Prognostic Value of Inflammation Scores and Hematological Indices in IgA and Membranous Nephropathies: An Exploratory Study.

Background and Objectives: Systemic-inflammation-based prognostic scores and hematological indices have shown value in predicting outcomes in various clinical settings. However, their effectiveness in predicting outcomes specifically for IgA nephropathy (IgAN) and membranous nephropathy (MN), the most common primary glomerular diseases diagnosed by kidney biopsy, has not been thoroughly investigated. Materials and Methods: We conducted a retrospective, observational study involving 334 adult patients with biopsy-proven IgAN (196 patients) and MN (138 patients) from January 2008 to December 2017 at a tertiary center. We assessed six prognostic scores [Glasgow prognostic score (GPS), modified GPS (mGPS), prognostic nutritional index (PNI), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), lymphocyte-to-C-reactive protein ratio (LCRP)] and two hematological indices [red blood cell distribution width (RDW), platelet distribution width (PDW)] at diagnosis and examined their relationship with kidney and patient survival. Results: End-stage kidney disease (ESKD) occurred more frequently in the IgAN group compared to the MN group (37% vs. 12%, p = 0.001). The mean kidney survival time was 10.7 years in the IgAN cohort and 13.8 years in the MN cohort. After adjusting for eGFR and proteinuria, lower NLR and higher LCRP were significant risk factors for ESKD in IgAN. In the MN cohort, no systemic-inflammation-based scores or hematological indices were associated with kidney survival. There were 38 deaths (19%) in the IgAN group and 29 deaths (21%) in the MN group, showing no significant difference in mortality rates. The mean survival time was 13.4 years for the IgAN group and 12.7 years for the MN group. In the IgAN group, a lower PLR was associated with a higher mortality after adjusting for age, the Charlson comorbidity score, eGFR, and proteinuria. In patients with MN, higher NLR, PLR, and RDW were associated with increased mortality. Conclusions: NLR and LCRP are significant predictors of ESKD in IgAN, while PLR is linked to increased mortality. In MN, NLR, PLR, and RDW are predictors of mortality but not kidney survival. These findings underscore the need for disease-specific biomarkers and indicate that systemic inflammatory responses play varying roles in the progression and outcomes of these glomerular diseases. Future studies on larger cohorts are necessary to validate these markers.

Management and Outcomes for Peritoneal Dialysis Patients Diagnosed with Abdominal Hernias.

BACKGROUND/OBJECTIVES: The success of peritoneal dialysis is highly dependent on the integrity of the abdominal wall. Therefore, routine examination and treatment of abdominal hernias can prevent peritoneal dialysis (PD) failure, discontinuation, and conversion to hemodialysis. In this present study, we present our examination protocol for patients proposed for PD and our attitude in treating parietal defects in patients on peritoneal dialysis. OBJECTIVES: highlight whether PD is a risk factor for the occurrence of ventral hernias, the relationship between associated pathologies and the occurrence of hernias and the need for an HD switch in the postoperative period. METHODS: Between January 2016 and December 2022, a group of 133 patients proposed for insertion of a PD catheter were evaluated according to the protocol established by our hospital. Routine examination for the diagnosis of abdominal hernias and repair before starting the DP is part of the procedure. We included patients with a 3 year minimum follow-up after insertion and evaluated the incidence of parietal defects that appeared during PD treatment. RESULTS: Nine patients were diagnosed and operated on for abdominal hernia before starting peritoneal dialysis and none of them had a recurrence of hernia during PD. Twelve patients were diagnosed with abdominal hernias during dialysis treatment (9% incidence) and the median length of time at which parietal defects occur during PD is 12.5 months [range 2-48]. Median BMI is 27.12 [range 22.3-31.24], with a female-male ratio of 2:1 Five patients were transferred to HD, three permanently and two patients temporarily. No patient abandoned PD treatment due to the presence of an abdominal parietal defect. CONCLUSIONS: Diagnosis of ventral hernias prior to the time of catheterization for PD leads to a decrease in the incidence of parietal defects during PD and is mandatory in patients who are candidates for PD. Open alloplastic surgical procedures are safe procedures with a low recurrence rate in PD patients. The postoperative continuation of PD is feasible but the decision is to be made by the multidisciplinary team and individualized for each patient.

Management of Peritoneal Dialysis-Associated Emergencies during the COVID-19 Pandemic: The Experience of a Center of Excellence.

