No abstract

Atheroembolic renal disease is caused by foreign-body reaction to cholesterol crystals flushed from the atherosclerotic plaques into the small-vessel system of the kidneys. It is an underdiagnosed entity, mostly related to vascular procedures and/or anticoagulation, and prognosis is considered to be poor. Besides the benefit of aggressive medical prevention of further embolic events, use of steroid therapy has been associated with greater survival. Here we report a case of a patient with a multisystemic presentation of the disease days after performance of percutaneous coronary intervention and anticoagulation initiation due to an episode of myocardial infarction. Renal, cutaneous, ophthalmic, neurological, and possibly muscular and mesenteric involvement was diagnosed. Although medical treatment with corticosteroids and avoidance of further anticoagulation was applied, the patient rapidly progressed to end-stage renal disease requiring hemodialysis and died 6 months after diagnosis. This is a case of catastrophic progression of the disease resistant to therapeutic measures. Focus on diagnosis and more efficient preventive and therapeutic protocols are therefore needed.

In alkaptonuria, deficiency of homogentisate 1,2-dioxygenase leads to the accumulation of homogentisic acid (HGA) and its metabolites in the body, resulting in ochronosis. Reports of patients with alkaptonuria who have decreased kidney function are rare, but this seems to play an important role in the natural history of the disease.We describe a 68-year-old female with chronic kidney disease (CKD) of unknown etiology who started peritoneal dialysis (PD) after 5 years of follow-up and who was diagnosed with alkaptonuria at this time. Progressive exacerbation of ochronotic manifestations had been noted during these last few years, as kidney function worsened. After PD initiation, the disease continued to progress, and death occurred after one year and a half, due to severe aortic stenosis-related complications. Her 70-year-old sister was evaluated and also diagnosed with alkaptonuria. She had no renal dysfunction. Higher HGA excretion and significantly milder ochronosis than that of her sister were found.We present two alkaptonuric sisters with similar comorbidities except for the presence of CKD, who turned out to have totally different evolutions of their disease. This report confirms that kidney dysfunction may be an important factor in determining the natural history of alkaptonuria.

The cardiorenal syndrome (CRS) is a pathophysiological condition characterized by a simultaneous combination of cardiac and renal dysfunction. When diuretic resistance occurs, fluid removal by ultrafiltration (UF) is beneficial. However, in progressive CRS type II multiple hospitalizations for intravenous therapy or extracorporeal UF due to recurrent decompensations have important implications in the deterioration of quality of life and in the use of hospital resources. Peritoneal daily sustained UF appears to be a good therapeutic tool for the chronic ambulatory management of these patients avoiding the risks of a central venous access, aggressive volume shifts and the circulatory stress of the extracorporeal techniques. Controversies on the results of peritoneal dialysis in cardiorenal patients are mostly dependent on therapy skills since individuals with heart failure have a narrower window of tolerance, presenting significant complications even in presence of small deviations from optimal fluid balance. The updated use of volume monitoring tools is recommended. Multifrequency bioimpedance allows detailed information on the total body water overload and, more importantly on the extracellular/intracellular water distribution. This is an instrument that can be longitudinally used to improve the accuracy of clinical judgment concerning volume status. Incremental PD with use of icodextrine besides the promising role of low sodium solutions and bimodal solutions are therapy issues that can improve clinical outcomes of cardio-renal patients under peritoneal dialysis, as a home-based continuous therapy.

<b><i>Introduction:</i></b> Exit-site infection (ESi) prevention is a key factor in lowering the risk of peritonitis. This study aimed to evaluate the associations between exit-site (ES) care protocols and the annual incidence rates of ESi and peritonitis in Portugal. <b><i>Methods:</i></b> We performed a national survey using two questionnaires: one about the incidence of catheter-related infections and the other characterizing patients’ education and ES care protocols. <b><i>Results:</i></b> In 2017 and 2018, 14 Portuguese units followed 764 and 689 patients. ESi incidence rate was 0.41 episodes/year, and the peritonitis incidence rate was 0.37. All units monitor catheter-related infections on a yearly basis, use antibiotic prophylaxis at the time of catheter placement, and treat nasal carriage of <i>S. aureus</i>, although with different approaches. Screening for nasal carriage of <i>S. aureus</i> is performed by 12 units, and daily topical antibiotic cream is recommended by 6 out of 14 of the units. We did not find statistical differences in ESi/peritonitis, comparing these practices. The rate of ESis was lower with nonocclusive dressing immediately after catheter insertion, bathing without ES dressing, with the use of colostomy bags in beach baths and was higher with the use of bath sponge. The peritonitis rate was lower with bathing without ES dressing and if shaving of the external cuff was performed in the presence of chronic ESi. <b><i>Conclusions:</i></b> We found potential proceedings associated with ESi and peritonitis. A regular national audit of peritoneal dialysis units is an important tool for clarifying the best procedures for reduction of catheter-related infections.