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Anti-Proteinuric Effect of GLP1-RA as Add-On to SGLT2-i and ACE-i in a Diabetic Patient with IgA Nephropathy

Maria Elena Malighetti1, Matteo Faletto2

1 Ambulatorio di Diabetologia, Casa di Cura Ambrosiana, Cesano Boscone, MI, Italia
2 Scuola di Specializzazione in Medicina Interna, IRCCS Istituto Clinico Humanitas, Rozzano, MI, Italia

Immunoglobulin A (IgA) nephropathy is a common glomerulonephritis, but its treatment remains matter of debate. Recommendation for corticosteroids has been supported, but renin-angiotensin inhibitors, RAAS, and sodium-glucose co-transporter 2 inhibitors (SGLT2i) are increasingly used because of a better benefit/safety balance in comparison with systemic steroids and immunosuppressive treatments. In this case report, a patient with type 2 diabetes (T2DM) and biopsy-proven nephrotic IgA-related nephropathy documented a rapid meaningful reduction of proteinuria and the effect was persistent for 2 years, after receiving the treatment with a GLP1-RA on top of the previous treatment with ACE-inhibitors and SGLT2-i. Considering the beneficial effects of GLP1-RA in diabetes related chronic kidney disease, the present case report supports the notion that these drugs could also represent a beneficial treatment option in IgA nephropathy.

Keywords: IgA nephropathy, Dulaglutide, Empagliflozin, DAPA-CKD, Empa-Kidney

Contrast-Enhanced Ultrasound as a Diagnostic Procedure in Renal Diseases: A Case Report

Simone Sellitto1, Luciano Tarantino2, Francesco Barone3, Nunzia Barone3, Angelica Perna4, Angela Lucariello5, Germano Guerra4, Antonio De Luca6, Amelia Filippelli7, Carmine Sellitto7

1 Institute of Radiology, Department of Medicine, University of Udine, Udine, Italy
2 Department of Surgery, Interventional Hepatology Unit, Luigi Curto Hospital, Polla, Italy
3 Emergency Unit, Dell’Immacolata Hospital, Sapri, Italy
4 Section of Human Anatomy, Department of Medicine and Health Sciences “Vincenzo Tiberio”, University of Molise, Campobasso, Italy
5 Section of Human Anatomy, Department of Sport Sciences and Wellness, University of Naples “Parthenope”, Naples, Italy
6 Section of Human Anatomy, Department of Mental and Physical Health and Preventive Medicine, University of Campania “Luigi Vanvitelli”, Naples, Italy
7 Section of Pharmacology, Department of Medicine, Surgery and Dentistry, “Scuola Medica Salernitana”, University of Salerno, Baronissi, Italy

Standard ultrasound (US) finds wide use in renal diseases as a screening procedure, but it is not always able to characterize lesions, especially in differential diagnosis between benign and malignant lesions. In contrast, contrast-enhanced ultrasonography (CEUS) is appropriate in differentiating between solid and cystic lesions as well as between tumors and pseudotumors. We show the case of a nephropathic patient who showed a complex, large, growing renal mass, characterized through a CEUS. This seventy-five-year-old diabetic heart patient showed a 6 cm-complex and plurisected cyst on ultrasound of left kidney. Laboratory data showed the presence of stage IIIb chronic renal failure with GFR 30 ml/min, creatinine 2.33 mg/dl, azotemia 88 mg/dl. The patient performed abdominal CT without contrast medium, showing at the level of the left upper pole, a roundish formation with the dimensions of approximately 70x53x50 mm. At the semiannual checkup, the nephrology examination showed a slight rise in creatinine and, therefore, after six months, it was decided to perform a CT scan without contrast medium again. CT showed a slight increase in the size of the mass located at the left kidney (74x56x57 mm). Given the increased size of the left mass, albeit modest, a CEUS was performed to reach a diriment diagnosis. CEUS concluded for complex cystic formation with presence of intraluminal solid-corpuscular material, with thrombotic-hemorrhagic etiology, in progressive phase of organization, classifiable as Bosniak type II cyst. CEUS in the kidneys is a cost-effective and valuable imaging technique; it is accurate in the characterization of indeterminate lesions and complex cysts.

Keywords: Contrast-Enhanced Ultrasound, CEUS, Renal Cyst, Indeterminate Renal Mass

Peritoneal Dialysis Network in North-East Italy: Survey About the Peritoneal Catheter Exit-Site Infection Management and Comparison with ISPD Guidelines

Antonino Previti1, Sabrina Milan Manani2, Vincenzo Cosentini3, Antonina Lo Cicero4, Marta Guizzo5, Apolloni Monica1, Marina Cappellari5, Sabina Rognini3, Mery Zuccolo4, Grazia Maria Virzì6, Giovanni Gambaro7.

1 UOS Nefrologia e Dialisi, Ospedale Alto Vicentino, Santorso (VI)
2 UOC Nefrologia e Dialisi, Ospedale Camposampiero e Cittadella (PD)
3 UOC Nefrologia e Dialisi, Ospedale Fracastoro, San Bonifacio (VR)
4 UOC Nefrologia e Dialisi, Ospedale si Sant’Antonio, San Daniele del Friuli (UD)
5 UOC Nefrologia e Dialisi, Ospedale Castelfranco Veneto, Castelfranco Veneto (TV)
6 UOC Nefrologia, Dialisi e Trapianto, Ospedale San Bortolo Vicenza (VI)
7 UOC Nefrologia e Dialisi, Azienda Ospedaliera Universitaria Integrata Verona, Verona

Introduction. The Triveneto Peritoneal Dialysis (PD) Network aims to bring together doctors and nurses who deal with PD in a collaborative network in which to exchange mutual knowledge and optimize the use of this method of replacing renal function. A topic of particular interest was the management of peritoneal catheter exit-site infection, given the recent publication of the new guidelines of the International Society of Peritoneal Dialysis (ISPD).
Materials and methods. The survey concerned the criteria for carrying out nasal swab and exit-site, management of exuberant granulation tissue “Proud Flesh”, treatment of exit-site infection (ESI), use of silver dressings, the role of subcutaneous tunnel ultrasound and cuff shaving.
Results. All PD centers in the North-East Italy area have joined the survey with at least one operator per centre. There was a wide variability between the indications for performing the exit-site swab. In the presence of ESI, the prevalent approach is that of oral systemic empiric therapy associated (20.0%) or less (28.9%) with topical therapy, and then adapting it in a targeted manner to the culture examination.
Discussion. From the discussion of the survey emerged the importance of the ESI as an outcome indicator, which allows us to verify whether our clinical practice is in line with the reference standards. It is essential to know and base our activity on what is indicated in national and international guidelines and to document the events that occur in the patient population of each dialysis unit.

Keywords: Peritoneal Dialysis, Exit-site management, Catheter-related Infections, Survey

Medical overuse, defensive medicine and new reform of professional mistake

Fabio Cembrani1, Piergiorgio Fedeli2, Diego De Leo3, Mariano Cingolani4

1 Professore a contratto, Università degli Studi di Verona
2 Associato di Medicina legale, Università di Camerino
3 Emerito di Psichiatria, Università di Brisbane (Australia)
4 Ordinario di Medicina legale, Università di Macerata

Reflecting on the inappropriateness (medical overuse) and on defensive medicine, the Authors wonder whether the new Italian reform of professional guilt, desired at all institutional levels, will actually contain the high economic costs produced by these large and widespread phenomena. After having characterized the medical overuse and the defensive medicine indicating the common traits and main differences, the reflection is conducted by exploring the many scientific evidence that does not document any causal link between the decriminalization of professional conduct and the containment of the costs produced by the prescriptive inappropriateness. They conclude by stating that, for their containment, a third reform of professional liability will not be helpful. Instead, it must focus on other issues, mainly addressing the excessive reliance on judicial recourse. It should provide for mandatory out-of-court conciliatory mechanisms and clarifying the protective umbrella of the doctor’s non-criminality.

Keywords: medical overuse, diagnostic inappropriateness, defensive medicine, malpractice

Executive Dysfunction in Patients Undergoing Chronic Haemodialysis Treatment: A Possible Symptom of Vascular Dementia

Giulia Belluardo1, Dario Galeano1, Concetto Sessa1, Luca Zanoli2, Walter Morale1

1 O.C Nefrologia e Dialisi, P.O. “Maggiore” di Modica. Azienda Sanitaria Provinciale di Ragusa, Italia
2 Nefrologia, Dipartimento di Medicina Clinica e Sperimentale, Università di Catania, Catania, Italia

Introduction. Patients undergoing chronic haemodialysis (HD) treatment have an 8-10 times higher risk of experiencing stroke events and developing cognitive impairment. The high vascular stress they are subjected to may be the basis for the development of vascular dementia (VaD).
Objective. The aim of the study is to investigate the executive functions, typically impaired in VaD, of patients undergoing chronic haemodialysis treatment.
Method. HD patients were recruited from the U.O.C. of Nephrology and Dialysis (ASP Ragusa). Risk factors for VaD were collected and then the Frontal Assessment Battery (FAB) was administered.
Results. 103 HD patients were included (males = 63%, age 66 ± 14 years). Risk factors for VaD included a high percentage of patients with anaemia (93%), hypertension (64%) and coronary artery disease (68%).  The cognitive data obtained via FAB show a percentage of 55% deficit scores. All risk factors found a significant association with cognitive scores. Anemia, hypertension, intradialytic hypotension, coronary artery disease, and homocysteine are negative predictors of executive function integrity.
Conclusions. More than half of the patients had deficit scores on the FAB. Reduced cognitive flexibility, high sensitivity to interference, poor inhibitory control and impaired motor programming with the dominant hand were evident. In conclusion, a marked impairment of the executive functions, generally located in the frontal lobes of the brain, was detected in the HD patient, which could be a symptom of a dementia of a vascular nature.

Keywords: hemodialysis, cognitive, impairment, vascular, dementia

Clinical implications of serum anti-PLA2R levels and glomerular PLA2R deposits in primary membranous nephropathy

Krishna Chaitanya Gunda1, Gerry George Mathew2, S Balasubramanian3, K S Sunil Kumar4

1 MD, DNB(Nephrology) Consultant Nephrologist, Department of Nephrology, Asian institute of Nephrology and Urology, Nungambakkam, Chennai, Tamil Nadu, India-600034
2 MD, DNB(Nephrology) Associate Professor, Department of Nephrology, SRM Medical College Hospital and Research Centre, Kattankulathur, Tamil Nadu, India-603203
3 MD, DNB(Nephrology) Senior Consultant Nephrologist, Department of Nephrology, Apollo hospital, Greams lane, 21, Greams road, Thousand lights, Chennai, Tamil Nadu, India-600006
4 MD, Consultant Pathologist, Department of Pathology, Apollo hospital , Greams lane, 21, Greams road, Thousand lights, Chennai, Tamil Nadu, India-600006

Introduction. The clinical implications of serum anti-PLA2R with glomerular PLA2R deposits in primary membranous nephropathy (PMN) is scarcely reported. Hence the study was designed to demonstrate the prevalence of serum anti-PLA2R levels and PLA2R staining in glomeruli in PMN and the clinical implications of the two parameters.

  1. Investigate the prevalence of anti PLA2R positivity in PMN.
  2. Ascertain correlation between serum anti-PLA2R levels and glomerular staining for PLA2R with clinical and lab parameters in PMN.

Patients and Methods. Fifty PMN patients during the period from October 2017 to December 2018 were included. Labs were done and eGFR was calculated as per MDRD 6. Anti-PLA2R titres were done in all patients. Titres more than 20 RU/ml were considered positive. Glomerular staining for PLA2R was graded on fresh frozen tissue by immunofluorescence technique.
Results. Anti-PLA2R antibody positivity and glomerular PLA2R deposition was observed in 42% (21/50) and 86% (43/50) patients respectively. 79.3% (23/29) had positive glomerular PLA2R deposition with negative serum anti PLA2R. Positive correlation were observed between serum PLA2R antibody and serum creatinine (p = 0.0001) and urine protein-creatinine ratio levels with tissue PLA2R staining grades (p = 0.04). Negative association was found between serum albumin (p = 0.026) and tissue PLA2R staining grades.
Conclusion. Serum anti-PLA2R wasn’t a sensitive marker of primary membranous nephropathy in our study group emphasising the need to consider a compendium of serological markers for diagnosis of primary membranous nephropathy and to rely more on glomerular deposition of PLA2R as a better clinical indicator for PMN.

Keywords: anti-PLA2R, Membranous Nephropathy, Glomerular PLA2R deposits, Tissue PLA2R staining, Nephrotic Syndrome

Factors Associated with Neonatal Arterial Hypertension: Case and Control Study

Carolina Gutiérrez-Cortés1, Catalina Lince-Rivera2, Adriana P. Bohórquez-Peñaranda3, Mariangel Castillo-Arteaga4, Ingrid Mayerly Gómez5, Juan Guillermo Cárdenas-Aguilera 6

1 Specialist in pediatric, Pontificia Universidad Javeriana, Bogotá, Colombia
2 Specialist in pediatric and neonatology, Pontificia Universidad Javeriana, Bogotá, Colombia
3 MSc Clinical Epidemiology, Pontificia Universidad Javeriana, Bogotá, Colombia
4 Specialist in pediatric nephrology, Hospital Universitario San Ignacio, Bogotá, Colombia
5 Specialist in pediatric and neonatology, Pontificia Universidad Javeriana, Bogotá, Colombia
6 Specialist in pediatric nephrology, Subred Integrada de Servicios de Salud Sur Occidente, Bogotá, Colombia

Background. Neonatal high blood pressure has been diagnosed more frequently in recent years, and its impact extends to adulthood. However, the knowledge gaps on associated factors, diagnosis, and treatment are challenging for medical personnel. The incidence of this condition varies depending on neonatal conditions. Patients in the Newborn Unit are at increased risk of developing high blood pressure. The persistence of this condition beyond the neonatal stage increases the risk of cardiovascular disease and chronic kidney disease in childhood and adulthood.
Methodology. A case-control study was carried out. It included hospitalized patients with neonatal hypertension as cases. Three controls were randomly selected for each case and matched by gestational age. The variables were analyzed based on their nature. Multivariate analysis was performed using a multivariate conditional regression model to identify variables associated with the outcome. Finally, the model was adjusted for possible confounders.
Results. 37 cases were obtained and matched with 111 controls. In the univariate analysis, heart disease (OR 2.86; 95% CI 1.22-6.71), kidney disease (OR 7.24; 95% CI 1.92-28.28), bronchopulmonary dysplasia (OR 6.62; 95% CI 1.42-50.82) and major surgical procedures (OR 3.71; 95% CI 1.64-8.39) had an association with neonatal arterial hypertension. Only the latter maintained this finding in the multivariate analysis (adjusted OR 2.88; 95% CI 1.14-7.30). A significant association of two or more comorbidities with neonatal arterial hypertension was also found (OR 3.81; 95% CI 1.53-9.49).
Conclusions. The study analyzed the factors related to high blood pressure in hospitalized neonates, finding relevant associations in the said population. The importance of meticulous neonatal care and monitoring of risk factors such as birth weight and major surgeries is highlighted.

Keywords: Hypertension, Prematurity, Bronchopulmonary Dysplasia, Epigenetics, Neonate, Prematurity, Kidney Disease, Blood Pressure

Cuff Shaving in Recurrent Exit-Site Infections in a Patient on Peritoneal Dialysis

Vincenzo Cosentini1, Sabina Rognini1, Lina Giannella Mantovani1, Laura Zennari1, Alireza Hasheminia2, Ivano Dal Dosso2, Linda Gammaro1

1 U.O.C. Nefrologia e Dialisi San Bonifacio, Verona, Italia
2 U.O.C. Chirurgia Generale San Bonifacio, Verona, Italia

In patients on peritoneal dialysis, the cutaneous emergency (exit-site) represents a potential access route to the peritoneum; consequently, it can become a site for microbial infections. These infections, initially localized to the exit-site, may spread to the peritoneum causing peritonitis, which is the most common cause of drop-out from peritoneal dialysis and transition to hemodialysis. Peritoneal catheters have dacron caps which have the function of counteracting the traction of the catheter itself and at the same time acting as a barrier for microorganisms, preventing the spread towards the peritoneum. Despite this, the same dacron cap can represent a sort of nest for microorganisms to colonize and, with the formation of a biofilm that facilitates their proliferation, make the same organisms impervious to antibiotic therapy and even resistance to them. The most effective tool for monitoring the health status of the exit-site is represented by the objective examination. This examination, through the use of well-defined scales, helps to provide a pathological score of the exit, facilitating the implementation of necessary precautions. In the presence of recurrent exit-site infections, from both Gram positive and Gram negative bacteria, minimally invasive surgical therapy is a valid approach to break this vicious circle. It helps avoid subjecting the patient to the removal of the peritoneal catheter, temporary transition to hemodialysis with the insertion of a central venous catheter, and subsequent repositioning of another peritoneal catheter. We propose the case of a recurrent Staphylococcus Aureus infection resolved after cuff shaving of the exit-site.

Keywords:  peritoneal dialysis, exit-site infection, cuff shaving

New Treatment Strategies in Patients with Heart Failure with Reduced Ejection Fraction: Beyond Neurohormonal Inhibition

Luca Di Lullo1, Cristina Galderisi1, Carlo Lavalle2, Marta Palombi2, Antonio De Pascalis3, Natale Di Belardino4, Sabrina Iannotti1, Vincenzo Barbera5, Antonio Bellasi6

1 UOC Nefrologia e Dialisi, Azienda USL Roma 6
2 Dipartimento di Scienze Cliniche, Internistiche, Anestesiologiche e Cardiovascolari, Azienda Ospedaliera Policlinico Umberto I, Sapienza Università di Roma, Roma
3 UOC Nefrologia e Dialisi, Ospedale “Vito Fazzi”, Lecce
4 UOC Cardiologia, Ospedali Riuniti, Anzio
5 UOC Nefrologia e Dialisi, Ospedale “L. Parodi – Delfino”, Colleferro
6 Dipartimento di Medicina, Divisione di nefrologia, Ente Ospedaliero Cantonale, Lugano (Svizzera)

Patients affected by heart failure (HF) with reduced ejection fraction (HFrEF) are prone to experience episodes of worsening symptoms and signs despite continued therapy, termed “worsening heart failure” (WHF). Although guideline-directed medical therapy is well established, worsening of chronic heart failure accounts for almost 50% of all hospital admissions for HF with consequent higher risk of death and hospitalization than patients with “stable” HF. New drugs are emerging as cornerstones to reduce residual risk of both cardiovascular mortality and readmission for heart failure.
The following review will debate about emerging definition of WHF in light of the recent clinical consensus released by the Heart Failure Association (HFA) of the European Society of Cardiology (ESC) and the new therapeutic strategies in cardiorenal patients.

Keywords: Heart Failure, Worsening Heart Failure (WHF), Cardiorenal Syndrome, Vericiguat

Palliative and Supportive Dialysis: Current Practices and Recommendations for Best Clinical Practice

Maria Cristina Pinerolo de Septis1,2, Elena Alberghini1,3, Marina Cornacchiari1,4, Andrea Galassi1,2, Marco Heidempergher1,5, Simone Vettoretti1,6, Rossella de Leonardis1,7, Luisa Sangalli1,8, Filippo Aucella9, Ciro Esposito1,10,11

1 Gruppo di Lavoro sulle Cure Palliative in Nefrologia, sezione Lombardia della Società Italiana di Nefrologia
2 UO Nefrologia e Dialisi, ASST Santi Paolo e Carlo Milano, Italia
3 UO Nefrologia e Dialisi, ASST Nord Milano Ospedale Edoardo Bassini, Italia
4 UO Nefrologia e Dialisi, ASST Ovest Milanese, presidio Ospedale di Magenta, Italia
5 UO Nefrologia e Dialisi, ASST Fatebenefratelli Sacco Milano, Italia
6 UO Nefrologia e Dialisi, Fond. IRCCS Ca’ Granda Osp. Maggiore Policlinico di Milano, Italia
7 UO Nefrologia e Dialisi, ASST Santi Paolo e Carlo Milano, Università degli Studi di Milano, Italia
8 Fondazione Teresa Camplani – Casa di Cura Domus Salutis di Brescia
9 Struttura Complessa di Nefrologia e Dialisi, Fondazione “Casa Sollievo della Sofferenza”, Istituto di Ricovero e Cura a Carattere Scientifico, San Giovanni Rotondo (FG)
10 UO Nefrologia e Dialisi, IRCCS Istituto Maugeri Pavia, Italia
11 Dipartimento di Medicina Interna e Terapia Medica, Università di Pavia

“Palliative dialysis” is defined as the renal replacement therapy directed to patients living the most critical phases of illness and the end-of-life stage. Offering targeted dialysis prescriptions becomes imperative when health conditions, along with comorbidities, unfavorable prognosis and complications, do not allow standard dialysis to be started or continued. Management should also integrate adequate supportive care measures in both incident and prevalent patients.

This document summarizes nephrological recommendations and scientifical evidence regarding the palliative approach to dialysis, and proposes operative tools for a good clinical practice. After planning and sharing the route of care (“shared-decision-making”), which includes multidimensional evaluation of the patient, a pathway of treatment should be started, focusing on combining the therapeutical available options, adequacy and proportionality of care and patients’ preferences.

We propose a framework of indications that could help the nephrologist in practicing appropriate measures of treatment in patients’ frailest conditions, with the aim of reducing the burden of dialysis, improving quality of life, providing a better control of symptoms, decreasing the hospitalization rates in the end-of-life stage and promoting a home-centered form of care. Such a decisional pathway is nowadays increasingly needed in nephrology practice, but not standardized yet.

Keywords: palliative care, chronic kidney disease, end-of-life, palliative dialysis, hemodialysis, peritoneal dialysis, shared-decision-making

The Medical Art Towards New Paradigms

Ortensio Zecchino1

1 Biogem Scarl, Via Camporeale snc, 83031 Ariano Irpino (AV), Italy

La chiave di rilancio della Sanità italiana è la sinergia

Mattia Altini

Presidente della SIMM e Direttore dell’Assistenza Ospedaliera della Regione Emilia-Romagna

The future of peritoneal dialysis

Valerio Vizzardi

1 ASST-Spedali Civili. UOC di Nefrologia, Dialisi e Trapianto

A Joint Vision of Peritoneal Dialysis in Italy: Census and Italian Registry of Dialysis and Transplantation

Maurizio Nordio1

1. Unità di Nefrologia, Ospedale di Treviso, Treviso, Italy

Advanced Care Planning (ACP) and Hemodialysis: a Pilot Project for the Application of Italian Law 219/2017 in Dialysis Units

Cristina Tantardini1, Clara Pelizzari2

1 UO Nefrologia e Dialisi, ASST Crema, Crema (CR), Italia
2 UO Psicologia Clinica, ASST Crema, Crema (CR), Italia

The law 219/2017 is the first Italian law about advanced care planning (ACP). ACP is an important part of the therapeutic relationship between patients and doctors: thanks to ACP patients can think and discuss about end of life decisions, considering clinical aspects, but also psychological, cultural, social and ethical issues. Patients prepare themselves in advance because of the possibility of future cognitive impairment, can identify a surrogate decision maker and make end-life decisions according to their goals and values.

End-stage kidney disease (ESRD) is often characterized by important symptoms, psychological suffering and social disadvantage, and patients affected by ESRD often have slow physical and cognitive decline. Despite this, access to palliative care is reduced for these patients as compared to patients affected by other end-stage organ failures. This is the reason why we want to explore the possibility of applying APC to ESRD patients.

This pilot study, regarding three patients from the Dialysis Unit of ASST Crema in Italy, has been conducted to verify the applicability of the law 219/2017 in Dialysis Units. It shows that we have to deeply investigate this issue from both sanitary workers’ and patients’ and families’ points of view. We need more studies with a larger number of patients and a longer period of follow-up, but we also need to teach sanitary workers how to approach APC and to teach people what APC is and why it’s so important for everyone.

Keywords: advanced care planning, end-stage kidney disease, dialysis

Role of the Opinions of the Nephrologist and Structural Factors in Dialysis Modality Selection. Results of a Peritoneal Dialysis Study Group Questionnaire

Loris Neri1, Giusto Viglino2, Valerio Vizzardi3, Silvia Porreca4, Claudio Mastropaolo5, Giancarlo Marinangeli6 e Gianfranca Cabiddu7 on behalf of the Peritoneal Dialysis Project Group of the Italian Society of Nephrology

1 Nefrologia e Dialisi, Ospedale “Michele e Pietro Ferrero”, Verduno, Cuneo, Italy
2 Referente per la Telemedicina dell’ASLCN2, Italy
3 Nefrologia e Dialisi, Spedali Civili, Brescia, Italy
4 Nefrologia e Dialisi, Policlinico Università A. Moro, Bari, Italy
5 Visionage SRL
6 UOC di Nefrologia e Dialisi, Ospedale di Giulianova, Teramo, Italy
7 ARNAS Brotzu, Università degli Studi di Cagliari, Italy

Background. The use of PD depends on economic, structural and organizational factors. The nephrologist’s opinion is that peritoneal dialysis is less used than it shold be. In Italy, PD is not carried out in private Centers, but neither is it in around one third of Public Centers. The aim of this study was to investigate the opinions of nephrologists on PD in Public Centers only, thereby nullifying the influence of the economic factors.
Materials and Methods. The investigation was carried out by means of an online questionnaire (Qs) via mail, and during meetings and Congresses in 2006-07. The Qs investigated the characteristics of the Centers, the nephrologists interviewed, and opinions on the various aspects of the choice of Renal Replacement Therapy Renal Replacement Therapy (RRT) (26 questions). Responses were received from 454 nephrologists in 270 public Centers. Among these, 205 centers (370 Qs) report PD (PD-YES), 36 (42 Qs) do not (PD-NO) and 29 (42 Qs) do not use it but send patients selected for PD to other Centers (PD-TRANSF).
Results. The PD-NO and PD-TRANSF Centers are significantly smaller, with greater availability of beds. In the PD-YES Centers the presence of a pre-dialysis pathway, early referral and nurses dedicated solely to PD are associated with a higher use of PD.
The nephrologists in the PD-NO Centers rate PD more negatively in terms of both clinical and non-clinical factors. The belief that more than 40% of patients can do either PD or HD differs among the nephrologists in the PD-YES (74.3%), PD-TRANSF (45.2%) and PD-NO (28.6%) Centers. Likewise, the belief that PD can be used as a first treatment in more than 30% of cases differs among the nephrologists in PD-YES (49.2%), PD-TRANSF (33.3%) and PD-NO (14.3%) Centers.
Conclusions. The use of PD in Public Centers is conditioned by both structural and organizational factors, and by the opinions of nephrologists on the use and effectiveness of the technique.



Graphical abstract


Keywords: Peritoneal Dialysis, Hemodialysis, Modality selection, Physicians opinion, Chronic Kidney Disease

Peritoneal Dialysis in Italy: the 8th GPDP-SIN Census 2022 – 2nd Part: the Centers

Loris Neri1, Giusto Viglino2, Valerio Vizzardi3, Silvia Porreca4, Claudio Mastropaolo5, Giancarlo Marinangeli6 e Gianfranca Cabiddu7 on behalf of the Peritoneal Dialysis Project Group of the Italian Society of Nephrology

1 Nefrologia e Dialisi, Ospedale “Michele e Pietro Ferrero”, Verduno, Cuneo, Italy
2 Referente per la Telemedicina dell’ASLCN2, Italy
3 Nefrologia e Dialisi, Spedali Civili, Brescia, Italy
4 Nefrologia e Dialisi, Policlinico Università A. Moro, Bari, Italy
5 Visionage SRL
6 UOC di Nefrologia e Dialisi, Ospedale di Giulianova, Teramo, Italy
7 ARNAS Brotzu, Università degli Studi di Cagliari, Italy

Objectives. The results are presented of the 8th National Census (Cs-22) of the Peritoneal Dialysis Project Group of the Italian Society of Nephrology relating to the characteristics of the Centers in Italy which used PD in 2022.
Materials and methods. The 227 non-pediatric centers which used Peritoneal Dialysis (PD) in 2022 took part. The data requested were sent in aggregate form. For the first time, the resources available and training were investigated as well as home visits. The Centers have been divided into Quartiles according to the number of prevalent PD patients at 31/12/2022.
Results. Centers with a smaller PD program (<9 pts) are characterized by 1. smaller overall size – 2. fewer personnel (doctors/nurses) dedicated to PD – 3. greater recourse to external personnel for training – 4. Less incremental prescription and evaluation of peritoneal permeability – 5. higher drop-out to HD in particular for choice/impossibility to continue and for adequacy/catheter-related issues. A lower peritonitis rate was recorded in Centers with a more extensive PD program (≥25 pts). Home visits are carried out regularly by a small minority of Centers. Conclusions. The analysis shows an association between size of Center PD program and available resources, PD modality and outcome.



Graphical abstract


Keywords: Peritoneal Dialysis, Center effect, technique failure

Apheresis Techniques for the Treatment of Hyperbilirubinemia in the Nephrology Unit

Emanuela de Pascale1, Gaia Marinelli1, Pietro Iulianiello2, Rossana Matrisciano2, Davide Viggiano2, Corrado Pluvio1

1 AORN dei Colli, “D. Cotugno” Hospital, Department of Dialysis with Hepatic-Infective Complications, via L. Bianchi, 80131, Naples, Italy
2 Department of Translational Medical Sciences, University of Campania “L. Vanvitelli”, Naples

Therapeutic apheresis is an important hematological and nephrological method for conditions with altered plasma composition. It is also indicated for the removal of protein-bound molecules, such as bilirubin. Several techniques can remove these compounds, such as the extracorporeal circulation molecular adsorption system (MARS), plasma exchange (PEX), and plasma adsorption and perfusion (PAP). Here we report our experience in the comparison between MARS, PEX and PAP, since current guidelines do not specify which method is the most appropriate and under which circumstances it should be used.

The choice of technique cannot be based on the desired plasma bilirubin concentration, since these three techniques show similar results with a similar final outcome (exitus). In fact, PAP, PEX and MARS significantly reduce bilirubin levels, but the degree of reduction is not different among the three. Furthermore, the three techniques do not differ in the rate of cholinesterase change, while less reduction of liver transaminases was found by using PAP.

MARS should be preferred in the case of renal involvement (hepatorenal syndrome with hyperbilirubinemia). PAP has the advantage of being simple and inexpensive. PEX remains an option when emergency PAP is not available, but the risk of using blood products (plasma and albumin) must be considered.

Keywords: Molecular Adsorbent Recirculating System, MARS, Plasma Adsorption Perfusion, plasma exchange

The Outpatient Activity of the Onconephrology Clinic of Cremona in the First Semester of 2023

Marina Foramitti1, Francesca Boni1, Gianluca Marchi1, Laura Cosmai2, Fabio Malberti1

1 UO Nefrologia e Dialisi, ASST Cremona, Italia
2 UO Nefrologia e Dialisi, ASST Fatebenefratelli Sacco

Despite the rapidly growing area of onconephrology in the last decade, nephropathic patients have been rarely involved in clinical trials of cancer therapy, particularly in the case of chronic kidney disease (CKD) stage 4 (CKD4) or stage 5 (CKD5). We could offer better therapeutic opportunities to our patients thanks to the Onconephrology Clinic and the Multidisciplinary group, in which a dedicated team of specialists guarantees the highest level of possible care. In this paper, we analysed the activity of the first Italian OnconephrologyClinic, twelve years after its foundation. We studied retrospectively a cohort of 174 patients referred to our center in the last six months (from 11/01/2023 to 12/07/2023), with a total of 262 visits (40 first visits). We highlight a prevalence of moderated or advanced kidney disease, in contrast with the literature, which is probably the result of a transversal II level clinic with different specialists involved. Furthermore, in patients with a prolonged follow-up, we observed a progressive better attention to every kidney involvement, particularly in patients in active cancer therapy, by the oncologist colleagues. We observed a reduction of treatment withdrawals due to kidney toxicity, thanks to a multidisciplinary approach and experienced-based management. On the other side, we highlight also a delayed addressing of patients with acute kidney injury (AKI), which often results in chronic kidney damage. This could be related to a delayed identification of the reduced renal function, which is difficult to correctly value in patients with cancer.

Keywords: onconephrology, cancer therapy, nephrectomy, kidney function

West Nile Infection and Kidney Disease: Description of Two Clinical Cases in Peritoneal Dialysis Patients

Roberto Scarpioni1, Teresa Valsania1, Sara De Amicis1, Chiara Rocca1, Valentina Blanco1, Maria Varì1, Michela Frittoli1, Vittorio Albertazzi1, Luigi Melfa1, Marco Ricardi1

1 UOC Nefrologia Dialisi, Ospedale AUSL “Guglielmo da Saliceto”, Piacenza, Italia

The West Nile Virus (WNV), an RNA arbovirus, has been transmitted by wild birds and conveyed by ticks and mosquitoes, with wide diffusion all over the world; it is not transmitted from human to human. It can give clinical symptoms only in a minority of infected subjects such as fever, headache, muscle tiredness, visual disturbances, drowsiness, convulsions and muscle paralysis; in the most serious cases even potentially fatal encephalitis. In the literature there are few reports on WNV infection in patients with kidney diseases: here we report our experience on two patients on peritoneal dialysis infected by WNV with a revision of the literature.

Keywords: West Nile virus infection, chronic kidney disease, end-stage kidney failure, peritoneal dialysis, kidney transplant

Calcified Fibrin Sheath After Stuck Catheter Removal: Case Report and Literature Review

Marco Taurisano1, Andrea Mancini1, Filomena D’elia1, Giuseppe Gernone2, Cosma Cortese3

1 UOC Nefrologia e Dialisi, Ospedale “Di Venere”, Bari
2 Dipartimento Nefrourologico- Nefrologia e Dialisi PP. OO. Putignano-Monopoli
3 UOC Nefrologia, Dialisi e Trapianto Policlinico di Bari

The prevalence of central venous catheters (CVC) in hemodialysis patients is around 20-30%. In this scenario, complications related to the use of the CVC are commonly observed, requiring active management by nephrologists. These include infectious complications as well as those related to CVC malfunction. Among the latter, the formation of a fibrin sheath around the catheter linked to foreign body reaction could cause CVC malfunction in various ways. Even after the removal of the catheter, the fibrin sheath can remain inside the vascular lumen (ghost fibrin sheath) and rarely undergo calcification. We describe the clinical case of a hemodialysis patient who, following the removal of a malfunctioning, stuck CVC, presented a calcified tubular structure in the lumen of the superior vena cava, diagnosed as calcified fibrin sheath (CFS). This rare occurrence, described in the literature in 8 other cases, although rare, is certainly underdiagnosed and can lead to complications such as sepsis resulting from CFS, pulmonary embolisms, and vascular thrombosis. Therapeutic approaches should be considered only in symptomatic cases and involve an invasive surgical approach.

Keywords: CVC complication, fibrin sleeve, fibrin sheath, calcified fibrin sheath, stuck catheter, hemodialysis

Steroid-Dependent Nephrotic Syndrome Due to Minimal Change Glomerulonephritis Treated with Rituximab

Fabrizio Cristiano1,2, Vittore Verratti3, Ginevra Di Matteo2, Stefania Fulle2, Jenny Cristiano4, Benito D’Angelo1, Ludovico Caravelli1, Cosima Posari1, Alessandra Schiazza1, Alessandra Piano1

1 UOSD Nefrologia Dialisi, Ospedale di Ortona, Contrada Santa Liberata ‒ Asl 2 Lanciano Vasto Chieti
2 Department of Neuroscience, Imaging and Clinical Science, G. D’Annunzio University of Chieti-Pescara
3 Department of Psychological, Health and Territorial Sciences, University “G. d’Annunzio” of Chieti-Pescara, Chieti
4 UOC Farmacia Ospedaliera – Ospedale Clinicizzato di Chieti – Asl 2 Lanciano Vasto Chieti

47-year-old woman suffering from minimal lesion glomerulonephritis previously undergone high-dose steroid therapy and subjected to exacerbations of nephrotic syndrome after therapy discontinuation. It was decided to initiate off-label treatment with Rituximab at a dosage of 375 mg/m2 administred at zero-time, one-month and three months with good therapeutic response and resolution of the clinical laboratory picture. The therapy was well tolerated and had no side effects. This scheme could be an alternative to the conventional therapeutic scheme with steroids or other classes of immunosuppressive drugs, especially in order to avoid problems related to prolonged exposure to steroid therapy.

Keywords: minimal change glomerulonephritis, Rituximab, steroid-dependent nephrotic syndrome

Examination of Urinary Sediment in a Patient with Lupus-Like HIV-Associated Immune Complex Kidney Disease (HIVICK) – Case Report and Review of the Literature

Gianmarco Borriello1, Michelangelo Nigro2, Pierluigi D’Angiò2, Simona Laurino2, Andrea Gigliotti2, Davide Viggiano1, Giuseppe Gigliotti2

1 UOC Nefrologia e Dialisi, Dipartimento di scienze mediche traslazionali, Univ. della Campania ‘Luigi Vanvitelli’, Napoli, Italia
2 UOC Nefrologia e Dialisi, ospedale di Eboli, Salerno, Italia

Renal involvement is very common in patients with HIV infection. The phenotype varies from the most frequently “collapsing” variant of focal and segmental glomerulosclerosis (FSGS) to “lupus-like HIV-immune complex kidney disease” (HIVICK). The latter is characterized by a histological picture that recalls lupus nephropathy.
Through a clinical case, we underline the importance of urinary sediment analysis in patients with suspected glomerulopathy. Findings such as the characteristic cells that show the typical appearance of Herpes virus (HSV) infection or LE cells have significantly supported the diagnosis of HIVICK. In light of the present observations, we suggest systematically carrying out a cytological examination of the urinary sediment to confirm diagnostic hypotheses of rare pathologies.

Keywords: HIV, HIVICK, HSV, LE cells, urinary sediment, cytology

Use of CFTR Modulators for Cystic Fibrosis in a Patient with Liver Transplant and ESRD on Hemodialysis

Lilio Hu1,2, Paolo Ferdinando Bruno3, Sara Signorotti3, Marco Ruggeri3, Veronica Sgarlato3, Fulvia Zanchelli3, Lucia Neri3, Antonio Giudicissi3, Giovanni Mosconi3

1 UO Nefrologia, Dialisi e Trapianto – IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italia
2 Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), Alma Mater Studiorum – Università di Bologna, Bologna, Italia
3 UO Nefrologia e Dialisi – Ospedale “M. Bufalini”, Cesena, Italia

Cystic fibrosis is an autosomal recessive disorder caused by mutations of the gene encoding the cystic fibrosis transmembrane conductance regulator (CFTR) protein. The most recent therapeutic approach to cystic fibrosis aims to correct structural and functional abnormalities of CFTR protein.
CFTR modulators including ivacaftor-tezacaftor-elexacaftor are used in patients with F508del mutation, with clinical improvement. To date, there are no experiences of CFTR modulator therapy in cystic fibrosis patients with organ transplantation and severe renal impairment.
We report the case of a patient diagnosed with cystic fibrosis with F508del mutation, who underwent liver transplantation at the age of 19 and started hemodialysis at the age of 24 due to end-stage renal disease secondary to membranous glomerulonephritis. She was treated with Kaftrio (ivacaftor-tezacaftor-elexacaftor) with clinical benefits on appetite, improvement of body mass index, and reduction of pulmonary exacerbations. A reduction of dosage to 75% of the standard dose was required due to alterations of the liver function.
Conclusions. Use of CFTR modulators in patient with cystic fibrosis, liver transplant and end-stage renal disease could be considered safe but a clinical and laboratoristic monitoring of hepatic function is needed.

Keywords: CFTR modulators, cystic fibrosis, ESRD, liver transplant

Esiste una scuola Italiana di nefrologia? Considerazioni di un nefrologo italiano in Francia

Giorgina Barbara Piccoli

Review and Practical Excursus of the Propensity Score: Low Protein Diet Compared to Mediterranean Diet in Patients With Chronic Kidney Disease

Vincenzo Calabrese1, Guido Gembillo1, Martina Buda2, Valeria Cernaro1, Elisa Longhitano1, Antonello Pontoriero3, Matteo Polizzi4, Daniela Metro1, Domenico Santoro1

1 Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, A.O.U. ‘G. Martino’, University of Messina, Messina, Italy
2 General and Oncologic Surgery Unit, Faculty of Medicine, University of Messina, G. Martino University Hospital, Messina, Italy
3 Unit of Nephrology, Department of medicine ASP 5 Messina, P.O. Milazzo
4 University of Messina, Messina, Italy

Although Randomized clinical trials (RCT) represent the gold standard to compare two or more treatments, the impact of observational studies cannot be ignored. Obviously, these latter are performed on unbalanced sample, and differences among the compared groups could be detected. These differences could have an impact on the estimated association between our allocation and our outcome. To avoid it, some methods should be applied in the analysis of observational cohort.
Propensity score (PS) can be considered as a value which sums up and balances the known variables. It aims to adjust or balance the probability of receiving a specific allocation group, and could be used to match, stratify, weight, and perform a covariate adjustment. PS is calculated with a logistic regression, using allocation groups as the outcome. Thanks to PS, we compute the probability of being allocated to one group and we can match patients obtaining two balanced groups. It avoids computing analysis in unbalanced groups.
We compared low protein diet (LPD) and the Mediterranean diet in CKD patients and analysed them using the PS methods. Nutritional therapy is fundamental for the prevention, progression and treatment of Chronic Kidney Disease (CKD) and its complications. An individualized, stepwise approach is essential to guarantee high adherence to nutritional patterns and to reach therapeutic goals. The best dietary regimen is still a matter of discussion.  In our example, unbalanced analysis showed a significant renal function preservation in LPD, but this correlation was denied after the PS analysis.
In conclusion, although unmatched analysis showed differences between the two diets, after propensity analysis no differences were detected. If RCT cannot be performed, balancing the PS score allows to balance the sample and avoids biased results.

Keywords: Chronic Kidney Disease, Low Protein Diet, Matching, Mediterranean Diet, Nutritional Therapy, Propensity Score, Randomized Clinical Trials

Therapeutic Plasma Exchange in a Patient with Chronic Hemodialysis and a New Diagnosis of Myasthenia Gravis

Giudicissi A.1, Vetrano D.2, Morresi S.3, Bruno P.F.1, Neri L.1, Signorotti S.1, Sgarlato V.1, Ruggeri M.1 Zanchelli F.1, Longoni M.3, Buscaroli A.1

1 Unità Operativa di Nefrologia e Dialisi, Ospedale “M. Bufalini”, Cesena, Italia
2 Unità Operativa di Nefrologia, Dialisi e Trapianto, IRCCS Azienda Ospedialiero Universitaria di Bologna, 40138, Bologna, Italia
3 Unità Operativa di Neurologia e Stroke Unit, Ospedale “M. Bufalini”, Cesena, Italia

Case Report. C.S.T. (♂, 71 years old) is a patient with multiple and severe comorbidities, undergoing thrice-weekly chronic hemodialysis since 2008 due to the progression of post-lithiasic uropathy. Over the past 2 months, the patient had been experiencing progressive ptosis of the eyelids, muscle weakness, and ultimately dysphagia and dysarthria that emerged in the last few days. Urgently admitted to the Neurology department, electromyography (EMG) was performed, leading to a diagnosis of predominant cranial myasthenia gravis (with borderline anti-acetylcholine receptor antibody serology). Prompt treatment with pyridostigmine and steroids was initiated.
Considering the high risk of acute myasthenic decompensation, therapeutic plasma exchange (TPE) with centrifugation technique was promptly undertaken after femoral CVC placement. TPE sessions were alternated with hemodialysis. The patient’s condition complicated after the third TPE session, with septic shock caused by Methicillin-Sensitive Staphylococcus Aureus (MSSA). The patient was transferred to the Intensive Care Unit (ICU). Due to hemodynamic instability, continuous veno-venous hemodiafiltration (CVVHDF) with citrate anticoagulation was administered for 72 hours.
After resolving the septic condition, intermittent treatment with Acetate-Free Biofiltration (AFB) technique was resumed. The patient completed the remaining three TPE sessions and, once the acute condition was resolved, was transferred back to Neurology. Here, the patient continued the treatment and underwent a rehabilitation program, showing significant motor and functional recovery until discharge.
Conclusions. The multidisciplinary interaction among Nephrologists, Neurologists, Anesthesiologists, and experts from the Immunohematology and Transfusion Medicine Service enabled the management and treatment of a rare condition (MG) in a high-risk chronic hemodialysis patient.

Keywords: Myasthenia Gravis, Plasmapheresis, Therapeutic Plasma Exchange, Hemodialysis, Continuous Renal Replacement Therapy

The Management of Patients with Adult Autosomal Dominant Polycystic Kidney Disease (ADPKD) Requires a Multidisciplinary Approach

Romina Bucci1, Liliana Italia De Rosa1, Matteo Brambilla Pisoni1, Sara Farinone2, Marta Vespa1, Giancarlo Joli1, Martina Catania1, Kristiana Kola1, Francesca Tunesi1, Elena Brioni1, Paola Carrera3, Giulia Mancassola3, Lorena Citterio1, Paolo Manunta1, Giuseppe Vezzoli1, Maria Teresa Sciarrone Alibrandi1

1 U.O. Nefrologia e Dialisi, IRCCS Ospedale San Raffaele, Milano, Italia; Università Vita Salute San Raffaele, Milano, Italia
2 Servizio di Psicologia Clinica e della Salute, IRCCS Ospedale San Raffale, Milano, Italia
3 Unit of Genomics for Human Disease Diagnosis, Division of Genetics and Cell Biology, IRCCS Ospedale San Raffaele, Milano, Italia

Autosomal dominant polycystic kidney disease (ADPKD) is the most common genetic kidney disease. Its main feature is the progressive enlargement of both kidneys with progressive loss of kidney function. ADPKD is the fourth leading cause of terminal renal failure in the world. Even today there are still uncertainties and poor information. Patients too often have a renunciatory and passive attitude toward the disease. However, there are currently no internationally accepted clinical practice guidelines, and there are significant regional variations in approaches to the diagnosis, clinical evaluation, prevention, and treatment of ADPKD. Therefore, we believe it is important to point out the conduct of our specialist outpatient clinic for ADPKD, which from the beginning has developed a multidisciplinary approach (nephrologists, geneticists, psychologists, radiologists, nutritionists) to face the disease at 360° and therefore not only from a purely nephrological point of view. Such a strategy not only enables patients to receive a timely and accurate diagnosis of the disease, but also ensures that they will receive a thorough and focused follow-up over time, that can prevent or at least slow down the disease in its evolution providing patients with a serene awareness of their condition as much as possible.

Keywords: ADPKD, genetics, clinical psychology, clinical nutrition, multidisciplinary approach

Correlation of Beta Trace Protein Levels with Serum Creatinine-Based Estimated Glomerular Filtration Rate Equations in Chronic Kidney Disease

Rengarajan Geethanjali1, Murugan Ganesh2, Anjana Vinod2, Elumalai Ramprasad3, Varadharajan Jayaprakash4

1 Department of Biochemistry, Government Medical College, Thiruvallur, India
2 Department of Biochemistry, Sri Ramachandra Institute of Higher Education and Research (SRIHER), Chennai
3 Department of Nephrology, Sri Ramachandra Institute of Higher Education and Research (SRIHER), Chennai
4 Department of Nephrology, SRM Medical College Hospital and Research Centre, SRM IST, Chengalpattu Dt, India

Background. Estimated GFR (eGFR) is calculated using serum creatinine (SCr) based equations which have their own limitations. Novel biomarkers like beta trace protein (BTP) are studied for eGFR estimation. The aim of this study is to determine the serum levels of BTP in healthy controls and chronic kidney disease (CKD) cases and to find out the correlation of BTP levels with that of SCr and SCr-based eGFR formulas.
Methods. The control group comprised of 20 healthy adults. The cases comprised of 20 patients each in CKD stages 3, 4, and 5, categorized based on eGFR calculated using MDRD formula. Baseline characteristics of the study population were recorded. BTP was measured by ELISA (Enzyme Linked Immunosorbent Assay) method and SCr by modified Jaffe’s method. The statistical analyses were performed with the SPSS for Windows, version 16.0.
Results. The median value of blood urea nitrogen (BUN) in the cases was 26.50 mg/dL (IQR 19.25-37) and for control it was 9.5 mg/dL (IQR 8-12). The median value of SCr in the cases was 2.75 mg/dL (IQR 1.725-4.45) and in the controls, it was 0.7mg/dL (IQR 0.6 -0.8). The median value of BTP in cases was 6389.25 ng/ml (IQR 5610.875-10713.75) and in controls, it was 1089.5 ng/ml (IQR 900.5-1309.75).
Conclusion. Serum BTP levels correlated with SCr levels and renal function. We could establish the relationship between the two biomarkers, SCr and BTP, and derive a regression equation.

Keywords: Beta trace protein, estimated GFR, CKD, correlation

Kikuchi-Fujimoto’s Disease: A Rare and Underdiagnosed Condition with Possible Renal Involvement

Enrica Falbo

Consultant Nephrologist at Healthbay Polyclinic Jumeirah ‒ 1-6 Al Wasl Rd ‒ Umm Al Sheif, Dubai, Emirati Arabi Uniti (UAE)

Kikuchi-Fujimoto disease (KFD), or Histiocytic Necrotizing Lymphadenitis, is a rare disease, with worldwide distribution but is best known in Japan and South Asia. The most common feature is cervical lymphadenopathy, accompanied by tenderness or high fever, with night sweats, but it can also be asymptomatic or with a very wide range of symptoms. The diagnosis is histopathological, on excisional biopsy. The Kikuchi-Fujmoto disease can mimic lymphoma but also tuberculosis and some autoimmune diseases, or be associated with them. Nephrologists need to be aware of it, considering the potential renal involvement. The association with systemic lupus erythematosus (SLE) is the most frequent but not the only one. Early diagnosis of this disease can prevent unnecessary investigations and aggressive therapies.

Keywords: Kikuchi-Fujimoto disease, Histiocytic Necrotizing Lymphadenitis, renal involvement, autoimmune disease, excisional biopsy, differential diagnosis

Type I Hyperprolinemia – What about the Kidney?

Manuela Rizzo1, Maria Amicone1, Maria Luigia Sellitti1, Antonella Marino1, Anna Sannino1, Ivana Capuano1, Antonio Pisani1

1 Dipartimento di Sanità Pubblica, Università degli Studi di Napoli “Federico II”, Napoli, Italia

Hyperprolinemia is a rare genetic condition due to mutations in proline metabolic pathway. Type I Hyperprolinemia (HPI) typically causes neuropsychiatric disorders, and diagnosis is usually confirmed in pediatric population with suggestive neuropsychiatric involvement by elevated serum proline levels and elevated urinary proline, hydroxyproline, and glycine levels.
The possible coexistence of nephropathy in patients with HPI, often specified as malformative urinary disease, is often mentioned. However, reports of HPI diagnosis due to kidney impairment do not exist in scientific literature yet.
Here we present the case of a patient presenting with chronic kidney disease secondary to obstructive nephropathy who received a HPI diagnosis in adulthood.
Interestingly, the family study showed the same 22q11.21 deletion and elevated blood proline levels in the father, who had no clinical anomalies.
We therefore suggest, in light of the high frequency of mutations involving 22q11 and PRODH in the general population, to consider these rare alterations in patients with congenital urinary malformations, even in the presence of nuanced neurological symptoms and negative family history.

Keywords: hyperprolinemia, type I hyperprolinemia, genetic nephropathy, malformative urinary disease

Congenital Nephrotic Syndrome: Role of Podxl Gene

Angela Zeni1, Luca Pecoraro1, Elisa Benetti2, Milena Brugnara1

1 UOC Pediatria C, Ospedale della Donna e del Bambino, Azienda Ospedaliera Universitaria Integrata Verona
2 UOC Nefrologia Pediatrica, Dipartimento di Salute della Donna e del Bambino, Azienda Ospedale Università Padova

In the last decades, our understanding of the genetic disorders of inherited podocytopathies has advanced immensely; this has been possible thanks to the development of next-generation sequencing technologies that offer the possibility to evaluate targeted genes at a lower cost than in the past. Identifying new genetic mutations has helped to recognize the key role of the podocyte in the health of the glomerular filter and to understand the mechanisms that regulate the cell biology and pathology of the podocyte. Here we describe a patient with congenital nephrotic syndrome due to a mutation in PODXL. This gene encodes podocalyxin, a podocyte-specific surface sialomucin known to maintain the characteristic architecture of the foot processes and the patency of the filtration slits.

Keywords: Proteinuria, Congenital nephrotic syndrome, Podocyte, PODXL, Podocalyxin

New Mutation of CYP24A1 in a Case of Idiopathic Infantile Hypercalcemia Diagnosed in Adulthood

F. Zanchelli1, A. Giudicissi1, L. Neri1, V. Sgarlato1, P.F. Bruno1, M. Ruggeri1, S. Signorotti1, D. Vetrano2, A. Buscaroli1

1 U.O. Nefrologia e Dialisi – Ospedale “M. Bufalini”, Cesena, Italia
2 Nefrologia, Dialisi e Trapianto, IRCCS Azienza Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum Università di Bologna, Italia

Mutations in the 24-hydroxylase gene CYP24A1 have been recognized as causes of childhood idiopathic hypercalcemia (IIH), a rare disease (incidence <1:1,000,000 live births) [1] characterized by increased vitamin D sensitivity [2], with symptomatic severe hypercalcemia.
IIH was first described in Great Britain two years after the start of a program of vitamin D supplementation in milk for the prevention of rickets, manifesting in about 200 children with severe hypercalcemia, dehydration, growth failure, weight loss, muscle hypotonia, and nephrocalcinosis [3].
The association between the epidemic occurrence of IIH and vitamin D administration was quickly attributed to intrinsic hypersensitivity to vitamin D [4], and the pathogenic mechanism was recognized in the inactivation of Cytochrome P450 family 24 subfamily A member 1 (CYP24A1), which was identified as the molecular basis of the pathology [5].
The phenotypic spectrum of CYP24A1 mutation can be variable, manifesting predominantly with childhood onset and severe symptomatology (severe hypercalcemia, growth retardation, lethargy, muscle hypotonia, dehydration), but also with juvenile-adult onset forms with nephrolithiasis, nephrocalcinosis, and alterations in phosphocalcium homeostasis [6].
We describe the case of a patient in whom the diagnosis of IIH was made in adulthood, presenting with finding of nephrocalcinosis in childhood, and with subsequent onset of severe hypercalcemia with hypercalciuria, hypoparathyroidism, hypervitaminosis D, and recurrent renal lithiasis.
Genetic investigation revealed the presence in homozygosity of the c_428_430delAAG_p.Glu143del variant in the CYP24A1 gene with autosomal recessive transmission, a mutation not reported in the literature.

Keywords: CYP24A1, Hypercalcemia, Infantile Idiopatic Hypercalcemia, Vitamin D, Nephrocalcinosis

Lo stato dell’arte

Gaetano La Manna

Editor in Chief Giornale Italiano di Nefrologia

The Early Years of Nephrology at Molinette Hospital in Turin Told by Those Who Lived and Built Them

Piero Stratta, Sandro Alloatti, Giuseppe Segoloni, Michele Rotunno, Giorgio Triolo, Margherita Dogliani, Giovanni Mangiarotti, Caterina Canavese, Giovanni B. Fogazzi

This article, written by several authors, describes the birth and early development of the nephrology at Molinette Hospital in Torino, Italy. In particular, it supplies important information on Antonio Vercellone, very motivated and innovative clinician and one of the fathers of Italian nephrology, and on Giuseppe Piccoli, his right-hand man and then his successor. This article also shows the strong professional and human engagement that was requested to the young doctors who, in the early Sixties and Seventies of the past century, had chosen to devote their professional lives to the patients with kidney diseases: from endless workdays without schedules to the anguish caused by the shortage of artificial kidneys to the cure of very fragile and unfortunate patients, and much more.

Keywords: History of Molinette Hospital, History of nephrology of Torino, History of Italian nephrology

The Educational Aspect in Promoting a Low-Sodium Diet, Physical Activity and Therapy Adherence among Patients with Autosomal Dominant Polycystic Disease: A Literature Review

Elena Brioni1, Giulia Villa2, Duilio Fiorenzo Manara2, Sara Farinone3, Cristiano Magnaghi4, Davide Scuratti1, Dina Moranda1, Emanuele Galli1, Maria Teresa Sciarrone5, Giuseppe Vezzoli5

1 Corso di Laurea in Infermieristica Università Vita Salute San Raffaele, Milano
2 Center for Nursing Research and Innovation, Università Vita-Salute San Raffaele, Milano
3 Servizio di Psicologia Clinica Ospedale San Raffaele, Milano
4 Segreteria Tecnico Scientifica Comitato Etico, IRCCS Ospedale San Raffaele, Milano
5 U.O Nefrologia e Dialisi IRCCS Ospedale San Raffaele, Università Vita-Salute San Raffaele, Milano

Background. Polycystic kidney disease (ADPKD) is the most common monogenic cause of End Stage Renal Disease (ESRD), and, thus, of kidney transplantation and dialysis. Educational interventions aimed to improve adherence to therapy, physical performance, and adequate food intake in patients can slow down disease progression by developing self-care skills, which are useful to promote their autonomy while aligning their life plans and required treatments.
The aim of this review is to analyze the adherence of patients with polycystic kidney to pharmacological therapy, low-sodium diet, and physical activity, as evidenced in the clinical literature to guide structured educational interventions.
Methods. We conducted a literature review from 01/09/2021 to 30/12/2022 through the combination of free keywords and MeSH terms on the databases: PubMed, CINAHL and Cochrane.
Results. Findings in medical literature show that physical activity can improve blood pressure control and a low-sodium diet can slow down the progression towards ESRD. Furthermore, although patients may adhere to the complex drug therapy, unresolved educational demands concern choices and behaviors of daily life that, involving the sphere of feelings and emotions, can evolve into manifestations of anxiety and stress. Conclusion. Among ADPKD patients a personalized educational support, considering disease stage and psychological factors, may enable them to acquire knowledge, skills, and behaviors that can improve clinical outcomes.

Keywords: autosomal dominant polycystic kidney disease, patient education, disease management

New Therapeutic Strategies in the Treatment of CKD Anemia: Hypoxia-Induced Factor Prolyl-Hydroxylase Inhibitors

Marco Taurisano1, Paolo Protopapa2, Silvia Barbarini2, Andrea Mancini1, Cosma Cortese3, Marcello Napoli2

1 UOC Nefrologia e Dialisi, Ospedale “Di Venere”, Bari
2 UOC Nefrologia e Dialisi, Ospedale “Vito Fazzi”, Lecce
3 UOC Nefrologia, Dialisi e Trapianto Policlinico di Bari

The link between chronic renal failure and anemia has been known for more than 180 years, negatively impacting the quality of life, cardiovascular risk, mortality, and morbidity of patients with chronic kidney disease (CKD). Traditionally, the management of anemia in CKD has been based on the use of replacement martial therapy, vitamin therapy, and the use of erythropoiesis-stimulating agents (ESAs). In recent years, alongside these consolidated therapies, new molecules known as hypoxia-induced factor prolyl-hydroxylase inhibitors (HIF-PHIs) have appeared. The mechanism of action is expressed through an increased transcriptional activity of the HIF gene with increased erythropoietin production. The drugs currently produced are roxadustat, daprodustat, vadadustat, molidustat, desidustat, and enarodustat; among these only roxadustat is currently approved and usable in Italy. The possibility of oral intake, pleiotropic activity on martial and lipidic metabolism, and the non-inferiority compared to erythropoietins make these drugs a valid alternative to the treatment of anemia associated with chronic kidney disease in the nephrologist practice.

Keywords: CKD, Anemia, Erythropoietin, HIF, Roxadustat

Management of the Central Venous Catheter in Patients Undergoing Hemodialysis Treatment

Sonia Sellami1, Daniele Pandolfi2, Luigi Apuzzo2

1 RN, UO Nefrologia e Dialisi, Casa di Cura Nuova Villa Claudia, Roma, Italia.
2 MSC, RN, UOS Fabbisogni, Standard e modelli Organizzativi delle professioni sanitarie, AGENAS, Roma, Italia

Background. Catheter-related bloodstream infection (CRBSI) is defined as the presence of bacteremia originating from a venous catheter and is one of the most common and costly complications, often followed by death and septicemia.
Objectives. To evaluate the effectiveness of specific interventions on CRBSI reduction rates and other outcomes.
Materials and Methods. The review has been performed by consulting scientific evidence through the PUBMED/MEDLINE database using MeSh terms and Boolean operators. Studies related to the formulated hypothesis have been selected and included.
Results. The results showed that thanks to a series of interventions it was possible to decrease the risk of CRBSI and lowered the risk of catheter removal, hospitalization rate and morbidity rate.
Discussion and Conclusions. Proper catheter care and follow-up procedures are the first steps in preventing infection. Audit and education of dialysis unit personnel is essential.

