[Uremic pruritus: an unresolved challenge]. / Lettera del Presidente.

Pruritus is a common and unpleasant symptom in the dialysis setting, affecting about half of all hemodialysis and peritoneal dialysis patients. It has a great impact on patients' quality of life and is also associated with increased mortality. The pathogenesis of uremic pruritus (UP) is clearly multifactorial and still poorly understood. At least four main hypotheses have been put forward: dermatological abnormalities, an immune-system derangement that results in a proinflammatory state, an imbalance of the endogenous opioidergic system, and a neuropathic mechanism. The neurophysiology of itch has been shown to be quite similar to that of pain, supporting the hypothesis that the two phenomena may be closely related in dialysis patients, who often also experience uremic neuropathy. Moreover, an array of other triggering factors may include uremic toxins, systemic inflammation, cutaneous xerosis, and common comorbidities such as diabetes mellitus, endocrinopathies and viral hepatitis. The first step in the treatment of UP focuses on some general strategies that include the optimization of the dialysis schedule using biocompatible membranes such as polymethyl methacrylate, and the control of the divalent ion metabolism. The second step may be local therapy with skin emollients and capsaicin creams. More specific treatments that appear promising but have not been proven to be definitively efficacious include UVB light, gabapentin and the novel k-opioid-agonist nalfurafine. Nephrologists, who still tend to neglect this disabling symptom, need to be aware that UP is associated with poorer patient outcomes and that a stepwise therapeutic approach is now available.

[A contrast with good intentions]. / Un contrasto a fin di bene.

A seventy-five-year-old woman with moderate chronic renal failure was admitted to evaluate a complex renal cyst in the frame of acquired cystic kidney disease. Computed tomography (CT) was performed without contrast media due to the risk of radiocontrast-induced nephrotoxicity. Sonographic investigation at our ultrasound unit revealed a hypoechoic lesion measuring 20x20 mm in size by conventional B-mode sonography, confirmed by NTHI. The Hypoechoic lesion was consistent with complex renal cyst or renal tumour. This finding triggered investigation with CEUS.A sulphur hexafluoride-filled microbubble contrast medium was injected intravenously. The focal lesion CES pattern was characterized by intralesional enhancement in the arterial phase. Further diagnostic imaging including CT with contrast media confirmed a lesion consistent with renal tumour. The patient underwent right-sided nephrectomy; histopathological work-up revealed a renal cell carcinoma. Contrast-enhanced sonography could be clinically useful for the differential diagnosis of kidney lesions in patients with chronic renal failure.

[Acute biocompatibility of hemodiafiltration with endogenous reinfusion (HFR)]. / Emodiafiltrazione con reinfusione endogena (HFR): profilo di biocompatibilità in acuto.

PURPOSE: In order to reduce the hemodialysis (HD)-induced pro-inflammatory activity we need to use a biocompatible dialysis membrane, avoid backfiltration and possibly use adsorbents. Hemodiafiltration reinfusion (HFR) is a new on-line hemodiafiltration (HDF) technique combining these aspects. This study aimed to evaluate the biocompatibility of the single dialysis session comparing standard HD and HFR. METHODS: Eighteen patients on chronic HD were enrolled in five Centers. Patients underwent one standard and two HFR study sessions; in each session we evaluated leukocyte activation at 0, 5, 15, 60 and 240 min; and interleukin-6 (IL-6), C-reactive protein (CRP) and IL-1 receptor antagonist (IL-1Ra) levels at 0, 60 and 240 min. RESULTS: Leukocyte activation was similar in HD and HFR, while the post-dialysis IL-6 increase was lower with HFR; CRP levels were stable during HFR, but increased after HD, and IL-1Ra did not demonstrate any difference. CONCLUSIONS: These preliminary data show that HFR still has a better biocompatibility in the single dialysis session.

[Macrohaematuria post-partum: an unusual case of acquired haemophilia after pregnancy]. / Macroematuria post-partum: un insolito caso di emofilia acquisita del peurperio.

BACKGROUND: Acquired hemophilia is a rare disorder due to spontaneous development of antibodies directed against the factor VIII molecule in patients with previously normal levels of factor VIII. In this paper we report an unusual case of acquired hemophilia admitted to our department of nephrology due to persisting gross hematuria. CASE REPORT: A 38-year-old primigravida woman, previously fit and well, had an uncomplicated pregnancy, labor and a caesarean delivery at 38 weeks of gestation. Two weeks after delivery she developed gross hematuria with anemia. She was therefore admitted to a department of urology where urinary system and hematological investigation did not reveal important anomalies. Due to persisting gross hematuria and suspected kidney disease, the patient was admitted to our department of nephrology where serious anemia and prolongation of aPTT were noted; factor VIII procoagulant activity was low with a Bethesda assay confirming the presence of anti human f VIII antibody. Diagnosis of acquired hemophilia was confirmed and treated with corticosteroid therapy, intravenous immunoglobulins and recombinant factor VIII. After 10 days, gross hematuria stopped with improvement of aPTT and level of factor VIII. DISCUSSIONS: It is postulated that pregnancy leads to an altered immune status whereby the F VIII from the embryo, through transplacental leakage, may be considered as a foreign antigen by the mother, leading to the formation of antibodies. Bleeding symptoms usually became apparent within 3 months of delivery but could be as late as 12 months post-delivery and sometimes coagulation investigation results are normal at the beginning. It is therefore very important to estimate many times the activated partial thromboplastin time in macrohematuria post-partum. Mortality due to hemorrhage varies between 14 and 22 % in previous series. In the vast majority complete remission is achieved spontaneously within a few months. The diagnosis of acquired hemophilia is of fundamental importance for an adequate treatment preventing serious complications and high mortality.