Pre-eclampsia is a valuable opportunity to diagnose chronic kidney disease: a multicentre study.

BACKGROUND: Pre-eclampsia (PE) and chronic kidney disease (CKD) are known to be associated. Our objective was to assess the prevalence of CKD in a large multicentre cohort of women without acknowledged CKD who experienced a PE episode. METHODS: The setting for the study was France (Le Mans, Central France) and Italy (Cagliari, Sardinia). The study participants were patients who experienced PE in 2018-19, identified from the obstetric charts. Patients with known-acknowledged CKD were excluded. Only singletons were considered. Persistent (micro)albuminuria was defined as present and confirmed at least 3 months after delivery. CKD was defined according to the Kidney Disease Outcomes Quality Initiative guidelines; urinary alterations or low eGFR confirmed at a distance of at least 3 months, or morphologic changes. Patients were divided into four groups: evidence of CKD; no evidence of CKD; unclear diagnosis-ongoing work-up; or persistent microalbuminuria. The outcome 'diagnosis of CKD' was analysed by simple and multiple logistic regressions. Temporal series (week of delivery) were analysed with Kaplan-Meier curves and Cox analysis. RESULTS: Two hundred and eighty-two PE pregnancies were analysed (Le Mans: 162; Cagliari: 120). The incidence of CKD diagnosis was identical (Le Mans: 19.1%; Cagliari: 19.2%); no significant difference was found in unclear-ongoing diagnosis (6.2%; 5.8%) and microalbuminuria (10.5%; 5.8%). Glomerulonephritis and diabetic nephropathy were more frequent in Cagliari (higher age and diabetes prevalence), and interstitial diseases in Le Mans. In the multivariate logistic regression, CKD diagnosis was associated with preterm delivery (adjusted P = 0.035). Gestation was 1 week shorter in patients diagnosed with CKD (Kaplan-Meier P = 0.007). In Cox analysis, CKD remained associated with shorter gestation after adjustment for age and parity. CONCLUSIONS: The prevalence of newly diagnosed CKD is high after PE (19% versus expected 3% in women of childbearing age), supporting a systematic nephrology work-up after PE.

Lung ultrasound and BNP to detect hidden pulmonary congestion in euvolemic hemodialysis patients: a single centre experience.

BACKGROUND: Dry weight assessment in hemodialysis (HD) remains a challenge. The aim of the study was to investigate the prevalence of subclinical pulmonary congestion using lung ultrasound (LUS) in maintenance HD patients with no clinical or bioimpedance signs of hyperhydration. The correlation between B-lines Score (BLS) and brain natriuretic peptide (BNP) was also evaluated. METHODS: Twenty-four HD patients underwent LUS and BNP dosage at the end of the mid-week HD session, monthly for 6 months . LUS was considered as positive when BLS was >15. Hospitalizations and cardiovascular events were also evaluated in relation to the BLS. RESULTS: LUS+ patients at baseline were 16 (67%), whereas 11 (46%) showed LUS + in at least 50% of the measurements (rLUS+ patients). Only the rLUS+ patients had a higher number of cardiovascular events [p=0.019, OR: 7.4 (CI 95%. 1.32-39.8)] and hospitalizations [p=0.034, OR 5.5 (CI 95% 1.22- 24.89)]. A BNP level of 165 pg/ml was identified as cut-off value for predicting pulmonary congestion, defined by BLS >15. CONCLUSION: Prevalence of pulmonary congestion as assessed by LUS and persistent or recurrent BLS >15 were quite prevalent findings in euvolemic HD patients. In the patients defined as rLUS+, a higher rate of cardiovascular events and hospital admissions was registered. BNP serum levels > 165 pg/ml resulted predictive of pulmonary congestion at LUS. In the dialysis care, regular LUS examination should be reasonably included among the methods useful to detect subclinical lung congestion and to adjust patients' dry weight.

Nutritional Aspects in Diabetic CKD Patients on Tertiary Care.

Background and objectives: Diabetes is largely prevalent in the chronic kidney disease (CKD) population. Both conditions have metabolic and nutritional abnormalities that affect body composition and the presence of diabetes makes the dietary management of CKD patients more difficult. The aim of this study was to assess peculiar nutritional and functional aspects of diabetic patients in an adult/elderly CKD population, and their predictive significance. Materials and methods: This prospective cohort study included 144 out-patients aged >55 years, affected by stage 3b-4 CKD, on tertiary care clinic; 48 (40 males) were type 2 diabetics and 96 (80 males) were nondiabetics. The two groups have similar age, gender, and residual renal function (30 ± 9 vs. 31 ± 11 mL/min×1.73). All patients underwent a comprehensive nutritional and functional assessment and were followed for 31 ± 14 months. Results: Diabetic CKD patients showed higher waist circumference and fat body mass, lower muscle mass, and lower number of steps per day and average daily METs. Meanwhile, resting energy expenditure (REE), as assessed by indirect calorimetry, and dietary energy intake were similar as well as hand-grip and 6 min walking test. Diabetic patients did not show a greater risk for all-cause mortality and renal death with respect to nondiabetics. Middle arm muscle circumference, phase angle, serum cholesterol, and serum albumin were negatively related to the risk of mortality and renal death after adjustment for eGFR. Conclusions: CKD diabetic patients differed from nondiabetics for a greater fat mass, lower muscle mass, and lower physical activity levels. This occurred at the same REE and dietary energy intake. The outcome of diabetic or nondiabetic CKD patients on tertiary care management was similar in terms of risk for mortality or renal death. Given the same residual renal function, low levels of muscle mass, phase angle, serum albumin, and cholesterol were predictive of poor outcome. Overall, a malnutrition phenotype represents a major predictor of poor outcome in diabetic and nondiabetic CKD patients.

