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Chronic hyperkalemia in cardiorenal patients: Q&A for the cardio-nephrologists.Chronic hyperkalemia is a serious medical condition often present in patients with chronic kidney disease (CKD) and heart failure (HF). It leads to poor outcomes and needs careful management by cardio-nephrologists. CKD, HF, diabetes and use of renin–angiotensin–aldosterone system inhibitors (RAASi) drugs are known to induce hyperkalemia.The current therapeutic options are not optimal as shown by the large number of CKD and HF patients suffering from hyperkalemia.The following review focuses on the main risk factors that lead to the development of hyperkalemia and provides a guide for the correct diagnosis and new approaches to therapy. [ABSTRACT FROM AUTHOR]

Sonography in peritoneal dialysis patents Traditionally computed tomography (CT) and more recently magnetic resonance (MR) are the imaging modalities of choice for the evaluation of peritoneum and peritoneal cavity in primary and secondary pathologic conditions. Nevertheless, ultrasound (US) also may be a valuable, accurate, safe, relatively inexpensive and readily accessible diagnostic tool to investigate the diseases that can affect the peritoneal membrane. US is able to provide quantitative information demonstrating much smaller quantities of free intraperitoneal fluid (ascites) being more sensitive than CT in this regard. Sonographic characteristics of ascites allow to detect the presence of blood, pus or neoplastic cells in echogenic fluid. Sonography is very helpful when planning and performing interventional procedures on abdominal wall such as: fine-needle aspiration, core biopsy and drainage: with modern devices lesions of less than 4 mm may be easily targeted. Ultrasonography is used in the assessment of several procedures and complications in peritoneal dialysis (PD) patents. Some of them are well documented whereas other indications are less clear. Peritoneal ultrasound fields of applications include some of the following: correct patents' enrollement, ultrasound-guided catheter's placement, potential diagnosis of exit site and tunnel infections and/or peritonitis (both infectious and/or sclerosing) and leakage amount's assessment. The purpose of this review is to describe an US technique for optimal detection and localization of the main complications commonly encountered in patents affected by chronic kidney disease undergoing peritoneal dialysis. [ABSTRACT FROM AUTHOR]

Thrombotic thrombocytopenic purpura (TTP) is an uncommon hematologic thrombotic disorder characterized by fever, hemorrhagic and neurologic signs. The advent of plasma exchange has dramatically improved the prognosis of this disease, which was once inevitably fatal. However, mortality rates remain significant. Antiplatelet drugs have been widely used in combination with plasma exchange. In this pilot study we investigated the effects of an adjunctive therapy consisting of the continuous, intravenous infusion of dipyridamole, a modality of administration that has not been previously tested in this setting.Sixteen untreated TTP patients, diagnosed consecutively at our clinic, received daily plasma exchange together with intravenous methylprednisolone (1–2 mg/kg/twice daily) and a continuous i.v. infusion of dipyridamole (100 mg/day). A complete response was defined as an improvement in the platelet count to more than 150 × 109/l for two consecutive days and no neurologic deterioration.The overall response rate was 87.5%. One patient failed to respond to the combination therapy but attained a consistent remission after autologous stem cells transplant. One patient was refractory to the combination therapy and died, after an initial but unsustained response.The results of this pilot study suggest that the continuous infusion of dipyridamole is safe and might provide additional benefit in the treatment of TTP when combined with plasma exchange and steroids. However, a randomized study will be necessary to properly test whether the addition of dipyridamole improves the efficacy of plasma exchange in patient with TTP. [Copyright &y& Elsevier]

Comments on an article which suggests the treatment of thrombotic thrombocytopenic purpura using plasma exchange, alone or combined with drugs. Result of the deficiency of metalloprotease; Case history of a patient whose disease remitted with high-dose cyclophosphamide.

Calciphylaxis, better described as "Calcific uremic arteriolopathy" (CUA), involves about 1-4% of hemodialysis patients all around the world with highmortality rates. We describe a rare clinical case of CUA in peritoneal dialysis patient associated with urological disease. Penile calciphylaxis represents rare clinical complication, and an early diagnosis and multidisciplinary approach are requested. Pathogenesis is still unclear, and therapeutic approaches need more long-term clinical trials to test their efficacy and safety [ABSTRACT FROM AUTHOR]

Presents a case of the treatment of a patient with hepatosplenic gamma delta T-cell lymphoma using pentostatine. Characteristics of hepatosplenic gamma delta T-cell lymphoma; Details of the medical history of the patient.

