Acetate-free biofiltration to remove fibroblast growth factor 23 in hemodialysis patients: a pilot study.

AIM: Serum levels of 32 kDa-phosphaturic hormone fibroblast growth factor 23 (FGF23) rise early in renal failure in order to keep phosphatemia within the normal range; however, this compensatory mechanism itself contributes to chronic kidney disease-mineral bone disorder. High FGF23 is also associated to left ventricular hypertrophy, vascular calcifications and thus increased cardiovascular risk. The aim of this pilot pre-post study was to evaluate the effects of a single hemodiafiltration session with acetate-free biofiltration (AFB) on FGF23 serum levels. METHODS: Nine hemodialysis patients were enrolled; sessions were performed using the Integra® monitor (Hospal, Bologna, Italy) and a polyacrylonitrile membrane. Peripheral venous blood samples were taken before (pre-HD), at mid- and after treatment (post-HD); dialysate samples were collected by the Quantiscan™ monitoring system. FGF23 was measured by a human FGF-23 ELISA kit. Mid- and post-HD values were corrected for hemoconcentration. RESULTS: Pre-HD FGF23 levels positively correlated with dialysis vintage (r = 0.7192; p = 0.0443). They were significantly reduced by the hemodialysis session (from 2.38 ± 1.80 to 1.15 ± 1.21 ng/ml, p = 0.0171) with a reduction ratio of 52.55 ± 28.76%. FGF23 was detected in the dialysate samples. CONCLUSION: FGF23 underwent a significant reduction during AFB. Such removal was greater than that induced by conventional hemodialysis as reported in the literature (19%-decrease using modified cellulosic membranes). This difference may be attributed to the ability of AFB hemodiafiltration to efficiently remove middle molecules by convection. Whether a better clearance of FGF23 during hemodialysis may result in improved cardiovascular outcomes in the long term needs to be confirmed by randomized controlled trials.

Effectiveness of Switch to Erythropoiesis-Stimulating Agent (ESA) Biosimilars versus Maintenance of ESA Originators in the Real-Life Setting: Matched-Control Study in Hemodialysis Patients.

BACKGROUND: In hemodialysis (HD), switching from erythropoiesis-stimulating agent (ESA) originators to biosimilars is associated with the need for doses approximately 10% higher, according to industry-driven studies. OBJECTIVE: The aim of this study was to evaluate the efficacy on anemia control of switching from ESA originators to biosimilars in daily clinical practice. METHODS: We retrospectively selected consecutive HD patients receiving stable intravenous ESA doses, and who had not been transfused in the previous 6 months, from 12 non-profit Italian centers. Patients switched from originators to biosimilars (n = 163) were matched with those maintained on ESA originators (n = 163) using a propensity score approach. The study duration was 24 weeks, and the primary endpoint was the mean dose difference (MDD), defined as the difference between the switch and control groups of ESA dose changes during the study (time-weighted average ESA dose minus baseline ESA dose). RESULTS: Age (70 ± 13 years), male sex (63%), diabetes (29%), history of cardiovascular disease (40%), body weight (68 ± 14 kg), vascular access (86% arteriovenous fistula), hemoglobin [Hb] (11.2 ± 0.9 g/dL) and ESA dose (8504 ± 6370 IU/week) were similar in the two groups. Hb remained unchanged during the study in both groups. Conversely, ESA dose remained unchanged in the control group and progressively increased in the switch group from week 8 to 24. The time-weighted average of the ESA dose was higher in the switch group than in the control group (10,503 ± 7389 vs. 7981 ± 5858 IU/week; p = 0.001), leading to a significant MDD of 2423 IU/week (95% confidence interval [CI] 1615-3321), corresponding to a 39.6% (95% CI 24.7-54.6) higher dose of biosimilars compared with originators. The time-weighted average of Hb was 0.2 g/dL lower in the switch group, with a more frequent ESA hyporesponsiveness (14.7 vs. 2.5%). Iron parameters and other resistance factors remained unchanged. CONCLUSIONS: In stable dialysis patients, switching from ESA originators to biosimilars requires 40% higher doses to maintain anemia control.