Keywords: Catheter, Blood Stream Infection, Hemodialysis Catheter Management, Nurse, Central Lines, Rate of Infections

Contrast Media Toxicity and Its Prevention

Concetto Sessa1, Luca Zanoli2, Giovanni Noto3, Ivana Alessandrello1, Dario Galeano1, Elisa Giglio1, Alfio Edoardo Giuffrida1, Giulio Distefano1, Vincenzo Ficara1, Roberta Maria Messina1, Stella Musumeci1, Viviana Scollo1, Fortunata Zirino1, Carmelo Zuppardo1, Walter Morale1

1 U.O.C. Nefrologia e Dialisi, P.O. Maggiore “Nino Baglieri”, Modica, Ragusa (RG)
2 Nefrologia, Dipartimento di Medicina Clinica e Sperimentale, Università di Catania, Catania (CT)
3 U.O.C. Medicina e Chirurgia d’Accettazione e Urgenza, P.O. Giovanni Paolo II, Ragusa (RG)

Intravenous iodinated contrast media are commonly used in clinical practice, ranging from medical imaging to interventional radiology (IR) procedures and endovascular interventions. Compared with patients with normal renal function, nephropathic patients have an increased risk of acute kidney injury (AKI). Nevertheless, this condition cannot represent a limit to diagnostics or endovascular interventions.
Despite the literature of the last five years, conflicting management and approaches for nephropathic patients persist, including the use of contrast agents and treatments replacing renal functions, which are often mistakenly considered as part of preventive strategies. Though the issue has been widely discussed, specialists often cope with uncertainty in handling properly the administration of contrast media and renal counselling requests. Furthermore, there is a general difficulty in distinguishing the Post-Contrast Acute Kidney Injury (PC-AKI) from the Contrast-Associated Acute Kidney Injury (CI-AKI).
The present review aims to provide an update on the issue and examine strategies to reduce the acute kidney injury risk after the administration of contrast media. These strategies include the early identification of high-risk individuals, the choice of the contrast media and the proper dosage, the suspension of nephrotoxic drugs, the follow-up of the high-risk individuals, and the early identification of AKI.

Keywords: Constrast Medium, Acute Kidney Injury, Prevention, Hydration

Contrast Induced Encephalopathy after carotid percutaneous transluminal angioplasty in a patient with end stage renal disease undergoing peritoneal Dialysis

Maria Mattiotti1,2,3, Sabrina Milan Manani1,2, Maddalena Gnappi1,2,4, Grazia Maria Virzì1,2, Matteo Marcello1,2, Davide Marturano1,2, Ilaria Tantillo1,2, Anna Giuliani1,2, Gaetano La Manna3, Claudio Ronco1,2,4 and Monica Zanella1,2

1 Department of Nephrology, Dialysis and Transplant, St Bortolo Hospital, Vicenza, Italy
2 IRRIV – International Renal Research Institute, Vicenza, Italy
3 Nephrology, Dialysis and Transplant Unit, IRCCS Policlinico Sant’Orsola, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.
4 DIMED, University of Padova, Padova, Italy

Introduction. Contrast Induced Encephalopathy (CIE) belongs to Major Adverse Renal and Cardiovascular Events (MARCE) after iodinated contrast medium (IOCM), especially for high-risk patients with several comorbidities such as hypertension, diabetes, heart failure, and Chronic Kidney Disease (CKD). We report a case of CIE in a Peritoneal Dialysis (PD)-patient.
Case report. A 78-year-old, affected by diabetes, hypertension, chronic heart failure, and End Stage Renal Disease (ESRD) treated with PD, underwent a carotid Percutaneous Angioplasty (PTA). Immediately after the exam, he developed mental confusion and aphasia. Encephalic CT scan and MRI excluded acute ischemia or hemorrhage but showed cerebral oedema.  Mannitol and steroids were administered and additional PD exchange was performed with depurative aim. Within 2 days the patient completely recovered.
Discussion. CIE mimics severe neurological diseases. It should be considered as a differential diagnosis if symptoms occur immediately after administration of IOCM, especially in high-risk patients and in case of intra-arterial injection. Clinical presentation includes transient cortical blindness, aphasia, focal neurological defects, and confusion. CIE is often a diagnosis of exclusion, and imaging plays a significant role. Symptoms generally resolve spontaneously within 24-48h, rarely in few days. Symptomatic therapy, including mannitol and steroids could be considered. In literature, CIE is reported only in a few patients affected by ESRD treated with chronic HD, and our is the first available case of a patient treated with chronic PD who developed this rare complication.

Keywords: Peritoneal Dialysis, Contrast-induced encephalopathy, contrast medium

Kidney Transplant in a Highly Sensitized Patient Treated with Imlifidase

Lorenzo D’Elia1, Luciano Cencioni1, Francesca Ciabattini2, Luca D’Argenzio2, Paola Vittoria Santirosi2

1 UOS Nefrologia e dialisi Ospedale “Santa Maria della Stella” Usl Umbria 2 Orvieto (TR)
2 UOC Nefrologia e dialisi Ospedale “San Giovanni Battista” Usl Umbria 2 Foligno (PG)

Through a clinical case, we will describe the difficulties associated with providing transplantation opportunities to highly immunized patients. We will therefore focus on new desensitization therapies and their pharmacological effects with the consequent improvement in clinical outcomes. The main desensitization strategies in use and the main future therapeutic prospects will also be discussed.

Keywords: Imlifidase, Kidney Transplant, Hyperimmune Patients

Autosomic Dominant Tubulo Interstitial Kidney Disease: Case Report of a New Variant of the UMOD Gene

Juan Guillermo Cárdenas Aguilera1, Lizeth Daniela Figueredo Rodriguez2, Kelly Rocio Chacón Acevedo3, Ana María Zarante Bahamón4, Juan Carlos Prieto5

1 Specialist in pediatric nephrology, Subred Integrada de Servicios de Salud Sur Occidente, Bogotá, Colombia
2 Specialist in Epidemiology, Subred Integrada de Servicios de Salud Sur Occidente, Bogotá, Colombia
3 MSc Clinical Epidemiology, Grupo de investigación traslacional, Instituto global de Excelencia Clínica Keralty, Bogotá, Colombia
4 Specialist in medical genetics, Hospital Universitario San Ignacio, Bogotá, Colombia
5 Specialist in medical genetics, Universidad Javeriana, Instituto de Genética Humana, Bogotá, Colombia

Autosomal dominant tubulointerstitial kidney disease (ADTKD) is a low-prevalence pathology mainly associated with pathogenic variants of the UMOD gene. It is characterized by the progressive deterioration of renal function, associated with hyperuricemia and accompanied by a family history of gout or hyperuricemia. Often, clinical variability and a lack of molecular testing results in diagnostic failure to determine the ADTKD-UMOD association.

Case presentation: We describe the case of a 14-year-old male who presented to the nephrology service with hyperuricemia, renal ultrasonographic changes, and progression to chronic kidney disease in 4 years. He had a family history of hyperuricemia. A probable genetic disease with an autosomal dominant inheritance pattern was considered, confirmed by the presence of a probably pathogenic variant of the UMOD gene, not previously reported in the literature.

Conclusion: The investigation of this case led to the identification of a new variant in the UMOD gene, broadening the spectrum of known variants for ADTKD-UMOD. In addition, in this case, a comprehensive anamnesis, that takes into account family history, was the key point to carry out genetic tests that confirmed the diagnosis suspicion. Directed Genetic tests are currently an essential diagnostic tool and should be performed as long as they are available and there is an indication to perform them.

Keywords: UMOD, Uromodulin, hyperuricemia, Uric acid, Familial Juvenile Hyperuricemic Nephropathy, case report

Collapsing Glomerulopathy Secondary to Anabolic Steroids for Bodybuilding: A Case Series

Roberta Passaro1, Pierluigi D’Angiò2, Simona Laurino2, Giuseppe Gigliotti2, Antonio Massa1, Antonio Mancini1, Annalisa Gonnella2, Anna Giammarino2, Gianmarco Borriello3

1 Dipartimento di Sanità Pubblica, Università degli Studi di Napoli “Federico II”, Napoli, Italia
2 UOC Nefrologia e Dialisi, PO Maria SS. Addolorata, Eboli, Italia
3 UOC Nefrologia e Dialisi, Università degli Studi della Campania “Luigi Vanvitelli”, Napoli, Italia

The abuse of anabolic androgenic steroids (AAS) for competitive (and non-competitive) purposes for bodybuilding practice is increasingly common. The consequences of these substances on the various organs are only partially known. Cases of FSGS following the use of AAS have been reported in the literature, even with evolution to ESKD.
We describe three cases of bodybuilding athletes who presented alterations in renal function indices after taking AAS for a long time. Three renal biopsies were performed with histological diagnosis of FSGS collapsing variant. We examine the lesions observed on histological examination. Two athletes had rapid progression of renal disease requiring replacement therapy. The third one continues conservative treatment for chronic renal failure.
We discuss the risks related to the intake of doping substances and how bodybuilders are exposed to different causes of kidney damage: anabolic steroids, supplements, and a high-protein diet.

Keywords: anabolic-androgenic steroids, bodybuilding, FSGS, collapsing variant, chronic kidney disease

Management of Cast Nephropathy

Emanuele De Simone1, Roberta Fenoglio1, Simone Cortazzi1, Andrea Careddu1, Giovanni Geraci1, Federico Bugliosi1, Savino Sciascia1 e Dario Roccatello1

1 University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy

Myeloma cast nephropathy is the most common cause of acute kidney injury in patients affected by multiple myeloma. The mainstay of management of cast nephropathy is the clone-based therapy by reducing production and thereby precipitation of light chains. Adjuvant therapy consists of inducing high urine volume flow and alkalinisation, where possible. Extracorporeal removal of light chains is still debated and the advantages of these procedures are not established. The use of safe and low expensive membranes may encourage their use and address their utility.

Keywords: multiple myeloma, cast nephropathy, dialysis

Classification and Management of MGRS Related Diseases

Andrea Angioi1, Nicola Lepori1, Daniele Derudas2, Matteo Floris1, Giacomo Mascia1, Gianfranca Cabiddu1 e Antonello Pani1

1 SCDU Nefrologia, Dialisi e Trapianto Renale ARNAS G. Brotzu, Cagliari
2 SC Ematologia ARNAS G. Brotzu, Cagliari

Monoclonal Gammopathies of Renal Significance (MGRS) are a complex group of disorders characterized by the production of aberrant monoclonal proteins that interact with kidney structures, causing tissue damage. Unlike neoplastic forms, kidney damage in MGRS does not correlate with clone mass or circulating monoclonal protein levels, conferring unique pre-neoplastic or non-neoplastic properties to the responsible clones.

This manuscript explores the heterogeneity of monoclonal proteins involved, varying from full immunoglobulins to free light chains (FLC), and how they result in a spectrum of kidney lesions with differing prognoses. We also elaborate on diagnostic challenges, emphasizing the indispensable role of kidney biopsy, including advanced techniques like laser microdissection and mass spectrometry (LMD/MS) for deposit characterization, particularly in ambiguous or complex cases. Clinical management and treatment considerations, including the necessity for clone identification, are also discussed.

Keywords: Plasma Cell Dyscrasias, Monoclonal gammopathy, Monoclonal gammopathy of renal significance, Kidney biopsy

How I Approach Light Chain Amyloidosis

Raad B. Chowdhury1, Nelson Leung2,3

1 Division of Renal Medicine, Department of Medicine, Brigham and Women’s Hospital, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
2 Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
3 Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA

Immunoglobulin Light Chain Amyloidosis (AL) is a progressive disease which leads to organ dysfunction and death.  Tremendous progress has been made in staging, response, and treatment.  The key to better survival though is early diagnosis which can be difficult since the symptoms are often nonspecific and can be seen in more common conditions. Once the diagnosis is confirmed, staging systems are available to provide prognosis on overall and renal survival.  There are a number of treatments now available that are effective and well-tolerated. Response criteria have also been developed for hematologic and renal response in order to maximize response and minimize adverse effects.  Newer therapies are being developed in particular anti-fibril therapies that are in clinical trials.  For those patients who had a very good partial response or better, kidney transplantation may be an option if the kidney failure is not reversed.

Keywords: amyloidosis, light chain amyloidosis, light chain, kidney transplantation

Can Patients with History of Malignancy Become Organ Donors?

Prof. Antonio Amoroso

Centro Regionale Trapianti Regione Piemonte e
SC Immunogenetica e Biologia dei Trapianti
Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino

Cancer transmission from solid organ donors to recipients is a known risk factor in transplantation. The Italian National Network for Transplantation (CNT) has adopted specific guidelines to evaluate the suitability of donors with history of malignancy. CNT also provides a Second Opinion service to assess oncological cases with a potential risk of neoplastic transmission to the recipient. CNT aims to minimize the risk of disease transmission from donors to recipients.

According to CNT guidelines, “standard” donors are defined as individuals with no signs of active malignancy and no history of cancer at the time of organ procurement. Unsuitable donors, defined as those with an “unacceptable risk”, are those patients with evidence of malignancy at the time of donation or in their medical history that carries an unacceptably high risk of disease transmission. Between these two categories, a broad spectrum of “non-standard” donors exists, where the risk of transmission is not entirely absent, but remains low enough to consider organ utilization. Malignancy should not be considered an absolute contraindication for organ donation.

CNT has also adopted a specific repository for adverse events (AE) after transplantation. Since 2012, with 10.493 donors and 34.193 performed transplants, 283 AE have been recorded, occurring in approximately 3% of donation processes and 1% of performed transplants. Oncological AE represented 13% of all reports. In the majority of cases, oncological AE resulted from missed diagnosis during organ procurement, benchwork, or transplantation surgery.

CNT guidelines, the oncological second opinion service, and the repository helped minimize the risk of cancer transmission with transplantation.

Keywords: cancer, organ donor, transplant

Onconephrology in Renal Transplant Patient: A Challenge for the Transplant Nephrologist

Enrico Sanna1, Ana Maria Manzione1, Silvia Mingozzi1, Luigi Biancone1

1 SC Nefrologia, Dialisi, Trapianto di Rene, Città della Salute e della Scienza di Torino, sede Molinette, Torino, Italia

Onconephrology, an emerging field in modern medicine, is gaining importance due to its intricate challenges derived from the mixing field of tumorous and renal diseases. The growing incidence of tumors in transplant patients requires preventive strategies and accurate monitoring. Pre-transplant screening is crucial, focusing on subjects with oncological history. Post-transplant follow-up must be personalized, tailoring screenings for patients with cancer history. Immunosuppressive therapy, although essential to prevent organ rejection, represents a delicate balance between controlling the immune response and cancer risk management.
Immune checkpoint inhibitors emerge as a fascinating potential for cancer therapy, but their use in transplant patients requires caution and further research to carefully evaluate their safety and effectiveness, balancing potential benefits with actual risk of rejection. In summary, onconephrology is a growing field that requires an interdisciplinary approach and constant research, aimed at successfully addressing the complex challenges associated with oncological diseases in renal and transplant patients.

Keywords: Onconephrology, Kidney transplant, Immunosuppressive therapy, Immune check-point inhibitors

Transplant Candidate with Cancer: Should We Proceed?

Giacomo Mascia1*, Matteo Floris1*, Andrea Angioi1, Nicola Lepori1, Davide Argiolas1, Gianfranca Cabiddu1,2 e Antonello Pani1,2

1 S.C. Nefrologia a Dialisi, Ospedale G. Brotzu, Cagliari, Italia
2 Università degli Studi di Cagliari, Dipartimento di Scienze Mediche, Cagliari, Italia
Gli autori contrassegnati con * hanno contribuito in maniera uguale alla pubblicazione

Individuals who suffer from end-stage renal disease are at a higher risk of developing certain types of tumors. This risk increases as kidney function deteriorates further. Dialysis patients often witness a surge in the incidence of such malignancies. Interestingly, after the initial period following a kidney transplant, there is a dip in the number of deaths related to neoplasms. However, a long-term view reveals a progressive increase in the risk of developing tumors. The evaluation process for transplant candidacy is thorough, taking into account several factors, including the individual’s history of neoplasms and the implications of immunosuppressive therapy. Immunosuppressive therapy is a double-edged tool in managing post-transplant complications, as it can foster environments conducive to neoplasm growth. It is essential to reevaluate, with the aid of an oncological opinion, the waiting time between cancer recovery and the listing for kidney transplantation, based on clinical data and follow-up. Independent of the type of tumor, the requirement to treat and achieve remission delays the listing process, consequently extending the time spent with end-stage renal disease and undergoing dialysis. These factors correlate with increased mortality, heightened risk of cardiovascular disease, and graft loss.

Keywords: Kidney transplant, cancer, immunosuppressant agents

The Treatment of Metastatic Renal Cell Carcinoma: An Update

Gaetano Pezzicoli1,2, Carlo Ganini1,2, Re Sartò Giulia Vanessa3,4, Marta Pirovano3,4, Laura Cosmai4*, Camillo Porta1,2*

1 Dipartimento Interdisciplinare di Medicina, Università degli Studi “A. Moro”
2 U.O.C. di Oncologia Medica, A.O.U. Consorziale Policlinico di Bari, Bari, Italia
3 Dipartimento di Scienze Biomediche e Cliniche, Università degli Studi di Milano
4 Ambulatorio di Onconefrologia, Divisione di Nefrologia e Dialisi, A.S.S.T. Fatebenefratelli-Sacco, Ospedale Fatebenefratelli, Milano, Italia
(*co-Senior Authors)

The therapeutic landscape for renal cell carcinoma (RCC) has undergone significant changes in recent years. In this Literature review, we offer a synopsis of the latest scientific evidence in this field. The introduction of a standard of care in the adjuvant setting, based on immune checkpoint inhibitors (ICI), was a breakthrough. The efficacy of this treatment, calculated as the relapse risk reduction, can vary depending on multiple factors, whose knowledge is important for the clinician in the therapeutic choice. Another innovation concerns the first-line therapy for metastatic RCC. In this setting, the new standard is represented by an immune combination, a therapy based either on a doublet of ICIs or on a combination between an ICI and one VEGFR-TKI. Making the best choice between the available options requires careful evaluation, in order to tailor the most appropriate treatment for each patient. The critical analysis of the most recent clinical trials is a fundamental tool to tailor the correct clinical management of localized and advanced RCC. Finally, this review focuses on the role of the nephrologist in the management of RCC patients, across different disease settings.

Keywords: Renal cancer, immunotherapy, tyrosin kinase-inhibitors

An Integrated Multidisciplinary Approach to the Care of Renal Cancer Patients Undergoing Nephrectomy

Matteo Floris1*, Andrea Angioi1*, Nicola Lepori1*, Giacomo Mascia1, Francesco Trevisani2, Michele Boero3, Mario Scartozzi, Gianfranca Cabiddu1,5 e Antonello Pani1,5

1 S.C. Nefrologia a Dialisi, Ospedale G. Brotzu, Cagliari, Italia
2 Dipartimento di Urologia e Urological Reserch Institute, Ospedale San Raffaele, Milano
3 S.C. Medicina Nucleare, Ospedale G. Brotzu, Cagliari, Italia
4 Oncologia Medica, AOU Cagliari Policlinico Duilio Casula, Monserrato, CA, Italia.
5 Università degli Studi di Cagliari, Dipartimento di Scienze Mediche, Cagliari, Italia
Gli autori contrassegnati con * hanno contribuito in maniera uguale alla pubblicazione

Kidney cancer is one of the most common cancers globally, ranking 9th and 14th among men and women, respectively. Advances in diagnostic techniques have enabled earlier and potentially less invasive interventions, however, this progress poses a challenge in managing low-malignancy tumors that were previously undiagnosed. To navigate treatment pathways, a deep understanding of the bidirectional relationship between Chronic Kidney Disease (CKD) and Renal Cell Carcinoma (RCC) is essential, influenced by risk factors such as hypertension and obesity.
The debate between partial (PN) and radical nephrectomy (RN) continues to be fueled by a rich body of studies in the last two decades, aiming to determine the precise benefits of renal function preservation and overall survival. However, long-term monitoring remains inadequate. There is an urgent need for heightened clinical vigilance, urging meticulous periodic evaluations that include both eGFR and the urinary albumin-creatinine ratio, to identify potential deteriorations early.
Furthermore, non-neoplastic renal parenchyma requires equal attention, often overshadowed by the assessment of tumor mass. A nuanced analysis is necessary to identify a range of nephropathies that guide more effective therapeutic strategies. A collaborative strategy that brings nephrologists, urologists, nuclear radiologists, oncologists, and pathologists together on a unified platform, focusing on a personalized medicine approach grounded on a profound analysis of individual risk factors, is pivotal in shaping the future of management and prevention strategies.
This approach ensures a detailed therapeutic outlook and facilitates early interventions, marrying vigilance with interdisciplinary cooperation, thereby guarding against late diagnoses and offering patients a robust shield in their battle against kidney afflictions.

Keywords: renal cancer, acute kidney injury, acute kidney disease, chronic kidney disease, nephrectomy, partial nephrectomy, chemotherapy, targeted anticancer agents

Hyposodiemia and Electrolyte Disorders in Cancer Patients

Giulia Florio1, Anna Iervolino1,2, Mariadelina Simeoni1, Alessandra F. Perna1, Francesco Trepiccione1,2

1 Nephrology, Department of Medical Translational Sciences, University of Campania “Luigi Vanvitelli”, Naples, IT
2 Biogem, Institute of Molecular Biology and Genetics, Ariano Irpino, IT

Onconephrology is a rising and rapidly expanding field of medicine in which nephrology and oncology meet each other. Besides multidisciplinary meetings, oncologists and nephrologists often discuss on timing of the treatment, dosage, and side effects management. Cancer patients often encounter different electrolyte disorders. They are mostly secondary to the tumor itself or consequences of its treatment. In the last years, the great efforts to find new therapies like targeted, immune, and cell-based led us to many new side effects. Hyponatremia, hypokalemia, hyperkalemia, hypercalcemia, and hypomagnesemia are among the most common electrolyte disorders. Data have shown a worse prognosis in patients with electrolytic imbalances. Additionally, they cause a delay in chemotherapy or even an interruption. It is important to diagnose promptly these complications and treat them. In this review, we provide a special focus on hyponatremia and its treatment as the most common electrolytes disorder in cancer patients, but also on newly described cases of hypo- and hyperkalemia and metabolic acidosis.

Keywords: hyposodiemia, cancer patients, electrolyte disorders, hyperkalemia

Renal Side Effects of Novel Molecular Targeted Oncologic Agents

Roberta Fenoglio1, Simone Cortazzi1, Martina Marchisio1, Gianluca Rabajoli1, Edoardo Terzolo1, Savino Sciascia1 e Dario Roccatello1

1 University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy

The introduction of innovative therapies has changed the scenario of complications. The delay in the recognition of kidney adverse effects is partly due to the timing of the development of the kidney damage which occurs later than the observation period of registration studies, and partly to the exclusion of patients with known kidney impairment from registration trials.

Renal disease has a significant impact on the management of cancer patients and often leads to discontinuation of therapy. Histological evaluations of kidney disorders induced by targeted/immunotherapy are very limited. Renal biopsy is critical for the management of renal toxicities and should be especially encouraged for patients showing adverse renal effects to novel cancer agents.

We recently examined the histological features of patients treated with new cancer agents who underwent renal biopsy for new onset renal failure and/or urinary abnormalities. The cohort included 42 patients. The most frequently administered therapies were immunotherapy (54.8%) and anti-angiogenic treatments (45.2%). The most common adverse effect was tubular interstitial nephritis in the first group and thrombotic microangiopathy in the second one. Based on histological findings, definitive discontinuation of treatment could be restricted to a very limited number of patients. All of them had anti-VEGF-related TMA. Treatment discontinuation was unneeded in patients treated with ICIs. In patients treated with multidrug therapy, the histological findings made it possible to identify the weight of drug-related specific injury. Based on this data, renal biopsy should be considered in every cancer patient who develops urinary abnormalities or shows a worsening of renal function during treatment with immunotherapy or targeted therapy.

Keywords: Onconephrology, Immune checkpoint, Targeted Therapies, Renal biopsy in oncotherapy, Thrombotic Micro-angiopathy, Interstitial tubular nephritis

Exploring Tyrosine Kinase Inhibitor (TKI)-Induced Nephrotoxicity: An Emerging Issue from Bench to Bedside

Debora Collotta1, Eleonora Aimaretti2, Massimo Collino1

1 Department of Neuroscience “Rita Levi-Montalcini”, University of Turin, Turin, Italy
2 Department of Clinical and Biological Sciences, University of Turin, Turin, Italy

Tyrosine Kinase Inhibitors (TKIs) have significantly contributed to revolutionizing cancer treatment, as they are orally administered small molecules able to target key pathways involved in tumor growth and angiogenesis. However, the clinical utility of TKIs may be compromised by adverse effects, which can affect tissues and organs, including kidneys. This comprehensive review offers a general overview of studies reporting the incidence and clinical characteristics of TKI-related nephrotoxicity and it explores the mechanisms underlying the intricate relationship between TKIs and renal toxicity. The biological rationale for the kidney manifestations of toxicity associated with TKI agents is here discussed, underlying potential off-target effects and emphasizing the importance of accurate risk assessment and tailored patient management strategies.

Deep insight into the molecular mechanisms of TKI nephrotoxicity will help to improve the global understanding of the pathophysiology of this peculiar toxicity and to develop more effective and safer therapies.

Keywords: Tyrosine kinase inhibitors, kidney, renal toxicity, cancer

Renal Replacement Therapy in Cancer Patients with AKI

Marco Pozzato1, Roberta Fenoglio1, Nunziante Caruso1, Cecilia Ceruti1, Giorgio Amore1, Savino Sciascia1 e Dario Roccatello1.

1 University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy

Acute renal failure (AKI) is a high-prevalence complication in patients with cancer. The risk of AKI after cancer diagnosis is 18% in the first year, 27% in the fifth year, and 40% of critically ill patients with cancer require renal replacement therapy.

The causes of AKI may be pre-renal due to hemodynamic problems, related to the cancer, metabolic complications, and drug or surgical treatment.

One must preventively protect renal function by hydration, use of non-nephrotoxic drugs, correction of anemia, prevention of contrast agent-induced AKI (CI-AKI), and adjustment of cancer therapy in patients with CKD. It is essential to check basal renal function, creatinine trend, electrolytes, urinalysis and proteinuria, perform imaging, renal biopsy if necessary.

The evaluation of patients should be multidisciplinary and timely including the initiation of renal replacement treatment (RRT). There are different modalities of replacement treatment depending on the clinical picture of the patient with AKI and cancer: intermittent hemodialysis (IHD), intermittent prolonged replacement therapy (PIRRT), and continuous replacement therapy (CRRT). The concept of dose administered, as opposed to prescribed dose, as well as the anticoagulation of extracorporeal circuits, which must be regional with citrate (RCA) as the first choice in the management of CRRT, turns out to be fundamental in order to achieve optimal circuit anticoagulation, with reduction of coagulation episodes and downtime, while maintaining the patient’s coagulation status.

The onco-nephrologic multidisciplinary approach is crucial to reduce the mortality rate, which is still high in this category of patients.


Keywords: AKI, cancer, RRT, citrate

Chronic Kidney Disease and Cancer: Ethical Choices

Chiara Lenoci1, Gino Gobber2, Giuliano Brunori3

1 Scuola Specialità in Nefrologia, Università Studi di Verona
2 UOC Cure Palliative, APSS Trento
3 UOC Nefrologia e Dialisi, APSS Trento

Cancer and chronic kidney disease prevalence both increase with age. As a consequence, physicians are more frequently encountering older people with cancer who need dialysis, or patients on dialysis diagnosed with cancer. Decisions in this context are particularly complex and multifaceted. Informed decisions about dialysis require a personalised care plan that considers the prognosis and treatment options for each condition while also respecting patient preferences. The concept of prognosis should include quality-of-life considerations, functional status, and burden of care. Close collaboration between oncologists, nephrologists, geriatricians and palliativists is crucial to making optimal treatment decisions, and several tools are available for estimating cancer prognosis, prognosis of renal disease, and general age-related prognosis. Decision regarding the initiation or the termination of dialysis in patients with advanced cancer have also ethical implications. This last point is discussed in this article, and we delved into ethical issues with the aim of providing a pathway for the nephrologist to manage an elderly patient with ESRD and cancer.

Keywords: Chronic Kidney Disease, Cancer, Dialysis, Ethic, Onconephrology

Management of Chemotherapy in Patients Subjected in Chronic Dialysis Treatment

Pirovano Marta1, Re Sartò Giulia Vanessa1, Cosmai Laura1

1 Ambulatorio di Onconefrologia, UOC Nefrologia Dialisi ASST Fatebenefratelli Sacco

The incidence of tumors is increased in patients with chronic renal failure and even more in patients on dialysis. Dialysis can affect both therapy and prognosis of oncological patients. It increases both cancer-related and non-cancer-related mortality rates and is the main cause of a suboptimal use of therapies. In patients with renal impairment, the dosage of many chemotherapies should be reduced but, due to the lack of real knowledge of the pharmacokinetic and pharmacodynamic properties of these drugs in dialysis, dosage adjustments are often done empirically and most often avoided.

Although many papers are available in the literature regarding chemotherapy in dialysis, there is a lack of consensus regarding drug dosages and administration schedules. Furthermore, guidelines are absent due to the lack of “evidence” for most of these patients, usually excluded from experimental treatments.

Specific onconephrologic trials are therefore mandatory to decide how much, how, and when to use chemotherapy in patients on dialysis and thereby ensure adequate treatment for these patients.

Keywords: onconephrology, dialysis, cancer, chemotherapy

Management of the Oncological Patient with Chronic Renal Failure

Roberta Fenoglio1, Simone Cortazzi1, Annalisa Guarino1, Roberta Longo1, Ilaria Caniggia1, Savino Sciascia1 e Dario Roccatello1

1 University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy

Cancer is a leading cause of death in people with chronic kidney disease (CKD). The incidence of CKD in patients with cancer is higher than in the non-cancer population. Across various populations, CKD is associated with an elevated risk of cancer incidence and cancer death compared with people without CKD, although the risks are cancer site-specific. The potential mechanisms for the increased risk of cancer observed in CKD, include patient factors, disease, and treatment factors. CKD has also a major impact on the treatment of cancer patients. The kidney is the primary route of elimination of many anticancer drugs. Dosing of anticancer agents according to kidney function is essential to avoid undertreatment and toxicity. Because of the systemic exclusion of patients with severe kidney dysfunction from clinical cancer trials, data are lacking to guide dosing of anticancer drugs in patients with chronic kidney disease. As a consequence, many therapies are denied to CKD patients due to their possible toxicities. An orchestrated effort by all stakeholders is required to fill the knowledge gap and improve the outcome of cancer patients with kidney dysfunction.

Medical Treatments in Oncology 2023

Alessandro Comandone1, Antonella Boglione1, Tiziana Comandone2

1 SC Oncologia Medica – Ospedale San Giovanni Bosco, Torino; Gruppo Italiano Tumori Rari
2 Scuola di Specializzazione in Farmacologia Ospedaliera- Università degli studi di Torino; Gruppo Italiano Tumori Rari

Medical Oncology since the beginning of the new millennium has recognized a great positive evolution in the care of cancer.
In fact, for more than 60 years the two classical pillars of the antineoplastic therapy were hormone therapies mainly applied in breast, prostate and thyroid cancer, and chemotherapy seldom curative and heavily toxic.
Nowadays some new treatments are available thanks to the advances in genomics, proteomics and molecular biology of tumor cells either to the advances in immunology studies.
Specific pathways in cancer cells have been recognized and hit by targeted drugs.
Monoclonal antibodies, tyrosine kinase inhibitors, checkpoint inhibitors, cellular therapies and vaccines are the new tools for oncologists.
The last discovery is the antibody-drug conjugates (ADCs), which combine monoclonal antibodies with cytotoxic drugs.
Unfortunately, these impressive advances have caused the appearance of new scientific, social, and financial problems.
All these topics are discussed in the article.

Keywords: oncology, survival, therapy, innovation

Cancer and the Kidney: A Deadly Embrace

Dario Roccatello1, Simone Cortazzi1, Francesca Bertinetto1, Alessandra La Rosa1, Lorenzo Nescis1, Savino Sciascia1 e Roberta Fenoglio1

1 University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy

A deadly embrace occurs between cancer and chronic kidney disease.   The estimation of kidney function in cancer patients is of utmost interest due to its direct impact on chemotherapy dosing, selection, and eligibility for chemotherapeutics. Overestimating kidney function (determined as estimated glomerular filtration rate -eGFR) can lead to overdosing and drug toxicity, while underestimating kidney function can prevent patients from receiving novel therapies. Notably, the current measures of eGFR are not validated in transplanted patients yet.

The field of onconephrology ranges from nephrotoxicity of existing and novel therapeutics, paraproteinemias, and cancer-associated electrolyte imbalance, fluid and acid-base disturbances, the effects of the destruction of cancer cells, and acute and/or chronic kidney injuries. Recently, the therapeutic armamentarium has been enriched with new agents that interfere with specific proteins involved in oncogenesis. These are the so-called target therapies, which although acquired as “targeted” therapies do not have absolute specificity and selectivity and tend to inhibit multiple targets, often involving the kidney. Renal biopsy may be critical in managing these adverse effects. Moreover, primary hematological and oncological disorders can have significant kidney implications in the form of glomerular or nonglomerular diseases presenting with proteinuria, hematuria, hypertension, and kidney function decline, specifically including cast nephropathy or systemic light chain amyloidosis, and paraneoplastic glomerulopathies that occur as a result of occult malignancy, such as Membranous Nephropathy and Minimal Change disease.

Keywords: Onconephrology, Target Therapies, Renal biopsy in onconephrology, Cancer and kidney

Ten Years of Onconephrology

Laura Cosmai

Ambulatorio di Onconefrologia, UOC Nefrologia e Dialisi, ASST Fatebenefratelli Sacco, Milano

Onconephrology is a subspecialty of Nephrology with the aim of fully dealing with the complex and bidirectional relationship between the tumor and the kidneys.
In a world where Nephrologists still too often consider Oncological patients as “lost” and in which Oncologists are afraid to administer oncological therapies to patients with renal failure due to the absence of Literature data, Onconephrology was created with the aim of guaranteeing patients with renal disease the same treatment opportunities as the general population.
Over the years this subspecialty has developed and more nephrologists, experts in the field, daily support oncologists in clinical-therapeutic decisions by dealing with cases of renal toxicity from oncological therapy, managing treatments in patients with renal failure and dealing with all those conditions associated with both oncological and renal pathology in terms of prevention and treatment.
In this paper we will retrace the history of Onconephrology by analyzing what are the results achieved and what are the objectives for the future. 

Keywords: onconephrology, history of onconephrology, oncological therapies

Onconefrologia: una sfida

Dario Roccatello1, Gaetano La Manna2, Roberta Fenoglio1

1 University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
2 UOC Nephrology, Dialysis and Transplantation, Policlinico di Sant’Orsola, Bologna, Italy

Decision Making, Legal Capacity, and Legal Protectionism of (Allegedly) Incapable People: the State of the Art in Italy

Fabio Cembrani1

1 Professore a contratto, Università degli Studi di Verona

Starting from the polysemy of capacity and its numerous expressive facets, the Author analyzes how and through which modalities the issue of the validity of consent and informed refusal is typically addressed in places of care. The discussion then moves on to examine the modifications brought about by the UN Convention on the Rights of Persons with Disabilities (CRPD) in this field, fully ratified by Italy, even though the law on informed consent and advance healthcare directives (Law No. 219 of 2017) did not take it into account. Finally, some practical suggestions are formulated to promote the virtuous practice of supported decision-making, which has not yet been developed in Italian care settings.

Keywords: legal capacity, decision-making capacity, Convention on the Rights of Persons with Disabilities, legal protectionism

In Memory of John Stewart Cameron

Attilio Losito1, Giovanni B. Fogazzi2

1 Già direttore della Struttura Complessa di Nefrologia, Dialisi e Trapianto dell’Ospedale Santa Maria Della Misericordia di Perugia
2 SC di Nefrologia, Dialisi e Trapianto di Rene, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano

Correlation of Acoustic Radiation Force Impulse Imaging with Chronicity Markers in Native Renal Biopsy

Gerry George Mathew1, Krishna Chaitanya Gunda2, K.C. Prakash3, Sudhakar Kattoju4, K.S. Sunil Kumar5

1 Department of Nephrology, SRM Medical College Hospital And Research Centre, Kattankulathur, Tamil Nadu, India-603203
2 Asian Institute of Nephrology and Urology, Nungambakkam, Chennai, Tamil Nadu, India-600034
3 Department of Nephrology, Apollo hospital Greams lane, 21, Greams road, Thousand lights, Chennai, Tamil Nadu, India-600006
4 Department of Radiology, Apollo hospital Greams lane, 21, Greams road, Thousand lights, Chennai, Tamil Nadu, India-600006
5 Department of Pathology, Apollo hospital Greams lane, 21, Greams road, Thousand lights, Chennai, Tamil Nadu, India-600006

Introduction. Acoustic Radiation Force Impulse (ARFI) is an ultrasound parameter which has shown promise in assessing liver stiffness, but there are limited data on the correlation of ARFI with chronicity markers in renal biopsies.

  1. Determine ARFI values in ultrasound and correlate with chronicity markers in renal biopsy
  2. Determine whether ARFI can be used as a non-invasive chronicity predictor compared to renal length, Resistive Index (RI), and cortical thickness.

Patients and Methods. Two hundred and fifty patients were enrolled in the study. The ultrasound variables ARFI, renal length, RI, and cortical thickness values were assessed by the radiologist prior to renal biopsy. The biopsy slides were graded as per the Mayo Clinic consensus report scoring system by an experienced pathologist.
Results. Among 250 study participants, 167 were males and 83 were females. IgA nephropathy was the most common pathology (n=47;19%), followed by diabetic nephropathy (n=42;17%), membranous nephropathy (n=35;14%), FSGS (n=27;11%), and MCD (n=19; 8%). The mean eGFR was 55.9 ± 42.12 ml/min/1.73 m2. The average renal length was 10.086 ± 1.01 cm. The average cortical thickness was 0.707 ± 0.134 cm. Resistive index was 0.68 ± 0.09. Acoustic radiation force impulse had weak negative correlation (r=-0.286; p=0.0001) with total pathological score and weak positive correlation with eGFR (r=0.279; p=0.0001). RI was a better indicator for histologically evaluated chronicity with positive correlation coefficient (r=0.416; p=0.0005) compared to renal length, cortical thickness, and ARFI.
Conclusion. ARFI didn’t corelate with the pathological score in renal biopsies. RI had better predictive value for chronicity in native renal biopsies.

Keywords: ARFI, Resistive index, Cortical thickness, Renal length, Chronicity

Treatment of a Severe Form of Euglycemic Ketoacidosis in a Patient Treated with SGLT-2 Inhibitors with the Aid of Somatostatin

Aristide Torre1, Nicola Bisogno1, Carmine Botta1, Antonella Caiazza1, Francesca D’Angelo1, Luigi Del Giudice1, Pio Fiorentini1, Luigi Marzano1, Rita Nigro1, Dario Sassone1, Paola Torre1, Daniela Vicedomini1

1 U.O.C. di Nefrologia e Dialisi, Ospedale Umberto I°, Nocera Inferiore (SA)

Currently, the use of SGLT2 inhibitors is becoming more widespread, both for their role in controlling diabetes, and for their pleiotropic effects on glomerular hyperfiltration and heart failure. Along with their positive effects, these drugs can lead to various complications, the most severe being euglycemic ketoacidosis. The clinical case we have reported precisely describes this potentially serious complication which occurred in a 47-year-old patient who had been on SGLT2 inhibitor therapy for 5 years. In the resolution of this case we used, in addition to standard therapy, the continuous infusion of somatostatin, resulting in a rapid resolution of ketoacidosis and an improvement in the clinical condition.

Keywords: SGLT-2, somatostatin, euglycemic ketoacidosis

The Cannulation of the Arteriovenous Fistula in the Presence of a Stent: Precautions, Risks, and Possibilities

Pasqualina Cecere1, Giacomo Forneris1, Daniele Savio2, Andrea Agostinucci3, Marco Pozzato1, Chiara Comelli2, Dario Roccatello1

1 Centro di Eccellenza Universitario per le malattie Nefrologiche Reumatologiche e Rare, Nefrologia e Dialisi-CMID (Membro ERK-net, ERN-ReConnet and RITA-ERN), Ospedale Hub San Giovanni Bosco e Dipartimento di Scienze Cliniche e Biologiche, Università di Torino
2 SSD Radiologia Interventistica, Dipartimento di Radiologia, Ospedale San Giovanni Bosco, Torino
3 SC Chirurgia Vascolare ed Endovascolare, Ospedale Giovanni Bosco, Torino

A proper management and tailored interventions represented two fundamental steps to ensure a long-term use of the arteriovenous fistula (AVF). AVF failure can be attributed to various factors, with stenosis being the most common cause. Different techniques are employed for treating complications, but percutaneous endovascular procedures are the most widely used. In addition to angioplasty (PTA), the possibility of utilizing stents, particularly stent grafts (SG), has further improved outcomes. However, the insertion of these devices involves commitment to a segment of the vessel, which may vary in length, making the indication necessitate a careful evaluation. The positioning of a stent graft indeed limits the space for needle insertion, and on the other hand, the cannulation of the device is considered off-label according to technical specification.

This work addresses the issue of puncturing these devices. Alongside a rapid overview, we describe a clinical case of continuous cannulation of a multiply stented AVF, for over 9 years, which opens up the discussion about the possibility of long-term cannulation through proper planning.

Keywords: stent, stentgraft, cannulation, arteriovenous fistula

Case Report: MPO-ANCA Associated Vasculitis After Pfizer-BioNTech COVID-19 mRNA Vaccination

Fabio Mazza¹, Angela Cicciarelli¹, Filomena Rubino¹, Martina Leopizzi³, Valeria Di Maio³, Bruna Cerbelli ³, Paola Tatangelo², Roberto Palumbo², Ernesto Anselmo Cioffi¹, Roberto Simonelli⁴

1 UO Nefrologia e Dialisi SS Trinità Sora, Italia
2 UO Nefrologia e Dialisi S.Eugenio Roma, Italia
3 Dipartimento di Scienze e Biotecnologie, Sapienza Università di Roma, Italia
4 UO Nefrologia e Dialisi Cassino, Italia

We report a case of MPO-anti-neutrophil cytoplasmic antibody ANCA-associated vasculitis, with pulmonary-renal syndrome, after the mRNA booster third dose vaccine Pfizer BioNTech against COVID-19 in 71-year-old Caucasian man with no specific past medical history. A kidney biopsy diagnosed ANCA-associated pauci-immune crescentic glomerulonephritis. Renal function and constitutional symptoms have been partially improved with treatment with dialysis, intravenous rituximab and steroid pulse therapy. No disease following either infection or vaccination with fourth dose against COVID-19.

Keywords: ANCA vasculitis (AAV), booster dose, cytokine storm, mRNA vaccine, SARS-CoV-2

Clozapine-induced Tubulointerstitial Nephritis

Maria Colao1, Clara Migotto1, Susanna Gilardi1, Fulvia Erasmi1, Ilaria Borettaz1, Marianna Boso2, Enrico Giuliani2, Renza Tiboldo1

1 U.O Nefrologia e Dialisi, Ospedale Vizzolo Predabissi, Italia
2 U.O. Pschiatria, Ospedale Vizzolo Predabissi, Italia

Tubulointerstitial nephritis is a common cause of acute renal failure, in two thirds of cases it is associated with drugs (mostly antimicrobials and NSAIDs), in 5-10% of cases it is associated with infections (bacterial/viral/parasitic), in 5-10% of cases it is idiopathic (this is the case of the TINU syndrome characterized by interstitial nephritis and bilateral uveitis, and the anti-glomerular basal membrane antibody syndrome), and finally in 10% of cases it is associated with systemic diseases (sarcoidosis, by Sjogren, LES). The pathogenesis is based on a cell-mediated immune response and in most cases removing the causative agent is the gold standard of therapy. However, a percentage of patients, in a variable range from 30% to 70% of cases, do not fully recover renal function, due to the rapid transformation of the interstitial cell infiltrate into vast areas of fibrosis.

Clozapine is a second generation atypical antipsycothic usually used for the treatment of schizophrenia resistant to other types of treatment; it can cause severe adverse effects among which the best known is a severe and potentially fatal neutropenia, furthermore a series of uncommon adverse events are recognized including hepatitis, pancreatitis, vasculitis. Cases of acute interstitial tubular nephritis associated with the use of clozapine have been described in the literature, although this complication is rare. Medical personnel using this drug need to be aware of this potential and serious side effect.

We describe the case of a 48-year-old man who developed acute renal failure after initiation of clozapine.

Keywords: Intestinal tubular nephritis, acute renal failure, clozapine

Sleep quality of patients in End Stage Renal Disease before and after starting chronic hemodialysis treatment: a longitudinal study

Giulia Belluardo1, Letizia Frasca2, Concetto Sessa1, Dario Galeano1, Luca Zanoli3, Walter Morale1

1 U.O.C Nefrologia e Dialisi, P.O. “Maggiore” di Modica. Azienda Sanitaria Provinciale di Ragusa, Italia
2 Servizio di Psicologia, Modica, Azienda Sanitaria Provinciale di Ragusa, (RG) Italia
3 Nefrologia, Dipartimento di Medicina Clinica e Sperimentale, Università di Catania, Catania, Italia

Introduction: Sleep disorders are very common in patients with chronic kidney disease, with a prevalence of poor sleep quality of around 40%.
Objectives: The purpose of the study is to compare the sleep quality of ESRD patients before hemodialysis (Pre-HD), three months (Post-HD 1) and six months after the start of treatment (Post-HD 2) through the use of the Pittsburgh Sleep Quality Index (PSQI).
Methods: Patients in ESRD were recruited from the U.O.C. of Nephrology and Dialysis of the Maggiore Hospital in Modica and biographical and anamnestic data were collected. The PSQI was administered in-person at the Pre-HD stage and by telephone re-test at the three- and six-month follow-up.
Results: A total of 71 patients (males=62%, age 68 ± 16) were included. At Pre-HD assessment 93% reported poor sleep quality, the percentage increased to 98% during Post-HD 1 and it partially improved during Post-HD 2 with a prevalence of 95%. Analysis of variance (ANOVA) by repeated measures showed a difference in sleep quality between the three time points.
Conclusions: Sleep quality undergoes important changes during the transition from conservative to hemodialysis patient, highlighting a critical period related to the first three months of treatment. More attention to this phase may improve the patient’s quality of life and reduce the associated risk of mortality.

Keywords: sleep, quality, hemodialysis, life, dialysis

The Nephrology School in Bari

Francesco Paolo Schena

Professore Emerito di Nefrologia nell’Università di Bari e Presidente della Fondazione Schena

This article describes the origin and development of the Nephrology School in Bari, which has noble roots in the Italian Medical School. The narrative begins with the description of my initial interest in Internal Medicine, and later in Nephrology, highlighting the important role that a teacher has on their students during their university education.

The second section describes the creation and development of the Nephrology School in Bari, which was influenced by the knowledge gained abroad and by the international scientific relationships that have been developed over the years.

The third section describes the historical origins of the Nephrology School in Bari, which has grown considerably over the course of 30 years. Finally, after a brief mention of my family, I could not hide my passion for sports, particularly running and soccer. Cinema and theatre are also excellent means of reflection.

In conclusion, my heartfelt hope is that my students will always remember to pursue goals of scientific excellence and, when choosing someone to train as a potential young researcher in the future, to always observe the two founding principles of the School: professional and scientific reliability, respectively based on excellent clinical expertise and scientific production.


Keywords: Nephrology School, Nephrology, Dialysis, Transplant, Clinical Research

The peritoneal equilibration test (PET) – Comment on the 8th GPDP-SIN 2022 Census data

Vincenzo La Milia

Nefrologia e Dialisi, Ospedale A. Manzoni, Lecco

Encapsulating Peritoneal Sclerosis – Comment on the 8th GPDP-SIN 2022 Census data

Guido Garosi1, Nicoletta Mancianti1

1 UOC Nefrologia, Dialisi e Trapianti, Azienda Ospedaliero-Universitaria Senese

Incremental Peritoneal Dialysis – Comment on the 8th GPDP-SIN 2022 Census data

Valerio Vizzardi

ASST-Spedali Civili. UOC di Nefrologia, Dialisi e Trapianto

Peritoneal Dialysis in Italy: the 8th GPDP-SIN census 2022

Loris Neri1, Giusto Viglino2, Valerio Vizzardi3, Silvia Porreca4, Claudio Mastropaolo5, Giancarlo Marinangeli6 e Gianfranca Cabiddu7 a nome del Gruppo di Progetto della Dialisi Peritoneale della Società Italiana di Nefrologia

1 Nefrologia e Dialisi, Ospedale “Michele e Pietro Ferrero”, Verduno, Cuneo, Italy
2 Referente per la Telemedicina dell’ASLCN2, Italy
3 Nefrologia e Dialisi, Spedali Civili, Brescia, Italy
4 Nefrologia e Dialisi, Policlinico Università A. Moro, Bari, Italy
5 Visionage SRL
6 UOC di Nefrologia e Dialisi, Ospedale di Giulianova, Teramo, Italy
7 ARNAS Brotzu, Università degli Studi di Cagliari, Italy

Objectives. The results are reported here of the 8th National Census (Cs-22) of Peritoneal Dialysis in Italy, carried out in 2022-23 by the Italian Society of Nephrology’s Peritoneal Dialysis Project Group and relating to 2022.
Methods. The Census was conducted in the 227 non pediatric centers which performed Peritoneal Dialysis (PD) in 2022. The results have been compared with the previous Censuses carried out since 2005.
Results. Incidence: in 2022, 1350 patients (CAPD=52.1%) started on PD (1st treatment for ESRD). PD was started incrementally by 35.3% in 136 Centers. The catheter was placed exclusively by a Nephrologist in 17.0% of known cases. Prevalence: there were 4152 (CAPD=43.4%) patients on PD on 31/12/2022, with 21.1% of prevalent patients on assisted PD (family member caregiver: 86.3%). Out: in 2022 the PD drop-out rate (ep/100 pt-yrs) was: 11.7 to HD; 10.1 death, down; 7.5 Tx. The main cause of transfer to HD remains peritonitis (23.5%), although its reduction over the years is confirmed (Cs-05: 37.9%). Peritonitis/EPS: the incidence of peritonitis in 2022 was 0.176 ep/pt-yr (696 episodes). The incidence of new cases of EPS fell in 2021-22 (7 cases). Other results: the number of Centers using 3.86% for the peritoneal equilibration test (PET) (57.7%) increased. PD for heart failure continues to be used in 44 Centers (66 pts).
Conclusions. Cs-22 confirms PD’s good results in Italy.

Keywords: Peritoneal Dialysis, technique failure, incremental Peritoneal Dialysis, peritonitis, peritoneal equilibration test (PET)

L’alluvione in Romagna: l’impatto sulle attività nefrologiche, i provvedimenti organizzativi e la lezione da imparare

Andrea Buscaroli1 e Matteo Righini1

a nome di:

Elisabetta Isola1, Matteo De Liberali1, Flavio Fortunato1, Romina Graziani1, Davide Martelli1, Vera Minerva1, Mattia Monti1, Maria Elena Poddie1, Mirna Saragoni1, Brunilda Sejdiu1, Elena Tampieri1, Antonella Troiano1, Chiara Valentini1, Antonio Giudicissi2, Loretta Zambianchi2, Katia Ambri2, Claudio Americo2, Maria Laura Angelini2, Paolo Ferdinando Bruno2, Francesca Ferrara2, Maria Francesca Lifrieri2, Marianna Napoli2, Lucia Neri2, Marco Ruggeri2, Veronica Sgarlato2, Sara Signorotti2, Alessandra Spazzoli2, Barbara Veterani2, Fulvia Zanchelli2

1 UOC Nefrologia e Dialisi Ravenna
2 UOC Nefrologia e Dialisi Forlì Cesena

Acute Kidney Injury Caused by Orellanic Syndrome: Case Report

Laila Qassim1, Andrea Malagoli1, Silvia Dian1, Lorenzo Citron1, Alessandro Dal Moro1, Antonio Del Vecchio1, Emanuela Rizzioli1, Giuseppe Mennella1

1 UOC Nefrologia e Dialisi, Ospedali Riuniti Padova Sud, Monselice (Pd), Italia

Orellanic syndrome is caused by fungi of the Cortinarius orellanus and speciosissimus (Europe) species, Cortinarius fluorescens (South America), and Cortinarius rainierensis (North America). Orellanic syndrome is characterized by initially nonspecific symptoms such as muscle and abdominal pain, and a metallic taste sensation in the mouth. After a few days, more specific symptoms appear, such as intense thirst, headache, chills without fever, and anorexia, followed by a phase of polyuria and then of oligoanuria. Renal failure occurs in 70% of cases and is often irreversible. The clinical case involves a 52-year-old man who developed acute renal failure from Orellanic syndrome, necessitating hemodialysis.

Keywords: Orellanic syndrome, Cortinarius mushroom, dialysis

In memoria di Giuseppe Curatola

Carmine Zoccali

Chronic Inflammatory Polyradiculopathy Post-Covid-19 and the Role of Therapeutic Apheresis: A Clinical Case

N. Coviello1, A. Carella1, C. Dell’Aquila2, GL. Masi2, MT. Nisi1, C. Prisciandaro1, G. Tarantino1, M. Taurisano1, G. Rinaldi2, F. D’Elia1

1 UOC Nefrologia e Dialisi, PO Di Venere, Bari
2 UOC Neurologia, PO Di Venere, Bari

There is a strong correlation between SARS-CoV-2 and the onset of autoimmune neurological disease with atypical clinical presentation, characterized by limited response to medical therapy, likely caused by the underlying mechanism of the virus itself.

In situations like these, after the failure of pharmacological therapy, therapeutic apheresis, including immunoadsorption, can be pursued.

Treatments with IMMUSORBA TR-350 columns have proven to be particularly effective in managing refractory forms of post-Covid-19 nephropathies, leading to complete recovery of disability and elimination of neurological signs and symptoms.

We discuss the case of a patient with chronic inflammatory polyradiculopathy post-Covid-19, resistant to medical therapy, effectively treated with immunoadsorption.

Keywords: Polyradiculopathy, SARS-CoV-2, Apheresis, Immunoadsorption

Omentopexy in Peritoneal Catheter Malfunction

Vincenzo Cosentini1, Ivano Dal Dosso2, Michela Scollica2, Alireza Hasheminia2, Linda Gammaro1, Alessandro Petrolino1, Deborah Millardi1, Alessia Corvo1, Carlo Rugiu1

1 U.O.C. Nefrologia e Dialisi San Bonifacio, Verona, Italia
2 U.O.C. Chirurgia Generale San Bonifacio, Verona, Italia

Among the various problems associated with peritoneal dialysis, besides infectious causes, the risk of catheter malfunction plays a significant role in conditioning the continuation of the method, accounting for up to 15-18% of the total causes of dialysis drop-out. When non-invasive maneuvers, such as the use of laxatives to stimulate intestinal peristalsis or heparin and/or urokinase have no effect, videolaparoscopy is the only method that directly detects the precise causes of peritoneal catheter malfunction. Those found are, with decreasing frequency, the winding of the catheter between the intestinal loops and the omentum (wrapping), the dislocation of the catheter, the combination of wrapping and dislocation, the occlusion of the catheter by a fibrin plug, the adhesions between the intestine and abdominal wall, the occlusion of the catheter by epiploic appendages or adnexal tissue and, occasionally, the presence of a new formation of endoperitoneal tissue enveloping and obstructing the peritoneal catheter. We report the case of a young patient of African ethnicity who, only five days after catheter placement, experienced malfunction. A videolaparoscopy revealed wrapping with invagination of omental tissue inside the catheter. After omental debridement, a proper peritoneal cavity washout with heparin was resumed, and after a couple of weeks, APD was initiated. About a month later, a new malfunction without signs of coprostasis or problems with the abdominal radiogram was observed. However, a subsequent catheterography confirmed the blockage of drainage. This was followed by another catheterography and omentopexy, with definitive solution of the Tenckhoff malfunction.

Keywords: peritoneal dialysis, peritoneal catheter, omentopexy

New Perspectives in Post-Surgical Acute Kidney Injury During Sepsis

Loretta Zambianchi1, Miriam di Nunzio2, Denise Cignesi2, Stefania Cristino1, Maria Laura Angelini1, Alessandra Spazzoli1, Claudio Americo1, Maria Francesca Lifrieri1, Andrea Buscaroli1

1 U.O. Nefrologia e Dialisi – Ospedale Nuovo Morgagni-Forlì
2 Scuola di Specializzazione in Nefrologia, Dialisi e Trapianto, IRCCS -Azienza Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum Università di Bologna, Italia

Postoperative acute kidney injury (PO-AKI) is a common complication of major surgery that is strongly associated with short-term surgical complications and long-term adverse outcomes. Risk factors for PO-AKI include older age and comorbid diseases such as chronic kidney disease and diabetes mellitus.  Sepsis is a common complication in patients undergoing surgery and is a major risk factor for the development of acute kidney injury (SA-AKI). Prevention of AKI in surgery patients is largely based on identification of high baseline risk, monitoring, and reduction of nephrotoxic insults. Early identification of patients at risk of AKI, or at risk of progressing to severe and/or persistent AKI, is crucial to the timely initiation of adequate supportive measures, including limiting further insults to the kidney. Although specific therapeutic options are limited, several clinical trials have evaluated the use of care bundles and extracorporeal techniques as potential therapeutic approaches.

Keywords: AKI, PO-AKI, sepsis, biomarkers, extracorporeal treatment


Renal Damage and Obesity: a Silent Pairing

Paola Nazzaro1, Alessandra Amatuzio1, Silvana Baranello1, Marcellino Corvinelli1, Giuseppe Di Cienzo1, Francesco Principe1, Paolo Trucillo1, Antonio Buondonno2, Caterina Vitagliano1, Filippo De Stefano3

1 U.O.C. Nefrologia e Dialisi, P.O. “A. Cardarelli”, Campobasso
2 U.O.C. Chirurgia Generale, P.O. “A. Cardarelli”, Campobasso
3 U.O.S. Dialisi, P.O. Veneziale, Isernia

Obesity is recognized as a true chronic disease and an independent risk factor for kidney disease. In particular, a correlation was observed between obesity and the development of focal segmental glomerulosclerosis. The clinical consequences of obesity on the kidney can include albuminuria, nephrotic syndrome, nephrolithiasis, and increased risk of development and progression of renal failure. Conventional therapy, which includes low-calorie diet, exercise, lifestyle changes, and drug therapy, including GLP1-RA, phentermine, phentermine/topiramate, bupropion/naltrexone, orlistat, is not always able to achieve the desired results and above all does not guarantee stabilization of body weight over time. On the other hand, bariatric surgery is giving excellent results in terms of efficacy and duration. Bariatric surgery techniques that are generally divided into restrictive, malabsorptive, and mixed are not free from possible metabolic complications such as anemia, vitamin deficiency, and stones. However, they are able to ensure a good maintenance of weight loss obtained with disappearance or reduction of the incidence and severity of comorbidities related to obesity.

Keywords: obesity, renal failure, bariatric surgery, sleeve gastrectomy

Acute Kidney Injury Caused by Mushrooms: A Case Report of Amanita Echinocephala Ingestion

Lorenzo D’Elia1, Luciano Cencioni1, Paola Vittoria Santirosi2

1 UOS Nefrologia e dialisi Ospedale “Santa Maria della Stella” Usl Umbria 2 Orvieto (TR)
2 UOC Nefrologia e dialisi Ospedale “San Giovanni Battista” Usl Umbria 2 Foligno (PG)

Mushroom poisoning can represent an acute event which the clinical nephrologist must deal with and which often leads to the need for emergency dialysis treatment. Through the exposed clinical case, we describe the secondary clinical manifestations of an acute intoxication sustained by Amanita Echinocephalae, and we will provide an overview of the main fungal intoxications of renal interest, the clinical presentation, the diagnostic strategies, and the subsequent treatment.

Keywords: Mushroom poisoning, AKI, Amanita Echinocephala

Acute Renal Failure, Lactic Acidosis, and Metformin: Two Case Reports and Literature Review

Guido Faggian1, Antonio Cesaro2, Roberto Faggian2, Carlo Del Piano2, Arcangelo Vitagliano2, Domenico Del Piano2, Michela Salzano3, Andrea Diglio 4, Angela Faggian 4

1 Sezione Diagnostica per Immagini e Radioterapia Univ. Federico II Napoli
2 UOSD Nefrologia ed Emodialisi, P.O. Moscati, Aversa (CE), Italia
3 Specialista in Radiodiagnostica Asl Na1 Centro
4 UOC Diagnostica per immagini, A.O.R.N. San Pio, Benevento, Italia

Lactic acidosis is a potential adverse event related to metformin therapy. Although metformin-associated lactic acidosis (MALA) is a rare condition (about 10 cases / 100,000 patients / year), new cases continue to be reported, with a mortality of 40-50%. We describe two clinical cases characterized by severe metabolic acidosis, hyperlactacidemia, and acute renal injury. The first also with NSTEMI, successfully treated.

Keywords: lactic acidosis, metformin, acute renal failure

SARS-CoV-2 mRNA-based vaccine in hemodialysis patients: a single center-experience

Vera Bonell¹, Nicola Mongera¹, Werner Passler¹, Maria Luisa Bonincontro¹, Maria Grazia Tabbì¹

1 Reparto di Nefrologia e Dialisi, Ospedale Centrale di Bolzano, Italia

Hemodialysis patients have an increased risk of severe complications when infected with SARS-CoV-2. The introduction of the SARS-CoV-2 vaccine represented an important progress in limiting severe forms of the disease.

The focus of our study is the detection of the antibody titer in chronic hemodialysis patients vaccinated with the mRNA vaccine BNT162b2 (Comirnaty, Pfizer-BioNTech).

