Thromboangiitis obliterans (Buerger'€™s disease) represents an inflammatory disease of limbs'€™ small arteries and veins causing vascular thrombosis, and partial or total obstruction. It affects mostly male gender aged 40 years old. The peculiarity of our case is underlined by presenting a 62 years, chronic tobacco user and not compliant female patient known with thromb oangiitisobliterans for almost 15 years. The arteriographic and clinical features with concomitant and sever affected upper and lower limbs are highly suggestive, emphasizing the possibility of Buerger'€™s disease development even in female patients.

Introduction. Arterial stiffness and vascular calcifications are independent predictors of cardiovascular morbidity and mortality in the chronic kidney disease (CKD) stage 5D population. According to the guidelines, patients on renal replacement therapy represent a very high cardiovascular risk class. Case report. We report the case of a 67-year-old hypertensive male patient, known with CKD stage 5D on hemodialysis (three times per week), secondary bone mineral disease, admitted for progressive right leg pain. The physical examination detected right dorsalis pedis artery pulse absence. Blood biochemistry emphasized hypercalcemia, hyperphosphatemia, increased alkaline phosphatase, metabolic acidosis, hypoalbuminemia, iPTH values above upper limits. The X-ray of right shin highlighted a vascular calcification with a “train track” aspect on the tibial-peroneal artery trunk and the thoracic X-ray (performed with low ray regime) showed calcium deposits in coronary arteries walls. Legs arteriography and coronary angiography were performed revealing multiple lesions on investigated vessels with an 80% narrowing of right coronary artery. The particularity of the case lies in the absence of angina in a chronic hemodialysis patient in whom multiple significant angiographically stenosis of the coronary arteries were found and successful endovascular therapy was performed. Conclusion. The broadening of the indication for coronary angiography should be considered in certain asymptomatic CKD stage 5D patients based on a risk score involving calcium, phosphate, PTH and acid-base imbalances, while considering their major influence on the structure and tone of vascular walls thus on cardiovascular morbidity and mortality rates. Abbreviations. ABI = ankle-brachial index,CAD = coronary artery disease,CKD = chronic kidney disease,CT = computed tomography, EBCT = electron-beam computed tomography,ESRD = end-stage renal disease,GFR = glomerular filtration rate,iPTH = intact parathormon,PCI = percutaneous coronary intervention

The stress a patient is subjected to during dialysis treatment can be reduced by using a synergetic approach by the medical team. The integration into therapy of the positive psychical resources such as: active positive coping mechanisms, individual or family mental resilience, improvement of the image and self-esteem, better tolerance to frustration can represent an important part in the improvement of the patient's quality of life, determination of a positive approach of the situations both for him and close friends and relatives.

The aim of this case report was to evaluate the feasibility of in vivo acquisition of microscopic images using fluorescent CD105 antibodies for molecular imaging in human colorectal cancer. After excluding the presence of tissue autofluorescence, the antibody solution was topically administered through a spray-catheter. The targeted area was analyzed by eCLE and images were recorded. The fractal dimension of tumor vessels and the vessel density were determined using ImageJ software. Immunohistochemistry was used as a gold standard. In vivo CLE analysis of CD105 expression enabled the study of tumor vascular network, revealing a chaotic structure.

BACKGROUND:Patients with stage 5 chronic kidney disease (CKD) begin chronic hemodialysis with variable diuresis levels correlated to a comparable low glomerular filtration rate. Residual diuresis influences long-term evolution of the hemodialyzed patient, modifying the prognosis even if optimal Kt/ V is achieved.AIM OF THE STUDY:The present study emphasizes the main determining factors of diuresis in a cohort of stage 5 CKD subjects at the beginning of hemodialysis.MATERIAL AND METHODS:216 patients with stage 5 CKD starting chronic hemodialysis were included in the study, and were grouped according to their residual diuresis: group A (urine output ≤ 500 mL/ day); group B (urine output between 500-1200 mL/ day); group C (urine output ≥ 1200 mL/ day).RESULTS:Glomerular etiology, cardiac systolic dysfunction, severe malnutrition, emergency dialysis initiation and lack of permanent vascular access were proved to be associated with significant low diuresis. Age, gender, estimated glomerular filtration rate (GFR) and the presence of systemic hypertension did not influence the amount of daily diuresis.CONCLUSIONS:In CKD stage 5 patients, residual diuresis presents large variations in conditions of comparable low GFR. Factors influencing residual diuresis may be distinct from those that influence residual GFR.

