[Kidney Transplant in a Highly Sensitized Patient Treated with Imlifidase].

Through a clinical case, we will describe the difficulties associated with providing transplantation opportunities to highly immunized patients. We will therefore focus on new desensitization therapies and their pharmacological effects with the consequent improvement in clinical outcomes. The main desensitization strategies in use and the main future therapeutic prospects will also be discussed.

[Acute Kidney Injury Caused by Mushrooms: A Case Report of Amanita Echinocephala Ingestion].

Mushroom poisoning can represent an acute event which the clinical nephrologist must deal with and which often leads to the need for emergency dialysis treatment. Through the exposed clinical case, we describe the secondary clinical manifestations of an acute intoxication sustained by Amanita Echinocephalae, and we will provide an overview of the main fungal intoxications of renal interest, the clinical presentation, the diagnostic strategies, and the subsequent treatment.

[Rapidly progressive Alport syndrome in a young woman: case report].

Alport syndrome is a hereditary clinical condition characterized by multisystemic changes (sensorineural and ocular deafness) associated with hematuria and proteinuria. Due to its genetic variability and multiple symptoms, it is often diagnosed by chance and too late. The present work focuses on this pathology through a clinical case report. It also mentions the new therapeutic possibilities relating to this disease.

Long-term follow-up of atherosclerotic renovascular disease. Beneficial effect of ACE inhibition.

BACKGROUND: Patients with atherosclerotic renovascular disease (ARVD) are almost invariably treated by revascularization. However, the long-term outcomes of this approach on survival and progression to renal failure have not been investigated and have not been compared with that of a purely medical treatment. The aim of this observational study was to investigate factors affecting long-term (over 5 years) outcome, survival and renal function of patients with ARVD treated invasively or medically. METHODS: ARVD was demonstrated angiographically in 195 patients who were consecutively enrolled into a follow-up study. Patient age was 65.6+/-11.2 years, serum creatinine was 1.74+/-1.22 mg/dl and renal artery lumen narrowing was 73.5+/-17.5%. A revascularization was performed in 136 patients, whereas 54 subjects having comparable characteristics were maintained on a medical treatment throughout the study; five patients were lost during follow-up. RESULTS: The main follow-up was 54.4+/-40.4 months. The assessment of cardiovascular survival and renal survival at the end of follow-up revealed 46 cardiovascular deaths, 20 patients with end-stage renal disease (ESRD) and 41 patients with an increase in serum creatinine of over one-third. The multivariate analysis showed that renal revascularization did not affect mortality or renal survival compared with medical treatment. Revascularization produced slightly lower increases in serum creatinine and a better control of blood pressure. A longer survival was associated with the use of angiotensin-converting enzyme inhibitors (ACEIs) (P = 0.002) in both revascularized and medically treated patients. The only significant predictor of ESRD was an abnormal baseline serum creatinine. CONCLUSIONS: On long-term follow-up, ARVD was associated with a poor prognosis due to a high cardiovascular mortality and a high rate of ESRD. In our non-randomized study, revascularization was not a major advantage over medical treatment in terms of mortality or renal survival. The use of ACEIs was associated with improved survival.

Association between brain natriuretic peptide and extracellular water in hemodialysis patients.