The antibody titers were measured in 57 hemodialysis patients, vaccinated with 3 doses according to ministerial criteria, by ElectroChemiLuminescence ImmunoAssay (ECLIA). The response was defined as an antibody titer above the dosable level > 0,8 UI/ml. A good antibody response was defined as titer > 250 UI/ml. Infections with SARS-CoV-2 and adverse effects to the vaccine were recorded.

Our study showed in 93% of the hemodialysis patients a dosable antibody response after the second dose of the vaccine. After the third dose of the vaccine, 100% of the hemodialysis patients reached a dosable antibody titer. The vaccine proved to be safe, no serious adverse events were observed. After the third dose, SARS-CoV-2 infections were still observed, but with reduced severity. A vaccination course against SARS-CoV-2 infection with three doses of BNT162b2 in the dialysis patient is associated with a good immune response and protects against severe infections.

Keywords: Hemodialysis patients, SARS-CoV-2, mRNA vaccine BNT162b2, ElectroChemiLuminescence ImmunoAssay (ECLIA)

Impact of remote monitoring in home dialysis: 5-year observation results

Massimo Morosetti 1, Michelina Peccerillo 1, Daniele Frattarelli1, Maria Iolanda Famà2

1 UOC Nefrologia e Dialisi. Ospedale G.B. Grassi. ASL Roma 3. Roma, Italia
2 Vree Health Italia s.r.l. Roma, Italia

Dialysis (hemodialysis and peritoneal dialysis) is one of the main therapeutic alternatives for patients with end-stage renal disease. It can be provided in different settings, including the home setting. Published literature shows that home dialysis improves both survival and quality of life, while producing economic advantages. However, there are also significant barriers. Home dialysis patients often report “abandonment issues” by healthcare personnel.

This work aimed at assessing the efficiency of the Doctor Plus® Nephro telemedicine system (adopted in the Nephrology Center of the P.O. G.B. Grassi di Roma-ASL Roma 3) in monitoring patient health status and improving the quality of care. From 2017 to 2022, N=26 patients were included in the analysis (mean duration of observation: 2.3 years). The analysis showed that the program was able to promptly identify possible anomalies of the vital parameters and activate a series of interventions aimed at normalizing the altered profile. During the study period, the system issued N=41,563 alerts (N=1.87 alerts per patient/day), of which N=16,325 (39.3%) were clinical and N=25,238 (60.7%) were missed measurements. These warnings ensured stabilization of the parameters, with clear benefits on patients’ quality of life. A trend of improvement was reported by patients, regarding their perception of the health state (EQ-5D questionnaire; +11.1 points on the VAS scale), the number of hospital admissions (-0.43 accesses/patient in 4 months), and of working days lost (-3.6 days lost in 4 months). Therefore, Doctor Plus® Nephro represents a useful and efficient tool for home dialysis patients’ management.

Keywords: chronic renal insufficiency, dialysis, hemodialysis, Doctor Plus® Nephro, remote monitoring

Evidence-Based Nephrology

Francesco Paolo Schena

Anti-MBG crescentic glomerulonephritis with negative immunofluorescence: case report and literature review

Gianmarco Borriello1, Michelangelo Nigro2, Pierluigi D’Angiò2, Andrea Gigliotti2, Antonio Mancini2, Antonio Massa2, Davide Viggiano1, Giuseppe Gigliotti2

1 UOC Nefrologia e Dialisi, Dipartimento di scienze mediche traslazionali, Univ. della Campania ‘Luigi Vanvitelli’, Napoli, Italia
2 UOC Nefrologia e Dialisi, ospedale di Eboli, Salerno, Italia

Anti-glomerular basement membrane (anti-GBM) antibody disease is a rapidly progressive glomerulonephritis characterized by (i) positivity to anti-GBM in serum reacting with a specific antigen present in type IV collagen at both the glomerular and alveolar levels (ii) presence of crescent on light microscopy and positivity to linear deposits of IgG and C3 on immunofluorescence. In the classic variant, the clinic is that of a nephro-pneumological syndrome but there are variants. Rarely, the glomerular damage is pauci-immune. We describe a case of a variant in which there is anti-MBG positivity in serum but negative immunofluorescence and offer a review of the literature and potential treatments.

Keywords: anti-GBM, crescents, immunofluorescence

Natura giuridica e questioni di diritto pratico relative alle Aziende Sanitarie Locali

Antonio Capasso

Università degli studi di Napoli – Parthenope

Nephrological nutritional office: a transversal organization model and access flowchart

Margherita Vischi 1, Benedetta Moreschi 2, Cristina Zanoni 2, Enrica Raschioni2, Paola Lanzi2, Nicola Vincenzo Orfeo3, Mario Cozzolino 1

1 SC Nefrologia e Dialisi, ASST Santi Paolo e Carlo Milano
2 SSD Servizio Dietetico e Nutrizione Clinica-ASST Santi Paolo e Carlo Milano
3 Direzione Sanitaria ASST Santi Paolo e Carlo Milano

The nutritional aspect has a critical relevance in the educational and care path of nephropathic patients. The Nephrology-Dietology synergy in the Hospital is conditioned by various factors, such as the difficulty for Dietology to provide capillary and personalized follow-up to nephropathic patients.

Hence the experience of a transversal II level nephrological clinic, dedicated to nutritional aspects throughout the path of nephropathic patients, from the earliest stages of kidney disease to replacement treatment. The access flowchart provides a nephrological indication: from chronic kidney disease (CKD), kidney stones, immunopathology, hemodialysis, peritoneal dialysis, and transplantation clinics, from the nephrological department, patients are selected for evaluation.

The clinic is conducted by an expert nephrologist and trained dietitians, and is divided into different settings: educational meetings in small groups (patients and caregivers); simultaneous dietary and nephrological visits to advanced CKD; nutritional-nephrological visits on specific problems: from metabolic screening of kidney stones to action on the intestinal microbiota in immunological pathologies, to the application of the ketogenic diet in obesity, metabolic syndrome, diabetes, and early kidney damage, to onconephrology. Submission to further dietological assessment is limited to critical and selected cases.

The synergistic model between nephrology and dietetics offers clinical and organizational advantages: guarantees a capillary follow-up, reduces the number of hospital accesses, thus enhancing compliance and clinical outcomes, optimizes available resources, and overcomes the critical issues of a complex hospital with the advantage of the always profitable multidisciplinarity.

Keywords: dietetic-nutritional therapy, nephrology, chronic kidney disease

Tic douloureux sustained by an eye tumor

Alessio Di Maria1, Laura Maria Scichilone1, Rossella Siligato1, Matteo Capone1, Marco Veronesi1, Francesca Ferrara1, Fabio Fabbian1, Alda Storari1, Stefano Gatto1

1 U.O. di Nefrologia e Dialisi, Ospedale S. Anna (Cona, FE), Azienda Ospedaliero-Universitaria di Ferrara

Cancer is a major cause of morbidity and mortality in solid organ transplantation. Nonmelanoma skin cancer (NMSC) such as basocellular (BCC) and spinocellular (SCC) carcinoma, are common in renal transplant recipients. We report a case of an SCC affecting a lacrimal gland in a subject with kidney transplantation.

A man aged 75 years who had suffered from glomerulopathy since 1967 and subsequently started haemodialysis, in 1989 was transplanted from a living donor. In 2019, he suffered paresthesia and pain in his right eyebrow arch and he was diagnosed to have neuralgia of the fifth cranial nerve. The failure of medical treatment and the development of a mass in his eyelid plus exophthalmos induced healthcare professionals to perform a magnetic resonance. The latter showed a retrobulbar mass measuring 39×22×16 mm3. Biopsy revealed an SCC and the patient underwent eye exenteration.

Although NMSC of the eye is an extremely rare condition, risk factors such as male sex, history of glomerulopathy, and duration of immunosuppression should be taken into consideration at the time of the onset of eye symptoms.

Keywords: Renal transplantation, immunosuppression, non-melanocitic skin cancer, eye cancer

Combined extracorporeal CO2 removal and renal replacement therapy in a pregnant patient with COVID-19: a case report

Pasquale Esposito1, Francesca Cappadona1, Filippo Sangregorio1, Elisa Costa1, Laura Mallia1, Valentina Zanetti1, Lorenzo Nescis1, Stefania Bianzina2, Fiorenza Ferrari3, Nicolò Antonino Patroniti4, Giovanni Battista Traverso1, Francesca Viazzi1

1 Clinica Nefrologica, Dialisi, Trapianto, Department of Internal Medicine, University of Genoa and IRCCS Ospedale Policlinico San Martino, Genoa, Italy
2 Neonatal and Pediatric Intensive Care Unit, Department of Critical Care and Perinatal Medicine, IRCCS Istituto Giannina Gaslini, Genova, Italy
3 Department of Anesthesia and Intensive Care Unit, I.R.C.C.S., San Matteo Hospital and University of Pavia, Pavia, Italy
4 Anesthesia and Intensive Care, San Martino Policlinico Hospital – IRCCS for Oncology and Neurosciences, Genoa, Italy; Department of Surgical Sciences and Integrated Diagnostics [DISC], University of Genoa, Genoa, Italy

Background. Pregnant women are at high risk of Coronavirus disease 2019 (COVID-19) complications, including acute respiratory distress syndrome. Currently, one of the cornerstones in the treatment of this condition is lung-protective ventilation (LPV) with low tidal volumes. However, the occurrence of hypercapnia may limit this ventilatory strategy. So, different extracorporeal CO2 removal (ECCO2R) procedures have been developed. ECCO2R comprises a variety of techniques, including low-flow and high-flow systems, that may be performed with dedicated devices or combined with continuous renal replacement therapy (CRRT).
Case description. Here, we report a unique case of a pregnant patient affected by COVID-19 who required extracorporeal support for multiorgan failure. While on LPV, because of the concomitant hypercapnia and acute kidney injury, the patient was treated with an ECCO2R membrane inserted in series after a hemofilter in a CRRT platform. This combined treatment reducing hypercapnia allowed LPV maintenance at the same time while providing kidney replacement and ensuring maternal and fetal hemodynamic stability. Adverse effects consisted of minor bleeding episodes due to the anticoagulation required to maintain the extracorporeal circuit patency. The patient’s pulmonary and kidney function progressively recovered, permitting the withdrawal of any extracorporeal treatment. At the 25th gestational week, the patient underwent spontaneous premature vaginal delivery because of placental abruption. She gave birth to an 800-gram female baby, who three days later died because of multiorgan failure related to extreme prematurity.
Conclusions. This case supports using ECCO2R-CRRT combined treatment as a suitable approach in the management of complex conditions, such as pregnancy, even in the case of severe COVID-19.

Keywords: pregnancy, COVID-19, lung-protective ventilation, hypercapnia, CO2 removal, acute kidney injury, continuous renal replacement therapy

Acute kidney injury in severely burned patient: prevention and treatment

Antonio Giudicissi1, Anna Magli2, Michela Venturi3, Paolo Ferdinando Bruno1, Fulvia Zanchelli1, Marco Ruggeri1, Lucia Neri1, Veronica Sgarlato1, Sara Signorotti1, Davide Melandri3, Andrea Buscaroli1

1 U.O. Nefrologia e Dialisi – Ospedale “M. Bufalini”, Cesena, Italia
2 Scuola di Specializzazione in Nefrologia, Dialisi e Trapianto, IRCCS Azienza Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum Università di Bologna, Italia
3 Centro Grandi Ustionati – Ospedale “M. Bufalini”, Cesena, Italia

Acute Kidney Injury (AKI) is associated with a great increase in morbidity and mortality in severely burned patients and occurs as a complication in more than 25% of these cases. The onset of ARF may be early or late. Early AKI depends mainly on reduced cardiac output resulting from fluid loss, rhabdomyolysis, or hemolysis. Late AKI, instead, is usually a consequence of sepsis and is often associated with multiorgan failure (MOF).

The first sign of AKI is the contraction of diuresis despite adequate volemic filling, which is followed by elevation of serum urea and creatinine. Fluid therapy is the main treatment in the burned victim: in the first few hours after injury, it aims to avoid hypovolemic shock and the possible related MOF, while later it becomes the cornerstone of treatment, besides antibiotic therapy in the case of sepsis onset. Particular care must also be taken in the choice of administered drugs in order to avoid possible nephrotoxic damage in addition to burning injury. Hemodialytic renal replacement therapy is used both for water balance management in patients requiring massive fluid infusions and for blood purification purposes to control the metabolic state, acid-base balance, and electrolytes abnormality. Our team has been collaborating for over 25 years in the management of severely burned patients admitted to the Centro Grandi Ustionati at the Bufalini Hospital in Cesena.

Keywords: Acute Kidney Injury (AKI), burn, sepsis, Continuous Renal Replacement Therapy (CRRT)

A case of acute kidney injury due to ethylene glycol intoxication

Giulia Lieti 1, Vincenzo L’imperio 2, Andrea Cavalli3, Chiara Ravasi3, Selena Longhi3, Giovanni Battista Fogazzi4, Vincenzo La Milia3

1 Università degli studi di Milano-Bicocca, Scuola di Specializzazione in Nefrologia
2 S.C. Anatomia Patologica I, Ospedale San Gerardo, Monza
3 U.O. Nefrologia e dialisi, Ospedale A. Manzoni, Lecco
4 Laboratorio clinico e di ricerca sul sedimento urinario, SC di Nefrologia, Dialisi e Trapianto di Rene, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano

In this article we describe a case of acute kidney injury caused by ethylene glycol intoxication which partially reversed after temporary hemodialysis treatment. The diagnosis was obtained after the patient’s clinical history and the finding of ethylene glycol in the blood, numerous intratubular crystals at renal biopsy, and the presence of large amounts of atypical – spindle-like and needle-like – calcium oxalate crystals in the urinary sediment.

Keywords: Ethylene glycol, acute kidney injury, urinary sediment, calcium oxalate crystals

Efficacy of sustained low-efficiency dialysis in the management of topiramate intoxication: case report

Silvia Barbarini1, Vilma Martella1, Emiliana Ferramosca1, Paolo Ria1, Anna Zito1, M.Luisa Lefons1, Maria Caterina Carbonara1, Giulia Fontò1,  Paolo Protopapa1,  Antonio De Pascalis1, Marcello Napoli1

1 Ospedale Vito Fazzi, Lecce, Italia. Dipartimento di nefrologia, dialisi e trapianto

Guidelines on the use of dialysis treatment in patients with chronic kidney disease (CKD) and TPM (Topiramate) intoxication are controversial. A 51-year-old man with epilepsy and CKD was carried to our emergency department for dysuria and sickness. He chronically assumed TPM 100 mg 3/day. Creatinine level was 2.1 mg/dL, blood urea nitrogen 70 mg/dL, and inflammation indexes were increased.

We started empirical antibiotic therapy and rehydration. The day two he had diarrhea and an acute insurgence of dizziness, confusion, and bicarbonate levels reduction. Brain CT resulted negative for acute events. During the night his mental status worsened, and urinary output results were about 200 mL in 12h. EEG showed desynchronized brain bioelectric activity. Thereafter, there was an episode of seizure and then anuria, hemodynamic instability, and loss of consciousness. Creatinine value was 5.39 mg/dL with a serious metabolic acidosis non-anion gap. We decided to start 6-hours Sustained Low Efficiency Hemo-Dia-Filtration (SLE-HDF). We assisted in the recovery of consciousness and later in the improvement of kidney function after 4 hours of treatment. TPM levels before SLE-HDF resulted in 123.1 µg/mL. At the end of treatment resulted in 30 µg/mL. To our knowledge, this is the first report of TPM involuntary intoxication in a patient affected by CKD who survived such a high TPM concentration treated with renal replacement therapy. SLE-HDF resulted in moderate elimination of TPM and acidemia resolution, continuous monitoring patient’s vital parameters in relation to his hemodynamic instability, since blood flow and dialysate flow are lower than conventional hemodialysis.

Keywords: Intoxication, Sustained Low-efficiency dialysis, hemodialysis, metabolic acidosis, continuous venovenous haemofiltration

Nefrologi e futuro

Gaetano La Manna

Editor in Chief Giornale Italiano di Nefrologia

Una monografia dedicata a Gabriele Monasterio (1903-1972), uno dei padri della nefrologia italiana

Fogazzi Giovanni B.

SC di Nefrologia, Dialisi e Trapianto di Rene, Fondazione, IRCCS, Ca’ Granda Ospedale Maggiore Policlinico, Milano

Ultrafiltration tolerance in patients on chronic dialysis: is an ultrasound based approach useful?

Lorenzo Gasperoni1, Federica Di Filippo1, Roberto Boccadoro1, Laura Maldini1, Stefano Bini1, Angelo Rigotti1, Emanuele Mambelli1

1UOC Nefrologia e Dialisi- Ospedale Infermi-Rimini-AUSL Romagna

Introduzione: L’ipotensione intradialitica è una delle complicanze più frequenti del trattamento emodialitico e si associa ad aumento della mortalità. Ad oggi non esistono fattori predittivi validati per stimare a priori la tolleranza emodinamica alla sottrazione idrica in corso di trattamento dialitico.
Scopo dello studio è stato valutare se i parametri ecografici inerenti alla vena cava inferiore (VCI) a inizio dialisi possano essere predittivi di tolleranza all’ultrafiltrazione in pazienti emodializzati cronici, clinicamente stabili, previa valutazione dello stato di idratazione con un’ecografia polmonare bed-side.
Materiali e metodi: Abbiamo condotto uno studio spontaneo, prospettico, osservazionale, monocentrico, esplorativo su 17 pazienti in emodialisi cronica. Prima dell’inizio della seduta dialitica, sono state eseguite l’ecografia della VCI e l’ecografia polmonare. Abbiamo confrontato i dati ecografici rilevati dal gruppo di pazienti che ha presentato almeno un episodio di ipotensione intradialitica con quelli dei pazienti che non ne hanno presentati.
Risultati: Dei 17 pazienti arruolati, 4 hanno presentato ipotensione. L’indice di collassabilità della VCI (IC-VCI) dei pazienti che presentavano ipotensione intradialitica è risultato significativamente aumentato rispetto ai pazienti che non andavano incontro a ipotensione. Il diametro minimo della VCI (VCI min) è risultato significativamente minore nei soggetti con ipotensioni intradialitiche. Il risultato si confermava anche nelle analisi multivariate in cui tali parametri si mantenevano significativi anche al netto del B-lines-score.
Conclusioni: I risultati del nostro studio permettono di ipotizzare che IC-VCI e VCI min possano essere considerati predittori di rischio di ipotensione intradialitica inpazienti in emodialisi cronica. Studi ulteriori saranno necessari per confermare i dati osservati.

Parole chiave: emodialisi, ipotensione intradialitica, ecografia vena cava inferiore, ecografia polmonare

Extended release calcifediol and paricalcitol in the treatment of secondary hyperparathyroidism: a network meta-analysis of indirect comparison

Matteo Franchi1, Andrea Galassi2, Giovanni Corrao1

1 Dipartimento di Statistica e Metodi Quantitativi, Università degli Studi di Milano-Bicocca, Milano (MI), Italia
2 SC Nefrologia e Dialisi, ASST Santi Paolo e Carlo, Milano

Introduction: Secondary hyperparathyroidism (SHPT) is a common and major complication of chronic kidney disease (CKD) among patients on dialysis and in patients with CKD stage G3 to G5. SHPT in CKD is caused by disturbances in metabolic parameters. Paricalcitol (PCT), other active vitamin D analogous (doxercalciferol and alfacalcidol), and active vitamin D (calcitriol) have been commonly used to treat SHPT in non-dialysis CKD (ND-CKD) for several years. However, recent studies indicate that these therapies adversely increase serum calcium, phosphate, and fibroblast growth factor 23 (FGF-23) levels. Extended release calcifediol (ERC) has been developed as an alternative treatment for SHPT in ND-CKD. The present meta-analysis compares the effect of ERC against PCT in the control of PTH and calcium levels.
Methods: A systematic literature review was conducted, according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines to identify studies for inclusion in the Network Meta-Analysis (NMA).
Results: 18 publications were eligible for inclusion in the network meta-analysis and 9 articles were included in the final NMA. The estimated PTH reduction from PCT (-59.5 pg/ml) was larger than the PTH reduction from ERC (-45.3 pg/ml), but the difference in treatment effects did not show statistical significance. Treatment with PCT caused statistically significant increases in calcium vs. placebo (increase: 0.31 mg/dl), while the marginal increase in calcium from treatment with ERC (increase: 0.10 mg/dl) did not reach statistical significance.
Conclusions: The evidence suggests that both PCT and ERC are effective in reducing levels of PTH, whereas calcium levels tended to increase from treatment with PCT. Therefore, ERC may be an equally effective, but more tolerable treatment alternative to PCT.

Keywords: secondary hyperparathyroidism, PTH, calcium, vitamin D

Psychological support in anxiety management for patients affected by chronic kidney disease and treated by dialysis

Chiara Gechelin1, Sabrina Milan Manani1,2, Grazia Maria Virzì1,2, Davide Marturano1,2,3, Maria Mattiotti1,2, Ilaria Tantillo1,2, Alida Ferrara2,4, Fortunata Zirino2,4, Anna Giuliani1,2, Claudio Ronco1,2,3, Monica Zanella1,2

1 I.R.R.I.V. (International Renal Research Institute) Foundation, Vicenza
2 Dipartimento di Nefrologia, Dialisi e Trapianto Renale, Ospedale “San Bortolo”, Vicenza
3 Dipartimento di Medicina (DIMED), Università degli Studi di Padova, Padova
4 U.O.C. Nefrologia e Dialisi, di Medicina Clinica e Sperimentale, Università degli Studi di Messina, Messina

Introduction: The quality of life of patients with chronic kidney disease stage V is strongly affected by the recommended therapies. Such a situation alters the state of anxiety, which expresses a perception connected to a specific context and it overlaps with trait anxiety, which evaluates relatively stable aspects of being prone to anxiety.
The study aims to analyze the anxiety level of uremic patients and to demonstrate the benefit of psychological support either in person or online in order to mostly reduce the state of anxiety.
Materials and methods: 23 patients treated at the Nephrology Unit of the San Bortolo Hospital in Vicenza have undergone at least 8 psychological sessions. The first and the eighth sessions have been held in person, while the others were either in person or online based on the patients’ preference.
The State-Trait Anxiety Inventory (STAI), which means to evaluate the current state of anxiety and aspects of being prone to anxiety, was submitted during the first and the eighth sessions.
Results: Patients, before being submitted to psychological treatment, showed high rates of both State and Trait anxiety levels. After eight sessions the trait anxiety features and even better the state anxiety ones have significantly reduced both thanks to in-person or online treatments.
Conclusions: A treatment of minimum eight sessions shows a significant improvement of the nephropathic patient’s trait and, even better, state anxiety level and it also fosters the achievement of advanced adjustment levels compared to the new clinical status together with an improvement of the quality of life.

Keywords: psychological support, chronic kidney disease, state anxiety, trait anxiety

Thrombophilic study in dialysis patients

Sandra La Rosa1, Stefania Pesce1, Chiara Guglielmo1, Pasquale Gallerano2, Luigi Rizzuto2, Antonio Granata3

1 U.O.S.D. Nefrologia e Dialisi, P.O. “Giovanni Paolo II”, Sciacca (AG) – Italy
2 U.O.C. Medicina Trasfusionale e Banca del Cordone, P.O. “Giovanni Paolo II”, Sciacca (AG) – Italy
3 U.O.C. Nefrologia e Dialisi Azienda Ospedaliera Cannizzaro, Catania (CT) – Italy

Chronic kidney disease is a complex phenotype that results from the association of underlying kidney disease and environmental and genetic factors. In addition to the traditional risk factors, genetic factors are involved in the etiology of renal disease, including single nucleotide polymorphisms which could account for the increased mortality from cardiovascular disease of our hemodialysis patients. The genes that influence the development and rate of progression of kidney disease deserve to be better defined. We have evaluated the alterations of thrombophilia genes in hemodialysis patients and in blood donors and we have compared the results obtained. The objective of the present study is to identify biomarkers of morbidity and mortality, which allow us to identify patients with chronic kidney disease at high risk, thanks to which it is possible to implement accurate therapeutic strategies and preventive strategies that have the objective of intensifying controls in these patients.

Keywords: single nucleotide polymorphisms, thrombophilia panel, biomarkers of mortality, omic sciences, chronic kidney disease, hemodialysis

When a rear-end collision turns out to be a revelation: a case of IgG4 related kidney desease

Lorenzo D’Elia1, Luciano Cencioni1, Martina Ferraresi2, Antonio Marciello2, Paolo Maurizio Perosa2, Antonietta Rizzuto2, Luisa Sandri2

1 UOS Nefrologia e dialisi Ospedale “Santa Maria della Stella” Usl Umbria 2 Orvieto (TR)
2 SS Nefrologia e dialisi Ospedale “E. Agnelli” di Pinerolo (TO) ASLTO3

IgG4 related renal disease represents a frequent manifestation of the wider IgG4 related disease, a fibroinflammatory disorder with a not fully understood etiology that affects several organs. Through the clinical case presented, we will focus attention on this pathology and on the diagnostic difficulties that may arise, and on the investigations necessary for the diagnosis. Finally, the main therapeutic options will be discussed.

Keywords: IgG4 related disease, IgG4 related kidney disease, fibroinflammatory disorders

IgA nephropathy and granulomatosis with polyangiitis-overlap: a rare coexistence of two glomerular nephropathies with remission after steroids and rituximab

Francesco Londrino1, Giovanni Giuliani1, Marisa Santostefano2, Olga Baraldi2, Maria Mattiotti2, Marco Mangiulli1, Paola Tatangelo1, Giorgia Gambardella1, Sara Dominijanni1, Marianna Napoli2, Gaetano La Manna2, Roberto Palumbo1

1 UO Nefrologia e Dialisi, Ospedale S. Eugenio, Roma, Italia
2 UO Nefrologia, Dialisi e Trapianto, IRCCS Azienza Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum Università di Bologna, Italia

Granulomatosis with polyangiitis (GPA) is an ANCA-positive systemic vasculitis that mainly involves lungs and kidneys. This condition rarely overlaps with other glomerulonephritides. A 42-year-old man with constitutional symptoms and haemophtoe was admitted to the Infectious Diseases department, where he was subjected to fibrobronchoscopy with BAL (broncho-alveolar lavage) and lung transbronchial biopsy that showed histological signs of vasculitis. The association with severe acute kidney injury with urine sediment alterations (microscopic haematuria and proteinuria) led the consultant nephrologist to a diagnosis of GPA. Thus the patient was transferred to the Nephrology department. During the hospitalization, the worsening of the clinical course and the development of alveolitis, respiratory failure, purpura, and rapidly progressive kidney failure (nephritic syndrome – serum creatinine 3 mg/dl) required the start of steroid therapy, according to EUVAS. The presence of florid crescents in 3 out of 6 glomeruli in the renal biopsy and the IgA positive immunofluorescence allowed to make a diagnosis of overlap of GPA and IgA nephropathy. Rituximab (RTX 375 mg/m² per week for 4 weeks) and plasma exchange (7 sessions) were added to steroid therapy. During follow-up, partial functional recovery was achieved after 4 months, whereas total regression, i.e. the absence of protein and red blood cells in urine sediment, was reached during the 4-years follow-up. The main therapy during the first 2 years of follow-up was RTX, followed by mycophenolate mofetil for the remaining 2 years.

Keywords: granulomatosis with polyangiitis, ANCA-associated vasculitis, IgA nephropathy and granulomatosis with polyangiitis-overlap, rituximab

The therapeutic management and economic burden of patients with chronic kidney disease non-dialysis-dependent with anemia and ESA treated: findings from a real-world study in Italy

Maura Ravera1, Paolo Mené2, Luca Degli Esposti3, Diego Sangiorgi3, Paolo Di Rienzo4

1 Ospedale Policlinico San Martino, Genova
2 Sapienza Università di Roma, Azienda Ospedaliera Sant’Andrea, Roma
3 CliCon S.r.l. Società Benefit, Bologna
4 Astellas Pharma Italia S.P.A., Milano

Background. This real-world study aimed to provide insights on the characteristics, drug utilization, and economic burden of chronic kidney disease non-dialysis-dependent (NDD-CKD) patients with anemia prescribed Erythropoiesis Stimulating Agents (ESA) in Italian clinical practice settings.
Methods. A retrospective analysis was performed based on administrative and laboratory databases covering around 1.5 million subjects across Italy. Adult patients with a record for NDD-CKD stage 3a-5 and anemia during 2014-2016 were identified. Eligibility to ESA was defined as the presence of ≥ 2 records of Hb < 11 g/dL over 6 months, and patients eligible and currently treated with ESA were included.
Results. Overall, 101,143 NDD-CKD patients were screened for inclusion, of which 40,020 were anemic. A total of 25,360 anemic patients were eligible to ESA treatment and 3,238 (12.8%) were prescribed ESA and included. The mean age was 76.9 years and 51.1% was male. More frequently observed comorbidities were hypertension (over 90% in each stage), followed by diabetes (37.8-43.2%) and cardiovascular condition (20.5-28.9%). Adherence to ESA was observed in 47.9% of patients, with a downward trend while progressing across stages (from 65.8% stage 3a to 35% stage 5). A consistent proportion of patients did not have nephrology visits during the 2 years of follow-up. Costs were mainly due to all drugs (€4,391) followed by all-cause hospitalization (€3,591) and laboratory tests (€1,460).
Conclusions. Findings from the study highlight an under-use of ESA in the management of anemia in NDD-CKD as well as a sub-optimal adherence to ESA and showed a great economic burden for anemic NDD-CKD patients.

Keywords: anemia, administrative databases, Erythropoiesis Stimulating Agents (ESA), chronic kidney disease (CKD), nephrology, real life

Tolvaptan resistance is related with a short-term poor prognosis in patients with lung cancer and syndrome of inappropriate anti-diuresis

Antonio Lacquaniti1, Susanna Campo1, Alessandro Russo2, Vincenzo Adamo2, Paolo Monardo1

1 Nephrology and Dialysis Unit, Papardo Hospital of Messina, Italy
2 Medical Oncology Unit A.O. Papardo & Department of Human Pathology, University of Messina, Messina, Italy

Purpose: Tolvaptan (TVP), a vasopressin receptor antagonist, represents a therapeutic option in the syndrome of inappropriate anti-diuresis (SIAD). The aim of this study was to evaluate the effect of TVP to treat and solve hyponatremia in oncologic patients.
Methods: 15 oncologic patients who developed SIAD have been enrolled. Patients receiving TVP belonged to group A, whereas group B was characterized by hyponatremic patients treated with hypertonic saline solutions and fluid restriction.
Results: In group A, the correction of serum sodium was achieved after 3.7±2.8 days. In group B, the target levels were obtained more slowly, after 5.2±3.1 days (p: 0.01) than in group A. The hospital stay and incidence of re-hospitalization were higher in group B than in group A. In this latter, 37% of patients had hyponatremic relapses, notwithstanding the progressive increase of doses from 7.5 to 60 mg per day of TVP, revealing a complete lack of response to TVP. In these patients, a growth of tumor mass or new metastatic lesions has been revealed.
Conclusion: TVP improved hyponatremia more efficiently and stably than hypertonic solutions and fluid restrictions. Positive consequences have been obtained about the rate of chemotherapeutical cycles concluded, hospital stay, rate of relapse of hyponatremia, and re-hospitalization.
Our study also suggested potential prognostic information that could be deduced from TVP patients, in whom sudden and progressive hyponatremia occurred, despite TVP dosage increase. A re-staging of these patients to rule out tumor mass growth or new metastatic lesions is suggested.

Keywords: hyponatremia, paraneoplastic syndrome, syndrome of inappropriate anti-diuresis, tolvaptan, vasopressin

High-flow fistula: a problem not easy to handle

Anna Mudoni1, Marina Cornacchiari2, Fabio Borin3, Amelia Liccardo2, Bianca Visciano2, Maria Giuseppina Ponticelli2, Carlo Guastoni2

1 Unità Operativa di Nefrologia e Dialisi Ospedale Cardinale G Panico, Tricase, Lecce
2 Unità Operativa di Nefrologia e Dialisi Ospedale G Fornaroli- Magenta. ASST OVEST MI
3 Unità Operativa di Chirurgia Vascolare Ospedale G Fornaroli- Legnano. ASST OVEST MI

High-output cardiac failure is a well-known phenomenon of high-flow fistula in hemodialysis patients. The definition of “high flow” is varied and almost always connected to proximal arteriovenous fistulas (AVF).
High flow access is a condition in which hemodynamics is affected by a greater rate of blood flow required for hemodialysis and this can compromise circulatory dynamics, particularly in the elderly in the context of pre-existing heart disease.
High access flow is associated with complications like high output heart failure, pulmonary hypertension, massively dilated fistula, central vein stenosis, dialysis associated steal syndrome or distal hypoperfusion ischemic syndrome.
Although there is no single agreement about the values of AVF flow volume, nor about the definition of high‐flow AVF, there is no doubt that AVF flow should be considered too high if signs of cardiac failure develop.
The exact threshold for defining high flow access has not been validated or universally accepted by the guidelines, although a vascular access flow rate of 1 to 1.5 l/min has been suggested.
Moreover, even lower values may be indicative of relatively excessive blood flow, depending on the patient’s condition.
The pathophysiology contributing to this disease process is the shunting of blood from the high-resistance arterial system into the lower resistance venous system, increasing the venous return up to cardiac failure.
Accurate and well-timed diagnosis of high flow arteriovenous hemodynamics by monitoring of blood flow of fistula and cardiac function is required in order to stop this process prior to cardiac failure.
We present two cases of patients with high flow arteriovenous fistula with a review of the literature.

Keywords: Blood flow, cardiac failure, vascular access, hemodialysis

Malnutrition and dialytic adequacy in patients on peritoneal dialysis: two sides of the same coin?

Giuseppe Leonardi¹, Maria Grazia Arcidiacono², Irma Figlia³, Gemma Patella³, Alessandro Comi³, Paola Cianfrone³, Giuseppe Coppolino³, Michele Andreucci³

1 UOC Nefrologia e Dialisi, Ospedale “Antonio Perrino”, Brindisi
2 UOC Nefrologia e Dialisi, Azienda Ospedaliero-Universitaria “Consorziale Policlinico”, Bari
3 Cattedra di Nefrologia, Dipartimento di Scienze della Salute, Università “Magna Graecia”, Catanzaro

Dialysis adequacy and a state of “eunutrition” are two essential elements to consider in the evaluation of patient undergoing dialysis treatment.

Dialysis inadequacy is often associated with malnutrition, and the combination of these two factors significantly worsens the prognosis.

In the following monocentric and prospective study, the correlation between nutritional markers and dialytic adequacy was tested in a cohort of patients permanently followed by the peritoneal dialysis clinic, followed consistently for two years.

It was therefore evaluated if modification of dialysis therapy, aimed to reach adequacy parameters, could simultaneously improve metabolic parameters.

Although there were no frankly malnourished patients, the group of “inadequate” patients had a significantly lower nPCR value.

In this same group, after about 6 months, therapeutic measures adopted allowed an overall improvement in Kt/V and nPCR, with other nutritional parameters (such as body weight, albumin, pre-albumin, total cholesterolemia) remaining stable.

At the end of the follow-up period the Kt/V of the “inadequate” (<1.7) was higher ​​than the baseline, reaching statistical significance at the 12th and 24th months. Early identification of a dialysis inadequacy, therefore, allowed the execution of therapeutic changes necessary to achieve a lasting improvement in “adequate” replacement therapy, and a temporary improvement in the patient's nutritional status. Suddenly, despite the persistent improvement of the Kt/V there was a new reduction of the nPCR. Keywords: Peritoneal Dialysis, Malnutrition, Dialytic Adequacy

Le nuove sfide della Nefrologia

Mariacristina Gregorini 1, Stefano Bianchi 2

1 Segretario, Società Italiana di Nefrologia
2 Presidente, Società Italiana di Nefrologia

Possible vaccine-induced immune thrombotic thrombocytopenia in a patient with diabetes and chronic kidney disease or random association?

Stefania Comolli1, Lucia Del Vecchio2, Valeria De Micheli3, Benedetta Tucci2, Marco D’Amico2, Giordano Fumagalli2, Beniamina Gallelli2, Francesca Gervasi2, Nicoletta Mezzina2, Mariagiulia Tettamanti2, Gianvincenzo Melfa2


1 Scuola di Specializzazione in Nefrologia, Università degli Studi di Milano-Bicocca, Milano, Italia
2 U.O. di Nefrologia e Dialisi, Ospedale Sant’Anna, ASST Lariana, Como, Italia
3 U.O.S. Emostasi e Trombosi, ASST Lecco, Lecco, Italia

We report the case of a 75-year-old man who developed acute myocardial infarction 12 hours after the first dose of ChAdOx1 nCov-19 vaccine. The event was associated with a transient decrease of platelet count and the detection of anti-PF4 antibodies approximately 45 days after the event.
Vaccine-induced thrombotic thrombocytopenia (VITT) is characterized by the onset of venous or arterial thrombosis in temporal relationship to the administration of anti-Sars-Cov-2 viral vector vaccines (ChAdOx1 nCov-19 and Ad26.COV2.S), thrombocytopenia and the production of anti-PF4 antibodies. It occurs mainly at a young age, even if the median age is 54 years; it is often associated with thrombosis in atypical sites, such as the cerebral sinus.
Our reported case does not present all the diagnostic criteria of VITT. However, the close temporal relationship between ChAdOx1 nCov-19 vaccine administration, thrombosis, and concomitant anti-PF4 antibodies positivity makes the case suggestive of a possible slight form of VITT.

Keywords: Sars-CoV-2, chronic kidney disease, vaccine, ChAdOx1 nCov-19, vaccine-induced immune thrombotic thrombocytopenia, VITT

Anti-angiogenic drugs and hypertension: from multidisciplinary collaboration to greater care

Francesca Tunesi1, Marco Simonini1, Giulia Sabetta2, Alice Bergamini2, Raffaella Cioffi2, Emanuela Raiabiotti2, Paolo Manunta1, Giuseppe Vezzoli1, Giorgia Mangili3, Chiara Livia Lanzani1

1 U.O. Nefrologia e Dialisi, IRCCS Ospedale San Raffaele, Milano, Italia; Università Vita Salute San Raffaele, Milano, Italia
2 U.O. Ginecologia ed Ostetricia, IRCCS Ospedale San Raffaele, Milano, Italia; Università Vita Salute San Raffaele, Milano, Italia
3 U.O. Ginecologia ed Ostetricia, IRCCS Ospedale San Raffaele, Milano, Italia

Anti-angiogenic drugs are widely used in cancer therapy. Their main targets of action are the vascular endothelial growth factor (VEGF) and its receptors (VEGF-R). Anti-angiogenic drugs are used to reduce the growth of the tumor and its metastases by acting on the phenomenon of tumor neo-angiogenesis. However, they are known for their side effects such as hypertension, acute kidney injury (AKI), and congestive heart failure.
Methods: retrospective study conducted on 57 consecutive patients known for ovarian cancer. Patients treated with Bevacizumab, as first-line, relapse, or maintenance treatment (2015-2022).
Results: according to FIGO staging, 98.2% (56 out of 57) of the patients in the study had third degree disease (G3). 49% of patients developed hypertension after starting Bevacizumab therapy (82% grade 2 according to CTCAE v.5). 89% of hypertensive patients started treatment and its management was multidisciplinary with nephrological consultation in 68% of cases. Only 3 out of 57 women discontinued treatment due to hypertension, and in only one of them it was not possible to restart it.
Conclusions: the evaluation of the patient by a multidisciplinary team (gynecologist and nephrologist) is essential to minimize the morbidity and mortality of patients, and to avoid the interruption of antineoplastic treatment.

Keywords: anti-angiogenic drugs, kidney injury, proteinuria, hypertension, ovarian cancer, multidisciplinary team

Impact of dialysis on the acid-base balance

Marco Marano

Unità Funzionale di Nefrologia e Dialisi, Casa di Cura Maria Rosaria, Pompei (NA)

In patients on hemodialysis, the reduced alkali urinary loss makes metabolic acidosis less severe. Unexpected is the large occurrence of respiratory alkalosis and acidosis.
During the therapy, the convective/diffusive inward fluxes of CO2 and bicarbonate and the loss of organic anions affect acid-base homeostasis.
In bicarbonate-dialysis, the neutralization of acids by bicarbonate and gain of gaseous CO from the dialysate cause an increase of CO2 content in the body water, which requires an increase in lung ventilation (>10%) to prevent hypercapnia. In on-line hemodiafiltration, the infusate drags additional CO2 into bloodstream, while in acetate – free biofiltration the dialysate is CO2 – free and this prevents any addition of CO2.
Bicarbonate and acetate diffuse into extracellular fluid according to their bath-to-blood concentration gradients. The initially large bicarbonate flux decreases rapidly because of the rapid increase in blood concentration. The smallest acetate flux is instead constant with time providing a constant source of alkali.
Rapid alkalinization elicits H+ mobilization that consumes most of the bicarbonate added. Some H+ are originated by back-titration of body buffers, but others are originated by new organic acid production, a maladaptive event that wastes metabolic energy. In addition, organic anions diffuse into dialysate causing a substantial increase in net acid production.
A novel dialysis protocol prescribes a low initial bath bicarbonate concentration and a stepwise increase during the therapy. Such a staircase protocol ensures a smoother increase of blood bicarbonate concentration avoiding the initial rapid growth and reducing the rate of organic acid production, thus making the treatment more effective.

Keywords: Acid-base, Bicarbonate, Carbon Dioxide, Dialysate, Hemodialysis

T-cell-mediated acute rejection

Alessandra Palmisano1, Marco Delsante1, Enrico Fiaccadori1,2, Umberto Maggiore1,2, Ilaria Gandolfini1

1 UO Nefrologia, Azienda Ospedaliera-Universitaria Parma
2 Dipartimento di Medicina e Chirurgia Università di Parma

Despite the advances in immunosuppressive therapies and improvements in short-term allograft survival, acute rejection still represents one of the major causes of graft loss. We present a case of early acute T-cell-mediated rejection treated efficaciously with pulse steroids and we review the current literature on the pathogenesis, diagnosis, and treatment of acute T-cell-mediated rejection. Pathogenetic mechanisms involve recruitment, activation, and proliferation of donor-specific T-cells, capable of inducing graft injury through direct and indirect mechanisms. Histologically, Banff classification provides standardized and reproducible definitions and scoring for rejection categories, including T-cell mediated rejection (TCMR) and borderline for TCMR. Although allograft biopsy still represents the gold standard for acute rejection diagnosis, new non-invasive biomarkers are emerging to improve diagnostic timeliness and assist therapeutic choices.

Therapy of TCMR largely depends on histologic severity and may range from the adjustment of maintenance immunosuppressive therapy to the use of thymoglobulin and other aggressive immunosuppressive approaches. Finally, the response to the anti-rejection treatment is normally detected through serum creatinine and surveillance biopsies. However, new biomarkers are emerging to non-invasively monitor this response.

Keywords: Kidney transplantation, Graft rejection, Graft rejection diagnosis, Graft rejection treatment, Graft rejection prognosis

Hemodialysis safety: from the study of the minimum data set to the creation of the CUSTODE hemodialysis surveillance flow sheet

Bazzurri Francesco1, Andreoli Desirèe2

1 USL UMBRIA 1, Perugia, Italia
2 S.C. di Nefrologia, dialisi e trapianto di rene, Azienda Ospedaliera Santa Maria della Misericordia, Perugia, Italia

Background: The purpose of the study is to identify, through a survey, the parameters that need to be monitored during a hemodialysis session and to merge them into a surveillance flow sheet that allows the optimal conduction of the treatment.
Methods: The study was conducted using the questionnaire methodology and involved 78 nurses working in the nephrological area in Italy. The majority of participants have an age of service greater than 10 years and belong to a hemodialysis context.
Results: The data show how the surveillance flow sheet is a diversified tool according to the treatments carried out. However, the majority of dialysis flow sheets have a section dedicated to the medical-nursing diary, a space for recording the access characteristics and there is also a good level of digitalization of the instrument.
The frequency of detection of vital and monitor-related parameters varies on the basis of the treatment carried out, the registration of the identification number and the filter label are not a uniform practice. Finally, the majority points out the need for an improvement of the surveillance card in use.
Conclusions: The research highlights the lack of uniformity of the dialysis surveillance process.
The study proposes as a solution to the problem a universal medical-nursing flow sheet, called CUSTODE, which can guide the professional in the management of hemodialytic treatment, through the registration of a minimum data set.

Keywords: hemodialysis surveillance flow sheet, minimum data set, hemodialysis, safety

Denosumab and fracture risk in kidney transplant

Michele Marchini1, Matteo Trezzi1, Michela Ardini1, Laura Panaro1, Sonila Mocka1, Paola Bizzoni2, Davide Rolla1

1 UO Nefrologia e Dialisi, Ospedale Sant’Andrea, La Spezia, Italia
2 UO Medicina Nucleare, Ospedale Sant’Andrea, La Spezia, Italia

Background: Kidney transplant patients bear a higher risk of bone disease. The monoclonal antibody Denosumab (Den), by binding RANKL, reduces osteoclastic activity and increases mineral density (BMD), thus limiting the risk of bone fractures. We evaluated the efficacy and safety of Den in kidney transplant patients who developed bone fractures.
Methods: Thirteen kidney transplant recipients (aged from 50 to 79 years 7M and 6F, with an average 9,9 years follow up after transplantation, and nearly normal renal function (GFR 62±15 ml/min/1.73m2), who developed low-energy vertebral fractures (21 dorsal and 1 lumbar) after transplantation, had been evaluated for 2 years with Dual-energy X-ray absorptiometry (DEXA) and morphometric absorptiometry (MXA) while receiving Den (four 60-mg doses). Data for vertebral heights and posterior-anterior height ratios (P/A), and BMD values for vertebral, femoral, and radius were obtained. The immunosuppressive regimen consisted of CNI and MMF, and 8 out of 13 were taking prednisone. A fixed dose of 450.000 UI-year of cholecalciferol was prescribed to all patients. Whole-PTH, 25-OHD3, and alkaline phosphatase (ALP) were also evaluated.
Results: After 2 years of Den treatment, we observed a significative increase in vertebral T-score (from -2.12±0.35 to -1.67±0.35; p< 0.02), while T score of femoral neck and radius did not show significative variation (-1.86±0.21 versus -1.84±0.23 and -3.04±0.42 versus -3.19±0.45, respectively). We found a lower incidence of fracture/patient-year pre and post Den 0.17 [95 CI 0.11-0.24] vs 0.07 [95% CI 0.02-0.3] respectively. No significative variations were observed in whole-PTH (89.31±19.9 pg/ml versus 68.38±9.8 pg/ml), 25OHD3 (24.02±2.75ug/L versus 26.67±2.29 ug/L) and alkaline phosphatase (78.46±12.73UI/L versus 56.77±7.14UI/L). No adverse events were registered. Conclusions: Treatment with Den improve BMD in vertebral bone and possibly reduces the risk of low-energy vertebral fractures in kidney transplant patients.

Keywords: Denosumab, low-energy fracture, transplant osteopathy

Pediatric Minimal Change Disease and AKI following the Pfizer-BioNTech COVID-19 Vaccine: causal or incidental correlation?

Luigi Annicchiarico Petruzzelli1, Bruno Minale1, Vittorio Serio1, Angela De Luca1, Giuseppina Marino Marsilia2, Severo Campione2, Francesca Diomedi Camassei3, Rosamunda D’Arcangelo1, Ilaria Luongo1, Lorenza Lepore4, Paolo Giannattasio1, Daniela Molino1, Laura Pirro1, Maria Concetta Lonardo1, Gabriele Malgieri1, Carmine Pecoraro1

1 Paediatric Nephrology, Dialysis and Renal Transplantation Santobono Pausilipon Children’s Hospital, Naples, Italy
2 Section of Pathology, Antonio Cardarelli Hospital, Naples, Italy
3 Department of Laboratories-Pathology Unit, Bambino Gesù Children’s Hospital, Rome, Italy
4 Emergency department, Antonio Cardarelli Hospital, Naples, Italy

The global coronavirus 2019 (COVID-19) pandemic required vaccination even in children to reduce infection.
We report on the development of acute kidney injury (AKI) and minimal change disease (MCD) nephrotic syndrome (NS), shortly after the first injection BNT162b2 COVID-19 vaccine (Pfizer-BioNTech).
A 12-year-old previously healthy boy was referred to our hospital with complaints of peripheral edema and nephrotic range proteinuria.
Nine days earlier he had received his first injection BNT162b2 COVID-19 vaccine (Pfizer-BioNTech).
Seven days after injection, he developed leg edema, which rapidly progressed to anasarca with significant weight gain. On admission, serum creatinine was 1.3 mg/dL and 24-hour urinary protein excretion was 4 grams with fluid overload.
As kidney function continued to decline over the next days, empirical steroid treatment and renal replacement therapy with ultrafiltration were started and kidney biopsy was performed.
Seven days after steroid therapy, kidney function began to improve, gradually returning to normal.
The association of MCD, nephrotic syndrome and AKI hasn’t been previously described following the Pfizer-BioNTech COVID-19 vaccine in pediatric population, but this triad has been reported in adults.
We need further similar case reports to establish the real incidence of this possible vaccine side effect.

Keywords: nephrotic syndrome, Acute Kidney Injury (AKI), SARS-CoV-2 vaccines, pediatric population

Methods for calculating the number of nephrons from ultrasound scans and kidney biopsies for nephrologists’ use

Gianmarco Borriello*, Ilenia Gravina*, Alessandra F. Perna, Davide Viggiano, Rosa Maria Pollastro
*these authors contributed equally

UOC Nefrologia e Dialisi, Dipartimento di scienze mediche traslazionali, Università degli Studi della Campania ‘Luigi Vanvitelli’, Napoli, Italia

The interest in determining the number of nephrons in the kidney dates back to the 1960s, when an influential laboratory method for determining ex vivo the number of nephrons in the kidneys was described by Bricker. Over the years, various methods have been developed to estimate the number of nephrons in living beings as accurately as possible. These modern methods combine data such as the glomerular density, the percentage of glomeruli in sclerosis calculated from biopsy samples, and the kidney volume, which can be precisely estimated from magnetic resonance, CT scan, or specific ultrasound methods. As the reduction in the number of functioning nephrons is closely connected with an increased risk of progression of renal disease (especially in patients with nephrotic syndrome) and hypertension, its introduction into clinical practice could allow a precise stratification of progression risk in patients with kidney disease and a better understanding of the mechanisms that contribute to the loss of functioning nephrons.

Keywords: nephrons number, kidney biopsy, CKD

Role of physical exercise in an overlooked nutcracker syndrome occurred in a patient with diaphragmatic relaxation: a case report

Carmine Sellitto1,2*, Angelica Perna3*, Nicola Mazzarella1, Ginevra Leo1, Germano Guerra3, Antonio De Luca1, Paolo De Blasiis1, Angela Lucariello4
*these authors contributed equally

1 Section of Human Anatomy, Department of Mental and Physical Health and Preventive Medicine, University of Campania “Luigi Vanvitelli”, Naples, Italy
2 Section of Pharmacology, Department of Medicine, Surgery and Dentistry, “Scuola Medica Salernitana”, University of Salerno, Baronissi, Italy
3 Section of Human Anatomy, Department of Medicine and Health Sciences “Vincenzo Tiberio”, University of Molise, Campobasso, Italy
4 Section of Human Anatomy, Department of Sport Sciences and Wellness, University of Naples “Parthenope”, Naples, Italy

Background: Nutcracker syndrome (NCS) is caused by extrinsic compression of the left renal vein (LRV), usually between the abdominal aorta (AA) and superior mesenteric artery (SMA). This rare disease includes symptoms such as hematuria, left flank pain or abdominal pain, varicocele in males, proteinuria, anemia, gynecological symptoms (dyspareunia, dysmenorrhea).
Case report: We report the case of a 48-year-old female patient, who experienced left abdominal colic after intensive physical exercise, finally resulting in a diagnosis of NCS. This abdominal pain was disabling for daily activities, it was controlled by analgesic drugs and led to hospital admissions. In-depth examinations were recommended to the patient to investigate the etiology of these attacks. A bad rotated and ectopic left kidney, which was located superior to the spleen, at the level of the left hemithorax base, was found due to the presence of a diaphragmatic relaxation in the posterior area, which caused an upward displacement of the kidney, part of the colon and omental fat. Because of the presence of a compression of the LRV by the SMA and the AA, the nephrologist diagnosed a NCS, presenting with abdominal pain following physical exercise, proteinuria and dysmenorrhea. Conservative treatment was chosen for the patient.
Conclusions: The patient was recommended to engage in a moderate and regular physical activity, avoiding acute and intense exercise: hypopressive abdominal gymnastics was suggested. The role of physical exercise in triggering painful attacks and its role in rehabilitation to prevent the same attacks was crucial for the patient.

Keywords: physical exercise, nutcracker syndrome, abdominal pain, diaphragmatic relaxation

Un percorso in costante crescita

Gaetano La Manna

Editor in Chief Giornale Italiano di Nefrologia

Emerging aspects of membranoproliferative glomerulonephritis

Dario Roccatello, Roberta Fenoglio, Laura Battaglia, Lucia Vizziello, Carla Naretto, Daniela Rossi, Savino Sciascia

Centro di Eccellenza Universitario per le malattie Nefrologiche (Membro ERK-net, ERN-ReConnet and RITA-ERN), Reumatologiche e Rare, Nefrologia – Dialisi e CMID, Ospedale San Giovanni Bosco, Dipartimento di Scienze Cliniche e Biologiche, Università di Torino

Historically, findings on light and electron microscopy have been used to subclassify membranoproliferative glomerulonephritis (MPGN). Recent advances in understanding of the underlying pathobiology have led to a classification scheme based on immunofluorescence findings. MPGN can result from subendothelial and mesangial deposition of complement owing to dysregulation of the alternative pathway of complement. Complement-mediated MPGN includes dense deposit disease and proliferative glomerulonephritis with C3 deposits. Dysregulation of complement cascade can result from genetic mutations or development of autoantibodies to complement regulating proteins. MPGN is also a pattern of injury that results from subendothelial and mesangial deposition of immune complexes (IC). The common causes of IC-mediated MPGN include chronic infections, autoimmune diseases, and monoclonal gammopathy/dysproteinemias. This category also includes mixed cryoglobulinaemia-glomerulonephritis. Most of these cases are associated with the presence of a hepatitis C virus (HCV) infection. A number of patients with high clinical suspicion for cryoglobulinaemic vasculitis show negative results for the detection of cryoglobulins using standard methods, but are found to have detectable levels of cyoprecipitable immunoglobulins (hypocryoglobulins) using more sensitive techniques. A subset of patients with low level of circulating hypocryoglobulins can present with glomerulonephritis, often isolated, with membranoproliferative pattern MPGN. They can be negative for HCV infection detection and can have normal rheumatoid activity and complement levels. Hypocryoglobulinemic nephritis might represent a distinct entity.

Keywords: Membranoproliferative Glomerulonephritis, C3 Glomerulonephritis, Hypocryoglobulinemic Nephritis

Nefropatia cronica del trapianto: focus sul ruolo della microinfiammazione

Gianluigi Zaza

Unità di Nefrologia, Dialisi e Trapianto, Dipartimento di Scienze Mediche e Chirurgiche, Università Degli Studi di Foggia.

La nefropatia cronica del trapianto è una condizione patologica multifattoriale presente in una larga percentuale di reni trapiantati la cui comprensione è stata accelerala dall’estesa applicazione della biologia molecolare e dall’impiego della biopsia protocollare in molti centri nefro-trapiantologici. Grazie a queste innovazioni, si è compreso che questo processo può comparire molto precocemente nel post-trapianto e che la microinfiammazione parenchimale gioca un ruolo chiave. Molte condizioni patologiche, anche precoci (come il danno da ischemia/riperfusione, la presenza di rigetti cellulari e umorali, e le infezioni virali e batteriche) possono contribuire alla genesi della fibrosi renale. Da un punto di vista prettamente biologico, il danno cronico inflammatorio-mediato del graft è orchestrato da cellule immunitarie (principalmente macrofagi, cellule dendritiche, linfociti) e cellule effettrici che mediano la deposizione di matrice extracellulare (ECM) e la fibrosi. Molti degli elementi chiave di questi pathway biologici potrebbero rappresentare in futuro ottimi bersagli terapeutici. Al momento, però, non esiste una terapia specifica per arginare questa condizione, ma appare evidente che l’impiego di una immunosoppressione sostenibile (utilizzo combinato di più farmaci alle più basse dosi possibili) e l’attenzione alle comorbidità (dedicando sufficiente tempo al follow-up clinico e incrementando il network multi-specialistico) sia la via da perseguire per ottenere un accettabile rallentamento della progressione delle lesioni croniche del graft e una sua maggiore sopravvivenza.

Parole chiave: Nefrologia, Trapianto renale, Microinfiammazione, Fibrosi, Immunosoppressione

Il rigetto acuto anticorpo-mediato

Nicola Bossini

U.O. di Nefrologia, ASST Spedali Civili di Brescia

VIII edizione Congresso di Nefrologia di Grado: Sistema Immunitario e Rene

Giuliano Boscutti

Direttore Struttura Complessa Nefrologia e Dialisi
Azienda Sanitaria Universitaria Integrata di Udine
Azienda Ospedaliera Santa Maria della Misericordia

La glomerulopatia da C3

Camillo Carrara1, 2

1 Unità di Nefrologia e Dialisi, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italia
2 IRCCS – Istituto di Ricerche Farmacologiche Mario Negri, Centro di Ricerche Cliniche per le Malattie Rare “Aldo e Cele Daccò”, Ranica

In recent years, the complement system, which plays a crucial role in the innate immunity, fostered renewed scientific interest. This process has brought a rare kidney disorder, named C3 glomerulopathy, in the center of a real revolution, highlighting the complex interactions between genotype, triggers and kidney microenvironment, which together contribute to the final phenotype of the disease. At the same time, experimental studies and clinical trials testing new complement inhibitors have multiplied enormously. It’s a very promising time for patients affected by C3 glomerulopathy, which didn’t have so far effective therapies in preventing the progression to the end-stage kidney disease.

Keywords: Membranoproliferative glomerulonephritis, C3 glomerulopathy, complement system, alternative pathway, kidney biopsy

Malattia a lesioni minime e glomerulosclerosi focale e segmentaria: uno sguardo alla patogenesi e alle nuove indicazioni dalle Linee Guida KDIGO 2021

Rossella Siligato1,2,3, Silvia Di Carlo1, Maria Rosa Di Franza1, Guido Gembillo 1,2, Valeria Cernaro1, Domenico Santoro1

1 Unità di Nefrologia e Dialisi, Dipartimento di Medicina Clinica e sperimentale, Azienda Ospedaliera Universitaria “G. Martino”, 98125 Messina, Italia
2 Dipartimento di Scienze Biomediche, Odontoiatriche e delle Immagini morfologiche e funzionali, Università di Messina, 98125 Messina, Italia
3 Unità di Nefrologia, Azienda Ospedaliera Universitaria Sant’Anna, 44124 Ferrara, Italia

Old and new transplant histocompatibility antigens

Antonio Amoroso

Dipartimento di Scienze Mediche Genetica dei Trapianti

The genetic system that most influences the outcome of organ transplants is the Major Histocompatibility Complex (MHC), which in humans is also known as the HLA (Human Leucocyte Antigens) system. These genes are highly polymorphic, meaning that each individual in the population has inherited a set of genes that combine in an almost unique way. They encode cell surface glycoproteins which therefore vary from one individual to another and are recognized as a target in the case of transplantation by the recipient’s immune system.

It is considered that the right match for HLA characteristics between donor and recipient can explain less than half of the immunological causes of transplant failure. It is well known that differences in other genetic characteristics may be responsible for a not small share of transplant failure due to immunological causes. These characteristics are defined as minor histocompatibility genes (and antigen their products).

The new approaches to study the genome allow to examine all the variability of a recipient, and compare it with that of the donor: in this way it is possible to evaluate whether particular genetic collisions (i.e. incompatibility for some of them) can influence the outcome of the transplant. These studies made it possible to define new genes whose compatibility between donor and recipient may be relevant for the success of the transplant.

Keywords: transplants, genomics, histocompatibility

Italian Pioneers in Cardionephrology: how some fundamental Italian cardiorenal researches have passed into oblivion

Attilio Losito

Former director of the Struttura Complessa di Nefrologia e Dialisi Santa Maria Della Misericordia Hospital, Perugia, Italy

A historical research was made on papers published by Italian scientists on cardiorenal diseases. The investigated period is between the beginning of the 20th century and the entry of Italy into the Second World War, 1940. 34 papers dealing with the relationship between the kidney and the cardiovascular system were retrieved. All but two articles were published in Italian medical periodicals. The topics covered are varied and range from cardiotoxicity of substances in uremia to the role of renal disease in vascular damage. Some articles are forerunners of later pathophysiological concepts and research technologies. These concern early atherosclerotic vascular damage and the presence of dialyzable cardiotoxic substances in renal insufficiency. Unfortunately, these highly innovative researches have had little diffusion and have fallen into oblivion in Italy and abroad. In conclusion, our research shows that in the first half of the 20th century in Italy there was a lively interest in cardio-renal diseases and that some researchers had produced precursor results of what was confirmed many years later.

Keywords: cardionephrology, cardiorenal studies, Italian scholars, history of nephrology

Is there really something wrong with the formalization processes of the anticipated will? Insist on DATs or (finally) promote advance care planning (ACP)?

