[Possible vaccine-induced immune thrombotic thrombocytopenia in a patient with diabetes and chronic kidney disease or random association?]

We report the case of a 75-year-old man who developed acute myocardial infarction 12 hours after the first dose of ChAdOx1 nCov-19 vaccine. The event was associated with a transient decrease of platelet count and the detection of anti-PF4 antibodies approximately 45 days after the event. Vaccine-induced thrombotic thrombocytopenia (VITT) is characterized by the onset of venous or arterial thrombosis in temporal relationship to the administration of anti-Sars-Cov-2 viral vector vaccines (ChAdOx1 nCov-19 and Ad26.COV2.S), thrombocytopenia and the production of anti-PF4 antibodies. It occurs mainly at a young age, even if the median age is 54 years; it is often associated with thrombosis in atypical sites, such as the cerebral sinus. Our reported case does not present all the diagnostic criteria of VITT. However, the close temporal relationship between ChAdOx1 nCov-19 vaccine administration, thrombosis, and concomitant anti-PF4 antibodies positivity makes the case suggestive of a possible slight form of VITT.

The burden of hypertension and kidney disease in Northeast India: the Institute for Indian Mother and Child noncommunicable diseases project.

Chronic noncommunicable diseases (NCDs) such as hypertension, atherosclerosis, acute myocardial infarction, stroke, diabetes, obesity, and chronic kidney disease are the major cause of death not only in high income, but also in medium and low income countries. Hypertension and diabetes, the most common causes of chronic kidney disease, are particularly common in southeast Asian Countries. Because early intervention can markedly slow the progression of these two killer diseases, assessment of their presence through screening and intervention program is a priority. We summarize here results of the screening activities and the perspectives of a noncommunicable diseases project started in West Bengal, India, in collaboration with the Institute for Indian Mother and Child (IIMC), a nongovernmental voluntary organization committed to promoting child and maternal health. We started investigating hypertension and chronic kidney disease with screen in school-age children and in adults >30 years old. We found a remarkable prevalence of hypertension, even in underweight subjects, in both children and adult populations. A glomerular filtration rate <60 mL/min was found in 4.1% of adult subjects significantly higher than that of 0.8% to 1.4% reported 10 years ago. Increased awareness and intervention projects to identify NCDs and block their progression are necessary in all countries.

Hypertension and kidney function in an adult population of West Bengal, India: role of body weight, waist circumference, proteinuria and rural area living.

AIM: Hypertension (HTN) and chronic kidney disease (CKD) are important emerging problems in low-income countries, with an increasing number of patients dying from their consequences. METHODS: A project for investigating these issues was carried out in West Bengal, India, in 2536 adult subjects. Body mass index (BMI) was classified using traditional and new cut-offs identified by the World Health Organization for Asian populations. HTN was classified according to the Joint National Committee 7 and CKD according to presence of estimated glomerular filtration rate (eGFR) of less than 60 mL/min per 1.73 m(2) . RESULTS: Normal BMI (Asian reference) was found in 41.5% of subjects, while 33.4% were underweight, 19.3% overweight and 5.8% obese. Prevalence of stage 1 and 2 HTN was 39.4%. Proteinuria (urine dipstick >1+) was present in 7.7% of the sample. In a subsample of 1526 subjects, eGFR of less than 60 mL/min per 1.73 m(2) was found in 4.2%. At multivariate analysis, factors associated with HTN were weight classes (P<0.001), presence of proteinuria (P<0.001) and family history of HTN (P=0.028), while living in rural areas was associated with lower risk for HTN (P=0.003). eGFR was inversely related to BMI (P=0.03), the presence of proteinuria (P<0.001) and HTN (P<0.003), and directly related to living in rural areas (P=0.003). CONCLUSION: High prevalence of HTN was found in subjects with very limited access to health care in West Bengal. HTN was more common in overweight individuals, but also affected normal weight and underweight subjects in a significant part of the tested population. Preventive medicine should be a strong priority in this setting.

[How to slow the progression of kidney damage today. Chronic kidney disease: an important personal, family and social problem]. / Rallentare la progressione del danno renale oggi. La malattia renale cronica: un rilevante problema personale, familiare e sociale.

