Tuesday, 1 September 2015

Onconephrology: two books from the same frontier

Cancer and the Kidney by Enric P. Choen has been for a long time the only book available on the market to address the area at the frontier of nephrology and oncology. It was a wonderful book and an easily accessible resource for a busy clinician like me.

And finally, a few weeks ago, another book has been published: 
Onconephrology by Kenar Jhaveri and Abdulla Salahudeen. I have read the whole book in only two weeks: it is wonderful too and its practical approach seems even more interesting than that of the seminal book of Choen and coauthors.. As it always happens with Springer editions (at least in my experience) the quality of proof-reading is lower than that of the book by Choen which was originally published by OUP. Nevertheless, the contents are appropriate, easily accessible and the authors made a great work to simplify a difficult issue. 
I highly recommend this book to whomever wants to improve his/her knowledge in this field.

Monday, 25 May 2015

Doc, please, don’t hate me!

Nephrologists may encounter a number of patients who disrupt the smooth functioning of their dialysis unit and exhibit behavior to which dialy­sis staff may be unsure how to respond. Obviously, this is not a major cause of professional satisfaction. 
By definition, "hateful patients" are those whom most physicians dread. An understanding of the "hateful patient" can therefore be very informative to the nephrologists. 

Traditionally, four categories of such patients may be described:
dependent clingers, 
entitled demanders 
manipulative help-rejecters and    
self-destructive deniers.

Hateful dialysis patients should not be allowed to continually compromise the care of other patients in the unit. The rights of difficult or disruptive patients should be balanced with those of other dialysis patients and staff.


Thursday, 19 March 2015

An Old Star among Killer-fruits for ESRD patients

There is a subtropical fruit whose consumption by those with ESRD can produce hiccups, vomiting, nausea, mental confusion and, in some cases, even fatal outcomes. The fruit has distinctive ridges running down its sides; in cross-section, it resembles a star, hence its name: starfruit.
The starfruit is known under different names in different countries. The Portuguese word carambola is also widely used to name this fruit. It is the fruit of Averrhoa carambola, a species of tree, especially popular throughout Southeast Asia and the South Pacific. Carambola is also common in Brazil, where it is served as a fresh beverage, in natura, or as an industrialized juice, as it is also served throughout the world. 
Starfruit intoxication may be harmful and even life threatening in ESRD patients. In this setting, daily haemodialysis (or CRRT in severe cases) is the ideal treatment, whereas peritoneal dialysis seems of no use, especially when disturbance of consciousness ensues. 

Thursday, 8 January 2015


Pregnancy in the setting of systemic lupus erythematosus (SLE) is associated with a higher risk of complications compared to normal women. 
Pregnancy in SLE patients should be accurately planned. First of all, you need to assess disease severity
Consider possible contraindications related to disease damage: severe renal failure, severe pulmonary fibrosis, cardiomiopathy, CVA, MI. In the event of severe damage, the main recommendation is for surrogacy/adoption/IVF with gestational carrier. 
If no significant damage is present, next step is to evaluate disease activity. Disease should be inactive for at least 6 months, check APL, anti-SSA/Ro, anti-SSB/La. Rate of fetal loss is up to 75% in patients with active lupus nephritis. Medications should be evaluated, if contraindicated changed to safe ones.  Do not stop HCQ: it is safe, studies show beneficial effects on pregnancy outcome, suspension increases the risk of flare.

PROMISSE study reported data on 386 pregnancies in SLE:  5% risk for severe flare, 15% for mild-moderate flare. When flares develop, they often occur during the first or second trimester or during the first few months after delivery. Disease flares during pregnancy should be treated using low-dose non fluorinated steroids, azathioprine, cyclosporine, tacrolimus, or IVIg. Use of fluorinated compounds, such as dexamethasone and betamethasone should be limited to a single course for fetal lung maturity, in cases of premature delivery. Repeated use has been associated with impaired neuro-psychological development of the child in later life.
The biggest issue is the 3-5 times higher risk of pre-eclampsia, complicating 16-30% of SLE pregnancies. 

Neonatal Lupus Syndromes (NLS) is a form of passively acquired fetal autoimmunity from maternal antibodies, anti-Ro and anti-La antibodies. Neonatal lupus typically manifests as congenital heart block or as lupus rash. In rare cases, it may manifest as hepatic or hematologic involvement. 

Risk of any manifestation of neonatal SLE is 20-25% with maternal Ro/La, congenital heart block (CHB) occurs in 2-3% but mortality is 20% and 60-80% require pacemaker. So in the event of previous CHB in neonate maternal Ro/La with, weekly fetal echo is recommended from 18 weeks.