[West Nile Infection and Kidney Disease: Description of Two Clinical Cases in Peritoneal Dialysis Patients].

The West Nile Virus (WNV), an RNA arbovirus, has been transmitted by wild birds and conveyed by ticks and mosquitoes, with wide diffusion all over the world; it is not transmitted from human to human. It can give clinical symptoms only in a minority of infected subjects such as fever, headache, muscle tiredness, visual disturbances, drowsiness, convulsions and muscle paralysis; in the most serious cases even potentially fatal encephalitis. In the literature there are few reports on WNV infection in patients with kidney diseases: here we report our experience on two patients on peritoneal dialysis infected by WNV with a revision of the literature.

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.

Mesenchymal Stromal Cells Prevent Renal Fibrosis in a Rat Model of Unilateral Ureteral Obstruction by Suppressing the Renin-Angiotensin System via HuR.

We studied Mesenchymal Stromal Cells (MSC) effects in experimental Unilateral Ureteral Obstruction (UUO), a fibrogenic renal disease. Rats were divided in 5 groups: sham, UUO, MSC treated-UUO, ACEi treated-UUO, MSC+ACEi treated- UUO. Data were collected at 1, 7, 21 days. UUO induced monocyte renal infiltration, tubular cell apoptosis, tubular atrophy, interstitial fibrosis and overexpression of TGFß, Renin mRNA (RENmRNA), increase of Renin, Angiotensin II (AII) and aldosterone serum levels. Both lisinopril (ACEi) and MSC treatment prevented monocyte infiltration, reduced tubular cell apoptosis, renal fibrosis and TGFß expression. Combined therapy provided a further suppression of monocyte infiltration and tubular injury. Lisinopril alone caused a rebound activation of Renin-Angiotensin System (RAS), while MSC suppressed RENmRNA and Renin synthesis and induced a decrease of AII and aldosterone serum levels. Furthermore, in in-vitro and in-vivo experiments, MSC inhibit Human antigen R (HuR) trascription, an enhancer of RENmRNA stability by IL10 release. In conclusion, we demonstrate that in UUO MSC prevent fibrosis, by decreasing HuR-dependent RENmRNA stability. Our findings give a clue to understand the molecular mechanism through which MSC may prevent fibrosis in a wide and heterogeneous number of diseases that share RAS activation as common upstream pathogenic mechanism.

Mesenchymal stromal cells reset the scatter factor system and cytokine network in experimental kidney transplantation.

BACKGROUND: In former studies we showed in a rat model of renal transplantation that Mesenchymal Stromal Cells (MSC) prevent acute rejection in an independent way of their endowing in the graft. In this study we investigated whether MSC operate by resetting cytokine network and Scatter Factor systems, i.e. Hepatocyte Growth Factor (HGF), Macrophage Stimulating Protein (MSP) and their receptors Met and RON, respectively. METHODS: MSC were injected into the renal artery soon after reperfusion. Controls were grafted untreated and normal rats. Rats were sacrificed 7 days after grafting. Serum and renal tissue levels of IFN-γ, IL-1, IL-2, IL-4, IL-6, IL-10, MSP/RON, HGF/Met systems, Treg lymphocytes were investigated. RESULTS: In grafted untreated rats IFN-γ increased in serum and renal tissue and IL-6 rose in serum. MSC prevented both the phenomena, increased IL-10 serum levels and Treg number in the graft. Furthermore MSC increased serum and tissue HGF levels, Met tubular expression and prevented the suppression of tubular MSP/RON expression. CONCLUSIONS: Our results demonstrate that MSC modify cytokine network to a tolerogenic setting, they suppress Th1 cells, inactivate monocytes/macrophage, recruit Tregs. In addition, MSC sustain the expression of the Scatter Factor systems expression, i.e. systems that are committed to defend survival and stimulate regeneration of tubular cells.

Multiple electrolyte disorders in a neurosurgical patient: solving the rebus.

BACKGROUND: It is important to ensure an adequate sodium and volume balance in neurosurgical patients in order to avoid the worsening of brain injury.Indeed, hyponatremia and polyuria, that are frequent in this patient population, are potentially harmful, especially if not promptly recognized.Differential diagnosis is often challenging, including disorders, which, in view of similar clinical pictures, present very different pathophysiological bases, such as syndrome of inappropriate antidiuresis, cerebral/renal salt wasting syndrome and diabetes insipidus. CASE PRESENTATION: Here we present the clinical report of a 67-year-old man with a recent episode of acute subarachnoid haemorrhage, admitted to our ward because of severe hyponatremia, hypokalemia and huge polyuria.We performed a complete workup to identify the underlying causes of these alterations and found a complex picture of salt wasting syndrome associated to primary polydipsia. The appropriate diagnosis allowed us to correct the patient hydro-electrolyte balance. CONCLUSION: The comprehension of the pathophysiological mechanisms is essential to adequately recognize and treat hydro-electrolyte disorders, also solving the most complex clinical problems.

The role of therapeutic drug monitoring in the treatment of cytomegalovirus disease in kidney transplantation.

Cytomegalovirus (CMV) infection is a common complication following solid organ transplantation that may severely affect the outcome of transplantation. Ganciclovir (GCV) and its prodrug valganciclovir are successfully used to prevent and treat CMV infection; however, in a small percentage of patients, CMV gene mutations may lead to drug resistance. GCV resistance is defined as increasing CMV viremia or progressive clinical disease during prolonged antiviral therapy, due to CMV gene mutation. This has emerged as a new challenge, especially because alternative drugs such as cidofovir and foscarnet have a number of important side effects. Here we report the case of a kidney transplanted patient who experienced life-threatening CMV disease, which initially appeared to be GCV-resistant, but was instead found to be associated with inadequate antiviral drug levels. The patient was then successfully treated by monitoring plasma GCV levels. We suggest using plasma GCV monitoring in the management of all cases of critical CMV disease, in which GCV resistance is suspected.