Efficacy of sustained low-efficiency dialysis in the management of topiramate intoxication: case report.

Guidelines on the use of dialysis treatment in patients with chronic kidney disease (CKD) and TPM (Topiramate) intoxication are controversial. A 51-year-old man with epilepsy and CKD was carried to our emergency department for dysuria and sickness. He chronically assumed TPM 100 mg 3/day. Creatinine level was 2.1 mg/dL, blood urea nitrogen 70 mg/dL, and inflammation indexes were increased. We started empirical antibiotic therapy and rehydration. The day two he had diarrhea and an acute insurgence of dizziness, confusion, and bicarbonate levels reduction. Brain CT resulted negative for acute events. During the night his mental status worsened, and urinary output results were about 200 mL in 12h. EEG showed desynchronized brain bioelectric activity. Thereafter, there was an episode of seizure and then anuria, hemodynamic instability, and loss of consciousness. Creatinine value was 5.39 mg/dL with a serious metabolic acidosis non-anion gap. We decided to start 6-hours Sustained Low Efficiency Hemo-Dia-Filtration (SLE-HDF). We assisted in the recovery of consciousness and later in the improvement of kidney function after 4 hours of treatment. TPM levels before SLE-HDF resulted in 123.1 µg/mL. At the end of treatment resulted in 30 µg/mL. To our knowledge, this is the first report of TPM involuntary intoxication in a patient affected by CKD who survived such a high TPM concentration treated with renal replacement therapy. SLE-HDF resulted in moderate elimination of TPM and acidemia resolution, continuous monitoring patient's vital parameters in relation to his hemodynamic instability, since blood flow and dialysate flow are lower than conventional hemodialysis.

Successful treatment of infectious endocarditis-associated glomerulonephritis during active hepatitis C infection: a case report.

BACKGROUND: Hepatitis C virus (HCV) may play a pathogenic role in several forms of immune complex glomerulonephritis (GN). We present a patient whose initial clinical presentation instilled suspicion of HCV-related renal involvement. Yet, histopathologic data oriented towards a different diagnosis. CASE PRESENTATION: A 68-year old man presented with kidney dysfunction, cryoglobulins, low C4 level, high HCV-RNA and cutaneous vasculitis. The first hypothesis was a hepatitis C-related cryoglobulinemic glomerulonephritis. Renal biopsy revealed endocapillary and mesangial cells hypercellularity with complement C3 and IgM deposits. The echocardiography showed an infectious endocarditis (IE) on aortic valve. Appropriate antibiotic therapy and a prosthetic valve replacement were performed, obtaining recovery of renal function. CONCLUSION: HCV infection may be linked to multiple renal manifestations, often immune-complex GN such as cryoglobulinemic membrano-proliferative GN. Renal disease due to IE is usually associated to focal, segmental or diffuse proliferative GN, with prominent endocapillary proliferation. The most common infectious agents are Staphylococcus aureus and Streptococcus species. This case report may be relevant because the renal dysfunction was highly suggestive of a cryoglobulinemic GN on a clinical ground, but the histologic pattern after performing the renal biopsy oriented towards a different cause of the underlying disease, that required a specific antibiotic treatment. The renal biopsy is always required to confirm a clinical suspicious in patients affected by multiple comorbidities.

The Pre-dilatation of vessels: A simple method to recruit small caliber veins for creating distal fistulas.

