Systemic Capillary Leak Syndrome triggered by SARS-CoV2 infection: Case Report and Systematic Review.

Objective: Systemic capillary leak syndrome (SCLS) is a severe condition characterized by the coexistence of hypovolaemic shock, haemococentration, and hypoalbuminaemia, without albuminuria, that may progress to multiorgan failure and an unfavourable outcome. Its development is often triggered by viral infections, such as influenza A virus, but it is unclear whether it is also triggered by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). We aimed to investigated the association between SARS-CoV-2 and SCLS.Method: We present the case of a 55-year-old-woman affected by SARS-CoV-2 infection who developed SCLS. Moreover, we performed a systematic review of the literature to identify any common features with other cases and to describe clinical characteristics and outcomes.Results: We found three other cases of SCLS occurring during SARS-CoV-2 infection in 2020. Taking all cases together, the mean age was 50 years (range 38-63), with a 1:1 gender ratio. Respiratory manifestations were the most common symptom, and all patients required admission to the intensive care unit. The mortality rate was 50%.Conclusions: SARS-CoV-2 infection may trigger SCLS disease, either by an overproduction of proinflammatory cytokines or by direct viral infection of the endothelium. Since SCLS may have a poor prognosis, in every SARS-CoV-2-infected patient presenting the suggestive triad of hypovolaemic shock, haemoconcentration, and hypoproteinaemia, an SCLS diagnosis should be considered and early treatment initiated.

[Objectives of the low-protein diet]. / Obiettivi della dieta ipoproteica.

The prescription of low-protein diets to patients with chronic kidney disease has several objectives: to lower the dietary phosphorus load and circulating phosphorus and parathyroid hormone levels, and to improve the acid-base control and uremic symptoms while preserving the nutritional status. However, such objectives are always subordinate to the necessity of maintaining adequate calorie intake. An important target of any reduction of dietary protein intake is the delay of renal death and start of dialysis, as demonstrated by several methodologically sound studies and meta-analyses. However, no prospective study has yet confirmed the nephroprotective potential of low-protein diets repeatedly shown in animal models. Such negative results in human studies could be explained by their frequent methodological flaws, as well as by the modest actual reduction of protein intake compared with pre-study levels. The recent Cochrane meta-analysis confirmed that reducing dietary protein intake can delay renal death and dialysis. The Number-to-Treat estimate in the Cochrane meta-analysis (NNT=16) was even better than similar estimates in the statin prevention trials ''4S'' and ''WOSCOPS''.

[Vascular access for dialysis in elderly: AVF versus permanent CVC]. / L'accesso vascolare nell'anziano: confronto FAV versus CVCp.

The type of hemodialysis vascular access (fistula, graft, catheter) employed plays an important role in the results of dialysis treatment. Moreover, different complications can affect the vascular access and interfere with the morbidity and mortality of patients. The ideal vascular access is the Cimino Brescia fistula, followed by graft. Tunnelled central venous catheters should be considered as 'second choice' because they present a higher incidence of complications, mainly due to thrombosis and infections. Finally, in elderly patients the vascular bed is frequently damaged and this may make it difficult to create a Cimino (Brescia) fistula (AVF). The use of instrumental tests, as echo-color Doppler or angiography in order to evaluate the real status of vascular bed in elderly patients can offer a great opportunity in order to find the best position where it is possible to create a fistula or graft. We suggest that a native fistula can be easily created in elderly patients and the 'second choice' access should be limited to a small proportion of patients. Although patient selection is important, even patients of 80 years or older who are considered suitable for surgical placement of access should not be denied an AVF solely because of age. Nephrologists or vascular surgeons, who create vascular access, should develop a good patient and site selection to predict which vascular access will function successfully rather than risk complications of prolonged central catheters.

[Low-protein dietary therapy in patients with chronic kidney disease]. / Terapia dietetica ipoproteica del paziente con IRC.

