Skin pigmentation as landmark for arteriovenous fistula cannulation in hemodialysis.

BACKGROUND: The cannulation of the arteriovenous fistula (AVF) for hemodialysis (HD) has traditionally depended on the nurse's tactile sensation, which has been associated with suboptimal needle placement and detrimental effects on vascular access (VA) longevity. While the introduction of ultrasound (US) has proven beneficial in mapping the AVF outflow vein and assisting in cannulation planning, aneurysmal deformations remain a common occurrence resulting from various factors, including inadequate cannulation techniques. Within this context, the utilization of skin pigmentation as a clinical landmark has emerged as a potential approach to enhance cannulation planning in HD. METHODS: A prospective longitudinal study was undertaken to investigate the correlation between the occurrence of venous morphological deformations and the cannulation technique guided by skin pigmentation after a 2-month period of implementation. RESULTS: Thirty patients were enrolled in the study with 433 cannulations being described within the first 2 months of AVF use. The overall rate of cannulation-related adverse events was 21.9%. Comparative analysis demonstrated a statistically significant relationship (p < 0.001) between aneurysmal deformation and non-compliance with the proposed cannulation technique, resulting in cannulation outside the designated points. Non-compliance was primarily attributed to nurse's decision (57.1%). CONCLUSION: The integration of US mapping of the AVF outflow vein and the utilization of skin pigmentation as a guiding tool have shown promising results in enhancing cannulation planning over time. Consistent adherence to a cannulation technique other than the area technique has been found to reduce the risk of AVF morphological deformation. These findings underscore the potential benefits of incorporating skin pigmentation as a clinical landmark in cannulation practices, highlighting its ability to impact positively cannulation outcomes.

Rare case of interstitial nephritis in a young adult under IgG therapy.

Immunoglobulin replacement therapy is an important therapeutic approach used in different diseases, such as immunodeficiency diseases. We report a case of a 19-year-old female patient with suspected common variable immunodeficiency who started replacement therapy with IgG. During the follow-up, she developed interstitial nephritis and the subsequent workup excluded other diseases or triggers except IgG therapy.

A Case of Acute Interstitial Nephritis After Two Doses of the BNT162b2 SARS-CoV-2 Vaccine.

BACKGROUND: The development of vaccines to prevent COVID-19 breakouts came with highly positive results but some unexpected side effects. Rare side effects have been seen with the BNT162b2 SARS-CoV 2 vaccine. CASE PRESENTATION: We present the case of a 45-year-old female patient who developed an acute kidney injury needing urgent hemodialysis one week after the second administration of the BNT162b2 SARS-CoV 2 vaccine. She developed a macular rash on her lower limbs and palms as well. A kidney biopsy was performed 10 days after vaccine inoculation, diagnosing acute interstitial nephritis and acute tubular necrosis with cellular casts. The patient was treated with three corticosteroid pulses followed by daily prednisolone. We witnessed clinical improvement 4 days after the initial corticosteroid treatment with progressive recovery of kidney function and hemodialysis withdrawal. After 2 weeks, the patient had recovered her kidney function. Immunophenotyping was performed, diagnosing a hypersensitivity to the vaccine and the polyethylene glycol excipient. CONCLUSION: Patients may develop acute reactions to vaccines. In this case, symptoms seem to correlate significantly with its inoculation and, although this case had a favourable outcome, these side effects must be made aware for clinicians and patients.

Biomarkers and genetic modulators of cerebral vasculopathy in sub-Saharan ancestry children with sickle cell anemia.

We investigated biomarkers and genetic modulators of the cerebral vasculopathy (CV) subphenotype in pediatric sickle cell anemia (SCA) patients of sub-Saharan African ancestry. We found that one VCAM1 promoter haplotype (haplotype 7) and VCAM1 single nucleotide variant rs1409419_T were associated with stroke events, stroke risk, as measured by time-averaged mean of maximum velocity in the middle cerebral artery, and with high serum levels of the hemolysis biomarker lactate dehydrogenase. Furthermore, VCAM-1 ligand coding gene ITGA4 variants rs113276800_A and rs3770138_T showed a positive association with stroke events. An additional positive relationship between a genetic variant and stroke risk was observed for ENPP1 rs1044498_A. Conversely, NOS3 variants were negatively associated with silent cerebral infarct events (VNTR 4b_allele and haplotype V) and CV globally (haplotype VII). The -alpha3.7kb-thal deletion did not show association with CV. However, it was associated with higher red blood cell and neutrophil counts, and lower mean corpuscular volume, mean corpuscular hemoglobin and red cell distribution width. Our results underline the importance of genetic modulators of the CV sub-phenotype and their potential as SCA therapeutic targets. We also propose that a biomarker panel comprising biochemical, hematological, imaging and genetic data would be instrumental for CV prediction, and prevention.

Hemodialysis Reliable Outflow graft: A valid option in patients with central venous stenosis.