Fabio Cembrani

Professore a contratto, Università degli studi di Verona

The author analyzes the possible paths for the formalization of the anticipated will regarding the care provided for by law no. 219/2017, identifying them in the advance treatment provisions (DAT) and in the shared care planning (advance care planning) of which he examines the merits and related defects. He proposes to invest better and more in shared care planning, indicating the advantages and opportunities that derive from its gradual formation within the care relationship, while signaling the need to proceed promptly with the appointment of the trustee, provided in an optional form by the law. He then addresses the role exercised by this representative figure which is to assist the care team throughout the disease trajectory and not only when it is necessary to honor the wishes and preferences expressed by the person when he was in a position to do so, and he does it criticizing the choice made by the legislator who indicated it in full possession of the ability to understand and want.

Keywords: anticipated will, advance treatment provisions, advance care planning, trustee, ability to understand and want, decision making

Update nelle vasculiti ANCA-Associate

Federica Mescia

U.O. Nefrologia ASST Spedali Civili di Brescia e Università di Brescia

Triple stenosis of brachio-basilic arteriovenous fistula: percutaneous transluminal angioplasty utility, case report and literature review

Marco Taurisano, Andrea Mancini, Filomena D’Elia

UOC di Nefrologia e Dialisi Ospedale di Venere Bari

The major haemodialysis arteriovenous fistula (AVF) complication is stenotic disease. It is represented by a reduction of the arterial or venous caliper forming the AVF. Most frequently it is located in the juxta- anastomotic region of the venous segment.
There are a lot of mechanisms responsible for the stenosis formation; some are correlated by the shear stress in the wall of venous tract with a lot of biochemical mechanisms, others are associated with the repetition of venipuncture during haemodialisys treatment
It is recommended that each dialysis center activate an AVF monitoring program capable of identifying and treating stenosis.
We describe a clinical case of a young woman with a multiple stenosis disease of a brachio-basilical transposed AVF.

Keywords: AVF, haemodialysis, stenosis, PTA, ecoguided PTA

Discovering uncommon nephropathies: a case of acute kidney damage from malaria

Francesca Chiappo1,5, Loretta Zambianchi1, Alessandra Spazzoli1, Maria Francesca Lifrieri1, Stefania Cristino1, Marco De Fabritiis1, Claudio Americo1, Maria Laura Angelini1, Benedetta Fabbrizio2, Giovanna Cenacchi3,4, Giovanni Mosconi1

1 U.O. Nefrologia e Dialisi di Forlì – Osp. Morgagni Pierantoni, AUSL della Romagna
2 Pathology Department, IRCCS Azienda Ospedaliero_Universitaria di Bologna, Bologna, Italy
3 Department of Biomedical and Neuromotor Science (DIBINEM), University of Bologna, Italy
4 IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
5 Nephrology, Dialysis and Renal Transplant Unit, IRCCS – Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum University of Bologna, Italy

Malaria is one of the most common infectious diseases in the world with a high prevalence in developing countries. Renal impairment occurs in 40% of Plasmodium falciparum infections; glomeruli, tubules or interstitium can be involved with different pathophysiological mechanisms. We describe a case of severe acute renal failure caused by P. falciparum malaria in a young woman from the Ivory Coast. Renal biopsy revealed severe and widespread acute tubular necrosis and the presence of blackish pigment granules in the glomerular and peritubular capillaries, negative for iron histochemical staining; in electron microscopy we found rounded-oval-shaped structures containing cytoplasmic organelles, electrondensic granules and cellular debris, likely of infectious origin, within monocyte-macrophages located in the tubular lumen. Specific Antigen for P. falciparum and malarial parasite in blood were positive, with very rare trophozoites and gametocytes compatible with Plasmodium falciparum. Steroid therapy and specific antiparasitic therapy were set up with progressive functional improvement until complete recovery. This case highlights the importance of paying maximum attention to low incidence pathologies in our country, considering the continuous migratory movements of these years that can cause an increase in these diseases; anamnestic data are essential for a timely diagnosis which can contribute to a rapid remission avoiding severe complications.

Keywords: malaria, acute kidney failure, tubular necrosis, Plasmodium falciparum

Le nefriti tubulointerstiziali acute

Nicola Lepori1, Antonello Pani1,2

1 Nefrologia e Dialisi, Ospedale G. Brotzu, Cagliari, Italy
2 Università degli Studi di Cagliari, Dipartimento di Scienze Mediche, Cagliari, Italy

Renal involvement in SLE

Marta Calatroni1,2, Francesco Reggiani1,2, Gabriella Moroni1,2

1 Nephrology and Dialysis Division, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Milan, Italy
2 Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele, Milan, Italy

Lupus nephritis (LN) is a frequent and severe manifestation of systemic lupus erythematous (SLE). Clinically, LN may occur with extremely variable clinical presentations, ranging from urinary anomalies to rapidly progressive glomerulonephritis. Renal biopsy remains the gold standard for the diagnosis of LN, as the clinical-laboratory presentation doesn’t always correlate with histological data. Treatment of LN includes supportive therapies and targeted immunosuppressive therapies with an induction phase, now called initial treatment and a maintenance phase, now called subsequent treatment. In addition to steroids, mycophenolate mofetil and cyclophosphamide, new drugs such as calcineurin inhibitors (voclosporin) and monoclonal antibodies such as belimumab and rituximab have been introduced in recent decades. Although patient and renal survival have significantly improved from 1970, LN still remains an important negative prognostic factor. Early diagnosis, targeted therapeutic protocols, prevention, and management of complications are the most important factors for the prognosis of these patients.

Keywords: lupus nephritis, immunosuppression, end-stage kidney disease, remission

Anti-Glomerular Basement Membrane Disease: new insights on an old disease

Bonelli GD, Uzzo M, Pieruzzi F, Sinico RA

Dipartimento di Medicina e Chirurgia, Università degli Studi di Milano Bicocca e Unità Operativa Clinicizzata di Nefrologia e Dialisi, ASST-Monza, Ospedale San Gerardo, Milano/Monza, Italia

Anti-glomerular basement membrane disease is a rare small-vessel immune-complex vasculitis (incidence <1/1.000000/year), characterized by the presence of serum antibodies directed against glomerular and pulmonary basement membrane antigens. It is characterized by rapidly progressive crescentic glomerulonephritis, active urinary sediment, subnephrotic proteinuria and oligo-anuria, often coupled to alveolar haemorrage. The main renal lesion on histology specimen is the presence of crescents, often associated to fibrinoid necrosis and linear pattern anti-glomerular basement membrane antibodies positivity on direct immunofluorescence. Lung involvement can be determined clinically, radiologically or by bronchoscopy, by isolation of macrophagic hemosiderin deposits. In order to rapidly remove the pathogenetic autoantibody, plasmapheresis is the mainstay of treatment, associated with cyclophosphamide and steroids, both to control the inflammation and reduce antibody production. A deep knowledge of the pathogenetic mechanisms involved in the anti-GBM disease is mandatory to reach a more and more appropriate diagnostic-therapeutic approach: on one hand, new triggers of the disease (SARS-COV2 infection) and new pathogenetic autoantigens (laminin-521, peroxidasin) have been identified; on the other hand, new therapeutic approaches to lower antibody clearance emerged. The monoclonal anti-CD20 antibody Rituximab can be reasonably used in refractory disease with persistence of antibody anti-GBM, or where standard therapy is not suitable. IdeS (Immunoglobulin G degrading enzyme of Streptococcus pyogenes), which cleaves pathogenetic IgG in a specific site, could be used in place of apheresis, if associated with immunosuppressive therapy. New studies are necessary to better understand pathogenesis, etiology, and treatment options. Key words: Anti-GBM, vasculitis, laminin-521, COVID-19, RItuximab, IdeS

Skin reaction with Eosinophilia and Systemic Symptoms after lenalidomide in peritoneal Dialysis

Silvia Cazzato1, Francesco Fontana2, Monica Maccaferri3, Marco Leonelli2, Elisabetta Ascione2, Riccardo Magistroni2, Gaetano Alfano2

1 Nefrologia e Dialisi Ospedale Ramazzini di Carpi, Azienda Unità Sanitaria Locale di Modena, Italia
2 Struttura Complessa di Nefrologia e Dialisi, Azienda Ospedaliero-Universitaria di Modena, Modena, Italia
3 Sezione di Ematologia, Dipartimento di Scienze Chirurgiche e Mediche, Università di Modena e Reggio Emilia, Azienda Ospedaliero-Universitaria di Modena, Modena, Italia

The Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) syndrome is a fatal and immune-mediated idiosyncratic drug reaction, with symptoms of fever, skin eruptions (that involves more than half of the body surface), facial oedema and hematological disorders, all presenting within the latent period following drug intake. Effects can also be seen on multiple organs, most notably hepatitis in liver and acute interstitial nephritis in kidney, generally post-administration of allopurinol. The European Registry of Severe Cutaneous Adverse Reactions (RegiSCAR) classifies the DRESS Syndrome cases as “definite”, “probable” or “possible”, based on clinical and laboratory features. Different pathogenetic mechanisms have been involved in this disease, including immunological reactions and HHV-6 reactivation. In our experience, a 72-year-old male, affected by myeloma in peritoneal dialysis, developed a rare case of DRESS syndrome after lenalidomide administration (less than ten cases are known) with HHV-6 reactivation. According to literature, we withdrew the drug and gave methylprednisolone 0,8 mg/kg orally and IVIG 1 gr/kg for two days. Despite this therapy, DRESS syndrome relapsed during steroid taper with rash, thrombocytopenia, hepatitis and high troponin level. A single cycle of intravenous immunoglobulin 0,5 g/kg for four days was enough for syndrome remission. Only few cases are reported in literature, but because of the increasing use of lenalidomide and the autoimmune sequelae of DRESS syndrome, a broad workup and a multidisciplinar careful approach could help in diagnosis, treatment and follow-up.

Keywords: eosinophilia, systemic drug reaction, DRESS Syndrome, interstitial nephritis, multiple myeloma, Lenalidomide

Il rene sclerodermico

Franco Cozzi

Studioso Senior – Dipartimento di Medicina-DIMED, Università degli Studi di Padova

La glomerulonefrite acuta post-infettiva

Carmelita Marcantoni, Roberta Aliotta, Luciano Gervasi

UOSD di Nefrologia e Dialisi, Azienda Ospedaliero Universitaria “G.Rodolico-San Marco”, Catania

La glomerulonefrite acuta post-infettiva è una nefropatia ben definita, immunomediata, che si verifica a causa e successivamente ad un evento infettivo prevalentemente di origine batterica. Nel passato, la forma più frequente di glomerulonefrite acuta post-infettiva era la post-streptococcica, più diffusa nei bambini e a prognosi benigna. Negli ultimi decenni si è osservata una variazione dello scenario epidemiologico e clinico con prevalenza maggiore negli adulti fragili, sostenuta da infezioni non streptococciche, a prognosi sfavorevole con evoluzione verso la malattia renale cronica.

Parola chiave: glomerulonefrite acuta post-infettiva

Sodium balance and peritoneal ultrafiltration in refractory heart failure

Giada Giovanna Olga Bigatti1, Elisa Nava1, Brunilda Xhaferi2, Daniele Ciurlino1, Elena Tagliabue3, Gianfranco Gensini4, Giuseppe Ambrosio5, Silvio Volmer Bertoli1

1 Nefrologia e Dialisi, IRCCS MultiMedica, Sesto San Giovanni (MI) e Clinica Santa Maria MultiMedica, Castellanza (VA)
2 Nefrologia e Dialisi, Ospedale San Jacopo, USL Toscana Centro
3 Value-based Healthcare Unit, IRCCS MultiMedica, Milano
4 Scientific Direction, IRCCS MultiMedica, Milano
5 Divisione di Cardiologia e Center for Clinical and Translational Research-CERICLET, Università di Perugia, Scuola di Medicina, Perugia

About 5% of patients with heart failure (HF) reach the end-stage of disease, becoming refractory to therapy. The clinical course of end-stage HF is characterized by repeated hospitalizations, severe symptoms, and poor quality of life. Peritoneal ultrafiltration (PUF), removing water and sodium (Na+), can benefit patients with end-stage HF. However, effects on fluid and electrolyte removal have not been fully characterized.

In this pilot study in patients with chronic HF and moderate chronic renal failure, we evaluated the effects of water and sodium removal through PUF on ventricular remodeling, re-hospitalization, and quality of life.

Patients with end-stage HF (NYHA class IV, ≥3 HF hospitalization/year despite optimal therapy), not eligible for heart transplantation underwent peritoneal catheter positioning and began a single-day exchange with icodextrin at night (n=6), or 1-2 daily exchanges with hypertonic solution (3.86%) for 2 hours with 1.5-2 L fill volume (n=3).

At baseline, average ultrafiltration was 500±200 ml with icodextrin, and 700±100 ml with hypertonic solution. Peritoneal excretion of Na+ was greater with icodextrin (68±4 mEq/exchange) compared to hypertonic solution (45±19 mEq/exchange).

After a median 12-month follow-up, rehospitalizations decreased, while NYHA class and quality of life (by Minnesota Living with HF questionnaire), improved.

In end-stage HF patients, PUF reduced re-hospitalization and improved quality of life. It can be an additional treatment to control volume and sodium balance.

Keywords: Peritoneal ultrafiltration, heart failure, sodium balance, renal failure

Dialysis withdrawal and shared end-of-life management between nephrology and palliative care: our three-year experience

Diana Zarantonello1, Carlo Abati2, Alessandro Laudon1, Massimo Destro2, Fabrizio Valente1, Maria Cecilia Fozzer2, Chiara Venturelli1, Stefano Zizzetti2, Gino Gobber2, Giuliano Brunori1

1 U.S.C. Nefrologia e Dialisi, Azienda Provinciale per i Servizi Sanitari (APSS)
2 Unità Multizonale di Cure Palliative, APSS

Most dialysis patients with end-stage kidney disease (ESKD) lack access to palliative care services. According to the data of the Dialysis Outcomes and Practice Study (DOPPS), Italy when compared to other countries included in the study, had the lowest rates of dialysis discontinuation. Indeed, there is a growing interest in the implementation of international and national programs for the co-management between nephrology and palliative care in end-of-life decision-making for patients with ESKD. On behalf of this, since 2017, we started in the nephrology outpatient clinic and hemodialysis facilities of the Provincia Autonoma of Trento a shared program between Nephrology and Palliative Care Units to improve the end-of-life quality of care in ESKD patients in conservative and dialytic therapy.
Methods: A retrospective analysis, from the 1st of January 2019 to 31st December 2021, of dialysis withdrawal in a cohort of patients undergoing hemodialysis and peritoneal dialysis.
Results: Dialysis withdrawal and subsequent death, according to the integrated protocol with the Palliative Care resources, were 24 in 2019, 20 in 2020, and 28 in 2021. The mean age was 75 years in 2019, 78 years in 2020, and in 2021. Most of the patients were male. Dialysis discontinuation was higher in chronic dialysis patients (80% in 2019 and 2020, and 79% in 2021), and considering the annual rates of death of all the dialysis patients, those who died because of dialysis withdrawal were 38% in 2019, 31% in 2020 and 40% in 2021. Survival after dialysis withdrawal was in most of the cases less than 7 days; only few patients lived more than 30 days. Furthermore, the data, in the 3 years considered, showed a reduction of hospitalization and an increase of the rate of death at home.
Conclusions: As described in the present study, strategies to expand palliative care by a shared protocol among nephrology and palliative care staff improved the quality of care in the end of life and reduced the hospitalization rates of admission of patients after dialysis withdrawal.

Keywords: Dialysis withdrawal, shared end-of-life management, palliative care

“New antigens” in membranous glomerulonephritis: let’s take a closer look

Mattia Rossi, Carolina Giannini, Concetta Gangemi, Giovanni Gambaro

Divisione di Nefrologia, Dipartimento di Medicina, Università di Verona, Verona

Membranous Nephropathy (MN) is characterized by the presence of subepithelial deposits. MN has been traditionally classified as primary if it is not associated with other pathologies, or secondary if it is associated with autoimmune diseases, infections or malignancies. The identification of target podocyte antigen was a critical point in the understanding of the disease: firstly in 2009 with M-type phospholipase A2 receptor (PLA2R) and then in 2014 with Thrombospondin Type 1 Domain Containing 7A (THSD7A). In the last years using an innovative approach based on laser microdissection and tandem mass spectrometry (MS/MS) has allowed the identification of new target antigen/protein as EXT1/2, NELL-1, NCAM1, SEMA3B, PCHD7, HTRA1, TGFBR3. Some of these proteins have been found in both primary and secondary MN, blurring the line between the two forms. Further studies are necessary to define and understand the clinical features of different antigen associated diseases. The aim of this review is to take a closer look at the new antigens and to evaluate how their discovery can change MN classification.

Keywords: Membranous Nephropathy, Renal Pathology, podocyte antigens, mass spectrometry

Thrombotic microangiopathy: atypical hemolytic uremic syndrome

Elena Bresin

Istituto di Ricerche Farmacologiche Mario Negri IRCCS Centro di Ricerche Cliniche per le Malattie Rare Aldo e Cele Daccò

Atypical hemolytic uremic syndrome is an ultra-rare disease characterized by acute kidney injury, thrombocytopenia, and microangiopathic hemolytic anemia (thrombotic microangiopathy) that occurs with a reported incidence of approximately 0.5 per million per year.

At least 50% of patients with aHUS have an underlying inherited and/or acquired complement abnormality, which leads to dysregulated activity of the alternative pathway at the endothelial cell surface.

Until recently, the prognosis for aHUS was poor, with the majority of patients developing end-stage renal disease within 2 years of presentation. However, with the introduction of eculizumab, a humanized monoclonal antibody against C5, effective to inhibit complement-mediated thrombotic microangiopathy, it is now possible to control the renal disease and prevent development of end-stage renal disease.

Dosing schedule and treatment duration remain controversial and should be rigorously studied.

On this regard, C5b-9 endothelial deposition assay may represent an advance to monitor complement activity in aHUS and to individualize therapy, but currently it can be performed in only specialized laboratories.


Keywords: Atypical hemolytic uremic syndrome, complement, anti-C5 monoclonal antibody, C5b-9 assay

Clinical Xenotransplantation: recent findings and remaining hurdles

Marta Vadori 1, Elisa Cuciz 2, Emanuele Cozzi 1,2

1 Dipartimento di Scienze Cardiologiche, Toraciche e Vascolari, e Sanità Pubblica, Università di Padova, Via Giustiniani, 5, 35128 Padova, Italia
2 Unità Operativa di Immunologia dei Trapianti, Azienda Ospedale-Università di Padova, Via Giustiniani, 2, 35128 Padova, Italia

Xenotransplantation, or transplantation between individuals from different species, has long been investigated with the objective to solve the shortage of human organs, tissues and cells for clinical transplantation. Decades of research have convinced scientists that the pig is the most appropriate donor species. Indeed, in addition to numerous anatomical and physiological similarities between pig and man, pig husbandry lends itself to providing the large number of animals necessary to meet the clinical demand.

In the last few years, research in the field of solid organ xenotransplantation has made sensational progress. In particular, in vitro studies and pre-clinical research using pig-to-nonhuman primate transplantation models have clarified the key immunological and physiological barriers to xenotransplantation and provided a better comprehension of the mechanisms underlying the lesions observed in rejected xenografts. This has ultimately resulted in the genetic engineering of specifically-designed, more compatible donor pigs.

The present review article describes the major hurdles that need to be overcome to enable successful solid organ xenotransplantation in humans. These include immunological, physiological and biosafety issues. Discussion on the ideal organ source and on the selection of the most appropriate candidates for first-in-human studies is provided. Particular attention has been dedicated to kidney xenotransplantation. Indeed, at this stage it would appear that the critical immunological and physiological obstacles to clinical xenotransplantation have never been perceived as surmountable as they appear today.


Keywords: Kidney, Patient selection, Genetically-engineered pigs, Xenotransplantation, Physiology

Kidney and immune system

Martina Tedesco 1,2, Federico Alberici1,2

1 Dipartimento di Specialità Medico-Chirurgiche, Scienze Radiologiche e Sanità Pubblica, Università degli Studi di Brescia, Brescia, Italia
2 UO di Nefrologia, Spedali Civili di Brescia, Brescia Italia

Il rene e il sistema immunitario sono caratterizzati da una stretta e complessa relazione multidirezionale. Il sistema immunitario è causa di nefropatie immunomediate oltre ad essere un fondamentale mediatore del danno parenchimale renale in corso di nefropatie acute e croniche. Occorre inoltre sottolineare come la disfunzione renale, soprattutto se cronica, ha un impatto determinante sulla funzionalità del sistema immunitario causando un’immunosenescenza accelerata ed “inflammaging”.

Questo articolato cross-talk fornisce potenzialmente numerose possibilità di intervento; da notare infatti come l’armamentario terapeutico per la gestione delle nefropatie immunomediate sia in significativo aumento con numerosi farmaci immunomodulanti già entrati nella pratica clinica o in prossimità di entrarvi. D’altro canto, strumenti in grado di modificare significativamente l’impatto del sistema immunitario sulla progressione del danno renale in corso di nefropatia, così come strumenti in grado di modulare l’effetto della nefropatia cronica sulla disfunzione ad essa secondaria del sistema immunitario, non sono ancora disponibili nella pratica clinica.

Scopo di questa review è quello di discutere la complessa interazione esistente tra rene e sistema immunitario con un focus particolare sulle potenziali traslazioni cliniche attuali e future.

Parole chiave: glomerulopatia, autoimmunità, complemento, anti-CD20, Blyss

Finerenone for the treatment of patients with chronic kidney disease

Michele Provenzano1, Luca De Nicola2, Loreto Gesualdo3, Gaetano La Manna1

1 Nephrology, Dialysis and Renal Transplant Unit, IRCCS—Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum University of Bologna, Bologna, Italy
2 Nephrology-Dialysis Unit, Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
3 Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Bari, Italy

Chronic kidney disease (CKD) is a clinical condition associated with a high risk of cardiovascular (CV) events, mortality and progression to most severe stage of the disease, also known as kidney failure (KF). CKD is characterized by a wide variability of progression, which depends, in part, on the variability of individual response to nephroprotective treatments. Thus, a consistent proportion of patients have an elevated residual risk both CV and renal events, confirmed by the evidence that about 70% of CKD patients followed by the nephrologist have residual proteinuria. Among the new therapeutic strategies, which have been developed precisely with the aim of minimizing this residual risk, a class of particular interest is represented by the new non-steroidal mineralocorticoid receptor antagonists (non-steroidal MRA). These drugs exert an important anti-fibrotic and anti-proteinuric effect and, unlike steroid MRAs, are associated with a much lower incidence of adverse effects. The non-steroidal MRA molecule for which the most data is available, which is finerenone, is potent and extremely selective, and this partly explains the differences in efficacy and safety compared to steroid MRAs. In clinical trials, finerenone has been shown to significantly reduce the risk of progression to KF. Furthermore, there is also evidence that the combination of non-steroidal MRAs together with SGLT2 inhibitors may represent a valid alternative to reduce the residual risk in CKD patients. Given this evidence, non-steroidal MRAs are gaining momentum in the care, and particularly in individualized care, of CKD patients.

Keywords: CKD, epidemiology, aldosterone, iperkalaemia, kidney failure, cardiovascular risk

Campylobacter: a vintage pathogen to the fore

Alice Tarroni1, Monica Repetto1, Emanuele Nadir Malfatto2, Claudio Burgarello3, Carmela Caputo1, Marzia Ciabattoni1, Debora Garneri1, Stefano Ferraro1, Ilaria Tallone1, Fanny Tosetti1, Emanuela Chiara Vigo1, Marco Anselmo2, Flavia Lillo3, Brisejda Koroveshi3

1 ASL 2 SSR Liguria, Struttura Complessa Nefrologia e Dialisi
2 ASL 2 SSR Liguria, Struttura Complessa Malattie Infettive
3 ASL 2 SSR Liguria, Laboratorio di Patologia Clinica, Sezione Microbiologia

Campylobacteriosis is caused by Gram bacteria. Most common species are C. jejuni and C. coli. Campylobacteriosis is a rare cause of sepsis, and in some European countries it is more common than salmonellosis, becoming a public health problem.
We have treated a 66-year-old patient, hypertensive, ischemic cardiopathic, scheduled for coronary angiography, hospitalized with AKI, in a state of shock after some days of acute diarrhea.
Because of the pathogen’s seasonal nature and the patient’s clinical features, in addition to common coproculture also Campylobacter has been sought, and found. Treated with volume repletion and antibiotics, within one week normal kidney functions were fully restored. He had a coronary angiography a week after being discharged from the hospital.

Keywords: Campylobacteriosis, AKI, diarrhea

A tribute to Arthur Cohen’s memory

Domenico Santoro

Prof. Ordinario di Nefrologia Dipartimento di Medicina Clinica e Sperimentale
Direttore UOC di Nefrologia e Dialisi Scuola di Specializzazione di Nefrologia
Università degli Studi di Messina

Controversy in estimating glomerular filtration rate through traditional equations in transgender people: discussion through a case report

Ingrid Sarmento Guedes1, Luiz Valério Costa Vasconcelos1, Ana Paula Pires Lázaro de Oliveira1, Elizabeth De Francesco Daher2, Geraldo Bezerra da Silva Junior1,2

1 Corso di Medicina, Centro di Scienze della Salute, Universidade de Fortaleza. Fortaleza, Ceará, Brasile.
2 Dipartimento di Medicina Clinica, Facoltà di Medicina, Universidade Federal do Ceará. Fortaleza, Ceará, Brasile.

Introduction: Chronic kidney disease (CKD) and the number of transgender people is on the rise. Hormone replacement therapy may be associated with the development of adverse effects, including kidney disease.
Objective: To report the case of a transgender patient using hormone therapy who developed CKD.
Case Report: Male transgender patient, 28 years old, using testosterone cypionate every 15 days, without any comorbidity. Evolved with hypertensive peaks of 160-150/110 mmHg and loss of kidney function (Ur 102 mg/dl, Cr 3.5 mg/dl, estimated Glomerular Filtration Rate (eGFR) of 22 ml/min/1.73m2 considering male gender and 16.6 ml/min/1.73m2 considering female gender). Abdominal ultrasound showed chronic parenchymal nephropathy. Due to the significant reduction in eGFR, the patient was referred for kidney transplantation, but he was not included in the list because he had a creatinine clearance of 23 ml/min/1.73m2 for males and 21.5 ml/min/1.73m2 for females in the most recent tests.
Conclusion: Hormone replacement may have contributed to the increase in the patient’s blood pressure and, consequently, to the development of CKD. There is still no well-established consensus on the best way to estimate the GFR in transgender people, and it seems to be more appropriate to consider the gender to which the person self-identifies or to perform the calculation for both genders, obtaining an estimate of the range in which the patient’s GFR lies.

Keywords: Transgender persons, chronic renal insufficiency, hypertension, hormone replacement therapy.

Hyperphosphatemic pseudotumoral calcinosis due to FGF23 mutation with secondary amyloidosis

Laura Sottini1, Patrizia Veniero1, Andrea De Gaetano1, Laura Olivi1 and Giuliano Brunori1

1 UOC Nefrologia e Dialisi, APSS Trento

A 44 years old man was admitted for nephrotic syndrome and rapidly progressive renal failure. Two firm, tumour-like masses were localized around the left shoulder and the right hip joint. Since the age of 8 years old, the patient had a history of metastatic calcification of the soft tissues suggesting hyperphosphatemic pseudotumoral calcinosis. Despite treatment for a long time with phosphate binders the metastatic calcinosis had to be removed with several surgeries. The patient had also a history of recurrent fever associated with pain localized toward the two masses and underwent multiple antibiotic courses. Laboratory findings at admission confirmed nephrotic syndrome. S-creatinine was 2.8 mg/dl. Calcium was 8.4 mg/dl, Phosphorus 8.2 mg/dl, PTH 80 pg/ml, 25 (OH)VitD 8 ng/ml. Serum amyloid A was slightly increased. We performed renal biopsy and we found AA amyloid deposits involving the mesangium and the tubules. The bone marrow biopsy revealed the presence of AA amyloid in the vascular walls. During the next two months renal failure rapidly progressed and the patient started hemodialysis treatment. We performed genetic analysis that confirmed homozygous mutation of the FGF23 gene. After 14 months on hemodialysis, the patient’s lesions are remarkably and significantly reduced in dimension. The current phosphate binder therapy is based on sevelamer and lanthanum carbonate. Serum amyloid A is persistently slightly increased as well as C reactive protein. Proteinuria is in the nephrotic range without nephrotic syndrome.

Keywords: pseudotumoral calcinosis, tumoral calcinosis, FGF23, AA amyloid, renal failure, dialysis

Peritoneal videodialysis: first Italian audit

Loris Neri1, Simonetta Caria2, Katia Cannas2, Roberto Scarpioni3, Alessandra Manini3, Chiara Cadoni4, Rosella Malandra5, Ines Ullo6, Giuseppe Rombolà6, Maurizio Borzumati7, Francesca Bonvegna7, Giusto Viglino1

1 Nephrology and Dialysis, “Michele e Pietro Ferrero” Hospital, Verduno (CN), Italy
2 Nephrology and Dialysis, Cagliari Local Health Authority, Quartu Sant’Elena
3 Nephrology and Dialysis, Piacenza Local Health Authority
4 Nephrology and Dialysis, Nostra Signora di Bonaria Hospital, San Gavino Monreale
5 Nephrology and Dialysis, Teramo Hospital
6 Nephrology and Dialysis, Sette Laghi Local Health Authority, Varese
7 Nephrology and Dialysis, Verbano Cusio Ossola Local Health Authority, Verbania

Conceived and developed since 2001 at the Alba Center, Videodialysis (VD) was used initially to prevent dropout in  prevalent PD patients by guiding them in performing dialysis (VD-Caregiver).

Subsequently, its use was extended to the clinical follow-up of critical patients (VD-Clinical), problems relating to transport to the Center (VD-Transport), and since 2016 for training/retraining all patients (VD-Training).

Since 2017 other Centers have employed VD using modalities analyzed in this paper.

Methods: the paper reports the findings of an Audit (February 2021) of the Centers using VD on 31-12-2020.

The Centers provided the following information:

  • the characteristics of the patients using VD;
  • the main and secondary reasons for using VD, considering nursing home (VD-NH) patients separately;
  • VD outcomes: duration, drop-out, peritonitis, patient/caregiver satisfaction (minimum: 1 – maximum: 10).

Results: VD, which began between 09-2017 and 12-2019, has been used in 6 Centers for 54 patients at 31-12-2020 (age:71.8±12.6 years – M:53.7% – CAPD:61.1% – Assisted PD:70.3%).

The most frequent reason has been VD-Training (70.4%), followed by VD-Caregiver (16.7%), VD-NH (7.4%), VD-Clinical (3.7%), and VD-Transport (1.9%), with differences between Centers.

VD-Training is used most with self-care patients (93.8% – p<0.05), while with patients on Assisted PD it is associated with secondary reasons (95.7% – p<0.02). VD-Training (duration: 1-4 weeks) has always been completed successfully.

No peritonitis was reported; satisfaction was 8.4±1.4.

Conclusion: videodialysis is a flexible, effective, safe, and valued tool that can be employed using various modalities depending on the choice of the Center and the complexity of the patient.

Keywords: Peritoneal Dialysis, Assisted Peritoneal Dialysis, Telemedicine, Videodialysis, Training

A narrative review on arteriovenous fistula for hemodialysis

Ersilia Satta1,2, Carmine Romano2, Carmelo Alfarone 2, Ilaria Raiola2, Lisa Scarpati2, Fabrizio Lo Iacono2, Monica Di Maio2, Luigi Russo3, Domenico Russo4, Margherita Maria Pagliuca5

1 CNP, Centro Nefrologico Polispecialistico, Nefrocenter srl
2 Nefrocenter Research
3 Nefrologia. Ospedale del Mare. Napoli
4 Dipartimento di Sanità Pubblica. Università di Napoli, Federico II
5 Department of Management Studies and Quantitative Methods (DISAQ) University of Naples “Parthenope”

Vascular access is the lifeline for hemodialysis patients. Autologous artero-venous fistula (AVF) is still the most popular vascular access for hemodialysis even if declining during the last decades. Compared to central venous catheters and vascular grafts, AVF is characterized by a lower risk of infection and lower number of hospitalizations, and by a better quality of life, higher dialysis efficiency, and more prolonged life expectancy for patients. Since the year 1966 when the two surgeons Cimino and Brescia had the idea of connecting the forearm vein and artery for chronic dialysis, several data have accumulated on surgical procedures, positioning of AVF (distal vs proximal), time for the first use, monitoring and surveilling.

All guidelines suggest that special care should be given by monitoring and surveilling AVF to avoid its failure or fatal closing. Attention should be paid to the patient’s vasculature before surgery, through the “maturation” phase and chronic use. Indeed, AVF requires constant and careful care. The crucial role is played by the patient itself in cooperation with devoted clinical staff participated by skilled nurses, nephrologists, surgeons, radiologists, and sonographers.

Literature on AVF is evaluated and guidelines suggestions reported as well as the data attained by the Accesso Vascolare per Emodialisi (AVE) project. This project aimed to evaluate the benefits of monitoring and surveilling, operated by a multidisciplinary team on dialysis adequacy, AVF longevity, and patient’s mortality.

Keywords: artero-venous fistula, dialysis, mortality, monitoring, surveilling

Quantitative imaging in nephrology: limits and potentials of elastosonography

Antonio Granata1, Giulio Distefano2, Rosario Maccarrone1, Francesco Pesce3, Costanza Giuseppa4, Antonio Digiacomo2, Antonio Basile5, Marcello Romano6, Vito Cantisani7

1 U.O.C. Nefrologia e Dialisi, A.O. per l’emergenza “Cannizzaro” – Catania (CT), Italia
2 U.O.C. Medicina Generale, Dipartimento di Medicina, Ospedale “R. Guzzardi” di Vittoria, ASP Ragusa, Ragusa, Italia
3 U.O.C. di Nefrologia, Dialisi e Trapianto d’organo, Dipartimento di Emergenze e Trapianti d’organo, Università “Aldo Moro” di Bari, Bari, Italia
4 UOC Nefrologia e Dialisi, P.O. “Vittorio Emanuele” – Gela, Caltanissetta, Italia
5 U.O.C. Radiologia I, Azienda Ospedaliero-Universitaria “Policlinico-San Marco, Università di Catania, Catania, Italia
6 U.O.C. Geriatria, Azienda Ospedaliera Garibaldi, Catania, Italia
7 Dipartimento di Radiologia, Policlinico Umberto I, “Università La sapienza” di Roma, Roma, Italia

Chronic kidney disease is characterized by increasingly amplified fibrotic processes regardless of etiology. The severity of renal fibrosis seems to correlate with an increased risk of end-stage renal disease; therefore, monitoring of renal fibrosis over time may play an important role in the follow-up of both focal and diffuse renal diseases and in evaluating the response to treatments. Renal biopsy is the only method capable of providing objective and comparable information on the extent of fibrosis, but it is not suitable for outpatient monitoring of chronic kidney disease due to its invasiveness. Elastosonography is an innovative and non-invasive ultrasound method that allows the measurement of tissue elasticity through the transmission of mechanical waves and the measurement of their propagation speed. Although some authors have demonstrated the usefulness of elastosonographic techniques for the quantification of liver fibrosis, few studies have investigated the applications of elastosonography in renal pathology. Furthermore, the depth of native kidneys, the high anisotropy of the renal tissue, and the possibility of examining only a small region of interest currently limit its spread in clinical practice. The aim of this review is to examine the physical principles of elastosonography and to review the latest evidence about the possible applications of the ARFI (acoustic radiation force impulse) technique in the study of kidney diseases.

Keywords: ultrasound, fibrosis, renal elastosonography, ARFI, quantitative imaging

Itching in dialysis, from the patient’s point of view

Santoro A.1, Gibertoni D.2, Ciangola T.3, Gallieni M.4, Vanacore G.5

1 Presidente Comitato Tecnico-Scientifico ANED Scuola Specializzazione in Nefrologia Univesità degli Studi di Bologna
2 U.O.C. Ricerca ed Innovazione Biostatistica, Epidemiologia clinica e Disegno della Ricerca IRCCS Azienda Ospedaliero-Universitaria di Bologna
4 Dipartimento di Scienze Biomediche e Cliniche, Università degli Studi di Milano U.O. Nefrologia e Dialisi – ASST Fatebenefratelli Sacco, Milano
5 Presidente ANED ONLUS

Itching is an annoying symptom, which afflicts patients with chronic renal failure. To assess the diffusion of itching in the dialysis population in Italy, we carried out a questionnaire, which was distributed to patients of various Italian dialysis centers. The purpose of this investigation was to bring out all those aspects, which make itching a state of chronic suffering, which daily undermines the quality of life of patients. The questionnaire had 16 questions on the intensity of itching, the timing of appearance, the report to doctors and nurses, and any suggested remedies, in addition to some other concerning age, sex, and dialysis age. The questionnaires were distributed to 153 Dialysis Centers and received 1905 responses. In 46.7% of the answered questionnaires, the patients declared the absence of itching. Instead, 53.3% of the patients interviewed reported having itching with varying degrees of intensity. We used for quantifying the intensity of itching the numerical rating scale (NRS). Among the interviewees, those (20.4%) who reported a greater intensity and severity of the symptom described it as often present always, even at night, so as to heavily condition sleep. Only 32.5% of patients solved the problem by contacting their nephrologist or dialysis nurse, and a lower percentage by contacting the dermatologist or general practitioner.

Keywords: itching in dialysis, survey, VAS scale, remedies for itching

The experience of a European nephrologist at the SIUT: the largest Nephrology-Urology Transplantation Unit in South East Asia

Enrica Falbo

Consultant Nephrologist at Valiant Hospital-Healthcare Dubai City Walk – 13th St, P. O. Box 414296, Al Wasl – Dubai (UAE)

An Italian nephrologist, during her long experience in the Middle East, is a guest at the SIUT (Sindh Institute of Urology & Transplantation) in Karachi, the largest centre of nephrology-urology and transplantation in South Asia. She discovers the “SIUT model” which guarantees a constant quality of health care, fighting organ trafficking despite the poor economic conditions of the country, Pakistan.

Nell’editoriale di questo numero voglio presentare due contributi, che rappresentano due modi di far fronte a diverse tematiche che interessano la nefrologia: da una parte si dà voce ad una importante e sottostimata problematica nefrologica attraverso una modalità di raccolta ed elaborazione del dato che tiene conto del parere dei pazienti, elaborato in maniera scientifica e coordinato da colleghi nefrologi; dall’altra è testimoniata l’esperienza di una collega che opera in un delicato contesto geopolitico, fortemente distante dal nostro, ma al contempo ricco di umanità, competenza e professionalità.

Si tratta di due contributi di grande impatto, che ritengo molto utili per poter riflettere sia su una tematica di significativo impatto clinico che nel breve periodo, tra l’altro, avrà anche nuove opportunità terapeutiche, quale è il prurito in dialisi, sia sul fatto che sempre più l’assistenza sanitaria del paziente, fatta di competenza e vitalità professionale ed umana, non può prescindere dalla peculiarità sociale del contesto ambientale; questo vale anche nella situazione italiana, che in passato pensavamo avesse un orizzonte incentrato solo su tecnicalità e innovazione e che invece deve fare sempre più i conti con l’invecchiamento della popolazione, l’aggravarsi della solitudine, la mancanza di risorse e la crescita della popolazione al di sotto del livello di povertà.

I pazienti e la creatività dei singoli sono una risorsa cui attingere per migliorare.

Gaetano La Manna

The COVID-19 emergency management in Nephrology: a cross-sectional survey on the procedures management to deal with the pandemic

Domenica Gazineo1, Lea Godino1, Serenella Savini2, Stefanizzi Grazia1, Emiliana Scarpo2, Marco Del Pin3, Canzi Mara4, Maria Pia Zito4, Cinzia Fabbri1

1 IRCCS Azienda Ospedaliera Universitaria di Bologna (BO), Italia
2 ASL Roma 4 Civitavecchia (Roma), Italia
3 ASUSF Ospedale di Palmanova (UDINE), Italia
4 Società Italiana Infermieri Area Nefrologica (SIAN), Italia

From mid-March 2020, the pandemic caused by COVID 19 has placed health facilities in front of the need to implement a rapid and profound reorganization. However, many hospitals have not had time to organize a rapid and effective response, both for the speed of spread of the virus, and for the lack of previous experience with a pandemic of this magnitude. With the aim of assessing the knowledge and adoption of the procedures and recommendations disseminated by hospitals during the COVID-19 pandemic, in the dialysis and hemodialysis services of Italian centers, a cross-sectional survey was designed by the Society of Nurses in Nephrology (SIAN). The online survey was conducted among nurses who work in the Italian services of dialysis and hemodialysis during the first and second waves.

The online survey was completed by 150 nurses. Although hospitals have set up protocols and procedures for patient management during the COVID-19 pandemic, among participants not all were aware of it. With regard to the training of personnel in the use of personal protective equipment, 18.6% declared that they have not received it. The majority implemented specific precautions for patient management, awareness and information.

Keywords: hemodialysis, peritoneal dialysis, nursing skills procedures, COVID-19

Comparison between Creatinine Clearance and eGFRcyst-crea: a real-life experience

Vincenzo Calabrese 1, Vincenzo Labbozzetta 1, Antonella Lipari1, Valeria Labbozzetta1, Guido Gembillo1, Valeria Cernaro1, Giovanni Luigi Tripepi2, Domenico Santoro1

1 Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, A.O.U. “G. Martino”, University of Messina, Messina, Italy
2 CNR-IBIM, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension of Reggio Calabria, Reggio Calabria, Italy

Introduction: The evaluation of renal function is computed using the estimated glomerular filtration rate methods or the measured glomerular filtration rate. Cystatin C has been well studied as marker of renal function compared to serum creatinine, but only few studies compare Glomerular Filtration Rates estimated including both creatinine and cystatin (eGFRcyst-crea) to creatinine clearance (CrCl). This cross-sectional study compares CrCl and eGFRcyst-crea with eGFRcrea and searches for correlation with comorbidities.
Methods: This cross-sectional study consists of 78 patients hospitalized for acute and/or chronic renal disease. We performed the concordance correlation coefficient analysis between the eGFRcrea and the CrCl and eGFRcyst-crea in the whole sample and in the various subgroups.
Results: Steiger’s comparison of correlations from dependent samples showed a correlation coefficient between C-reactive protein and eGFRcyst-crea stronger than between C-reactive protein and CrCl (Z: 2.51, p=0.012). Similar results were showed with the association with procalcitonin (Z: 5.24, p<0.001), serum potassium (Z: -3.13, p=0.002), and severe CKD (Z: -2.54, p=0.011). The concordance correlation coefficient test showed major differences between diagnostic methods compared to eGFR-crea in diabetic subgroup, severe CKD, and in procalcitonin higher than 0.5ng/ml. Discussion: The demonstration of a strong concordance between the eGFRcrea and the eGFRcyst-crea allows us to diagnose and to stage CKD better than creatinine clearance in patients with high inflammatory status. Furthermore, this information opens new research scenarios, and further, larger studies are needed to confirm these hypotheses.
Keywords: Phosphorus, Hemoglobin, Anemia, Chronic Kidney Disease, FGF23, Generalized estimating equation

The construction of nephrology nurse’s core competencies between problems and safety

Andreoli Desirèe

S.C. di Nefrologia, dialisi e trapianto di rene, Azienda Ospedaliera Santa Maria della Misericordia, Perugia, Italia.

Background: Nephrology, dialysis and kidney transplant facilities welcome patients with such different characteristics that they push the nurse into the sphere of care complexity, often generating criticality for the client and the professional. The purpose of the study is to understand the perception nephrological area nurses have about safety and the main difficulties encountered during the training course.

Methods: The research was carried out through the questionnaries methodology and involved 104 nurses who work or have worked in the nephrological area in Italy. 58% of participants have an age of service over 16 years.

Results: The data show how much the study path is judged to be lacking in the ability to provide adequate basic knowledge to deal with insertion in a context of Nephrology and dialysis. The study shows that those who have worked for less than 5 years consider the training methods unsatisfactory, generating insecurity at the end of the course. The main technical-professional difficulties encountered are the conduct of the hemodialysis and the management of the arteriovenous fistula.

Conclusions: The research demonstrates how the construction of core competencies in the new hire is an issue widely experienced by the professional but not always shared nationwide.

Keywords: safety, training, skill building, nephrology and dialysis.

Sonographic artifacts in nephrology

Andrea Mancini, Marco Taurisano, Filomena D’elia

Unità Operativa Complessa Dipartimentale di Nefrologia e Dialisi Ospedale Di Venere, Bari

The huge spreading of sonography in the field of nephrology led to the use of more performant equipment with construction of better quality images, but with an unfavorable signal/noise ratio, that bring to the generation of artifacts: false signals which creates images not corresponding to reality.

Interaction between ultrasounds and biological structures generates a lot of physical phenomena: reflection, dispersion, absorption and diffraction; these elements create not only the images but also the artifacts.

The artifacts, which don’t correspond to anatomic reality, could be related to the extreme difference of acoustic impedance between the biological structures, or to an error in the settings of B-Mode and color-doppler functions.

Sometimes they can be dangerous and make a diagnosis hard, but most of the time they are useful and pathognomonic of a lesion or physiologic structure.

It’s fundamental for the sonographer being able to discern between real to artifact; the rule is that everything that is repeated in all scans with different insonation angles is true, while what is not repeated in all scans can be an artifact.

Keywords: B-mode artifacts, Colordoppler artifacts, nephrological sonography

Interview with Vito Cagli: his life as a nephrologist and more

Giovanni B. Fogazzi1, Attilio Losito2, Bianca Gualandi3

1 U.O.C. di Nefrologia, Dialisi e Trapianto di Rene, Fondazione, IRCCS, Ca’ Granda Ospedale Maggiore Policlinico, Milano
2 S.C. di Nefrologia e Dialisi, Ospedale Santa Maria della Misericordia, Perugia.
3 Research fellow, Università di Bologna, già membro della redazione del Giornale Italiano di Nefrologia

This interview describes the numerous and important contributions that Vito Cagli, who was born in Ancona in 1926, has given to the Italian Nephrology and to other fields of Medicine. These contributions, that are very poorly known today, were produced especially in the years in which Cagli worked as deputy director of the Centre for the Investigation and Treatment of Hypertension and Renal Diseases at Policlinico Hospital Umberto I in Rome. This interview also describes the early phase of Italian Nephrology before the introduction in our country of renal biopsy and of hemodialysis.

Keywords: History of Nephrology, History of Italian Nephrology, History of arterial hypertension

Arteriovenous fistula thrombosis in hemodialysis patients with COVID-19: epiphenomenon or marker of severe clinical disease?

Vincenzo Calabrese1, Cristina Micali2, Ylenia Russotto2, Natascia Laganà2, Chiara Gullotta2, Anna Pisano3, Domenico Santoro1, Giuseppe Nunnari2, Emmanuele Venanzi Rullo2

1 Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
2 Unit of Infectious disease, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
3 CNR-Institute of Clinical Physiology; Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Reggio Calabria, Italy

Background: Pandemic condition due to Coronavirus disease (COVID-19) caused a fastest augmentation of hospitalization, impairing the healthcare organization. As a consequence, diagnostic and therapeutic delays have been showed. COVID-19-associated coagulopathy is an endothelial disease related to SARS-CoV-2 infection. Our study evaluated the thrombosis of arteriovenous fistula (AVF) as risk marker of mortality.
Methods: the analysis included 24 dialysis-dependent patients admitted in a period between March 2020 and June 2021. Patients were divided based on AVF thrombosis: the A group without AVF thrombosis (13 patients), and the B group with AVF thrombosis events (11 patients). Pearson or Spearman’ correlation tests were performed to detect possible confounding variable to include in multivariate models. Kaplan Meier and Cox regression analysis were performed to compute mortality analysis.
Results: Delta D-dimer (Rho: 0.613, p=0.007), over-infections (Rho 0.456; p= 0,026), C-reactive Protein (CRP) (Rho=0.417, p=0.043), death (Rho=0.492, p=0.027), positive pulmonary imaging (Rho 0.388, p=0.074), and high OLT (0.408, p=0.047) were related to AVF thrombosis, using Pearson or Spearman correlation tests. Kaplan Meier test showed a death average of 19 days in group B compared to a global average of 38 days (p=0.029), and Cox analysis showed an HR of 5.01, 95% CI 1.01-24.99, p=0.049. Furthermore, AVF thrombosis explained about the 68% of the mortality, evaluated through the Harrel’s C test.
Conclusion: We can speculate that AVF thrombosis in hemodialysis patients with COVID-19 could be an early marker of both pro-coagulative process and severe clinical disease and it could be used to stratify patients and identify the ones that can be considered “frail”.

Keywords: COVID-19, Thrombosis, Hemodialysis, Survival analysis

Peritoneal Dialysis in Italy: the 7th GSDP-SIN census 2019

Loris Neri1, Giusto Viglino1, Valerio Vizzardi2, Roberto Russo3, Carlo Taietti4, Silvia Porreca5, Antonino Ragusa6, Caudio Mastropaolo7, Giancarlo Marinangeli8, Gianfranca Cabiddu9, on behalf of the Peritoneal Dialysis Project Group of the Italian Society of Nephrology

1 Nefrologia e Dialisi, Ospedale “Michele e Pietro Ferrero”, Verduno, Cuneo, Italy
2 Nefrologia e Dialisi, Spedali Civili, Brescia, Italy
3 Nefrologia e Dialisi, Policlinico Università “Aldo Moro”, Bari, Italy
4 Nefrologia e Dialisi, ASST Bergamo Ovest – Treviglio, Bergamo, Italy
5 Nefrologia e Dialisi, Ospedale della Murgia “Fabio Perinei”, Bari, Italy
6 Nefrologia e Dialisi, Ospedale “San Vincenzo”, Taormina, Italy
7 Visionage SrL, Italy
8 Nefrologia e Dialisi, Ospedale “Maria SS dello Splendore”, Giulianova, Teramo, Italy
9 Dipartimento Scienze mediche e sanità pubblica – Università di Cagliari – ARNAS Brotzu – Cagliari

Objectives: Analysis of the results of the 7th National Census (Cs-19) of Peritoneal Dialysis in Italy, conducted in 2020-21 by the Peritoneal Dialysis Project Group of the Italian Society of Nephrology, for the year 2019.
Materials and methods: The data was initially collected using specially designed software, which after entering the data of individual patients allows the aggregate extraction of the necessary information. The difficulties due to the COVID pandemic made it necessary to also use the traditional on-line questionnaire used previously. Of the 237 Centers envisaged, 198 responded, of which 177 with complete data for HD also in 2016.
Results: Overall incidence and prevalence (31/12/2019) were respectively 1,363 (CAPD/APD = 741/622) and 3,922 (CAPD/APD = 1,857 / 2,065) patients. The percentage incidence and prevalence (177 Centers) decreased compared to 2016, respectively, from 23.8% to 22.1% and from 17.3% to 16.6%. 31.4% started PD incrementally in 60.3% of the Centers. The catheter is placed by the Nephrologist alone in 19.7%. Assisted PD is used by 24.5% of the prevalent patients, mostly (83.8%) by a family member. In 2019, the exit from PD (ep/100 years-pts: 11.6 in HD; 8.9 death; 6.0 Tx) is decreasing for all causes. The main cause of transfer to HD remains peritonitis (26.8%). The incidence of peritonitis in 2019 dropped further to 0.190 ep/year-pts as well as the incidence of new cases of EPS (0.103 ep/100 years-pts).
Conclusions: The Cs-19 confirms the good results of the DP in Italy.

Keywords: Peritoneal Dialysis, technique failure, incremental Peritoneal Dialysis, peritonitis, home visits, peritoneal equilibration test (PET)

Intoxications in nephrology: clinical cases and local experience of Sciacca Hospital

Sandra La Rosa1, Stefania Pesce1, Chiara Guglielmo1, Maurizio Virnuccio1, Francesca De Gregorio1, Alessandra Ocello1, Valeria Cassini1, Vittorio Sabella1, Giovanni Pugliese1, Calogero Cirafisi2, Antonio Granata3

1 U.O.S.D. Nefrologia e Dialisi, P.O. “Giovanni Paolo II”, Sciacca (AG) – Italy
2 U.O.S Servizio Psichiatrico di Diagnosi e Cura (S.P.D.C) P.O. “Giovanni Paolo II”, Sciacca (AG) – Italy
3 U.O.C. Nefrologia e Dialisi Azienda Ospedaliera Cannizzaro, Catania (CT) – Italy

Intoxications are a common problem all over the world and cause acid-base balance disturbances, dysionias or acute renal failure; they can develop rapidly leading to severe cellular dysfunction and death.

Intoxications and drug overdoses often require the intervention of Nephrologists, for the correction of acidosis, the administration of selective inhibitory enzymes and also hemodialysis treatment. Extracorporeal therapies have been used to remove toxins for over fifty years and have acquired an increasing role, thanks to the use of new treatment modalities in intoxicated patients. In our clinical practice in the Covid period we have found an increase in clinical cases of intoxication with psychiatric drugs, including benzodiazepines, clozapine, lithium, quetiapine and cocaine.

KEYWORDS: intoxication, neuroleptic abuse, rhabdomyolysis, extracorporeal therapy, Covid 19.

Rupture of renal cyst secondary to blunt trauma: case report and review of the literature

Mariateresa Rumolo1, Biagio Francesco Menna1, Angela Faggian2, Guido Faggian1, Andrea Diglio2, Aldo Delle Cave3, Alfonso Bencivenga2

1 Diagnostica per Immagini e Radioterapia, Dipartimento di Scienze Biomediche Avanzate, Università Degli Studi di Napoli Federico II
2 UOC Diagnostica per Immagini, Dipartimento dei Servizi Sanitari ed Organizzativi, Azienda Ospedaliera San Pio, Benevento
3 UOC Urologia, Dipartimento di Scienze Chirurgiche, Azienda Ospedaliera San Pio, Benevento

Rupture of a renal cyst can be spontaneous, iatrogenic or consequent to a trauma even of minor entity, especially in predisposing conditions such as cysts, tumors or hydronephrosis.

Kidneys are, in fact, involved in about 25% of abdominal traumas. The grading system of the American Association for the Surgery of Trauma (AAST) classifies renal injuries into five categories based on renal involvement and abnormalities detected on contrast-enhanced CT, modality of choice in the evaluation of abdominal trauma with suspicion of intraperitoneal hemorrhage.

Hematuria and/or flank pain are the most frequent presenting symptoms, although some patients may be also asymptomatic.

Treatment is usually conservative, but sometimes nephrectomy may be necessary.

In our manuscript we describe the case of a patient who comes to our observation with left side pain reporting a minor accidental fall occurred the day before.

Ultrasound examination and CT with contrast medium revealed hemoretroperitoneum resulting from rupture of a hemorrhagic renal cyst. We will describe the imaging characteristics and therapeutic choices below.

Keywords: renal cyst, renal hemorrhage, blunt renal trauma, hemoperitoneum

Long-term efficacy and safety of treatment with cinacalcet in hypercalcemic persistent secondary hyperparathyroidism in renal transplant

Carlo Massimetti1, Anteo Di Napoli2, Sandro Feriozzi1

1 Centro di Riferimento di Nefrologia e Dialisi, Ospedale Belcolle, Viterbo
2 Istituto Nazionale per la promozione della salute delle popolazioni Migranti e per il contrasto delle malattie della Povertà (INMP), Roma

Introduction: persistent hypercalcemic secondary hyperparathyroidism (PSHPT) in kidney transplantation (KTx) can expose renal transplant recipients (RTRs) to a series of complications. Cinacalcet has been shown to be effective in controlling hypercalcemic PSHPT. Therefore, we evaluated the efficacy and tolerability of cinacalcet, over a period of 3 years, in the treatment of hypercalcemic PSHPT in a group of RTRs.

Patients and Methods: eight patients with a kidney transplant age > 12 months, parathyroid hormone (PTH) levels > 120 pg/ml and total serum calcium (TCa) levels > 10.5 mg/dl, were treated with cinacalcet at an initial dose of 30 mg/day. Hypercalcemic PSHPT picture must have been present for at least 6 months before the start of treatment with cinacalcet. Every 6-8 weeks were determined: estimated glomerular filtration rate (eGFR), PTH, TCa, serum phosphorus, fractional excretion of calcium (FECa), tubular maximum reabsorption rate of phosphate (TmP/GFR), serum tacrolimus. Annually all patients underwent to ultrasound control of the transplanted kidney. The main endpoints of the study were the reduction of PTH levels > 30% from baseline and the normalization of TCa levels (<10.2 mg/dl).

Results: the results are shown as median ± interquartile range (IQR). At follow-up PTH levels decreased from 223 (202-440) to 135 pg/ml (82-156) (P < 0.01), with a percentage decrease of -54 (-68;-44), TCa levels decreased from 11.0 (10.7-11.7) to 9.3 mg/dl (8.8-9.5) (P < 0.001). Serum phosphorus levels increased from 2.7 (2.0-3.0) to 3.2 mg/dl (2.9-3.5) (P < 0.05). Fractional excretion of calcium did not change, while TmPO4/GFR increased even not significantly. Renal function and serum levels of tacrolimus did not change throughout the observation period. At end of the study the average cinacalcet dosages were 30 mg/day (30-30). Ultrasound scans of the transplanted kidney showed no development of nephrocalcinosis and/or nephrolithiasis. Conclusions: cinacalcet has proved effective and well tolerated in the treatment of hypercalcemic PSHPT in RTRs.

Keywords: cinacalcet, hypercalcemia, persistent hypercalcemic secondary hyperparathyroidism, renal transplant.

Tolvaptan in ADPKD patients at the University of Padova Nephrology Unit: impact on quality of life, efficacy and safety

Irene Cirella, Valentina di Vico, Matteo Rigato, Beatrice Bugnotto, Paola Baldini Anastasio, Daniela Campo, Gianni Carraro e Lorenzo A. Calò

UOC Nefrologia, Dialisi e Trapianto, Dipartimento di Medicina (DIMED), Università di Padova.

Autosomal dominant polycystic kidney disease (ADPKD) is responsible of the 10% of the dialysis patients. Tolvaptan is a consolidate option for treatment of ADPKD patients; it slows renal deterioration rate and cysts’ growth, although its acquaretic effects often impact on quality of life (QoL) and treatment adherence. Few studies have documented the tolvaptan long term efficacy and safeness profiles and, mostly, the impact of treatment with tolvaptan on patients’ QoL. Our study aimed to investigate in 13 ADPKD patients of our cohort the differences in terms of QoL before and after the start of treatment via a questionnaire based on SF-36 and PSQI tests, integrated with other original questions. In addition we have also examined the tolvaptan long term efficacy and safeness profiles.

The results of our study show that tolvaptan does not significantly reduce patients QoL notwithstanding its expected acquaretic effects, the only reported side effects. Finally, the average annual renal deterioration rate was lower in patients treated with tolvaptan than in the others.

Relevant limits of our study are the small number of selected patients and the relative short study duration. However, on one hand, the results of our study provide further information to the few data available in literature; on the other hand, they may serve as a useful working hypothesis for further studies with a larger number of patients enrolled and an extended study duration. They would demonstrate the absence of significant impact of tolvaptan on patients’ QoL.

Keywords: ADPKD, tolvaptan, QoL

The FRASNET study: identification of clinical and social factors of renal failure in an elderly population

Elena Brioni1, Cristiano Magnaghi1, Giulia Villa2, Noemi Giannetta2, Duilio Fiorenzo Manara2, Giulia Magni3, Giulia Delli Zotti1, Simone Fontana1, Francesca Tunesi1, Laura Zagato1, Chiara Lanzani4, Angelo Manfredi4, Paolo Manunta4

1 IRCCS Ospedale San Raffaele, Milano, Italia
2 Centro per la ricerca e innovazione infermieristica, Università Vita Salute San Raffaele, Milano, Italia
3 IRCCS Multimedica, Sesto S. Giovanni, Milano, Italia
4 IRCCS Ospedale San Raffaele, Milano, Italia; Università Vita Salute San Raffaele, Milano, Italia

Background. Chronic renal failure is an epidemic in elderly patients. Older population have an increased prevalence of frailty and sarcopenia, associated with a wide range of adverse health outcomes such as falls, hospitalization, disability.
Aim. Describe the sociodemographic and clinical variables of an elderly Lombard population and identify predictors of renal insufficiency.
Materials and methods. Cross-sectional observational study conducted in hospitals, in recreational centers for the elderly, in the Universities of the Third Age of the provinces of Milan and Monza-Brianza conducted through a convenience sampling of 1250 subjects over the age of 65.
Results. The study identified living alone, annual individual income < € 10,000, polypharmacy, sarcopenia and frailty as predictors of chronic kidney failure. The sample has a mean eGFR of 71.74 mL/min/1.73m2 (SD ± 16.56). Older people living alone are more likely to develop CRI (P = 0.031, confidence interval, CI [1.031-1.905]) as well as having an income < € 10,000 (P = 0.002, CI [0.392-0.923]). Taking more than 11 drugs a day increases the probability of having chronic renal failure by 16 times (P = 0.012, CI [1.155-3.16]). Sarcopenia and frailty increase the likelihood of having chronic renal failure (CRI) (P = 0.001, CI [1.198-2.095]).
Conclusions. Identifying predictors of chronic kidney failure is a key step in introducing preventive measures and providing better care to the elderly population.