Several prospective studies and meta-analyses including the recent Cochrane meta-analysis have demonstrated that reducing the protein content in the diet delays renal death and the start of dialysis in patients with chronic kidney disease (CKD). Reducing the dietary protein intake offers other benefits such as lowering accumulation of uremic toxins and circulating phosphates and improving symptoms and metabolic derangements. Following the publication of the Cochrane meta-analysis, some of the most renowned experts in Italy on dietary therapy in the CKD patient established a working group within the Italian Society of Nephrology (SIN), the ''Nephrontieres'' project. The current supplement of GIN presents the views of the members of the ''Nephrontieres'' group on a range of issues related to dietary therapy in CKD. A CME program for Italian nephrologists also originated from the collaborative work of the group.

[Low-protein diet in Italy today: the conclusions of the Working Group from the Italian Society of Nephrology]. / La dieta ipoproteica oggi in Italia: le conclusioni del Gruppo di Lavoro SIN.

The high estimated prevalence of chronic kidney disease (CKD) forcefully supports the need for collaboration among nephrologists, cardiologists, diabetologists and general practitioners, to reduce the cardiovascular risk of CKD patients and delay the start of dialysis. Many studies confirm that reducing the dietary intake of proteins improves uremia as well as acid-base and phosphorus disorders without exposing the CKD patient to the risk of malnutrition. The possibility of delaying renal death and the start of dialysis by almost one to two years is also recognized, thanks in part to the antiproteinuric effect of low-protein diets supplemented with keto acids and essential amino acids. Reducing the dietary protein intake delays the start of dialysis independently of the effect of renin-angiotensin system (RAS)-active antihypertensive drugs. Reduction of the dietary protein intake is indicated in patients with a glomerular filtration rate <25 mL/min (CKD stages 4 and 5). Some situations may, however, require an earlier switch to a low-protein diet, e.g., high proteinuria, renal function worsening at more than 5 mL/min/year, diabetes, and metabolic decompensation. If well designed and properly carried out, reduction of the dietary intake of proteins is not associated with low serum albumin levels or malnutrition, and does not affect patients death. Today, highly palatable, high-quality reduced protein preparations are widely available to reduce the protein intake of CKD patients.

Morbidity and mortality of CAPD and hemodialysis.

We have reappraised studies on morbidity and mortality in continuous ambulatory peritoneal dialysis (CAPD), comparing it with hemodialysis (HD), the standard treatment for end-stage renal disease (ESRD). More hospitalization is required for CAPD, the difference being related to peritonitis, to the more frequent presence of some risk factors (such as diabetes and atherosclerosis) in the patients selected for CAPD, and to the lack of experience in the early years of CAPD practice. CAPD patients have less acute morbidity during treatment that not always requires hospitalization: hypotension, hypertension, arrhythmias, and myocardial ischemia. Cardiac performance is also better in CAPD patients, who develop less myocardial hypertrophy than HD patients. Hospitalization due to infectious disease not referable to technique, beta 2-microglobulin related morbidity, signs of uremic neuropathy, osteodystrophy, and malnutrition are similar in both groups. Method survival is better for HD, the difference being completely accounted for by peritonitis. Patient survival adjusted for pre-treatment differences is similar in CAPD and HD, and this is not an artifact of more drop-outs on CAPD. A high incidence of peritonitis is accompanied by an increased risk of death. Older patients have a lesser risk of death on CAPD than on HD. Diabetics have a worse survival than non-diabetics, with no difference between the two methods. Although patient survivals on CAPD and HD are the same, differences in the mode of blood purification have an interesting impact on particular aspects of morbidity.

Diet or dialysis in the elderly? The DODE study: a prospective randomized multicenter trial.

There are no solid data on the real advantage of an early start of dialysis, as suggested by the DOQI guidelines. Uremic patients frequently have a poor nutritional status. However, we cannot distinguish between the detrimental effect on nutrition of too low a residual renal function or too long a period of low protein-diet, per se. However, it appears that a very-low-protein diet (VLPD) supplemented with essential amino acids and keto-analogs of amino acids, and with an adequate quantity of calories, can prevent hypoalbuminemia at the start of dialysis and can slow the progression of chronic renal failure. EDTA and USRDS data suggest that most patients starting dialysis nowadays are elderly, who also have the highest incidence of morbidity and mortality. Moreover, hospitalization rate becomes higher after the start of dialysis compared to the pre-dialysis period. Can an aminoacid-supplemented VLPD, prolonged beyond the GFR limits suggested by DOQI, offer elderly patients better survival and better quality of life than dialysis? The answer can only come from a prospective, randomized trial, in elderly patients, starting at the GFR values suggested by the NKF-DOQI for starting dialysis, comparing outcomes with a vegetarian VLPD supplemented with a mixture of keto-analogs of amino acids and essential amino acids, and with dialysis.

