Sunday, 15 October 2017

Challenging Choices in Nephrology: Should dialysis be offered to advanced cancer patients?


Decisions at the end of life are always challenging...

Should dialysis be offered to patients with advanced cancer?

I think there is only one response to this question: Clinical Judgement.
What is Clinical Judgement? It's hard to define, but certainly Clinical Judgemenet should be seen in the 3 domains of pathos, ethos and logos.


I give some, hopefully useful, advices to answer this question in this lecture



Wednesday, 27 September 2017

Good night stories for mankind

I have just listened an amazing story. I need to share it:

In 1954, #RaulFollereau asked Russia and US presidents to donate the cost of one B52 bomber for the treatment of the leprosy patients. He had estimated that money would have been enough to treat all world leprosy patients. Follereau didn't receive any response to his letter. Some years later, he saw several dismissed B52 bombers. He said himself "Here are my 2 airplanes too... Now it's too late, the 2 presidents of Russia and US are retired and they have missed a great opportunity and a great and pleasant memory for their retirement".

Friday, 21 July 2017

My lost lecture on FLCs test in kidney diseases


Last year, I was honoured to give a lecture on the clinical use of the Free Light Chains test in kidney diseases. It was my first time as a presenter in one of the most popular Universities of Rome.


It was very exciting to take the stage after such a big name of Clinical Medicine as Prof Giampaolo Merlini. Fortunately, it was a success.


Many delegates asked me to share my slides, but, moving back at home, I lost my USB drive... I found it only two days ago.

So, here's my Lost Lecture 

A lecture on the use of Body Composition Monitor

A few months ago, I gave a lecture con BCM use in dialysis.
Here's the link to the slides:


 https://www.dropbox.com/s/jvst82uxds8e7qw/BCM%20Fresenius%202.ppt?dl=0 

Tuesday, 9 May 2017

Physical examination skills and NNT: number needed to teach

A number of physical examination techniques have been abandoned because of poor reproducibility. Studies have shown that many physicians are unable to use them appropriately. Thus it seems, they simply don't work. Is this type of evidence really applicable to the teaching of physical examination?
Is there any threshold or any NNT (number needed to teach) to justify the emerging practice of omitting the teaching of this techniques?
Why shouldn't we continue to teach these techniques even if there will be only 1 of 1000 students skilled enough to perform them successfully?

Tuesday, 22 November 2016

A Spoiler of Two RCTs on Extracorporeal FLCs Removal (Eulite and MYRE)

At the time of Multiple myeloma (MM) diagnosis, severe AKI secondary to Myeloma Cast Nephrpathy is a common complication. Recovery of renal function is a key prognostic factor. Two RCTs have recently investigated the use of extracorporeal dialysis strategies to rapidly remove circulating monoclonal free light chains (FLC).
Waiting for final results publication, this is a spoiler of available data:
-          Eulite Study90 patients with severe de novo dialysis-dependent AKI secondary to biopsy–proven Myeloma cast nephropathy were randomised to receive either standard high-flux dialysis (n=47) or free light chain (FLC) removal haemodialysis using a HCO dialyzer (n=43).  Dialysis sessions in HCO group were longer (6 hours on day 0, then 8 hours on days 2, 3, 5–7, 9+10. After day 12, participants received 8 hours of haemodialysis on alternate days. After day 21, if patients still required renal support the dialysis schedule was reduced to 6 hours three times per week) and more frequent than the conventional dialysis received by the control arm (4h x3/wk). All patients received standardised chemotherapy (bortezomib based regime). The primary endpoint of the study I, i.e. independence of dialysis at 3 months from enrolment, was achieved in 55.8% of patients in HCO group and 51.6% in standard HF-HD group (p=0.65). An increase in mortality was reported in the treatment group mainly due to delay in chemotherapy and infection.
-          MYRE Study. Patients with severe de novo dialysis-dependent AKI secondary to biopsy–proven Myeloma cast nephropathy received 21-day courses of Bortezomib and dexamethasone (BD), reinforced by cyclophosphamide after 3 cycles in the absence of haematological response (HR). Patients were randomized to receive  conventional high-flux dialysis or  intensive HD (8 sessionsof 5 hours over the first 10 days, then thrice weekly) using a HCO dialyzer. Baseline characteristics in the control arm (n=48) and HCO arm (n=46) were close, including similarly high serum FLC levels (median 6,015mg/L).  HD independence was achieved in 33% and 43% (p= 0.31) at 3 and in 37.5% and 60 % (p=0.03) at 6 months, in the control and HCO arms, respectively. HR rate at 3 months based on FLC was 48% in control and 59% in HCO groups (p=0.29). At 12 months, 17 pts have died (10 vs 7).  


Differences in clinical outcomes could be theoretically justified by the more intensive treatment regimen adopted in Eulite Study. 

Tuesday, 1 November 2016

Cryoglobulinemic Syndrome: the essentials (My first ebook)

My first e-book, Cryoglobulinemic Syndrome: the essentials, is now freely available for Download

I hope you will enjoy it.