Maturation failure remains a major clinical problem of distal arteriovenous fistula (AVF). Early failure (EF) is associated with the small size of the veins. For about 10 years we have used in more than 1000 fistulas, the Vessels Pre-Dilatation (VPD) to increase the recruitment of small veins for creating distal AVFs. The purpose of this study is to highlight if the VPD can reduce the incidence of EF or failure to mature (FTM) in AVFs created with small veins. Data of all the consecutive patients directly admitted to our Department for their first distal AVF from January to December 2019 were collected. The patients were divided in two groups, one with a vein diameter after the tourniquet ⩽2.0 mm (G1) and one >2 mm (G2). Both in G1 then in G2 the vessels had undergone VPD. Immediate failure (IF), EF, FTM, delayed or arrested maturation rate (DAM), unassisted AVFs and matured AFVs were evaluated. The patients recruited totalled 104, 37 in G1, and 67 in G2. The two groups were homogeneous in age, incidence of diabetes, obesity, heart disease, peripheral vasculopathy, and race. Female were more numerous in G1 (51% vs 12%, p < 0.001). In G1 and G2 occurred respectively 3 IF versus zero (p < 0.05), 10 EF (29%) versus 6 (9%) (p < 0.05), 6 DAM (16%) versus 6 (9%), 21 unassisted AVFs (57%) versus 57 (85%) (p < 0.01). Dividing the patients into groups of unassisted and assisted AVFs, female and low vein diameter are more represented in the assisted group. There were 32 matured AVFs (86%) in G1 and 65 (97%) in G2. In order to increase the incidence of the distal AVF, the PDV allows to include small veins. However, more patients require further interventions to achieve maturation of the fistula.

How to create and preserve distal fistulas in a large number of patients: the experience of a single centre.

Background: Distal arterio-venous fistula (AVF) is considered the gold standard for vascular access in hemodialysis. The aim of this retrospective study is to report our experience on two innovative techniques, Intraoperative Transluminal Angioplasty (ITA) and Vessel Pre-Dilatation (VPD). Methods: We collected data from all the consecutive patients directly admitted to our Department from January 2014 to October 2018 in order to create or repair an AVF. Early Failure (EF), Failure to Mature (FTM), Late Failure (LF), Primary and Secondary patency rate were evaluated. Results: All patients underwent VPD; of the total 647 AFVs, 128 received an ITA for the presence of suboptimal vessels. 98.3% of AVFs were located on the forearm. EF occurred in 83 cases; in 67 of these a new AVF was successfully created upstream from the previous one. LF occurred in 100 cases; of these, the access was abandoned in 32 cases and we performed a new AVF upstream from the previous one in 68 cases. FTM occurred in 57 cases, 31 of which were treated with Percutaneous Transluminal Angioplasty (PTA) whilst 26 were resolved performing a new anastomosis upstream. Primary and secondary patency at 1, 2, 3 and 4 years were, respectively, 80%, 74%, 68%, 64% and 94%, 91%, 89%, 88%. By dividing patients into an ITA group and a control group, we did not find any difference in primary and secondary patency. Conclusions: VPD and ITA could be useful to increase the incidence and the prevalence of distal AVF.

[Imaging in CKD].

Imaging has contributed to the successful reduction of cardiovascular morbidity and mortality in the general population and it has demonstrated excellent potential among patients with chronic kidney disease (CKD). The well-known severity of cardiovascular disease in patients suffering from CKD requires an accurate risk stratification of these patients in several clinical situations. Alterations of both structure and function of the myocardium as well as severe vasculopathy are highly prevalent in patients with advanced CKD. Hence sophisticated imaging techniques are at times necessary to make an accurate assessment of risk. Two main forms of arterial pathology develop in patients with CKD: atherosclerosis, with accumulation of inflammatory cells, lipids, fibrous tissue and calcium in the sub-intimal space of the artery, and arteriosclerosis. The latter is characterized by thickening and calcification of the muscular layer of the arterial wall and it is not necessarily associated with typical atherosclerotic changes. This review explores the indications, strengths and weaknesses of several invasive and non-invasive imaging modalities employed to evaluate myocardial and vascular disease in CKD.

The density of calcified plaques and the volume of calcium predict mortality in hemodialysis patients.