INTRODUCTION: Central venous stenosis can be the main obstacle to the creation of an autologous vascular access in the upper limbs. The Hemodialysis Reliable Outflow graft was developed to provide an upper limb vascular access option to such patients, avoiding alternative, less advantageous options, such as lower limb vascular accesses or central venous catheters. Its advantages include catheter avoidance and, in case of lower limbs accesses, reduction of the ischemic risk and iliac vein thrombosis, potentially compromising a future kidney transplant. PATIENTS AND METHODS: Revision of the clinical files of the four patients who were placed a Hemodialysis Reliable Outflow device in our Center, including demographic variables, implantation technique characteristics, surgical complications, episodes of infection and thrombosis of the access, and need to place a transitory central venous catheter to undergo hemodialysis treatment. RESULTS: Four Hemodialysis Reliable Outflow grafts were placed, which resulted in a significant improvement in the dialysis efficacy in all patients, with a median raise in the Kt/V of 36.7%. Two cases needed thrombectomy, one of which was unsuccessful. The actual time of patency varies between 3 and 28 months. CONCLUSION: Our experience with the Hemodialysis Reliable Outflow device showed that it was a safe option for patients with central venous stenosis and was associated with good clinical and analytic outcomes.

Bioinspired oxidation in cytochrome P450 of isomers orientin and isoorientin using Salen complexes.

RATIONALE: Orientin and isoorientin are C-glycosidic flavonoids, considered as markers of some plant species such as Passiflora edulis var. flavicarpa Degener, and reported in the literature to have pharmacological properties. In order to evaluate and characterize the in vitro metabolism of these flavonoids, phase I biotransformation reactions were simulated using Salen complexes. METHODS: These flavonoids were oxidized separately in biomimetic reactions in different proportions, using one oxidant, m-chloroperbenzoic acid or iodosylbenzene, and one catalyst, the Jacobsen catalyst or [Mn(3-MeOSalen)Cl]. The [Mn(3-MeOSalen)Cl] catalyst was synthesized and characterized using spectrometric techniques. The oxidation potentials of the catalysts were compared. All reactions were monitored and analyzed using ultrahigh-performance liquid chromatography diode-array detection (UHPLC-DAD) and high-performance liquid chromatography/tandem mass spectrometry (HPLC/MS/MS). RESULTS: The analysis by UHPLC-DAD and HPLC/MS/MS showed that isoorientin produces more products than orientin and that [Mn(3-MeOSalen)Cl] produces more products than the Jacobsen catalyst. In addition, [Mn(3-MeOSalen)Cl], which has a higher oxidation potential, formed products with the addition of one or two atoms of oxygen, while the Jacobsen catalyst formed compounds with only one added oxygen atom. The products with the addition of one oxygen atom were mainly epoxides, while those with two added oxygens formed an epoxide in the C-ring and incorporated the other oxygen into the glycosidic moiety. CONCLUSIONS: The formation of epoxides is common in biomimetic reactions and they may represent a safety risk in medicinal products due to their high reactivity. This study may serve as a basis for subsequent pharmacological and toxicological studies that investigate the presence of these compounds as phase I metabolites, and ensure the safe use of plant products containing orientin as a chemical marker.

Genetic modulators of fetal hemoglobin expression and ischemic stroke occurrence in African descendant children with sickle cell anemia.

Sickle cell anemia (SCA) is an autosomal recessive monogenic disease with significant clinical variability. Cerebrovascular disease, particularly ischemic stroke, is one of the most severe complications of SCA in children. This study aimed to investigate the influence of genetic variants on the levels of fetal hemoglobin (Hb F) and biochemical parameters related with chronic hemolysis, as well as on ischemic stroke risk, in ninety-one unrelated SCA patients, children of sub-Saharan progenitors. Our results show that a higher Hb F level has an inverse relationship with the occurrence of stroke, since the group of patients who suffered stroke presents a significantly lower mean Hb F level (5.34 ± 4.57% versus 9.36 ± 6.48%; p = 0.024). Furthermore, the co-inheritance of alpha-thalassemia improves the chronic hemolytic pattern, evidenced by a decreased reticulocyte count (8.61 ± 3.58% versus 12.85 ± 4.71%; p < 0.001). In addition, our findings have confirmed the importance of HBG2 and BCL11A loci in the regulation of Hb F expression in sub-Saharan African SCA patients, as rs7482144_A, rs11886868_C, and rs4671393_A alleles are significantly associated with a considerable increase in Hb F levels (p = 0.019, p = 0.026, and p = 0.028, respectively). Concerning KLF1, twelve different variants were identified, two of them novel. Seventy-three patients (80.2%) presented at least one variant in this gene. However, no correlation was observed between the presence of these variants and Hb F level, severity of hemolysis, or stroke occurrence, which is consistent with their in silico-predicted minor functional consequences. Thus, we conclude that the prevalence of functional KLF1 variants in a sub-Saharan African background does not seem to be relevant to SCA clinical modulation.

Reduction of stool bacterial counts and prevention of diarrhea using an oral homeopathic product in newborn lambs.

