Pancreatitis Is a Silent Killer in Peritoneal Dialysis With Difficult Diagnostic Approach.

Until 2018, 236 cases of acute pancreatitis have been reported in patients who underwent peritoneal dialysis. Here, we presented a patient with double renal transplantation with chronic renal failure, under renal replacement therapy by peritoneal dialysis, who developed acute pancreatitis with abdominal pain, nausea, vomiting, leukocytosis with neutrophil left shift which is complicated by pancreatic pseudocyst, candida peritonitis, fungal sepsis, overlapping of Acinetobacter baumannii sepsis, and pneumonitis. After the percutaneous cystogastrostomy drainage of pancreatic pseudocyst, changes from peritoneal dialysis to hemodialysis, various thoracentesis, and polyantibiotics therapy, the resolution of the sepsis state was seen. The particular aspect of our case is the various comorbidity risks, severe pancreatitis associated with candida and A baumannii sepsis, and treatment strategy that lead to heal this kind of the high mortality rate condition.

[Magnesium, calcium and potassium: "no one was born alone"]. / Magnesio, calcio e potassio: "Nessuno nasce solo o è nato per sé solo".

In contrast to other ions, magnesium is treated as an orphan by the body: there are no hormones that have a substantial role in regulating urinary magnesium excretion, and bone, the principal reservoir of magnesium, does not readily exchange with circulating magnesium.The Mg ++ is often overlooked by physicians in the differential diagnosis because it is considered insignificant, but its role is crucial for cells function, first of all neurons and cardiomyocytes. A condition of hypocalcemia associated with hypokalemia, especially in the presence of chronic renal failure, should raise suspicion of a lack of Mg ++.We report the case of an old man of 77 year with kidney transplant for 13 years, treated with cyclosporine, and sodium mycophenolate and steroid who, for about a month, accused impaired balance and walking instability, who fell accidentally down with wrist fracture.Blood tests showed hypocalcemia and hypokalemia, and so we required dosage of serum and urinary magnesium. A significant reduction in the ion plasma concentration was seen, associated to a fraction of excretion inappropriately high in relation to the degree of hypomagnesemia.The cause of this important renal loss is likely attributable to cyclosporine, a drug that has as a side effect the inhibition of the reabsorption of Mg ++ in the distal convoluted tubule. then, oral supplementation was started (244 mg of Mg ++ ion / day), with subsequent normalization, after a few days, not only of magnesiemia, but also in serum calcium and potassium levels, and improvement of neurological symptoms.Hypomagnesaemia is common in patients with renal transplantation in therapy with calcineurin inhibitors ICN, due to the effects of such drugs on the TRPM6 transporter present in the kidney distal convoluted tubule. To prevent complications caused by chronic and severe depletion of magnesium in this particular population, we recommend periodic monitoring of magnesium plasma levels.

[PET with C-methionine and hyperparathyroidism].

Scintigraphy 99mTc-sestamibi, in association ultrasound of the neck, is currently the technique of choice for the location of parathyroid adenomas in patients with hyperparathyroidism then undergo parathyroidectomy. After surgery, from 2% to 7% of patients continues to have a persistence of the disease. In this case, the sensitivity of scintigraphy with MIBI in locating ectopic parathyroid glands is limited and varies from 30% to 80%. Thanks to the introduction of a new method radiological, PET with 11C-methionine, it is now possible to detect the possible presence of parathyroid adenomas in patients with MIBI scintigraphy been examined and is also useful for false positives. PET with 11C-methionine is a diagnostic accurate in locating the parathyroid adenomas of the neck with a sensitivity of 91%, allowing you to run parathyroidectomy focused with a reduced invasiveness of surgery, with reduction of postoperative pain and better results aesthetic. In addition, a method is clinically useful in patients with secondary hyperparathyroidism and tertiary. The limits of this promising method are the poor availability of the tracer, the fact that it is executed in only four centers in Italy and the high cost. We present the cases of two patients who are diagnosed with hyperparathyroidism. They are submitted in the first instance to MIBI parathyroid scintigraphy parathyroidectomy and after removal of pathological glands. Persisting high values of PTH, patients are executed before a new scintigraphy with MIBI which is however negative and then a PET with 11C-methionine which shows accumulation of tracer in a different place not detected by scintigraphy.

[Candida peritonitis and sepsis due to Acinetobacter baumannii in peritoneal dialysis: an association with prognosis not always unfavourable]. / Peritonite da Candida e sepsi da Acinetobacter baumannii in dialisi peritoneale: un'associazione con prognosi non sempre infausta.

Fungal infections have a high incidence in patients receiving peritoneal dialysis. (1)Peritoneal dialysis is often complicated by peritonitis which has only minimally mycotic etiology, but nonetheless it is associated with 15-45% mortality (8). The opportunistic pathogens such as Candida can cause infection in immunocompromised conditions. Even the Acinetobacter tends to infect immunocompromised individuals and it has the same risk factors for infection as Candida: immunosuppression, malignancy, HIV positivity and all the other conditions of immunosuppression, central venous catheterization, mechanical ventilation and prolonged antibiotic therapy. The sepsis by Acinetobacter predicts a negative prognosis with the mortality rate between 20 to 60% (12), especially in cases of isolation of multi-resistant germs. We present a case report of a CKD patient undergoing peritoneal dialysis therapy who was hospitalized for acute pancreatitis, later complicated by the development of pancreatic pseudocysts, C. albicans peritonitis with hematologic spread of the fungus, superimposed Acinetobacter baumannii sepsis and pneumonia. She has been subjected to percutaneous drainage of pseudocysts, to switch from peritoneal dialysis to hemodialysis, to various evacuative thoracentesis, and to polymicrobial therapy (meropenem, teicoplanina, tigeciclina, linezolid, colimicina, fluconazolo, etc.) that allowed the resolution of sepsis. The peculiarity of this case is represented by the numerous morbidity that the patient developed simultaneously, with the genesis of a complex clinical picture, by the combination of infections due to Candida albicans and Acinetobacter baumannii. Successful treatment strategies allowed to fight and cure a medical condition associated with a high mortality rate.

