), respectively, to 1.25 and 0.25 mmol/L. In 5 patients (26%), a further reduction of CaD to 0 mmol/L has been necessary, and 3 patients must be considered nonresponders after three months of treatment. In conclusion, the use of calcitriol as pulse therapy (three times weekly), and at low doses, allows a good control of secondary hyperparathyroidism in 85% of patients who are using phosphate binders without aluminum, if CaD is reduced in some patients to 1.25 or even to 0 mmol/L.

Peritoneography and peritoneal computerized tomography: a new approach to non-infectious complications of CAPD.

The introduction of the contrastographic medium (PG) eventually combined with CT scan (PCT) has been used in the study of non-infectious abdominal complications of patients on CAPD. In 27 patients on CAPD from 0 to 98 months we infused, through the peritoneal catheter, 100-200 ml of iopamidol and 500-2000 ml of peritoneal dialysis solution, effecting radiograms in different projections (27 cases), with contiguous axial scannings of 10 mm (8 cases). The information obtained was useful with regard to the therapeutic choices; it clarified the extent, the width, and the anatomical relations of hernias (7/7); the leakage site at the introduction point of the catheter (2/5), and site of surgical treatment (2/5); an inguinal hernia (1/4) and the previousness of the peritoneovaginal duct (3/4) in cases of the genital oedema; a displaced non-opaque catheter (1/4); obstruction of the terminal hole (2/4); wrapping of the omentum in a catheter malfunction (1/4); the presence of scar tissue and pathological recesses in the reduction of ultrafiltration (2/3); and the extension of secondary scar tissue after surgery and before CAPD was started. There were no infective complications or allergic reactions during the research. In conclusion, after reparative surgical intervention, PG and PCT are simple, convenient investigations, with significant diagnostic usefulness, before the introduction of the catheter and/or in cases of complications during CAPD.