Drug abuse and kidney

Hippokratia 2011; 15 (Suppl 2): 4-8

K. Pantelias, E. Grapsa

Abstract

Over the past 30 years, the number of drugs' dependents has increased. Drugs cause psychosomatic changes and ultimately death. The rapid increasing of illicit drug use is an important social health problem. Their use may be therapeutic under medical supervision or illegal by users in dependency. The majority of these substances or their metabolites are excreted through the kidneys and renal complications of drug abuse are frequently encountered. They include a wide range of glomerular, interstitial and vascular diseases. The damage may be acute and reversible or chronic and may lead to end stage renal failure. The involvement of the kidney in drug use is either attributed to their elimination through it, to a direct nephrotoxic effect, or through other mechanisms. Acute renal failure (ARF) can be caused by rhabdomyolysis, hypotension and dehydration or by the direct toxic effect of heroin, cocaine abuse, MDMA or volatile solutes use. Glomerulonephritis and nephrotic syndrome can be presented as focal glomerulosclerosis in heroin nephropathy and cocaine abuse, post infectious or associated to HBV, HIV or HCV infection nephropathy. Chronic parenteral drug users may develop secondary amyloidosis. Finally, drug abuse can lead to ESRD mainly by causing deterioration of preexisting renal disease at a higher rate. In conclusion, significant alterations have been observed in the kidneys' structure since they participate in drug metabolism. There is lack of retrospective studies and information has been given from case reports. The continuation of substance abuse after the appearance of renal damage increases the risk of permanent renal disease and consequently may lead to end stage renal failure.

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Cardiorenal-anemia syndrome - definition, epidemiology and management: The Cardiologist's view

Hippokratia 2011; 15 (Suppl 2): 9-14

D. Farmakis, G. Filippatos

Abstract

The term "cardiorenal anemia syndrome" (CRAS) was introduced to describe the frequent coexistence of heart failure (HF), renal dysfunction and anemia as well as the close pathogenetic relationship between them. Up to two thirds of patients with acute heart failure (HF) and nearly one third of those with chronic HF have at least moderate renal dysfunction. Anemia, on the other hand, is detected in 10-60% of HF patients, depending on definitions and HF severity. Data on the coexistence of anemia and kidney disease in HF is quite variable and a prevalence of 3-22% is reported by various studies. Both renal dysfunction and anemia are independent predictors of adverse prognosis in HF and seem to have an additive effect on patients' survival. Anemia pathogenesis in CRAS is multifactorial and among other factors includes reduced synthesis of and/or resistance to erythropoietin and iron deficiency. As a result, erythropoiesis stimulating agents (ESA) and iron supplementation have both emerged as potential therapeutic modalities for CRAS. Although the first small clinical trials on ESA were promising, the subsequent large-scale testing of those agents resulted in controversial findings. Recent studies on the use of iron therapy in HF patients with iron deficiency have shown beneficial effects regarding patients' symptoms, functional status and quality of life, which seem to occur irrespectively of the presence of anemia. However, there are several issues that need to be clarified, including whether the correction of iron deficiency is followed by better long-term prognosis, what patients benefit the most and therefore need to be treated or what therapeutic targets should be pursued.

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The present and the future of Peritoneal Dialysis

Hippokratia 2011; 15 (Suppl 2): 15-20

C. Fourtounas

Abstract

Peritoneal Dialysis (PD) has been established as an effective renal replacement therapy complementary to hemodialysis (HD) for End-Stage Renal Disease (ESRD) patients. However, its prevalence has been decreasing during the last decades in Western Europe and USA, whereas in some regions such as Hong Kong or Mexico its penetration remains higher than 70%. These dramatic differences around the world can not be explained only by medical reasons. There are also many "hidden" factors such as financial issues (for profit HD), completely unproven dogmatic beliefs about the superiority of HD over PD, or more recently a fear about "the epidemic" of encapsulating peritoneal sclerosis in long standing PD. During the last two decades, there has been a significant progress in many fields of PD, such as reduced PD related peritonitis rates by new connectology systems, prevention of exit site infections by mupirocin or gentamycin ointments, wide application of automated PD by reliable cyclers, use of icodextrin for the long exchanges, better preservation of residual renal function, newer and more biocompatible PD solutions and timely placement of PD catheters by nephrologists. In addition, basic and clinical research is focusing on future improvements such as the use of two icodextrin exchanges per day, the application of new PD solutions with low sodium concentration, the wider use of "assisted" PD, and a better understanding of the pathogenetic mechanisms that may lead to peritoneal sclerosis with new therapies that may prevent it. The dilemma regarding the best modality for ESRD (HD or PD?) should be abandoned and the modern nephrologist should be wise enough to recognize the possible advantages and contraindications of each modality and confident enough to offer both of them to the ESRD patients as appropriate.