Introduction and Aims: Acute kidney injury (AKI) is an important public health problem.AKI is a risk factor for progression of kidney disease, incidence of chronic kidney disease (CKD) and mortality.The aim of the study was to assess characteristics, renal survival and mortality of patients who developed AKI stage 3, according to KDIGO guidelines, and needed renal replacement therapy (RRT), not in intensive care unit.Methods: All patients who required RRT due to AKI stage 3 along two years were included, excluding patients in intensive care unit.Demographic and personal history data, previous renal function, cause of AKI, renal function, renal survival, and mortality at one, three, six and twelve months after AKI were recorded.Results: A total of 107 patients were enrolled (incidence 134 patients/106 population/ year).Mean age 72.2±13.9(range 25-92), 57.9% men.Patient's characteristics: 77.6% were hypertensive, 40.2% were diabetics, 45.8% were dyslipemics, 41.1% were obese, 27.1% were smokers, and 61.2% with chronic renal failure (eFG<60mil/min) of which 54% stage 3, 36.5% stage 4, and 9.5% stage 5. Cause of AKI: renal disease 63.6%, prerrenal 28.9% and obstructive causes 7.5%.Renal function: Serum creatinine before AKI 1.78±1.12mg/dL; maximum serum creatinine during AKI hospitalization 7.39 ±4.43mg/dL; at discharge, 2.64±1.62mg/dL;one month later, 2.07±1.36mg/dL;three months later, 2.35±1.60mg/dL;six months later, 2.25±1.85mg/dLand one year later, 1.95±1.14mg/dL.During hospitalization, 24.3% died, 16.8% kept on RRT at discharge, and 58.9% recovered partial or completely renal function.One month after AKI, 31.7% had died, 15.8% kept on RRT, and 52.5% preserved renal function, 5.6% was missing.Three months later, 45.7% died, 10.9% kept on RRT, and 43.5% preserved renal function, 14% was missing.Six months later, 48.3% had die, 10% kept on RRT, and 33.3% preserved renal function, 8.3% were missing.Finally, one year after AKI, 71.8% of patients had died, 9.9% needed RRT, 18.3% recovered partial or completely renal function and 33.6% missing.AKI in diabetic or dyslipemic patients has an increased mortality ( p=0.03 and p=0.06 respectively).CKD before AKI is not associated with increased mortality.Renal function according to KDOQI classification of patients who had AKI stage 3 was: at discharge: stage 1 1.6%, 2 16.1%, 3 24.2%, 4 37.1% and 5 21.0%; three months after AKI : stage 1 2.5%, 2 15%, 3 30%, 4 32.5% and 5 17.5%; six months after AKI: 1 6.5%, 2 12.9%, 3 38.7%, 4 19.4% and 5 19.4% and one year after AKI, renal function was: 2 25%, 3 41.7%, 4 25% and 5 8.3%.Conclusions: In our health area AKI stage 3 requiring RRT have a incidence similar to other studies.Mortality in AKI patients exceeds 70% one year after AKI episode and renal survival decreases in this period.Nephrology follow-up must be established in patients who survive AKI.The develop of tools to identify high-risk patients and to promote renal recovery is important to reduce burden of CKD and mortality.

Introduction and Aims: Although some guidelines recommend salt restriction, few studies have examined the association between salt restriction and clinical outcomes in hemodialysis (HD) patients.Methods: We conducted a retrospective cohort study of 88,115 adult patients enrolled in the Japanese Society for Dialysis Therapy (JSDT) registry ( 2008) who had received HD for at least two years and were considered anuric.The primary outcome measure was all-cause mortality at one year, and the secondary outcome was cardiovascular (CV) mortality.Estimated salt intake was the main predictor, and was calculated from interdialytic weight gain and pre-and postdialysis serum sodium levels according to the validated method of Kimura and Ramdeen.Nonlinear logistic regression was used to determine the association of salt intake with mortality, adjusting for age, gender, body mass index, vintage of HD, dialysis time, Kt/V, protein catabolic rate normalized to body weight, comorbid conditions, type of vascular access, serum potassium, phosphate, calcium, CRP level, and endotoxin level in dialysate.Cubic splines were plotted and the reference was median salt intake.Salt consumption was categorized by intake levels of 2 g per day and the association with mortality examined.Results: Median [25th-75th percentile] salt intake at baseline was 6.4 [4.6-8.3]g per day.At one year, all-cause mortality occurred in 1,845 (2.1%) patients, including cardiovascular mortality in 821 (0.9%).We observed an association between low salt intake and clinical outcomes (all-cause and CV mortality) (Fig. 1).We observed the highest all-cause mortality in the low salt group (<6g/day) (Fig. 2), and no association between all-cause mortality and high salt intake.Further, we observed similar associations between salt intake and CV mortality.Conclusions: Low salt intake is associated with all-cause and CV mortality.These findings do not support current clinical guidelines, which recommend restricting salt intake to less than 6g per day.

