Acute pyelonephritis (APN) is a common disease which rarely evolves into abscesses.
We prospectively collected clinical, biochemical and radiological data of patients hospitalized with a diagnosis of ...APN from 2000 to 2008.
Urinary culture was positive in 64/208 patients (30.7%) and blood cultures in 39/182 cases (21.4%). Two hundred and thirteen patients were submitted to computed tomography (CT) or nuclear magnetic resonance (NMR): confirmation of APN was obtained in 196 patients (92%). Among these, 46 (23.5%) had positive urine culture, 31 (15.8%) had positive blood culture and 15 (7.6%) had positive cultures of both urine and blood. In 98 patients, either urine or blood cultures were negative, but CT/NMR were positive for APN. Fifty of the 213 patients submitted to CT/NMR (23.5%) had intrarenal abscesses: only 2 were evidenced by ultrasound examination. No differences were found between patients with positive or negative CT with regards to fever, leucocytosis, C-reactive protein, pyuria, urine cultures and duration of symptoms before hospitalization. No differences were found between patients with or without abscesses with regards to these parameters and risk factors. Patients with abscesses had a longer duration of treatment and hospitalization.
Our data suggest that in APN it is not always possible to routinely document urinary infection in a clinical setting. This finding could be explained by previous antibiotic treatment, low bacterial growth or atypical pathogens. Systematic CT or NMR is necessary to exclude evolution into abscesses, which cannot be suspected on clinical grounds or by ultrasound examination and may also develop in the absence of risk factors.
An increase in mortality due to accelerated atherosclerosis has been reported in patients affected with Systemic Lupus Erythematosus (SLE). Anti-phospholipid antibodies (aPA) may play a pathogenetic ...role in the development of atherosclerosis. We measured carotid intima-media thickness (IMT), as a surrogate parameter of atherosclerosis, by B-mode ultrasound examination in 42 patients affected with SLE (11 men and 31 women) and in 42 healthy age- and sex-matched subjects. Lupus Anticoagulant (LA) (APTT sensitive, silica clotting time, DRVVT), Anti-cardiolipin antibodies (ACA) IgG and IgM, anti-β2glycoprotein 1 (anti-β2GP1) IgG and IgM and anti-prothrombin (anti-PT) IgG and IgM in ELISA (Orgentec Bouty) were also detected. IMT was 0.538±0.128 mm (0.310–0.866 mm) in SLE vs 0.473±0.084 mm in healthy subjects (-p 0.003–). IMT correlated with patients’ age (p<0.005) and with C Reactive Protein (CRP) (p<0.005), but not with years of disease, hypertension, number of anti-hypertensive drugs, total cholesterol, serum creatinine and proteinuria. Sixteen patients (38%) had aPL: 12 LA, 6 ACA IgG, 4 ACA IgM, 4 anti-β2GP1 IgG, 3 anti-β2GP1 IgM, 2 anti-PT IgG and 1 anti-PT IgM. IMT was not statistically correlated with aPA. Positive and negative aPA patients only differed as regards glomerular filtration rate (76 ml/min vs 113 ml/min - p<0.01–). Frequency of aPA positivity was 50% in Patients with IMT >0.600 mm and 33.3% in those with IMT <0.600 mm. If LA positivity was considered separately, it was 41.6% in patients with IMT >0.600 mm and 23.3% in patients with IMT <0.600 mm. Among the 5 patients with IMT >0.7 mm, 2 had LA positivity (40%) vs 10/37 (27%) of those with minor carotid thickness. In conclusion, IMT, a surrogate parameter of atherosclerosis, was correlated with Patients’ age and CRP and not with presence of aPA, even though, in the group of patients with greater IMT, there was a non-significant higher proportion of positivity for anti-phospholipid antibodies, in particular for Lupus Anticoagulant.
The purpose of this study was to assess the management of both hypertension and micro/macroalbuminuria in a cohort of type II diabetic patients. In the first 6 months of the year 2000, 5815 diabetic ...patients were identified through prescriptions for antidiabetic drugs in our sanitary district (191 568 inhabitants). In all, 65% (3810) of these type II diabetic patients were also given prescriptions for antihypertensive drugs. A total of 400 diabetic patients were randomly selected and 171 entered the study (gender: 94/77 M/F; age: 66.6+/-8 years; diabetes duration: 12+/-9 years): 100 patients (group DT) were treated with antihypertensive drugs and 71 (group DU) were untreated. Blood pressure, urine albumin-to-creatinine ratio (ACR), and glycated haemoglobin were measured in the two groups. A total of 80% (57/71) of DU patients were hypertensive (BP>/=130/85 mmHg). Specifically, 24.4% had diastolic hypertension (BP>/=85 mmHg) and 79% systolic hypertension (BP>/=130 mmHg). Only 63% (100/157) of the hypertensive patients were treated with antihypertensive drugs (two drugs/patient on average, range 1-5). In addition, only 13% of the DT patients were adequately controlled (BP<130/85 mmHg), while the others had above target blood pressure levels (14%: 130-139/85-89 mmHg; 40%: 140-159/90-95 mmHg, and 33%>/=160/95 mmHg). Angiotensin converting enzyme inhibitors (ACE-I) and angiotensin receptor blockers (ARB) were included in the antihypertensive medical regimen in 70% of the DT patients (ACE-I: 62%; ARB: 8%; diuretics: 39%; dihydropyridine calcium antagonists: 38%; alpha-blockers: 20%, beta-blockers: 17%; clonidin: 8%; nondihydropyridine calcium antagonists: 5%). Only 33% of type II diabetic patients underwent a screening for microalbuminuria as assessed on clinical records. The same percentage of micro- and macroalbuminuric patients (13.5%) was observed in the DT group, whereas 25% micro vs 3% macro were found in the DU group. In all, 73% of microalbuminuric patients were not on ACE-I/ARB. Hypertensive type II diabetic patients were often left untreated and only a minority of those treated were optimally controlled. The importance of an elevated systolic pressure is underestimated and the number of antihypertensive drugs prescribed insufficient. Screening and treatment of albuminuria are inadequate.
