To evaluate the incidence of progressive renal damage in patients with chronic renal insufficienc... more To evaluate the incidence of progressive renal damage in patients with chronic renal insufficiency and renal-artery stenosis undergoing percutaneous transluminal angioplasty and stenting (PTA-stenting), color Doppler ultrasound (CDU)-guided, a procedure requiring low-contrast medium doses, or digital subtraction angiography were compared. Thirty patients with renal artery stenosis and severe renal insufficiency underwent PTA-stenting for revascularization, 15 patients with CDU guidance and 15 patients with standard selective digital subtraction angiography (SDSA). Serum creatinine (Cr) concentrations were compared in the two groups at 6 days and 12 months after revascularization. The stents were properly positioned and resolved the renal artery stenosis. None of the patients who underwent ultrasound-guided PTA-stenting had significantly increased Cr values (>50% or >1 mg/dL) at 6 days after surgery (95% confidence interval (95% CI), 0-21.8); and none had progressive chronic renal insufficiency at 12 months. Conversely, six of the 15 patients in the group who underwent PTA-stenting with standard SDSA had significantly increased Cr values at 6 days (95% CI, 16.3-67.7) and two patients had progressive chronic renal insufficiency at 12 months. Our results suggest that PTA-stenting under CDU guidance, a procedure requiring low-contrast medium doses, is suitable for patients with severe renal dysfunction and especially for those with diabetes mellitus undergoing percutaneous renal revascularization.
Atherosclerotic ischemic renal disease is a frequent cause of end-stage renal failure leading to ... more Atherosclerotic ischemic renal disease is a frequent cause of end-stage renal failure leading to dialysis among the elderly; Its prevalence is inferred from autopsy or retrospective arteriographic studies. This study has been conducted on 269 subjects over 50 with hypertension and/or CRF, unrelated to other known causes of renal disease. All 269 patients were studied either by color-flow duplex sonography (n = 238) or by renal scintigraphy (n = 224), and 199 of the 269 patients were evaluated using both of these techniques. 40 patients, found to have renal artery stenosis (RAS), were subjected to 3D-contrast enhancement Magnetic Resonance Angiography (MRA) and/or Selective Angiography (SA). An additional 23 cases, negative both to scintigraphy and to ultrasound study, underwent renal angiography (MRA and/or SA). Color-duplex sonography, carried out in 238 patients, revealed 49 cases of RAS. MR or SA was carried out in 35 of these 49 patients, and confirmed the diagnosis in 33. Color...
Rhabdomyolysis is a syndrome due to a damage of skeletal muscle and the leakage of intracellular ... more Rhabdomyolysis is a syndrome due to a damage of skeletal muscle and the leakage of intracellular contents into the extracellular fluid and the circulation. Several causes may induce rhabdomyolysis and the major one is the crush syndrome. Most cases of non-traumatic rhabdomyolysis are related to drugs. Many molecules are subject to hepatic metabolism and the concomitant use of drugs, as statins, with other medications acting as substrates of the same isoenzymes can interact and increase the risk of myopathy. Subclinical rise of creatine kinase may be expression of rhabdomyolysis that can range even to medical emergency such as acute kidney injury (AKI), compartment syndrome, cardiac dysrhythmias and disseminated intravascular coagulopathy. The main pathophysiological mechanisms of myoglobinuric-related AKI are renal vasoconstriction, formation of intraluminal casts and direct cytotoxicity promoted by heme-protein. The aim of this review is to analyze the pathophysiology of myolysis, ...
The aim of our study was to investigate the plasma chromogranin A (CgA) and adrenomedullin (AM) l... more The aim of our study was to investigate the plasma chromogranin A (CgA) and adrenomedullin (AM) levels in patients with pheochromocytomas. We collected blood samples for measurement of plasma CgA and AM in 21 patients with pheochromocytomas, 43 healthy subjects and 26 patients with solid non-functioning adrenocortical adenomas. In 11 patients with pheochromocytomas plasma CgA and AM were measured again four weeks after tumor removal. CgA and AM were measured by means of a novel solid-phase two-site immunoradiometric assay based on monoclonal antibodies (CgA-RIA CT, CIS bio international) and by a specific radioimmunoassay (RIA, Phoenix Pharm. Inc.), respectively. The mean plasma CgA level (+/- SD) in patients with pheochromocytomas (204 +/- 147.9 ng/mL) was significantly higher (P < 0.001) than that in healthy subjects (41.6 +/- 10.7 ng/mL) and in patients with non-functioning adrenocortical adenomas (47.3 +/- 17.6 ng/mL). The mean plasma AM concentration (+/- SD) in patients wit...
