[Clopidogrel- induced hepatotoxicity in hemodialyzed patient: a case report]. / Epatotossicità da clopidogrel in emodializzato: caso clinico.

Drug-induced liver injury is a frequent cause of acute liver failure. It may cause clinical manifestations ranging from simple alteration of the common liver function tests until more severe manifestations including encephalopathy, coagulopathy, and in many cases progressive multi-organ dysfunction. The condition, therefore, may be associated with higher morbidity and mortality as well as higher consumption of economic resources. In this paper, we present the case of a 71-year-old patient treated with hemodialysis, diabetic, with ischemic cardiopathy and severe peripheral vascular disease. The patient presented a progressive clinical deterioration with the development of ascites, jaundice and significant deterioration of liver function. Diagnostic studies have ruled out viral and immunological diseases and, in agreement with the score obtained from the Maria and Victorino scale, clopidogrel was identified as the major factor responsible for the damage. After the suspension of the drug, the follow-up has led to the complete and stable recovery of liver function.

Sexual dysfunction in women with ESRD requiring hemodialysis.

BACKGROUND AND OBJECTIVES: The few existing studies of sexual dysfunction in women on hemodialysis are limited by small sample size. This large, cross-sectional study evaluated the prevalence and correlates of female sexual dysfunction in advanced kidney disease. DESIGN, SETTING, PARTICIPANTS, METHODS: A total of 1472 women with ESRD undergoing hemodialysis were recruited to a multinational, cross-sectional study conducted within a collaborative dialysis network in Europe and South America. Sexual dysfunction was identified by the Female Sexual Function Index. Correlates of self-reported sexual dysfunction were identified by regression analyses. RESULTS: Of the 1472 women, 659 completed questionnaires (45%). More than half (362 of 659 [55%]) lived with a partner, and 232 of 659 (35%) reported being sexually active. Of these 659 respondents, 555 (84%) reported sexual dysfunction. Women with a partner (282 of 362 [78%]) were less likely to report sexual dysfunction than those without a partner (273 of 297 [92%]) (P<0.001). Sexual dysfunction was independently associated with age, depressive symptoms, less education, menopause, diabetes, and diuretic therapy. Nearly all women who were not wait-listed for a kidney transplant and were living without a partner (249 of 260 [96%]) reported sexual dysfunction. More than half (128 of 232 [55%]) of sexually active women reported sexual dysfunction, associated with age, depressive symptoms, menopause, low serum albumin, and diuretic therapy. CONCLUSIONS: This descriptive study suggests most women on hemodialysis experience sexual problems. Additional research on the relevance of sexual dysfunction to symptom burden and quality of life in these women is needed.

Prevalence and correlates of erectile dysfunction in men on chronic haemodialysis: a multinational cross-sectional study.

BACKGROUND: Factors associated with erectile dysfunction in men on haemodialysis are incompletely identified due to suboptimal existing studies. We determined the prevalence and correlates of erectile dysfunction and identified combinations of clinical characteristics associated with a higher risk of erectile dysfunction using recursive partitioning and amalgamation (REPCAM) analysis. METHODS: We conducted a multinational cross-sectional study in men on haemodialysis within a collaborative network. Erectile dysfunction and depressive symptoms were evaluated using the erectile function domain of the International Index of Erectile Function questionnaire and the Center for Epidemiological Studies-Depression Scale, respectively. RESULTS: Nine hundred and forty-six (59%) of 1611 eligible men provided complete data for erectile dysfunction. Eighty-three per cent reported erectile dysfunction and 47% reported severe erectile dysfunction. Four per cent of those with erectile dysfunction were receiving pharmacological treatment. Depressive symptoms were the strongest correlate of erectile dysfunction [adjusted odds ratio 2.41 (95% confidence interval (CI) 1.57-3.71)]. Erectile dysfunction was also associated with age (1.06, 1.05-1.08), being unemployed (1.80, 1.17-2.79) or receiving a pension (2.05, 1.14-3.69) and interdialytic weight gain (1.9-2.87 kg, 1.92 [CI 1.19-3.09]; >2.87 kg, 1.57 [CI 1.00-2.45]). Married men had a lower risk of erectile dysfunction (0.49, 0.31-0.76). The prevalence of erectile dysfunction was highest (94%) in unmarried and unemployed or retired men who have depressive symptoms. CONCLUSIONS: Most men on haemodialysis experience erectile dysfunction and are untreated. Given the prevalence of this condition and the relative lack of efficacy data for pharmacological agents, we suggest that large trials of pharmacological and non-pharmacological interventions for erectile dysfunction and depression are needed.

Desmopressin acetate in percutaneous ultrasound-guided kidney biopsy: a randomized controlled trial.

