Chronic kidney disease (CKD) is a complex and multifactorial disease, and one of the most prevalent worldwide. Chronic kidney disease–mineral bone disorders (CKD–MBD) with biochemical and hormonal alterations are part of the complications associated with the progression of CKD. Pathophysiology of CKD–MBD focused on abnormalities in serum levels of several biomarkers (such as FGF-23, klotho, phosphate, calcium, vitamin D, and PTH) which are discussed in this review. We therefore examine the prognostic association between CKD–MBD and the increased risk for cardiovascular events, mortality, and CKD progression to end-stage kidney disease (ESKD). Lastly, we present specific treatments acting on CKD to prevent and treat the complications associated with secondary hyperparathyroidism (SHPT): control of hyperphosphatemia (with dietary restriction, intestinal phosphate binders, and adequate dialysis), the use of calcimimetic agents, vitamin D, and analogues, and the use of bisphosphonates or denosumab in patients with osteoporosis.
Background and Aims Hyperoxaluria is a rare metabolic disorder chacterized by widespread calcium oxalate deposition, if plasmatic oxalate level (pOx) overcomes saturation threshold. It could be primary (PH), a recessive disease associated with mutation of the liver enzyme LDH, or secondary (SH), in 75% due to intestinal malabsorption. Urolithiasis could be the first complication, and renal involvement could progress until end-stage renal disease (ESRD). Mean pOx is higher in chronic dialysis patients than healthy individuals because of impaired renal clearance. Oxalate molecular weight (MW) is 88 Da and its clearance is that of low MW uremic toxins. Our aim is to assess an association between arteriovenous fistula (AVF) failures and Hyperoxaluria. Method In the period between 1/1/2004 and 12/31/2020, diagnosis of Hyperoxaluria was carried out in 6 patients out of 1530 chronic dialysis patients (0.39%). The median age of patients was 65.5 [26-72] years, the male/female ratio was 3:3 and the median dialysis vintage was 36 [1-181] months. Three patients come to nephrological referral at stage 5 of CKD while 1 patient came to Italy when chronic HD was already started. At that time pOx was not considered. In these 4 patients the presumptive diagnosis of ESRD was urolithiasis and diagnosis of Hyperoxaluria was carried out after the beginning of chronic dialysis, when pOx and genetic analysis were performed. In 1 case biopsy on the kidney graft and in 1 case kidney biopsy after nephrectomy were performed: oxalate deposition was detected. For 2/6 patients diagnosis was carried out after biopsy of native kidneys before starting dialysis. All patients started medical therapy for hyperoxaluria. Five out of 6 patients were eligible to HD, 1/6 to PD. AVF was judged the first choice vascular access. Results PH was diagnosed in 3/6 patients: mutations were detected on chromosome 2. Malabsorption secondary to short bowel syndrome and chronic pancreatitis could be assumed as causes of SH in 3 patients. Patient 1 underwent 2 combined liver-kidney transplantation: the first failed by arterial grafts thrombosis and the second by renal primary non-function but the liver was still functioning, he died on HD after 12 years. Patient 2 underwent liver and kidney transplantation and she is nowadays dialysis-free. The median pOx pre-dialysis and before diagnosis was 165 [98-259] umol/L (Table 1). Patients on chronic HD underwent median of 3 [2-5] AVF interventions. Nine AVFs were distal and 4 were proximal. The most frequent complication was AVF thrombosis despite ASA treatment: half of the cases showed secondary AVF non-function, the other half of AVFs failed to mature. Six tunneled cuffed permanent catheters (TCCs) as definitive vascular access were successfully placed in the 5 patients on chronic HD. Warfarin therapy was started to avoid TCCs thrombosis. The median survival of TCCs was 9.5 [3-48] months. All the patients had a history of deep venous thrombosis (DVT). Conclusion To our knowledge this is the first case series of multiple AVF failures in patients with hyperoxaluria. In our experience TCCs show longer survival then AVF in this group of patients, even if it could not be excluded the role of warfarin in favoring this result. Even though a link between hyperoxaluria and thrombosis is well established, the exact underlying mechanism is still uncleared. The role of PD as dialysis technique of “first choice” should be enhanced also when residual renal function is abolished. In ESRD patients with urolithiasis, diagnosis of Hyperoxaluria should be ruled out before AVF placement.