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Magnesium levels and magnesium containing phosphate binders in haemodialysis patients

Hippokratia 2011; 15 (Suppl 2): 21-26

E Koulouridis, I. Kostimpa, E. Klonou, I. Koulouridis, B. Tsilimpari, Z. Nikolaidou, X. Goudeli, A. Krokida, E. Liapi, I. Bregova

Abstract

Background and aim: Sufficient evidence suggests that serum magnesium exerts beneficial effect upon cardiovascular status and arterial calcification among dialysis patients. Magnesium containing salts are as effective as the usual phosphate binders in lowering serum phosphorus in haemodialysis patients and posses the advantage of increasing serum magnesium levels which may play an important role in cardiovascular outcome. The aim of this study was To investigate serum magnesium levels among dialysis patients before and after administration of magnesium containing phosphate binders and its clinical significance.
Patients and Methods: In this prospective cohort we investigated 70 patients (45 men, 25 women) undergoing standard bicarbonate dialysis, thrice weekly (3-4 hours) for longer that 6 months. Age 66.1±13.2 (33-88) years, dialysis duration 62.6±57.9 (7-267) months. Presence of coronary artery disease (CAD) was established by previous history of acute myocardial infarction or coronary angiography. Chronic use (>1 year) of proton pump inhibitors (PPIs) was sought from previous history of the patients. Patients with serum magnesium levels lower than 3 mg/dl were eligible to be administered calcium acetate-magnesium carbonate (CalMag) as phosphate binder. We estimated serum calcium, phosphorus, magnesium and calcium-phosphate product monthly and iPTH every three months. In order to avoid hypermagnesaemia after two months patients receiving CalMag underwent dialysis with low magnesium dialysate (0.75 mEq/L) while the rest continued dialysis with usual magnesium dialysate (1 mEq/L).
Results: Lower magnesium levels were identified among patients with coronary artery disease (p=0.01) as well as among patients chronically receiving proton pump inhibitors (p=0.03). Administration of CalMag showed a considerable increase in the magnesium level (p=0.0004) and a significant decrease of phosphate level (p=0.01). Substitution with low magnesium dialysate (0.75 mEq/L) showed a considerable decrease of serum magnesium level (p=0.005). Variations in the levels of calcium, phosphate and calcium-phosphate product between the individual phosphate binders (PBND) showed no statistically significant difference. The estimated three month cost for the individual phosphate binders was lower for calcium carbonate and CalMag compared to the other phosphate binders.
Conclusions: The results of this study suggest that presence of coronary artery disease and chronic use of PPIs is related to lower serum magnesium levels. Administration of CalMag in haemodialysis patients is related to lower phosphorus levels and increased magnesium levels. Low dialysate magnesium concentration reduces effectively serum magnesium levels. The efficacy of CalMag in lowering serum phosphorus level is comparable with the usual phosphate binders. The lower cost of CalMag suggests its more frequent use in clinical practice among selected patients.

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Peritoneoscopic insertion of peritoneal dialysis catheters by nephrologists. A single centre preliminary experience

Hippokratia 2011; 15 (Suppl 2): 27-29

E. Fourtounas, P. Dousdampanis, A. Hardalias, K. Trigka, JG Vlachojannis

Abstract

Background: Peritoneal Dialysis (PD) catheter has been characterized as the "lifeline" of PD patients. Timely and effective insertion of the PD catheter is essential for the success of a PD program. We describe our initial experience with peritoneoscopic implantation of PD catheters by nephrologists. Patients and Methods: Twenty-one patients underwent peritoneoscopic PD catheter implantation in our centre during 2007 - 2009. Their mean age was 57.3±14.7 years, 8 patients (38%) were transferred from hemodialysis and 12 patients (57%) had a previous history of uncomplicated abdominal surgery for various reasons.
Results: All PD catheters were inserted under local anaesthesia in a nephrology ward. There were no major complications during, or immediately after catheter implantation. There were 4 cases of eosinophilic peritonitis following air entrapment in the peritoneal cavity. PD fluid leak was observed in two cases and an abdominal hernia in one case. The PD catheter did not work properly in 3 cases and in two of them the catheter was removed and replaced by a new one by surgeons. During the follow up period a total of 5 catheters were removed: three of them after successful renal transplantation and two due to poor functioning.
Conclusions: PD catheter insertion by nephrologists with peritoneoscopy is a rather simple, safe and efficient method. It offers the opportunity for timely initiation of PD and a relative independence from surgeons, reducing the waiting times and therefore enhancing PD uptake.

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Evolution of secondary hyperparathyroidism one year after successful renal transplantation

Hippokratia 2011; 15 (Suppl 2): 30-32

P. Dousdampanis, K. Trigka, C. Fourtounas, JG Vlachojannis

Abstract

Background: The natural history of parathyroid function after successful renal transplantation (Tx) as well as the factors predisposing to persistent secondary hyperpathyroidism (sHPT) are not well established, whereas regression of sHPT is not always observed and depends on renal graft function. The aim of the present study was to evaluate the post-Tx natural history of parathyroid function in patients with a well functioning renal graft.
Patients and Methods: One hundred and five (105) patients, which underwent successful renal transplantation, were studied. Sixteen (16) patients had a history of previous parathyroidectomy for severe HPT.
Results: Parathyroid hormone (PTH) mean value presented a significant fall from 373.2±418 to 128±121 pg/ml (p<0.001) at 12 months post-Tx. Pre-Tx PTH levels were significantly correlated with 12 months post-Tx levels (r= 0.46, p< 0.001). Serum calcium did not present significant alterations, whereas serum phosphorus decreased significantly, since the third month post-Tx from 5.9±1.67 mg/dl to 3.2±0.75 mg/dl (p<0.001). Renal graft function remained well preserved and mean serum creatinine was 1.59±0.44 mg/dl at the 12th month post-Tx. Eighteen (18) patients presented severe HPT (PTH > 800 pg/ml) at the time of transplantation. In this group of patients, PTH was also significantly decreased, but remained in abnormal levels (PTH > 100 pg/ml) after 12 months post-Tx in 6 cases.
Conclusions: These results suggest an improvement of parathyroid function as measured by PTH levels, during the first year after successful renal transplantation in patients with mild or moderate sHPT. Twelve months' PTH levels depend on pre-Tx levels. However severe pre-existing sHPT may persist even after one year post-Tx in a significant number of patients.

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