Renal artery stenosis (RAS) is a known cause of hypertension and ischemic nephropathy. Stenting o... more Renal artery stenosis (RAS) is a known cause of hypertension and ischemic nephropathy. Stenting of the artery is a valid approach, in spite of cases of unexpected adverse evolution of renal function. In this study, 27 patients with unilateral RAS were subjected to stenting and followed for a period of one year, while 19 patients were observed while on medical treatment only. The group of 27 patients, 67.33 +/- 6.8 years of age, creatinine of 2.15 +/- 0.9 mg/dl, following stenting, were followed at intervals with biochemical tests, renal scintigraphy and doppler ultrasonography. The control group (70.0 +/- 6.1 years, creatinine 1.99 +/- 0.7 mg/dl) was also followed for one year. One year after stenting mean creatinine clearance (Ccr) increased from 36.07 +/- 17.2 to 40.4 +/- 21.6 ml/min (NS). Arterial BP, decreased after 1,3,6, and 12 months (p < 0.05). The number of antihypertensive drugs also decreased (p < 0.05). A significant increase in proteinuria was also observed. In th...
Aneurysms of tibial arteries are extremely rare. Here we report a case of a true posterior tibial... more Aneurysms of tibial arteries are extremely rare. Here we report a case of a true posterior tibial artery aneurysm in a young patient without any associated pathology and discuss surgical and endovascular treatment. A young Caucasian male was admitted to our department for painful and pulsatile swelling of the right calf. Colour Doppler ultrasound scan visualised an aneurysmal dilation of the posterior tibial artery. The patient had no trauma to the area and denied other history of vascular disease. Angio-CT and angio-magnetic resonance imaging showed a larger aneurysm compared to ultrasound scan. We performed an embolisation of the aneurysm because of the risk of rupture, as distal collateral circulation ensured foot vascularisation. Endovascular treatment of aneurysms of small arteries seems to be a safe therapeutic and non-invasive choice, particularly in young patients in whom the presence of collaterals guarantees distal vascularisation.
Giornale italiano di nefrologia : organo ufficiale della Società italiana di nefrologia
Cardiovascular mortality and morbidity are higher in patients with chronic renal disease than in ... more Cardiovascular mortality and morbidity are higher in patients with chronic renal disease than in the general population. Patients with chronic renal disease are in the highest risk group for thromboembolic disease and many clinical trials have demonstrated the greater safety and efficacy of low-molecular-weight heparin (LMWH) versus unfractionated heparin (UFH). LMWH is cleared only by the kidneys while UFH is cleared by the renal and hepatic routes. Furthermore, LMWH has a significant accumulative effect in patients with impaired renal function (creatinine clearance <30 mL/min). The aim of this study was to evaluate the risk of bleeding when LMWH is used as an anticoagulant in hemodialysis or for treatment of acute thromboembolic disease in patients with renal failure. Twenty-one adult patients were enrolled, 13 with end-stage renal disease requiring chronic hemodialysis and 6 with acute thromboembolic disease and severe renal insufficiency (creatinine clearance <30 mL/min). ...
T regulator lymphocytes (Tregs) play a key role in the maintenance of immune tolerance and in the... more T regulator lymphocytes (Tregs) play a key role in the maintenance of immune tolerance and in the development of autoimmune diseases. Expression of Foxp3 is specific for Tregs, and can be used for the identification of these cells. This study investigated the variations of Tregs Foxp3+ in the kidney biopsies inflammatory infiltrate of different lupus nephritis classes compared to that of ANCA glomerulonephritis, acute tubulointerstitial nephritis and nephroangiosclerosis. Sections of paraffin-embedded tissue have been stained by immunohistochemistry with anti-CD3 and anti-FoxP3 antibodies. We find that the ratio of FoxP3+/CD3+ cells is significantly lower in patients with lupus nephritis class IV and in patients with vasculitides than in the course of nephroangiosclerosis, tubulointerstitial nephritis and lupus nephritis class V. The data presented herein demonstrate a decrease of FoxP3+ Treg cells in the inflammatory infiltrate of lupus nephritis, particularly during the most activ...