BACKGROUND AND AIM: In the general population lipid-rich plaques are prone to rupture and healing of the plaque involves calcification. Patients undergoing hemodialysis have a severe derangement of mineral metabolism and calcification of the arterial tree may have different implications. METHODS: Between 2004 and 2005, 125 hemodialysis patients (60 men) underwent computed tomography imaging for quantification of coronary artery calcium via the Agatston and the Volume methods. Since the Agatston score is derived by multiplying the density by the volume of a calcified lesion, the Agatston/Volume ratio (AVR) is an indication of the density (i.e. calcium accumulation) within the plaque. RESULTS: Patients were classified as high AVR (>1) or low (≤1) AVR. Survival analyses tested the association between AVR and all-cause mortality during a median follow-up of 5 years. The mean age was 57.2±13.5 years; 75% of the patients had AVR >1. The mortality rate of patients with AVR >1 was significantly higher than in patients with AVR ≤1 (Hazard Ratio(HR): 2.46; 95% Confidence Intervals(CI): 1.16-5.21, p ≤0.018). After adjustment for confounders, AVR >1 remained independently associated with all-cause mortality (HR: 2.24; 95% CI: 1.02-4.88, p ≤0.042). There was a significant interaction of plaque density and calcium volume on mortality. CONCLUSIONS: Increased plaque density is an independent predictor of all-cause mortality in hemodialysis patients. These data suggest that increased calcium content in the coronary arteries of patients in dialysis is an index of high-risk rather than a marker of plaque stabilization.

Aneurysms and pseudoaneurysms in dialysis access.

Aneurysms are a common and often difficult complication seen with arteriovenous vascular access for haemodialysis. The purpose of this narrative review is to define and describe the scale of the problem and suggested therapeutic strategies. A narrative review of the published literature illustrated by individual cases is presented with the aim of summarising the relevant literature. The definitions of aneurysm are inconsistent throughout the literature and therefore systematic review is impossible. They vary from qualitative descriptions to quantitative definitions using absolute size, relative size and also size plus characteristics. The incidence and aetiology are also ill defined but separation into true aneurysms and false, or pseudoaneurysms may be helpful in planning treatment, which may be conservative, surgical or radiological. The lack of useful definitions and classification along with the multitude of management strategies proposed make firm evidence based conclusions difficult to draw. Further robust well designed studies are required to define best practice for this common problem.

Continuous ultrafiltration for congestive heart failure: the CUORE trial.

Background: There are limited data comparing ultrafiltration with standard medical therapy as first-line treatment in patients with severe congestive heart failure (HF). We compared ultrafiltration and conventional therapy in patients hospitalized for HF and overt fluid overload.Methods and Results: Fifty-six patients with congestive HF were randomized to receive standard medical therapy (control group; n = 29) or ultrafiltration (ultrafiltration group; = 27). The primary endpoint of the study was rehospitalizations for congestive HF during a 1-year follow-up. Despite similar body weight reduction at hospital discharge in the 2 groups (7.5 ± 4.5 and 7.9 ± 5.0 kg, respectively;P = .75), a lower incidence of rehospitalizations for HF was observed in the ultrafiltration-treated patients during the following year (hazard ratio 0.14, 95% confidence interval 0.04-0.48; P = .002).Ultrafiltration-induced benefit was associated with a more stable renal function, unchanged furosemide dose, and lower B-type natriuretic peptide levels. At 1 year, 7 deaths (30%) occurred in the ultrafiltration group and 11 (44%) in the control group (P = .33).Conclusions: In HF patients with severe fluid overload, first-line treatment with ultrafiltration is associated with a prolonged clinical stabilization and a greater freedom from rehospitalization for congestive HF.

3D FIESTA pulse sequence for assessing renal artery stenosis: is it a reliable application in unenhanced magnetic resonance angiography?

OBJECTIVES: To assess the capability of the three-dimensional (3D) Fast Imaging Employing Steady-State Acquisition (FIESTA) sequence in evaluating renal artery stenosis (RAS). METHODS: We retrospectively analysed 79 patients referred for suspected RAS, examined by 3D FIESTA and contrast-enhanced magnetic resonance angiography (CE-MRA), using a 1.5T whole-body scanner. Image quality was assessed as well as the presence and grade of RAS. Patients with RAS ≥ 50% were evaluated for possible digital subtraction angiography (DSA). Sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), and accuracy of 3D FIESTA were calculated with ROC analysis using CE-MRA and DSA as the standard of reference. RESULTS: A total of 186 renal arteries were assessed; 36 had RAS ≥ 50 % demonstrated by CE-MRA. Ten patients underwent DSA, for a total evaluation of 22 arteries. Sensitivity, specificity, NPV, PPV, and accuracy of 3D FIESTA were 91.7%, 100%, 98%, 100%, and 98%, respectively, as compared to CE-MRA, and 88.2%, 100%, 71.4%, 100%, and 91%, respectively, as compared to DSA. The area under the ROC curve (AUC) of 3D FIESTA as compared to CE-MRA and DSA was 0.958 and 0.941, respectively. CONCLUSIONS: Our study demonstrated the capability of the 3D FIESTA sequence in evaluating RAS, with high-quality images and good diagnostic accuracy. KEY POINTS: The 3D FIESTA sequence provides a robust evaluation of RAS. The 3D FIESTA sequence allows non-invasive evaluation of the renal arteries. The 3D FIESTA sequence could be a useful tool in evaluating RAS.

