Hepatitis B vaccination in haemodialysis patients: an underestimated problem. Factors influencing immune responses in ten years of observation in an Italian haemodialysis centre and literature review.

OBJECTIVES: Despite universal infection control precautions, the risk of hepatitis B virus (HBV) infection in patients on chronic haemodialysis (HD) remains high. For this reason anti-HBV vaccination is recommended in these subjects. In hemodialyzed patients vaccinal response is often suboptimal and it's not clear what factors may influence it. STUDY DESIGN: The aim of our study is to assess the influence of some clinical and laboratory factors on seroconversion rate after anti HBV vaccination in a cohort of patients on maintenance HD. METHODS: We analysed 60 patients on regular HD, 40 men and 20 women (age 64±12 years, range 40-88 years), immunized with Engerix B ® vaccine, followed for an average time of 62 month (12-120 months). For each patient the following data were collected: age, serum albumin (sAlb), Blood urea nitrogen before HD session (BUN), age at vaccination, dialysis vintage, presence of systemic disease, type of vascular access, dialysis modality. Correlation between these factors and anti Hbs titer was estimated with multiple regression analysis. RESULTS: Anti-Hbs seroconversion rate ( Anti Hbs > 10 IU/l) was 77%. Better rate of seroconversion (86%) was observed in patients with arteriovenous fistula (AVF) and serum albumin > 3,5 g/dL (93%), while higher rate of not responders (50%) in patients with systemic diseases. The only parameter correlated to anti Hbs titer was sAlb (p =0,0012). sAlb was correlated to age in all patients (p=0,01) and age was correlated to higher anti Hbs titer in the responder group (p=0,018). DISCUSSION: In our experience an early vaccination, when patients on chronic HD are younger and in better nutritional conditions, improves anti-HBV response.

Suspect carbon dioxide embolism during retroperitoneoscopic adrenalectomy.

During a retroperitoneoscopic adrenalectomy in the prone position, a sudden increase in end-Tidal CO2 (EtCO2) (from 42 to 68 mmHg) followed by an abrupt decrease (from 68 to 35 mmHg) was observed, concomitantly with a right adrenal vein laceration. Heart rate decreased to 30 bpm, and the systolic blood pressure decreased to 40 mmHg. The patient was slightly turned in the left lateral and Trendelenburg position and vasoactive drugs were administered. The systemic blood pressure, EtCO2, CO2 elimination (VCO2) and pulse oximetry (SpO2) progressively improved within 10 minutes and, at the end of the surgery, the blood pressure recovered from hypotension. ECG returned to normal, with sinusal rhythm and heart rate approximately 70 bpm. The patient was extubated and moved to the Intensive Care Unit (ICU). This case suggests that gas embolisms may occur during retroperitoneoscopic adrenalectomy, and acute changes in EtCO2 should alert the clinicians to these rare but potentially lethal complication. EtCO2 monitoring is essential during laparoscopy, as it may help an early detection of CO2 embolism, characterized by a transient and rapid increase in EtCO2, followed by an abrupt decrease.

Acute renal failure due to amiodarone-induced hypothyroidism.

Renal alterations in hypothyroidism include decreased glomerular filtration rate and renal plasma flow. We herein report a case of amiodarone -induced hypothyroidism associated with a rapid decrease of renal function, reversible upon amiodarone withdrawal. A 72-year-old man presented to our clinic in August 2007 reporting a recent deterioration of renal function. Ten weeks before he was admitted to another hospital for a supraventricular tachyarrhythmia treated with carvedilol 12.5 mg/day and amiodarone 400 mg/day. On admission, laboratory tests revealed altered renal function (serum creatinine 6 mg/dl, blood urea nitrogen 78 mg/dl) and severe hypothyroidism (free T4 0.27 pg/ml, free T3 1.49 pg/ml, TSH 183.36 mU/l). Amiodarone and carvedilol were stopped, while levothyroxine 75 mcg/die was started. After three months renal function had completely recovered to 1.9 mg/dl, BUN 28 mg/dl, with concurrent improvement of thyroid function free T4 14.2 pg/ml, free T3 6.4 pg/ml, TSH 15.5 mU/l.

[Use of sildenafil in the chronic uremic patient]. / L'uso del sildenafil nel paziente uremico.

BACKGROUND: Erectile dysfunction is one of the factors influencing negatively the quality of life of patients in hemodialytic treatment. The international literature shows that erectile dysfunction is present in 30% of patients with chronic renal failure and in 50% of patients undergoing dialytic treatment. Fertility, libido and erectile dysfunction, suffer progressive worsening with time, in spite of hemodialysis. The availability of a drug like Sildenafil can improve the quality of life of the patient and give him a normal sexual activity. METHODS: Twenty patients between 29 and 51 years, were selected; 2 of these had been subjected to renal transplant, with a dialytic treatment time varying from 3 to 13 years. Before the treatment all the patients have been subjected to an andrological screening (testosterone, prolactin, penile color Doppler ultrasound) and proposed the IIEF test. Therapeutic strategy included the assumption of the drug in the days in which the patients were not subjected to dialysis, with an interval from 1 to 3 weeks between assumption and another. The dose was 25-50 mg. At the end of three months of therapy the patients were again subjected to the IIEF test. RESULTS: All patients reported an improvement in sexual activity and sexual desire with very good repercussions on general and psychophysical conditions. CONCLUSIONS: The results demonstrate at least that Sildenafil is also effective in uremic patients in dialytic treatment or after renal transplant and that it can therefore resolve one of the main problems for the normal development of the life of such patients.