CAPD is a first class treatment: results of an eight-year experience with a comparison of patient and method survival in CAPD and hemodialysis.

An 8-year experience on CAPD, in a single center with all treatments of ESRF (end-stage renal failure) available, is presented. Method choice was left to the patient, after extensive counselling. However, CAPD selection was very negative, and CAPD patients were older, with a much larger percentage of diabetics and loaded by more risk factors, suggesting an influence of the staff preferences on patient choice. After a first period with unsatisfactory results, we obtained an important improvement of patient and method survival coinciding with the introduction of a new connector with disinfectant (Y-system) which allowed a reduction of peritonitis rate to 1 episode for 36 patient/months. For the period 1.1.81 to 31.12.86 a comparison was made (life table analysis) between new ESRF patients placed initially on CAPD or on HD. The 5-year survival was not statistically different in spite of the very negative CAPD selection of patients, who were 10 years older, on the average. Excluding diabetics, survival curves were identical in the two methods. Age at death and causes of death were not different. Method survival was better on HD (98% vs. 71% on CAPD, at 5 years, p less than 0.01): significance and limits of this evaluation are discussed. Drop-out figures were definitely lower than in the literature and this was attributed to the sharp reduction in peritonitis rate. Only 1.7% of CAPD patients discontinued the method due to inadequate ultrafiltration. In 29 CAPD and 28 HD patients with more than 4 years treatment some biochemical and clinical data were compared. Serum cholesterol was significantly higher and serum proteins lower in CAPD.(ABSTRACT TRUNCATED AT 250 WORDS)

CAPD viability: a long-term comparison with hemodialysis.

OBJECTIVE: To compare the long-term viability of continuous ambulatory peritoneal dialysis (CAPD) to that of hemodialysis (HD). DESIGN: Retrospective study of patients of our institution starting dialysis between January 1, 1981, and December 31, 1993, and surviving for at least 2 months. PATIENTS: Five hundred and seventy-eight new patients (51.3% on CAPD and 48.6% on HD). MAIN OUTCOMES STUDIED: Cox-adjusted assessment of patient and technique survival, and of technique success. Differences in results for two successive periods of time. RESULTS: Patient survival did not differ between CAPD and HD after adjusting for age and comorbidity, and significantly improved in the second part of the follow-up (1987-1993). Technique failure was significantly higher on CAPD, in which it was inversely related to age. The probability of a patient continuing on the first method of dialysis ("technique success") was significantly lower on CAPD than on HD, but the difference decreased progressively with age and disappeared in patients > or = 75 years. CONCLUSION: CAPD is as effective as HD in preserving life in uremic patients in the long-term, and gives better results in the older elderly. In adults, the lower technique success rate may not be a problem for patients with access to a good transplantation program; for others, this drawback must be weighed against the advantages of home treatment.

Low incidence of peritonitis with the T-set.

Peritonitis is still one of the most important complications of peritoneal dialysis. Over the last few years, many efforts have been made in developing new device systems. A remarkable improvement has been obtained by modifying the original connection between the catheter and the bag, especially after the introduction of the Y-set. The aim of this study was to verify whether the use of a new device system, called the T-set, could reduce the incidence of peritonitis. This connector adds the advantages of the Y-set to those of the twin bag. In a group of 53 patients enrolled in a three-year period with a follow-up of 797 patient-months, we observed an incidence of peritonitis of one episode every 50 months. Furthermore, in the subgroup of 39 new patients, we observed an incidence of peritonitis of one episode every 89 patient-months. This new device can be a further step in the evolution of connectors that reduce the incidence of peritonitis.