Introduction: AILD-type T-cell lymphoma is characterized by very poor prognosis in most patients and the response rate to conventional chemotherapy is unsatisfactory.Materials and methods: Two patients (a 65 year old female and a 67 year old male) with AILD-type lymphoma who did not respond to conventional treatment with steroids or aggressive chemotherapy were treated with Methotrexate and Prednisone. Both patients received a weekly dose of MTX (10 mg/m2) that was administered orally in combination with PDN at an initial dose (15 mg/day), given on a daily basis.Results: Both patients responded rapidly showing marked improvement with no major side effects. Complete clinical remission was recorded in the two patients who were treated with this combination after conventional chemotherapy had failed to produce any improvement.Conclusion: Our observations in two patients with refractory/relapsed AILD-type lymphoma who were given low-dose oral MTX as salvage treatment, suggest that this agent has immunosuppressive effects that can be beneficial for treating patients with AILD-type T-cell lymphoma. Pilot clinical trials are needed to verify its efficacy in this setting.The Hematology Journal (2001) 2, 393–395 [ABSTRACT FROM AUTHOR]

Rivaroxaban and Chronic Kidney Disease: evidence from the present and future prospects Cardiovascular diseases represent the main cause of comorbidly in chronic kidney disease (CKD) patients, with a 7% incidence in atrial fibrillation (AF) in end-stage renal disease (ESRD) patients. Until recently, prophylactic treatment of atrial fibrillation complications (such as thromboembolism) was mainly based on vitamin K antagonists (VKA) or heparin. In the last years, direct oral anticoagulants (DOACs) have been made available; however, their renal clearance limits their use on patients with severe renal impairment (eGFR <15 mL/min). Among DOACs, Rivaroxaban, a factor X-activated (Xa) inhibitor, shows good renal profile and it can be used in CKD patients up to stage 4 as well as in ESRD patients (at the moment only in North America and Canada). [ABSTRACT FROM AUTHOR]

Abstract Aims Direct oral anticoagulant (DOAC) has been recently introduced in the clinical practice. Rather than interfering with vitamin K-dependent posttranscriptional modification of various proteins, DOACs selectively inhibit factors involved in the coagulation cascade. In particular, in contrast with Warfarin, Rivaroxabn does not interfere with activation of matrix Gla Protein (MGP), a potent vascular calcification Inhibitor. We herein sought to investigate the impact of Rivaroxaban and Warfarin on cardiac valve calcifications in a cohort of moderate-to advanced CKD patients. Methods and results This is a multicenter, observational, retrospective, longitudinal study. Consecutive CKD stage 3b – 4 (according to KDIGO guidelines) patients from 8 cardiologic outpatient clinics were enrolled between May 2015 and October 2017. All patients received anticoagulation (100 Warfarin vs 247 Rivaroxaban) as part of their non-valvular atrial fibrillation management. Cardiac valve calcification was evaluated via standard trans-thoracic echocardiogram. 347 patients (mean age: 66 years; mean eGFR: 37 ml/min/1.73 m2) were studied. Over a mean follow-up period of 16 months, Rivaroxaban compared to Warfarin reduced both mitral and aortic valve calcifications (p < 0.001) independently of the degree of calcifications at baseline and potential confounders. Notably, Rivaroxaban use was also associated with a significant reduction in C reactive protein (CRP) (p < 0.001) during follow-up. Conclusion This study generates the hypothesis that the use of Rivaroxaban associates with a reduction of cardiac valve calcification deposition and progression as compared to Warfarin, in a cohort of CKD stage 3b-4 patients. Future endeavors are needed to confirm and to establish the mechanisms responsible for these findings. Highlights • Anticoagulation therapy in CKD patients • First in vivo data on DOACs and calcifications • A new modifiable risk factor for valvular calcifications. [ABSTRACT FROM AUTHOR]