Ultrasound-guided trans-hepatic embolization of a renal artery pseudoaneurysm in a patient with acquired solitary kidney and with chronic renal failure secondary to phenacetin abuse.

A patient with a pseudoaneurysm of the right renal artery underwent treatment with percutaneous approach. No complications were observed. Based on the experience described in this report, a percutaneous ultrasound guided approach can be proposed in selected patients. Renal insufficiency and allergic reactions are potential contraindications to angiography with conventional ionic iodinated contrast dye in patients who need endovascular stent-graft placement. Real-time contrast-enhanced ultrasound (CEUS) guided endovascular procedures may provide an alternative to overcome these limitations. We report an endovascular renal artery repair in a solitary kidney patient with an asymptomatic infrarenal aortic aneurysm and renal insufficiency due to phenacetin abuse. The precise placement of the stent-graft was performed with CEUS and intraprocedural angiographic fluoroscopy without the use of any nephrotoxic contrast dye. During follow-up, CEUS was used to exclude endoleaks, stent-graft failure or malposition.

Continuous ultrafiltration for congestive heart failure: the CUORE trial.

BACKGROUND: There are limited data comparing ultrafiltration with standard medical therapy as first-line treatment in patients with severe congestive heart failure (HF). We compared ultrafiltration and conventional therapy in patients hospitalized for HF and overt fluid overload. METHODS AND RESULTS: Fifty-six patients with congestive HF were randomized to receive standard medical therapy (control group; n = 29) or ultrafiltration (ultrafiltration group; n = 27). The primary end point of the study was rehospitalizations for congestive HF during a 1-year follow-up. Despite similar body weight reduction at hospital discharge in the 2 groups (7.5 ± 5.5 and 7.9 ± 9.0 kg, respectively; P = .75), a lower incidence of rehospitalizations for HF was observed in the ultrafiltration-treated patients during the following year (hazard ratio 0.14, 95% confidence interval 0.04-0.48; P = .002). Ultrafiltration-induced benefit was associated with a more stable renal function, unchanged furosemide dose, and lower B-type natriuretic peptide levels. At 1 year, 7 deaths (30%) occurred in the ultrafiltration group and 11 (44%) in the control group (P = .33). CONCLUSIONS: In HF patients with severe fluid overload, first-line treatment with ultrafiltration is associated with a prolonged clinical stabilization and a greater freedom from rehospitalization for congestive HF.

Diffusion tensor imaging and tractography of the kidneys: assessment of chronic parenchymal diseases.

OBJECTIVE: To assess renal dysfunction in chronic kidney diseases using diffusion tensor imaging (DTI). METHODS: Forty-seven patients with impaired renal function (study group) and 17 patients without renal diseases (control group) were examined using DTI sequences. Cortical and medullary regions of interest (ROIs) were located to obtain the corresponding values of the apparent diffusion coefficient (ADC) and the fractional anisotropy (FA). The mean values of the ADC and FA, for each ROI site, were obtained in each group and were compared. Furthermore, the correlations between the diffusion parameters and the estimated glomerular filtration rate (eGFR) were determined. RESULTS: In both the normal and affected kidneys, we obtained the cortico-medullary difference of the ADC and the FA values. The FA value in the medulla was significantly lower (P = 0.0149) in patients with renal function impairment as compared to patients with normal renal function. A direct correlation between DTI parameters and the eGFR was not found. Tractography visualised disruption of the regular arrangement of the tracts in patient with renal function alteration. CONCLUSION: DTI could be a useful tool in the evaluation of chronic kidney disease and, in particular, the medullary FA value seems to be the main parameter for assessing renal damage. KEY POINTS: • Magnetic resonance diffusion tensor imaging (MRDTI) provides new information about renal problems. • DTI allows non-invasive repeatable evaluation of the renal parenchyma, without contrast media. • DTI could become useful in the management of chronic parenchymal disease. • DTI seems more appropriate for renal evaluation than diffusion-weighted imaging.