Hypertension is a common manifestation of antiphospholipid syndrome (APS). Antiphospholipid antibodies (aPL) have been described in patients with hypertension secondary to renal artery stenosis ...(RAS). Twenty-six patients with RAS and 25 patients with severe essential hypertension (diastolic blood pressure >110 mmHg or ±3 hypertensive drugs) were studied and compared to 61 age- and sex-matched healthy subjects. Serum samples were tested for lupus anticoagulant (LA), anticardiolipin (aCL) IgG and IgM, antiprothrombin (aPT) IgG and IgM, anti-β2glycoprotein 1 (aβ2GP1) IgG and IgM. aPL were negative in all patients with RAS. Two patients with essential hypertension had positive aPL (8%) (LA in one patient confirmed in a second assay and aβ2GP1-IgG in the other patient confirmed one year later together with aCL IgG positivity). Among healthy subjects, one case (1.6%) was found to be positive for LA, aCL IgM, aβ2GP1 IgM, aPT IgG, aPT IgM. In conclusion, the association between RAS and aPL seems to be casual rather than an expression of an elective thrombotic localization of APS. The positive finding of aPL in 8% of patients with essential hypertension, a frequency higher than that of the control population, deserves further studies in larger series to better explore the relationship between aPL and hypertension.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, OILJ, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
Intradialytic hypotension (IDH) is still a major clinical problem for haemodialysis (HD) patients. Haemodiafiltration (HDF) has been shown to be able to reduce the incidence of IDH.
Fifty patients ...were enrolled in a prospective, randomized, crossover international study focussed on a variant of traditional HDF, haemofiltration with endogenous reinfusion (HFR). After a 1-month run-in period on HFR, the patients were randomized to two treatments of 2 months duration: HFR (Period A) or HFR-Aequilibrium (Period B), followed by a 1-month HFR wash-out period and then switched to the other treatment. HFR-Aequilibrium (HFR-Aeq) is an evolution of the haemofiltration with endogenous reinfusion (HFR) dialysis therapy, with dialysate sodium concentration and ultrafiltration rate profiles elaborated by an automated procedure. The primary end point was the frequency of IDH.
Symptomatic hypotension episodes were significantly lower on HFR-Aeq versus HFR (23 ± 3 versus 31 ± 4% of sessions, respectively, P l= l0.03), as was the per cent of clinical interventions (17 ± 3% of sessions with almost one intervention on HFR-Aeq versus 22 ± 2% on HFR, P <0.01). In a post-hoc analysis, the effect of HFR-Aeq was greater on more unstable patients (35 ± 3% of sessions with hypotension on HFR-Aeq versus 71 ± 3% on HFR, P <0.001). No clinical or biochemical signs of Na/water overload were registered during the treatment with HFR-Aeq.
HFR-Aeq, a profiled dialysis supported by the Natrium sensor for the pre-dialysis Na(+) measure, can significantly reduce the burden of IDH. This could have an important impact in every day dialysis practice.
The aim of this work was to review evidence on the role of the sympathetic nervous system (SNS) in chronic renal failure (CRF). Three main points are discussed: 1) SNS and pathogenesis of arterial ...hypertension; 2) SNS and cardiovascular risk; 3) implication of SNS in arterial hypotension during hemodialysis. Several lines of evidence indicate the presence of a sympathetic hyperactivity in CRF, and its relationship with arterial hypertension. It is suggested that diseased kidneys send afferent nervous signals to central integrative sympathetic nuclei, thus contributing to the development and maintenance of arterial hypertension.
The elimination of these impulses with nephrectomy could explain the concomitant reduction of blood pressure. Several experiments confirmed this hypothesis. Regarding SNS and cardiovascular risk, some data suggest that reduced heart rate variability identifies an increased risk for both all causes and sudden death, independently from other recognized risk factors. Symptomatic hypotension is a common problem during hemodialysis treatment, occurring in approximately 20-30% of all hemodialysis sessions and is accompanied by acute withdrawal of sympathetic activity, vasodilation and relative bradicardia. This reflex is thought to be evoked by vigorous contraction of a progressively empty left ventricle, activating cardiac mechanoceptors. This inhibits cardiovascular centers through vagal afferents, and overrides the stimulation by baroreceptor deactivation. Alternative explanations include cerebral ischemia and increased production of nitric oxide, which inhibit central sympathetic activity. It is hoped that therapies aimed at modulating sympathetic nerve activity in patients with CRF will ameliorate their prognosis and quality of life.
Celotno besedilo
Dostopno za:
DOBA, IJS, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
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