Introduction:Depression represent an important and predictable complication in chronic haemodialysis.Objectives:The prevalence of depression, QoL indicators, correlations between number of years of hemodialysis, depression and quality of life.Aims:To determine if higher depressive levels are correlated with years spent on haemodialysis.Methods:We used Beck questionnaire two times, one at the beginning of the year, and one at the end for 102 patients, excluding diabetes, who were undergoing hemodialysis three times a week, for 4 hours and SF 36 questionnaire. We considered these values for depression: Normal: 0-10, Mild: 11-15, Moderate: 16-23, Severe: 24-63 according to Romanian Guidelines in Nephrology.Results:98 pacients answered to the Beck questionnaire. Years of haemodialysis: min=0.25, max=18, average=5.7, standard deviation= 4.37 (n=102). SF 36 has close values distributed between the intervals 80-100, 60-80, < 60%. The linear correlation between average depression and years of hemodialysis is very, very weak, square of the coefficient of regression is 0.00- (by the linear model we can explain < 0.1% of the dates) and also between SF36 total and years of hemodialysis:square of the coefficient of regression is 0.04- (by the linear model we can explain 4% of the dates). We followed other models (logaritmic, polinomial, exponential), for both correlations, but we couldn’t notice better results.Conclusions:The study proved high levels of mild depression, lack of linear correlation between years of haemodialysis, depression and QoL indicators. Although this, there is an influence of time spent in haemodialysis and QoL.

UNLABELLED:Metabolic acidosis slowly develops during renal impairment natural evolution towards ESRD and represents an important contributing factor of CKD progression. Although, several clinical and experimental trials reported the major impact of metabolic acidosis on CKD evolution, the pathophysiology mechanism remains a matter of debate. Furthermore, international guidelines do not impose a specific treatment scheme for metabolic acidosis in CKD patients, and metabolic acidosis is not fully compensated once hemodialysis starts. Therefore, the aim of our study was to determine an adequate follow-up of metabolic acidosis therapy benefits and risks in HD patients.PATIENTS AND METHODS:164 HD patients were evaluated according to the following protocol: bioumoral laboratory tests, the measure of different important parameters (residual diuresis, UF, BP, LVMI, volemia status). The assessed data were statistic analyzed using non-paired Student's t-test for continuous variables and chi-square (χ²) test for qualitative parameters (p-value <0.05 was considered statistically significant).RESULTS:HD individuals were followed-up depending on their predialysis-alkaline reserve value. After therapy started, predialysis-alkaline reserve mean level increased from 19.4 mEq/L to 22.6 mEq/L (p<0.001). Furthermore, we observed a significant decrease of nitrogenous waste products values (T=10.87<1.66) and intradialytic hypotension events (p<0.001).CONCLUSIONS:Our findings emphasize the beneficial effects of correcting metabolic acidosis using the proposed treatment scheme with direct impact on hemodynamic status improvement.

In the present article, we discuss the case of 67-year-old female patient diagnosed with inferior limbs calciphylaxis and hemodialyzed since 2006. The clinical manifestations and pathological lab findings are typical for this rare and extremely severe complication in chronic hemodialyzed individuals. The favorable treatment response to sodium thiosulfate, not often used as elected therapy in international studies, represents the particularity of the case.

Introduction and Aims: Stroke remains a major cause of disability and mortality in hemodialysis [HD] patients with studies deriving predominantly from US & Japanese cohorts.By contrast the worldwide variability in stroke epidemiology is poorly characterized and associations between treatment parameters and stroke are not well explored.Methods: The MONitoring Dialysis Outcomes [MONDO] consortium consists of HD databases from Renal Research Institute [RRI] clinics in the US, Fresenius Medical Care [FMC] clinics in Europe, Asia Pacific [AP], Latin America [LA], KfH clinics in Germany, Imperial College in UK, Hadassah Medical Center in Israel, and University of Maastricht, Netherlands [Usvyat et al, Blood Purif 2013].Databases from RRI, FMC Europe [17 countries] & FMC Latin America [FMC LA, 5 countries] identified all patients with in-center treatments [1/2000-12/2012] who survived ≥12 months on HD.Only those with ≥1 all-cause hospitalizations were included [assuring proper recording] and hospitalizations for stroke were studied.The mean of clinical & laboratory parameters were computed for the whole patient exposure time.Results: We studied 27,252 patients [FMC Europe n=14,742; FMC LA n=6,890; RRI n=5,620].Overall 2% of the cohort [n=575] experienced stroke events [Table 1; p-values shown if <0.1].Older age, cerebrovascular comorbidity, higher mean pre-dialysis systolic blood pressure [SBP] and variability in SBP, and lower serum creatinine levels were associated with stroke across all databases.Diabetes was associated with stroke in Latin America & RRI but not in Europe.Lower IDWG was associated with stroke in Europe & Latin America but not in the US.Albumin and nPCR appeared to be lower in the patients with stroke events although not always significant.Conclusions: Higher predialysis SBP variability is associated with stroke on HD populations suggesting a potential role for cerebral perfusion instability.We confirm known associations between age, diabetes, pre-existent cerebrovascular disease and hypertension.In contrast to studies in non-dialysis patients we do not find an association between EPO dose and stroke.Interventional trials of blood pressure management on stroke are recommended.