Evaluation of the Effects of the Metha® Short Stem on Periprosthetic Bone Remodelling in Total Hip Arthroplasties: Results at 48 Months.

INTRODUCTION: Total hip arthroplasty is one of the most performed procedures in orthopaedic surgery. Implantation of a prosthesis determines changes in the distribution of loads on the host bone, and this phenomenon, known as stress shielding, is related to the biomechanical characteristics of the implant. Usually stress shielding involves the proximal portion of the femur by reducing the mechanical strength and ability to withstand the transmitted loads. The aim of our study is to demonstrate how the use of a short hip stem reduces the stress shielding phenomenon to the proximal femur. MATERIALS AND METHODS: The study analyzed 20 patients undergoing hip prosthesis surgery with a short stem (Metha<, B. Braun Medical, Inc., Bethlehem, Pennsylvania) at the Ist Orthopaedic Division of Pisa University (between December 2008 and January 2010). Each patient was subjected to analysis of periprosthetic bone mineral density by a bone densitometry (dual emission X-ray absorptiometry [DEXA] with the metal removal software) at 0, 6, 12, 18, 24, and 36 months, following a protocol based on the evaluation of the changes of bone density in the seven Gruen zones. RESULTS: We recorded minimal changes in bone mineral density (BMD) at the level of the greater trochanter (-1.44%) and at the level of the calcar (-3.7%). BMD increased significantly after four years at the level of the lateral distal regions (R2 +9.6% - R3 + 12.4%) and at the level of the distal medial regions (R5 + 8.2% - R6 + 13.1%). We compared the results obtained with the literature data at 12 and 24 months with the same stem (Metha<). At 12 months follow up, we did not see a significant difference between our data and the data published in the literature. However, after 48 months of follow-up, we recorded significant differences in the curves of periprosthetic bone reabsorption at the level of the greater trochanter (Zone 1) and at the level of the calcar (Zone 7). DISCUSSION: The data obtained from our study are in agreement with other studies in the literature, which demonstrates how the use of short stems preserves the metaphyseal bone stock at the level of the proximal femur, reducing the stress shielding phenomenon. From our data, obtained at 24 months and confirmed at 36, stress shielding seems to minimally occur at the level of the calcar. At the level of the great trochanter, we saw a good load distribution that maintained the baseline BMD; these data are in opposition to the literature data that showed a high increase of BMD at the level of the calcar (+12.9%) and a decrease at the level of the great trochanter. From the analysis of the radiographic images of our cases, and of the cases published with the same stem, these differences in load transfer encountered between the great trochanter and the calcar seems to be related to the level of the femoral neck osteotomy and the consequent stem position (varus/valgus). CONCLUSION: We conclude that the amount of periprostetic bone reabsorption around the Metha< stem seems to be strictly related to the surgical technique and the final implant position.

Prevalence and correlates of hyperkalemia in a renal nutrition clinic.

Hyperkalemia (HK) is a frequent complication of chronic kidney disease (CKD). Vegetable-based renal diets are considered at risk due to the high potassium (K) content. The aim of this study was to describe the prevalence and correlates of chronic hyperkalemia (HK) in CKD patients on nutritional care, and in particular, the risk of HK in patients on plant-based versus animal-based low-protein diets. We recruited adult patients affected by CKD not on dialysis, afferent to our renal nutrition clinic from November 2014 to May 2019. We evaluated a total of 870 accesses in 219 patients (172 m, 47 f, age 67 ± 13 years). HK was defined as mild when K serum level was 5.1-5.9 mEq/l, moderate when K serum level was 6.0-6.9 mEq/l, and severe HK when K serum level was ≥ 7 mEq/l. Biochemical, anthropometric data and medications were recorded. The prevalence of HK in all the renal nutrition visits was 26.1%; all but six cases were mild HK, whereas no severe HK was observed. The prevalence of HK was associated with decreased eGFR, up to 36.5% for eGFR < 20 ml/min. Medications were similar in hyperkalemic and normokalemic patients, RAASi being present in up to 85% of patients. In a follow-up of 40 ± 14 months, no association was found between HK and mortality, whereas HK, at the start of follow-up, showed a trend to increased ESRD risk. Serum potassium levels and prevalence of HK were not different between patients on animal-based low-protein diet and plant-based low-protein diet. In conclusion, chronic HK is quite prevalent in a renal nutrition clinic, especially when eGFR falls down below 60 ml/min, thereby reaching the highest prevalence in CKD stage 4. Hyperkalemia is mostly mild, being moderate to severe HK quite infrequent. Hyperkalemia was not associated with higher risk of mortality, whereas a trend, although not statistically significant, was observed for lower ESRD-free survival. Plant-based low-protein diet is not associated with significant higher prevalence of HK with respect to animal-based LPD at the same residual kidney function.