BACKGROUND: Bleeding complications occur in one-third of percutaneous kidney biopsies and increase costs of the hospital stay. The aim of the study was to evaluate the effect of prebiopsy administration of desmopressin acetate versus placebo in the incidence of postbiopsy bleeding complications. STUDY DESIGN: Double-blind randomized controlled clinical trial. SETTING & PARTICIPANTS: We enrolled all patients with serum creatinine level ≤1.5 mg/dL and/or estimated glomerular filtration rate ≥60 mL/min/1.73 m(2) and normal coagulation parameters undergoing ultrasound-guided biopsy of the native kidney in our unit from August 2008 to December 2009. INTERVENTION: We examined prebiopsy subcutaneous administration of desmopressin acetate, 0.3 µg/kg, compared with placebo. OUTCOMES & MEASUREMENTS: The primary outcome was incidence of bleeding complications. Secondary outcomes were hematoma size, postbiopsy hemoglobin level, coagulation parameters, glomerular filtration rate, blood pressure, and length of hospital stay. RESULTS: 162 adult patients (88 men and 74 women) were enrolled; 80 were allocated to desmopressin treatment, and 82, to the placebo group. Desmopressin compared with placebo significantly decreased the risk of postbiopsy bleeding (11 of 80 [13.7%] vs 25 of 82 [30.5%]; relative risk, 0.45; 95% CI, 0.24-0.85; P = 0.01), hematoma size (median, 208 [25th-75th percentile, 120-300] vs 380 [25th-75th percentile, 270-570] mm(2); P = 0.006] in the 36 patients who experienced bleeding, and mean hospital stay (4.9 ± 1.1 vs 5.9 ± 1.7 days; P = 0.004); postbiopsy hemoglobin levels were not affected significantly in either group. LIMITATION: Single-center design of the study. CONCLUSIONS: Prebiopsy desmopressin administration decreases the risk of bleeding and hematoma size in patients undergoing percutaneous kidney biopsy without a cost increase.

Prevalence and correlates of self-reported sexual dysfunction in CKD: a meta-analysis of observational studies.

BACKGROUND: Sexual dysfunction is an under-recognized problem in men and women with chronic kidney disease (CKD). The prevalence, correlates, and predictors of this condition in patients with CKD have not been evaluated comprehensively. STUDY DESIGN: Systematic review and meta-analysis. SETTING & POPULATION: Patients treated using dialysis (dialysis patients), patients treated using transplant (transplant recipients), and patients with CKD not treated using dialysis or transplant (nondialysis nontransplant patients with CKD). SELECTION CRITERIA FOR STUDIES: Observational studies conducted in patients with CKD only or including a control group without CKD. PREDICTOR: Type of study population. OUTCOMES: Sexual dysfunction in men and women with CKD using validated tools, such as the International Index of Erectile Function, the Female Sexual Function Index (FSFI), or other measures as reported by study investigators. RESULTS: 50 studies (8,343 patients) of variable size (range, 16-1,023 patients) were included in this review. Almost all studies explored sexual dysfunction in men and specifically erectile dysfunction. The summary estimate of erectile dysfunction in men with CKD was 70% (95% CI, 62%-77%; 21 studies, 4,389 patients). Differences in reported prevalence rates of erectile dysfunction between different studies were attributable primarily to age, study populations, and type of study tool used to assess the presence of erectile dysfunction. In women, the reported prevalence of sexual dysfunction was assessed in only 306 patients from 2 studies and ranged from 30%-80%. Compared with the general population, women with CKD had a significantly lower overall FSFI score (8 studies or subgroups, 407 patients; mean difference, -9.28; 95% CI, -12.92 to -5.64). Increasing age, diabetes mellitus, and depression consistently were found to correlate with sexual dysfunction in 20 individual studies of patients with CKD using different methods. LIMITATIONS: Suboptimal and lack of uniform assessment of outcome measures. CONCLUSIONS: Sexual dysfunction is highly prevalent in both men and women with CKD, especially among those on dialysis. Larger studies enrolling different ethnic groups, using validated study tools, and analyzing the influence of various factors on the development of sexual dysfunction are needed.

Treatment options for sexual dysfunction in patients with chronic kidney disease: a systematic review of randomized controlled trials.

BACKGROUND AND OBJECTIVES: Sexual dysfunction is very common in patients with chronic kidney disease (CKD), but treatment options are limited. The benefits and harms of existing interventions for treatment of sexual dysfunction were assessed in patients with CKD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: MEDLINE (1966 to December 2008), EMBASE (1980 to December 2008), and the Cochrane Trial Registry (Issue 4 2008) were searched for parallel and crossover randomized and quasi-randomized trials. Treatment effects were summarized as mean differences (MD) or standardized mean difference (SMD) with 95% confidence intervals (CI) using a random effects model. RESULTS: Fourteen trials (328 patients) were included. Phosphodiesterase-5 inhibitors (PDE5i) compared with placebo significantly increased the overall International Index of Erectile Function-5 (IIEF-5) score (three trials, 101 patients, MD 1.81, 95% CI 1.51 to 2.10), all of its individual domains, and the complete 15-item IIEF-5 (two trials, 80 patients, MD 10.64, 95% CI 5.32 to 15.96). End-of-treatment testosterone levels were not significantly increased by addition of zinc to dialysate (two trials, 22 patients, SMD 0.19 ng/dl, 95% CI -2.12 to 2.50), but oral zinc improved end-of-treatment testosterone levels. There was no difference in plasma luteinizing and follicle-stimulating hormone level at the end of the study period with zinc therapy. CONCLUSIONS: PDE5i and zinc are promising interventions for treating sexual dysfunction in CKD. Evidence supporting their routine use in CKD patients is limited. There is an unmet need for studying interventions for male and female sexual dysfunction in CKD considering the significant disease burden.