Atrial fibrillation (AF) is the most common arrhythmia in patients with chronic kidney disease (CKD). In this population, AF is associated with an increased risk of thromboembolism and stroke as a result of a progressive decline in the glomerular filtration rate. However, CKD patients, in particular those on renal replacement therapy, also have an increased risk of bleeding, especially from the gastrointestinal tract. Oral anticoagulation is the most effective form of thromboprophylaxis in patients with AF presenting an increased risk of stroke. Limited evidence of its efficacy, the increased risk of bleeding as well as some concern regarding the use of warfarin in CKD have often resulted in the underuse of anticoagulation in CKD patients. A large body of evidence suggests that non-vitamin-K-dependent oral anticoagulants (NOACs) significantly reduce the risk of stroke, intracranial hemorrhage and mortality. Hence, they are currently recommended for patients with AF at risk of stroke. However, the metabolism of NOACs is largely dependent on the kidneys for elimination and little is known about their use in patients with creatinine clearance <25 mL/min, who have been excluded from all pivotal phase III NOAC trials. This review focuses on the current pharmacokinetic, observational and prospective data on NOACs in patients affected by moderate to advanced CKD (creatinine clearance 15-49 mL/min) and in those on dialysis. [ABSTRACT FROM AUTHOR]

Galectin-3 is a 32- to 35-kDa member of the galectin family of b-galactoside-binding lectins, which is characterized by a carbohydrate recognition domain. Through its carbohydrate-binding function, it regulates cell growth, differentiation, and inflammation. It also plays a complex, context-dependent role in the kidneys. During the development, it promotes nephrogenesis and is strongly expressed in the ureteric bud and its derivatives. An increase in the concentration of galectin-3 has been reported to be associated with fibrosis of the kidneys. Elevated levels of plasma galectin-3 are also associated with increased risks of rapid renal function decline, incident chronic kidney disease, and progressive renal impairment, and also with cardiovascular endpoints, infection, and all-cause mortality in patients with renal function impairment. This review discusses a general survey on galectin-3 expressions in nephrogenesis, kidney injury in animal models, clinical renal diseases, and renal transplantation and the potential role of galectin-3 for treatment in kidney disease. [ABSTRACT FROM AUTHOR]

Vitamin D represents the precursor of calcitriol, crucial for bone and mineral metabolism. The high prevalence of vitamin D deficiency and the detection of vitamin D receptor (VDR) both in the heart and vessels have focused the interest on potential cardiovascular effects of vitamin D. Although several experimental data showed the protective role of vitamin D, on the other hand vitamin D "overdose"can contribute to heart and vascular calcification. Meta-analyses of randomized-controlled trials (RCTs) underlined the association of vitamin D deficiency and increased cardiovascular morbidity and mortality but no significant improvements on cardiovascular outcomes are provided by the supplementation of vitamin D. The following review provides an update on pathophysiology of vitamin D and vitamin D receptor (VDR) discussing on the association with cardiovascular risk factors and disease and on the role of vitamin D supplementation in preventing cardiovascular disease in chronic kidney disease (CKD) patients. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: To compare the effectiveness, safety and time needed to perform central venous catheterization (CVC) in the presence or absence of an ultrasound (US) guide. Methods: Between January 1999 and February 2002 we performed CVCs in 196 patients: 105 patients received US guided CVC (group I) and 91 patients had CVC without US guide (group II). Results: The average time to perform CVC was shorter with US guide (4 vs 7min). The utilization of the US guide was also associated with improved success (98.09% vs 91.2%, p<0.025) and lack of major complications (0% vs 9.8%, p<0.001). Conclusions: US-guided CVC affords an easier, safer and more rapid cannulation of a central vein. It is especially helpful in those patients with anatomical variation or difficult veins (small or not visible, non-palpable landmarks) and in those with coagulative disorders. [Copyright &y& Elsevier]

Atrial fibrillation (AF) and chronic kidney disease (CKD) are strictly related; several independent risk factors of AF are often frequent in CKD patients. AF prevalence is very common among these patients, ranging between 15% and 20% in advanced stages of CKD. Moreover, the results of several studies showed that AF patients with end stage renal disease (ESRD) have a higher mortality rate than patients with preserved renal function due to an increased incidence of stroke and an unpredicted elevated hemorrhagic risk. Direct oral anticoagulants (DOACs) are currently contraindicated in patients with ESRD and vitamin K antagonists (VKAs), remaining the only drugs allowed, although they show numerous critical issues such as a narrow therapeutic window, increased tissue calcification and an unfavorable risk/benefit ratio with low stroke prevention effect and augmented risk of major bleeding. The purpose of this review is to shed light on the applications of DOAC therapy in CKD patients, especially in ESRD patients. [ABSTRACT FROM AUTHOR]