Integration of clinical and imaging data to predict death in hemodialysis patients.

In a prior publication, we demonstrated that a model integrating clinical and simple imaging data predicted the presence and severity of coronary artery calcification in prevalent hemodialysis patients. Herein we report the ability of the same model to predict all-cause death. We assessed all-cause mortality in 141 consecutive maintenance hemodialysis patients from two dialysis centers followed for a median of 79 months from enrollment. Patients were risk stratified according to a simple cardiovascular calcification index (CCI) that included patient's age, dialysis vintage, calcification of the cardiac valves, and abdominal aorta. The mean patients' age was 55 ± 14 years. Abdominal aorta calcification was present in 57% of the patients, and 44% and 38% had aortic and mitral valve calcification, respectively. During follow-up, 75 deaths (93 deaths per 1000 person-years) were recorded. The CCI was linearly associated with risk of death, such that the unadjusted hazard risk (HR) increased by 12% for each point increase in CCI (P < 0.001). Further adjustments for age, sex, study center, diabetes mellitus, history of cardiovascular disease, hypertension, congestive heart failure, left ventricular hypertrophy, systolic, and diastolic blood pressure did not substantially change the strength of this association (HR 1.10; 95%CI: 1.00-1.21; P = 0.03). The CCI is a simple clinical model that can be used to risk stratify maintenance hemodialysis patients.

[Assessment of right ventricular function in patients with chronic kidney disease stage IV NKF]. / Valutazione della funzione ventricolare destra in pazienti affetti da malattia renale cronica in stadio I-V NKF.

Cardiovascular diseases are accountable for almost 50% of over-all mortality rates in chronic kidney disease (CKD) patients, especially in those who undergo hemo-dialysis or peritoneal dialysis.Hemodialysis patients present higher rates of pulmonary hypertension (PH), an independent risk factor for cardiovascular mortality among this patient population, due in part to the presence and hemodynamic effects of vascular access (both artero-venous fistula and central venous catheter). Echocardiographic TAPSE (tricuspid annular plane systolic excursion) index represents a helpful tool for investigation of right ventricular function together with PAPs (systolic pulmonary artery pressure) evaluation.The following study protocol, introduced by the Cardionephrology Study Group of the Italian Society of Nephrology, aims to evaluate the incidence of right ventricular dysfunction and PH in CKD patients. This is a multicentric, case- control study which includes two arms, each comprising 200 patients, and which will last 24-36 months.Glomerular filtration rates (GFR) are calculated using the eGFR EPI equation, while echocardiographic evaluation includes atrial and ventricular dimension and area, left ventricular systolic function (ejection fraction), diastolic function, TAPSE index measurement and PAPs evaluation.

Cardiac valve calcification is a marker of vascular disease in prevalent hemodialysis patients.

BACKGROUND: Vascular and valvular calcifications are a common finding in chronic kidney disease (CKD) patients and are associated with increased morbidity and mortality. We investigated the hypothesis that calcification of the cardiac valves is a marker of coronary artery calcification (CAC) and thoracic aorta calcification (AoC) in hemodialysis (CKD-5) patients. METHODS: This was a cross-sectional study of 145 maintenance CKD stage 5 (CKD-5) patients. All patients underwent electron beam tomography for quantification of CAC and AoC score via the Agatston score. The presence of calcification of the cardiac valves was assessed by standard bi-dimensional echocardiography. RESULTS: Eighty-four of the study patients (58%) had echocardiographic evidence of valvular calcification. A significant and graded association between valvular calcification and CAC as well as AoC was detected. Patients with 1 or 2 calcified valves had a significantly greater likelihood of having a CAC score >1,000 (odds ratio [OR] = 5.94; 95% confidence interval [95% CI], 1.91-18.44; p=0.002; and OR=3.27; 95%CI, 1.36-7.88; p=0.007, respectively). Similarly, the presence of 1 or 2 calcified valves was associated with an eightfold and threefold increased probability of an AoC score greater than the third quartile, respectively. CONCLUSIONS: This cross-sectional analysis shows that calcification of the cardiac valves is closely associated with vascular calcification, an established marker of risk in prevalent hemodialysis patients.