Socio-Economic Factors, Food Habits and Phosphorus Levels in Patients on Hemodialysis.

BACKGROUND: Hyperphosphoremia is one of the most important risk factors for morbidity and mortality for chronic kidney disease (CKD) patients, and also, for the general population. Excessive dietary intake of phosphate (P) is one of the key factors. In particular, P in its inorganic form, which is contained in food additives, is more readily absorbed. Unfortunately, these food additives are mostly present in convenience so called "fast foods" (pre-cooked), soft drinks, which represent the typical food consumed by our hemodialysis (HD) population, composed by elderly people, mostly low-socio economic class, who often live alone. OBJECTIVES: We performed an observational retrospective multicenter study to find any association between social, cultural and economic situation, as well as food habits, and P levels in a cohort of patients on HD. Secondarily; we also examined the association between the fast food consumption and increased P levels, as well as patient compliance for P binding products. PATIENTS AND METHODS: To explore the association between socio-economic factors and serum P levels, we enrolled 100 patients on periodic HD treatment from three different units. Information on social, cultural, economic, diet habits, therapy for hyperphosphoremia and hematological and clinical parameters had been collected through specific questionnaires, administered by a physician. RESULTS: Results showed serum P level was reduced in patients who live alone compared to patients in family (P = 0.04), in self-sufficient (P = 0.05) and in patients belonging to middle-upper class, versus low-class (P = 0.003). Fast foods intake correlates with increase in P serum levels (P = 0.002), whilst the same correlation was not found for cheese intake. Our data show that socio-economic status and food habits are useful predictors of P serum levels. CONCLUSIONS: In conclusion, dietary counseling of patients on HD is mandatory. Interventions that consider the socio-economic situation allow delivering important messages on foods with the least amount of P and adequate protein content, and they may be a successful strategy in targeting patients at a higher risk of hyperphosphoremia.

Unexpected hypercalcemia in a diabetic patient with kidney disease.

We report a case of a diabetic patient with progressive chronic kidney disease and unexplained hypercalcemia. This unusual presentation and the investigation of all possible causes led us to perform a renal biopsy. The systemic sarcoidosis diagnosis was confirmed by the presence of interstitial multiple granulomas composed of epithelioid and multinucleated giant cells delimited by a thin fibrous reaction, and by pulmonary computed tomography finding of numerous lumps with ground-glass appearance. Sarcoidosis most commonly involves lungs, lymph nodes, skin and eyes, whilst kidney is less frequently involved. When it affects males it is characterized by hypercalcemia, hypercalciuria, and progressive loss of renal function. Early treatment with steroids allows for a gradual improvement in renal function and normalization of calcium serum values. Otherwise, the patient would quickly progress to end stage renal disease. Finding of hypercalcemia in a patient with renal failure must alert physicians because it may be a sign of several pathological entities.

[Lupus Nephritis and Enteritis, a dual simultaneous involvement with Arteriolar Thrombosis]. / Nefrite ed Enterite Lupica, un doppio coinvolgimento simultaneo con trombosi arteriolare.

Arteriolar thrombosis is a complication that may occur during systemic lupus erithematosus. The pathophysiology could be related to abnormal endothelial function secondary to immune dysregulation. In particular renal and intestinal vessels may be target of thrombosis. We report a simultaneous appearance of lupus nephritis and enteritis in a young female who presented with renal failure and proteinuria. The presence of renal arteriolar thrombosis together with intestinal ischemia lead us to speculate a possible common pathways.

Chronic kidney disease requiring healthcare services: a new approach to evaluate epidemiology of renal disease.