A young Caucasian male was admitted for claudication intermittens, hyposphygmia on the right lowe... more A young Caucasian male was admitted for claudication intermittens, hyposphygmia on the right lower limb, high blood pressure and deterioration of renal function. Instrumental investigations documented right renal artery stenosis, multiple steno-obstructive manifestations of the splanchnic artery system, occlusion of the right external iliac artery and dissection of the left superficial femoral artery. The patient had not been previously diagnosed with antiphospholipid syndrome. Subsequently, the vascular lesions, because of his thrombophilic state, needed endovascular treatment and anticoagulant therapy.
We analyzed the association between the renal arterial resistive index (RI) and the histologic fe... more We analyzed the association between the renal arterial resistive index (RI) and the histologic features of lupus nephritis. All consecutive patients with systemic lupus erythematosus (SLE) who required a kidney biopsy were enrolled. The study protocol included ultrasonographic assessment to measure the RI and kidney biopsy (International Society of Nephrology/Renal Pathology Society classification). A RI &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt; 0.7 was considered pathologic. Patients with non-renal SLE and healthy patients were studied as control groups. We enrolled 42 patients with renal SLE, 10 with non-renal SLE and 14 healthy patients: their mean (±standard deviation) RI values were 0.64 ± 0.08, 0.60 ± 0.04 and 0.59 ± 0.01, respectively (p = not significant). RIs &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt; 0.7 were recorded only in patients with renal SLE (5/42, 11.9%). The percentage of patients with a pathologic RI was significantly higher in class IV nephritis in comparison with other classes (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.009). In conclusion, we found a significant correlation between pathologic RI and class IV nephritis, suggesting a role for RI as a severity marker.
Patients with nephrotic syndrome are at increased risk for thromboembolic events such as deep ven... more Patients with nephrotic syndrome are at increased risk for thromboembolic events such as deep venous and arterial thrombosis, renal vein thrombosis and pulmonary embolism. This thrombophilic phenomenon has been attributed to a &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;hypercoagulable&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; state in which an imbalance between naturally occurring pro-coagulant/pro-thrombotic factors and anti-coagulant/antithrombotic factors promotes in situ thrombosis in deep veins or arteries. Management of thromboembolic events may be divided in prophylactic and therapeutic strategies. Hypoalbuminemia is the most significant independent predictor factor of thrombotic risk, especially for values &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;2 g/dL. However, the most important question in these patients is whether to anticoagulate prophylactically or not. The decision depends on type of glomerulonephritis, proteinuria severity, other predisposing factors and prior history of thrombosis. Reviewing the recent literature, we suggest the best therapeutic management of anticoagulation for patients with nephrotic syndrome, focusing on prophylactic strategies.
Ask-Upmark kidney is a rare diagnosis of segmental hypoplasia in pediatric population clinically ... more Ask-Upmark kidney is a rare diagnosis of segmental hypoplasia in pediatric population clinically characterized by severe hypertension potentially treatable with partial to total nephrectomy. Although originally was described only as a congenital anomaly, recent data suggest to be caused by vesicoureteral reflux, either in utero or in early childhood and pyelonephritis. The case we reported indicates that Ask-Upmark kidney should be considered as potential cause of hypertension and renal failure both in children and adults. The renal biopsy is necessary for early diagnosis and may consent to normalize blood pressure with nephrectomy; however, if renal damage is severe and progressive with tubulointerstitial nephritis, surgical management is excluded and renal transplant should be considered.
