[Tic douloureux sustained by an eye tumor].

Cancer is a major cause of morbidity and mortality in solid organ transplantation. Nonmelanoma skin cancer (NMSC) such as basocellular (BCC) and spinocellular (SCC) carcinoma, are common in renal transplant recipients. We report a case of an SCC affecting a lacrimal gland in a subject with kidney transplantation. A man aged 75 years who had suffered from glomerulopathy since 1967 and subsequently started haemodialysis, in 1989 was transplanted from a living donor. In 2019, he suffered paresthesia and pain in his right eyebrow arch and he was diagnosed to have neuralgia of the fifth cranial nerve. The failure of medical treatment and the development of a mass in his eyelid plus exophthalmos induced healthcare professionals to perform a magnetic resonance. The latter showed a retrobulbar mass measuring 39×22×16 mm3. Biopsy revealed an SCC and the patient underwent eye exenteration. Although NMSC of the eye is an extremely rare condition, risk factors such as male sex, history of glomerulopathy, and duration of immunosuppression should be taken into consideration at the time of the onset of eye symptoms.

[Economic impact of kidney patients with sepsis in hospital setting].

Introduction: Over the last decades, sepsis has become a real medical emergency, with a high mortality rate and often requiring admission to an intensive care unit. An increasing number of CKD patients contracts sepsis due to several clinical risk factors (use of catheters, immunosuppressive therapy, comorbidity, etc.) and is treated in Nephrology wards, generating additional costs that are not covered by hospital Diagnosis Related Groups (DRG) reimbursement. The aim of the study is to evaluate the costs of sepsis in one Nephrology Unit and to detect the mortality rate of CKD patients with sepsis. Methods: We conducted a retrospective study on a cohort of CKD patients admitted into one Nephrology Unit in 2017. CKD inpatients were divided in two groups: patients with sepsis (SP) and without (control group). Socio-demographic, clinical and therapeutic data, as well as routine biochemistry, were collected through a "sepsis form". SP were identified thanks to hospital discharge records (HDR). The hospital-related costs of a SP were obtained by summing up: (1) the average cost of an inpatient day of care for the average length of stay in the Nephrology Unit; (2) the average cost of the antimicrobial therapy, as recorded on the clinical folder. Results: Among the 408 CKD inpatients, 61 were septic. The overall average cost of a SP was 23.087,57 €; the average cost of the hospital stay and of the antimicrobial therapy was 19.364,98 € and 3.722,60 € respectively. The average length of stay in the Nephrology Unit was 16.7 days. The in-hospital mortality rate was 41.7%, with a 312% additional mortality rate. Conclusions: SP had an overall average cost three times higher than CKD inpatients without sepsis (9.290,79 €). This additional cost was due to a longer hospital stay (8.7 days more on average) and a higher cost of antimicrobial therapy per case (€ 221,24). A national multi-centre study is needed to confirm our data and to promote an adjustment of reimbursement tariff for DRG-sepsis, which is now applicable only to an ICU setting.

[The effect of intradialytic parenteral nutrition (IDPN) on the amino acid pool, a kinetic study]. / Effetto della nutrizione parenterale intradialitica (IDPN) sul patrimonio aminoacidico: studio cinetico.

BACKGROUND: Malnutrition in dialysis patients could be offset by intradialytic parenteral nutrition (IDPN), provided it is possible to demonstrate that this technique improves the aminoacid (AA) pool, despite clearance during dialysis. METHODS: A kinetic study was conducted in 10 malnourished patients, undergoing thrice- weekly low-flux HD, 240 mins/session (Bologna Malpighi and Trento Hospitals, Italy). After an HD session without IDPN (baseline), the patients received an IDPN solution with 16 AAs (all-in-one bag,NutriSpecialipid: 625 ml, Prot 35.9 gr) over a one-month period. At baseline, after 2 and 4 weeks, pre- and post-HD plasma and dialysate AA concentrations were measured. RESULTS: Even with a low-flux dialyzer and in the absence of IDPN infusion, AA loss in the dialysate occurred, increasing with the addition of IDPN infusion (3.9+0.3 gr/session with no IDPN compared to 7.7+0.5 with IDPN, p=0.00043), accounting foralmost 26% of the infused AA mass. Nevertheless, the AA mass balance was positive in the patients studied (+21.06+0.95 gr AA/session). After a one-month period with IDPN, the pre-dialysis concentration of each AA infused had indeed increased when compared with baseline concentrations, with a mean overall increase of 36.8%. No severe glucose imbalance was reported. CONCLUSION: After a one-month period, overall increase in the plasma concentration of all the infused AAs was observed, supporting the hypothesis that the use of IDPN for longer periods may result in increased protein synthesis.

[Superior vena cava syndrome unrelated to central venous catheter in a patient on chronic hemodialysis]. / Sindrome cavale superiore in un paziente in dialisi cronica: non e' sempre colpa del catetere venoso centrale!

A 67-year-old woman with end-stage renal disease (polycystic kidney disease) who had been on dialysis for 10 years came to our department for a second opinion about upper left arm edema homolateral to the arteriovenous fistula (AVF). Because of the suspicion of venous stenosis she had already been submitted to angiographic examination of the AVF which, however, did not show any occlusive process. In addition to the kidney problem, the clinical history included dilated cardiomyopathy, and 2 years earlier a biventricular implantable cardioverter defibrillator (ICD) had been placed. The patient had never had a central venous catheter (CVC). She presented a typical superior vena cava syndrome picture with arm, neck and hemifacial edema and superficial cutaneous venous reticulum. The venous pressure during extracoroporeal circulation was high and blood recirculation was documented. Angio-CT was performed to look for a compressive process in the chest, but this was excluded. We then performed a new trans-AVF angiography to study extensively the axillary-subclavian-superior vena cava district. At first, no stenosis or thrombosis was observed, but the presence of ICD and its leads (left-sided implanted) in the anonymous vein created obstacles to diagnosis. Repeated injections of contrast medium and focusing imaging on the leads route allowed us to highlight a venous stenosis in the anonymous vein. Transluminal angioplasty was successfully carried out during the same procedure. 1) In hemodialysis patients the appearance of signs of intrathoracic vein drainage obstacles is not always associated with previous CVC implantation; 2) in the hemodialysis patient, any device (PM, ICD) should be implanted contralaterally to the fistula arm in order to avoid the risk that a venous stenosis may cause AVF dysfunction.