[Effectiveness of oral supplements of folates, vitamins B12 and B6 in hemodialysed patients. Preliminary results after 5 months of follow-up]. / Efficacia dei supplementi orali di folti, vitamine B12 e B6 in pazienti emodializzati. Risultati preliminari dopo 5 mesi di follow-up.

BACKGROUND: Elevated serum levels of homocysteine have increasingly been associated as a risk factor of cardiovascular disease. Recent reports demonstrated that supplements of folates, vitamin B12 (B12) and vitamin B6 (B6) are effective in correcting serum Hcy levels in hemodialysed patients. AIM: to assess the effectiveness of oral supplements of folates, B12 and B6, in order to reduce serum Hcy levels in our cohort of hemodialysed patients. METHODS: Sixty-one hemodialysed patients have been enrolled in the study (age 68+/-13 years; hemodialysis 62+/-42 months). Oral supplements of calcium folinate (30 mg 3 times a week), B12 (500 mg 3 times a week) and B6 (200 mg 3 times a week) were administered at the end of each hemodialysis session. Serum levels of Hcy, folic acid and B12 were tested at the beginning of the study and at 2 month intervals. RESULTS: After 5 months of follow-up, serum levels of Hcy were normalised in 19% of our patients and in total 70% of them showed a reduction >8% when compared with the basal Hcy levels. No side effects related to folates, B12 or B6 supplementation were observed. CONCLUSIONS: Oral supplements of folates, B12 and B6 are a safe and effective treatment of hyperhomocysteinemia in hemodialysed patients.

[Infections from extemporaneous catheters for hemodialysis. Experience in a center]. / Infezione dei cateteri estemporanei per emodialisi. Esperienza di un centro.

BACKGROUND AND AIMS: This study reports a retrospective evaluation of the predominance of infection in 67 dual lumen central venous catheters (CVC), 35 of which were positioned in the femoral vein by the nephrological team and 32 in the subclavian vein by anesthetists. METHODS: The microorganisms responsible for infection, the prevalence of clinically symptomatic infections, the relationship between CVC-correlated infection and the time the catheter remained inserted were evaluated, together with a comparison between the two different insertion sites. RESULTS: Culture tests, performed using Maki's semiquantitative technique, gave positive results in 16/67 (23.8%) cases. The main pathogenic agents found were Staphylococcus epidermidis (37.5%) and Staphylococcus aureus (31.2%). In 3/16 cases (18.78%) infections were clinically symptomatic. The mean permanence of CVC with positive cultures was not statistically different to the mean permanence of CVC with negative cultures (22.44 +/- 13.48 vs 18.38 +/- 17.76). The microorganisms isolated on femoral and subclavian catheters showed a comparable distribution and the prevalence of infection was not statistically different in the two insertion sites. CONCLUSIONS: In conclusion, in the absence of infection, the authors tend to keep working catheters in the site, thus avoiding repeated invasive manoeuvres for replacement and/or repositioning, whereas in the presence of suspected systemic infection they feel it is more prudent to remove the CVC without waiting for the results of the hemoculture, starting first empiric and then specific antibiotic treatment on the basis of the antibiogram.

[Brown tumor of the jaws]. / Tumore bruno dei mascellari.

