Background pacemaker (PMK) implantation is a routinary procedure although it isn’t free from complications, some of with could be life–treathing. Case report: A female 84 years old with hypertensive cardiomiopathy and atrial fibrillation on anticoagulation theraphy with Dabigatran was subjected on a pacemaker implantation (29th Sept) for sick sinus syndrome (SSS) after syncope. The day after the implantation a chest radiography showed a left–apical pneumothorax (PNX) without necessity of surgical drain (fig. 1). Few days after (3th Oct) patient showed dyspnoea, desaturation and pain on left hemithorax so a chest CT was performed with detection of massive hydropneumothorax needed surgical drain. After 5 days a check CT was performed (9th Oct) showing resolution of the PNX but documented a circumferential 30 mm pericardial effusion “worthy of cardiological reevalutation” meanwhile the patient was hemodynamically stable. At echocardiographic look there was a pericardial effusion of 15 mm. After the re–evalutation of the CT imeges by a cardiologist, in the suspicion of myocardial perforation, patient were centralized in a cardio–surgery center. Transesophageal echocardiography evidenced a pericardial effusion of 19 mm with initial signs of haemodynamic impact and visualization of the lead in the percardual sac by 15 mm. The patient underwent (11th Oct) extraction of the ventricular lead in median sternotomy and epicardial reimplantation in a hybrid arrhythmological and cardiosurgery operating theater. Conclusions cardiac perforation and PNX are two serious but rare complication of PMK implantation with an incidence of 0,1% and 1%, but only anecdotally described together in the literature. The initial finding of PNX which was attributed the syntomatology was a confounding factor that delay the diagnosis of miocardial perforation. The unavailability of a programmer for interrogating the device didn’t allow early documentatio of the alteration of the electrical parameters. In the first CT of 3th Oct no pericardial effusion were reported but, from a retrospective analysis the images were alredy suggestive while they leave no doubts in the second radiological examination (fig 2,3).

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Introduction Chronic kidney disease (CKD) has become a health concern with an extensive burden on incidence and prognosis. While the increasing lifespan contributes to a higher incidence of CKD among the elderly, the diagnostic picture in this age group is complicated by senescence-related changes. A better understanding of the etiology and progression of the disease warrants renal biopsy in such patients. This study aims to explore the histopathological spectrum of native renal biopsies leading to CKD in elderly patients in a tertiary care hospital. Methods Among the list of patients who had undergone renal biopsy at our institute from January 2015 to March 2020, elderly patients aged ≥ 60years were chosen for this study. Their demographic details, lab investigations and histopathological reports were collected. The sex distribution and prevalence of different renal diseases was calculated. The subjects were classified into four broad diagnostic groups - primary glomerular disease, diabetic nephropathy, hypertensive nephropathy, and tubulointerstitial disease. The estimated glomerular filtration rate (eGFR) values were calculated and used to stage chronic kidney disease in these patients. Statistical analysis was carried out to find a correlation between diagnostic groups and CKD presence and between serum C3 values and immunofluorescence for the same on biopsy. Results One hundred thirty-two patients formed the study sample with a male to female ratio of 1.28:1, showing a slight male predominance. The most common diagnostic group was primary glomerular disease (46%), among which focal segmental glomerulosclerosis (FSGS) was the most common entity (12%). 47.7% and 66.6% of patients in the study sample showed elevated serum blood urea nitrogen (BUN) and creatinine values, respectively. 86% of our study sample had low eGFR values, and the majority (35%) of the patients were classified under CKD stage 3. CKD incidence was high among patients with primary glomerular diseases, but no significant statistical correlation was found. 43.5% of all IF positive cases showed low serum C3 values and established a positive correlation between IF and serum C3 values. Conclusion There is no statistically significant correlation of the four diagnostic groups to the CKD. CKD in the elderly may be multifactorial, and a collaborative study across the nations may be needed to further evaluate the etiology.