[Hormonal markers of early-stage osteitis fibrosa in patients on hemodialysis]. / Indici ormonali di osteite fibrosa in fase iniziale nel paziente emodializzato.

The diagnosis of renal osteodystrophy is straightforward when the disease has reached an advanced stage and the pathology is extremely difficult to treat, whereas it is considerably more complex during the early stages. A study was carried out to assess the sensitivity of some biochemical, hormonal and instrumental markers in the early diagnosis of osteitis fibrosa in patients undergoing hemodialysis due to chronic renal insufficiency. Of these markers, the assay of whole molecule PTH appeared to be the most sensitive and specific biological marker.

[Use of ultrafiltration in refractory cardiac decompensation]. / Impiego dell'ultrafiltrazione nello scompenso cardiaco refrattario.

Traditional therapy for heart failure (diuretics, digitalic compound, vasodilators, inodilatory ACE-inhibitors) cannot arrest the progressive overloading of the circulatory system so that it is inevitable that a refractory stage to all forms of treatment will be reached when more specialised techniques, such as heart transplant and ultrafiltration will be needed. The paper reports the results obtained in 13 patients in ultrafiltration treatment for refractory heart failure: in the majority of these, a marked improvement in general conditions (edema, dyspnea) was recorded together with a regression from class 5 to class 3 NYHA in 5 patients, and to class 2 for others. The ultrafiltration method in spite of not altering the prognosis which remains negative in these patients, allow those waiting for heart transplant to survive and may improve their chances of surviving heart surgery.

[Arterial hypertension in pregnancy: evaluation of renal damage through the study of NAG urinary activity]. / Ipertensione arteriosa in gravidanza: valutazione del danno renale attraverso lo studio dell'attività NAG-urinaria.

NAG-urinary activity was assessed in order to study the renal effects of arterial hypertension in pregnant women. The results obtained showed that there were no significant differences between mean levels of enzymuria in control subjects and normotensive pregnant women. On the contrary, significant differences were found between these two groups and hypertensive pregnant women (above all if arterial hypertension predated pregnancy). The paper stresses the usefulness of this method, which is reliable and non-invasive, for an accurate assessment of the extent of renal damage caused by arterial hypertension during the course of pregnancy.

[The evaluation of urinary NAG activity in patients undergoing urography]. / Valutazione dell'attività NAG-urinaria in pazienti sottoposti ad urografia.

A study has been carried out to verify the nephrotoxic effect of hyperosmotic substances used as a contrast medium in radiology employing the enzymuria technique (NAG). The research was carried out in 202 patients, some of whom diabetic, suffering from various pathologies and subjected to perfusion urography by inoculating an iodate contrast medium (isopaque). The result showed that NAG urinary activity grows significant in the 24-36 hours subsequent to X-ray examination in both diabetics and nondiabetics although the increase is greater in the former. After 5-7 days, enzymuria returns to normal in nondiabetic patients but remains high in the diabetic.

[A comparison between the urinary and serum NAG activity in subjects with chronic nephropathies and essential arterial hypertension]. / Confronto tra le attività urinaria e sierica del NAG in soggetti affetti da nefropatie croniche e da ipertensione arteriosa essenziale.

Various substances can interfere with the urinary activity of N-acetyl-beta-D-glycosaminidase (NAG), particularly certain bacteria that exert inhibitory or enhancing effects on the enzyme. Clearly, all this constitutes a limitation on the use of the technique. For these reasons, in patients suffering from interstitial and glomerular nephropathies and essential arterial hypertension a comparative study was carried out between the activity of urinary and serum NAG to establish if the latter produces more reliable results than the former. The results of urinary NAG activity confirm that there is no significant difference between healthy subjects and those with essential arterial hypertension; on the other hand, nephropathic patients present significantly higher urinary enzyme activity than healthy controls. On the other hand, evaluation of serum NAG does not seem to provide any practical aid as it does not highlight any difference between measurements carried out in healthy subjects and those carried out in hypertensive patients or those suffering from interstitial or glomerular nephropathy.

[A case of epidermoid cyst of the testis]. / Un caso di cisti epidermoide del testicolo.

The epidermoid cyst of the testis represents about 1% of all testicle tumours. The average age of presentation ranges from the second and the fourth decade of life. Its clinical features do not differ from those of a testis malignancy. Preliminary clinical and laboratory findings do not determine the diagnosis. The Authors report a case and review the Literature (about 150 cases up to 1985). Therapeutic strategy is also discussed: orchiectomy or simple removal of the cyst.