Comparison of long-term survival between hemodialysis and peritoneal dialysis.

We have reviewed the literature and our own center's results for patients on long-term continuous ambulatory peritoneal dialysis (CAPD) in comparison to results for patients on hemodialysis (HD). Contrary to recent American data showing one-year survivals to be worse on CAPD, the Canadian Registry and other studies show no significant difference in survivals on the two methods. Results are also conflicting for diabetics. Insufficient adjustments for age and case-mix variations are probably the most important causes for differences. For the general population, personal Cox-adjusted data show no difference between CAPD and HD up to ten-year follow-up, with very close curves for the adults and non-significant differences for the elderly. Old elderly (> 75 years) have better survival on CAPD in the first years of treatment. Dropout, which is higher on CAPD, decreases with age, and the patient retention on CAPD is worse than on HD for all patients, except the old elderly, for whom it is similar. These data were obtained in patients receiving a standard treatment, modified in order to give a more adequate dialysis dose only in recent years. The results of a prospective three-year study on the effect of nutritional [serum albumin and transferrin, normalized protein catabolic rate (PCRN), and subjective global assessment of malnutrition] and adequacy indices [Kt/V, creatinine clearance (Ccr), residual renal function] on patient survival on CAPD and HD are reported. Survival was not different for the two methods. Using the Cox analysis, nutritional indices did not affect survival whereas adequacy indices did. The effect of low serum albumin on survival was referable to the predialysis nutritional state. The similar survivals obtained on CAPD and HD, with Kt/V more or less than 1.0/treatment for HD and 1.7/week for CAPD, support the "peak concentration hypothesis" of Keshaviah et al. Survival in different groups of patients with different Kt/V and Ccr shows that the adequate dose on CAPD is Kt/V between 1.96 and 2.03 and Ccr > or = 70 L/week. A group of 26 patients who remained on CAPD treatment for more than eight years was also studied. Patient age and predialysis comorbidity were the most important factors affecting survival. Patients surviving longest had > 3 g/dL of serum albumin, > 0.8 g/kg/day of PCRN, a Kt/V > 1.6, and a weekly Ccr > 54L/week.

Hospitalization: CAPD versus hemodialysis and transplant.

We studied morbidity in 648 patients treated in our center in a ten-year period as indicated by duration of hospitalization: 232 patients were on CAPD, 188 on hemodialysis (HD) and 228 had cadaveric kidney transplants (Tx). Duration of hospitalization was divided into four groups according to its causes. The age of the patients on CAPD was 61 +/- 14 years, 53 +/- 17 on HD and 36 +/- 10 in the Tx group. The total follow-up was 629 patient-year (p-y) on CAPD, 458 p-y on HD and 928 p-y on Tx. The first admission was longer on CAPD (30 +/- 18 days) and on Tx (36 +/- 18 days) than on HD (18 +/- 12). After the first admission, the total days of hospitalization (days/patient-year, d/p-y) were more for CAPD than HD and Tx. Analysis of these data showed that the difference was due to peritonitis and to the different percentage of elderly patients in the CAPD group. With a reduction in the incidence of infectious complications (peritonitis, tunnel or exit-site), hospitalization in CAPD could be reduced to a length of time similar to that currently needed by HD and Tx patients. This can result in important cost-saving.

Nutritional status in long-term CAPD patients.

We studied normalized urea nitrogen appearance (NUNA), normalized protein catabolic rate (NPCR), and normalized daily creatinine excretion (NDCE) in twenty-one patients (15 men, 6 women; mean age 63 +/- 9 years) on CAPD for more than 4 years (80 +/- 27 months). In the same patients we evaluated the changes in serum albumin and transferrin with time. After 74 +/- 26 months on CAPD, NUNA was 0.12 +/- 0.03 g/Kg IBW/day, NPCR = 1.09 +/- 0.19 g/Kg IBW/day; NDCE = 15.1 +/- 3.1 mg/Kg IBW/day; serum albumin = 3.8 +/- 0.2 g/dl. NUNA was correlated with NPCR (p < 0.001) and both were correlated with NDCE (p = 0.007 and p = 0.008). NPCR significantly decreased as patient age increased (p = 0.007) but was not correlated with time on CAPD, sex or serum albumin. Serum albumin did not change as age increased. Serum albumin and serum transferrin had not significantly changed after 4 years (after 8 years in a subgroup of eight patients). Finally, we compared these data to the initial data recorded for the same patients (mean interval: 64 +/- 21 months). NUNA, NPCR and NDCE did not change significantly. Changes in NPCR were directly related to changes in NDCE (p = 0.019). This study supports that long-term CAPD does not necessarily impair nutritional status and suggests that the oldest patients can maintain stable serum albumin concentrations on lower protein intake than younger ones.