Background: Patients with autosomal dominant polycystic kidney disease (ADPKD) may require specific therapy with vasopressin receptor antagonists to slow the progression of renal disease. Because of its mechanism of action, the most common side effects are polyuria, nocturia, and polydipsia. Elevations of liver enzyme levels can also occur during treatment with Tolvaptan. Temporary drug withdrawal may be indicated if the patient is unable to hydrate adequately or if there are concomitant causes of dehydration, including major infectious events. During the Coronavirus Disease 2019 pandemic, this should be considered in the management of patients on Tolvaptan therapy. Case Report: We present the clinical case of a 51-year-old male with severe acute respiratory syndrome Coronavirus-2 (SARS-CoV-2) infection and ADPKD receiving Tolvaptan therapy with particular reference to the medical management of the patient during the infectious event. The patient was instructed to discontinue promptly Tolvaptan as soon as symptoms appeared. He was treated with forced hydration and symptomatic therapy.
Background and Aims Dialysis per se represents an independent risk factor for peripheral arterial obliterating disease and in particular for critical ischemic limb. Conventional by-pass surgery or endovascular revascularization frequently did not avoid major limb amputation in dialysis patients or are excluded for wild calcificating atherosclerosis. Extracorporeal LDL-apheresis by means of Heparin-induced LDL Precipitation (H.E.L.P.) is proposed in some cases in combination to the traditional clinical approach. Method Here we describe the case of a 83-year old patient who undergoes thrice weekly hemodialysis from 1 year and who is affected by COPD, ischemic cardiopathy, previous stroke and had a Charson score of 6. He was also affected by dry necrosis of the second toe and parcel of the third toe of the right foot. The patient was not affected by diabetes. Lower limb arteriography showed right tibial artery obstruction anterior to the distal and dorsal third and severe stenosis with short sub-obstruction in subarticular area of the left popliteal artery. The plan foot x-ray excluded osteomyelitis. The vascular surgery consultant found the arterial lesions not suitable for revascularization advising monitoring and dressing of lesions. Nonetheless the patient complained of pain and opioid analgesics were administered. Cardioaspirin and atorvastatin were also administered. The patient was considered eligible for (H.E.L.P.) apheresis for the rescue of his limb. The patient underwent 8 sessions of H.E.L.P. apheresis once a week for eight weeks in a non-dialysis day. His vascular access was a permanent cuffed hemodialysis catheter. H.E.L.P. consists firstly in plasma separation, then apolipoprotein B-containing lipoproteins and fibrinogen are precipitated at a pH-value of 5.12 by the addition of a mixed acetate-heparin buffer to plasma. Before returning the plasma to the patient, the excess heparin is adsorbed and the pH normalized by a bicarbonate dialysis. A total of 3 litres of plasma per session was treated. Each session lasted 3 hours and was carried out in the Dialysis ward. Blood samples were obtained directly before and immediately after each H.E.L.P. apheresis for laboratory measurements. Results A C-reactive protein of 4 mg/dL reflected systemic inflammation. At baseline (prior to H.E.L.P. apheresis), fibrinogen was 394 mg/dL, LDL cholesterol was 122 mg/dL, lipoprotein(a) was 50.5 mg/dL. Total cholesterol was fairly normal even before H.E.L.P. apheresis with concentrations of 170 mg/dL. The pre vs post H.E.L.P. values were significantly reduced for all the parameters considered (p<0.0001). The median reduction rate (RR) per session for fibrinogen was 63.8% (range 57.1-75.3%), for lipoprotein(a) 66.1% (range 54.6-76.5), for LDL-cholesterol 50.8% (range 40-59.3%), for total cholesterol 40.7% (range 35.4-43.5%) (Figure 1). C reactive protein RRs was 61.2% (range 56.2-63.2%). Nonetheless, in the period between the H.E.L.P. apheresis a rebound was observed: for fibrinogen it was 64.9% (range 52.5-73.4%), for total cholesterol 29.2% (range -4 – 54.3%), for LDL cholesterol 36.4% (range -20 – 68.8%), for lipoprotein(a) 69.1% (range 44.1-73.9%). After the 8 sessions of H.E.L.P. apheresis, fibrinogen RR was 21%, LDL cholesterol RR was 75.4%, total cholesterol RR was 64%, lipoprotein(a) RR was 17%. After 6 months the patient underwent minor amputation of the second toe of the right foot, the third toe healed completely. The lesions of the foot before and after 1 year after HELP are showed in Figure 2. Conclusion Drastic reductions of fibrinogen, LDL cholesterol and lipoprotein(a), together with an adequate wound care, reduced the risk of major limb amputation in this dialysis patient with critically ischemic foot that was not qualified for revascularization.
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.
hi@scite.ai
10624 S. Eastern Ave., Ste. A-614
Henderson, NV 89052, USA
Copyright © 2024 scite LLC. All rights reserved.
Made with 💙 for researchers
Part of the Research Solutions Family.