BACKGROUND: Brain natriuretic peptide (BNP) is a hormone released by the left ventricle (LV) as a consequence of pressure or volume load. BNP increases in left ventricle hypertrophy (LVH), LV dysfunction, and it can also predict cardiovascular mortality in the general population as well as those undergoing hemodialysis (HD). We investigated the association between BNP and volume load in HD patients. METHODS: We studied 32 HD patients (60 +/- 17.1 years) treated thrice-weekly for at least 6 months. Exclusion criteria were: LV dysfunction, atrial fibrillation, malnutrition. Blood chemistries and BNP were determined on mid-week HD day. Blood pressure (BP) and cardiac diameters were determined on mid-week inter-HD day by using 24-hour ambulatory blood pressure monitoring and echocardiography. Bioimpedance was performed after HD and extracellular water (ECW%), calculated as a percentage of total body water, was considered as the index of volume load. RESULTS: Patients were divided into quartiles of 8 patients depending on the BNP value: 1st qtl BNP < or =45.5 pg/ml (28.4 +/- 10.9 pg/ml), 2nd qtl BNP > 45.5 pg/ml and < or =99.1 pg/ml (60.9 +/- 15.8 pg/ml), 3rd qtl BNP > 99.1 pg/ml and < or =231.8 pg/ml (160.5 +/- 51.8 pg/ml), 4th qtl BNP > 231.8 pg/ml (664.8 +/- 576.6 pg/ml). No inter-quartile differences were reported in age, HD age, body mass index spKt/V, or blood chemistries. As expected patients in the 4th BNP quartile showed the highest values of 24-hour pulse pressure (PP) and LV mass index (LVMi). The study of body composition revealed significant differences in ECW%, which was higher in the 4th quartile when compared to the others (4th q: 50 +/- 9.6%, vs 1st q. 40.1 +/- 2.4%, 2nd q. 41.9 +/- 5%, 3rd q. 42.8 +/- 6.9%). Using multiple stepwise linear regression where BNP was the dependent variable, and PP and ECW% the independent variables, only ECW% maintained statistical significance as a predictor of BNP levels (PP: Beta = 0.86, p = 0.58; ECW%: Beta = 0.64, p < 0.001 p < 0.001). CONCLUSIONS: Few studies have investigated the relationship between plasma BNP and volume load, and direct evidence is lacking. We used bioimpedance and the determination of ECW% to assess volume state in HD patients finding an association between BNP and ECW. The increased synthesis and release of BNP from the LV in HD patients appear to be mainly related to volume stress rather than to pressure load.

Association between extracellular water, left ventricular mass and hypertension in haemodialysis patients.

BACKGROUND: Hypertension and left ventricular hypertrophy (LVH) are present in the majority of patients undergoing haemodialysis (HD). These two pathologies persist after dialysis onset, and pharmacological therapy is often required for adequate control of blood pressure (BP). Although fluid overload is a determinant of hypertension, clinical assessment of this parameter remains difficult and unsatisfactory. Bioimpedance analysis (BIA) spectroscopy and the relative determination of extracellular water (ECW%) may provide a simple and inexpensive tool for investigating fluid overload. We studied 110 patients on thrice-weekly HD to determine whether ECW body content correlates with hypertension and LVH in this patient population. METHODS: Hypertension was determined according to the WHO criteria (office BP >/= 140/90 and/or the use of antihypertensive therapy). Twenty-four hour BP monitoring and echocardiography were performed on midweek inter-HD days. Blood chemistries, dialysis dose (spKt/V) and bioimpedance were analysed on midweek HD days. RESULTS: Hypertension was present in 74.5% of patients. There were no differences for age, spKt/V, haemoglobin, serum creatinine and residual renal function between normotensive and hypertensive patients. Twenty-four hour systolic BP (SBP), 24 h diastolic BP and 24 h pulse pressure were higher in hypertensive patients, in spite of antihypertensive therapy. LVH was present in 61.8% of patients. BIA revealed that ECW% was increased in LVH+ patients (LVH+ = 47.5 +/- 7.9%, LVH- = 42.4 +/- 6.2%, P = 0.01) and in hypertensive patients compared with normotensives (46.5 +/- 7.7% vs 43 +/- 7.2%, P = 0.02). Dry body weights and inter-HD body weight increases did not differ between hypertensive and normotensive patients nor between patients with or without LVH. ECW was correlated with SBP (r = 0.35, P < 0.01) and with left ventricular mass index (LVMi(g/sqm)) (r = 0.49, P < 0.001). A stepwise multiple linear regression model revealed that LVMi(g/sqm) was significantly correlated with ECW%, SBP and male gender (r = 0.65, P < 0.001). CONCLUSIONS: LVH and hypertension are present in a majority of HD patients and they are closely correlated with one another. We found associations between fluid load, measured by BIA and expressed as ECW, and BP and LVM.