[Acute phosphate nephropathy (APN)]. / Nefropatia acuta da fosfati.

Acute phosphate nephropathy (APN) is a clinical condition, appeared in the last decade, in patients under treatment with oral sodium phosphate bowel purgative (OSPS). Renal damage induced by OSPS may occur as acute or chronic disease. The former commonly appears within few hours after bowel cleansing with OSPS. It is clinically characterized by severe hyperphospatemia (4.519.4 mmol/l) and hypocalcemia (11.17mmol/l). Recovery of renal function may occur in some patients, while others develop chronic kidney disease (CKD), with possible evolution towards end-stage renal disease (ESRD). Renal biopsy reveals acute nephrocalcinosis characterized by abundant distal tubular calcium phosphate deposits, associated with tubular athrophy and interstitial fibrosis. Predisposing factors for the onset of APN include female sex, senescence, diabetes mellitus, arterial hypertension, CKD and use of diuretic or drugs acting on renin-angiotensin system (RAS). The diagnosis is suggested by the timely association between assumption of OSPS for bowel cleansing and acute kidney injury. However, chronic complications may remain unrecognized, without periodic control of renal function after OSPS assumption.Most importantly, the definitive diagnosis needs to be confirmed by renal biopsy. In 2006, FDA published an alert, recommending caution in the use of OSPS in patients with impaired renal function.

Asymptomatic pulmonary congestion and physical functioning in hemodialysis patients.

BACKGROUND AND OBJECTIVES: Poor physical performance is common in patients with kidney failure on dialysis (CKD-5D). Whether lung congestion, a predictable consequence of cardiomyopathy and fluid overload, may contribute to the low physical performance of CKD-5D patients has not been investigated in hemodialysis patients. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This study investigated the relationship between the physical functioning scale of the Kidney Disease Quality of Life Short Form and a validated ultrasonographic measure of lung water in a multicenter survey of 270 hemodialysis patients studied between 2009 and 2010. RESULTS: Moderate to severe lung congestion by lung ultrasonography was observed in 156 (58%) patients; among these, 60 (38%) were asymptomatic (New York Heart Association [NYHA] class I). On univariate analysis, physical functioning was inversely associated with lung water in the whole group (r=-0.22; P<0.001) and in the subgroup of asymptomatic patients (r=-0.40; P=0.002). Age (r=-0.45; P<0.001) and past cardiovascular events (r=-0.22; P=0.002) were also inversely associated with physical functioning, whereas albumin (r=0.23; P<0.001) was directly associated with the same parameter. NYHA class correlated strongly with physical functioning (r=-0.52; P<0.001). In a multiple regression analysis, both NYHA class and lung water maintained an independent association with physical functioning, whereas albumin and background cardiovascular events failed to independently relate with the same outcome. CONCLUSIONS: Symptomatic and asymptomatic lung congestion is associated with poor physical functioning in hemodialysis patients. This association is independent of NYHA, suggesting that this measurement and NYHA may have complementary value to explain the variability in physical performance in hemodialysis patients.

Pro-inflammatory cytokines and bone fractures in CKD patients. An exploratory single centre study.

BACKGROUND: Pro-inflammatory cytokines play a key role in bone remodeling. Inflammation is highly prevalent in CKD-5D patients, but the relationship between pro-inflammatory cytokines and fractures in CKD-5D patients is unclear. We studied the relationship between inflammatory cytokines and incident bone fractures in a cohort of CKD-5D patients. METHODS: In 100 CKD-5D patients (66 on HD, 34 on CAPD; males:63, females:37; mean age: 61 ± 15; median dialysis vintage: 43 months) belonging to a single renal Unit, we measured at enrolment bone metabolic parameters (intact PTH, bone and total alkaline phosphatase, calcium, phosphate) and inflammatory cytokines (TNF-α, IL-6, CRP). Patients were followed-up until the first non traumatic fracture. RESULTS: During follow-up (median: 74 months; range 0.5 -84.0) 18 patients experienced fractures. On categorical analysis these patients compared to those without fractures had significantly higher intact PTH (median: 319 pg/ml IQ range: 95-741 vs 135 pg/ml IQ: 53-346; p = 0.04) and TNF-α levels (median: 12 pg/ml IQ: 6.4-13.4 vs 7.8 pg/ml IQ: 4.6-11; p = 0.02). Both TNF-α (HR for 5 pg/ml increase in TNF-α: 1.62 95% CI: 1.05-2.50; p = 0.03) and intact PTH (HR for 100 pg/ml increase in PTH: 1.15 95% CI: 1.04-1.27; p = 0.005) predicted bone fractures on univariate Cox's regression analysis. In restricted (bivariate) models adjusting for previous fractures, age, sex and other risk factors both PTH and TNF-α maintained an independent association with incident fractures. CONCLUSIONS: In our bivariate analyses TNF-α was significantly associated with incident fractures. Analyses in larger cohorts and with adequate number of events are needed to firmly establish the TNF α -fracture link emerged in the present study.