Keywords: Chronic Kidney Failure, elderly, fraility, sarcopenia

Home Hemodialysis: new organizational models to favor the economic and environmental sustainability in the province of Belluno

Lucrezia Carlassara1, Giordano Pastori1, Umberto Savi1, Lara Cicciarella1, Morena Giozzet2, Andrea Bandera1

1 U.O.C. Nefrologia e Dialisi, Ospedale di Belluno, Italia
2 U.O.C. Nefrologia e Dialisi, Ospedale di Feltre, Italia

The prevalence of chronic kidney disease is 7.05% in Italy [1]. The replacement dialysis treatments determine greenhouse gas emissions [2] thus contributing to climate change, an important source of risk to global health [3]. Furthermore, the percentage of the Italian Gross Domestic Product destined to public health expenditure has progressively contracted [4]. The province of Belluno has an area of 3610 km2, with a population density of 56 people/km2, an old age index of 248.5 [5], and offers 4 dialysis centers; however, several patients take up to 8 hours/week to commute to the dialysis center, with a consequent significant environmental and economic impact.

We have investigated the Home Hemodialysis (H-HD) models, both as Assisted Home Hemodialysis (AH-HD), and as Not-assisted Home Hemodialysis (NH-HD), to evaluate their environmental and economic sustainability, and the actual impact due to their adoption by 5 patients.

Thanks to AH-HD it is possible a reduction up to 3767 kg of CO2 per year, and an economic saving of € 32 456 per year. Utilizing a NH-HD treatment, it is possible a reduction of 5330 kg of CO2 per year, and a reduction in annual healthcare costs up to € 30 156 per year. Furthermore, the adoption of H-HD treatment for 5 patients allowed an effective reduction of 14 537 kg of CO2 emitted and a net economic saving of 57 975 €.

Therefore, we consider H-HD methods a valid option for patients living in areas with low population density, where transports have a significant impact, allowing a net reduction of CO2 equivalent emissions and a considerable saving of the health resources.

Keywords:  In-center Hemodialysis, Home Hemodialysis, economic sustainability, healthcare expense, environment sustainability, CO2 emission.

Staphylococcus-associated glomerulonephritis without IgA deposits: a case report

Michela Tonoli 1, Paolo Foini 2, Gianluca Marchi 2, Marco Ungari 3, Simona Fisogni 4, Fabio Malberti 2

1 UO Nefrologia e Dialisi ASST Spedali civili di Brescia – Scuola di specializzazione in Nefrologia di Brescia
2 UO Nefrologia e Dialisi ASST Cremona
3 UO Anatomia Patologica ASST Cremona
4 UO Anatomia Patologica ASST Spedali Civili di Brescia

Staphylococcus-associated glomerulonephritis (SAGN) represents a possible version of parainfectious glomerulonephritis and is a pathological entity that’s now constantly increasing in developed countries. It is known how bacterial infections can be a possible trigger for various type of glomerulonephritis with clinical onset and evolution comparable to the ones observed in parainfectious glomerulonephritis. Furthermore, in clinical practice the identification and isolation of the pathogenic microorganism responsible for the development of parainfectious glomerulonephritis is not always possible. Therefore, in those cases in which SAGN is suspected, it is often necessary to recur to kidney biopsy in order to come to as much as possible correct diagnosis. Historically, according to scientific literature, the most distinctive anatomopathological feature of SAGN is represented by predominant or codominant mesangial IgA deposits, sometimes associated with C3 deposits. These findings make the differential diagnosis between SAGN and IgA nephropathy often necessary. However, many reports describe how SAGN can also be characterized by a varying spectrum of immunological deposits. In some cases, for example, IgA deposits can be absent and in some other cases it is described a net dominance of C3 deposits. In this case, it becomes extremely important to exclude a possible occurrence of C3 glomerulopathy (C3GN), considering how different are the therapeutic approach and the prognostic implications associated to it. However, the differential diagnosis between SAGN and C3GN can be very hard.

Here’s a case report about a patient who has been hospitalized into our Unit after developing a form of Staphylococcus Aureus associated glomerulonephritis which presented atypical anatomopathological features.

Keywords: staphylococcus-associated glomerulonephritis, C3GN, differential diagnosis, histopathology features.

Could incremental haemodialysis be a new standard of care? A suggestion from a long-term observational study

Francesco Gaetano Casino1, Teodoro Lopez2, Giovanni Santarsia2, Salvatore Domenico Mostacci2 Andrea Sabato2. Maria Di Carlo2, Clelia Procida2, Angelo Saracino2, Javier Deira3 and Carlo Basile4

1 Dialysis Centre SM2, Policoro (Matera), Italy
2 Division of Nephrology, “Madonna delle Grazie Hospital”, Matera, Italy
3 Section of Nephrology, Department of Internal Medicine, Universitary Hospital of Cáceres, Cáceres, Spain
4 Associazione Nefrologica Gabriella Sebastio, Martina Franca (Taranto), Italy

Introduction: The term incremental haemodialysis (HD) means that both dialysis dose and frequency can be low at dialysis inception but should be progressively increased, to compensate for any subsequent reduction in residual kidney function. Policy of the Matera Dialysis Center is to attempt an incremental start of HD without a strict low-protein diet in all patients choosing HD and with urine output (UO) >500 ml/day. The present study aimed at analyzing the results of this policy over the last 20 years.
Subjects and methods: The dataset of all patients starting HD between January 1st, 2000 and December 31st, 2019 was retrieved from the local electronic database. Exclusion criteria were: urine output <500 ml/day or follow-up <3 months after the start of the dialysis treatment.
Results: A total of 266 patients were retrieved; 64 of them were excluded from the study. The remaining 202 patients were enrolled into the study and subdivided into 3 groups (G1, G2 and G3) according to the frequency of treatment at the start of dialysis: 117 patients (57.9%) started with once-a-week (1HD/wk) (G1); 46 (22.8%) with twice-a-week (2HD/wk) (G2); 39 (19.3%) with thrice-a-week (3HD/wk) dialysis regimen (G3). Patients of G1 remained on 1HD/wk for 11.9 ±14.8 months and then transferred to 2HD/wk for further 13.0 ±20.3 months. Patients of G2 remained on 2HD/wk for 16.7 ±23.2 months. Altogether, 25943 sessions were administered during the less frequent treatment periods instead of 47988, that would have been delivered if the patients had been on 3HD/wk, thus saving 22045 sessions (45.9%). Gross mortality of the entire group was 12.6%, comparable to the mean mortality of the Italian dialysis population (16.2%). Survival at 1 and 5 years was not significantly different among the 3 groups: 94% and 61% (G1); 83% and 39% (G2); 84% and 46% (G3). Conclusions: Our long-term observational study suggests that incremental HD is a valuable option for incident patients. For most of them (80.7%) it is viable for about 1-2 years, with obvious socio-economic benefits and survival rates comparable to that of the Italian dialysis population. However, randomized controlled trials are lacking and therefore urgently needed. If they will confirm observational data, incremental HD will be a new standard of care.

Keywords: haemodialysis, incremental haemodialysis, kidney urea clearance, urea kinetic modeling, urine output

Left atrial appendage occlusion as replacement of coumarin anticoagulants in calciphylaxis

Maria Andolfatto1, Marianna Tangredi1, Margherita Vischi1, Cristina Pinerolo1, Alberto Cereda2, Pietro Napodano1, Mario Cozzolino1

1 Renal Division, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, Italy.
2 Cardiology Division, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, Italy.

Calcific uremic arteriolopathy (CUA), often referred to as calciphylaxis, is a rare condition potentially life-threatening seen in 1-4% of patients with kidney failure on chronic dialysis. Pathogenesis is not clear, but several risk factors have been identified, one of the most known among them is coumarin anticoagulants therapy (tAC). When CUA occurs, tAC is contraindicated: the left atrial appendage occlusion, in dialysed patients affected by non-valvular atrial fibrillation, could be contemplated in replacement of tAC, that should be considered by nephrologist and discussed by a multidisciplinary team including cardiologists.

Keywords : Calciphylaxis, Warfarin, anticoagulant therapy, left atrial appendage occlusion, chronic kidney disease

Renal cell carcinoma: an overview of the epidemiology, diagnosis, and treatment

Sara Bahadoram1, Mohammad Davoodi2, Shakiba Hassanzadeh1, Mohammad Bahadoram3, Maedeh Barahman3, Ladan Mafakher1

1 Thalassemia and Hemoglobinopathy Research Center, Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
2 Department of Radiology, School of Medicine, Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Imam Khomeini Hospital, Tehran University of Medical Sciences, Iran
3 Department of Radiation Oncology, Firoozgar Hospital, Firoozgar Clinical Research Development Center (FCRDC), Iran University of Medical Sciences (IUMS), Tehran, Iran

Renal cell carcinoma (RCC) is the most common type of urogenital cancer. It has a mortality rate of 30-40% and is more commonly seen in men than women. In addition to gender, other risk factors of RCC include obesity, hypertension, smoking, and chronic kidney disease. Following the improvements in diagnostic tests, such as CT and MRI imaging, the incidence of patients diagnosed with RCC has rapidly increased over the past decades. The most common type of RCC, based on histological and molecular subtypes, is clear cell carcinoma which occurs frequently due to mutations in the VHL gene. Nephron-sparing surgery is a selective technique to maintain kidneys in patients while radical nephrectomy and partial nephrectomy are used to remove small tumors. In addition to surgical approaches, adjuvant therapy and targeted therapy are applied in patients with metastatic RCC. In this review, we give an overview of the most recent research on RCC which would help physicians to better manage patients with RCC.

Keywords: renal cell carcinoma, kidney cancer, genetics

Managing CKD and promoting health: the perspective of the Istituto Superiore di Sanità

Prof. Silvio Brusaferro

Presidente dell’Istituto Superiore di Sanità

COVID-19 recurrence due to reinfection with SARS-CoV-2 in a hemodialysis patient: there and back again

Federica N. Vigotti1, Simona Bianco1, Victor Alfieri1, Donatella Bilucaglia1, Daria Motta1, Angelo Pignataro1, Marco Timbaldi1, Elisa Torta1, Giulio Cesano1

1 Nefrologia e Dialisi, Ospedale Martini, ASL Città di Torino

The COVID-19 pandemic has caused millions of infections and deaths so far. After recovery, the possibility of reinfection has been reported.

Patients on hemodialysis are at high risk of contracting SARS-CoV-2 and developing serious complications. Furthermore, they are a relatively hypo-anergic population, in which the development and duration of the immune and antibody response is still partially unknown. This may play a role in the possible susceptibility to reinfection. To date, only 3 cases of SARS-CoV-2 reinfection from strains prior to the Omicron variant in patients on chronic hemodialysis have been reported in literature. In all of them, the first infection was detected by screening in the absence of symptoms, potentially indicating a poor immune response, and there are no data about the antibody titre developed.

We report a case of recurrence of COVID-19 in 2020 − first infection likely from Wuhan strain; reinfection likely from English variant (Alpha) after 7 months − in a hemodialysis patient with clinical symptoms and pulmonary ultrasound abnormalities. Swabs were negative in the interval between episodes (therefore excluding any persistence of positivity) and the lack of antibody protection after the first infection was documented by the serological test.

The role of the potential lack − or rapid loss − of immune protection following exposure to SARS-CoV-2 in hemodialysis patients needs to be better defined, also in consideration of the anti-COVID vaccination campaign and the arrival of the Omicron variant, which appears to elude the immunity induced by vaccines and by previous variants. For this purpose, prospective multicenter studies are in progress in several European countries.

This case also highlights the need for a careful screening with nasopharyngeal swabs in dialysis rooms, even after patients overcome infection and/or are vaccinated.


Keywords: SARS-CoV-2, COVID, hemodialysis, COVID-19 recurrence

Monoclonal gammopathies and kidney: a diagnostic challenge without any clues

Giulia Schiavone1, Fausta Catapano1, Enza Ratto1, Benedetta Fabbrizio2, Elena Mancini1

1 IRCCS Azienda Ospedaliero-Universitaria di Bologna. U.O. Nefrologia, Dialisi, Ipertensione, Bologna, Italia
2 IRCCS Azienda Ospedaliero-Universitaria di Bologna. SSD Diagnostica Istopatologica e Molecolare degli Organi Solidi e del relativo Trapianto, Bologna, Italia

Diagnosis of monoclonal gammopathy of renal significance (MGRS) with histopathologic features of proliferative GN with monoclonal immunoglobulin deposits (PGNMID) is a challenge for clinicians because of the absence of laboratory findings suggestive of glomerular involvement in paraproteinemia. Renal biopsy remains the gold standard for diagnosis of PGNMID because it is a monoclonal gammopathy with kidney damage often “without a detectable serum/urine clone”. Through this case report, we want to focus on the complexity both in the diagnostic process and in monitoring the renal-hematological response to therapy.


Keywords: monoclonal gammopathies, nephrotoxic paraproteins, kidney damage

Eosinophilic granulomatosis with polyangiitis complicated with rapidly progressive glomerulonephritis in a young man who is a healthy cyclist

David Micarelli1, MD, Ilaria Duca2, MD, Lida Tartaglione1, MD, Nicla Frassetti1, MD, Bettina Coppola1, MD, Francesca Polistena1, MD, Giuseppe Roberto Iannacci1, MD, Carmela Comegna1, MD, Roberto Addesse1, MD, Pasquale Polito1, MD

1 Nephrology and Dialysis Unit, San Giovanni Evangelista Hospital, Tivoli, Italy
2 Rheumatology Consultant, ASL Roma 5, Tivoli, Italy

Eosinophilic granulomatosis with polyangiitis (EGPA), formerly known as Churg-Strauss syndrome, is a rare systemic vasculitis. Rapidly progressive glomerulonephritis (RPGN) is a rare complication of EGPA. We report a case of a 60-year-old man, who is also a skilled cyclist, who was hospitalized to investigate a symptomatology that had arisen over the previous months and worsened in the last few weeks, to the point of limiting normal everyday activities. The physical examination revealed the presence of livedo reticularis of the four limbs, purpura of the lower limbs, arthritis of the ankles, and low-grade fever; the patient showed intense asthenia, loss of appetite, retrosternal heartburn, and a scarcely pharmacologically controlled asthma. He also reported weight loss (about 5 kg in the last 6 months). Rapidly progressing renal failure was observed with hyper-eosinophilia (4.7 thousand/μL eosinophils, 44% of total leukocytes), pulmonary opacities on chest computed tomography (CT), and sinusitis on CT of the facial massif. The search for antibodies directed against neutrophil cytoplasm (ANCA) revealed a high level of pANCA (pANCA ++, ELISA anti-MPO 666 UI/ml), associated with an increment of inflammation indicators. The induction therapy was high-dosage intravenous glucorticoids and cyclophosphamide, to improve the short and long-term prognosis. After 7 months of treatment, the patient reported a considerable improvement of the symptoms, which at that point did not necessitate pharmacological interventions. The eosinophils value was 0 cells/mm³, the inflammation indexes were back to the norm, and the renal function appeared significantly improved.

Keywords: eosinophilic granulomatosis with polyangiitis, Churg-Strauss Syndrome, rapidly progressive glomerulonephritis, ANCA-associated vasculitis

Uremic pruritus through healthcare administrative data

Giulia Ronconi1, Silvia Calabria1, Carlo Piccinni1, Letizia Dondi1, Enrico Cinconze1, Antonella Pedrini1, Immacolata Esposito2, Alice Addesi2, Lucio Manenti3, Filippo Aucella4, Nello Martini1

1 Fondazione ReS (Ricerca e Salute), Casalecchio di Reno (Bologna), Italia
2 Drugs and Health, Roma, Italia
3 Ospedale Universitario di Parma, Unità Nefrologica, Parma, Italia
4 Dipartimento Scienze Mediche, Ospedale “Casa Sollievo della Sofferenza”, San Giovanni Rotondo (Foggia), Italia

Background: This retrospective observational study aimed at describing patients on hemodialysis with/without uremic pruritus (UP), their healthcare resource consumption and costs from the perspective of the Italian National Health Service (INHS).

Methods: Through the cross-linkage of the healthcare administrative data collected in the ReS (Ricerca e Salute) database from 2015 to 2017, patients undergoing in-hospital/outpatient hemodialysis (index date) for ≥2 years were selected. After the exclusion of subjects with other causes of pruritus, UP/non-UP cohorts were created based on the presence/absence of UP-related treatment supplies and characterized. Treatments, hospitalizations and costs were analyzed.

Results: Of 1239 patients on hemodialysis for ≥2 years (20.2% of all hemodialysis subjects), 218 (17.6%) were affected by UP. Both cohorts were mostly males and elderly. One year before and after the index date, 58.1% and 65.1% of UP patients received UP-related treatments, of which >50% were treated with antihistamines (mostly cetirizine), 10% gabapentin and 1.4% ultraviolet light therapy. The mean annual overall cost per patient with/without UP was €37,065/€35,988. Outpatient specialist services accounted for 80% (>77% hemodialysis), hospitalizations for 10% (>60% hemodialysis).

Conclusions: Though the prevalence of UP and related healthcare costs charged to the INHS were underestimated, the burden of UP was not negligible. High-efficiency dialytic therapies performed to UP patients seemed to largely weigh on the overall mean annual cost. The availability of specific and effective treatments for UP might offer cost and healthcare offsets.


Keywords: chronic kidney disease, pruritus, public health practice, database

Lo stress ossidativo è ridotto in pazienti con ADPKD trattati con tolvaptan

Matteo Rigato1, Gianni Carraro1, Irene Cirella1, Silvia Dian1, Valentina Di Vico1, Verdiana Ravarotto1, Giovanni Bertoldi1, Lorenzo A Calò1

1 UOC Nefrologia, Dialisi e Trapianto, Dipartimento di Medicina, Università di Padova, Padova, Italia

La malattia renale policistica autosomica dominante (ADPKD) è la malattia renale monogenica più frequente e causa ipertensione arteriosa e malattia renale progressiva, entrambe legate allo stress ossidativo (OxSt). Il tolvaptan è una opzione di trattamento nota in ADPKD ma i meccanismi molecolari coinvolti non sono stati completamente chiariti. Questo studio valuta lo OxSt In 9 soggetti per gruppo attraverso: l’espressione proteica di p22phox, lo stato della fosforilazione di MYPT-1 (Western blot) e l’eme ossigenasi-1 (HO-1) (ELISA).

L’espressione proteica di p22phox era ridotta nei pazienti ADPKD trattati con tolvaptan e nei soggetti di controllo rispetto ai pazienti ADPKD non trattati: 0.86 ±0.15 d.u. p=0.015; 0.53 ±0.11, p<0.001; 1.42 ±0.11. Lo stesso si riscontrava per la fosforilazione di MYPT-1: 0.68 ±0.09, p=0.013, 0.47 ±0.13, p<0.001, 0.96 ±0.28 mentre HO-1 dei pazienti non trattati era ridotta sia rispetto ai controlli che ai pazienti trattati: 1.97 ±1.22, ng/mL, 2.08 ±0.79, p=0.012, 5.33 ±3.34, p=0.012. I pazienti ADPKD trattati con tolvaptan presentano una riduzione dello OxSt che potrebbe contribuire a rallentare la perdita di funzione renale. Parole chiave: tolvaptan, ADPKD, stress ossidativo, Rho chinasi

Vascular ultrasonography in the preparation and surveillance of arteriovenous fistula: a monocentric experience

Maurizio Borzumati1, Loredana Funaro1, Francesco Laurendi1, Elvira Mancini1, Patrizia Vio1, Francesca Bonvegna1, Pantaleo Ametrano1, Maria Carmela Vella1

1 Struttura Operativa Complessa Nefrologia e Dialisi Azienda Sanitaria Locale del Verbano Cusio Ossola, Verbania, Italy

Creating an arteriovenous fistula (AVF) is complicated by the gradual increase in the average age of patients initiating chronic haemodialysis treatment and by the greater prevalence of pathologies that impact the cardiovascular system.

In the past, the choice of which vessels to use for the creation of the AVF was essentially based on the physical examination of the upper limbs. Current international guidelines suggest that a colour doppler ultrasound (DUS) should be performed to complete the physical examination. Similarly, vascular ultrasound is fundamental in the post-operative phase for appropriately monitoring the access.

We have conducted a retrospective analysis on the use of DUS in clinical practice in our centre, in order to determine the repercussions on vascular access survival. To this end, we identified three phases, according to the methods that were used for pre-operative vascular evaluation and monitoring of the AVF, that saw the progressive integration of clinical and ultrasound parameters.

The analysis of the data highlighted a statistically significant higher rate of survival for all vascular accesses, evaluated as a whole, and for distal AVFs, in the third phase, despite a greater percentage of patients over 75 (48% vs 28%).

In conclusion, we believe that an approach integrating clinical and ultrasound evaluation is indispensable to identify the most suitable AVF site and guarantee its efficiency over time.


Keywords: haemodialysis, arteriovenous fistula, colour doppler ultrasound, monitoring, vascular access

Reactogenicity of COVID-19 vaccine in hemodialysis patients: a single-center retrospective study

Gaetano Alfano1,2, Niccolò Morisi3, Francesco Fontana1, Roberta Scarmignan3, Laura Tonelli3, Camilla Ferri3, Martina Montani3, Andrea Melluso3, Silvia Giovanella2,3, Giulia Ligabue3, Giacomo Mori1, Erica Franceschini4, Giovanni Guaraldi4, Gianni Cappelli3, Riccardo Magistroni1,3, Gabriele Donati1,3

1 Nephrology, Dialysis and Transplant Unit, University Hospital of Modena, Modena, Italy
2 Clinical and Experimental Medicine Ph.D. Program, University of Modena and Reggio Emilia, via del Pozzo 71, 41124 Modena, Italy
3 Surgical, Medical and Dental Department of Morphological Sciences, Section of Nephrology, University of Modena and Reggio Emilia, via del Pozzo 71, 41124 Modena, Italy
4 Clinic of Infectious Diseases, University Hospital of Modena, Modena, Italy

Introduction: Some hemodialysis patients are reluctant to undergo COVID-19 vaccination for the fear of developing adverse events (AEs). The aim of this study was to verify the safety of the mRNA-1273 vaccine in hemodialysis patients.

Methods: We conducted a retrospective analysis of in-center hemodialysis patients who underwent mRNA-1273 vaccine from March 1st to April 30th, 2021. All AEs occurring after the first and the second doses were collected and classified as local or systemic.

Results: Overall, 126 patients on chronic maintenance dialysis without a prior COVID-19 diagnosis were vaccinated with two doses of mRNA-1273 vaccine. Mean age was 68 (IQR, 54,7-76) years and 53.6% of patients were aged ≥65 years. During the observational period of 68 (IQR, 66-70) days, AEs occurred in 57.9% and 61.9% of patients after the first dose and second dose, respectively. The most common AEs were: injection-site pain (61.9%), erythema (4.8%), itching (4.8%), swelling (16.7%), axillary swelling/tenderness (2.4%), fever (17.5%) headache (7.9%), fatigue (23.8%), myalgia (17.5%), arthralgia (12.7%), dyspnoea (2.4%), nausea/vomiting (7.1%), diarrhoea (5.6%), shivers (4%) and vertigo (1.6%). The rates of local AEs were similar after the first and second doses (P=0.8), whereas systemic AEs occurred more frequently after the second dose (P=0.001). Fever (P=0.03), fatigue (P=0.02) and nausea/vomiting (P=0.03) were significantly more frequent after the second dose of the vaccine. There were no age-related differences in the rate of AEs. Overall, vaccine-related AEs in hemodialysis patients seem to be lower than in the general population.

Conclusion: The RNA-1273 vaccine was associated with the development of transient AEs after the first and second doses in patients on chronic maintenance hemodialysis. They were mostly local, whereas systemic AEs were more prevalent after the second dose. Overall, all AEs lasted for a few days, without any apparent sequelae. 

Keywords: COVID-19, mRNA-1273, safety, vaccine, hemodialysis, HD, side effects, SARS-COV-2

A possible relationship between anti-SARS-CoV-2 vaccination and glomerular dis-eases: food for thought for the nephrologist

Manuela Rizzo1, Antonella Marino2, Anna Sannino2, Valentina Urciuoli2, Ivana Capuano2, Antonio Pisani2

1 Dipartimento di Medicina, Chirurgia e Odontoiatria, Università degli Studi di Salerno, Salerno, Italia
2 Dipartimento di Sanità Pubblica, Università degli Studi di Napoli “Federico II”, Napoli, Italia

In order to fight the SARS-CoV-2 pandemic, mass-vaccination programs have been launched globally starting December 2020. The pace of COVID-19 vaccines development was impressive and although data from clinical trials and post-authorization studies showed acceptable safety profile, additional studies and long-term population-level surveillance are needed. A possible link between all type of vaccination and immunological diseases is perhaps one of the hottest topics in literature; correspondingly, there is growing concern over the small but growing number of case reports linking COVID-19 vaccines with the development of glomerular disease. Our group conducted a systematic review of such cases. Results showed that IgA nephropathy (IgAN) and Minimal Change Disease (MCD) are the most frequently associated glomerulopathies. Interestingly, IgAN cases are mostly flares occurring few hours after the second dose of RNA vaccines and have a good clinical outcome, while both de novo and recurring MCD can occur up to 28 days after the first or second dose of vaccines. RNA vaccines are the most common vaccine type to be associated with glomerulopathy. Of course, this may simply reflect the more widespread use of these vaccines. However, compared to traditional vaccines, they do seem produce a higher antibody response and a stronger CD8+ T- and CD4+ T-cell response, including higher production of chemokines and cytokines.


Keywords: anti-SARS-CoV-2 vaccination, glomerulopathy, immuno-mediated nephropathy

Atrial fibrillation, oral anticoagulation and nephroprotection: caution or bravery?

Luca Di Lullo, MD, PhD1, Michele Magnocavallo, MD2, Giampaolo Vetta, MD2, Carlo Lavalle, MD2, Vincenzo Barbera, MD1, Claudio Ronco, MD3, Ernesto Paoletti, MD4, Maura Ravera, MD4, Maria Fusaro, MD5, Domenico Russo, MD6, Antonio De Pascalis7, Antonio Bellasi, MD3

1 UOC Nefrologia e Dialisi, Ospedale Parodi-Delfino, 00034 Colleferro, Italia
2 Dipartimento di Scienza Cliniche, Internistiche, Anestesiologiche e Cardiovascolari, Policlinico Universitario Umberto I, Sapienza Università di Rome, 00161 Roma, Italia
3 UOC Nefrologia Dialisi e Trapianto, Ospedale San Bortolo, Vicenza, Italia.
4 Nefrologia, Dialisi e Trapianto, Policlinico San Martino, 16132 Genova, Italia
5 CNR, Istituto di Fisiologia Clinica, 35122 Pisa, Italia
6 Dipartimento di Nefrologia, Università Federico II di Napoli, 80137 Napoli, Italia
7 UOC Nefrologia e Dialisi, Ospedale Vito Fazzi, Lecce, Italia

Atrial fibrillation (AF) and chronic kidney disease (CKD) are strictly related and share several risk factors (i.e. hypertension, diabetes mellitus, congestive heart failure). As consequence, AF is very common among CKD patients, especially in those with end stage renal disease (ESRD). Moreover, patients with AF and advanced kidney disease have a higher mortality rate than patients with preserved renal function due to an increased incidence of stroke and an unpredicted elevated hemorrhagic risk. The adequate long-term oral anticoagulation in this subgroup of patients represents a major challenging issue faced by physicians in clinical practice. Direct oral anticoagulants (DOACs) are currently contraindicated in patients with ESRD while vitamin K antagonists (VKAs) are characterized by a narrow therapeutic window, increased tissue calcification and an unfavorable risk/benefit ratio with low stroke prevention effect and augmented risk of major bleeding. The purpose of this review is to shed light on the applications of DOAC therapy in CKD patients, especially in ESRD patients.

Keywords: atrial fibrillation, chronic kidney disease, warfarin, direct oral anticoagulants, end stage renal disease, left atrial appendage occlusion

Lymphocytic leukopenia in two patients affected by polycystic kidney disease waiting for renal transplantation

Elisa Costa1,3, Anna Giuliani2,3, Valentina Corradi2,3, Carlotta Caprara3, Matteo Rigato2,3, Sabrina Milan Manani2,3, Ilaria Tantillo2,3, Claudio Ronco3,4, Fiorella Gastaldon2,3, Monica Zanella2,3

1 Clinica Nefrologica, Dialisi e Trapianto, IRCCS Ospedale Policlinico San Martino, Genova, Italia
2 Dipartimento di Nefrologia, Dialisi e Trapianto, Ospedale San Bortolo, Vicenza, Italia
3 International Renal Research Institute of Vicenza (IRRIV), Vicenza, Italia
4 DIMED, Università di Padova, Padova, Italia

Autosomal dominant polycystic kidney disease (ADPKD) is the most common hereditary kidney disease, responsible for 10% of patients on renal replacement therapy. The disease is well known to be associated with many extrarenal manifestations. Leukopenia may also be present, even if it is not commonly identified as a typical extrarenal manifestation.

Herein we describe two case reports of ADPKD patients with leukopenia. The first case is about a 47-year-old patient affected by ADPKD, regularly treated with peritoneal dialysis, who showed a progressive reduction of white blood cell count, mostly of lymphocytes. Lymphocytic leukopenia was so severe that, when he was called for transplantation from a deceased donor, he was considered temporarily not eligible. We then describe a second ADPKD patient regularly treated with peritoneal dialysis, who had stable lymphopenia for years. Six years after starting PD, it was necessary to perform bone marrow aspirate to investigate the simultaneous presence of hypogammaglobulinemia together with M-protein and to exclude monoclonal gammopathy.

All the exams performed did not show any significant results, the patients were re-included in the waiting list and one of them was transplanted. Given our experience and what is reported in the literature, there seems to be enough evidence to consider leukopenia as an extrarenal manifestation of ADPKD.

However, the clinical significance of leukopenia in ADPKD patients is not known. It could be interesting to investigate the leucocytes’ function and if ADPKD patients with leukopenia are more susceptible to infection, or not. Moreover, it would be very useful to analyze the relationship between such manifestation and genotype/phenotype.

Keywords: ADPKD, lymphopenia, leukopenia, kidney transplant, chronic kidney disease

Peritoneal dialysis: what have we learned from the Covid-19 pandemic?

Valerio Vizzardi1, Vincenzo Terlizzi1, Diana Bertoni1, Federico Alberici1,2, Francesco Scolari1,2

1 U.O.C. di Nefrologia, ASST-Spedali Civili di Brescia. Brescia, Italy
2 Dipartimento di Specialità Medico-Chirurgiche, Scienze Radiologiche e Sanità Pubblica. Università degli Studi di Brescia. Brescia, Italy

In questi mesi contraddistinti dalla pandemia da Covid-19, il lockdown a domicilio è stato considerato una strategia fondamentale per rallentare il diffondersi del virus. Anche la domiciliazione terapeutica ha rappresentato una parte importante del confinamento. La dialisi peritoneale, pur essendo praticata autonomamente dal paziente a casa propria con un’efficacia depurativa sovrapponibile all’emodialisi, è ancora oggi utilizzata solo da circa l’11% della popolazione in dialisi. Nei pazienti in dialisi peritoneale si è osservato globalmente una ridotta incidenza di infezione da SARS-Cov-2 rispetto ai pazienti in emodialisi. Questi ultimi devono recarsi più volte la settimana in ospedale esponendosi al rischio di contagio. La domiciliazione della metodica si è dimostrata il principale fattore protettivo che ha permesso ai pazienti in dialisi peritoneale di esser meno coinvolti dalla pandemia. Gli strumenti logistici ed economici messi in campo in aiuto alla sanità italiana dovrebbero stimolare anche una maggiore utilizzazione della dialisi peritoneale con l’assistenza infermieristica domiciliare e con incentivi economici per i caregiver. Serve altresì una maggiore collaborazione tra le Unità di nefrologia per permettere a tutti i pazienti di accedere alla dialisi peritoneale anche se non disponibile nella sede di residenza.

Parole chiave: dialisi peritoneale, pandemia da COVID-19, teledialisi

PGNMID and anti-CD38 monoclonal antibody: a therapeutic challenge

Elnaz Rahbari1, Antonella Barreca2, Barbara Nicolino3, Chiara Ciochetto3, Valentina Piraina1, Serena Maroni1, Maria Chiara Deagostini1, Rosaria Patti1, Piergiorgio Bertucci4, Silvana Savoldi1

1 Nephrology and Dialysis Unit, ASL TO4, Turin, Italy
2 Division of Pathology, Città della Salute e della Scienza Hospital, Turin, Italy
3 Hematology Unit ASL TO4, Turin, Italy
4 Public hygiene service ASL TO4, Turin, Italy

Monoclonal gammopathy of renal significance (MGRS) designates disorders induced by a monoclonal protein secreted by plasma cells or B-cell clones in patients who do not meet the diagnostic criteria for multiple myeloma or other B-cell malignancies. Proliferative glomerulonephritis with monoclonal immunoglobulin deposits (PGNMID) is a form MGRS.

Until now, no guidelines to decide the best therapeutic approach to manage PGNMID exist, and most patients progress to End Stage Renal Disease (ESRD) without therapy. Recently, daratumumab has showed an acceptable improvement in proteinuria and renal function in patients with PGNMID.

We report the clinical outcome and the histological renal evolution and treatment complication of our patient, who was initially treated with a combination regimen including bortezomib, dexamethasone, and cyclophosphamide and then with anti-CD38 monoclonal antibody-based regimen.

Keywords: monoclonal gammopathy of renal significance, proliferative glomerulonephritis with monoclonal immunoglobulin deposits, histological evaluation, pharmacological therapies, case report

Ultrasound-guided paracentesis: technical, diagnostic and therapeutic aspects for the modern nefrologist

Fulvio Fiorini¹, GianFranco Natali2, Yuri Battaglia3

1 UOC Nefrologia e Dialisi, P.O. S.M. della Misericordia, Rovigo, Azienda ULSS5 Polesana; Responsabile Iter Formativo SIN-SIUMB in Ecografia Nefrologica; Direttore Scuola Specialistica di Ecografia Nefrologica SIUMB di Rovigo, Italia
2 UOC di Medicina, Azienda ULSS5 Polesana, P.O. San Luca Trecenta, Rovigo, Italia
3 Dipartimento di Medicina, Università di Verona; UO Nefrologia e Dialisi, Ospedale Pederzoli, Peschiera del Garda, Verona, Italia

Ascites is a pathological accumulation of fluid in the peritoneal cavity due to various etiologies, often associated with renal failure. Paracentesis is a simple method of removing ascitic fluid by inserting a needle into the peritoneal cavity, often performed at the patient’s bedside. It can be both diagnostic and therapeutic. Ultrasound imaging allows the diagnosis of ascites, the identification of the puncture site on the abdominal wall during the pre-procedural phase, the real time evaluation of the needle and the continuous course of the maneuver. This eco-guide technique has higher effectiveness and lower risk of complications than the “blind” venipuncture technique. Ultrasound-guided paracentesis, when performed by nephrologists, reduces the waiting time both for the execution of paracentesis and for the diagnosis, treatment and follow-up of ascites.

Keywords: ascites, paracentesis, ultrasonography, bedside, cirrhosis, peritoneal cavity

New year, new variant: drawing lessons from frail elderly people

Nadia Foligno1, Marta De Filippo1, Liliana De Rosa1, Costanza Bagnati1, Chiara Pomaranzi1, Rebecca De Lorenzo2, Lorena Citterio2, Elisabetta Messaggio2, Laura Zagato2, Angelo Manfredi1, Patrizia Rovere-Querini1, Paolo Manunta1, Chiara Lanzani2

1 Università Vita Salute San Raffaele, Milano, Italia
2 IRCCS Ospedale San Raffaele, Milano, Italia

A recent study called FRASNET enrolled on a voluntary basis a cohort on 1240 elderly people. They were either patients of the Nephrology and Dialysis unit at San Raffaele hospital in Milan, guests of care homes, or members of cultural, social and recreational centers for the elderly in the wider Milan area. Demographic, anthropometric and biochemical data were collected, together with information on comorbidities and pharmacological therapies, psychophysical test results and biological samples.

After the first wave of the SARS-Cov-2 pandemic, we have interviewed the members of this same cohort to gather information on possible coronavirus infections and evaluate the impact of the pandemic on frail patients. It emerged that the prevalence of SARS-Cov-2 infections was 0.7% within this cohort. This encouraging result seems to confirm the effectiveness of the measures taken at the start of the pandemic, especially social distancing and personal protective equipment.

Keywords: FRASNET study, frail patients, elderly, SARS-Cov-2

Pius X (1835-1914): the last gouty pope

Gout is a common, complex, systemic and well-studied form of chronic inflammatory arthritis in adults. It is due to the deposition of sodium monourate crystals in peripheral joints and periarticular tissues driven by hyperuricemia. Gout is the oldest recorded inflammatory arthritis to affect humankind, with roots stretching back to 2460 BC. It is known as “the rich man’s disease”, “the patrician malady”, “a disease of plenty”, “disease of kings”, “disease of Western Society”, and also “a life-style disease”. Few studies have addressed the problem of gout among popes, affluent people who usually live longer than their contemporaries and are among the most scrutinized persons. Pius X (1835-1914) was the last pope with gout.

Gout seems to have affected 26 out of 265 popes (9.81%) from Saint Peter to Benedict XVI (34-2013 AD). The first was Gregory I Magnus, who was pope in the years 590-604, the last was Pius X, who reigned from 1903 to 1914 at age 79. Their age at death was 71.7 ±9.2 years (Mean ± SD). All popes were elderly men, some had voracious appetites and/or were wine drinkers. Several were sedentary and obese, while others were sober eaters, who took long walks or went riding. Chiragra (arthritic pain in the hands), podagra (arthritic pain in the big toe) and renal stone disease were among the most frequent disturbances.

The causes of death, due to CKD, strokes and infections are discussed along with the fact that gout disappeared from the Vatican Palace on August 22, 1914. However, in accordance with the Theory of Epidemiological Transition, gout seems likely to become a problem for the general population, increasingly adopting unhealthy lifestyle choices, in the absence of a correct education.

Keywords: gout, popes, Pius X, renal death, death due to infection, death due to stroke

Book review ‘Nefrologia Critica’ by Claudio Ronco (Piccin, 2021)

Vincenzo Cantaluppi1, Gabriele Guglielmetti2

1 Professore Associato in Nefrologia, Direttore SCDU Nefrologia e Trapianto Renale, Università del Piemonte Orientale (UPO), AOU Maggiore della Carità di Novara, Italia
2 Dirigente Medico, SCDU Nefrologia e Trapianto Renale, Università del Piemonte Orientale (UPO), AOU Maggiore della Carità di Novara, Italia

“Naked” exit-site for peritoneal dialysis catheters

Antonino Previti1, Umberto Savi2, Paolo Lentini3, Andrea Bandera2

1 UOS Nefrologia e Dialisi, Ospedale Alto Vicentino, Santorso (VI), Italia
2 UOC Nefrologia e Dialisi, Ospedale San Martino, Belluno (BL), Italia
3 UOC Nefrologia e Dialisi, Ospedale San Bassiano, Bassano del Grappa (VI), Italia

Exit site infections (ESI) and peritoneal catheter tunnel infections are strongly associated with peritonitis. Alternative exit-site dressings can include the use of water and soap and the absence of sterile gauze. This article reports our experience with “naked” exit-sites, meaning without any kind of gauze to cover them. From January 2017 to October 2020, we enrolled 38 patients of the Nephrology and Dialysis Unit of the “San Martino” Hospital in Belluno. Nine of these patients had a “naked” exit-site. At the end of the study, no significant differences were found in the percentage of ESI-free patients, in the incidence rate of ESI, in the relative risk of developing ESI and in the incidence rate of peritonitis.

Keywords: peritoneal dialysis, exit-site dressing, exit-site infections

The genetic basis of post-bone marrow transplant thrombotic microangiopathy: is this the last piece of the puzzle?

Nicoletta Mancianti1, Andrea Guarnieri1, Sergio Tripodi2, Domenica Paola Salvo1, Fabio Rollo1, Mariapia Lenoci3, Francesca Toraldo3, Alessandro Bucalossi3, Guido Garosi1

1 Department of Emergency-Urgency and Transplantation, Nephrology, Dialysis and Transplantation Unit, University Hospital of Siena, Siena, Italy
2 Department of Oncology, Anatomical Pathology Unit, University Hospital of Siena, Siena, Italy
3 Stem Cell Transplant and Cellular Therapy Unit, University Hospital, Siena, Italy

Transplant-associated thrombotic microangiopathy (TA-TMA) is a complication of hematopoietic stem cell transplantation (HSCT) associated with kidney injury and significant mortality. Recent studies indicate that dysregulation of the alternate complement pathway may be at the basis of the development of TA-TMA. Currently, there are no pre-transplant screening tools to identify patients at risk. To explore the mechanism of TA-TMA, we performed a genetic study that allowed us to identify the deletion of the CFHR3-CFHR1 region in homozygosity.

We report the clinical case of a 47-year-old woman who underwent haploidentical HSCT complicated by TA-TMA confirmed by renal biopsy. The patient discontinued treatment with calcineurin inhibitors (potential inducers of TA-TMA) with a brief introduction of prednisone until complete resolution of renal damage and microangiopathy.

Identifying genetic variants that affect the mechanism of the alternate complement pathway could help in the stratification of the risk of TA-TMA and in implementing a personalized therapeutic approach.

Keywords: transplant-associated thrombotic microangiopathy, genetic susceptibility, hematopoietic cell transplantation, complement alternative pathway

Urinary tract infections in nephrology: antibiotic therapy in the era of antibiotic resistance

Giuseppa Costanza1, Rosario Maccarrone2, Sandra La Rosa3, Giuseppe Seminara4, Epifanio Di Natale5, Antonio Granata4

1 UOC Nefrologia e Dialisi, P.O. “Vittorio Emanuele” – Gela (CL), Italia
2 UOC Nefrologia e Dialisi, P.O. “San Giovanni di Dio” – Agrigento, Italia
3 UOC Nefrologia e Dialisi, P.O. “Giovanni Paolo II” – Sciacca (AG), Italia
4 UOC Nefrologia e Dialisi, A.O. per l’Emergenza “Cannizzaro” – Catania, Italia
5 UOC Nefrologia e Dialisi, P.O. “V. Cervello” – Palermo, Italia

Urinary tract infections (UTIs) are an emerging health problem. Kidney patients with UTI are at increased risk of antimicrobials resistance (AMR) and bad prognosis. In the nephrological setting, optimizing the management of UTIs is certainly a challenge, but it is indispensable for a favorable clinical outcome and in fighting AMR.

When UTIs caused by multidrug-resistant germs are suspected, it is necessary to initiate empirical antibiotic therapy timely, pending microbiological study and bacterial sensitivity. The empirical choice of antibiotic must be based on: guidelines, resistance rates recorded in the region, and knowledge of pharmacokinetic and pharmacodynamic characteristics of the drug, in order to maximize efficacy, reduce adverse effects and minimize AMR development.

Recently, the clinical use of old drugs such as colistin has increased, due to the limited circulation of resistant bacterial strains. On the other hand, ceftolozane/tazobactam, ceftazidime/avibactam, cefiderocol, imipenem/cilastatin/relebactam and meropenem-vaborbactam are very promising new antibiotics. Ongoing clinical studies will be able to determine the place for these interesting molecules in the treatment of infections and in fighting AMR.

Keywords: urinary tract infections, antibiotics, antibiotic resistance

The origins of the Renal Immunopathology Group of the Italian Society of Nephrology

Giovanni B. Fogazzi, Giovanni Barbiano di Belgiojoso, Francesco Paolo Schena, Franco Ferrario, Giovanni Banfi, Guido Monga, Gianna Mazzucco, Leonardo Cagnoli, Silvia Casanova, Sonia Pasquali

This article describes the birth and development of the Renal Immunopathology Group of the Italian Society of Nephrology. It collects the stories of nephrologists and pathologists who, since the early Seventies up to the first decade of this century, devoted their professional lives to the study of renal pathology with a strong personal involvement, characterized by enthusiasm, commitment, ability, strong spirit of cooperation, and friendship. All this enabled the Group to: propose the criteria for a standardized histological and immuno-histological examination of renal biopsies and reporting; produce several multicenter studies, whose results were also published in important international journals; to set up a national registry of renal biopsies; to organize a number of courses, some of which were associated with the publication of monographs, on various renal diseases.

This article also traces the history of renal pathology in Italy from the second half of the Sixties – when young Italian nephrologists and pathologists from different institutions moved to French laboratories to learn new techniques to apply to renal biopsies – up to the present days. It also shows us how Italian renal pathology has been an essential tool for the development of the nephrological clinical practice and the advancement of scientific research.

Keywords: history of Renal Immunopathology Group, history of Italian Society of Nephrology, history of Italian Nephrology, history of Italian Nephropathology

Rapidly progressive Alport syndrome in a young woman: case report

Lorenzo D’Elia1, Antonella Barreca2, Luciano Cencioni1, Martina Ferraresi3, Antonio Marciello3, Antonietta Rizzuto3, Paolo Maurizio Perosa3, Luisa Sandri3, Paola Vittoria Santirosi4

1 UOS Nefrologia e dialisi Ospedale “Santa Maria della Stella” USL Umbria 2 Orvieto (TR), Italia
2 Anatomia Patologica, AOU Città della Salute e della Scienza, Torino, Italia
3 SS Nefrologia e dialisi ASLTO3, Ospedale “E. Agnelli” di Pinerolo (TO), Italia
4 UOS Nefrologia e Dialisi Ospedale “San Matteo degli infermi” Usl Umbria 2 Spoleto (PG), Italia

Alport syndrome is a hereditary clinical condition characterized by multisystemic changes (sensorineural and ocular deafness) associated with hematuria and proteinuria. Due to its genetic variability and multiple symptoms, it is often diagnosed by chance and too late.

The present work focuses on this pathology through a clinical case report. It also mentions the new therapeutic possibilities relating to this disease.

Keywords: Alport syndrome, kidney damage, clinical case, novel therapies

Acute severe respiratory distress in chronic haemodialytic patients affected by SARS-CoV-2 pneumonia: prevalence and associated factors. A single-centre experience from Cardarelli Hospital in Naples (Italy)

Valerio Bertino1, Olga Credendino1, Livia Sorrentino1, Pietro Alinei1, Deborah Avino1, Marianna Bencivenga1, Claudia Coppola1, Marco Del Prete1, Tito Di Muro1, Ciriana Evangelista1, Paolo Giannattasio1, MariaRosaria Iannuzzi1, Giacomo Lus1, Raffaele Meo1, Davide Stellato1, Francesca Iacobellis2, Luigia Romano2, Valentina De Angelis3, Margherita Perrotta4, Silvio Borrelli4

1 Unità di Nefrologia dell’Azienda Ospedaliera di Rilievo Nazionale “Antonio Cardarelli”, Napoli, Italia
2 Dipartimento di Radiologia Generale e di Urgenza dell’Azienda Ospedaliera di Rilievo Nazionale “Antonio Cardarelli”, Napoli, Italia
3 Servizio di Radiologia “N.S. di Lourdes” Massa di Somma (Napoli), Italia
4 Unità di Nefrologia dell’Università degli studi della Campania “Luigi Vanvitelli”, Napoli, Italia

Background: SARS‑CoV‑2-induced severe acute respiratory syndrome is associated with high mortality in the general population; however, the data on chronic haemodialysis (HD) patients are currently scarce.
Methods: We performed a retrospective analysis to evaluate the onset of acute respiratory distress syndrome (ARDS) in patients with SARS‑CoV‑2-induced interstitial pneumonia diagnosed by PCR test and detected by high resolution computed tomography (HRCT). For each patient, we calculated a CT score between 0 and 24, based on the severity of pneumonia. The primary outcome was the onset of ARDS, detected by P/F ratio >200. We included 57/90 HD patients (age: 66.5 ±13.4 years, 61.4 % males, 42.1% diabetics, 52.6% CV disease) treated at the Cardarelli Hospital in Naples (Italy) from 1st September 2020 to 31st March 2021. All patients were treated with intermittent HD.
Results: Patients who experienced ARDS had a more severe pneumonia (CT score: 15 [C.I.95%:10-21] in ARDS patients vs 7 [C.I.95%: 1-16] in no ARDS; P=0.015). Logistic regression showed that the CT score was the main factor associated with the onset of ARDS (1.12; 95% c.i.: 1.00-1.25), independently from age, gender, diabetes, chronic obstructive pulmonary disease, and prior CV disease. Thirty-day mortality was much greater in ARDS patients (83,3%) than in no-ARDS (19.3%).
Conclusions: This retrospective analysis highlights that HD patients affected by SARS-CoV-2 pneumonia show an increased risk of developing ARDS, dependent on the severity of CT at presentation. This underlines once again the need for prevention strategies, in primis the vaccination campaign, for these frail patients.

Keywords: SARS‑CoV‑2, acute respiratory distress syndrome, chronic haemodialysis, retrospective analysis, prevalence, associated factors

Too bad to be true: pseudo-AKI due to traumatic bladder rupture

Marco Ruggeri1, Costanza Martino2, Antonio Giudicissi1, Sara Signorotti1, Giovanni Mosconi1

1 Nephrology and Dialysis Unit – Ospedale “M. Bufalini”, Cesena, Italy
2 Intensive Care Unit – Ospedale “M. Bufalini”, Cesena, Italia

Acute Kidney Injury (AKI) is described as a rapid decline in Glomerular Filtration Rate (GFR), reflected by an increase in serum creatinine (SCr) and/or contraction of diuresis. The traditional paradigm considers pre-renal, renal and post-renal causes of AKI. However, there are some settings in which an elevated SCr does not reflect a real decline in GFR. Here we describe the case of a pseudo-AKI, consequence of a massive intraperitoneal urinary leakage due to a traumatic bladder rupture. Besides the pathophysiological considerations, we want to raise awareness about this condition, especially in relation to patients presenting with oliguria, hematuria, apparent AKI, abdominal pain and ascites, particularly after trauma; we do this not only to prevent late diagnosis complications, but also to avoid costly and risky overtreatment.

Keywords: pseudo-AKI, creatinine, urinary ascites, bladder rupture, trauma

Physical exercise in chronic kidney disease: an empty narrative or an effective intervention?

Yuri Battaglia1, Nicola Lamberti2, Giovanni Piva3, Fabio Manfredini2,4, Alda Storari1

1 Unità Operativa di Nefrologia e Dialisi, Azienda Ospedaliero-Universitaria di Ferrara, Via Aldo Moro 8, 44124 Ferrara, Italia
2 Dipartimento di Neuroscienze e Riabilitazione, Università degli studi di Ferrara, Via Luigi Borsari 46, 44121 Ferrara, Italia
3 PhD program in Environmental Sustainability and Wellbeing, Università degli studi di Ferrara, Via Paradiso 12, 44121 Ferrara, Italia
4 Unità Operativa di Medicina Riabilitativa, Azienda Ospedaliero-Universitaria di Ferrara, Via Aldo Moro 8, 44124 Ferrara, Italia

Chronic kidney disease (CKD) is growing worldwide, with increasing numbers of patients facing end-stage renal disease, high cardiovascular risk, disability and mortality. Early recognition of CKD and improvements in lifestyle are crucial for maintaining or recovering both physical function and quality of life.

It is well known that reducing sedentariness, increasing physical activity and initiating exercise programs counteract cardiovascular risk and frailty, limit deconditioning and sarcopenia, and improve mobility, without side-effects. However, these interventions, often requested by CKD patients themselves, are scarcely available. Indeed, it is necessary to identify and train specialists on exercise in CKD and to sensitize doctors and health personnel, so that they can direct patients towards an active lifestyle. On the other hand, effective and sustainable interventions, capable of overcoming patients’ barriers to exercise, remain unexplored.

Scientific societies, international research teams and administrators need to work together to avoid that exercise in nephrology remains an empty narrative, a niche interest without any translations into clinical practice, with no benefit to the physical and mental health of CKD patients.

Keywords: chronic kidney disease; physical activity; exercise; quality of life; sarcopenia; disability; physical function; barriers.

Psychological evaluation of patient on chronic dialysis treatment: comparison between home and hospital replacement techniques

Francesca Manari1, Lorenzo Di Liberato2, Mario Bonomini1

1 Dipartimento di Medicina e Scienze dell’Invecchiamento, Università degli Studi G. D’Annunzio di Chieti-Pescara, UOC Clinica Nefrologica, P.O. SS. Annunziata, Chieti, Italia
2 UOSD Dialisi, P.O. SS. Annunziata, Chieti, Italia

The psychologist’s work at the Nephrology and Dialysis Unit of SS. Annunziata Hospital in Chieti begins at the early stages of chronic kidney disease and continues in pre-dialysis and after renal replacement therapy begins. Psychological intervention aims to provide support to patients and caregivers facing a chronic organ disease, as well as to the health personnel constantly exposed to chronic patients.

The perceptual and emotional experience of dialysis changes according to the different modalities of renal replacement therapy: hospital or home hemodialysis, peritoneal dialysis. These different emotional and perceptive experiences seem to emerge while the patient prepares for dialysis and influence the process of accepting and adapting to the disease and its therapy.

Keywords: psychology, nephrology, dialysis, psychological intervention, pre-dialysis

Immunosuppressive therapy reduction and early post-infection graft function in kidney transplant recipients with COVID-19

Gaetano Alfano1,2*, Francesca Damiano1*, Francesco Fontana1, Camilla Ferri3, Andrea Melluso3, Martina Montani3, Niccolò Morisi3, Lorenzo Tei3, Jessica Plessi3, Silvia Giovanella2,3, Giulia Ligabue3, Giacomo Mori2, Giovanni Guaraldi4, Riccardo Magistroni1,3, Gianni Cappelli1,3, Gabriele Donati1,3

1 Nephrology, Dialysis and Transplant Unit, University Hospital of Modena, Modena, Italy
2 Clinical and Experimental Medicine Ph.D. Program, University of Modena and Reggio Emilia, via del Pozzo 71, 41124 Modena, Italy
3 Surgical, Medical and Dental Department of Morphological Sciences, Section of Nephrology, University of Modena and Reggio Emilia, via del Pozzo 71, 41124 Modena, Italy
4 Clinic of Infectious Diseases, University Hospital of Modena, Modena, Italy
* both authors contributed equally as first author

Background: Kidney transplant (KT) recipients with COVID-19 are at high risk of poor outcomes due to the high burden of comorbidities and immunosuppression. The effects of immunosuppressive therapy (IST) reduction are unclear in patients with COVID-19.
Methods: A retrospective study on 45 KT recipients followed at the University Hospital of Modena (Italy) who tested positive for COVID-19 by RT-PCR analysis.
Results: The median age was 56.1 years (interquartile range,[IQR] 47.3-61.1), with a predominance of males (64.4%). Kidney transplantation vintage was 10.1 (2.7-16) years, and 55.6 % of patients were on triple IST before COVID-19. Early immunosuppression minimization occurred in 27 (60%) patients (reduced-dose IST group) and included antimetabolite (88.8%) and calcineurin inhibitor withdrawal (22.2%). After SARS-CoV-2 infection, 88.9% of patients became symptomatic and 42.2% required hospitalization. One patient experienced irreversible graft failure. There were no differences in serum creatinine level and proteinuria in non-hospitalized patients before and post-COVID-19, whereas hospitalized patients experienced better kidney function after hospital discharge (P=0.019). Overall mortality was 17.8%. without differences between full- and reduced-dose IST. Risk factors for death were age (odds ratio [OR]: 1.19; 95%CI: 1.01-1.39), and duration of kidney transplant (OR: 1.17; 95%CI: 1.01-1.35). One KT recipient developed IgA glomerulonephritis and two ones experienced symptomatic COVID-19 after primary infection and SARS-CoV-2 mRNA vaccine, respectively.
Conclusions: Despite the reduction of immunosuppression, COVID-19 affected the survival of KT recipients. Age of patients and time elapsed from kidney transplantation were independent predictors of death . Early kidney function was favorable in most survivors after COVID-19.

Keywords: COVID-19, kidney transplant, immunosuppressive therapy, graft function, proteinuria, mortality, transplant, SARS-COV-2, reinfection

GLP-1 receptor agonists in the treatment of diabetes mellitus type 2: cardioprotection, and more!

Antonio Granata1, Rosario Maccarrone2, Sandra La Rosa3, Giulio Distefano4, Massimiliano Anzaldi5, Antonio Di Mauro6, Giuseppe Leonardi7, Francesco Pesce8, Francesco Amico9, Loreto Gesualdo8

1 U.O.C. Nefrologia e Dialisi, A.O. per l’emergenza “Cannizzaro”, Catania (CT), Italia
2 U.O.C. Nefrologia e Dialisi, P.O. “San Giovanni di Dio”, Agrigento (AG), Italia
3 U.O. Nefrologia e Dialisi, P.O. “Giovanni Paolo II”, Sciacca (AG), Italia
4 Radiology Unit 1, Department of Medical Surgical Sciences and Advanced Technologies “GF Ingrassia”, University Hospital “Policlinico-Vittorio Emanuele”, University of Catania, 95123 Catania, Italy
5 U.O.C. di Malattie Endocrine, del Ricambio e della Nutrizione, A.O. per l’emergenza “Cannizzaro”, Catania (CT), Italia
6 U.O. PS e OBI, A.O. per l’emergenza “Cannizzaro”, Catania (CT), Italia
7 U.O.C. Cardiologia, Azienda Ospedaliera Universitaria Policlinico “G. Rodolico – San Marco”, P.O. “San Marco”, Catania, Italia
8 Dip. di Nefrologia, Dialisi e Trapianto, AOU “A. Moro” Università di Bari, Bari, Italia
9 U.O.C. Cardiologia, A.O. per l’emergenza “Cannizzaro”, Catania (CT), Italia

Optimal glycemic control in diabetic patients remains a difficult goal to achieve. Hypoglycemia, nausea and weight gain can compromise the patients’ adherence to antidiabetic therapy over time. GLP-1 receptor agonists have been shown to improve glycemic control and reduce the incidence of side effects both when used in monotherapy and in combination with other hypoglycemic drugs. The growing interest of nephrologists in GLP-1 receptor agonists derives from numerous studies showing that not only they positively affect traditional cardiovascular risk factors, but also exert a protective effect on renal function regardless of their hypoglycemic effects, thus delaying the development and progression of diabetic nephropathy. The aim of this paper is to review the latest evidence on pharmacokinetics and pharmacodynamics and the direct and indirect mechanisms through which GLP-1 receptor agonists confer nephroprotection, improving the renal outcomes of diabetic patients.

Keywords: diabetes mellitus type 2, incretins, GLP-1, kidney protection

Nephrology and nephrologists in Italy between the two World Wars

Attilio Losito

Già direttore della Struttura complessa di Nefrologia Dialisi e Trapianto dell’Ospedale Santa Maria della Misericordia di Perugia.

The First World War was a turning point for medicine worldwide and the following 20 years brought many important innovations. Kidney studies in Italy were part of this general trend. In this contribution, all the papers relating to kidney physiology, pathology and therapeutics produced by Italian scientists in the years between the two World Wars are retrieved and examined. The authors who produced strictly nephrological articles are also singled out and their activity described. This research retrieved 638 articles dealing with kidneys and published by Italian scientists over the period described. The topics covered were up-to-date, and the level was consistent with that of foreign contemporaries. Among the authors, a group of young scientists particularly dedicated to the study of the kidney emerges. Most of them would subsequently be among the founders of the Italian Society of Nephrology and leaders of Italian nephrology.

Keywords: history, nephrology, Italy, scientists, World Wars

Is peritoneal dialysis the first-choice renal replacement therapy for patients waiting for a kidney transplant?

Luca Nardelli1,2, Antonio Scalamogna1, Maurizio Gallieni2,3, Evaldo Favi4, Piergiorgio Messa1,2, Giuseppe Castellano 1,2

1 UOC di Nefrologia, Dialisi e Trapianti di Rene, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano, Italia
2 Scuola di Specializzazione in Nefrologia, Università degli Studi di Milano, Milano, Italia
3 UOC di Nefrologia e Dialisi, ASST Fatebenefratelli Sacco, Milano, Italia
4 Chirurgia dei Trapianti di Rene, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano, Italia

Kidney transplantation is the gold-standard treatment of end-stage renal disease. Receiving a pre-emptive transplant ensures the best survival for both the recipient and the allograft. However, due to an overwhelming discrepancy between available donors and patients on the transplant waiting list, the vast majority of transplant candidates require prolonged periods of dialytic therapy before transplant.

Peritoneal dialysis and hemodialysis have been traditionally considered as competitive renal replacement therapies. This dualistic vision has been recently questioned by emerging evidence suggesting that an individualized and flexible approach may be more appropriate. Tailored and cleverly planned shifts between different modalities, according to the patient’s needs, represents the best option.

Remarkably, recent data seem to support the use of peritoneal dialysis over hemodialysis in patients waiting for a kidney transplant. In this specific setting, the perceived advantages of PD are better overall recipient survival and quality of life, longer preservation of residual renal function, lower incidence of delayed graft function and reduced cost.