Evidence for optimal hemoglobin targets in chronic kidney disease.

Even though anemia occurs frequently in patients with chronic kidney disease and therapeutic options are widely available, the ideal hemoglobin target level is not clearly established. We start from 2 anecdotes and review the evidence in favor of and against higher (>12 g/dL) and normal hemoglobin targets as compared to subnormal or low hemoglobin levels in different subsets of chronic kidney disease (either predialysis or dialysis). Current clinical trials and their systematic reviews have found that higher hemoglobin levels (>12 g/dL) do not significantly impact on patient-level cardiovascular end points including cardiovascular and all-cause mortality. Patients feel better, and enhanced quality of life parameters have been identified in most short-term studies when higher hemoglobin levels are achieved. However, achieving and maintaining higher hemoglobin levels carry the risk of hypertension and vascular access thrombosis in dialysis patients and are costly. In addition, a potential for increased risk of death (or no benefit at most) with higher Hb levels has been found in patients with severe cardiac disease in a larger trial. Benefits of and harm from hemoglobin targets should be carefully weighed, and certainly more, proper studies are needed before higher hemoglobin levels (>12 g/dL) are widely adopted in these high-risk patients.

Antihypertensive agents in patients with diabetes: trade-off between renal and cardiovascular protection.

PURPOSE: Management of hypertension in patients with diabetes should address both renal and cardiovascular protection. The use of angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) for control of hypertension in patients with diabetic nephropathy is widely advocated by various international guidelines. Use of any agent that provides tight control of blood pressure is indicated in patients with diabetes but without nephropathy. METHODS: In this article, the authors present a clinical case scenario and review current clinical evidence supporting the use of ACE inhibitors and ARBs in patients with diabetic nephropathy. In addition, the use of ACE and ARBs in patients with diabetes but without nephropathy will be discussed. RESULTS: Available trial evidence confirms the survival benefits of patients taking ACE inhibitors with diabetic nephropathy. However, the efficacy of ARB inhibitors on survival is unknown. In patients with diabetes without nephropathy, only ACE inhibitors have been found to reduce the risk of onset of microalbuminuria, while all agents affect survival provided a tight control of blood pressure is monitored. CONCLUSIONS: Dose of ACE inhibitors should be titrated appropriately to obtain proven benefits. In summary, current evidence supports the use of ACE inhibitors in patients with and without nephropathy because of renal and cardiovascular benefits.

Predictors of bleeding complications in percutaneous ultrasound-guided renal biopsy.

BACKGROUND: The risks associated with performing a percutaneous renal biopsy have substantially decreased in the past two decades because of technical advances in the method. However, bleeding complications still occur, resulting in increased hospital stay and treatment costs. METHODS: We investigated the predictive value of demographics (age, gender), clinical data (blood pressure), baseline chemistry (hemoglobin/hematocrit, prothrombin time, partial thromboplastin time, bleeding time, serum creatinine, daily proteinuria), and needle size for the risk of major (need for blood transfusion, nephrectomy, or angiography) or minor (no need for any intervention) postrenal biopsy bleeding complications. This was a prospective cohort study of 471 patients who underwent ultrasound-guided biopsy of native kidney by automated needle in a single center; all biopsies were performed by two experienced nephrologists. Patients with transplant kidneys were excluded from the study. Predictors of postbiopsy bleeding were assessed by multiple linear and multivariate logistic regression analysis. Data are presented as unadjusted (OR) and adjusted odds ratios (AOR) with 95% confidence intervals (CI). RESULTS: The study cohort consisted of 471 (277 males, 194 females) patients. Of these, 161 (34.1%) experienced postbiopsy bleeding [157 (33.3%) hematomas, 2 (0.4%) gross hematuria, 2 (0.4%) arteriovenous fistula]. Major complications were seen in 6 (1.2%) patients (blood transfusion, N= 2; angiography, N= 3; nephrectomy, N= 1), but no deaths occurred. The risk of postbiopsy bleeding was higher in women (39.7% women, 30.3% men, AOR 2.05, 95% CI 1.26 to 3.31, P= 0.004), younger subjects (35.0 +/- 14.5 years vs. 40.3 + 15.4, AOR 0.80, CI 0.68 to 0.94, P= 0.006), and patients with higher baseline partial thromboplastin time (102.7 + 11.8% vs. 100.1 + 10.0%, AOR 1.26, CI 1.02 to 1.54, P= 0.032). These findings were independent of size of hematoma. CONCLUSION: Although the methods for performing a percutaneous renal biopsy have improved in the past two decades, renal biopsy is still not a risk-free procedure. Of the data routinely collected for potential predictors of postbiopsy bleeding complications, only gender, age, and baseline partial thromboplastin time show a significant predictive value. The other variables investigated do not have any predictive value.