The COVID-19 pandemic struck unexpectedly; emergency services and chronic care institutions, including dialysis centers, were overloaded. A significant problem was the care of COVID-positive patients alongside the care of chronically dialyzed patients who presented emergencies. In our hospital, which became a COVID support center for dialysis patients with severe forms of the disease, we had to care for PD patients with dialysis-related emergencies. We present two cases of patients managed on an outpatient basis or 1-day hospitalization who were treated successfully without compromising the quality of the care provided. We used remote monitoring, worked in a multidisciplinary team, and shortened the duration of the patients' hospitalization (and implicitly the risk of contact). In pandemic conditions, the advantage of PD was the possibility of patient isolation; in the first 6 months of the pandemic, we recorded no deaths in this category of patients. In hemodialysis patients, infection and mortality rates were high. Although we expected an increase in the number of peritoneal dialysis patients in the post-pandemic period, this did not happen. We continue to plead for the popularization of the PD method among patients and doctors, which has proven advantages in pandemic conditions.

Peritoneal Dialysis-Induced Encapsulating Peritonitis: Diagnostic and Therapeutic Challenges in Women with Benign Gynecological Pathology.

Background: Peritoneal sclerosis (PS) and its most severe form, encapsulating PS (EPS), are rare entities that can occur in various procedures (liver transplantation, intraperitoneal chemotherapy) or secondary to medications (beta-blockers); however, PS or EPS typically occur in patients undergoing peritoneal dialysis as a form of renal function substitution. Medical or surgical treatments can be applied, but morbidity and mortality have high rates. This condition typically presents clinically as an intestinal obstruction caused by the inclusion of the intestinal loops in the peritoneal fibrous membrane. Methods: Herein, we present data from a single tertiary surgery center that has dedicated teams for patients receiving dialysis. Over 12 years, we analyzed a group of 63 patients admitted for catheter replacement/removal or for acute surgical pathology. In five cases (7.9%), we diagnosed EPS. Two patients with EPS presented with atypical abdominal pathologies requiring emergency surgery: one case of hemoperitoneum caused by a ruptured ovarian cyst and one case of uterine fibroids and metrorrhagia. Results: The definitive diagnoses were established intraoperatively and by analyzing the morpho-pathological changes in the peritoneum. The possible intraoperative challenges included laborious dissection, difficulties in restoring the correct anatomical landmarks, an increased duration of the surgical intervention and a high rate of incidents and accidents. Conclusions: The aim of the present study was to emphasize the possibility of other surgical pathologies overlapping with EPS, increasing the complexity of the surgical intervention.

Effects of a supplemented hypoproteic diet in chronic kidney disease.

OBJECTIVE: We assessed the effect of a severe hypoproteic diet supplemented with ketoanalogues (SVLPD) for 48 weeks on certain metabolic disorders of chronic kidney disease (CKD). DESIGN: We performed a prospective, open-label, parallel, randomized, controlled trial. SETTING: The study took place in the Nephrology Department at the Dr Carol Davila Teaching Hospital of Nephrology, Bucharest, Romania. PATIENTS: A total of 53 nondiabetic patients with CKD with an estimated glomerular filtration rate less than 30 mL/min/1.73 m(2) (Modification of Diet in Renal Disease formula), proteinuria less than 1 g/g urinary creatinine, good nutritional status, and anticipated good compliance with the diet were randomly assigned to two groups. INTERVENTION: Group I (n = 27) received the SVLPD (0.3 g/kg/d of vegetable proteins and ketoanalogues, 1 capsule for every 5 kg of ideal body weight per day). Group II (n = 26) continued a conventional low mixed protein diet (0.6 g/kg/d). OUTCOME MEASURES: Nitrogen waste products retention and calcium-phosphorus and acid-base disturbances were primary efficacy parameters, and "death" of the kidney or the patient and the estimated glomerular filtration rate were secondary efficacy parameters. The nutritional status and compliance with the diet were predefined as safety variables. There were no differences between groups in any parameter at baseline. RESULTS: In the SVLPD group, serum urea significantly decreased (56 +/- 7.9 mmol/L vs. 43.2 +/- 10 mmol/L), and significant improvements in serum bicarbonate (23.4 +/- 2.1 mmol/L vs. 18.1 +/- 1.5 mmol/L), serum calcium (1.10 +/- 0.17 mmol/L vs. 1.00 +/- 0.15 mmol/L at baseline), serum phosphates (1.45 +/- 0.66 mmol/L vs. 1.91 +/- 0.68 mmol/L), and calcium-phosphorus product (1.59 +/- 0.11 mmol(2)/L(2) vs. 1.91 +/- 0.10 mmol(2)/L(2)) were noted after 48 weeks. No death was registered in any group. Significantly lower percentages of patients in group I required renal replacement therapy initiation (4% vs. 27%). After 48 weeks, estimated glomerular filtration rate did not significantly change in patients receiving SVLPD (0.26 +/- 0.08 mL/s vs. 0.31 +/- 0.08 mL/s at baseline), but significantly decreased in controls (0.22 +/- 0.09 mL/s vs. 0.30 +/- 0.07 mL/s). The compliance with the keto-diet was good in enrolled patients. No significant changes in any of the parameters of the nutritional status and no adverse reactions were noted. CONCLUSION: SVLPD seems to ameliorate the nitrogen waste products retention and acid-base and calcium-phosphorus metabolism disturbances and to postpone the renal replacement therapy initiation, preserving the nutritional status in patients with CKD.