Role of ultrasound in management of long-term complications after to radical cystectomy and orthotopic neobladder construction: case report.

Radical cystectomy with urinary diversion is considered the gold standard treatment for bladder cancer. We report a case of 66-years-old male with long term complications, after radical cystectomy and an ileal neobladder according to Hautmann. He developed uroseptic episodes, stones, post-void residual, stenosis of the uretero-neobladder anastomosis, metabolic acidosis and progressive deterioration of renal function. Renal ultrasound helped us to identify the dilation of the urinary tract, the grade of hydronephrosis and the presence of stones. During the follow-up, it is very important the collaboration between urologist and nephrologist and the role of ultrasound for an early correction of the hydronephrosis and the elective replacement of the stents in order to preserve the renal function.

All-cause mortality in hemodialysis patients with heart valve calcification.

BACKGROUND AND OBJECTIVES: Calcification of the mitral and aortic valves is common in dialysis patients (CKD-5D). However, the prognostic significance of valvular calcification (VC) in CKD is not well established. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: 144 adult CKD-5D patients underwent bidimensional echocardiography for qualitative assessment of VC and cardiac computed tomography (CT) for quantification of coronary artery calcium (CAC) and VC. The patients were followed for a median of 5.6 years for mortality from all causes. RESULTS: Overall, 38.2% of patients had mitral VC and 44.4% had aortic VC on echocardiography. Patients with VC were older and less likely to be African American; all other characteristics were similar between groups. The mortality rate of patients with calcification of either valve was higher than for patients without VC. After adjustment for age, gender, race, diabetes mellitus, and history of atherosclerotic disease, only mitral VC remained independently associated with all-cause mortality (hazard ratio [HR], 1.73; 95% confidence interval [CI], 1.03 to 2.91). Patients with calcification of both valves had a two-fold increased risk of death during follow-up compared with patients without VC (HR, 2.16; 95% CI, 1.14 to 4.08). A combined CT score of VC and CAC was strongly associated with all-cause mortality during follow-up (HR for highest versus lowest tertile, 2.21; 95% CI, 1.08 to 4.54). CONCLUSIONS: VC is associated with a significantly increased risk for all-cause mortality in CKD-5D patients. These findings support the use of echocardiography for risk stratification in CKD-5D as recently suggested in the Kidney Disease Improving Global Outcomes guidelines.

Arterial stiffness in chronic kidney disease: the usefulness of a marker of vascular damage.

Increased arterial stiffness is a marker of vasculopathy in chronic kidney disease (CKD) patients, suggesting a significant cardiovascular damage. Detection of arterial stiffness provides physicians with useful prognostic information independent of traditional cardiovascular (CV) risk factors. In addition, this knowledge may help guide appropriate therapeutic choices and monitor the effectiveness of antihypertensive therapies. We review the relationship between arterial stiffness and CKD, as well as the prognostic implications of increased arterial stiffness and the potential therapeutic strategies to ameliorate arterial compliance and outcome in CKD.

Renal diffusion tensor imaging: is it possible to define the tubular pathway? A case report.

The authors report a case of unilateral xanthogranulomatous pyelonephritis, associated with chronic lithiasis studied by standard clinical magnetic resonance imaging protocol and diffusion tensor imaging (DTI). Maps of apparent diffusion coefficient (ADC) and fractional anisotropy (FA) and tractography were reconstructed on both healthy and pathologic kidney. ADC and FA values are in agreement with the literature. Tractography reconstruction of tubular renal architecture was confirmed by histology. This result suggests the potential ability of DTI to detect structural alterations in the architecture of the kidney, as noninvasive tool, preceding the onset of clinical-laboratory alterations.