The number of patients with chronic kidney disease (CKD) is increasing worldwide like an unstoppable tsunami. This causes considerable suffering for patients and families and places a severe economic burden also on society, especially when the patient reaches the stage of being in need of renal replacement therapy. Accordingly, a program of prevention and treatment of CKD at its earlier stages is of great importance, also in view of the fact that the general population is getting older and older and is more frequently affected by comorbidities such as hypertension, diabetes, obesity and cardiovascular disease. All these factors increase the likelihood of the development and worsening of CKD. In the meantime, nephrologists have developed new and better strategies to halt or at least slow the progression of CKD. These are based on the prescription to quit smoking and on dietary interventions guaranteeing an adequate calorie, protein, phosphate and sodium intake together with the correction of metabolic acidosis through either the supplementation of sodium bicarbonate or the choice of basic proteins. The treatment of hypertension and proteinuria (when detectable) by means of RAS inhibitors is another important strategy, where partial correction of anemia and statin use may be of help. Other treatments have not proven to be effective or their introduction into clinical practice is still far away.

High prevalence of hypertension in normal and underweight Indian children.

BACKGROUND: Childhood hypertension is an established predictor of adult hypertension and organ damage, an underestimated problem in developing countries. The aim of the study was to assess the prevalence of arterial hypertension, as well as the relationship of blood pressure values and weight class and urinary abnormalities in 1176 children (aged 5-12 years) from a suburban area south of Kolkata, India. METHOD: Arterial blood pressure, height, weight and waist circumference were measured. Weight class was defined according to the tables of the International Obesity Task Force. Urinalysis was performed with reagent strips to detect glucosuria, microhematuria and proteinuria. RESULTS: The majority of children (74.7%) were underweight and 5.2% had systolic and/or diastolic blood pressure values higher or equal to the 95th percentile, according to the National High Blood Pressure Education Program normograms. Hypertension had a high prevalence both in underweight children (4.3%) and in normal-weight children (6.9%) and significantly increased in the rare overweight children (4/20, 20%). A fraction of 8.5% of hypertensive children had urinary abnormalities (microhematuria only) vs. 12.5% in nonhypertensive children (P value 0.36). CONCLUSION: Prevalence of hypertension in North-Eastern Indian children is higher than in Western countries and only partly associated to weight class. Causes of hypertension do not seem to be related to overt kidney disease and remain to be elucidated.

Chronic kidney disease-associated anemia: new remedies.

Erythropoiesis stimulating agents (ESAs) are effective drugs that correct anemia in patients with chronic kidney disease (CKD). Recombinant human erythropoietin (EPO), the first ESA that became available more than 20 years ago, is similar to the naturally occurring molecule. In subsequent years, pharmacological research focused on the development of new agents with improved characteristics, with the creation of high molecular weight ESAs having been the first approach. In more recent years, new agents have been developed, including peginesatide (Hematide; Affymax Inc/Takeda Pharmaceutical Co Ltd), which is a dimeric peptide with a chemical structure unrelated to EPO that is being evaluated in phase III clinical trials. In addition, the clinical development of two inhibitors of hypoxia-inducible transcription factor has been resumed recently, while other approaches, such as gene therapy and EPO fusion proteins, and the inhibition of GATA and hematopoietic cell phosphatase remain far from being applicable in clinical practice. New iron compounds, which are becoming increasingly available, will facilitate an integrated approach to anemia management using both iron and/or ESAs, according to the clinical needs of patients. This review discusses new therapeutic options (already available or still under development) for the treatment of CKD-associated anemia, including ESAs and intravenous iron molecules.

The growing problem of intradialytic hypertension.

Intradialytic hypertension is not a rare complication of dialysis, with a prevalence of 5-15% among hemodialysis patients, and it seems to be associated with adverse outcomes. This complex phenomenon is not well understood, and many uncertainties exist regarding its pathophysiologic mechanisms and appropriate treatment strategies. Mechanisms that might be involved in the pathogenesis of intradialytic hypertension include extracellular volume overload, increased cardiac output, changes in electrolyte levels (particularly sodium), activation of the renin-angiotensin-aldosterone system, overactivity of the sympathetic nervous system, and endothelial cell dysfunction. Most current treatment strategies are based only on expert opinion and not on the results of randomized clinical trials, as very little data on the therapy of intradialytic hypertension are available. The most important treatment is adequate sodium and water removal, but reducing sympathetic hyperactivity and reducing endothelin-1 levels should also be considered. Well-designed, randomized clinical trials are urgently needed to better understand the pathophysiologic mechanisms of this complex phenomenon and to improve its diagnosis, prognosis and treatment.