Patients with small vessel vasculitis present fluctuating antineutrophil cytoplasmic antibodies (... more Patients with small vessel vasculitis present fluctuating antineutrophil cytoplasmic antibodies (ANCA) levels to the point that positive ANCA may be missed even if only up to 10% of patients with microscopic polyangiitis (MPA) are ANCA-negative. The first-line treatment of MPA is the association of steroids and cyclophosphamide, especially in the presence of a rapidly progressive glomerulonephritis. Plasmapheresis, intravenous immunoglobulins, and tumor necrosis factor inhibitors have been proposed as alternative to standard therapy. Disseminated intravascular coagulation (DIC) is a possible event in the course of small vessel vasculitis. Gabexate mesylate is a protease inhibitor able to suppress endothelial cell injury, and it may be administered to treat DIC related to different diseases. In ANCA-associated vasculitis, cytokines play a key role in promoting endothelial damage. DIC-related thrombocytopenia may be misinterpreted as drug-induced because of the immunosuppressive properties of cyclophosphamide. Two cases of ANCA-positive MPA associated with DIC and treated with gabexate are reported in the literature with improvement of both hematological disorder and renal function. Our patient presented a rapidly progressive glomerulonephritis, and the renal biopsy showed MPA, in the absence of ANCA. After two weeks of steroid treatment, our patient developed a DIC. This case represents the first report of ANCA-negative MPA managed with gabexate, which showed improvement of coagulation disorders and kidney function. In conclusion, the anti-inflammatory properties of gabexate could be helpful in MPA at increased bleeding risk when immunosuppressive treatment is contraindicated, even in ANCA-negative vasculitis.
To investigate whether an imaging technique combining color Doppler ultrasonography and selective... more To investigate whether an imaging technique combining color Doppler ultrasonography and selective renal artery digital subtraction angiography reduces contrast requirements in patients with progressive renal insufficiency undergoing renal artery angioplasty and stenting. Eight patients (5 men; mean age 58 years) with renal artery stenosis and renal insufficiency underwent percutaneous transluminal angioplasty and stenting under color Doppler ultrasound guidance. Color Doppler ultrasound imaging yielded the information necessary for verifying catheter position, stent placement and expansion, and hemodynamics after revascularization. The combined imaging technique considerably reduced contrast requirements to only 10 mL in each case. No worsening of renal function was seen in any patient. The combined imaging procedure uses low doses of contrast agent and is especially suited to patients with renal dysfunction undergoing percutaneous renal revascularization.
A 55-year-old hypertensive female was referred for renal artery color Doppler examination because... more A 55-year-old hypertensive female was referred for renal artery color Doppler examination because of a suspicion of renovascular hypertension. Renal artery aneurysm was occasionally detected at the distal portion of the artery in the single left kidney, without the presence of stenosis. An aneurysm was confirmed via magnetic resonance angiography and arteriographical examination.
To evaluate the incidence of progressive renal damage in patients with chronic renal insufficienc... more To evaluate the incidence of progressive renal damage in patients with chronic renal insufficiency and renal-artery stenosis undergoing percutaneous transluminal angioplasty and stenting (PTA-stenting), color Doppler ultrasound (CDU)-guided, a procedure requiring low-contrast medium doses, or digital subtraction angiography were compared. Thirty patients with renal artery stenosis and severe renal insufficiency underwent PTA-stenting for revascularization, 15 patients with CDU guidance and 15 patients with standard selective digital subtraction angiography (SDSA). Serum creatinine (Cr) concentrations were compared in the two groups at 6 days and 12 months after revascularization. The stents were properly positioned and resolved the renal artery stenosis. None of the patients who underwent ultrasound-guided PTA-stenting had significantly increased Cr values (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;50% or &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;1 mg/dL) at 6 days after surgery (95% confidence interval (95% CI), 0-21.8); and none had progressive chronic renal insufficiency at 12 months. Conversely, six of the 15 patients in the group who underwent PTA-stenting with standard SDSA had significantly increased Cr values at 6 days (95% CI, 16.3-67.7) and two patients had progressive chronic renal insufficiency at 12 months. Our results suggest that PTA-stenting under CDU guidance, a procedure requiring low-contrast medium doses, is suitable for patients with severe renal dysfunction and especially for those with diabetes mellitus undergoing percutaneous renal revascularization.
Atherosclerotic ischemic renal disease is a frequent cause of end-stage renal failure leading to ... more Atherosclerotic ischemic renal disease is a frequent cause of end-stage renal failure leading to dialysis among the elderly; Its prevalence is inferred from autopsy or retrospective arteriographic studies. This study has been conducted on 269 subjects over 50 with hypertension and/or CRF, unrelated to other known causes of renal disease. All 269 patients were studied either by color-flow duplex sonography (n = 238) or by renal scintigraphy (n = 224), and 199 of the 269 patients were evaluated using both of these techniques. 40 patients, found to have renal artery stenosis (RAS), were subjected to 3D-contrast enhancement Magnetic Resonance Angiography (MRA) and/or Selective Angiography (SA). An additional 23 cases, negative both to scintigraphy and to ultrasound study, underwent renal angiography (MRA and/or SA). Color-duplex sonography, carried out in 238 patients, revealed 49 cases of RAS. MR or SA was carried out in 35 of these 49 patients, and confirmed the diagnosis in 33. Color...
