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The struggle for personalized medicine: from genes to viruses in the modern transplant era
Full text linkIl ruolo del Rituximab nella terapia delle glomerulonefriti secondarie.
No full textRituximab (RTX), a B-lymphocytes depleting monoclonal antibody, has been deeply changing the therapeutic landscape of secondary glomerulonephritis over the past decade.
RTX has proved to be as effective as cyclophosphamide in inducing remission in ANCA-associated vasculitis and better than azathioprine as maintenance therapy in three different RCT. Treatment duration and modality, however, remain debated.
RTX has been widely used in resistant or relapsing proliferative lupus nephritis (LN), with positive results reported by retrospective studies; however, when employed as an “add-on” induction therapy in a RCT, it did not show a definite additive effect to standard therapy with mycophenolate mofetil and steroid in moderate forms of LN. In prospect, it remains a promising tool both as second-line therapy for resistant forms and as a “steroid-sparing” agent to strenghten induction and allow reduced or minimal maintenance therapy.
RTX is effective in the treatment of HCV-related cryoglobulinemic vasculitis, including glomerulonephritis. Monotherapy appears more effective than traditional cytostatic drugs in anti-viral drugs resistant forms. Association of RTX with antiviral therapy (pegINFα e ribavirin) determines a more rapid and effective immunological response with a similar virological one. Direct antiviral agents are beginning to be employed in association with traditional ones and RTX with promising results.
RTX has been also anecdotally employed in fibrillary glomerulonephritis and in “monoclonal immunoglobulin deposits-related glomerulopathy” (mIgGN) secondary to non-Hodgkin lymphomas, either alone or within the setting of a hematological chemotherapy.
Although many aspects need to be clarified, the role of RTX in treatment of secondary glomerulonephritis has become increasingly important due to a favorable risk/benefit profile
A nephrologist's point of view on sodium-glucose linked transporter-2 inhibitors: not all that glitters is gold.
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Hypomagnesemia and progressive chronic kidney disease: thinking of HNF1B and other genetic nephropathies
No full textKidney transplant recipients receiving mTOR inhibitors experienced twice as many thrombotic events: a single cohort observational study.
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New trends of an old disease: the acute post infectious glomerulonephritis at the beginning of the new millenium.
No full textThe association between acute renal disease and infection has been known since themid '800s: acute post-infectious glomerulonephritis (PIGN) is a reactive immunological
process against the kidney secondary to an infection, classically caused by a streptococcus. The typical clinical presentation of PIGN is an acute nephritic syndrome
with macro- or microscopic hematuria, proteinuria, hypertension, edema and renal function impairment of variable degree. The histology is characterized by an intracapillary glomerular proliferation, but may rarely be associated with an extracapillary proliferation.
The classical childhood form is still present nowadays, even with severe cases, in developing countries, while in the last decades it almost disappeared in industrialized
countries, where post-infectious GN are often found in elderly patients with multiple comorbidities. These clinical variants are usually related to other infective agents, like
staphylococcus aureus, both methicillin resistant (MRSA) and susceptible, and may be characterized by an IgA-dominant deposition.
Kidney biopsy is rarely needed, especially in the child, while in the adult or old patient a biopsy is warranted if there is an atypical presentation or evolution, like rapidly
progressive renal failure, absent or delayed function recovery, persisting low C3, nephrotic range proteinuria and persisting high proteinuria.
Current therapy strategies rely on culture-guided systemic antibiotics, especially in the old patient, in which MRSA are relatively frequent, support therapy and only in very
selected cases on steroids. These latter cases include the rare PIGN with crescents and those with a severe interstitial inflammation
Allocating kidneys from expanded criteria donors: Karpinsky score provides independent predictors of renal function and graft survival.
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