Keywords: peritoneal dialysis, kidney transplant, hemodialysis, renal replacement therapy, waiting-list, residual renal function, quality of life, delayed graft function

AKI in hospitalized patients with COVID-19: a single-center experience

Gaetano Alfano1,2, Silvia Giovanella2,3, Francesco Fontana2, Jovana Milic3,4, Giulia Ligabue3, Niccolò Morisi1, Francesco Giaroni3, Giacomo Mori2, Riccardo Magistroni1,3, Erica Franceschini4, Andrea Bedini4, Giacomo Cuomo4, Margherita DiGaetano4, Marianna Meschiari4, Cristina Mussini4, Gianni Cappelli1,3, Giovanni Guaraldi4

1 Nephrology, Dialysis and Transplant Unit, University Hospital of Modena, Modena, Italy
2 Clinical and Experimental Medicine Ph.D. Program, University of Modena and Reggio Emilia, Modena, Italy
3 Surgical, Medical and Dental Department of Morphological Sciences, Section of Nephrology, University of Modena and Reggio Emilia, Modena, Italy
4 Clinic of Infectious Diseases, University Hospital of Modena, Modena, Italy

Atheroembolic renal disease: risk factors, diagnostics, histology, and therapeutic approaches

Concetto Sessa1, Walter Morale1, Luca Zanoli2, Luigi Biancone3, Antonella Barreca4, Giuseppe Seminara5, Francesco Londrino6, Antonio Granata5

1 U.O.C Nefrologia e Dialisi, P.O. “Maggiore” di Modica. Azienda Sanitaria Provinciale di Ragusa, Italia
2 Nefrologia, Dipartimento di Medicina Clinica e Sperimentale, Università di Catania, Catania, Italia
3 Nefrologia Dialisi e Trapianto, AOU città della salute e della Scienza, Torino, Italia
4 Anatomia Patologica, AOU città della salute e della Scienza, Torino, Italia
5 U.O.C di Nefrologia e Dialisi, A.O. per l’Emergenza “Cannizzaro”, Catania, Italia
6 U.O.C. Nefrologia e Dialisi, ASL Roma 2, A.O. “Sant’Eugenio”, Roma, Italia

The increase in patients’ average age, the enhancement of anticoagulation therapy and the growth of vascular interventions represent the perfect conditions for the onset of atheroembolic renal disease. AERD is observed in patients with diffuse atherosclerosis, generally after a triggering event such as surgery on the aorta, invasive procedures (angiography, catheterization of the left ventricle, coronary angioplasty) and anticoagulant or fibrinolytic therapy. The clinical signs are heterogeneous, a consequence of the occlusion of downstream small arterial vessels by cholesterol emboli coming from atheromatous plaques of the aorta, or one of its main branches. The proximity of the kidneys to the abdominal aorta, and the high flow of blood they receive, make them a major target organ. For this reason, AERD represents a pathological condition that always needs to be taken into account in the nephropathic patient, although its systemic nature makes the diagnosis difficult.

This manuscript presents a review of the existing literature on this pathology, to provide an updated summary of the state of the art: risk factors, diagnostics, histology and therapeutic approaches.

Keywords: atherosclerosis, cholesterol crystal embolism, contrast media, acute kidney injury, chronic kidney disease

Home hemodialysis: multicenter observational study

Paolo Lentini1, Alessandro Gemelli2, Yuri Battaglia3, Antonina Ambrogio2, Raffaela Esposito2, Luca Zanoli4, Antonino Previti1, Roberto Dell’Aquila1, Fulvio Fiorini2

1 UOC Nefrologia, Ospedale “San Bassiano”, Bassano del Grappa (VI), Italia
2 UOC Nefrologia e Dialisi, Ospedale “Santa Maria della Misericordia”, Rovigo, Italia
3 Azienda Ospedaliero Universitaria, Ferrara, Italia
4 UOC Nefrologia, Università degli Studi di Catania, Catania (CT), Italia

Home dialysis is a primary objective of Italian Ministry of Health. As stated in the National Chronicity Plan and the Address Document for Chronic Renal Disease, it is mostly home hemodialysis and peritoneal dialysis to be carried out in the patient’s home. Home hemodialysis has already been used in the past and today has found new technologies and new applications. The patient’s autonomy and the need for a caregiver during the sessions are still the main limiting factors.

In this multicenter observational study, 7 patients were enrolled for 24 months. They underwent six weekly hemodialysis sessions of 180′ each; periodic medical examinations and blood tests were performed (3, 6, 12, 18 and 24 months). After 3-6 months of home hemodialysis there was already an improvement in the control of calcium-phosphorus metabolism (improvement in phosphorus values, (p <0.01), a reduction in parathyroid hormone (p <0.01)); in the number of phosphorus binders used (p <0.02); in blood pressure control (with a reduction in the number of hypotensive drugs p <0.02). Home hemodialysis, although applicable to a small percentage of patients (10-15%), has improved blood pressure control, calcium-phosphorus metabolism and anemia, reducing the need for rhEPO.

Keywords: chronic kidney disease, home dialysis, home hemodialysis

The Italian National Association of Emodialysis patients (ANED) and nephrology

Giuseppe Vanacore

Slowing progression of chronic kidney disease in polycistic kidney disease patients with tolvaptan: from guidelines to clinical practice

Anna Giuliani1,2, Davide Marturano2,3, Valentina Corradi1,2, Carlotta Caprara2, Matteo Rigato1,2, Matteo Marcello2,4, Fiorella Gastaldon1,2, Claudio Ronco1,2,3, Monica Zanella1,2

1 Dipartimento di Nefrologia, Dialisi e Trapianto, Ospedale San Bortolo, Vicenza, Italia
2 International Renal Research Institute of Vicenza (IRRIV), Vicenza, Italia
3 DIMED, Università di Padova, Padova, Italia
4 Libera Università Vita Salute San Raffaele, Milano, Italia

Autosomal dominant polycystic kidney disease (ADPKD) is the most common hereditary kidney disease and accounts for∼10% of patients on renal replacement therapy. In the last decade, no specific treatment was available and only preventive measures could be put in place to delay the onset of ESRD. Following the results of the TEMPO 3:4 study, tolvaptan was approved in many countries, for the purpose of slowing the progression of renal insufficiency.

In Italy tolvaptan is available since 2016 for patients with chronic kidney disease (CKD) stage 1-3, and since 2020 for patients with CKD stage 4, who fulfil the criteria of “rapid disease progression”, according to the European recommendations.

After this approval, Italian nephrology units have had to change their organization to be able to identify the patients eligible for the drug and to guarantee frequent patient monitoring.

In this paper, we present our three-year experiences with tolvaptan, focusing on its safety profile and tolerability, but also on the high burden of care that such therapy represents not only for doctors, but also for patients. Strategies to implement remote monitoring may be useful to reduce the burden of assistance on one side, and the medicalization of ADPKD patients in the early stage of the disease, on the other.

Keywords: ADPKD, tolvaptan, remote monitoring, burden of care

ADPKD and intracranial aneurysms: indications for screening, follow-up and clinical management

Laura Econimo1, Letizia Zeni1, Roberta Cortinovis1, Federico Alberici1,2, Claudia Izzi1,3, Francesco Scolari1,2

1 ASST Spedali Civili di Brescia, Unità Operativa di Nefrologia, Brescia, Italia
2 Università degli Studi di Brescia, Dipartimento di Specialità Medico-Chirurgiche, Scienze Radiologiche e Sanità Pubblica, Brescia, Italia
3 Università degli studi di Brescia, Dipartimento di Ginecologia ed Ostetricia, Brescia, Italia

Autosomal dominant polycystic kidney disease (ADPKD) is the most frequent hereditary nephropathy and is the fourth most common cause for end-stage renal disease in Europe. ADPKD is a systemic disease; besides the typical renal involvement, characterized by progressive cyst expansion leading to massive enlargement and distortion of the kidney architecture and, ultimately, to end-stage renal disease, multiple extrarenal manifestations can be observed included cysts in other organs, diverticulosis, cardiac valvulopathies, abdominal and inguinal hernias, vascular anomalies. The rupture of an intracranial aneurysm is one of the most serious complications in ADPKD patients. Aim of this review is to provide useful indications for the clinician to define the risk of intracranial aneurysms in ADPKD population, to identify screening criteria (which patients to screen, how often and with which diagnostic methods), to estimate the risk of rupture of intracranial aneurysms, which may require intervention.

Keywords: ADPKD, intracranial aneurysms, screening, risk of rupture, treatment

Immunotherapy in kidney cancer: how it has changed and what are the challenges for the nephrologist – focus on pembrolizumab

Laura Cosmai1, Marta Pirovano2, Giulia Vanessa Re Sartò2, Maurizio Alberto Gallieni1,3

1 UO Nefrologia e Dialisi, ASST Fatebenefratelli-Sacco, Milano, Italia
2 Scuola di Specializzazione in Nefrologia, Università degli Studi di Milano, Milano, Italia
3 Dipartimento di Scienze Biomediche e Cliniche L. Sacco, Università degli Studi di Milano, Milano, Italia

Kidney cancer accounts for about 3.5% of all malignant neoplasms; in 85% of cases the tumor arises from cells of the renal parenchyma, with an incidence of 70% of the clear cells subtype.

Surgery, at present, is the treatment of choice for most renal cancers; medical therapy, on the other hand, has only palliative purposes and is used only in the relapsed or metastatic patients.

The therapeutic toolbox available in the fight against renal cancer is continuously renewed due to the approval of new drugs. In particular, in the 2000s, antiangiogenic drugs were introduced and showed good efficacy in terms of increased survival in patients with advanced renal carcinoma.

Immunotherapy was a treatment strategy for renal cancer in the 1980s, when cytokines such as Interleukin-2 and Interferon were administered. The advent of antiangiogenic drugs had bound immunotherapy to a secondary role until the discovery of immune check-point inhibitors (ICIs), which have been approved in the various lines of treatment, in monotherapy or in combination with other drugs, as they have shown to increase the oncological outcome.

In this review we analyze the evolution of immunotherapy for the treatment of kidney tumor from the viewpoint of nephrologists, with a special focus on renal adverse events, pembrolizumab and its recent approval as first line therapy in association with axitinib.

Keywords: immunotherapy, kidney cancer, interstitial nephritis, acute kidney injury, molecularly targeted agents.

Alström syndrome, a rare cause of renal failure: case report and review of the literature

Guido Faggian1, Antonio Cesaro2, Roberto Faggian2, Carlo Del Piano2, Arcangelo Vitagliano2, Domenico Del Piano2, Loredana Tibullo 3 , Angela Faggian4

1 Sezione Diagnostica per Immagini e Radioterapia, Università Federico II Napoli, Italia
2 UOSD Nefrologia ed Emodialisi, P.O. Moscati, Aversa (CE), Italia
3 UOC Medicina A.O.R.N. Moscati, Avellino, Italia
4 UOC Diagnostica per immagini, A.O.R.N. Rummo, Benevento, Italia

We describe the case of a 26-year-old male patient with a previous diagnosis of Alström Syndrome who presented drowsiness, dyspnea, tremors, and a dull abdominal pain, without signs of peritoneal irritation. The patient also presented sensorineural hearing loss, decreased vision, due to chorioretinal dystrophy, difficulty walking with back-lumbar double curve scoliosis, impaired glycemic homeostasis, and a significant deterioration of renal function.

Alström syndrome is a multisystem disease characterized by rod-cone dystrophy, hearing loss, obesity, insulin resistance and hyperinsulinemia, type 2 diabetes mellitus, dilated cardiomyopathy, and progressive renal and hepatic dysfunction. Around 450 cases have been identified worldwide. Clinical signs, age of onset and severity can vary significantly between different families and within the same family.

Careful nephrological follow-up is necessary in patients with syndromic ciliopathies, since long-term kidney problems can have an impact on other diseases, eg. cardiovascular disease.

Keywords: rare diseases, ciliopathies, chronic kidney failure

Impact of the Covid-19 pandemic on kidney transplantation: focus on the Sicilian experience

Anna Clementi1, Giuseppe Coppolino2, Barbara Buscemi3,4, Bruna Piazza5, Giovanni Giorgio Battaglia1

1 U.O.C. Nefrologia e Dialisi, Ospedale Santa Marta e Santa Venera, Acireale, Italia
2 Renal Unit, Department of Health Sciences, “Magna Graecia” University, Catanzaro, Italia
3 Istituto di Ricovero e Cura a Carattere scientifico (IRCCS), Palermo, Italia
4 Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italia
5 Centro Regionale Trapianti Sicilia, Palermo, Italia

The COronaVIrus Disease 2019 (Covid-19) pandemic has rapidly changed hospital structures in our country, radically modifying clinical activity. Nephrology, and kidney transplant in particular, has been heavily influenced by it, with a reduced number of organ donations and, consequently, transplantations.

Here we report the data on kidney transplants in our region, Sicily, for the period 2019-July 2021, and we analyze the effects of the pandemic.

Keywords: Covid-19, pandemic, kidney transplantation, Sicilian experience

Which future solutions for peritoneal dialysis?

Mario Bonomini1,2, Lorenzo Di Liberato3, Carmela Rago1, Teresa Lombardi1, Vittorio Sirolli1,2, Arduino Arduini4

1 Dipartimento di Medicina e Scienze dell’Invecchiamento, Scuola di Specializzazione in Nefrologia, Università degli Studi “G. d’Annunzio”, Chieti – Pescara, Italia
2 UOC Clinica Nefrologica, Ospedale SS. Annunziata, Chieti, Italia
3 UOSD Dialisi, Ospedale SS. Annunziata, Chieti, Italia
4 Dipartimento Ricerca e Sviluppo, CoreQuest Sagl, Lugano, Svizzera

Peritoneal dialysis is an efficient renal replacement therapy for uremic patients but is currently under-prescribed. This is partly due to the unfavorable effects on peritoneal morphology and function (bioincompatibility) of current glucose-based solutions. Use of standard solutions can cause several peritoneal alterations including inflammation, mesothelial to mesenchymal transition, and neo-angiogenesis. The final step is fibrosis, which reduces the peritoneal filtration capacity and can lead to ultrafiltration failure and transfer of the patient to hemodialysis. Bioincompatibility can be local (peritoneum) but also systemic, due to the excessive absorption of glucose from the dialysate. Several strategies have been adopted to improve the biocompatibility of peritoneal dialysis solutions, based on the alleged causal factors. Some new solutions available on the market contain low glucose degradation products and neutral pH, others contain icodextrin or aminoacids. Clinical benefits have been associated with the use of these solutions, which however have some limitations and a debated biocompatibility profile. More recent strategies include the use of cytoprotective agents or osmo-metabolic agents in the dialysate. In this article, we review the different approaches currently under development to improve the biocompatibility of peritoneal dialysis solution and hence the clinical outcome and the viability of the technique.

Keywords: peritoneal dialysis, biocompatibility, peritoneum, dialysate, peritoneal dialysis solution

Hemodialysis and nursing: a pilot study on patient-perceived quality

Francesco Bazzurri1,2, Gianmarco Troiano1,3, Alessandra Cartocci4,5, Nicola Nante1,5

1 Scuola Post-Laurea Senese di Sanità Pubblica, Dipartimento di Medicina Molecolare e dello Sviluppo, Università di Siena, Siena, Italia
2 Azienda Ospedaliera Perugia, Perugia, Italia
3 ASST Melegnano e della Martesana, Vizzolo Predabissi (MI), Italia
4 Dipartimento di Biotecnologie mediche, Università di Siena, Siena, Italia
5 Dipartimento di Medicina Molecolare e dello Sviluppo, Università di Siena, Siena, Italia

Introduction: Dialysis is a form of renal replacement therapy that requires several changes in the relational, emotional, work, and family sphere. It can be a cause of stress due to various factors.

Objective: The purpose of our study has been to evaluate the perception of the nursing care received by dialyzed patients.

Method: In 2021, a cross sectional study was conducted in Perugia hospital by administering to dialyzed patients a questionnaire built on the Newcastle satisfaction with nursing scale.

Results: 30 patients participated in the study: the mean age was 68.9 ±15.1, 66.7% were male, 50% had a high school diploma, 86.7% were retired, and 50% were dialyzed for less than 5 years. Negative perceptions of the assistance received were mainly reported by women, younger patients, and patients who had been in therapy for only a few years.

Discussion: Our study highlights several aspects that are fundamental to improving the quality of nursing care. There also needs to be a greater attention to certain types of patients, to improve their experience and consequently their quality of life.

Keywords: nursing, quality, dialysis, questionnaire, Newcastle satisfaction with nursing scale

Cephalic arch stenosis. Case report and literary review

Anna Mudoni1, Fernando Musio1, Antonella Accogli1, Maria Dolores Zacheo1, Maria Domenica Burzo1, Davide Gianfreda1, Carlo Maisto2, Carlo Patrizio Dionisi3, Francesco Caccetta1

1 U.O. Nefrologia e Dialisi Ospedale Cardinale Panico, Tricase (Le), Italia
2 Dipartimento di Nefrologia, IRCCS Ospedale Policlinico San Martino, Genova, Italia
3 U. O. Chirurgia Vascolare Ospedale Cardinale Panico, Tricase (Le) , Italia

Dysfunctional AVF represents one of the leading causes of morbidity in the hemodialysis population, with venous stenosis-related dysfunction being the most common underlying problem.

Cephalic arch is a well-known site for the development of stenosis, especially in patients with brachiocephalic fistulas. The pathophysiology of cephalic arch stenosis (CAS) is still being investigated and various contributing factors have been suggested.

The treatment options for CAS are many and include angioplasty, endovascular stent insertion, access flow reduction and surgical interventions, but none of the current modalities are ideal. Therefore, the treatment of CAS is difficult, as the stenosis in this area tends to recur leading to the need for repeat angioplasty, stents or surgical revision.

A 57-year-old woman undergoing hemodialysis (HD) through a right brachiocephalic arteriovenous fistula was found to have high venous pressure during HD and prolonged bleeding after HD. Clinical examination revealed a hyperpulsatile fistula suggestive of outflow obstruction. Doppler ultrasound examination showed cephalic vein thrombosis, severe outflow stenosis and juxta-anastomotic area. A 10 x 40 mm stent (Cordis Smart stent) was positioned appropriately in the cephalic arch and deployed, the stenotic lesion in juxta-anastomotic area was dilated with angioplasty balloon with improvement in flow.

After 14 months, the fistula is still working perfectly with adequate flow.

Keywords: cephalic arch, stenosis, brachiocephalic fistula, hemodialysis

The treatment of lupus nephritis, between consolidated strategies and new therapeutic options: a narrative review

Francesco Fontana1, Gaetano Alfano1,2, Gianni Cappelli1,2

1 S.C. di Nefrologia e Dialisi, Azienda Ospedaliero Universitaria di Modena, Modena, Italia
2 Dipartimento medico, chirurgico e odontoiatrico di Scienze Morfologiche con Interesse Trapiantologico, Oncologico e di Medicina Rigenerativa, Università degli Studi di Modena e Reggio Emilia, Modena, Italia

Over a half of patients with Systemic Lupus Erythematosus will develop lupus nephritis (LN). The diagnosis of LN, suspected based on clinical data (proteinuria, active urinary sediment, renal dysfunction), is confirmed with renal biopsy. The immunosuppressive treatment of proliferative classes of LN is based on an induction phase, where high-dose steroids are used in conjunction with mycophenolate mofetil (MMF) or cyclophosphamide, and a subsequent maintenance phase, that combines low-dose steroids with MMF or azathioprine. Different classes of drugs (calcineurin inhibitors, anti-CD20) can be used as an alternative, or in resistant forms of LN, although their role is less well-established. Recently published (or nearing completion) studies have opened up the possibility of using new drugs in LN. In particular, depletion (Obinutuzumab, anti-CD20 monoclonal antibody) or neutralization (Belimumab, anti-“B-cell activating factor” monoclonal antibody) of B lymphocytes, and the use of a calcineurin inhibitor with a low profile of renal and systemic toxicity (Voclosporin) demonstrated an improvement in renal response in addition to standard therapy.

Keywords: lupus nephritis, immunosuppressive treatment, systemic lupus erythematosus

Effectiveness of physical exercise on cardiovascular endurance and functional capacity in hemodialysis patients: a systematic review and meta-analysis

Francesco Burrai1, Elena Brioni2, Maddalena Iodice3, Luigi Apuzzo4

1 SC Formazione, Ricerca e Cambiamento Organizzativo, ATS Sardegna, Italia
2 U.O. Nefrologia e Dialisi, IRCCS Ospedale San Raffaele, Milano, Italia
3 Ospedale San Paolo, ASL Roma 4, Civitavecchia, Italia
4 Hospice Oncologico Carlo Chenis, ASL Roma 4, Civitavecchia, Italia

Background. Physical exercise is a health intervention in the treatment of numerous chronic diseases. In patients on hemodialysis, physical exercise has been introduced during hemodialysis for different outcomes. Several meta-analyses show uncertainty about the effects.
Objective. Our systematic review and meta-analysis aim at summarizing and evaluating the evidence of the effects of physical exercise on cardiovascular endurance and functional capacity of hemodialysis patients.
Results. Five studies were included in the review (462 patients). Physical exercise brought an improvement in cardiovascular endurance and functional capacity (MD, 95%CI:62.24 [18.71, 105.77], p=0.005), compared to the control group. Most trials were at high risk of bias due to lack of blinding between the patients and the personnel, and between the patients and the outcome assessor.
Conclusions. Physical exercise may have beneficial effect on cardiovascular endurance and functional capacity in hemodialysis patients. The quality of evidence is low and the strength of recommendations is weak for cardiovascular endurance. Future studies should consider a power analysis for an adequate sample size and minimize the risk of sample bias. Further research should provide the additional results required for an acceptable estimate of the effects of physical exercises in hemodialysis patients.

Keywords: physical exercise, hemodialysis, cardiovascular endurance, functional capacity, systematic review, meta-analysis

The link between homocysteine, folic acid and vitamin B12 in chronic kidney disease

Andrea Angelini1, Maria Laura Cappuccilli1, Giacomo Magnoni1, Anna Laura Croci Chiocchini1, Valeria Aiello1, Angelo Napoletano1, Francesca Iacovella1, Antonella Troiano1, Raul Mancini1, Irene Capelli1, Giuseppe Cianciolo1

1 Unità Operativa di Nefrologia, Dialisi e Trapianto, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum Università di Bologna, Italia

Patients with chronic kidney disease or end-stage renal disease experience tremendous cardiovascular risk. Cardiovascular events are the leading causes of death in these patient populations, thus the interest in non-traditional risk factors such as hyperhomocysteinemia, folic acid and vitamin B12 metabolism is growing.  Hyperhomocysteinemia is commonly found in CKD patients because of impaired renal metabolism and reduced renal excretion. Folic acid, the synthetic form of vitamin B9, is critical in the conversion of homocysteine to methionine like vitamin B12. Folic acid has also been shown to improve endothelial function without lowering homocysteine, suggesting an alternative explanation for the effect of folic acid on endothelial function. Whether hyperhomocysteinemia represents a reliable marker of cardiovascular risk and cardiovascular mortality or a therapeutic target in this population remains unclear. However, it is reasonable to consider folic acid with or without methylcobalamin supplementation as appropriate adjunctive therapy in patients with CKD. The purpose of this review is to summarize the characteristics of homocysteine, folic acid, and vitamin B12 metabolism, the mechanism of vascular damage, and the outcome of vitamin supplementation on hyperhomocysteinemia in patients with CKD, ESRD, dialysis treatment, and in kidney transplant recipients.

Keywords: hyperhomocysteinemia, folic acid, vitamin B12, chronic kidney disease, end-stage renal disease, cardiovascular disease

Social media for continuing education in nephrology. Myth or reality?

Vincenzo Montinaro1, Maurizio Gallieni2,3,4, Adriano Montinaro1, Francesca Rella4, Elena Coppari5, Maria Rinaldi Miliani6, Giuseppe Quintaliani7, Eugenio Santoro8

1 U.O. Nefrologia Universitaria, Azienda Ospedaliero-Universitaria Policlinico di Bari, Bari, Italia
2 Dipartimento di Scienze Biomediche e Cliniche ‘L. Sacco’, Università degli Studi di Milano, Milano, Italia
3 UO Nefrologia e Dialisi, ASST Fatebenefratelli-Sacco, Milano, Italia
4 Scuola di Specializzazione in Nefrologia, Università degli Studi di Milano, Milano, Italia
5 Esperta di Marketing, Comunicazione e Fundraising
6 Freelance Social Media Manager
7 Segretario Fondazione Italiana del Rene, Master in comunicazione scientifica
8 Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italia

About 60% of the world population has access to the Internet in 2021, making it the main tool in fostering communication between people. Lately, digital information and communication have especially taken place on platforms known as Social Media (SoMe) or Social Networks. In the last decade the usefulness of these tools in carrying information aimed at updating professionals in Medicine and Nephrology has become evident. There are several examples of SoMe utilization in Nephrology, as demonstrated by the existing accounts or Pages operated by the main international nephrological Scientific Societies, or the most renowned specialized medical journals. Twitter, Facebook and YouTube are the most versatile SoMe for these objectives; however, other platforms such as Tik Tok, Linkedin, Instagram, and WhatsApp may serve the same purpose. This digital revolution in disseminating information has proved very useful during the recent COVID-19 pandemic, even though some inappropriate uses have emerged, such as the diffusion of fake news, which has favored the emergence of “adverse effects” or a surge of antiscientific positions.

In this review, we examine how physicians and nephrologists can take advantage of digital information for their continuing education. We quote the main resources in the international scenario and illustrate some specific national examples, such as the Journal Club of the Nephrology post-graduate program of the University of Milan and the Facebook group “Medical and Nephrology Community”.

Keywords: social media, social network, internet, continuing education, digital dissemination of scientific information

COVID-19 in patients starting hemodialysis in the Alentejo region: case reports

Iolanda Oliveira1, Rui Silva2, Ricardo Santos3, Carlos Pires4

1 Hospital do Espírito Santo de Évora, Portugal. ORCID
2 Hospital do Espírito Santo de Évora, Portugal. ORCID
3 Hospital do Espírito Santo de Évora, Portugal. ORCID
4 Hospital do Espírito Santo de Évora, Portugal. ORCID

COVID-19 has a wide spectrum of clinical presentation, ranging from asymptomatic or mild symptoms to severe multiorgan failure. In Portugal, the first cases affecting patients on a chronic hemodialysis program arose in the city of Oporto.

The authors report here two cases of COVID-19 infection in patients incident in renal replacement therapy in the Alentejo region and hypothesise that the high serum concentration of urea may decapitate the appearance of typical symptoms of the SARS-CoV-2 infection. The fact that the hemodialysis population can present active infection without fever may lead to a delayed diagnosis and consequently an increased risk of mortality.

Keywords: COVID-19, hemodialysis, urea, case reports, Alentejo region

Anti-SARS-CoV-2 vaccination in patients with immune-mediated kidney diseases. Recommendations of the Italian Society on Nephrology’s Working Group on Renal Immunopathology (Vaccine Task Force)

Fausta Catapano1, Simonetta Cimino2, Domenico Santoro3, Renato Alberto Sinico4, Dario Roccatello5, Loreto Gesualdo6, Federico Alberici7. Task Force Vaccini del Gruppo di Progetto di Immunopatologia Renale

1 IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italia
2 AUSL Modena- Ospedale di Carpi, Carpi, Italia
3 Università di Messina – Policlinico di Messina, Messina, Italia
4 Università di Milano Bicocca – ASST Monza, Monza, Italia
5 Università di Torino – Ospedale San Giovanni Bosco, Torino, Italia
6 Università di Bari – Policlinico di Bari, Bari, Italia
7 Università di Brescia – ASST Spedali Civili di Brescia, Italia

2021: towards a new phase for Nephrology

Paola Romagnani

Book review: ‘Il Connettivista’ di Claudio Ronco (Angelo Colla Editore, 2019)

A cura di Gaetano La Manna

Acute kidney injury and single-dose administration of aminoglycoside in the Emergency Department: a comparison through propensity score matching

Sergio Venturini1, Francesco Cugini2, Daniele Orso3,4, Massimo Crapis1, Sara Fossati1, Astrid Callegari1, Elisa Pontoni5, Laura De Santi5, Domenico Arcidiacono5, Manuela Lugano3,4, Luigi Vetrugno3,4, Tiziana Bove3,4

1 Department of Infectious Diseases, ASFO Hospital of Pordenone, Pordenone, Italy
2 Department of Emergency Medicine, ASUFC Hospital of San Daniele, San Daniele (UD), Italy
3 Department of Medicine (DAME), University of Udine, Udine, Italy
4 Department of Anesthesia and Intensive Care Medicine, ASUFC Hospital of Udine, Udine, Italy
5 Department of Emergency Medicine, ASFO Hospital of Pordenone, Pordenone, Italy

Purpose: According to the Surviving Sepsis Campaign, aminoglycosides (AG) can be administered together with a β-lactam in patients with septic shock. Some authors propose administering a single dose of an AG combined with a β-lactam antibiotic in septic patients to extend the spectrum of antibiotic therapy. The aim of this study has been to investigate whether a single shot of AG when septic patients present at the Emergency Department (ED) is associated with acute kidney injury (AKI).

Methods: We retrospectively enrolled patients based on a 3-year internal registry of septic patients visited in the Emergency Department (ED) of Pordenone Hospital. We compared the patients treated with a single dose of gentamicin (in addition to the β-lactam) and those who had not been treated to verify AKI incidence.

Results: 355 patients were enrolled. The median age was 71 years (IQR 60-78). Less than 1% of the patients had a chronic renal disease. The most frequent infection source was the urinary tract (31%), followed by intra-abdominal and lower respiratory tract infections (15% for both). 131 patients received gentamicin. Unmatched data showed a significant difference between the two groups in AKI (79/131, 60.3% versus 102/224, 45.5%; p=0.010) and in infectious disease specialist’s consultation (77/131, 59% versus 93/224, 41.5%; p=0.002). However, after propensity score matching, no significant difference was found.

Conclusion: Our experience shows that a single-shot administration of gentamicin upon admission to the ED does not determine an increased incidence of AKI in septic patients.

Keywords: aminoglycosides, acute kidney injury, gentamicin, safety, sepsis

Nutritional therapy in chronic proteinuric nephropathy

Paolo Ria1, Marcello Napoli1, Anna Zito1, Silvia Barbarini1, Maria Luisa Lefons1, Antonio De Pascalis1

1 UOC Nefrologia e Dialisi, Ospedale Vito Fazzi, Lecce, Italy

Proteinuria is a well-known marker of renal damage and, at the same time, an important factor in the progression of chronic kidney disease itself. The scientific community has always sought to investigate and provide answers on how nutritional therapy can influence and modify proteinuria and therefore limit its impact on progression to end-stage renal disease. However, despite the importance of the topic, the studies rarely take the form of randomized and controlled trials; in any case, they are often limited to protein intake only, conducted on very heterogeneous populations and, finally, they rarely indicate the precise values of proteinuria. The aim of this work is to explore the different nutritional approaches and their implications in the pathological conditions associated with proteinuria.

Keywords: proteinuria, end stage renal disease, diet, low protein, chronic renal failure

Interview to Attilio Losito: my half-century life as a nephrologist in Perugia

Attilio Losito1, Giovanni B. Fogazzi2

1 Già direttore della Struttura Complessa di Nefrologia, Dialisi e Trapianto dell’Ospedale Santa Maria Della Misericordia di Perugia
2 U.O.C. di Nefrologia, Dialisi e Trapianto di Rene, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano

In this interview Attilio Losito tells us about his first nephrological experiences gained in the late sixties of the past century in the Institute of Patologia Medica in Perugia directed by Giovanni Gigli, and his subsequent experiences, which also included a period at Guy’s Hospital in London. The interview also describes the important contributions that the school of Perugia produced in the field of nephrology and its main protagonists. This nephrological life story highlights: the role that internal medicine, with its multidisciplinary approach, had in the development of nephrology in its beginnings; the importance of cooperation with foreign institutions; the contributions that specialised research laboratories attached to renal units have given to the improvement of the diagnosis and to the understanding of the pathogenesis of nephropathies.

Keywords: history of nephrology, history of Italian nephrology, history of Italian internal medicine

Nephrology: where we stand and where we should go

Giuseppe Quintaliani1, Maurizio Nordio2, Gianpaolo Reboldi3, Filippo Aucella4, Giuliano Brunori5

1 Segretario Fondazione Italiana del Rene, Roma, Italy
2 Unità di Nefrologia, Ospedale di Treviso, Treviso, Italy
3 Commissione Epidemiologia SIN; Dipartimento di Medicina, Università di Perugia, Perugia, Italy
4 IRCCS “Casa Sollievo Della Sofferenza”, Istituto scientifico per la ricerca e cura, San Giovanni Rotondo (FG), Italy
5 SC di Nefrologia e Dialisi, Ospedale di Trento, Trento, Italy

In the last year, the Italian National Health Service as a whole and the Nephrology community have been severely challenged by the pandemic. It has been a dramatic stress test for the entire healthcare system, not only in Italy but worldwide. The general organization of our Nephrology units and our models of care were put under extreme pressure, and we had to quickly adopt unprecedented clinical practice recommendations and organizational models to overcome the impasse caused by the pandemic. The time has come to evaluate these new experiences, ask how we could have been better prepared and look for change. In this editorial, we outline a few proposals and suggestions for the future, weighing the information gathered in the 2018 Nephrology Census against the new organizational requirements imposed by the COVID-19 pandemic.

Keywords: Nephrology Census, National Health Service, new organizational requirements, COVID-19 pandemic

Panoramica del danno renale acuto nella COVID-19

Claudia Altobelli1, Emanuela de Pascale1, Gabriella Di Natale1, Gaia Marinelli1, Maristella Minco1, Francesco Mirenghi1, Roberta Russo1, Corrado Pluvio1

1 A.O.R.N. Ospedali dei Colli – Monaldi, Cotugno, CTO – P.O. Domenico Cotugno, U.O.C. Nefrologia e Dialisi, Napoli, Italia

L’infezione da SARS-CoV-2 è responsabile della malattia sistemica da coronavirus 2019 (COVID-19). Nel complesso quadro della COVID-19 è possibile riscontrare anche un danno renale dalla patogenesi non univoca e multifattoriale che clinicamente si può presentare con alterazioni urinarie come proteinuria ed ematuria, accompagnate o meno ad una riduzione della funzionalità renale. Il danno renale acuto (AKI) non è infrequente, soprattutto nei pazienti critici ospedalizzati in terapia intensiva. L’AKI è un fattore prognostico negativo ed è gravato da una elevata mortalità intraospedaliera. La diagnosi tempestiva di danno renale acuto e la valutazione dei fattori di rischio eventualmente presenti, permetterà al nefrologo di attuare strategie terapeutiche adeguate del tipo farmacologico o di supporto extracorporeo. La mortalità nei pazienti con AKI in corso della COVID-19 rimane ancora elevata. La COVID-19 AKI è una area di studio tuttora in evoluzione.

Parole chiave: COVID-19, AKI, Cotugno, CRRT, terapie di purificazione extracorporee

Frailty score before admission as risk factor for mortality of renal patients during the first wave of the COVID pandemic in London

Dr. Aegida Neradova1,2, Dr. Gisele Vajgel3,4,5, Heidy Hendra1,3, Dr. Marilina Antonelou1,3, Dr. Ioannis D. Kostakis6, David Wright1, Dr. Philip Masson1, Sarah E. Milne1, Dr. Gareth Jones1, Prof. Dr. Alan Salama1,3, Prof. Dr. Andrew Davenport1, Prof. Dr. Áine Burns1

1 Department of Nephrology & Transplantation, Royal Free London NHS Foundation Trust, UK
2 Dianet Amsterdam, Amsterdam UMC Department of Nephrology, Amsterdam, The Netherlands
3 Department of Renal Medicine, Royal Free Campus, UCL, Rowland Hill Street, London, UK
4 Nephrology Department, Hospital das Clinicas – Federal University of Pernambuco (HC-UFPE), Brazil
5 Laboratório Imunopatologia Keizo Azami – Federal University of Pernambuco (LIKA/UFPE), Brazil
6 Department of HPB Surgery and Liver Transplantation, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK

Background: Frailty is a known predictor of mortality and poor outcomes during hospital admission. In this large renal retrospective cohort study, we investigated whether frailer COVID-19 positive renal patients had worse outcomes.

Design: All SARS-Cov-2 positive renal patients aged ≥18 years who presented to the emergency department at the Royal Free Hospital or at the satellite dialysis centres from 10th of March until the 10th of May 2020, with recent data on frailty, were included. The follow up was until 26th of May 2020. Age, gender, ethnicity, body mass index, chronic kidney disease stage, modality of renal replacement therapy, co-morbidities, Rockwood clinical frailty score (CFS), C reactive protein and the neutrophil-to-lymphocyte count were collected at presentation. The primary outcome was the overall mortality rate following COVID-19 diagnosis. Secondary outcomes included the need for hospital admission.

Results: A total of 200 renal patients were SARS-Cov-2 positive. In the 174 patients who had a CFS recorded, the age was 65.4 years ± 15.8 (mean ± SD) and 57,5% were male. At the end of follow up, 26% had died. Frail patients (CFS 5-7) were more than three times more likely to die compared to less frail patients (CFS of 1-4) (odds ratio (OR) 3.3, 95% confidence interval (CI) 1.0-10.6). 118 patients (68%) required admission, but there was no difference in hospital admission rates for frail vs non-frail patients (OR 0.6, CI 0.3-1.7).

Conclusions: Frailty is a better predictor of mortality than age and co-morbidities in COVID-19 positive renal patients.

Keywords: frailty, renal patients, SARS-Cov-2

Farmaci, tossici e rene

Giuliano Boscutti1, Domenico Montanaro2

1 Direttore Struttura Operativa Complessa di Nefrologia, Dialisi e Trapianto Renale Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), Ospedale Santa Maria della Misericordia di Udine
2 Già Direttore Struttura Operativa Complessa di Nefrologia, Dialisi e Trapianto Renale Azienda Sanitaria Universitaria Integrata di Udine

Glomerulonefriti da tossici e farmaci

Elisa Delbarba1 , Mattia Zappa1, Alice Guerini1, Chiara Salviani1, Roberta Zani1, Federico Alberici1,2, Francesco Scolari1,2

1 ASST Spedali Civili di Brescia, Unità Operativa di Nefrologia, Brescia
2 Università degli Studi di Brescia, Dipartimento di Specialità Medico-Chirurgiche, Scienze Radiologiche e Sanità Pubblica, Brescia

Relevance of an accurate microscopic examination of urinary sediment in a patient after mitral valve surgery

Carla Covarelli1, Rachele Brugnano2, Stefano Pasquino3, Emanuela Buoncristiani4, Rachele Del Sordo1, Angelo Sidoni1

1 S.C. di Anatomia e Istologia Patologica, Ospedale S. Maria della Misericordia, Perugia, Italia
2 Specialista in Nefrologia, membro della Società Italiana di Nefrologia, Perugia, Italia
3 S.C. di Cardiochirurgia, Ospedale Santa Maria della Misericordia Perugia, Italia
4 S.C. di Nefrologia e Dialisi, Azienda USL Umbria 1, Italia

Hemoglobinuria, clinically revealing as gross hematuria associated with anemia, increased hemolysis indices, acute kidney injury (AKI), can all be caused by mechanical intravascular hemolysis following mitral valve surgery. It can result from factors related to the surgical procedure or acquired later, such as paravalvular leak (PL), whose definite diagnosis is based on transesophageal echocardiography. 

We report the case of a patient who experienced macrohematuria and AKI, initially attributed to acute glomerulonephritis, two months after mitral valve surgery. Careful microscopic examination of the urinary sediment was a diriment diagnostic tool to differentiate acute renal failure caused by hemoglobinuria from hematuria in the course of acute glomerulonephritis, directing clinicians to investigate post-operative valvular dysfunction. From the literature review we can deduce that, notwithstanding new technologies in cardiac surgery, this rare form of AKI from intravascular hemolysis requires immediate nephrological attention and that the use of microscopic urinary sediment is decisive.

Keywords: hemoglobinuria, urinary sediment, gross hematuria, acute kidney injury (AKI), mitral valve surgery, hemolytic anemia

Self-efficacy and self-management in patients in hemodialysis: a narrative review of multidisciplinary theories

Elena Brioni1, Giulia Delli Zotti2, Luigi Apuzzo3, Cristiano Magnaghi2, Maddalena Iodice4, Francesco Burrai5, Paolo Manunta6, Giuseppe Vezzoli1, Duilio Fiorenzo Manara6, Giulia Villa6

1 Università Vita-Salute San Raffaele, IRCCS Ospedale San Raffaele, Milano, Italia
2 IRCCS Ospedale San Raffaele, Milano, Italia
3 Hospice Carlo Chenis, ASL Roma 4, Civitavecchia, Italia
4 Ospedale San Paolo, Asl Roma 4, Civitavecchia, Italia
5 Formazione, Ricerca e Cambiamento Organizzativo, ATS Sardegna Sassari, Italia
6 Università Vita-Salute San Raffaele, Milano, Italia

Hemodialysis is the most common treatment in patients with end-stage chronic kidney disease and the wide accessibility of this therapy has prolonged the patients’ lifespan. However, it involves alterations in their emotional sphere and, often, a reduction in therapeutic compliance as the chronicity of kidney disease requires lifestyle changes difficult to maintain in the long term. The management of a chronic medical condition is in fact a complex process that necessarily requires multidisciplinary action.

The concepts of “Self-efficacy” and “Self-management” fall within the Self-Determination Theory and are relevant in this context because they refer to the beliefs that everyone has about their abilities to control behavior and determine the success in adhering to prescribed therapies.

Furthermore, the promotion of self-efficacy and self-management through an educational approach that makes use of so-called “eHealth” tools can help develop greater self-awareness in dialysis patient, a better control over their care choices and an increased adherence to therapeutic-dietary indications.

This article aims at highlighting the importance of implementing an approach based on eHealth in the management of hemodialysis patients. It also wants to raise awareness of the related multidisciplinary theories to be applied in this clinical context to promote greater therapeutic adherence, and therefore a better quality of life and care.

Keywords: self-efficacy, self-management, hemodialysis, kidney disease, eHealth

Calcolosi renale e nefrocalcinosi da farmaci e tossici

Corrado Vitale1

1 SC Nefrologia e Dialisi. AO Ordine Mauriziano di Torino.

Diverse terapie farmacologiche, pur correttamente condotte, possono favorire sia la comparsa di precipitati cristallini a livello dei tubuli e dell’interstizio renale, con aspetti morfologici di nefrocalcinosi e quadri clinici di insufficienza renale acuta, sia la formazione di veri e propri calcoli, con possibili fenomeni di uropatia ostruttiva.

I cristalli e i calcoli possono essere costituiti dal farmaco somministrato, oppure dai componenti litogeni urinari di più comune riscontro (sali di calcio o acido urico), precipitati in conseguenza di alterazioni metaboliche indotte dalla terapia farmacologica. In quest’ultimo caso, la corretta diagnosi causale può talora sfuggire, giacché la composizione chimica dei calcoli è identica a quella osservabile in caso di litiasi idiopatica.

In questo articolo sono illustrate le caratteristiche cliniche e metaboliche essenziali delle tipologie più significative di nefrolitiasi farmaco-correlata, con alcuni riferimenti anche ai rari casi riportati di nefrolitiasi riconducibile a sostanze tossiche.

I calcoli contenenti i farmaci sono per lo più radiotrasparenti e rilevabili mediante ecografia oppure TC con mezzo di contrasto. La metodica più idonea a definirne la composizione chimica è la spettrofotometria a raggi infrarossi, applicabile sia sui calcoli espulsi, sia su depositi cristallini eventualmente riscontrabili in campioni bioptici renali.

Dal punto di vista terapeutico, la sospensione del farmaco e/o la sua sostituzione con altra molecola più solubile in ambiente urinario sono generalmente risolutive. Le misure di profilassi generale della calcolosi urinaria (idratazione e manipolazione del pH urine ove possibile), oltre a prevenire l’insorgenza della malattia nei casi a rischio, quando sia sospesa la terapia farmacologica possono contribuire alla progressiva dissoluzione dei cristalli presenti nel rene.

In alcuni casi, i precipitati cristallini possono indurre reazioni infiammatorie con reliquati fibrotici permanenti a livello del parenchima renale.

Parole chiave: nefrolitiasi, urolitiasi, nefrocalcinosi, farmaci.

Immunosoppressivi alternativi ai CNI: Schemi terapeutici e tossicità

Gianluigi Zaza1

1 Unità di Nefrologia, Dipartimento di Medicina, Università degli Studi di Verona.

In un’ottica di preservazione del danno acuto e cronico del graft, negli ultimi anni sta emergendo una nuova filosofia terapeutica per i pazienti affetti da trapianto renale che contempli l’utilizzo combinato di tutti i farmaci immunosoppressivi disponibili in commercio e la minimizzazione/sospensione degli inibitori della calcineurina. Lo scopo di questa nuova visione (immunosoppressione sostenibile) è quello di contrastare lo sviluppo di comorbidità ed evitare un drammatico impatto negativo sulla sopravvivenza dei pazienti nefro-trapiantati. L’utilizzo degli inibitori di mTOR e di nuovi agenti biologici (come Belatacept e il nuovissimo Iscalimab) potrebbe aiutarci a raggiungere questo obiettivo e superare il classico approccio alle cure “organo-centrico” verso quello “paziente-centrico”.

Inibitori della calcineurina e trapianto renale

Claudio Ponticelli

Ex direttore Nefrologia,IRCCS Ospedale Maggiore Policlinico Milano

Gli inibitori della calcineurina (CNI) hanno rivoluzionato i risultati del trapianto d’organo e sono tuttora i farmaci immunosoppressori più usati nel trapianto. I CNI inibiscono un sistema di fosfatasi necessario per consentire la translocazione  nel nucleo di un fattore di trascrizione da cui dipende la sintesi di interleuchina-2. Questo passaggio è fondamentale per la successiva proliferazione e differenziazione delle cellule T. In questo articolo vengono brevemente riassunte le caratteristiche farmacocinetiche e farmacodinamiche di CNI, i loro  potenziali effetti collaterali renali ed extra-renali ed i risultati ottenuti con CNI nel trapianto renale. Per prevenire eventi avversi  le dosi di CNI  dovrebbero essere ridotte  in presenza di insufficienza renale o ipertensione severa, l’uso di farmaci nefrotossici dovrebbe essere evitato quando possibile, molta attenzione dovrebbe essere posta nell’usare   farmaci che interferiscono con l’attività del citocromo P450 o della glicoproteina P. Inoltre, non va fatto troppo affidamento ai livelli ematici di CNI, che non riflettono la concentrazione intracellulare, che è molto superiore e molto più importante  di quella plasmatica.

I due inibitori della calcineurina (CNI) attualmente in commercio sono ciclosporina (CsA) e tacrolimus (TAC). CsA è un polipeptide ciclico composto da circa 11 aminoacidi derivato dal fungo Tolypocladium inflatum gums. TAC è un antibiotico macrolide derivato dal fungo Streptomyces tsukubaensis. I due CNI hanno una struttura molecolare diversa, ma entrambi hanno simili caratteristiche farmacologiche ed un simile meccanismo d’azione consistente nell’inibizione della calcineurina intra-cellulare.

I due CNI originali sono stati sostituiti rispettivamente da una nuova microemulsione per la CsA  (Neoral) e da una formulazione che consente una mono-somministrazione giornaliera per il TAC (Adavagraf). Sono anche disponibili formulazioni generiche.

Steroidi tra necessità e tossicità

Silvio Sandrini1, Stefania Affatato1, Bernardo Lucca1

1 Unità Operativa Complessa e Cattedra di Nefrologia. ASST Spedali Civili e Università di Brescia

Steroid minimization has always been one of the most desired goals regarding immunosuppressive therapy after renal transplantation. Following the introduction of cyclosporine different steroid-free protocols became available, but their implementation was limited due to the high risk of acute rejection. In the last few years, the use of a very low dose of prednisone (5 mg/day) has been deemed to guarantee a good balance between steroid toxicity and efficacy. However, high interpatient variability in prednisolone exposure prevented the standard low dose to be as safe as expected in all patients. Therefore, steroid side effects can still be observed in a variable percentage of patients. In this setting, the personalization of steroid dosage might prevent an over exposure to the drug, but this strategy is not available yet. Thus, steroid withdrawal remains the only available strategy to limit side effects. In the last 40 years, we learned that steroid free protocols are associated with a higher risk of acute rejection, but they do not reduce graft survival. Hence, patients at higher risk for acute rejection or recurrence of their primary renal disease are usually excluded from these protocols. Early steroid withdrawal (within 7 days after transplantation) has been widely used and also suggested by American guidelines. However, steroid withdrawal 3-4 months after transplantation has been preferred by many Authors and deemed equally efficient. In addition, early but not late steroid withdrawal should always be associated to induction therapy. Lastly, Tacrolimus plus Mycophenolic Acid has become the most used association in steroid minimization protocols.

Metodiche dialitiche in terapia intensiva: terapie tipiche, modalità somministrative, farmacocinetica e farmacodinamica

Ugo Gerini

S.C. Nefrologia e Dialisi Ospedale di Cattinara & Ospedale Maggiore Trieste; ASUGI Trieste, Via Giovanni Sai, Trieste

Il paziente in dialisi peritoneale: terapie tipiche, modalità somministrative, farmacocinetica e farmacodinamica

Gianpaolo Amici

Struttura Complessa di Nefrologia e Dialisi, Ospedali San Daniele del Friuli e Tolmezzo, ASUFC Udine

Le aree specifiche di trattamento farmacologico in dialisi peritoneale (DP) sono riassumibili in trattamento delle peritoniti e delle infezioni dell’exit-site e tunnel del catetere, la prevenzione del degrado sclerotico del peritoneo e la cura della peritonite sclerosante incapsulante.

La peritonite batterica è una comune complicanza della DP e il tasso di episodi viene considerato un indicatore di qualità. Tutti i programmi di DP hanno un protocollo terapeutico empirico che prevede gli antibiotici direttamente nel liquido peritoneale e l’utilizzo di almeno due antibiotici in associazione ad ampio spettro in attesa dei risultati delle colture. Vengono indicati: vancomicina o cefalosporine di prima generazione per i germi Gram positivi associate a cefalosporine di terza generazione o aminoglicosidi per i germi Gram negativi. Successivamente all’isolamento si procede con terapia mirata.

Le infezioni legate all’exit-site e al tunnel sottocutaneo del catetere peritoneale costituiscono un fattore di rischio di peritonite. La ricerca microbiologica tramite tampone e coltura deve essere mirata agli episodi di infezione con evidenza di secrezione. La terapia antibiotica empirica utilizza cefalosporine di prima generazione o penicilline protette per via orale. Il trattamento successivo è mirato. L’isolamento di stafilococco aureo e di pseudomonas aeruginosa richiede due antibiotici mirati in associazione e un trattamento di almeno tre settimane.

La sclerosi peritoneale semplice è un processo di fibrosi diffusa della membrana legato alla DP nel tempo. La prevenzione prevede l’utilizzo di soluzioni per DP biocompatibili, la riduzione dell’esposizione a elevate concentrazioni di glucosio e l’eliminazione dei betabloccanti, infine è opportuno valutare attentamente i pazienti con peritoniti ripetute e quelli con un tempo in DP lungo. Risulta dimostrato che inibire il SRAA contrasta la sclerosi per cui ACEI e ARB sono i farmaci antipertensivi di prima scelta nei pazienti in DP.

La peritonite sclerosante incapsulante (EPS) è una complicanza della DP molto rara ma temibile. Gli aspetti infiammatori e immunologici delle biopsie peritoneali supportano l’approccio immunosoppressivo con steroidi, ciclofosfamide e/o micofenolato. Importanti evidenze mostrano che il trattamento tamoxifene riserva una maggiore sopravvivenza indipendentemente da altri farmaci associati. Per l’EPS post-trapianto nei pazienti in DP vi sono evidenze che gli inibitori della calcineurina (ciclosporina e tacrolimus), svolgano un ruolo pro-fibrotico, per cui potrebbe essere indicato un protocollo immunosoppressivo personalizzato per il trapianto nei pazienti in DP basato su mTOR-I, steroidi e micofenolato.

Parole chiave: Dialisi peritoneale, trattamenti farmacologici, peritonite, infezione dell’exit-site, antibioticoterapia, sclerosi peritoneale semplice, peritonite sclerosante incapsulante.

Il paziente in trattamento emodialitico cronico: terapie tipiche, modalità somministrative, farmacocinetica e farmacodinamica

Francesco Bianco

S. C. Nefrologia e Dialisi, Ospedale di Cattinara & Ospedale Maggiore Trieste. ASUGI Trieste, Via Giovanni Sai, Trieste

La polifarmacologia dei pazienti in emodialisi è nota: da una indagine di prevalenza in ottobre 2019 nel nostro centro dialisi di Trieste si è osservato che su una popolazione di 154 emodializzati il numero dei farmaci assunti per os a domicilio era in media di 8,3 e che quelle infusi per via endovenosa in fine dialisi era di 2,2. Tra i farmaci più frequentemente utilizzati nei pazienti emodializzati erano gli antipertensivi (90%) gli inibitori di pompa (73%), gli antianginosi-antiaritmici (68%). Il 50% dei pazienti assumeva almeno tre farmaci per il controllo CKD – MBD. Solo il 7% della popolazione assumeva farmaci antalgici oppiacei per il controllo del dolore. Nel caso clinico 1 si descrive un paziente emodializzato affetto da cheratoacantoma recidivante trattato con metotrexate intralesionale con un evidente guarigione della lesione, ma che ha sviluppato una aplasia midollare. Nel caso clinico 2 si descrive un paziente emodializzato affetto da calcifilassi coinvolgente l’80% della superficie corporea che oltra alla terapia di supporto è stato trattato con Sodio Tiosolfato. L’effetto collaterale più grave del STS è l’ipotensione.

Il paziente con insufficienza renale cronica. Terapie tipiche, modalità di somministrazione, farmacocinetica e farmacodinamica

Alessandra Marega1

1 Azienda Sanitaria Universitaria Friuli Centrale (ASUFC) Ospedale “Santa Maria della Misericordia” Udine, Dipartimento di Medicina Specialistica: Nefrologia, Dialisi e Trapianto Renale

Investigators in the 1960s found that patients with poor kidney function were predisposed to various adverse drug reactions. Research demonstrated that impaired kidney function affects not only clearance but also absorption, distribution, metabolism and non-renal-clearance of drugs: these aspects represents the pharmacokinetic (PK) of drugs and the basic rules was written by Calvin Kunin and Luzius Dettli. To determinate the right dose of drugs doesn’t depend only by PK, but also by the pharmacodynamics (PD) that represents the effect that drug achieve; the therapeutically effective range of a drug depends on its Hill coefficient. To provide precision in pharmacotherapy, near PK and PD, there is pharmacogenomics that tests for genetic variation in genes that are responsible for drug metabolism, transport and target of drug action and can be used to select the best medication or aid in dosing. To better study the drug toxicity, the PK and physiology of kidney, there are novel technology in the field of engineering which provides new options like kidney-on-a-chip that mimic organ level functions and disease to replace some traditional animal and human studies.

Tossicità renale da farmaci antineoplastici

Nicola Lepori1, Matteo Floris1, Andrea Angioi1, Francesco Trevisani2, Stefania Aresu1, Gianfranca Cabiddu1,3 e Antonello Pani1,3

1 C. Nefrologia a Dialisi, Ospedale G. Brotzu, Cagliari, Italia
2 Dipartimento di Urologia e Urological Reserch Institute, Ospedale San Raffaele, Milano
3 Università degli Studi di Cagliari, Dipartimento di Scienze Mediche, Cagliari, Italia

L’onconefrologia è una recente disciplina sorta in campo nefrologico e oncologico, volta ad esplorare le numerose connessioni tra patologie neoplastiche e renali. Tra i numerosi campi di applicazione dell’onconefrologia, un ruolo significativo è ricoperto dalla gestione degli eventi avversi in corso di terapia antineoplastica attraverso una analisi individualizzata dei fattori di rischio del paziente, delle caratteristiche dei farmaci oncologici prescritti e l’instaurazione di un preciso follow-up che spesso prosegue anche al termine del trattamento oncologico. Lo scopo di questa revisione è, oltre che descrivere i fattori di rischio per la nefrotossicità da farmaci antitumorali, analizzare le principali criticità onco-nefrologiche legate alle specifiche classi di farmaci. I chemioterapici classici presentano un profilo variabile di tossicità renale, per la maggior parte dei casi ben definito, che consente di mettere in campo delle collaudate strategie terapeutiche per la gestione degli eventi avversi renali. Le terapie a bersaglio molecolare e i farmaci immunoterapici nonostante abbiano dimostrato di migliorare significativamente la prognosi a breve e lungo termine in numerose neoplasie presentano un ampio profilo di tossicità renale ancora in fase di definizione. La costante analisi dei report relativi alle specifiche molecole, associata ad un a condotta proattiva per la definizione istologica delle lesioni renali in questo contesto clinico, è la chiave per completare rapidamente la definizione del profilo di sicurezza ampliando contestualmente la platea dei pazienti che potranno beneficiare  dei nuovi farmaci antineoplastici.

Parole chiave: Danno renale acuto, AKI, cisplatino, gemcitabina, anti-VEGF, immunoterapia, bevacizumab

Environmental toxic and direct drug-related renal toxicity. Antibiotics

Silvana Savoldi1

1 S.C. Nefrologia e Dialisi, ASL TO4, Torino, Italia

Antibiotics are a relatively common cause of acute kidney injury that occurs mainly in patients with underlying risk factors. Adverse reactions from antibiotics can be classified as type A when they are foreseeable, we know the cause and are often dose dependent and type B when they occur in an unpredictable way, are independent of the dose and due to hypersensitivity and / or immunoallergic phenomena. All compartments of the kidney are prone to antibiotic damage which, clinically, results in tubular dysfunction, acute renal failure, nephritic syndrome and chronic renal failure. The drugs most responsible are vancomycin, aminoglycosides and beta lactamines. The occurrence of acute renal failure correlates with the length of hospitalization and the risk of death. It therefore becomes of fundamental clinical importance to know the antibiotics with potential nephrotoxic effect in order to establish the dosage on the basis of renal function and correct all the factors that can enhance their toxicity.

Keywords: nephrotoxicity, direct antibiotics-related renal toxicity , antibiotics, adverse drug reactions


Farmaci antinfiammatori non steroidei

Cataldo Abaterusso

UOC Nefrologia – distretto Asolo – AULSS2 Marca trevigiana.

I farmaci antiinfiammatori non steroidei (FANS) rappresentano una delle classi di farmaci maggiormente prescritta ed utilizzata a livello globale, con milioni di somministrazioni quotidiane, e con un mercato mondiale in ulteriore espansione.

La situazione italiana, invece, appare in controtendenza, come dimostrato dai report annuali dell’Agenzia del Farmaco (AIFA), con un lento progressivo decremento sia della prescrizione che dell’utilizzo complessivo includendo quello da automedicazione (over-the-counter). Sebbene la prescrizione ed il consumo di FANS in Italia riconosca differenze evidenti tra le regioni settentrionali e quelle meridionali, si conferma comunque la progressiva contrazione annuale del mercato.

Nonostante siano ben conosciuti gli effetti collaterali e tossici di questa classe di farmaci a carico di diversi organi ed apparati, le segnalazioni di eventi avversi (AEs) renali risultano minimali nei registri AIFA se rapportate agli effetti collaterali su altri organi ed apparati. La sottostima degli eventi avversi renali risulta ancora più evidente se si considera che nella popolazione geriatrica italiana, generalmente sottoposta a multiterapia farmacologica (in media 6.7 sostanze pro-capite), i FANS rappresentano il 32% delle prescrizioni risultando la quarta classe di farmaci più prescritta dopo antiulcera, antitrombotici e ipolipemizzanti.

Nella review sono elencate in sintesi le principali complicanze (alterazioni funzionali o comparsa di danno istologicamente definito) renali da FANS, le condizioni favorenti indispensabili per il determinismo del danno e cenni sui possibili meccanismi patogenetici.

Resta però evidente, pur a fronte di una sicura e non meglio quantificabile sottostima degli eventi avversi , che la loro frequenza sia abbastanza contenuta nella popolazione generale aumentando discretamente in quella a rischio.

La conoscenza dei meccanismi farmacologici e delle condizioni cliniche coinvolte nella genesi degli eventi avversi renali associati ai FANS, nonché l’epidemiologia e la frequenza delle complicanze, possono certamente contribuire alla acquisizione di una appropriatezza prescrittiva in equilibrio tra demonizzazioni semplicistiche e sottovalutazioni colpevoli. La accuratezza della diagnosi sulla causa del dolore risulta quindi prioritaria per la scelta terapeutica ragionata sul bilancio rischio-beneficio.

Al nefrologo esperto compete quindi  la responsabile (in)formazione sull’approccio non semplicistico e fai-da-te della terapia antalgica nei soggetti anziani ad alto rischio renale.

Droghe d’abuso e rene

Giuliano Boscutti1, Vittorio Di Maso2, Alessandra Marega1, Ugo Gerini2, Alberto Zacchi3, Francesco Bianco2

1 Struttura Operativa Complessa di Nefrologia, Dialisi e Trapianto Renale Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), Ospedale Santa Maria della Misericordia di Udine
2 Struttura Complessa di Nefrologia e Dialisi Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), Ospedali di Cattinara e Maggiore di Trieste
3 Struttura Complessa di Anatomia ed Istologia Patologica Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), Ospedale di Cattinara di Trieste

Here we present a case of acute renal failure needing dialysis in a heroin addict patient chronically treated with Metadone.  This give us the opportunity to review the renal effects of the main drugs of abuse, highlighting the shift occured from the four “old sisters” (Marijuana, Cocaine, Heroin and Amphetamine) to the news synthetic drugs (chiefly  Synthetic  Cathinones and Cannabinoids), that poses problems due to  large diffusion, easy  procurement, legal  non-regulation and difficult analytical identification,  raising medical and forensic questions. From a Nephrological point of view is essential to take great care over the need to diagnose this kind of pathology and to widen the search trying anyway to recognize the substances potentially involved.