Rhabdomyolysis is a syndrome due to a damage of skeletal muscle and the leakage of intracellular ... more Rhabdomyolysis is a syndrome due to a damage of skeletal muscle and the leakage of intracellular contents into the extracellular fluid and the circulation. Several causes may induce rhabdomyolysis and the major one is the crush syndrome. Most cases of non-traumatic rhabdomyolysis are related to drugs. Many molecules are subject to hepatic metabolism and the concomitant use of drugs, as statins, with other medications acting as substrates of the same isoenzymes can interact and increase the risk of myopathy. Subclinical rise of creatine kinase may be expression of rhabdomyolysis that can range even to medical emergency such as acute kidney injury (AKI), compartment syndrome, cardiac dysrhythmias and disseminated intravascular coagulopathy. The main pathophysiological mechanisms of myoglobinuric-related AKI are renal vasoconstriction, formation of intraluminal casts and direct cytotoxicity promoted by heme-protein. The aim of this review is to analyze the pathophysiology of myolysis, ...
The aim of our study was to investigate the plasma chromogranin A (CgA) and adrenomedullin (AM) l... more The aim of our study was to investigate the plasma chromogranin A (CgA) and adrenomedullin (AM) levels in patients with pheochromocytomas. We collected blood samples for measurement of plasma CgA and AM in 21 patients with pheochromocytomas, 43 healthy subjects and 26 patients with solid non-functioning adrenocortical adenomas. In 11 patients with pheochromocytomas plasma CgA and AM were measured again four weeks after tumor removal. CgA and AM were measured by means of a novel solid-phase two-site immunoradiometric assay based on monoclonal antibodies (CgA-RIA CT, CIS bio international) and by a specific radioimmunoassay (RIA, Phoenix Pharm. Inc.), respectively. The mean plasma CgA level (+/- SD) in patients with pheochromocytomas (204 +/- 147.9 ng/mL) was significantly higher (P < 0.001) than that in healthy subjects (41.6 +/- 10.7 ng/mL) and in patients with non-functioning adrenocortical adenomas (47.3 +/- 17.6 ng/mL). The mean plasma AM concentration (+/- SD) in patients wit...
Renal artery stenosis (RAS) is a known cause of hypertension and ischemic nephropathy. Stenting o... more Renal artery stenosis (RAS) is a known cause of hypertension and ischemic nephropathy. Stenting of the artery is a valid approach, in spite of cases of unexpected adverse evolution of renal function. In this study, 27 patients with unilateral RAS were subjected to stenting and followed for a period of one year, while 19 patients were observed while on medical treatment only. The group of 27 patients, 67.33 +/- 6.8 years of age, creatinine of 2.15 +/- 0.9 mg/dl, following stenting, were followed at intervals with biochemical tests, renal scintigraphy and doppler ultrasonography. The control group (70.0 +/- 6.1 years, creatinine 1.99 +/- 0.7 mg/dl) was also followed for one year. One year after stenting mean creatinine clearance (Ccr) increased from 36.07 +/- 17.2 to 40.4 +/- 21.6 ml/min (NS). Arterial BP, decreased after 1,3,6, and 12 months (p < 0.05). The number of antihypertensive drugs also decreased (p < 0.05). A significant increase in proteinuria was also observed. In th...
Aneurysms of tibial arteries are extremely rare. Here we report a case of a true posterior tibial... more Aneurysms of tibial arteries are extremely rare. Here we report a case of a true posterior tibial artery aneurysm in a young patient without any associated pathology and discuss surgical and endovascular treatment. A young Caucasian male was admitted to our department for painful and pulsatile swelling of the right calf. Colour Doppler ultrasound scan visualised an aneurysmal dilation of the posterior tibial artery. The patient had no trauma to the area and denied other history of vascular disease. Angio-CT and angio-magnetic resonance imaging showed a larger aneurysm compared to ultrasound scan. We performed an embolisation of the aneurysm because of the risk of rupture, as distal collateral circulation ensured foot vascularisation. Endovascular treatment of aneurysms of small arteries seems to be a safe therapeutic and non-invasive choice, particularly in young patients in whom the presence of collaterals guarantees distal vascularisation.