Brown tumour is one of the forms in which fibrous-cystic osteitis, which represents the terminal stage of the bone remodelling processes during primary or secondary hyperparathyroidism, is manifested. For years brown tumour was regarded as a typical lesion of primary hyperparathyroidism, but cases of brown tumours in patients with hyperparathyroidism secondary to renal failure were increasingly often reported in the literature. From an epidemiological point of view, the frequency of brown tumours in patients with renal insufficiency is extremely variable, as is the bone site affected. Several bone segments can be affected at once, but the ethmoid and frontal sinus are rarely reported. Symptoms are caused by the considerable dimensions of the brown tumour and its localisation: in the jawbones it may present sometimes painful, hard and clearly palpable swellings; if large, the tumour may deform the appearance of the bone segments affected or alter the function of the masticatory apparatus. In other cases, there is a complete absence of clinical symptoms and diagnosis may be totally coincidental during the radiological examinations. In histological terms, brown tumours are made up by a cell population consisting of rounded or spindle-like mononucleate elements, mixed with a certain number of plurinucleate giant cells, resembling osteoclastic cells, among which recent haemorrhagic infiltrates and hemosiderin deposits (hence the brown colour) are often found. The aim of this study was to report three cases from a population of 107 patients undergoing haemodialysis at the Turin University Centre. In conclusion, the localisation of maxillary brown tumours appears to prefer a young, female population; brown tumours are rarely an early sign of hyperparathyroidism in haemodialysis patients, but they often appear in conditions of advanced hyperparathyroidism which have escaped medical control either owing to unsuitable therapy or scant patient compliance; they are rapidly evolving lesions whose regression may be very slow or not occur even after total parathyroidectomy; the severity of the lesion caused by a brown tumour may lead to evident osteolysis in the maxillofacial district, thus suggesting the need for early and regular radiological screening; in the event of lesions which are already present, from the authors' point of view, the choice of treatment must be oriented towards parathyroidectomy.

Scleroderma renal crisis is still a life-threatening syndrome.

Scleroderma renal crisis (SRC) was known as a rare and catastrophic syndrome responsible for acute renal failure (ARF) in a context of widespread microvascular disease occurring in progressive systemic sclerosis (PSS). Following pathogenetic hypoteses, angiotensin converting enzyme (ACE) inhibitors, plasma infusions (PI), and plasma-exchange (PE) have been employed in SRC with favorable results. Our purpose was to verify whether these therapies have consistently changed the fatal prognosis of SRC, even in our experience. In the last 10 years, SRC was diagnosed in eight patients (all eight with histologic data). The first five cases were treated with steroids, antihypertensive-cocktail, and PI: all five died, two within 48 hours, three after 10, 15, and 300 days, respectively. Three other patients were treated with ACE inhibitors, PI, and PE: all three died after 1, 9, and 12 months of HD. Clinical-histological correlations showed a strong relationship between the extent of glomerular involvement and the degree of renal failure, while arterial lesions seem to be more related to the past history of PSS, independently from the previous existence of hypertension. We conclude that "true" SRC diagnosed by restrictive criteria is still a rare life-threatening syndrome, and, unfortunately, no clear predictive biochemical or clinical signs could be identified; vascular renal involvement correlates to the duration of PSS independently of previous clinical evidence of renal failure or hypertension; a glomerular pattern similar to that reported for hemolytic-uremic syndrome (HUS)/thrombotic thrombocytopenic purpura (TTP) syndrome is directly related to the degree of acute renal involvement; SRC may occur even in the absence of hypertension, mainly if cardiomyopathy is present: in our experience. ACE inhibitors and plasma therapies have changed the short-time prognosis of SRC, but they may be unable to provide recovery from dialysis and do not avoid further evolution of extrarenal PSS exiting in late death.

[Comparison between biopsy data and the resistive index obtained by Doppler echography in the evaluation of the transplanted kidney]. / Confronto fra dato bioptico ed indice di resistenza ottenuto con eco-Doppler nella valutazione del rene trapiantato.

Doppler sonography is nowadays considered as a "first step" tool for diagnosis of vascular complications in kidney transplantation. Quite recently, it has been sometimes considered useful and effective investigation in order to obtain information about parenchymal dysfunctional pathologies, particularly about acute rejection. This has been obtained by studying the variation of resistive indexes. The goal of the following investigation was compare Doppler sonography data and histological examination in 50 kidney transplanted recipients in whom the renal biopsy was performed on a clinical basis. In the Authors' experience. Doppler sonography and study of the resistive index does not offer any reliable help in differentiating acute rejection from cyclosporine A toxicity.