Key Words: Acute Kidney Injury; Acute renal failure; Illicit drugs; Rhabdomyolysis.

Environmental toxicity and direct renal toxicity from drugs: herbs and plants

Mauro Dugo1

1 UOC Nefrologia, Dialisi e Trapianti Renali, Ospedale Ca’Foncello, Treviso.

Traditional medicine is a widespread treatment method in the world. Despite the WHO’s confirmation of the progressive spread of national policies responsible for controlling the production and distribution of phytotherapy, the risk of toxic side effects is high even if the real incidence is not known. These risks largely result from the self-prescription supported by the assumption that what is natural is not dangerous to health. The phytotherapic industry turnover is progressively increasing, favored by the ease with which products can be purchased without prescription in pharmacies in some countries or online.

In particular, Chinese herbs can be nephrotoxic and clinicians should consider the possibility of their role in some cases of AKI or CKD with unknown etiology. Furthermore, in the collection of the pharmacological history of patients with CKD or kidney transplantation it is necessary to exclude the use of some phytotherapics of common use that may be contraindicated for possible interactions with drugs of conventional medicine.

Keywords: Traditional Medicine, Phytotherapy, Chinese herbs, Aristolochic acid, nephrotoxicity.

Metalli pesanti

Paolo Lentini

UOC Nefrologia e Dialisi – Ospedale “San Bassiano”

In biochimica i Metalli Pesanti  (MP) vengono definiti come composti cationici in grado di formare dei complessi citoplasmatici intracellulari: in tal classificazione rientrano sia gli elementi in traccia come Arsenico, cobalto, ferro e iodio ma anche i MP propriamente detti che sono tossici anche a basse concentrazioni come cadmio, mercurio, cromo e piombo.

Sono oltre 30 i composti metallici in grado di causare danno renale; i MP più comunemente coinvolti nelle patologie renali sono arsenico, bario, cadmio, cobalto, rame, piombo, litio, mercurio platino, tallio; la loro tossicità dipende da fattori fisici (stato fisico, temperatura), da fattori chimici (solubilità e cinetica) ma anche da fattori biochimici come il tropismo per le catene mitocondriali umane.

Il rene è un organo bersaglio per i MP, a causa della sua abilità nello riassorbire e concentrare i metalli divalenti; gran parte degli effetti si esplicano a livello del segmento convoluto del tubulo prossimale. La forma ionizzata del MP è responsabile di tossicità cellulare diretta verso la membrana apicale del tubulo prossimale; la forma non ionizzata o inerte del MP viene coniugata con metallotioneine e glutatione, rilasciata nel sangue dal fegato e infine riassorbita  per endocitosi nel semento S1 del tubulo prossimale.
L’entità e la modalità del danno renale dipende dal tipo di metallo, dalla dose e dal tempo di esposizione.

L’approccio terapeutico in presenza di una intossicazione acuta da metalli pesanti prevede misure di supporto (fluidi e.v, supporto inotropo, ventilatorio, emotrasfusioni), la decontaminazione (lavanda gastrica, emetici, carbone attivo), le metodiche depurative extracorporee (quando indicate) e ovviamente la terapia chelante.

Un mondo sempre più complesso: tossici ambientali e nefropatie

Diego Serraino1

SOC Epidemiologia Oncologica Centro di Riferimento Oncologico, IRCCS, Aviano Via F. Gallini, 2 33081 Aviano

Si stima che siano circa 70.000 le persone alle quali, ogni anno in Italia, viene diagnosticata una nefropatia direttamente o indirettamente causata dall’inquinamento ambientale di aria, acqua e suolo. In aggiunta a descrivere alcuni aspetti epidemiologici delle nefropatie in Italia, vengono qui  prese in esame le evidenze prodotte in tema di  inquinamento e malattie renali dovute alla presenza di sostanze nefrotossiche disperse negli ambienti di vita quotidiana.

Young Nephrologists’ Arena: a new joint GIN-JN project

Parameters predicting arterious-venous fistula maturation in pre surgery vascular mapping

Marco Taurisano1, Andrea Mancini1, Filomena D’Elia1

1 S.C. di Nefrologia e Dialisi, Ospedale Di Venere, Bari, Italia

Arterious-venous fistula (AVF) represents the first-choice vascular access for haemodialysis. Pre-surgery evaluation is mandatory to identify the appropriate vessels and to predict the success of AVF creation. Echo-color Doppler provides a wealth of morphological and functional values useful to create an optimal vascular access for haemodialysis. The purpose of this study has been to identify pre-surgery echo-color Doppler parameters useful to predict AVF maturation. 44 patients were enrolled, and 44 AVF created. During pre-surgery evaluation we collected the following data: cephalic vein and radial artery calibers; radial artery flow and caliber; flow and resistive index (RI) of the brachial artery. We also performed a reactive hyperemia test. During the post-surgery evaluation after 30 days, we collected: AVF flow; resistive index of the brachial artery; post-anastomosis cephalic vein caliber. The results showed a direct correlation between AVF flow and some parameters: cephalic vein, radial artery and brachial artery caliber, reduction of RI after reactive hyperemia test and, in the post-surgery evaluation, between AVF flow and post-anastomosis cephalic vein caliber. We divided patients into two groups: “A”, representative of AVF adequate maturation, and “B”, representative of AVF early failure (EF) and AVF failure to mature (FTM). We observed some statistically significant differences in the two groups. With the creation of Receiver Operating Characteristic (ROC) curves we identified two parameters able to predict the AVF outcome (Δ IR = 0.15; Δ flow = 150 ml/m). This study identifies pre-surgery echo-color Doppler parameters that could be useful, together with others, to predict the outcome of the AVF creation.


Keywords: echo-color Doppler, arterious-venous fistula, resistive index, fistula flow, reactive hyperemia

C3 Glomerulopathy, a pathology with scarce evidence. A case report

Andrés Felipe Barragán1, Elías Quintero-Muñoz1, Daniel Quintero-Muñoz2, Paula V Rodriguez-Segura3

1 Internal Medicine Resident; La Sabana University, Chía, Colombia
2 MD, La Sabana University, Chía, Colombia
3 MD, Internist, Nephrologist, Hospital Universitario de La Samaritana – Grupo de investigación UROHUS, Bogotá, Colombia.

C3 Glomerulonephritis (C3GN) is a rare disease with an estimated incidence of 1-2 cases per million, caused by an alteration in the alternative complement pathway, although its complete physiopathology remains uncertain. Treatment evidence is poor. Immunosuppressive therapy can be initiated in more severe cases. Progression rates to end stage kidney disease are of up to 50% within a decade, and the posttransplant recurrence rates of 45-60%. We describe the case of a young man without any past medical history, with lower extremities edema, dyspnea, and kidney function deterioration. The patient was ultimately diagnosed with C3GN.

Key words: C3 glomerulopathy, glomerulonephritis, alternative complement pathway

Lithium sulfate poisoning treated with hemodialysis in a patient with normal renal function: a case report

Antonio Cesaro1, Guido Faggian1, Carlo Del Piano1, Domenico Del Piano1, Arcangelo Vitagliano1, Roberto Faggian1, Eufrasia Silvestro3, Angela Faggian2

1 UOSD Nefrologia ed Emodialisi, P.O. Moscati, Aversa (CE), Italia
2 UOC Diagnostica per immagini, A.O. Rummo, Benevento, Italia
3 UOC Anestesia e Rianimazione, P.O. Moscati, Aversa (CE), Italia

Lithium is the milestone of psychiatric patients’ therapy, in particular in bipolar disorder. Despite its high therapeutic efficacy, there are several side effects (renal, thyroid, parathyroid, dermatological) and management problems linked to its narrow therapeutic range, which exposes patients to a high risk of toxicity.

We describe the case of a male patient with bipolar disorder in therapy with lithium sulfate who developed a severe acute-on-chronic intoxication. He came to our attention in a somnolent state with lithemia >3 mEq/L and therefore underwent hemodialysis.

In view of the high toxicity of lithium, a timely and correct therapeutic choice is important to improve the patient’s outcome. In this context, considering lithemia, but also kidney function and the patient’s clinical status, it is necessary to consider extracorporeal treatments, of which hemodialysis is the most preferable.


Keywords: lithium, poisoning, dialysis, bipolar disorder

Hyperkalemia-induced acute flaccid paralysis: a case report

Martina D’Ercole1,2, Leda Cipriani1,2, Daniela Picciotto1, Stefania Bianzina3, Elisa Russo1,2, Francesca Viazzi1,2, Pasquale Esposito1,2

1 Unit of Nephrology, Dialysis and Transplantation, IRCCS Ospedale Policlinico San Martino, Genova, Italy
2 Department of Internal Medicine, University of Genova, Genova, Italy
3 Neonatal and Pediatric Intensive Care Unit, G. Gaslini Institute, Genova, Italy

Acute flaccid paralysis is a medical emergency that may be caused by primary neuro-muscular disorders, metabolic alterations, and iatrogenic effects. Severe hyperkalemia is also a potential cause, especially in elderly patients with impaired renal function. Early diagnosis is essential for appropriate management.

Here, we report the case of a 78-year-old woman with hypertension and diabetes presenting to the emergency department because of pronounced asthenia, rapidly evolving in quadriparesis. Laboratory examinations showed severe hyperkalemia of 9.9 mmol/L, metabolic acidosis, kidney failure (creatinine 1.6 mg/dl), and hyperglycemia (501 mg/dl). The electrocardiography showed absent P-wave, widening QRS, and tall T-waves. The patient was immediately treated with medical therapy and a hemodialysis session, presenting a rapid resolution of electrocardiographic and neurological abnormalities. This case offers the opportunity to discuss the pathogenesis, the clinical presentation, and the management of hyperkalemia-induced acute flaccid paralysis.

Keywords: hyperkalemia, acute flaccid paralysis, hemodialysis, diabetes

Multiple myeloma, plasma cell dyscrasias and kidneys: a few symptoms, extensive damage

Lorenzo D’Elia1, Antonella Barreca2, Martina Ferraresi1, Antonio Marciello1, Antonietta Rizzuto1, Luisa Sandri1, Paolo Maurizio Perosa1

1 SS Nefrologia e dialisi, Ospedale “E. Agnelli” di Pinerolo, ASLTO3, Torino, Italia
2 Anatomia Patologica, AOU città della salute e della Scienza, Torino, Italia

Multiple myeloma represents one of the main universal oncological diseases. Due to its clinical characteristics, it is often diagnosed only too late, when it has already determined systemic effects; this results in greater therapeutic difficulty and worse prognostic results. Through the clinical case discussed in this article, we want to focus on the often aspecific manifestations of this pathology and on the need for a correct clinical and diagnostic framework. The main renal manifestations secondary to the deposition of immunoglobulins in both the glomerular and tubular areas will also be examined.

Keywords: AKI, multiple myeloma, plasma cell dyscrasias, kidney injury

Which is the role of the oral iron therapies for iron deficiency anemia in non-dialysis-dependent chronic kidney disease patients? Results from clinical experience

Angela Maria Pellegrino1, Matteo Piemontese1, Rachele Grifa1 e Filippo Aucella1

1 Struttura Complessa di Nefrologia e Dialisi, Fondazione “Casa Sollievo della Sofferenza”, IRCCS, San Giovanni Rotondo.

Iron deficiency afflicts about 60% of dialysis patients and about 30% of non-dialysis-dependent CKD patients (ND-CKD). The role of iron deficiency in determining anemia in CKD patients is so relevant that guidelines from the Kidney Disease Improving Global Outcomes (KDIGO) initiative recommend treating it before starting with erythropoiesis-stimulating agents. KDIGO guidelines suggest oral iron therapy because it is commonly available and inexpensive, although it is often characterized by low bioavailability and low compliance due to adverse effects.

A new-generation oral iron therapy is now available and seems to be promising. We therefore conducted a study to determine whether an association of iron sucrose, folic acid and vitamins C, B6, B12, can improve anemia in ND-CKD patients, stage 3-5. Our study shows that iron sucrose is a safe and effective oral iron therapy and that it is capable of correcting anemia in ND-CKD patients, although it does not seem to replete low iron stores.

Keywords: iron deficiency, chronic kidney disease, CKD, anemia, oral iron

Urgent-start PD: a viable approach

Luca Nardelli1,2, Antonio Scalamogna1, Silvia Pisati1, Maurizio Gallieni2,3, Piergiorgio Messa1,2

1 UOC di Nefrologia, Dialisi e Trapianti di Rene, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano, Italia
2 Scuola di Specializzazione in Nefrologia, Università degli Studi di Milano, Milano, Italia
3 UOC di Nefrologia e Dialisi, ASST Fatebenefratelli Sacco, Milano, Italia

Despite the many potential benefits of peritoneal dialysis (PD), the percentage of dialysis patients treated with PD is around 10% worldwide. Up to 70% of the subjects who progress to end-stage renal disease (ESRD) start dialysis without a well-defined therapy plan. Most of these patients are unaware of having chronic kidney disease, while others with stable CKD incur in unpredictable and acute worsening of kidney function.

As a matter of fact, 80% of incident HD patients start dialysis with a central venous catheter (CVC) even though starting HD with a CVC is independently associated with increased mortality, high rates of bacteremia, and increased hospitalization rates. Thus, PD is an excellent but underused mode of dialysis. Offering it to patients who present late to dialysis therapy, due to uremic state or hypervolemia, may help increase its application in the future.

This approach has been recently denominated “urgent-start peritoneal dialysis” (UPD). Based on the break-in period, it is possible to differentiate UPD from “early-start peritoneal dialysis” (EPD). The outcome of UPD depends on the right selection of patients, the appropriate placement of the catheter and the adequate education of the nursing and medical staff. Moreover, using modified catheter insertion technique aimed at creating a tight seal between the inner cuff and the abdominal tissues, as well as employing protocols that use low-volume exchanges in a supine posture, could minimize the occurrence of early mechanical complications.

Although the probability of mechanical complications is higher in early-start PD patients, UPD/EPD show a mortality rate, a PD survival and an infectious complication rate comparable with conventional PD. In comparison to urgent-start hemodialysis via a CVC, UPD can be a safe and cost-effective alternative that decreases the incidences of catheter-related bloodstream infections and hemodialysis-related complications. Furthermore, UPD can promote the diffusion of PD.


Keywords: peritoneal dialysis, urgent-start, early-start, leakage, displacement, low-volume

Management of Primary Hyperoxaluria Type 1 in Italy

Pietro Manuel Ferraro1, Giovanni Gambaro2, Giorgia Mandrile3, Giovanni Montini4, Andrea Pasini5, Licia Peruzzi6

1 Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia
2 Azienda Ospedaliera Universitaria Integrata Verona – Ospedale Maggiore Verona, Italia
3 SSD Microcitemie e Counselling genetico, AOS S. Luigi Gonzaga, Orbassano (TO), Italia
4 Fondazione IRCCS Cà Granda – Ospedale Maggiore Policlinico e Università degli Studi di Milano, Milano, Italia
5 Azienda Ospedaliero-Universitaria Sant’Orsola-Malpighi, Bologna, Italia
6 Ospedale Infantile Regina Margherita, Torino, Italia

Primary hyperoxaluria type 1 is a rare genetic disease; the onset of symptoms ranges from childhood to the sixth decade of life and the disease may go unrecognized for several years. There is an urgent need for drugs able to inhibit the liver production of oxalate and to prevent the disease progression; lumasiran, an innovative molecule based on RNAi interference, is one of the most promising drugs. A group of leading Italian experts on this disease met to respond to some unmet medical needs (early diagnosis, availability of genetic tests and dosage of plasma oxalate, timing of liver transplantation, need for etiologic treatment), based on the analysis of the main scientific evidence and their personal experience. Children showing the characteristic symptoms of the disease usually undergo a metabolic screening and obtain an early diagnosis, while the experience is very limited in adults and the diagnosis difficult. It is therefore essential to increase the knowledge around this disease and the importance of metabolic and genetic screening to define a checklist of shared clinical and laboratory criteria and to establish a multidisciplinary management of potential patients. Oxalate is the cause of the disease: it is crucial to reduce both oxaluria and oxalemia through appropriate therapeutic strategies, able to prevent and/or reduce renal and systemic complications of primary type 1 hyperoxaluria. Lumasiran allows to significantly reduce the levels of oxalate both in blood and in urine, halting the course of the disease and preventing serious renal and systemic complications, if the therapy is started at an early stage of the disease.

Keywords: primary hyperoxaluria type 1, hyperoxalemia, hyperoxaluria, lumasiran

The management of nephropathic patients during the Covid-19 pandemic: the experience of Ragusa

Walter Morale1, Concetto Sessa1, Ivana Alessandrello1, Giorgio Aprile1, Dario Galeano1, Elisa Giglio1, Vincenzo Ficara1, Stella Musumeci1, Viviana Scollo1, Carmelo Zuppardo1, Andrea Baglieri1, Giovanni Rizza1, Pietro Bonomo2, Salvatore Modica2, Giuseppe Patriarca3, Raffaele Elia3, Angelo Aliquò3, Salvatore Musso1

1 U.O.C Nefrologia e Dialisi, P.O. “Maggiore” di Modica. Azienda Sanitaria Provinciale di Ragusa, Ragusa, Italy
2 Direzione Sanitaria Ospedale “Maggiore”, Modica (RG), Italy
3 Direzione Generale Azienda Sanitaria Provinciale di Ragusa, Ragusa, Italy

The public emergency caused by Covid-19 has forced health services to reorganize in order to separate positive patients from negative ones. In nephrology, this reorganization involves several levels of assistance concerning hospitalizations, ambulatory care and haemodialysis.

Within the Complex Unit of Nephrology in Ragusa, the distribution of nephro-dialytic resources has involved four different hospitals, hence ensuring haemodialysis services for asymptomatic and pauci-symptomatic Covid-19 patients as well as for patients in Covid-Unit, Sub-Intensive Therapy and Intensive Care Unit. In this complex context, we had to create a common protocol involving all the professionals who provide assistance in our Unit, across the different structures.

We also report some encouraging data that seem to indicate the effectiveness of the protocols put in place.

Keywords: Covid-19, Nephrology, devices for individual protection, management of the renal patient, dedicated paths

Hemodialysis shake-up on the front lines of the Covid-19 pandemic: the Treviglio Hospital experience

Simona Zerbi1, Maura Alletto1, Roberta Aloardi1, Stefania Galantucci1, Daniela Palmetti1, Laura Danelli2, Marco Tagliaferri1, Margherita Massazza1, Gigliola Palmerio1, Silvia Cassamali1, Carlo Taietti1, Giuseppe Voddo1, Carla Bonaita1, Emilio G. Galli1

1 Nephrology and Dialysis Unit – Treviglio Hospital – ASST Bergamo Ovest, Italy
2 Psychology Unit – Treviglio Hospital – ASST Bergamo Ovest, Italy

The new coronavirus disease (Covid-19) pandemic in Italy formally started on 21st February 2020, when a 38-years old man was established as the first Italian citizen with Covid-19 in Codogno, Lombardy region. In a few days, the deadly coronavirus swept beyond expectations across the city of Bergamo and its province, claiming thousands of lives and putting the hospital in Treviglio under considerable strain.

Since designated Covid-dialysis hospitals to centrally manage infected hemodialysis patients were not set up in the epidemic areas, we arranged to treat all our patients. We describe the multiple strategies we had to implement fast to prevent/control Covid-19 infection and spread resources in our Dialysis Unit during the first surge of the pandemic in one of the worst-hit areas in Italy. The recommendations provided by existing guidelines and colleagues with significant experience in dealing with Covid-19 were combined with the practical judgement of our dialysis clinicians, nurses and nurse’s aides.

KEYWORDS: COVID-19, hemodialysis, end-stage kidney disease, coronavirus, pandemic.

Covid-19 vaccination and renal patients: overcoming unwarranted fears and re-establishing priorities

Maria Teresa Sciarrone Alibrandi1, Marta Vespa1, Giancarlo Joli1, Romina Bucci1, Elena Brioni1, Rodolfo F. Rivera2

1 University Vita Salute San Raffaele, IRCCS San Raffaele Scientific Institute, Milano, Italia
2 U.O. Nefrologia e Dialisi, Ospedale di Desio – ASST – Brianza, Desio, Italia

The SARS-CoV-2 (Covid-19) has infected about 124 million people worldwide and the total amount of casualties now sits at a staggering 2.7 million. One enigmatic aspect of this disease is the protean nature of the clinical manifestations, ranging from total absence of symptoms to extremely severe cases with multiorgan failure and death.

Chronic Kidney Disease (CKD) has emerged as the primary risk factor in the most severe patients, apart from age. Kidney disease and acute kidney injury have been correlated with a higher risk of death. Notably the Italian Society of Nephrology have reported a 10-fold increase in mortality in patients undergoing dialysis compared to the rest of the population, especially during the second phase of the pandemic (26% vs 2.4). These dramatic numbers require an immediate response.

At the moment of writing, three Covid-19 vaccines are being administered already , two of which, Pfizer-BioNTech and Moderna,  share the same mrna mechanism and Vaxzevria (AstraZeneca) based on a more traditional approach.  All of them are completely safe and reliable. The AIFA scientific commission has suggested that the mRNA vaccines should be administered to older and more fragile patients, while the Vaxzevria (AstraZeneca) vaccine should be reserved for younger subjects above the age of 18. The near future looks bright: there are tens of other vaccines undergoing clinical and preclinical validation, whose preliminary results look promising.

The high mortality of CKD and dialysis patients contracting Covid-19 should mandate top priority for their vaccination.


Keywords: SARS-CoV-2 (Covid-19), chronic kidney disease, vaccine

Phosphorus binders: trigger for intestinal diverticula formation in an ADPKD patient

Maurizio Garozzo1, Concetta Luisa Monica Gullè1, Anna Clementi1, Filippo Milone1, Giovanni Giorgio Battaglia1

1 Azienda Sanitaria Provinciale di Catania, Ospedale Santa Marta e Santa Venera di Acireale, Unità Operativa Complessa di Nefrologia e Dialisi. Acireale (CT), Italia

Hyperphosphoremia is common in patients with chronic kidney disease and is an important risk factor in this patient population. Phosphate binding drugs are a key therapeutic strategy to reduce phosphoremia levels, although they have significant side effects especially in the gastrointestinal tract, such as gastritis, diarrhoea and constipation. We report the case of a haemodialysis-dependent patient suffering from chronic kidney disease stage V KDIGO secondary to polycystic autosomal dominant disease; treated with phosphate binders, the case was complicated by the appearance of diverticulosis, evolved into acute diverticulitis.


Keywords: hyperphosphoremia, phosphate binding drugs, chronic kidney disease, polycystic autosomal dominant disease, diverticulosis, acute diverticulitis

Flying at high altitude

Gaetano La Manna

Editor in Chief Giornale Italiano di Nefrologia

“New humanism” in nephrology

Prof. Loreto Gesualdo


Presidente Scuola di Medicina – Università degli Studi di Bari “Aldo Moro”, Bari, Italia

My life as a nephrologist with a passion for renal pathology

Giovanni Barbiano di Belgiojoso1, Giovanni B. Fogazzi2

1 Già primario Nefrologo Ospedale Luigi Sacco di Milano e già docente di Nefrologia al Corso di Laurea in Medicina e Chirurgia, Polo Universitario Sacco, Milano, Italia
2 U.O.C. di Nefrologia, Dialisi e Trapianto di Rene, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano, Italia

This article retraces the nephrological life of Giovanni Barbiano di Belgiojoso, which started in the late 1960s. Since the beginning renal pathology was his main interest and he was among the pioneers who introduced in Italy the use of immunofluorescence technique in the examination of renal biopsies. Over the years Barbiano di Belgiojoso has carried out, often in cooperation with other nephrological groups, many clinico-pathological studies on a wide spectrum of glomerular diseases. He also played a key role in the foundation and in the activities of the “Group of Renal Immunopathology” of the Italian Society of Nephrology.

Keywords: history of nephrology, history of Italian nephrology, history of renal pathology

Kidney involvement in Waldenström’s disease – case report

Luigi Fomasi1, Paolo Foini2, Gianluca Marchi2, Paolo Ghiringhelli2, Alfredo Molteni3, Marco Ungari4, Simona Fisogni5, Fabio Malberti2

1 UO Nefrologia e Dialisi ASST Spedali civili di Brescia – Scuola di specializzazione in Nefrologia di Brescia, Italia
2 UO Nefrologia e Dialisi ASST Cremona, Italia
3 UO Ematologia ASST Cremona, Italia
4 UO Anatomia Patologica ASST Cremona, Italia
5 UO Anatomia Patologica ASST Spedali Civili di Brescia, Italia

Waldenström’s disease is a rare haematological neoplasm involving B lymphocytes, characterized by medullary infiltrated lymphoplasmacytic lymphoma and by the presence of a monoclonal M paraprotein. Although rarely, this condition may lead to heterogeneous renal involvement and cause severe renal failure.

We report the clinical case of a patient with overt nephrotic syndrome in Waldenström’s disease treated with a combination chemotherapy (rituximab, cyclophosphamide, dexamethasone) until complete renal and haematological remission.


Keywords: Waldenström’s disease, nephrotic syndrome, rituximab, cyclophosphamide, dexamethasone

Psychiatric and psychological evaluation in living donor kidney transplantation: a single center experience

Valentina Martinelli1, Marilena Gregorini2, Fulvia Erasmi2, Pierluigi Politi1, Concetta De Pasquale3, Maria Luisa Pistorio4, Massimo Abelli5, Elena Ticozzelli5, Matteo Chiappedi6, Andrea Pietrabissa5, Teresa Rampino2

1 Dipartimento di scienze del Sistema nervoso e del comportamento, Università di Pavia, Italia
2 UOC Nefrologia, Dialisi, Trapianto, Fondazione IRCCS Policlinico San Matteo, Pavia, Italia
3 Dipartimento di Scienze Formative, Università di Catania e Unità operativa di Chirurgia vascolare e Centro trapianti – Ospedale Universitario, Catania, Italia
4 Dipartimento di scienze mediche e chirurgiche, Università di Catania e Unità operativa di Chirurgia vascolare e Centro trapianti – Ospedale Universitario, Catania, Italia
5 SC Chirurgia Generale, Fondazione IRCCS Policlinico San Matteo, Pavia, Italia
6 Developmental Psychopathology Research Unit, IRCCS Mondino Foundation, Pavia, Italia

Background: Living donor kidney transplantation (LDKT) is the treatment of choice for end stage renal disease. LDKT involves complex psychosocial issues, which remain partially unexplored.
Methods: The study involved all potential living donors and recipient pairs consecutively referred for psychosocial evaluation from the nephrologist. Clinical and sociodemographic variables including prior psychiatric history, previous and current use of psychopharmacological therapy, motivation and information about the transplant procedure were collected. Study participants completed the Symptom Checklist-90-R (SCL-90-R) to assess psychopathological distress.
Results: Fifty-three donor/recipient pairs underwent psychiatric and psychological evaluation. Seven subjects (13%) in the recipient group and 13 subjects (25%) in the donor group reported a history of psychological distress and/or psychiatric conditions. A psychiatric diagnosis was confirmed in 4 recipients (7.5% of the study sample, including autism spectrum disorder, histrionic personality disorder, and anxiety-depressive disorders) and 5 donors (9%, including narcissistic personality disorder in one case and anxiety-depressive disorders). SCL-90-R GSI mean scores were 0.3 ±0.3 and 0.2 ±0.2 for the recipient and donor groups, respectively. Overall, 8 couples (15%) suspended the living donation pathway before transplantation. Four couples were excluded for a new onset medical condition. The psychological and psychiatric evaluation excluded one candidate. One couple dropped out before completing the scheduled exams. One recipient refused to undergo crossover renal transplantation, while 1 donor candidate withdrew her consent for transplantation at the end of the evaluation process.
Conclusions: Limited but significant psychopathological distress in donors and recipients supports the usefulness of psychiatric and psychological competencies within the transplant team.

Keywords: living donor kidney transplantation, psychiatric disorders, psychological distress

A comparison between 24h urine collection and overnight spot urines in evaluating the risk of stone disease

Martino Marangella1, Michele Petrarulo2, Pietro Manuel Ferraro3,4, Roberto Miano5

1 Fondazione Scientifica Ospedale Mauriziano Onlus, Torino
2 Laboratorio Calcolosi Renale Ospedale Mauriziano, Torino
3 Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma
4 Università Cattolica del Sacro Cuore, Roma
5 Dipartimento di Urologia, Università di Tor Vergata, Roma

Despite being recommended by most guidelines, the metabolic evaluation of patients with nephrolithiasis has limited diffusion due to difficulties relating both to the access to laboratory investigations and to urine collection modalities. Consequently, in addition to the classical 24-h collection, alternative and simplified collection modes have been proposed. We report here on the comparison between metabolic evaluation carried out on 24-h double collection (Lithotest) and overnight spot urines (RF test). Fifty-four patients with stone disease were enrolled, excluding patients with infection or cystine stones. For Lithotest, we measured all analytes necessary to calculate state of saturation (ß) with calcium oxalate, brushite and uric acid, by means of For RF, we measured calcium, magnesium, oxalate, citrate, sulphate, phosphate, pH and creatinine. The comparison was made with creatinine ratios. An estimate of ßCaOx, ßbrushite and ßAU was obtained also on RF urines by using simplified algorithms. We found highly significant correlations between all parameters, despite quite different means. There was a nice correspondence between the two sets of measurements, assessed by the Bland-Altmann test, for calcium, oxalate, citrate, sulphate, urate and pH. Overnight urine had higher saturations compared to 24-h one owing to higher concentration of the former. In conclusion, RF test on overnight urine cannot completely replace Lithotest on 24-hr urine. However, it can represent a simplified tool for either preliminary evaluation or follow-up of patients with stone disease.


Keywords: metabolic evaluation, state of saturation, 24-h urine, spot urine, calcium nephrolithiasis, uric acid nephrolithiasis

Renal function performance in CKD stage 5: a sealed fate?

Daniela Cecilia Cannarile1, Matteo De Liberali1, Rossella Gaggi1, Chiara Reno2, Dino Gibertoni2, Elena Mancini1

1 U.O. Nefrologia, Dialisi, Ipertensione. IRCCS Azienda Ospedaliero-Universitaria di Bologna. Bologna, Italia
2 Dipartimento di Scienze Biomediche e Neuromotorie. Università di Bologna, Bologna, Italia

Introduction and aims: Stages 4 and 5 of chronic kidney disease (CKD) have always been considered hard to modify in their speed and evolution. We retrospectively evaluated our CKD stage 5 patients (from 01/1/2016 to 12/31/2018), with a view to analyzing their kidney function evolution.

Material and Methods: We included only patients with longer than 6 months follow-up and at least 4 clinical-laboratory controls that included measured Creatinine Clearance (ClCr) and estimated GFR with CKD-EPI (eGFR). We evaluated: the agreement between ClCr and eGFR through Bland-Altman analysis; progression rate, classified as fast (eGFR loss >5ml/min/year), slow (eGFR loss 1-5 ml/min/year) and non-progressive (eGFR loss <1 ml/min/year or eGFR increase). We also evaluated which clinical-laboratory parameters (diabetes, blood pressure control, use of ACEi/ARBs, ischemic myocardiopathy, peripheral obliterant arteriopathy (POA), proteinuria, hemoglobin, uric acid, PTH, phosphorus) were associated to the different eGFR progression classes by means of bivariate regression and multinomial multiple regression model. Results: Measured CrCl and eGFR where often in agreement, especially for GFR values <12ml/min. The average slope of eGFR was -3.05 ±3.68 ml/min/1.73 m2/year. The progression of kidney function was fast in 17% of the patients, slow in 57.6%, non-progressive in 25.4%. At the bivariate analysis, a fast progression was associated with poor blood pressure control (p=0.038) and ACEi/ARBs use (p=0.043). In the multivariable model, only peripheral obliterative arteriopathy proved associated to an increased risk of fast progression of eGFR (relative risk ratio=5.97).

Discussion: Less than one fifth of our patients presented a fast GFR loss (>5 ml/min/year). The vast majority showed a slow progression, stabilisation or even an improvement. Despite the limits due to the small sample size, the data has encouraged us not to consider CKD stage 5 as an inexorable and short journey towards artificial replacement therapy.


Keywords: chronic kidney disease, CKD, disease progression, glomerular filtrate, chronic renal failure

State of art and new perspectives in the induction regimen of ANCA-associated vasculitis with renal involvement: from histopathology to therapy

Martina Uzzo1, Federico Alberici2,3

1 Dipartimento di Medicina e Chirurgia, Università di Milano-Bicocca e ASST Monza, Monza, Italia
2 Dipartimento di Medicina e Chirurgia, Scienze Radiologiche e Salute Pubblica, Università di Brescia, Brescia, Italia
3 Unità di Nefrologia, Spedali Civili, ASST Spedali Civili di Brescia, Brescia, Italia

Anti-neutrophil cytoplasmic antibodies (ANCA)-associated vasculitis (AAV) are rare autoimmune diseases characterised by medium and small vessels inflammation. Renal vasculitic involvement is one of the most severe manifestations, with high mortality in case of a delayed diagnosis and a significant impact on patients’ long-term prognosis. Histological classifications and scores for the definition of renal involvement in AAV exist and correlate with the renal outcome. Current induction regimen consists of a high dose of glucocorticoids and immunosuppressive drugs: cyclophosphamide (CYC), rituximab (RTX) or a combination of both. RTX use is expanding thanks to randomised control trials suggesting its non-inferiority compared to the standard CYC therapy in general AAV and a better safety profile; its cost has also reduced thanks to the availability of biosimilars. However, the equivalence of RTX and CYC in patients with severe renal involvement is still debated.

The quest for the ideal induction regimen in AAV is moving towards a more personalized approach: on the one hand, efforts are made to use already existing therapies in the most appropriate way; on the other, new insights into AAV pathogenesis has allowed the discovery of new targets, such as the complement factor C5a.

Thanks to this new AAV management, renal outcome and overall survival has visibly improved. New studies are needed to reach a more personalized approach in the induction regimen of ANCA-associated glomerulonephritis and AAV in general.


Keywords: ANCA, vasculitis, glomerulonephritis, rituximab, cyclophosphamide, renal biopsy

Mini-invasive surgical techniques for rescuing the peritoneal catheter in refractory tunnel infections

Antonio Scalamogna1, Luca Nardelli1,2, Cosa Francesco3, Pisati Silvia1, Piergiorgio Messa1,2

1 UOC di Nefrologia, Dialisi e Trapianti di Rene, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano, Italia
2 Scuola di Specializzazione in Nefrologia, Università degli Studi di Milano, Milano, Italia
3 UOC di Nefrologia e Dialisi, Ospedale di Legnano, ASST Milano Ovest, Legnano (MI), Italia

Infections continue to be a major cause of morbidity and mortality in patients on renal replacement therapy with peritoneal dialysis (PD). Despite great efforts in the prevention and treatment of infective complications over the two past decades, catheter-related infections represent the most relevant cause of technical failure. Recent studies support the idea that exit-site/tunnel infections (ESI/TI) have a direct role in causing peritonitis. Since the episodes of peritonitis secondary to TI lead to catheter loss in up to 86% of cases, it is advised to remove the catheter when the ESI/TI does not respond to medical therapy. This approach necessarily entails the interruption of PD and, after the placement of a central venous catheter, the shift to haemodialysis (HD). In order to avoid the change of dialytic method, the simultaneous removal and replacement (SCR) of the PD catheter has also been proposed. Although SCR avoids temporary HD, it requires the removal/reinsertion of the catheter and the immediate initiation of PD, with the risk of mechanical complications such as leakage and malfunction. Several mini-invasive surgical techniques have been employed as rescue procedures: curettage, cuff-shaving, the partial reimplantation of the catheter and the removal of the superficial cuff with the creation of a new exit-site. These procedures allow to save the catheter and have a success rate of 70-100%. Therefore, in case of ESI/TI refractory to antibiotic therapy, a mini-invasive surgical revision must always be considered before removing the catheter.


Keywords: peritoneal dialysis, exit-site infection, tunnel infection, peritonitis, cuff-shaving, ultrasounds.

CEUS, a world to discover. Three clinical cases and literature review

Marina Cornacchiari1, Anna Mudoni2, Bianca Visciano1, Marco Mereghetti3, Carlo Guastoni1

1 ASST Ovest Milanese, Ospedale Magenta, Nefrologia e Dialisi. Magenta (MI), Italia
2 UOC di Nefrologia e Dialisi, Azienda Ospedaliera Card. G. Panico. Tricase (LE), Italia
3 ASST Ovest Milanese, Ospedale Magenta, Reparto di Medicina. Magenta (MI), Italia
Tutti gli autori hanno partecipato nella stesura dell’articolo in ugual misura

Currently, CEUS (Contrast-Enhanced UltraSound) is used in the evaluation of different organs and systems. It offers valuable information about vascular disease, both on a macro- and a micro-vascular level, and has a series of well-established applications in the monitoring of adult patients; official guidelines and recommendations are also available. Its use in a nephrological setting is constantly growing thanks to the lack of nephrotoxicity of the contrast agent, the absence of ionizing radiation and the possibility of characterizing focal pathologies, for diagnosis and in clinical practice. We describe here 3 clinical cases relating to renal diseases and we review the relevant literature with a specific focus on the use of CEUS in a nephro-urological setting.


Keywords: Contrast-enhanced ultrasound, CEUS, contrast agents, imaging, microbubbles

Lettera a Francesco. In memoria di Francesco Quarello (16/08/1944 – 7/10/2020)

The origin of the modern Italian nephrology at the dawn of the 20th century

Attilio Losito M.D.

Ospedale Santa Maria Della Misericordia, Perugia, Italy

The author singled out the first decade of the 20th century as the time in which the renewal of academic medicine in post-unification Italy was concluded, while the changes that would be induced by the following war had not yet started. A bibliographic research relating to this period was undertaken with the aim of investigating the number and the quality of the studies on kidneys published by Italian scientists. A total of 176 publications of Italian scientists dealing with kidney diseases or physiology was retrieved, 10.8% of which was published on foreign journals. The analysis of the topics treated shows that they were up to date and comparable with the contemporary studies across Europe. Moreover, the issues raised remained of interest throughout the following decades up to our day. Top Italian researchers were fairly cited, especially if they published on international journals. While at the time the state of other organs was mainly assessed by examining physical signs and symptoms, kidney studies required laboratory facilities. This limitation meant that kidney scholars usually belonged to well established medical faculties. From these schools, a few figures stood out among the others for the importance of their studies, both physiological and clinical in nature. The same figures also gave birth to the major Italian schools of internal medicine from which, half a century later, originated the Italian Society of Nephrology. The findings of this research support the conclusion that the basis of modern nephrology can be traced back to that decade.

Keywords: nephrology, history, Italy, clinical schools.

The CROFF pavilion at the Policlinico Hospital in Milan: the beginnings

Giovanni B. Fogazzi1, Diego Brancaccio, Claudio Ponticelli, Bruno Redaelli, Giorgio Graziani, Enrico Imbasciati, Francesco Locatelli, Emilio Rivolta

1 U.O.C. di Nefrologia, Dialisi e Trapianto di Rene, padiglione Croff, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano

This article collects the personal stories of the young doctors who in the early sixties contributed to the birth and development of the Croff pavilion at the Policlinico Hospital in Milan. Inaugurated on October 19, 1964, this has been the first institute in Italy entirely devoted to patients with kidney diseases. Since its inception, it has significantly contributed to the progress of nephrology thanks to important and pioneering investigations in the main fields of our specialty, which still continue nowadays. The different stories reported here follow the chronological order in which the young doctors arrived at Croff, each story representing a personal narrative that interweaves and integrates that of others. This gives rise to a vivid many-voiced account, from which emerge not only the figures of these young doctors, but also those of patients, nurses, and laboratory technicians.

Keywords: history of nephrology, history of Italian nephrology, history of dialysis, history of kidney transplant, history of renal histopathology

How to create and preserve distal fistulas in a large number of patients: the experience of a single centre

Marcello Napoli, Anna Zito, Maria Luisa Lefons, Paolo Ria, Emiliana Ferramosca, Vilma Martella, Maria Caterina Carbonara, Efisio Sozzo, Antonio De Pascalis

Nephrology Unit Vito Fazzi Hospital, Lecce. Italy.

Background: Distal arterio-venous fistula (AVF) is considered the gold standard for vascular access in hemodialysis. The aim of this retrospective study is to report our experience on two innovative techniques, Intraoperative Transluminal Angioplasty (ITA) and Vessel Pre-Dilatation (VPD).
Methods: We collected data from all the consecutive patients directly admitted to our Department from January 2014 to October 2018 in order to create or repair an AVF. Early Failure (EF), Failure to Mature (FTM), Late Failure (LF), Primary and Secondary patency rate were evaluated.
Results: All patients underwent VPD; of the total 647 AFVs, 128 received an ITA for the presence of suboptimal vessels. 98.3% of AVFs were located on the forearm. EF occurred in 83 cases; in 67 of these a new AVF was successfully created upstream from the previous one. LF occurred in 100 cases; of these, the access was abandoned in 32 cases and we performed a new AVF upstream from the previous one in 68 cases. FTM occurred in 57 cases, 31 of which were treated with Percutaneous Transluminal Angioplasty (PTA) whilst 26 were resolved performing a new anastomosis upstream. Primary and secondary patency at 1, 2, 3 and 4 years were, respectively, 80%, 74%, 68%, 64% and 94%, 91%, 89%, 88%. By dividing patients into an ITA group and a control group, we did not find any difference in primary and secondary patency.
Conclusions: VPD and ITA could be useful to increase the incidence and the prevalence of distal AVF.

Keywords: intraoperative transluminal angioplasty, vessel pre-dilatation, distal arterio-venous fistula, early failure, failure to mature, late failure, patency

Infection-related glomerulonephritis: the new face of an old disease

Mattia Zappa1,2, Chiara Salviani2, Mario Gaggiotti2, Federico Alberici1,2, Francesco Scolari1,2

1 U.O. Nefrologia – ASST Spedali Civili di Brescia
2 Dipartimento di Specialità Medico-Chirurgiche, Scienze Radiologiche e Sanità Pubblica – Università degli Studi di Brescia

In the last decades there have been important changes in the epidemiology and natural history of bacterial infection-related glomerulonephritides. Once defined as an infancy-onset acute nephritic syndrome following a streptococcal infection, and characterized by a relative benign course, infection-related glomerulonephritis nowadays also affects the adult population, particularly the elderly and the chronically ill. The infectious agents and infection sites have become more diversified, and the prognosis is burdened by a higher rate of mortality, chronic kidney disease, end-stage renal disease and acute overload complications.

In this review we highlight the main clinical features of infection-related glomerulonephritis, offering an insight into its pathogenesis and the elements that allow an appropriate differential diagnosis. We also address the uncertainties around the role of immunosuppression in its therapeutic management.


Keywords: glomerulonephritis, infection, nephrotic syndrome, Staphylococcus.

Therapeutic options to reduce arterial stiffness in chronic kidney disease

Concetto Sessa1, Pietro Castellino2, Giovanni G Battaglia3, Pasquale Fatuzzo4, Agostino Gaudio2, Antonio Granata5, Paolo Lentini6, Carmelita Marcantoni7, Walter Morale1, Salvatore Musso1, Francesco Rapisarda4, Domenico Santoro8, Luca Zanoli4,7. For the Inflammation and Arterial Stiffness Study Group.

1 U.O.C. Nefrologia e Dialisi, P.O. “Maggiore” di Modica, Ragusa (RG), Italy
2 Medicina Interna, Dipartimento di Medicina Clinica e Sperimentale, Università di Catania, Catania (CT), Italy
3 U.O.C. Nefrologia e Dialisi, P.O. S. Marta e S. Venera, Acireale (CT), Italy
4 Nefrologia, Dipartimento di Medicina Clinica e Sperimentale, Università di Catania, Catania (CT), Italy
5 U.O.C di Nefrologia e Dialisi, A.O. per l’Emergenza “Cannizzaro”, Catania (CT), Italy
6 U.O.C. Nefrologia e Dialisi, Ospedale San Bassiano, Bassano del Grappa (VI), Italy
7 U.O. Nefrologia e Dialisi, A.O.U. Policlinico Catania, Catania (CT), Italy
8 U.O.C. Nefrologia e Dialisi, Dipartimento di Medicina Clinica e Sperimentale, Università di Messina, Messina (ME), Italy

Chronic kidney disease is associated with an increased cardiovascular risk. Several uremic toxins are also vascular toxins and may contribute to the increase of the cardiovascular risk through the development of aortic stiffening. In this process, oxidative stress and endothelial dysfunction play an important role. Considering that aortic stiffness is a known cardiovascular risk factor and a vascular biomarker involved in the development of chronic cardiac dysfunction, and that the reduction of aortic stiffness is associated with an improved survival of patients with end-stage kidney disease, we aim at reviewing the therapeutic options to reduce aortic stiffness and potentially the cardiovascular risk.


Keywords: arterial stiffness, cardiorenal syndrome, chronic kidney disease, inflammation, intima-media thickness, uremic toxins

Application of proteomics and metabolomics to study inherited kidney disorders: from big data to precision medicine

Angela Cervesato1#, Raffaele Raucci1#, Dario Buononato1, Emanuela Marchese3, Giovanna Capolongo1, Alessandra Perna1, Giovambattista Capasso1,2, Miriam Zacchia1

1 Sezione di Nefrologia, Dipartimento di Scienze Mediche Traslazionali, Università degli Studi della Campania “L. Vanvitelli”
2 Biogem Scarl, Ariano Irpino (AV)
3 Dipartimento di Salute Mentale e Fisica e Medicina Preventiva, Università degli Studi della Campania “L. Vanvitelli”
# Questi autori hanno contribuito in maniera eguale al manoscritto

The recent application of proteomics and metabolomics to clinical medicine has demonstrated their potential role in complementing genomics for a better understanding of diseases’ patho-physiology. These technologies offer the clear opportunity to identify risk factors, disease-specific or stage-specific biomarkers and to predict therapeutic response. This article is an overview of the recent insights obtained by metabolomic and proteomic studies in inherited kidney disorders. Proteomics studies have allowed the definition of a detailed picture of protein composition, post-translational modifications and interactions in kidney-derived samples, improving our understanding of renal physiology, especially of tubular transport and primary cilium-related functions. Studies on patients’ urine samples and experimental models of inherited kidney diseases have provided clues suggesting novel potential pathological mechanisms and biomarkers of disease, for example in polycystic kidney disease. Metabolomic-based studies have been recently applied to assess biological system disturbances caused by specific genetic mutations resulting in inherited kidney disorders. These studies have been mainly carried out on mouse and rat models of cystic and metabolic disorders (such as Fabry disease), and on patients’ urine samples. They have provided a significant contribution in understanding disease pathophysiology, promoting the discovery of aberrant biochemical pathways and contributing to the development of targeted therapies.


Keywords: proteomics, metabolomics, inherited kidney disorders, ciliopathies, tubulopathies, Fabry disease

COVID-19 emergency management at the Nephrology and Dialysis Unit in Savona, Albenga and Cairo Montenotte

Monica Repetto1, Carmela Caputo1, Marzia Ciabattoni1, Debora Garneri1, Oscar Santoni1, Alice Tarroni1, Fanny Tosetti1, Emanuela Chiara Vigo1, Laura Cappuccino1, Anna Maria Murgia1, Giancarlo Mancuso1

1 ASL 2 SSR Liguria, Struttura Complessa Nefrologia e Dialisi

Our Nephrology and Dialysis Unit includes three Haemodialysis Centres based in Savona, Albenga and Cairo Montenotte. These provide assistance to 150 patients. We have a Peritoneal Dialysis Clinic with 35 patients, two Post-Transplant Clinics with about 120 patients in follow-up in Savona and Albenga, and three Pre-Dialysis Clinics across the three locations. Finally, there is an autonomous hospital ward with 15 beds that has continued its activity, even if at reduced regimes.

With this report we intend to share the strategy we used to prevent the spread of the SARS CoV-2 virus among the patients and the staff at our Unit, following the National, Regional and Corporate guidelines published during “Phase 1”.

We decided that the Haemodialysis Centres needed to remain a safe place. To insure this, medical and nursing staff and patients had to behave conscientiously and collaboratively, and according to the official Hospital guidance. Our main concern was to protect patients who, despite suffering complications and being at high risk because of their age, immunodepression and multiple comorbidities, were forced to leave their house three times a week to be treated with dialysis.

The results of this strategy have ensured that, of the 150 patients undergoing haemodialysis, only 3 have been tested positive: no patients in Albenga, 2 in Savona and 1 in Cairo Montenotte, all of them lived and were infected in their nursing homes. Also, there was no positivity among any of the staff members across the three locations.

Our results are extremely positive and confirm the validity that prevention and protection procedures had in the earlier stages of the pandemic.


Keywords: COVID-19, safety, prevention, dialysis

SARS CoV-2 related disease features in a population of chronic hemodialysis patients

Cristina Silvestri1, Silvio Di Stante1, Veronica Bertuzzi1, Mauro Martello1, Marco Palladino1, Xhensila Grabocka1, Hrissanthi Kulurianu1, Flavia Manenti1, Francesca Pizzolante1, Assunta Cardillo1, Angelo Francioso1, Osmy Paci Della Costanza1, Chiara Valentini1, Marina Di Luca1

1 U.O.C. Nefrologia e Dialisi Azienda Ospedaliera Ospedali Riuniti Marche Nord Pesaro – Fano

Patients on chronic dialysis have an increased risk for SARS CoV-2 virus disease and its complications because of multiple comorbidities and alterations in the immune response caused by renal disease. In this retrospective observational study we describe the clinical features and the evolution of SARS CoV-2-related disease in 19 patients of our Pesaro and Fano facilities, where incidence and mortality of the epidemic were among the highest in Italy. A total of 176 patients were undergoing chronic treatment, 153 hemodialysis and 23 peritoneal dialysis. The incidence of infection was 10,8%, with 84% needing hospitalization and mortality amounting to 53%. The most frequent onset symptom was fever (84,2%) and the most used therapy was an association of low molecular weight heparin and hydroxychloroquine (57,9%).

Comparing the deceased and survivor populations we noticed significant differences in age and presence of cardiopathy for what concerns anamnestic data and in fatigue and dyspnea in terms of clinical presentation. LDH and CPK resulted highest among deceased patients, while the use of enoxaparin was more frequent in survivors. By observing contagions over time, we also noticed that most of the cases, and the ones with worse clinical condition and outcome, all occurred in the early stage of the epidemic and in particular within the first 20 days from the implementation and codification of the measures to prevent its spread, the only modifiable factor that had an unmistakable effect on the evolution of events.


Keywords: SARS Cov-2, COVID-19, dialysis, nephrology

The COVID-19 pandemic and hemodialysis: a multicentric experience

Antonino Previti1*, Paolo Lentini2*, Antonio Di Caprio2, Milvia Marchiori1, Roberto Dell’Aquila1-2

* Questi autori hanno contribuito in maniera eguale alla stesura dell’articolo
1 UOC Nefrologia e Dialisi, Ospedale Alto Vicentino, Santorso (VI), Italia
2 UOC Nefrologia e Dialisi, Ospedale San Bassiano, Bassano del Grappa (VI), Italia

The SARS-CoV-2 pandemic has forced a reshaping of economic, productive, commercial and healthcare systems. The last one had the dual mandate to limit intra-hospital infections and strengthen its ability to deal with the ongoing emergency. In this paper we report the experience gained by the staff of the Nephrology and Dialysis Unit of the AULSS7 Pedemontana (Vicenza – Veneto region) and the organizational model pursued during the first wave of the pandemic.


Keywords: hemodialysis, SARS-Cov2, COVID center, CRRT

Covid-19 pandemic: an anthropological emergency

Fabio Cembrani1 e Giuliano Brunori2

1 Direttore U.O. di Medicina legale, Azienda provinciale per i Servizi sanitari di Trento
2 Direttore U.O. di Nefrologia, Ospedale S. Chiara di Trento. Past president della Società italiana di Nefrologia

Come editore del giornale ho voluto dare spazio alle esperienze di chi ha affrontato le fasi iniziali della malattia con grande competenza scientifica ed organizzativa. Si tratta di uno spaccato di ciò che è avvenuto, fatto di linee guida e di orientamenti clinici, per la maggior parte condivisi successivamente tra tutti i centri. Questa sezione è dedicata a chi per primo ha dovuto affrontare l’esplosione del contagio in Italia e ha avviato percorsi terapeutici ed organizzativi che sono stati di grandissima utilità a tutti, affinché tutti potessimo organizzarci e provvedere a fronteggiare quell’onda che ha colpito, in misura più o meno severa, tutto il nostro territorio, e non solo.
Gaetano La Manna

In memory of Giovanni Civati (14/11/1939-12/7/2020)

The specialist skills of the nurse in hemodialysis: report of an explorative survey. A challenge for professional recognition

Daniele Giannerini1, Francesco Rossi1, Sara Bocci Benucci2, Mirco Pertici1, Stefano Troiani1, Jessica Sanchez Pisfil3, Paolo Maria Tommaso Procaccio4, Cristiano Magnaghi5, Maria Teresa Parisotto6, Danilo Massai7, Duilio Fiorenzo Manara8, Elena Brioni8

1 U.O. Nefrologia e Dialisi, Azienda Ospedaliero Universitaria Careggi, Firenze, Italy
2 Facoltà di Psicologia, Università degli studi di Firenze, Firenze, Italy
3 Servizio di Emodialisi dell’IFCA, Casa di Cura Ulivella e Glicini, Firenze, Italy
4 Nefrologia e Dialisi Santa Maria Nuova, Firenze, Italy
5 U.O Nefrologia e Dialisi, IRCCS Ospedale San Raffaele, Milano, Italy
6 European Specialist Nurses Organization (ESNO), Bruxelles, Belgium
7 Ordine delle Professioni Infermieristiche Firenze-Pistoia, Firenze, Italy
8 Università Vita-Salute San Raffaele, Milano, Italy

Nursing requires a complex set of skills encompassing professional clinical judgment, values and attitudes. In order to outline the future career path of the specialist nurse, the European Federation of Nurses Association compared the EU Directive 2013/55/EU with the Competency Framework, an important document on guidelines written by a group of experts and focusing on the recognition of nurses’ educational requirements.

The aim of our research is to identify the special skill set required from nurses on haemodialysis wards through the development of an exploratory survey and the comparison of its results with the EFN guidelines and the Directive 2013/55/EU. The survey was conducted across eighteen dialysis centers in Tuscany. Through focus groups, debates and reflections, 28 skills were identified as pertaining exclusively to nurses working with haemodialysis patients.

This preliminary study aims at demonstrating the need to define and recognize these specialist skills in order to ensure an effective and integrated nursing leadership in disease management.


Keywords: haemodialysis, skills, specialization, nurse

Spondylodiscitis in hemodialysis patients: a new emerging disease? Data from an Italian Center

Lara Traversi1*, Elisa Nava1*, Brunilda Xhaferi2, Giada Giovanna Olga Bigatti1, Silvia Tedoldi1, Tiziana Mazzullo1, Irene Maria Caterina Botticelli1, Stefania Martino1, Margarita Nora Villa1, Daniele Ciurlino1, Silvio Volmer Bertoli1

1 Nephrology and Dialysis Unit, IRCCS Multimedica, Sesto San Giovanni, Milan, Italy
2 Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy

* These authors contributed equally to this manuscript

Hemodialysis (HD) patients are at high risk for infectious complications such as spondylodiscitis. The aim of this retrospective study was to evaluate the cases of infective spondylodiscitis occurred between May 2005 and October 2019 among HD patients at our center.

In 14 years, there were 9 cases (mean age 69±12 years). The main comorbidities found were diabetes mellitus (55.6% of patients), hypertension (55.6%), bone diseases (22.2%), cancer (11.1%) and rheumatoid arthritis treated with steroids (11.1%). The clinical onset included back pain (100% of cases), fever (55.6%), neurological deficits (33.4%), leukocytosis (55.6%) and elevated CRP level (88.9%).

Most cases were diagnosed by magnetic resonance imaging (66.7%) with more frequent involvement of lumbar region (77.8%). Blood cultures were positive in five patients (mostly for S. aureus); three of them used catheters as vascular access and, in two cases, their removal was necessary. The mean time interval between the onset of symptoms and the diagnosis was 34±42 days.

All patients received antibiotic treatment for a mean duration of 6 weeks; most cases were initially treated with vancomycin or teicoplanin plus ciprofloxacin. Most patients (77.8%) recovered after a mean of 3.5 months; one patient had a relapse after 2 years and one patient had long-term neurologic sequelae.

Infective spondylodiscitis in HD must be suspected in the presence of back pain, even in the absence of fever or traditional risk factors. An early diagnosis could improve the outcome. Close monitoring of vascular access, disinfection procedures and aseptic techniques are important to avoid this complication.


Keywords: spondylodiscitis, hemodialysis, back pain, vascular access, infectious complications, bacteremia

Utility of computerized vascular access monitoring: a pilot study

Giovanni Grasso1, Laura Buzzi1, Maria Cristina Gambirasio1, Paolo Fabbrini1, Ivano Baragetti1

1 UO Nefrologia e Dialisi, Ospedale Bassini ASST Nord Milano, Cinisello Balsamo, Italia

The surveillance of a vascular access (VA) is of primary importance for its outcome and for the patients’ survival. However, there is still confusion about its usefulness, who should make it (physician or nurse) and when, and what is the best functional test to use. This retrospective analysis reports our experience of VA monitoring; it is based on the collaboration between concept doctors and nurses and on parameters integration, realized with the help of a software for vascular access monitoring (SMAV) designed by us. The analysis confronts the data gathered on a group of 100 patients, 13 months before the adoption of the SMAV, and another 100 patients, 19 months after. Of these patients, 13 belonged to both groups and were “controls of themselves”. The number of thrombosis and angioplasties (PTA) plummeted in the 19 months in which the SMAV was used, from 10 (10%; 0.008 thrombosis/patient month) to 1 (1%; 0.0005 thrombosis/patient month) (p <0.01) and from 49 (49%; 0.037 PTA/patient month) to 27 (27%; 0.014PTA/patient month) (p <0.05) respectively. In the 13 control patients, a reduction of 70% in the number of PTA (from 26 to 8) was observed. SMAV allowed us to integrate the many functional parameters, making it easy to share information, encouraging teamwork, strengthening professional skills, and favouring the best management of AVs. The result was a reduction in thrombotic events and, surprisingly, a reduction of the need for PTA, most likely thanks to the higher level of attention in the evaluation and puncture of AV.


Keywords: arterio-venous fistula, surveillance, SMAV

Long-term efficacy and safety of etelcalcetide in hemodialysis patients with severe secondary hyperparathyroidism

Carlo Massimetti1, Marco Tondo1, Sandro Feriozzi1

1 Centro di Riferimento di Nefrologia e Dialisi, Ospedale Belcolle, Viterbo

Introduction: Etelcalcetide has proven effective and well tolerated in the treatment of secondary hyperparathyroidism (IPS) in patients on hemodialysis (HD). Since long-term studies are scarce, we assessed the efficacy and safety of etelcalcetide in the treatment of severe IPS in a group of HD patients over a 12-month period. Patients and Methods: We selected 24 HD patients with PTH levels > 500 pg/mL (range 502-2148 pg/mL), despite following a therapy with cinacalcet and/or vitamin D analogues. The initial dosage of etelcalcetide was 7.5 mg/week, then it was adjusted based on the trend of the levels of the total albumin-corrected serum calcium (CaALb_c) and PTH. Treatment was temporarily suspended if CaALb_c levels were <7.5 mg/dL or if hypocalcemia was symptomatic. CaALb_c, phosphorus, PTH and total alkaline phosphatase (t-ALP) were measured monthly. The main endpoint was the decrease in PTH levels >30% compared to baseline values. Results: At F-U, the reduction in PTH levels was > 30% in 83% of our patients. PTH levels decreased from 1169 ± 438 to 452±241 pg/mL at F-U (P <0.001). The percentage of reduction in PTH levels at F-U was -56 ± 25%. CaALb_c and phosphate levels decreased from 9.8 ± 0.4 mg/dL to 9.0 ± 0.6 mg/dL (P <0.001), and from 6.1 ± 1.3 mg/dL to 4.9 ± 1.3 mg/dL (P <0.01), respectively. The main side effect was hypocalcaemia, but never so severe as to require the interruption of treatment. Hypocalcemia was more pronounced in patients with higher basal levels of PTH and t-ALP. During the study, the percentage of patients treated with calcium carbonate increased from 33% to 54% and that of patients treated with paricalcitol from 33% to 79%. At F-U the average weekly dosage of etelcalcetide was 21.0 ± 9.5 mg (range 7.5-37.5 mg/week). Conclusions: The treatment of severe IPS with etelcalcetide has been proved effective and safe in the long term. Hypocalcaemia, the most frequent side effect, was more evident in patients with the most severe forms of IPS and was probably due to a reduction in bone turnover rather than to the direct effect of etelcalcetide.


Key words: etelcalcetide, hemodialysis, secondary hyperparathyroidism, paricalcitol, cinacalcet.