Giornale italiano di nefrologia : organo ufficiale della Società italiana di nefrologia
Cardiovascular mortality and morbidity are higher in patients with chronic renal disease than in ... more Cardiovascular mortality and morbidity are higher in patients with chronic renal disease than in the general population. Patients with chronic renal disease are in the highest risk group for thromboembolic disease and many clinical trials have demonstrated the greater safety and efficacy of low-molecular-weight heparin (LMWH) versus unfractionated heparin (UFH). LMWH is cleared only by the kidneys while UFH is cleared by the renal and hepatic routes. Furthermore, LMWH has a significant accumulative effect in patients with impaired renal function (creatinine clearance <30 mL/min). The aim of this study was to evaluate the risk of bleeding when LMWH is used as an anticoagulant in hemodialysis or for treatment of acute thromboembolic disease in patients with renal failure. Twenty-one adult patients were enrolled, 13 with end-stage renal disease requiring chronic hemodialysis and 6 with acute thromboembolic disease and severe renal insufficiency (creatinine clearance <30 mL/min). ...
T regulator lymphocytes (Tregs) play a key role in the maintenance of immune tolerance and in the... more T regulator lymphocytes (Tregs) play a key role in the maintenance of immune tolerance and in the development of autoimmune diseases. Expression of Foxp3 is specific for Tregs, and can be used for the identification of these cells. This study investigated the variations of Tregs Foxp3+ in the kidney biopsies inflammatory infiltrate of different lupus nephritis classes compared to that of ANCA glomerulonephritis, acute tubulointerstitial nephritis and nephroangiosclerosis. Sections of paraffin-embedded tissue have been stained by immunohistochemistry with anti-CD3 and anti-FoxP3 antibodies. We find that the ratio of FoxP3+/CD3+ cells is significantly lower in patients with lupus nephritis class IV and in patients with vasculitides than in the course of nephroangiosclerosis, tubulointerstitial nephritis and lupus nephritis class V. The data presented herein demonstrate a decrease of FoxP3+ Treg cells in the inflammatory infiltrate of lupus nephritis, particularly during the most activ...
A young Caucasian male was admitted for claudication intermittens, hyposphygmia on the right lowe... more A young Caucasian male was admitted for claudication intermittens, hyposphygmia on the right lower limb, high blood pressure and deterioration of renal function. Instrumental investigations documented right renal artery stenosis, multiple steno-obstructive manifestations of the splanchnic artery system, occlusion of the right external iliac artery and dissection of the left superficial femoral artery. The patient had not been previously diagnosed with antiphospholipid syndrome. Subsequently, the vascular lesions, because of his thrombophilic state, needed endovascular treatment and anticoagulant therapy.
We analyzed the association between the renal arterial resistive index (RI) and the histologic fe... more We analyzed the association between the renal arterial resistive index (RI) and the histologic features of lupus nephritis. All consecutive patients with systemic lupus erythematosus (SLE) who required a kidney biopsy were enrolled. The study protocol included ultrasonographic assessment to measure the RI and kidney biopsy (International Society of Nephrology/Renal Pathology Society classification). A RI &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt; 0.7 was considered pathologic. Patients with non-renal SLE and healthy patients were studied as control groups. We enrolled 42 patients with renal SLE, 10 with non-renal SLE and 14 healthy patients: their mean (±standard deviation) RI values were 0.64 ± 0.08, 0.60 ± 0.04 and 0.59 ± 0.01, respectively (p = not significant). RIs &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt; 0.7 were recorded only in patients with renal SLE (5/42, 11.9%). The percentage of patients with a pathologic RI was significantly higher in class IV nephritis in comparison with other classes (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.009). In conclusion, we found a significant correlation between pathologic RI and class IV nephritis, suggesting a role for RI as a severity marker.