Effects of additional iron doses on hepcidin-25 level in hemodialysis patients without evident iron deficiency.

BACKGROUND: Serum hepcidin-25 is not only a marker of iron stores, but also an acute phase reactant, and it could fluctuate in response to erythropoietic activity. STUDY DESIGN: Prospective interventional, 3-months duration, investigating the influence of additional intravenous (IV) iron on hepcidin-25 in hemodialysis (HD) patients without obvious iron deficiency (ID). SETTINGS AND PARTICIPANTS: Single HD unit, 41 patients. MEASUREMENTS: Hepcidin-25 (ELISA method), ferritin, transferrin, transferrin saturation (TSAT), C-reactive protein and serum albumin--at baseline and assessment; hemoglobin, iron and darbepoetin doses--monthly. INTERVENTION: Additional IV iron doses were administered, driven by hemoglobin trend: iron dose increased by 25 % for each 0.5 g/dL hemoglobin drop for baseline ferritin of 200-800 ng/mL. Iron was discontinued for stable hemoglobin or >13 g/dL. Darbepoetin doses were adjusted for 11 g/dL target hemoglobin. RESULTS: At baseline, 21 % of patients had "optimal" iron status; none had "absolute" or "functional" ID, while 15 % had iron "overload." Hepcidin levels were 112.8 (95 % CI 105.3-121.8) ng/mL. Hemoglobin was within the target range. After 75 % augmentation in iron doses, hepcidin-25 decreased by 70 %. Transferrin increased, and TSAT and ferritin decreased. Prevalence of "functional" ID rose to 24 % and of iron "overload" declined to 0 %. Reversal of iron-restricted erythropoiesis was further sustained by unchanging hemoglobin and decrease in darbepoetin doses and darbepoetin resistance index. Reasonable associations between assessment versus baseline ratios for hepcidin-25 and transferrin (inverse), TSAT and ferritin (direct) were found. Despite the increased inflammation, decrease in transferrin and increase in ferritin ratios were independent predictors of hepcidin variability (model of logistic regression r (2) 0.34; p < 0.0001). LIMITATIONS: Low number of participants, less diabetic nephropathy/vascular diseases than general dialyzed population, uncontrolled design, use of hepcidin-25 ELISA assay. CONCLUSIONS: Activation of erythropoiesis by additional IV iron administration overcomes moderate inflammation in suppressing hepcidin-25. Thus, hepcidin-25 could be clinically useful to evaluate iron status in patients with renal anemia.

A rare case of digestive hemorrhage in an elderly patient: diagnosis and treatment difficulties.

Abdominal pain represents one of the most common clinical conditions. However, there are some challenging cases in which an extensive work-up is mandatory for the diagnosis. We present the case report of a 65-year-old man admitted to our department for diffuse abdominal pain, nausea, vomiting, diarrhea, painful joints and rectal tenesmus. He initially had an urticarial rash, followed by palpable purpura involving the lower extremities. The diarrheic stools evolved towards melena. Endoscopic examination of the upper gastrointestinal tract showed hiatal hernia, superficial erosions in the stomach and multiple areas of deep and superficial ulcerations disseminated from the second to the third portion of the duodenum. Terminal ileum intubation at colonoscopy showed redness, edema, swelling, petechiae and ecchymosis, irregular erosions and ulcers. Endoscopic biopsy specimens showed non-specific inflammation. Computed tomography showed moderate ascites, small pleural effusion, mesenteric lymphadenopathy and small bowel wall thickening at the level of the second duodenum, proximal jejunum and segments of ileum. The urine analysis revealed microscopic hematuria with nephrotic range proteinuria, red cells and cellular casts. Therapy with corticosteroids and pulses of cyclophosphamide was started with significant clinical improvement. Three weeks after the first admission, the patient developed an acute peritonitis due to an intestinal perforation and acute mesenteric ischemia of the small bowel. We concluded that the patient had a Henoch-Schönlein type vasculitis with acute mesenteric ischemia and perforation of the small bowel.