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Although Metformin (MT) is a first-line therapy for the treatment of type 2 diabetes mellitus, some patients may not receive it owing to the risk of MALA (metformin-associated lactic acidosis), an exceptionally rare but fatal adverse event. Then, the drug is contraindicated in many individuals with impaired kidney function because of concerns of MALA. MT, along with other drugs in the biguanide class, increases plasma lactate levels in a plasma concentration-dependent manner by inhibiting mitochondrial respiration predominantly in the liver. Elevated plasma MT concentrations (as occur in individuals with renal impairment) and a secondary event or condition that further disrupt lactate production or clearance (e.g., acute illness in diabetic patients where cardiac, hepatic, pulmonary, or renal function are compromised), are typically necessary to cause MALA. As these secondary events may be unpredictable and the mortality rate for MALA approaches 50%, MT has been contraindicated in moderate and severe renal impairment since its FDA approval in patients with normal renal function or mild renal insufficiency to minimize the potential for toxic MT levels and MALA. However, the reported incidence of MALA in clinical practice has proved to be very low. Several groups have suggested that current renal function cutoffs for MT are too conservative, thus depriving a substantial number of type 2 diabetes patients from the potential benefit of MT therapy. In keeping with these data the FDA and the EMA recently revised the warning regarding MT. Considering these new recommendations the authors propose a territorial diagnostic and therapeutic path on the use of MT in the Chronic Kidney Disease., non disponibile

Un numero sempre maggiore di pazienti anziani inizia la dialisi. Tuttavia, malgrado i potenziali vantaggi della DP rispetto all'HD, tale tecnica è sottoutilizzata, specialmente nell'anziano. È, di recente, comparso un dibattito sulla rivista Seminars in Dialysis, relativamente al fatto di considerare o meno la DP come terapia sostitutiva di prima scelta per il paziente anziano., An increasing number of elderly patients start dialysis. Despite peritoneal dialysis' potential benefits this technique is underutilized, particularly in the elderly. Recently, a debate entitled “Should peritoneal dialysis be the first option offered to the elderly who require renal re-placement therapy for continued longevity?” was published on Seminars in Dialysis.

La diagnosi differenziale nei casi d'insufficienza renale acuta del postpartum associata ad anemia emolitica microangiopatica e trombocitopenia, include, tra le altre: pre-clampsia grave/eclampsia, grave eclampsia, la sindrome HELLP (Hemolysis, Elevated Liver enzyme, Low Platelet), la acute fatty liver of pregnancy (AFLP), la porpora trombotica trombocitopenica/sindrome emolitico-uremica associata alla gravidanza (TTP/aHUS), esordio acuto o flare di LES in gravidanza e la sindrome catastrofica da anticorpi antifosfolipidi (CAPS). Si tratta di condizioni potenzialmente pericolose per la vita data la presenza di disfunzione multiorgano. Il verificarsi di uno stato di ipercoagulabilità e la concentrazione decrescente di ADAMTS 13 in gravidanza e nel post-parto aumentano il rischio di sviluppare porpora trombotica trombocitopenica (TTP). Vi è però una notevole sovrapposizione riguardo la clinica ed i test di laboratorio tra queste condizioni, e quindi la diagnosi può essere un problema anche per clinici esperti. Tuttavia è importante stabilire un'accurata diagnosi poiché la gestione e le complicanze di tali sindromi possono essere differenti. Il caso presentato sottolinea la complessità connessa alla diagnosi differenziale dei quadri clinici che includono anemia emolitica microangiopatica e trombocitopenia connessi alla gravidanza ed il ruolo del plasma exchange nella loro gestione., The differential diagnosis of postpartum acute renal failure associated with microangiopathic hemolytic anemia and thrombocytopenia includes, among others: severe preeclampsia, eclampsia, HELLP syndrome (hemolysis, elevated liver enzyme, low platelet), acute fatty liver of pregnancy (AFLP), thrombotic thrombocytopenic purpura/hemolytic uremic syndrome associated with pregnancy (TTP/aHUS), acute onset or flare of SLE in pregnancy and catastrophic antiphospholipid syndrome (CAPS). These conditions are potentially life threatening due to the presence of multi-organ dysfunction. The occurrence of an hypercoagulable state with decreasing concentration of ADAMTS 13 in pregnancy and in postpartum increases the risk of developing thrombotic thrombocytopenic purpura (TTP). Yet there is a considerable overlap of the clinical and laboratory tools detecting these conditions, therefore the diagnosis may be problematic even for experienced clinicians. However, it is important to establish an accurate diagnosis as the management and complications of these syndromes may be different. This case highlights the complexity of the differential diagnosis in case of microangiopathic hemolytic anemia and thrombocytopenia associated with pregnancy and the role of plasma exchange in their management.