Patients with nephrotic syndrome are at increased risk for thromboembolic events such as deep ven... more Patients with nephrotic syndrome are at increased risk for thromboembolic events such as deep venous and arterial thrombosis, renal vein thrombosis and pulmonary embolism. This thrombophilic phenomenon has been attributed to a &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;hypercoagulable&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; state in which an imbalance between naturally occurring pro-coagulant/pro-thrombotic factors and anti-coagulant/antithrombotic factors promotes in situ thrombosis in deep veins or arteries. Management of thromboembolic events may be divided in prophylactic and therapeutic strategies. Hypoalbuminemia is the most significant independent predictor factor of thrombotic risk, especially for values &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;2 g/dL. However, the most important question in these patients is whether to anticoagulate prophylactically or not. The decision depends on type of glomerulonephritis, proteinuria severity, other predisposing factors and prior history of thrombosis. Reviewing the recent literature, we suggest the best therapeutic management of anticoagulation for patients with nephrotic syndrome, focusing on prophylactic strategies.
Ask-Upmark kidney is a rare diagnosis of segmental hypoplasia in pediatric population clinically ... more Ask-Upmark kidney is a rare diagnosis of segmental hypoplasia in pediatric population clinically characterized by severe hypertension potentially treatable with partial to total nephrectomy. Although originally was described only as a congenital anomaly, recent data suggest to be caused by vesicoureteral reflux, either in utero or in early childhood and pyelonephritis. The case we reported indicates that Ask-Upmark kidney should be considered as potential cause of hypertension and renal failure both in children and adults. The renal biopsy is necessary for early diagnosis and may consent to normalize blood pressure with nephrectomy; however, if renal damage is severe and progressive with tubulointerstitial nephritis, surgical management is excluded and renal transplant should be considered.
Patients with small vessel vasculitis present fluctuating antineutrophil cytoplasmic antibodies (... more Patients with small vessel vasculitis present fluctuating antineutrophil cytoplasmic antibodies (ANCA) levels to the point that positive ANCA may be missed even if only up to 10% of patients with microscopic polyangiitis (MPA) are ANCA-negative. The first-line treatment of MPA is the association of steroids and cyclophosphamide, especially in the presence of a rapidly progressive glomerulonephritis. Plasmapheresis, intravenous immunoglobulins, and tumor necrosis factor inhibitors have been proposed as alternative to standard therapy. Disseminated intravascular coagulation (DIC) is a possible event in the course of small vessel vasculitis. Gabexate mesylate is a protease inhibitor able to suppress endothelial cell injury, and it may be administered to treat DIC related to different diseases. In ANCA-associated vasculitis, cytokines play a key role in promoting endothelial damage. DIC-related thrombocytopenia may be misinterpreted as drug-induced because of the immunosuppressive properties of cyclophosphamide. Two cases of ANCA-positive MPA associated with DIC and treated with gabexate are reported in the literature with improvement of both hematological disorder and renal function. Our patient presented a rapidly progressive glomerulonephritis, and the renal biopsy showed MPA, in the absence of ANCA. After two weeks of steroid treatment, our patient developed a DIC. This case represents the first report of ANCA-negative MPA managed with gabexate, which showed improvement of coagulation disorders and kidney function. In conclusion, the anti-inflammatory properties of gabexate could be helpful in MPA at increased bleeding risk when immunosuppressive treatment is contraindicated, even in ANCA-negative vasculitis.
To investigate whether an imaging technique combining color Doppler ultrasonography and selective... more To investigate whether an imaging technique combining color Doppler ultrasonography and selective renal artery digital subtraction angiography reduces contrast requirements in patients with progressive renal insufficiency undergoing renal artery angioplasty and stenting. Eight patients (5 men; mean age 58 years) with renal artery stenosis and renal insufficiency underwent percutaneous transluminal angioplasty and stenting under color Doppler ultrasound guidance. Color Doppler ultrasound imaging yielded the information necessary for verifying catheter position, stent placement and expansion, and hemodynamics after revascularization. The combined imaging technique considerably reduced contrast requirements to only 10 mL in each case. No worsening of renal function was seen in any patient. The combined imaging procedure uses low doses of contrast agent and is especially suited to patients with renal dysfunction undergoing percutaneous renal revascularization.
A 55-year-old hypertensive female was referred for renal artery color Doppler examination because... more A 55-year-old hypertensive female was referred for renal artery color Doppler examination because of a suspicion of renovascular hypertension. Renal artery aneurysm was occasionally detected at the distal portion of the artery in the single left kidney, without the presence of stenosis. An aneurysm was confirmed via magnetic resonance angiography and arteriographical examination.
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