Two years of experience with a new device system: a multicenter study.

Peritonitis is a crucial complication of peritoneal dialysis. Over the last few years, new device systems have been developed to reduce episodes of peritonitis caused by exogenous contamination. Remarkable improvement has been obtained by modifying the original connection between the catheter and the bag with the introduction of the Y-set. The aims of this study were to test the reliability and simple use of a double-bag system without disinfectant in-line (Gemini, Gambro) and to evaluate the incidence of peritonitis in a 2-year period of follow-up. In a group of 167 patients, enrolled in 14 dialysis units in Italy, with a follow-up of 2433 patient-months, we observed 82 episodes of peritonitis in 52 patients, with a cumulative incidence of 1 episode every 29.7 patient-months. At 12 months the percentage of patients peritonitis-free was 69.7%, and at 24 months it was 62.8%. The training to complete the bag exchange, assessed by patient and nursing staff, was defined as "easy" in 61% of the cases and "difficult" in only 12% of the cases. The percentage of patients requiring a partner was 23%. For patients this device system presents easy handling in terms of the bag exchange, and it may prevent peritonitis.

Simultaneous catheter replacement-removal during infectious complications in peritoneal dialysis.

The aim of this study was to verify whether the replacement of the peritoneal catheter in a single operation and during infectious complications of peritoneal dialysis is effective and safe. Sixty-eight infectious complications refractory to appropriate antibiotic therapy were treated by this technique: 26 tunnel infections, 22 peritonitis-complicating tunnel infections, 12 refractory peritonitis, and 8 recurrent peritonitis. Operations were successful in all cases of tunnel infection and recurring peritonitis, and in all cases but one of peritonitis-complicating tunnel infection. Ten failures occurred among the 12 catheters removed for refractory peritonitis. Microorganisms cultured in these 10 failures were: Fungi (3 cases), Mycobacterium (2 cases), Pseudomonas (2 cases), Acinetobacter (1 case), Acinetobacter+Pseudomonas (1 case), and Enterococcus (1 case). Complications were 3 one-way obstructions and 2 external dialysate leaks. This study supports the simultaneous catheter replacement-removal procedure during infectious complications of peritoneal dialysis (PD) with the exception of refractory peritonitis; this technique spares the patient the temporary vascular access, the shift to hemodialysis, and a second operation to insert a new catheter. There are few complications.

Which vascular access for chronic hemodialysis in uremic elderly patients?

The type of hemodialysis vascular access (fistula, graft, catheter) employed plays an important role in the results of dialysis treatment. Moreover, different complications can affect the vascular access and interfere with the morbidity and mortality of patients. The ideal vascular access is the Cimino Brescia fistula. Graft and catheter methods should be considered as 'second choice' because they present a higher incidence of complications, mainly due to thrombosis and infections. Finally, in elderly patients the vascular bed is frequently damaged and this may make it difficult to create a Cimino Brescia fistula. In a 5-year period, 140 elderly patients (>65 years) and 63 'young' patients (< 65 years) started dialysis treatment in our facility. In the elderly group, a native fistula was created in 88% of cases, whereas in the younger patients the percentage was 94% (p: NS). The grafts were, respectively, 11% in elderly and 6% in young patients. Only in one case, in one elderly patient, was a permanent catheter the first vascular access. We also report survival rate of the first vascular access, the incidence of thrombosis, and the need for creating another type of access. We suggest that a native fistula can be easily created in elderly patients and a 'second choice' access should be limited to a small proportion of patients.