Lamb farming is generally a secondary activity for farmers, and many breeding systems suffer from management failures that impair production. One reason for decline in performance is enteritis, usually affecting newborn lambs. Enteritis can be fatal, especially in dairy herds. Generally, lambs are fed sucrose or unprocessed milk from sheep or cow that is heated and fed to animals two or three times a day in baby bottles. However, on most farms, milk temperature differs among feeds, as often the process of alteration among diet adaptations is deficient, contributing to enteritis and consequent diarrhea. Therefore, the objective of the present study was to verify the administration of the homeopathic product (Dia 100®) in newborn and bottle-fed lambs, in order to prevent or minimize the occurrence of diarrhea. We studied 60 lambs, divided into two groups with ten repetitions each (n = 30) and during the nursing period (1-45 days of life). Animals in the treated group received the homeopathic product (36 g) orally divided into three doses (1, 7 and 14 days of life). We measured weight gain, mortality, bacterial counts (Escherichia coli and total coliforms) in feces, hematological analysis (leukocytes, hematocrit, hemoglobin and erythrocytes) and biochemical analyses (glucose, triglycerides, cholesterol, albumin, globulin, urea and total protein) at four time-points. There were no differences in weight gain between groups (P > 0.05); however, there was a higher mortality rate in the control group (13%) than in the treated group (6%). E. coli counts were significantly higher in the stools of control group lambs on days 15 and 45 of the experiment (P < 0.05). Total leukocyte counts were greater in treated animals due to greater numbers of lymphocytes on day 15 of the experiment (P < 0.05). In the treated group, we found higher serum levels of total protein, urea (day 15), globulin and triglycerides (days 15 and 30). In the period of administration of the homeopathic product, there was substantial and significant reduction of cases of diarrhea (up to day 14); however, after this period, there were no difference between groups. Based on these results, we concluded that the homeopathic product had moderate efficacy in terms of control of diarrhea. The treated lambs made better use of nutrients, contributing to the development of their immune responses.

Homeopathic treatment as an alternative prophylactic to minimize bacterial infection and prevent neonatal diarrhea in calves.

Bovine neonatal diarrhea is common due low immunity in newborn calves, poor management (or absence) of sanitary barriers, and other factors. Newborn calves with diarrhea in the first days of life suffer failure to thrive and may die if left untreated. The aim of this study was to evaluate whether prophylactic administration of a homeopathic product (Dia 100®) can control bovine neonatal diarrhea in calves born on a farm with substantial sanitary challenges. We counted total bacteria and protozoan parasites in fecal samples. We measured serum glucose, total protein, globulin, albumin, cholesterol and triglycerides on days 1, 7 and 14 of life. Twenty newborn calves were maintained in individual stalls, and were divided in two groups: ten untreated animals (control) and ten animals treated with Dia 100®. Fecal consistency was evaluated daily. We diagnosed diarrhea in five animals in the treated group, and in all animals from the control group. Infections with Escherichia coli and Giardia duodenalis were identified as the responsible organisms. The E. coli count was low in the treatment group on day 7 of life compared with the control group. Antibiotics were given to eight animals in the control group, and to two animals in the treatment group. On day of life 7, serum levels of total protein and globulins were higher in the control group, but were lower on day 14. Serum levels of glucose and triglycerides were greater in treated animals on days 7 and 14, suggesting that the homeopathic product contributes to improvement of intestinal health and absorption and nutrients. We conclude that Dia 100® controls diarrhea with 50% of efficacy, and reduces antibiotic utilization.

Subcapsular liver hematoma as a complication of an atypical hemolytic uremic syndrome / Hematoma subcapsular hepático como complicación de síndrome hemolítico urémico atípico

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Gitelman syndrome with hiponatremia, a rare presentation

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Genetic variation in CD36, HBA, NOS3 and VCAM1 is associated with chronic haemolysis level in sickle cell anaemia: a longitudinal study.

Chronic haemolysis stands out as one of the hallmarks of sickle cell anaemia, a clinically heterogeneous autosomal recessive monogenic anaemia. However, the genetic architecture of this sub-phenotype is still poorly understood. Here, we report the results of an association study between haemolysis biomarkers (serum LDH, total bilirubin and reticulocyte count) and the inheritance of 41 genetic variants of ten candidate genes in a series of 99 paediatric SS patients (median current age of 9.9 yr) followed up in two general hospitals in Greater Lisboa area (median follow-up per patient of 5.0 yr). Although in a large number of tests a seemingly significant (i.e. P < 0.05) association was observed, the following ones were confirmed upon correction for multiple comparisons: (i) an increased serum LDH level was associated with haplotype 7 within VCAM1 gene; (ii) a lower total bilirubin was associated with the 3.7-kb deletion at HBA gene, rs2070744_T allele at NOS3 gene, and haplotype 9 within VCAM1 promoter; and (iii) a diminished reticulocyte count was associated with the 3.7-kb deletion at HBA, whereas an increased count was associated with rs1984112_G allele at CD36 gene. On the whole, our findings suggest a complex genetic architecture for the sickle cell anaemia haemolysis process involving multiple pathways, namely control of vascular cell adhesion, NO synthesis and erythrocyte volume and haemoglobinisation.