Videocapsule endoscopy (VCE) can identify lesions in the small bowel which would otherwise be hard to detect. We have selected 53 patients with digestive symptoms in which upper and lower endoscopy had provided no findings. Patients were classified into three groups, based on their main indication for VCE exploration: group one obscure gastrointestinal bleeding (OGIB); group two unspecific abdominal symptoms; group 3 monitoring of a prior known pathology. We found that VCE has high predictive values, sensibility and specificity in the diagnosis of OGIB. VCE was also useful in the detection and extent evaluation of lesions in Crohn’s and celiac disease. VCE is also able to detect tumors of the small bowel with sufficient accuracy, and can be used to monitor patients with hereditary pre-malignant diseases such as FAP. There were few light adverse effects and no major complications. We conclude that VCE is a safe and effective procedure for the detection of small bowel lesions.

Introduction and Aims: Chronic kidney disease (CKD) is associated with a large range of metabolic alterations among which insulin resistance and dyslipidemia are well-documented features of renal failure.Numerous studies point toward an important role of ectopic fat accumulation in the pathophysiology of type 2 diabetes and cardiovascular disease.Many data from literature indicated a positive correlation between visceral tissue mass and insulin resistance both in diabetic patients than in CKD patients reinforcing the idea that the adipose tissue could be a source of metabolic disturbances in CKD patients.We hypothesize that a phenomenon of lipotoxicity and ectopic fat redistribution could begin at an early stage of kidney disease as a result of early adipocyte dysfunction and be responsible for the insulin-resistance associated to CKD.Methods: C57BL/6 mice underwent a 5/6 nephrectomy and were compared to pair fed sham-operated mice.Mice had free access to water with 80mM Na2CO3 to prevent acidosis.Insulin sensitivity was estimated through intra-peritoneal insulin (ipITT) and glucose tolerance (ipGTT) tests.Anthropometric (body weight, lean and fad pad mass) and metabolic parameters (glycemia, insulin, cholesterol, triglycerides) were measured.The phosphorylation of a key protein of insulin signaling pathway ( protein kinase B, PKB/Akt) was studied by Western blot after ex-vivo insulin stimulation (100nM, 30 min) of gastrocnemius muscle.The intra-muscular and intra-hepatic lipids were extracted using Chloroform-Methanol (2:1, v/v).Results: The CKD mice exhibited a marked decrease in insulin sensitivity (-76%, p<0.01) and altered glucose tolerance (+24%, p<0.001).CKD mice exhibited a profile of insulin resistance with hyperglycemia (84±3 vs 97 ±5 mg/dl, +16%, p<0.05), hyperinsulinemia (11±6 vs 60 ±11 pg/dl +455%, p<0.05), hypertriglycidemia (70±5 vs 118 ±12 mg/dl +67%, p<0.05), hypercholesterolemia (64±4 vs 123±11 mg/dl +79%, p<0.05).CKD mice exhibited a significant decrease in white adipose tissue accretion (-57%, p< 0.001) associated with increased muscle (+138%, p <0.05) and liver (+38%, P <0.05) lipid contents compared to sham-operated mice.The CKD mice presented a blunted insulin-induced Akt phosphorylation (-34%, p< 0.05) in gastrocnemius muscle.Conclusions: In subtotally nephrectomized mouse model we showed an ectopic intramuscular and intrahepatic lipid redistribution concomitant with insulin resistance.Insulin resistance and lipotoxicity may represent the missing links (beyond the classical cardiovascular risk factors) that may help explain the increased risk of cardiovascular disease in CKD.Further studies are however needed to thoroughly decipher the molecular mechanisms linking this ectopic lipid accumulation and the associated insulin resistance and to also assess the role of adipose tissue dysfunction in the altered fat distribution.