BACKGROUND: Screening-based CKD estimates may not provide a sufficient insight into the impact of CKD on the use of healthcare resources in clinical practice. The aim of this study was to evaluate the epidemiology of "medicalized" CKD, that is, CKD requiring healthcare services, in an outpatient setting. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS: This is a retrospective, longitudinal population-based study conducted in a large general practice setting in Southern Italy (Caserta) using a healthcare database. Over 2006-2011, all patients with a CKD diagnosis, either through CKD-related indications of use associated with drug prescriptions or through CKD-related hospital discharge diagnoses/procedures, were identified using this database. The prevalence of "medicalized" CKD in the general population of Caserta was estimated by age, gender, and calendar year. RESULTS: Overall, 1,989 (1.3%) patients with a diagnosis of CKD were identified from 2006-2011 in the Caserta general population. The one year prevalence increased from 0.9% in 2006 to 1.6% in 2011, which is much lower compared to previous screening-based studies. The prevalence was slightly higher in males and increased significantly with advancing age (in 2011, 0.2% in ≤44 years old versus 9.2% in >80 years old). CONCLUSIONS: The findings of this study suggest that, in the general population, the prevalence of "medicalized" CKD is lower compared to the screening-based CKD prevalence.

[Jakairá project: the adolescent parents as authors and actors of their own future]. / Proyecto Jakairá: adolescentes madres y padres como autores y actores de su propio devenir.

The purpose of the following paper is to present a project developed within the framework of collaboration between two foundations, Fundación Kaleidos (Argentina) and Children Action (Switzerland). The aim of this project is to developed diverse programs to support and empower adolescent mothers and fathers as well as their children. Adolescents whose rights are very often not respected and who find themselves alone having to confront the negative prejudices of the adults around them regarding the parenthood, which they now face. The objectives of the programs are as follows: the promotion of the well-being of the adolescents and the development of a personal project around education or work, the promotion of early child development of their infants, to address the problems around gender inequality and the promotion of an intersectional network between distinct sectors of society (public, private and NGO). By means of an integral program, we aim to tackle the diverse aspects of the lives of the adolescents in question and their children. Their rights and their environment are key to developing the maximum potential of each individual and their families.

Proyecto Jakairá: adolescentes madres y padres como autores y actores de su propio devenir / [Jakairá project: the adolescent parents as authors and actors of their own future].

The purpose of the following paper is to present a project developed within the framework of collaboration between two foundations, Fundación Kaleidos (Argentina) and Children Action (Switzerland). The aim of this project is to developed diverse programs to support and empower adolescent mothers and fathers as well as their children. Adolescents whose rights are very often not respected and who find themselves alone having to confront the negative prejudices of the adults around them regarding the parenthood, which they now face. The objectives of the programs are as follows: the promotion of the well-being of the adolescents and the development of a personal project around education or work, the promotion of early child development of their infants, to address the problems around gender inequality and the promotion of an intersectional network between distinct sectors of society (public, private and NGO). By means of an integral program, we aim to tackle the diverse aspects of the lives of the adolescents in question and their children. Their rights and their environment are key to developing the maximum potential of each individual and their families.

Proyecto Jakairá: adolescentes madres y padres como autores y actores de su propio devenir. / [Jakairá project: the adolescent parents as authors and actors of their own future].

The purpose of the following paper is to present a project developed within the framework of collaboration between two foundations, Fundación Kaleidos (Argentina) and Children Action (Switzerland). The aim of this project is to developed diverse programs to support and empower adolescent mothers and fathers as well as their children. Adolescents whose rights are very often not respected and who find themselves alone having to confront the negative prejudices of the adults around them regarding the parenthood, which they now face. The objectives of the programs are as follows: the promotion of the well-being of the adolescents and the development of a personal project around education or work, the promotion of early child development of their infants, to address the problems around gender inequality and the promotion of an intersectional network between distinct sectors of society (public, private and NGO). By means of an integral program, we aim to tackle the diverse aspects of the lives of the adolescents in question and their children. Their rights and their environment are key to developing the maximum potential of each individual and their families.