Resilience in COVID-19 times: general considerations on the recovery of a 93-year-old patient on haemodialysis treatment

Giovanni Mosconi1, Alessandra Spazzoli1, Paolo Ferdinando Bruno1, Maria Laura Angelini1, Stefania Cristino1, Maria Francesca Lifrieri1, Claudio Americo1, Marco De Fabritiis1, Katia Ambri1, Giorgio Dirani2, Simona Semprini2, Vittorio Sambri2, Loretta Zambianchi1

1 Unità Operativa Nefrologia e Dialisi, Forlì-Cesena
2 Unità Operativa Microbiologia – Laboratorio Unico Azienda USL della Romagna

We report the case of a 93-year-old woman on haemodialysis treatment for more than 30 months and with multiple comorbidities who recovered from a Covid-19 infection without any significant clinical problems. The patient has shown a delay in viral clearance with swab test negativization (confirmed) after 33 days; after testing positive again, she has resulted persistently negative, (confirmed after 49 days).

After the first negative swab, IgG and IgM antibodies have been found; these have remained persistently positive after a month. As well as highlighting an unexpected resilience in an extremely fragile context, the analysis of this case draws attention to patients’ management and, potentially, to the need to arrange dialysis treatments in isolation for some time after their “laboratory recovery”.


Keywords: Covid-19, dialysis, resilience, nasal swab, antibodies

Multidisciplinary management of a typical case of acute kidney failure in the course of COVID-19 infection

Carmela Caputo, Marzia Ciabattoni, Debora Garneri, Monica Repetto, Oscar Santoni, Alice Tarroni, Fanny Tosetti, Emanuela Chiara Vigo, Giancarlo Mancuso

S.C. Nefrologia e Dialisi Ospedale San Paolo Savona

We report the case of a 68-year-old patient who arrived at the hospital with a fever and a cough for 7 days, a history of high blood pressure and chronic kidney failure stage 2 according to CKD-EPI (GFR: 62 ml/minute with creatinine: 1.2 mg/dl). Home therapy included lercanidipine and clonidine. A chest radiograph performed in the emergency department immediately showed images suggestive of pneumonia from COVID-19, confirmed in the following days by a positive swab for coronavirus. Kidney function parameters progressively deteriorated towards a severe acute kidney failure on the 15th day, with creatinine values of 6.6 mg/dl and urea of 210 mg/dl. The situation was managed first in the intensive care unit with CRRT cycles (continuous renal replacement therapy) and then in a “yellow area” devoted to COVID patients, where the patient was dialyzed by us nephrologists through short cycles of CRRT. In our short experience we have used continuous techniques (CRRT) in positive patients hemodynamically unstable and intermittent dialysis (IRRT) in our stable chronic patients with asymptomatic COVID -19. We found CRRT to be superior in hemodynamically unstable patients hospitalized in resuscitation and in the “yellow area”. Dialysis continued with high cut-off filters until the normalization of kidney function; the supportive medical therapy has also improved the course of the pathology and contributed to the favorable outcome for our patient. During the COVID-19 pandemic, our Nephrology Group at Savona’s San Paul Hospital has reorganized the department to better manage both chronic dialyzed patients and acute patients affected by the new coronavirus.


Keywords: COVID-19, “yellow area”, AKI, ACE2, viral particles, nephrology, CRRT

SARS-CoV-2: recommendations on nursing care for dialyzed and transplanted patient

Luigi Apuzzo1, Mara Canzi2, Maria Pia Zito2, Marilena Galli2, Cristiana Dente2, Emiliana Scarpo 2, Grazia Stefanizzi2, Marco Del Pin3, Cinzia Fabbri2

1 SIAN-Italia Board Research Centre, Bologna; AORN Sant’Anna e San Sebastiano di Caserta
2 Comitato direttivo SIAN-Italia, Bologna
3 Webmaster SIAN-Italia, Udine

Coronavirus disease 2019 is an infectious respiratory syndrome caused by the virus called SARS-CoV-2, belonging to the family of coronaviruses. The first ever cases were detected during the 2019-2020 pandemic. Coronaviruses can cause a common cold or more serious diseases such as Middle Eastern Respiratory Syndromes (MERS) and Severe Acute Respiratory Syndrome (SARS). They can cause respiratory, lung and gastrointestinal infections with a mild to severe course, sometimes causing the death of the infected person. This new strain has no previous identifiers and its epidemic potential is strongly associated with the absence of immune response/reactivity and immunological memory in the world population, which has never been in contact with this strain before. Most at risk are the elderly, people with pre-existing diseases and/or immunodepressed, dialyzed and transplanted patients, pregnant women, people with debilitating chronic diseases. They are advised to avoid contacts with other people, unless strictly necessary, and to stay away from crowded places, also observing scrupulously the recommendations of the Istituto Superiore di Sanità.

In this article we detail the recommendations that must be followed by the nursing care staff when dealing with chronic kidney disease patients in dialysis or with kidney transplant patients. We delve into the procedures that are absolutely essential in this context: social distancing of at least one meter, use of PPI, proper dressing and undressing procedures, frequent hand washing and use of gloves, and finally the increase of dedicated and appropriately trained health personnel on ward.


Keywords: COVID-19, hemodialysis, transmission, prevention

Reorganization of haemodialysis during COVID-19 emergency: a report from Dialysis Centers of Parma province

Cristina Zambrano1, Vincenzo Oliva1, Elisabetta Parenti1, Tommaso Di Motta1, Alessio Di Maria1, Maria Teresa Farina1, Andrea Palladini1, Alice Parmigiani1, Paola Affanni2,3, Maria Eugenia Colucci2,3, Cesira Isabella Maria Pasquarella2,3, Sarah Pioli4, Enrico Fiaccadori1,3

1 UO Nefrologia, Azienda Ospedaliera Universitaria di Parma, Parma
2 Laboratorio di Igiene e Sanità Pubblica, Dipartimento Medicina e Chirurgia Università di Parma
3 Dipartimento di Medicina e Chirurgia, Università di Parma, Parma
4 CAL Parma, AUSL Parma, Parma

The epidemic wave that hit Italy from February 21st, 2020, when the Italian National Institute of Health confirmed the first case of SARS‑CoV‑2 infection, led to a rapid and efficient reorganization of Dialysis Centers’ activities, in order to contain large-scale spread of disease in this clinical setting.

We herein report the experience of the Hemodialysis Unit of Parma University Hospital (Azienda Ospedaliero-Universitaria, Parma, Italy) and the Dialysis Centers of Parma territory, in the period from March 1st, 2020 to June 15, 2020.

Among patients undergoing chronic haemodialysis, 37/283 (13%) had positive swabs for SARS‑CoV‑2, 9/37 (24%) died because of COVID-19. Twenty-three patients required hospitalization, while the remaining were managed at home.

The primary measures applied to contain the infection were: the strengthening of personal protective equipment use by doctors and nurses, early identification of infected subjects by performing oro-pharyngeal swabs in every patient and in the healthcare personnel, the institution of a triage protocol when entering Dialysis Room, and finally the institution of two separate sections, managed by different doctors and dialysis nurses, to physically separate affected from unaffected patients and to manage “grey” patients.

Our experience highlights the importance and effectiveness of afore-mentioned measures in order to contain the spread of the virus; moreover, we observed a higher lethality rate of COVID-19 in dialysis patients as compared to the general population.


Keywords: COVID-19, haemodialysis, Parma, Emilia-Romagna

The peak of the Coronavirus emergency and hemodialysis patients: the experience of the Dialysis Center in Crema

Giorgio Carlo Depetri1, Maria Alessandra Brazzoli1, Fabio Puricelli1, Valeria Ogliari1, Cristina Tantardini1, Angelo Grassini2

1 UO Nefrologia e Dialisi ASST-Crema, Italia
2 UO Laboratorio analisi chimico-cliniche ASST-Crema, Italia

Lombardy was violently hit by Covid-19 between the end of February and the beginning of March 2020. On 09.05.2020 there were 81225 total registered Covid-19+ cases (8051 / million inhabitants) with 14924 deaths (1479 deaths / million inhabitants). The province of Cremona presented a higher number of Covid-19+ cases and a worse relative mortality than the already high regional average.

Patients on regular hemodialysis treatment present a high risk of infection due to the co-pathologies present, while healthcare workers may represent a risk for themselves and for the patients, due to the treatment environment and the close contact with them.

All patients and healthcare workers of the Dialysis Center in Crema were evaluated (oro-pharyngeal swab for viral RNA research, qualitative anti-Covid-19 antibodies, quantitative IgG antibodies, co-pathologies), regardless of the symptomatology, over a 60-day period.

Hemodialysis patients have a risk of infection that is 12.7 times that of the local population, while healthcare workers outperform the patients for Covid-positivity (30.3% vs 21.6%). Lethality in infected patients is high (31% of Covid-19+ subjects), while it is zero among healthcare professionals. The antibody response (qualitative and quantitative) in Covid-19+ patients is adequate, when compared to that of Covid-19+ healthcare staff.

In our Center, the most critical phase lasted about 45 days but, thanks to the measures taken, it was possible to make the dialysis area Covid-free, as it remains after 128 days.


Keywords: Covid-19, Haemodialysis, LIAISON SARS-CoV2 S1/S2, JusCheck 2019-nCoVIgG/IgM

Efficacy of serological tests for COVID-19 in asymptomatic HD patients: the experience of an Italian hemodialysis unit

Lorena Traversari1, Manuela Camilli1

1 U.O.S.D Nefrologia, AUSL Toscana sudest, Ospedale S. Andrea Massa Marittima, Italia.

We report the brief experience of the Nephrology Center located in a “no-COVID” Hospital in Massa Marittima.

We describe the actions taken to prevent the transmission of the virus SARS-CoV-2 among hemodialysis patients and healthcare workers and the methods for diagnosing COVID-19, with particular attention to serological tests and nasopharyngeal swabs in asymptomatic subjects.

The detection of IgM and IgG antibodies through the serological test performed on 34 patients, all negative for nasopharyngeal swabs, showed positivity in 41,18% of cases. These have been classified as false positives following repeated negative nasopharyngeal swabs, the evaluation of clinical and epidemiological history and of clinical manifestations and, finally, a second serological test performed after 18 days, which resulted negative for all patients.

Interpreting serological tests is not easy; the strategies for diagnosis should include clinical and epidemiological history and clinical manifestations, as well as the results of confirmation tests and the evaluation over a precise observation period. Otherwise, there is a risk of considering as protected by antibodies subjects that are in fact false positives.


Keywords: COVID-19, SARS CoV-2, serological tests, asymptomatic subjects, false positives


Piergiorgio Messa

Presidente Incoming Società Italiana di Nefrologia
Università degli Studi di Milano
UOC Nefrologia Dialisi e Trapianto
Fondazione IRCCS Ca’ Granda
Ospedale Maggiore – Policlinico di Milano
Tel. 02-55034552

Come editore del giornale ho voluto dare spazio alle esperienze di chi ha affrontato le fasi iniziali della malattia con grande competenza scientifica ed organizzativa. Si tratta di uno spaccato di ciò che è avvenuto, fatto di linee guida e di orientamenti clinici, per la maggior parte condivisi successivamente tra tutti i centri. Questa sezione è dedicata a chi per primo ha dovuto affrontare l’esplosione del contagio in Italia e ha avviato percorsi terapeutici ed organizzativi che sono stati di grandissima utilità a tutti, affinché tutti potessimo organizzarci e provvedere a fronteggiare quell’onda che ha colpito, in misura più o meno severa, tutto il nostro territorio, e non solo.
Gaetano La Manna

Cholecalciferol supplementation improves secondary hyperparathyroidism control in renal transplant recipient

Carlo Massimetti1, Gea Imperato1, Sandro Feriozzi1

1 Centro di Riferimento di Nefrologia e Dialisi, Ospedale Belcolle, Viterbo, Italia

Introduction: Vitamin D deficiency (25(OH)D <30 ng/mL) in renal transplant recipients (RTRs) is a frequent finding and represents an important component in the pathogenesis of secondary hyperparathyroidism (SHPT). Therefore, its more systematic supplementation is recommended. We herein report our experience on the impact of cholecalciferol supplementation on PTH and 25(OH)D levels in a group of RTRs with 25(OH)D <30 ng/mL and SHPT. Patients and Methods: For this purpose, 52 RTRs with SHPT were treated with cholecalciferol at the fixed dose of 25,000 IU p.o. weekly for 12 months. For the control group we selected 23 RTRs with SHPT and 25(OH)D levels <30 ng/mL. Every 6 weeks eGFR, sCa and sPO4 levels were evaluated; PTH, 25(OH)D, FECa e TmPO4 were evaluated every 6 months. Results: At baseline, the two groups had similar clinical characteristics and biohumoral parameters. Parathormone was negatively correlated with 25(OH)D levels (r=-0.250; P <0.001) and TmPO4 values (r=-0.425; P<0.0001). At F-U there was a significant reduction in PTH levels in the supplemented group, from 131 ± 46 to 103 ± 42 pg/mL (P<0.001), while vitamin D levels, TmPO4 values, PO4 and sCa levels increased significantly, from 14.9 ± 6.5 to 37.9 ± 13.1 ng/mL (P<0.001), from 1.9 ± 0.7 to 2.6 ± 0.7 mg/dL (P<0.001), from 3.1 ± 0.5 to 3.5 ± 0.5 mg/dL (P<0.001), and from 9.3 ± 0.5 to 9.6 ± 0.4 (P<0.01), respectively. During the study there were no episodes of hypercalcaemia and/or hypercalciuria, while 25(OH)D levels always remained <100 ng/mL. In the control group, at F-U, PTH levels increased from 132 ± 49 to 169 ± 66 pg/ml (P <0.05), while 25(OH)D levels remained stable at <30 ng/mL. Conclusions: Vitamin D deficiency in RTRs is very frequent. Cholecalciferol supplementation is associated with a better control of SHPT and a correction of vitamin D deficiency in most patients, representing an effective, safe and inexpensive therapeutic approach to IPS.

Keywords: vitamin D, cholecalciferol, renal transplant, secondary hyperparathyroidism

The underlying cause of kidney disease is often unknown in dialysis patients: a possible genomic approach

Francesca Testa1, Davide Scalabrini3, Rossella Perrone1,2, Giulia Ligabue1,2, Gianni Cappelli1,2, Riccardo Magistroni1,2

1 Azienda Ospedaliero-Universitaria di Modena, Dipartimento interaziendale ad attività integrata Malattie Nefrologiche, Cardiache e Vascolari, Divisione di Nefrologia, Dialisi e Trapianto Renale, Modena, Italy
2 Dipartimento Chirurgico, Medico, Odontoiatrico e di Scienze Morfologiche con Interesse Trapiantologico, Oncologico e di Medicina Rigenerativa, Università di Modena e Reggio Emilia, Modena, Italy
3 Università di Modena e Reggio Emilia, Modena, Italy

As much as 16-17% European and American patients on renal replacement therapy do not have a conclusive diagnosis of the cause of their renal failure. This may have important implications on the types of morbidity they can develop in case of systemic diseases with extrarenal involvement, or recurrent renal diseases in transplanted patients. A better knowledge of the underlying disease can have important prognostic and therapeutic repercussions.

In this study we evaluated the rate of uremic patients who can benefit from a genomic diagnostic approach. Patients liable to a future genomic diagnostic study were selected based on two criteria: (i) age of dialysis entry less or equal to 55 years, and (ii) presence of a non-conclusive diagnosis. Based on the data extracted from the REGDIAL registry, we analyzed 534 patients undergoing renal replacement therapy. We identified 300 patients with age of entry into replacement therapy <55 years (56.2% of the overall study population). Among these, we identified 107 patients with missing or inconclusive diagnosis, which was equal to 20% of the overall population. Of these patients, 32.8% reported a positive family history of kidney disease. This study confirms that a significant proportion of patients on renal replacement therapy do not have an etiological diagnosis and may be subject to a genomic evaluation. With the increasing availability of genomic sequencing technology and the falling of related costs, nephrologists will be increasingly inclined to incorporate clinical genetic testing into their diagnostic armamentarium. There is therefore a need for in-depth, multicenter studies aimed at developing evidence-based guidelines, clear indications and at confirming the usefulness of genetic testing in nephrology. Keywords: end stage renal disease, epidemiology, nephrosclerosis

Frail nephropathic patients: maximum conservative therapy or dialysis? Results from a retrospective observational study

Mariarosa Maiorana1,2, Paolo Giorgi Rossi3, Marta Ottone3, Francesco Iannuzzella1, Mariacristina Gregorini1

1 U.O.C. Nefrologia e Dialisi, Azienda USL-IRCCS Reggio Emilia, Emilia Romagna
2 Clinical and Experimental Medicine PhD Program, Università degli Studi di Modena e Reggio Emilia, Emilia Romagna
3 U.O. Epidemiologia, Azienda USL-IRCCS Reggio Emilia, Emilia Romagna

Background and objectives: Chronic dialysis in frail nephropathic patients can worsen the symptom load and their functional autonomy, increasing the risk of early mortality. It is key to evaluate if dialysis treatment represents a real advantage for these patients; Maximum Conservative Therapy (MCT) associated with palliative care, could improve their residual quality of life, avoiding dialysis. The aim of this work is to describe the application and the relative terms of MCT in a complete series of cases followed in our Nephrological Clinic.

Study design and setting: This is a retrospective observational study on a cohort of 48 frail nephropathic patients in MCT and 58 on dialysis, in the period between January 2013 and December 2019. The place of death, Incidence Rate (IR) and Incidence Rate Ratio (IRR) related to survival and hospitalization rates were studied.

Results: The average duration of MCT was 9.7 months vs 13.5 months of dialysis treatment. One-year probability of survival of dialysis patient was 0.52 [CI 0.38-0.64] vs 0.48 [CI 0.33-0.62] in MCT patients; however, dialysis patients had higher rates of hospitalization (IR 2.780 vs 1.269 in MCT patients), IRR 2.19 [CI 1.66-2.89], according to literature [13]. 67% of dialysis patients died in hospital versus 35% of MCT patients. 34% of MCT patients are still alive at the time of data analysis (January 31, 2020); no dialysis patients are still alive on the same date.

Conclusions: The use of dialysis has shown a marginal, even though significant, effect on the average survival of frail nephropathic patients; however, they present a higher hospitalization rate, with consequent impact on the quality of life. The choice of the treatment (MCT vs dialysis) should not be merely based on the presence of comorbidities, but rather on the type of comorbidity found, which represents each time an element in favor of MCT or dialysis.

Keywords: conservative therapy, dialysis, survival, fragility

A delicate balance: Gitelman syndrome and gestational diabetes. A case report

Mauro Pezzotta1, Roberta Magri2, Valentina Stagnati2, Annalisa Feliciani1, Luciano A. Pedrini1

1 U.O.C. Nefrologia e Dialisi, Nephrocare S.p.A, c/o Ospedale Bolognini di Seriate, ASST Bergamo Est, Italia
2 U.O.C. Ginecologia e Ostetricia, Ospedale Bolognini di Seriate, ASST Bergamo Est, Italia

Gitelman’s syndrome (GS) is a rare autosomal recessive disorder characterized by hypokalemia, hypomagnesaemia, metabolic alkalosis, hypocalciuria and secondary hyperaldosteronism. The impact of GS on pregnant patients is still not clear, despite the many clinical cases described in literature. In particular, there is no data on the development of gestational diabetes. Altered glucose metabolism and insulin sensitivity have recently been described in patients with GS.

We describe here the clinical case of a young woman suffering from GS who started pregnancy and developed gestational diabetes. Our experience, while confirming the need of assiduous ionic monitoring especially in the first trimester of pregnancy, seems to help scaling down the maternal-fetal risk in patients suffering from GS. We also suggest the introduction of a low-glucose diet to prevent the onset of gestational diabetes, a condition burdened with severe complications. Finally, a reminder that drugs active on ionic balance must be of proven maternal and fetal safety.

Keywords: Gitelman’s Sydrome, Gestational diabetes, Hypokalemia, Hyperaldosteronism, rare deseases

Acute HCV-induced hepatitis in a patient affected by atypical hemolytic uremic syndrome (aHUS) treated with Eculizumab – case report

Paolo Trucillo1, Silvana Baranello1, Marcellino Corvinelli1, Giuseppe Di Cienzo1, Paola Nazzaro1, Maurizio Brigante1

1 U.O.C. Nefrologia e Dialisi, P.O. A. Cardarelli di Campobasso, Italia

Atypical hemolytic uremic syndrome (aHUS) is a rare and heterogenous disease caused by a disregulation of the alternative pathway of the complement cascade. Specifically, microvascular damage is produced that can lead to acute kidney disease, hemolytic anemia and thrombocytopenia. It accounts for 10% of all hemolytic uremic syndromes and can result in death or in end stage renal disease since the first episode [1,2]. We can differentiate two forms of aHUS: a sporadic form (80%), affecting adult people, and a familial form (20%) that usually became manifest during infancy [1, 4]. In the acute phase of the disease, frequent and severe anemia requires multiple blood transfusions, exposing patients to the risk of catching an infective disease. HCV hepatitis is the most prevalent chronic hepatitis worldwide, with approximately 170 million chronically infected individuals – many of which are unaware of their condition. The evolution of the HCV infection is variable: almost 20% of patients spontaneously clear the infection over time (Anti HCV positive, HCV RNA negative patients); 80% of patients cannot control the virus and develop chronic infection (Anti HCV positive; HCV RNA positive patients) that can evolve into liver cirrhosis and hepatocellular carcinoma [12, 15]. The aim of this paper is to describe a clinical case of acute HCV hepatitis in a patient with aHUS treated with Eculizumab.

Keywords: atypical hemolytic uremic syndrome, aHUS, hepatitis C virus, HCV, Eculizumab, acute hepatitis

A case of AL amyloidosis with fulminant evolution

Vincenzo Cosentini1, Maria Vitale1, Linda Gammaro1, Alessandro Petrolino1, Martina Tinelli2, Andrea Remo3, Carlo Rugiu1

1 U.O.C. Nefrologia e Dialisi Ospedale Fracastoro, San Bonifacio, Verona, Italia
2 U.O.S.D. Oncologia Ospedale Fracastoro, San Bonifacio, Verona, Italia
3 U.O.C. Anatomia Patologica Ospedale Fracastoro, San Bonifacio, Verona, Italia

Amyloidosis represents a heterogeneous group of pathologies characterized by the deposit, in the form of fibrils, in the various organs and tissues of the body, of abnormal proteins; the deposits made up of these fibrils are called amyloid or amyloid substance. AL amyloidosis, also called “light chains”, is a primary form characterized by deposits of light chains of monoclonal immunoglobulins, proteins that are produced by the bone marrow with the aim of protecting the body from pathological processes; for unknown reasons, these immunoglobulins, once fulfilled their function, do not dissolve but, on the contrary, they transform into amyloid fibrils and accumulate progressively, transported by the bloodstream, in the various organs and tissues. Below we report the case of a 77-year-old Caucasian male patient hospitalized at our Operative Unit for nephrotic syndrome and creatinine increase in the last couple of months, compared to previous normal tests. The patient underwent a renal biopsy and a bone marrow smear with evidence of AL amyloidosis (or primary amyloidosis) and of the presence, at serum immunofixation, of small IgG multiple myeloma k. Treated with bortezomib (1 mg/m2) and soldesam (10 mg) first and with lenalidomid after, the patient had a clinical course burdened by symptomatic hypotension, due to severe dysautonomia. He had to start replacement treatment with haemodiafiltration for terminal kidney disease two months after the onset of illness. He died 4 months after the first hospitalization for nephrotic syndrome.


Keywords: AL amyloidosis, multiple myeloma, renal failure, haemodiafiltration

Case report: the thoracoscopic surgery in peritoneal-pleural leakage. A valid therapeutic strategy

Giada Giovanna Olga Bigatti 1, Brunilda Xhaferi2, Elisa Nava1, Lara Traversi1, Daniele Ciurlino1, Tiziana Mazzullo1, Silvia Tedoldi1, Stefania Martino1, Margarita Nora Villa1, Matteo Oriani3, Massimo Castiglioni4, Silvio Volmer Bertoli1

1 Department of Nephrology, IRCCS Multimedica, Sesto San Giovanni, Milan, Italy
2 Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
3 Department of Radiology, IRCCS Multimedica, Sesto San Giovanni, Milan, Italy
4 Department of Thoracic Surgery, IRCCS Multimedica, Sesto San Giovanni, Milan, Italy

Pleuro-peritoneal leakage is an uncommon complication of peritoneal dialysis (PD). In this study, we report the case of a male patient (age 83), treated with PD (daytime single-exchange). In October 2019, hospitalization was necessary due to dyspnoea and a reduction of peritoneal ultrafiltration. A right pleural leakage resulted at chest x-ray. A regression of the pleural leakage was immediately observed after interrupting PD.

It was then performed a pleuro-peritoneal CT scan at baseline, followed by a second scan performed 4 hours after the injection of 2 L of isotonic solution with 100ml of contrast medium, which evidenced a pleuro-peritoneal communication. It was then decided to perform a video-assisted thoracoscopic surgery (VATS), that showed no evidence of diaphragm communication. It was then executed a pleurodesis using sterile talcum. The patient was released on the 3rd day, with a conservative therapy and a low-protein diet. After 2 weeks a new pleuro-peritoneal CT scan with contrast medium was executed. This time the scan evidenced the absence of contrast medium in the thoracic cavity. The patient then resumed PD therapy, with 3 daily exchanges with isotonic solution (volume 1.5 L), showing no complications.

Concerning the treatment of pleuro-peritoneal leakage, VATS allows both the patch-repairing of diaphragmatic flaws and the instillation of chemical agents. In our case, VATS allowed the chemical pleurodesis which in turn enabled, in just 2 weeks of conservative treatment, the resuming of PD. In conclusion, this methodology is a valid option in the treatment of pleuro-peritoneal leakage in PD patients.


Keywords: pleuro-peritoneal leakage, video-assisted thoracoscopic surgery, peritoneal dialysis, end stage renal disease

Treating anaemia in patients with chronic kidney disease: what evidence for using ESAs, after a 30-year journey?

Francesco Locatelli1, Lucia Del Vecchio2, Luca De Nicola3, Roberto Minutolo3

1 Già Direttore del Dipartimento di Nefrologia e Dialisi, Ospedale Alessandro Manzoni, ASST Lecco
2 Ricercatore indipendente, Como
3 Nefrologia, DU Scienze Mediche e Chirurgiche Avanzate, Università L. Vanvitelli, Napoli

Erythropoiesis Stimulating Agents (ESAs) are well-tolerated and effective drugs for the treatment of anaemia in patients with chronic kidney disease.

In the past, scientific research and clinical practice around ESAs have mainly focused on the haemoglobin target to reach, and to moving towards the normality range; more cautious approach has been taken more recently. However, little attention has been paid to possible differences among ESA molecules. Although they present a common mechanism of action on the erythropoietin receptor, their peculiar pharmacodynamic characteristics could give different signals of activation of the receptor, with possible clinical differences.

Some studies and metanalyses did not show significant differences among ESAs. More recently, an observational study of the Japanese Registry of dialysis showed a 20% higher risk of mortality from any cause in the patients treated with long-acting ESAs in comparison to those treated with short-acting ESAs; the difference increased in those treated with higher doses. These results were not confirmed by a recent, post-registration, randomised, clinical trial, which did not show any significant difference in the risk of death from any cause or cardiovascular events between short-acting ESAs and darbepoetin alfa or methoxy polyethylene glycol-epoetin beta. Finally, data from an Italian observational study, which was carried out in non-dialysis CKD patients, showed an association between the use of high doses of ESA and an increased risk of terminal CKD, limited only to the use of short-acting ESAs.

In conclusion, one randomised clinical trial supports a similar safety profile for long- versus short-acting ESAs. Observational studies should always be considered with some caution: they are hypothesis generating, but they may suffer from bias by indication.

Keywords: anaemia, erythropoiesis stimulating agents, ESAs, mortality, chronic kidney disease, long acting, short acting

The definition of chronic kidney disease in a context of aging population

Gaetano Alfano1,2, Francesco Fontana1, Giacomo Mori1, Riccardo Magistroni1,2, Gianni Cappelli1,2

1 Struttura Complessa di Nefrologia e Dialisi, Policlinico di Modena, Modena
2 Dipartimento Chirurgico, Medico, Odontoiatrico e di Scienze Morfologiche con Interesse Trapiantologico, Oncologico e di Medicina Rigenerativa

Chronic kidney disease (CKD) is a progressively chronic disease that carries a high burden of morbidity and mortality and is associated with significant healthcare utilization and costs. Recent trends shown that the prevalence of CKD is stable in Europe and USA, whereas tends to decline in some countries with a high standard of care.

According to international guidelines, chronic kidney disease (CKD) is defined as the presence of kidney damage or a glomerular filtration rate (eGFR) less than 60 ml/min. This staging method has a main drawback, its imprecise assessment of renal function at the extremes of the age bracket: the use of a fixed threshold value (glomerular filtration rate [GFR <60 ml /min]) to define chronic renal failure appears an imprecise measure in the young and in the elderly. In these two groups, in fact, the measurement of GFR is difficult to categorize in a "rigid" system of classification. The reduction of the GFR with aging is due to a complex process that leads to a steady reduction of the functioning nephrons over 40 years of age. Taken together, these findings should spur us to adopt a new definition of CKD. An age-adapted definition of CKD could be a good solution to avoid a diagnosis of CKD in elderly patients (GFR >45 ml/min) when there are no prognostic implications on survival. The adoption of this new definition would also reduce the high prevalence of the disease in the general population, with a beneficial reduction of the costs associated with monitoring a mildly decreased eGFR.

The complex etiopathogenesis of focal segmental glomerulosclerosis

Martina Tedesco1,2,3, Elisa Delbarba2, Claudia Izzi2, Francesco Scolari1,2, Federico Alberici1,2

1 Università degli Studi di Brescia, Dipartimento di Specialità Medico-Chirurgiche, Scienze Radiologiche e Sanità Pubblica (DSMC), Brescia, Italia
2 ASST Spedali Civili, Brescia, Italia
3 Dipartimento di scienze biomediche e cliniche ‘Luigi Sacco’, Milano, Italia

Focal segmental glomerulosclerosis (FSGS) is a pathological spectrum subtended by heterogeneous etiologies. A good knowledge of FSGS and its causes should be included in the nephrologists’ clinical background, as it deeply influences the subsequent management of the affected patients. In fact, while immunosuppressive treatment should be considered in idiopathic FSGS, the treatment of secondary forms should primarily aim at curing or containing the underpinning etiologic factors. Furthermore, in contrast to secondary FSGS, idiopathic FSGS tends to relapse after kidney transplantation.

Although FSGS has a wide spectrum of etiologies, several pathogenetic “moments” are shared. Furthermore, recent studies have identified a pool of glomerular cells potentially capable of regenerating lost podocytes; these cells might represent a promising therapeutic target.

The primary aim of this review is to describe the etiologic factors associated with FSGS, with a focus on the main pathogenetic mechanisms involved in its development.

Keywords: focal segmental glomerulosclerosis, nephrotic syndrome, podocytopathy

SGLT2 inhibitors, beyond glucose-lowering effect: impact on nephrology clinical practice

Giuseppa Costanza1, Francesco Pesce2, Mauro Forcella3, Giuseppe Leonardi4, Giuseppe Seminara6, Epifanio Di Natale5, Antonio Granata6

1 UOC Nefrologia e Dialisi, P.O. “Vittorio Emanuele” – Gela, Caltanissetta.
2 UOC Nefrologia, Dialisi e Trapianto, Università “A. Moro” – Bari.
3 UOC Nefrologia, Dialisi e Trapianto, Università di Foggia – Foggia.
4 UOC Cardiologia, AOU “Vittorio Emanuele-Policlinico” – Catania, Italia
5 UOC Nefrologia e Dialisi, P.O. “V. Cervello” – Palermo.
6 UOC Nefrologia e Dialisi, A.O. per l’Emergenza “Cannizzaro” – Catania

Epidemiological data show an increasing diffusion of diabetes mellitus worldwide. In the diabetic subject, the risk of onset of chronic kidney disease (CKD) and its progression to the terminal stage remain high, despite current prevention and treatment measures. Although SGLT2 inhibitors have been approved as blood glucose lowering drugs, they have shown unexpected and surprising cardioprotective and nephroprotective efficacy. The multiple underlying mechanisms of action are independent and go beyond glycemic lowering. Hence, it has been speculated to extend the use of these drugs also to subjects with advanced stages of CKD, who were initially excluded because of the expected limited glucose-lowering effect. Non-diabetic patients could also benefit from the favorable effects of SGLT2 inhibitors: subjects with renal diseases with different etiologies, heart failure, high risk or full-blown cardiovascular disease. In addition, these drugs have a good safety profile, but several post-marketing adverse event have been reported. The ongoing clinical trials will provide clearer information on efficacy, strength and safety of these molecules. The purpose of this review is to analyze the available evidence and future prospects of SGLT2 inhibitors, which could be widely used in nephrology clinical practice.

Keywords: diabetes, oral hypoglycemic agents, SGLT2 inhibitors, chronic kidney disease

Comment on the Italian Society of Nephrology’s 2018 census. Strength and weaknesses

Giuliano Brunori1, Filippo Aucella2, Giuseppe Quintaliani3

1 Presidente della Società Italiana di Nefrologia
2 Segretario della Società Italiana di Nefrologia
3 Consiglio Direttivo della Società Italiana di Nefrologia, responsabile censimento

Italian Society of Nephrology’s 2018 census of renal and dialysis units: their structure and organization

Giuseppe Quintaliani1, Anteo Di Napoli2, Paolo Reboldi3, Maurizio Postorino4, Piergiorgio Messa5, Filippo Aucella6, Giuliano Brunori7

1 Direttivo SIN, Perugia
2 Istituto Nazionale Salute Migrazione e Povertà (INMP), Roma, Italia
3 Department of Medicine, University of Perugia, Perugia, Italia
4 UOC Nefrologia Dialisi e Trapianto e Centro dell’Ipertensione Arteriosa Grande Ospedale Metropolitano Reggio Calabria
5 Divisione di Nefrologia, Dialisi e Trapianto, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milano, Italia
6 IRCCS “Casa Sollievo Della Sofferenza” Istituto scientifico per la ricerca e cura, San Giovanni Rotondo, Italia.
7 SC DI Nefrologia e Dialisi, Ospedale di Trento, Trento, Italia

Background: Given the public health challenge represented by chronic kidney disease, the Italian Society of Nephrology (SIN) promoted a census of the renal and dialysis units to analyze structural and human resources, organizational aspects, activities and workload, referring to the year 2018. Methods: An on-line questionnaire including 60 questions, exploring structural and human resources, organizational aspects, activities and epidemiological data referred to 2018, was sent to the heads of all identified Italian renal or dialysis unit. Results: 567 renal units were identified, 3.3 public and full renal unit pmp. The nephrology beds are about 37.6 pmp. The nurses were 8,130 in HD wards, 1,827 in the nephrology wards, only 432 for outpatient clinics. Conclusions: Data from this census may be used for benchmarking and comparison between centers, regions and groups of regions. These data offer a snapshot of the clinical management of renal disease in Italy.

Keywords: census, nephrology unit, organization, workforce, workload

Italian Society of Nephrology’s 2018 census of renal and dialysis units: the nephrologist’s workload

Giuseppe Quintaliani1, Anteo Di Napoli2, Paolo Reboldi3, Maurizio Postorino4, Piergiorgio Messa5, Filippo Aucella6, Giuliano Brunori7

1 Direttivo SIN, Perugia
2 Istituto Nazionale Salute Migrazione e Povertà (INMP), Roma, Italia
3 Department of Medicine, University of Perugia, Perugia, Italia
4 UOC Nefrologia Dialisi e Trapianto e Centro dell’Ipertensione Arteriosa Grande Ospedale Metropolitano Reggio Calabria
5 Divisione di Nefrologia, Dialisi e Trapianto, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milano, Italia
6 IRCCS “Casa Sollievo Della Sofferenza” Istituto scientifico per la ricerca e cura, San Giovanni Rotondo, Italia.
7 SC DI Nefrologia e Dialisi, Ospedale di Trento, Trento, Italia

Background: Given the public health challenge represented by chronic kidney disease, the Italian Society of Nephrology (SIN) promoted a census of the renal and dialysis units to analyze structural and human resources, organizational aspects, activities and workload, referring to the year 2018. Methods: An on-line questionnaire including 60 questions, exploring structural and human resources, organizational aspects, activities and epidemiological data referred to 2018, was sent to the heads of all identified Italian renal or dialysis unit. Results: Renal and dialysis activity was performed by over 2,718 physicians (41 pmp). The management of the acute renal failure was one of the most relevant activities in the public renal units (3,000 pmp patients in ICU and 183.000 dialysis sessions). Italian Nephrologists performed about 6000 AV fistulas out of a total of 9300. In the survey there are a lot of data regarding organization, workforce and workload of the renal unit in Italy. Conclusions: Data from this census may be used for benchmarking and comparison between centers, regions and groups of regions. These data offer a snapshot of the clinical management of renal disease in Italy.

Keywords: census, nephrology unit, organization, workforce, workload

Home dialysis and home assistance: from institutional aids to a sustainable model

Gianpaolo Amici1, Elisa Vidotti2, David Turello2, Francesca Katiana Martino3, Giacomo Benedetti4, Enza Castenetto1, Antonina Lo Cicero1, Antonio Gobetti5

1 Nefrologia e Dialisi, P.O. San Daniele del Friuli e Tolmezzo, ASUFC Udine
2 Distretto Sanitario 3 San Daniele del Friuli, ASUFC Udine
3 Nefrologia, Dialisi e Centro Trapianti, Ospedale San Bortolo, AULSS 8 Vicenza
4 Distretto Sanitario 2, ASUGI Trieste
5 Associazione Nazionale Emodializzati, Comitato Friuli Venezia Giulia

Home dialysis, and mainly peritoneal dialysis, is indicated as the optimal choice as far as the comfort and lifestyle of uremic patients is concerned. Despite this, home treatments show a lack of growth. The reasons are mainly linked to the patients’ cognitive, psychosocial, familiar and physical barriers due to aging and morbidity. To overcome these barriers, we analyzed all the available institutional aids: civil disability, not-self-sufficiency funds, home, social and nursing assistance, expenses refunds. 

The assessment of the patients’ needs is performed through validated instruments such as multidimensional evaluation (VMD) and equivalent economic index (ISEE). Overall, economic relief is limited to low income patients, and those in serious distress. Some Italian regions have issued specific measures dedicated to home dialysis. Our review shows a great heterogeneity of measures, centered in some cases on economic aids and on home assistance in others. Moreover, some Italian dialysis centers directly provide caregivers for home dialysis. 

The international literature describes many experiences relating to home dialysis assistance. Their common message is that, in developed countries, economic help is generally sustainable despite the heterogeneity of health care systems. Home support and economic aids for dialysis, in fact, are made possible by the overall savings enabled by home treatments and by the careful redistributions of the funds.

Keywords: home dialysis, peritoneal dialysis, economic aids, assisted peritoneal dialysis sustainable assistance models

Ultrasonography for diagnosis and management of nephrolithiasis: state of the art and new perspectives

Antonio Granata1, Rosario Maccarrone2, Francesco Giuseppe Raspanti2, Daniela Puliatti1, Giuseppa Costanza3, Paolo Cantavenera1, Luca Di Lullo4, Mauro Forcella5, Francesco Pesce6, Fulvio Fiorini7

1 U.O.C. di Nefrologia e Dialisi, A.O. per l’Emergenza “Cannizzaro”, Catania – Italia
2 U.O.C. di Nefrologia e Dialisi, P.O. “San Giovanni di Dio”, Agrigento – Italia
3 U.O.C. di Nefrologia e Dialisi, P.O. “Vittorio Emanuele”, Gela (CL) – Italia
4 U.O.C. di Nefrologia e Dialisi, P.O. “L. Parodi – Delfino”, Colleferro (Roma) – Italia
5 S.C. Nefrologia, Dialisi e Trapianto, A.O.U. ” OO.R.R.”, Università di Foggia, Foggia – Italia
6 Dip. di Nefrologia, Dialisi e Trapianto, A.O.U. “A. Moro” Università di Bari, Bari – Italia
7 U.O.C. di Nefrologia e Dialisi, P.O. “S.M. della Misericordia”, Rovigo – Italia

The correct management of patients with kidney stones is a crucial issue for nephrologists. In recent years, the incidence and prevalence rates of nephrolithiasis have maintained a growing trend worldwide, showing a strong correlation with other systemic disease such as diabetes mellitus, hypertension, obesity, metabolic syndrome and chronic kidney disease. International guidelines indicate computed tomography as the first choice for all adult patients with suspected acute symptoms for obstructive nephrolithiasis. Intravenous pyelogram is more useful in the follow-up of patients with relapsing nephrolithiasis and known stone composition, while the high costs and the long image acquisition times limit the routine use of magnetic resonance. Recent innovative tools have improved the accuracy of kidney stone localization and measuring with B-Mode and color Doppler imaging, thereby reducing the gap between ultrasonography and computer tomography. The aim of this review is to report the latest evidence on risk factors and on the pathophysiology of nephrolithiasis, and to compare the utility of the available imaging techniques in the management of patients with kidney stones, focusing on the role of ultrasonography and the present and future strategies to improve its accuracy.


Keywords: nephrolithiasis, diagnostic imaging, ultrasonography, B-Mode imaging, color Doppler imaging, twinkling artifact

Use of ultrasounds in PD catheter-related infections: indications and clinical implications

Luca Nardelli1,2, Antonio Scalamogna1, Matthias Zeiler3, Piergiorgio Messa1,2

1 UOC di Nefrologia, Dialisi e Trapianti di Rene, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano
2 Scuola di Specializzazione in Nefrologia, Università degli Studi di Milano, Milano
3 UOC Nefrologia e Dialisi, Ospedale “Carlo Urbani”, Jesi

Peritoneal dialysis (PD) related infections continue to be a major cause of morbidity and mortality in patients undertaking renal replacement therapy with PD. Nevertheless, despite the great effort invested in the prevention of PD infective episodes, almost one third of technical failures are still caused by peritonitis. Recent studies support the idea that there is a direct role of exit-site (ESIs) and tunnel infections (TIs) in causing peritonitis. Hence, both the prompt ESI/TI diagnosis and correct prognostic hypothesis would allow the timely start of an appropriate antibiotic therapy decreasing the associated complications and preserving the PD technique.

The ultrasound exam (US) is a simple, rapid, non-invasive and widely available procedure for the tunnel evaluation in PD catheter-related infections.

In case of ESI, the US possesses a greater sensibility in diagnosing a simultaneous TI compared to the clinical criterions. This peculiarity allows to distinguish the ESI episodes which will be healed with antibiotic therapy from those refractories to medical therapy. In case of TI, the US permits to localize the catheter portion involved in the infectious process obtaining significant prognostic information; while the US repetition after two weeks of antibiotic allows to monitor the patient responsiveness to the therapy.

There is no evidence of the US usefulness as screening tool aimed to the precocious diagnosis of TI in asymptomatic PD patients.


Keywords: peritoneal dialysis, exit-site infection, tunnel infection, peritonitis, ultrasounds, Tenckhoff catheter.

Economic impact of ferric carboxymaltose in haemodialysis patients

Andrea Aiello1, Patrizia Berto1, Paolo Conti2, Vincenzo Panichi3, Alberto Rosati4

1 CERTARA Italy, Milano, Italia
2 O.C. Nefrologia e Dialisi – Arezzo; Dipartimento “Area Omogenea Nefrologia e Dialisi” Azienda Sanitaria USL Toscana Sud-Est, Italia
3 O.C. Nefrologia e Dialisi USL Nord-Ovest Toscana–Versilia, Italia
4 O.C. Nefrologia Firenze 1 ed Empoli Nuovo Ospedale San Giovanni di Dio (NSGD) USL Toscana Centro, Italia

Intravenous iron supplementation is essential in hemodialysis (HD) patients to recover blood loss and to meet the requirements for erythropoiesis and, in patients receiving erythropoietin, to avert the development of iron deficiency. In a recent real-world study, Hofman et al. showed that a therapeutic shift from iron sucrose (IS) to ferric carboxymaltose (FCM) in HD patients improves iron parameters while reducing use of iron and erythropoietin. The objective of this economic analysis is to compare the weekly cost of treatment of FCM vs IS in hemodialysis patients in Italy. The consumption of drugs (iron and erythropoietin) was derived from Hofman’s data, while the value was calculated at Italian ex-factory prices. The analysis was carried on the total patient sample and in two subgroups: patients with iron deficiency and patients anemic at baseline. In addition, specific sensitivity analyses considered prices currently applied at the regional level, simulating the use of IS vs iron gluconate (FG) and epoetin beta vs epoetin alfa. In the base-case analysis, the switch to FCM generates savings of -€12.47 per patient/week (-21%) in all patients, and even greater savings in the subgroups with iron deficiency -€17.28 (-27%) and in anemic patients -€23.08 (-32%). Sensitivity analyses were always favorable to FCM and confirmed the robustness of the analysis. FCM may represent a cost-saving option for the NHS, and Italian real-world studies are needed to quantify the real consumption of resources in dialysis patients.


Keywords: ferric carboxymaltose, intravenous iron supplementation, chronic kidney disease, hemodialysis, drugs consumption, economic impact

New strategies for prevention and early diagnosis of iodinated contrast-induced nephropathy: a systematic review

Rosario Maccarrone1, Luca Di Lullo2, Mauro Forcella3, Antonio Bellasi4, Antonio Granata5

1 U.O.C. di Nefrologia e Dialisi, P.O. “San Giovanni di Dio”, Agrigento, Italia
2 U.O.C. di Nefrologia e Dialisi, P.O. “L. Parodi – Delfino”, Colleferro, Roma, Italia
3 S.C. Nefrologia e Dialisi a direzione Universitaria, Azienda Ospedaliero-Universitaria OO.R.R., Foggia, Italia
4 Unità di Ricerca, Innovazione e Brand Reputation, ASST Papa Giovanni XXIII, Bergamo, Italia
5 U.O.C. di Nefrologia e Dialisi – A.O. “Cannizzaro”, Catania, Italia

Iodinated contrast-induced nephropathy is one of the most feared complications of percutaneous coronary interventions and is associated with increased cardio-vascular mortality and a faster progression towards end stage renal disease. The effects of the iodinated contrast medium on intra-renal hemodynamics and its direct cytotoxic action on proximal tubular cells contribute synergistically to the pathophysiology of renal damage. Since the therapeutic options are extremely limited, the rapid identification of risk factors and the timely implementation of preventive strategies are mandatory to reduce the incidence of iodinated contrast-induced nephropathy. To date, the criteria for defining and staging contrast medium nephropathy are still based on the increase of serum creatinine and/or contraction of diuresis, which are lacking in specificity and therefore do not allow early diagnosis. The aim of this review is to report the latest evidence on the pathophysiological mechanisms that contribute to renal damage by iodinated contrast medium, on the risk stratification tools and on the new early biomarkers of contrast-induced nephropathy, while also focusing on the most validated prevention strategies.


Keywords: contrast medium, nephropathy, risk factors, early diagnosis, prevention

A diagnostic-therapeutic pathway for patients with kidney stone disease: 2020 update

Adamasco Cupisti1, Alberto. Trinchieri2, Marco Lombardi3, Simone Agostini4, Teresa Arcidiacono5, Paolo Beltrami6, Elisa Berri7, Luigi Bevilacqua8, Salvatore Campo9, Rossella Cannavò10, Emanuele Croppi11, Giuseppe Casarrubea12, Cosimo Caviglioli13, Alfonso Crisci14, Alessandro D’Addessi15, Marco De Sio16, Annalaura Fantuzzi17, Maria Fusaro18, Giovanni Gambaro19, Marco Garofalo20, Salvatore Micali21, Martino Marangella22, Michele Petrarulo23, Gaetano Piccinocchi24, Alberto Sessa25, Andrea Tasca26, Giuseppe Vezzoli27, Corrado Vitale28, Filiberto Zattoni29 a nome del Gruppo di Studio Multidisciplinare per la Calcolosi Renale

1 Dipartimento di Medicina Clinica e Sperimentale, Università di Pisa
2 Scuola di Specializzazione in Urologia, Università di Milano, Milano
3 UOC Nefrologia e Dialisi, Firenze-2, Ospedale SM Annunziata e del Mugello ASL Toscana Centro, Firenze
4 SOD Radiodiagnostica Emergenza e Urgenza, Azienda Ospedaliero Universitaria Careggi, Firenze
5 Unità di Nefrologia e Dialisi, IRCCS, Ospedale San Raffaele e Università Vita Salute San Raffaele, Milano
6 Clinica Urologica, Università di Padova, c/o Ospedale Civile, Padova
7 Dietista Renale AUSL Modena
8 Cattedra di Urologia, Università di Modena e Reggio Emilia
9 Responsabile Area Urologica della Società Italiana Medicina Generale.
10 UOC Nefrologia e Dialisi, Ospedale SM Annunziata – Firenze-2, ASL Toscana Centro, Firenze
11 Medico di Medicina Generale ASL 10, Firenze, Specialista in Nefrologia e Professore A.C. Università di Firenze
12 UOC Radiologia Ospedaliera, Azienda Ospedaliera di Padova
13 SOD Medicina e Chirurgia d’Urgenza e Accettazione, Azienda Ospedaliero Universitaria Careggi, Firenze
14 Clinica Urologica, Università degli Studi di Firenze
15 Fondazione Policlinico Universitario A. Gemelli IRCCS
16 UO e Cattedra di Urologia Università degli Studi della Campania “L. Vanvitelli”
17 Referente ambulatorio di Dietetica delle Malattie Renali Ospedale di Sassuolo spa
18 Istituto di Fisiologia Clinica CNR, Pisa e Dipartimento di Medicina Università di Padova
19 Nefrologia, Università di Verona
20 Policlinico S. Orsola, Clinica Urologica, Università di Bologna
21 Cattedra di Urologia, Università di Modena e Reggio Emilia
22 Fondazione Scientifica Mauriziana ONLUS, Torino
23 Laboratorio Analisi-Chimico Cliniche e Microbiologia, A.O. Ordine Mauriziano di Torino
24 Società Italiana di Medicina Generale
25 Presidente Regionale SIMG Lombardia
26 Università Internazionale per la Pace, Roma
27 Unità di Nefrologia e Dialisi, IRCCS, Ospedale San Raffaele e Università Vita Salute San Raffaele, Milano
28 S.C. Nefrologia e Dialisi, A.O. Ordine Mauriziano di Torino
29 Clinica Urologica, Università di Padova, c/o Ospedale Civile, Padova

The natural history of urinary kidney stone disease includes the risk of relapses and can be associated with the risk of chronic kidney disease, bone and cardiovascular disease. For this reason, a wide clinical-metabolic assessment of the kidney stone patient is of great importance since the first presentation of the stone, to set an appropriate preventive treatment. The proposed diagnostic-therapeutic pathway includes a careful medical history, in order to highlight a secondary kidney stone disease and the main risk factors for kidney stones, chronic renal disease, or cardiovascular and bone disease; a metabolic evaluation on multiple levels, according to the severity of the disease, and the presence or absence of risk factors, and appropriate instrumental investigations.

Thus, the information collected makes it possible to set a preventive treatment consisting of general rules and, if necessary, specific pharmacological or nutritional interventions.

This paper has been prepared by the Italian Multidisciplinary Study Group for Kidney Stone Disease, and it is addressed to the several professional figures involved in the management of patients suffering from nephrolithiasis, from the emergency doctor to the general practitioner, urologist, nephrologist, radiologist, and dietician.

A diagnostic-therapeutic pathway for patients with kidney stone disease was first published on this Journal in 2010. The present contribution aims at amending and updating the article published exactly ten years ago, to serve as an easy-to-use reference and to guide good clinical practice in this field.


Keywords: kidney stones, urolithiasis, nutrition, diagnosis, prevention

Linee guida di pratica clinica sulla cura peri- e post-operatoria delle fistole e delle protesi arterovenose per emodialisi negli adulti. Sintesi delle raccomandazioni delle “European Renal Best Practice (ERBP)”

Gruppo di sviluppo delle linee guida

Maurizio Gallieni1, Markus Hollenbeck2, Nicholas Inston3, Mick Kumwenda4, Steve Powell5, Jan Tordoir6, Julien Al Shakarchi7, Paul Berger8, Davide Bolignano9,10, Deirdre Cassidy11, Tze Yuan Chan12, Annemieke Dhondt13, Christiane Drechsler10,14, Tevfik Ecder15, Pietro Finocchiaro16, Maria Haller10,17, Jennifer Hanko18, Sam Heye19, Jose Ibeas20, Tamara Jemcov21, Stephanie Kershaw22, Aurangzaib Khawaja23, Laura Labriola24, Carlo Lomonte25, Marko Malovrh26, Anna Marti i Monros27, Shona Matthew28, Damian McGrogan7, Torsten Meyer29, Sotirios Mikros30, Ionut Nistor10,31, Nils Planken32, Ramon Roca-Tey33, Rose Ross34, Max Troxler35, Sabine van der Veer36, Raymond Vanholder13, Frank Vermassen13, Gunilla Welander37, Teun Wilmink38, Muguet Koobasi10, Jonathan Fox10,39, Wim Van Biesen10,13 and Evi Nagler10,13, a nome del ERBP Guideline Development Group on Vascular Access.

1. ASST Fatebenefratelli Sacco, Università degli Studi di Milano, Italy
2. Knappschaftskrankenhaus Bottrop, Bottrop, Germany
3. University Hospital Birmingham, Birmingham, UK
4. Glan Clwyd Hospital, Denbighshire, UK
5. Rutherford Diagnostics, Newport, UK
6. Maastricht University Medical Centre, Maastricht, The Netherlands
7. West Midlands deanery, Birmingham, UK
8. Zilveren Kruis, Leiden, The Netherlands
9. Institute of Clinical Physiology of the Italian National Council of Research, Reggio Calabria, Italy
10. European Renal Best Practice, London, UK
11. GE Healthcare, Chalfont St. Giles, UK
12. Royal Liverpool University Hospital, Liverpool, UK
13. Ghent University Hospital, Ghent, Belgium
14. University of Würzburg, Würzburg, Germany
15. Istanbul Bilim University School of Medicine, Istanbul, Turkey
16 GOM, Reggio Calabria, Italy
17. Ordensklinikum Linz Elisabethinen, Linz, Austria
18. Belfast Health and Social Care Trust, Belfast, UK
19. Jessa Hospital, Hasselt, Belgium
20. Parc Taulí Hospital Universitari, Institut d’Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Barcelona, Spain
21. Clinical Hospital Centre Zemun, University of Belgrade, Belgrade, Serbia
22. Norfolk and Norwich University Hospital, Norfolk, UK
23. Queen Elisabeth Hospital, University Hospitals Birmingham, West Midlands deanery, Birmingham, UK
24. Cliniques universitaires Saint-Luc, Brussels, Belgium
25. Miulli General Hospital, Acquaviva delle Fonti, Italy
26. Medical Centre Ljubljana, Ljubljana, Slovenia
27. Hospital General Universitario, Valencia, Spain
28. University of Dundee, Dundee, UK
29. City Hospital Braunschweig, Braunschweig, Germany
30. Thriassion General Hospital, Athens, Greece
31. University of Medicine and Pharmacy, Iasi, Romania
32. Amsterdam University Medical Center, Amsterdam, The Netherlands
33. Hospital de Mollet, Fundació Sanitària Mollet, Barcelona, Spain
34. Ninewells Hospital Scotland, Dundee, UK
35. Leeds Teaching Hospitals Trust, Leeds, UK
36. University of Manchester, Manchester, UK
37. Centralsjukhuset Karlstad, Karlstad, Sweden
38. Heart of England NHS foundation Trust, Birmingham, UK
39. University of Glasgow, Glasgow, United Kingdom

Healthcare, European Stability Mechanism and public funding following the Covid-19 pandemic

Luigi Spampinato

Dottore di ricerca in Economia e gestione delle aziende e delle amministrazioni pubbliche, Dirigente del Ministero dell’Economia e delle Finanze – Ragioneria Generale dello Stato

The aim of this editorial is to illustrate the new public funding framework of the Italian National Health System following the Covid-19 pandemic. The document reviews the measures put in place by the Italian Government and European Institutions such as the European Commission (EC), the European Central Bank (ECB) and the European Stability Mechanism (ESM) to deal with this health crisis and subsequent severe economic recession, with particular reference to sources and uses of resources.

The use of new budgetary financial spaces in deficit entails greater attention to the assessment of interventions and makes it necessary to keep expenditure under strict control. At the same time, the remodeling of expenditure within its aggregates, public investment in innovation, and the removal of administrative obstacles can strengthen the capacity of the healthcare system to meet the extraordinary needs deriving from the spread of Covid-19 and its resilience to future health shocks.


Keywords: Covid-19, public governance, health spending review, national health system, ESM, digital healthcare

In memory of Professor Cambi

A cura di Salvatore David

Risk-based analysis in the handling of sensitive data in the health sector

Filippo Lorè

Professore a contratto per l’insegnamento “Trattamento dei dati sensibili” – Dipartimento di Informatica dell’Università degli studi di Bari “A. Moro”

This contribution delves into the EU Regulation 2016/679 that defines the accountability of data controllers, with regard to the processing of personal data, and imposes the adoption of technological and organizational measures demonstrating a full commitment to European data protection laws. A risk-based analysis and an impact-based approach are recommended for all personal data, and especially those concerning health, in order to safeguard the rights and freedoms of the data subjects.

The article also describes the processes that should be put in place to avoid errors and violations in the handling of personal data, which can result in physical, material or non-material damage to natural persons. The controller, in fact, needs to evaluate the situation carefully and follow a series of compulsory steps to assess any potential weaknesses in the system.

A balancing act between public health concerns and privacy protection is necessary; this can be obtained through a detailed analysis of the norms and their careful implementation.


Keywords: data concerning health, privacy, risk-based analysis, impact-based approach, data protection

Evaluation via ecocolordoppler before creating a vascular access for hemodyalisis: a monocentric experience

Marina Cornacchiari1, Anna Mudoni2, Fabio Borin3, Antonia Stasi1, Maria Giuseppina Ponticelli1, Bianca Visciano1, Carlo Guastoni1-3

1 ASST Ovest Milanese Ospedale G Fornaroli via Donatore di Sangue 51 Magenta
2 U.O. di Nefrologia e Dialisi A.O. “Card. G. Panico”, Tricase (Le)
3 ASST Ovest Milanese Ospedale Legnano via Papa Giovanni Paolo II

The use of a preoperative echocolordoppler improves the clinical evaluation because provides anatomical and hemodynamic information that make it an important tool in planning vascular access strategy.

The preoperative ultrasound study of the vessels can significantly reduce the failure rate and the incidence of complications of vascular access.

We describe the experience of our center, lasting 10-year, where the ultrasound assessment was performed in all patients before the creation of vascular access.

Indeed, ultrasound reduces the rate of fistula failure and increases the utilization of fistula, allowing proper selection of vessels.

In addition, the presence of the vascular access team has allowed us to achieve quite satisfactory results.


Keywords: vascular access, imaging, ecocolordoppler, presurgical evaluation, hemodyalisis

Cholecalciferol supplementation improves secondary hyperparathyroidism control in hemodialysis patients

Carlo Massimetti1, Antonio Bellasi2, Sandro Feriozzi1

1 Centro di Riferimento di Nefrologia e Dialisi, Ospedale Belcolle, Viterbo
2 Research, Innovation and Brand Reputation, ASST Papa Giovanni XXIII, Bergamo

Introduction: Vitamin D deficiency is common among hemodialysis (HD) patients and is an important component in the pathogenesis of secondary hyperparathyroidism (SHPT). We herein report our experience on the impact of cholecalciferol supplementation on PTH levels in a group of HD patients.

Patients and methods: We selected 122 HD patients. The main selection criteria were 25-hydroxyvitamin D (25(OH)D) levels ≤30 ng/mL and SHPT defined as PTH levels >300 pg/mL or PTH levels between 150-300 pg/mL during therapy with cinacalcet or paricalcitol. 82 patients agreed to receive cholecalciferol at the fixed dose of 25,000 IU per week orally for 12 months, while the remaining 40 represented the control group. The main endopoints of the study were the reduction in PTH levels ≥30% compared to baseline values and the increase of 25(OH)D levels to values >30 ng/mL.

Results: At follow-up PTH levels decreased in the supplemented group from 476 ±293 to 296 ± 207 pg/mL (p<0.001), 25(OH)D levels increased from 10.3 ± 5.7 to 33.5 ± 11.2 ng/mL (p<0.001), serum calcium increased from 8.6 ± 0.5 to 8.8 ± 0.6 mg/dL (p<0.05) while serum phosphorus did not change. In this group the mean doses of paricalcitol were significantly reduced, from 8.7 ± 4.0 to 6.1 ± 3.9 µg/week (p<0.001). Moreover, in this group there were a significant increase of hemoglobin levels, from 11.6 ± 1.3 to 12.2 ± 1.1 g/dL (p <0.01) and a significant reduction of erythropoietin doses (p<0.05). In the control group the 25(OH)D and PTH levels did not change, while cinacalcet doses increased from 21 ±14 to 43 ± 17 mg/d (p<0.01).

Conclusions: Vitamin deficiency is very common in HD patients. Cholecalciferol treatment significantly increased serum 25(OH)D levels, significantly decreased PTH levels and paricalcitol doses, concurrently entailing a better control of anemia. 

Keywords: vitamin D, cholecalciferol, hemodialysis, secondary hyperparathyroidism, paricalcitol

Tolvaptan in ADPKD: a turning point or an unsustainable therapy? One year of “real life” experience

Maria Amicone, Eleonora Riccio, Valentina Angelucci, Antonio Pisani

Cattedra di Nefrologia, AOU Federico II di Napoli, Italia

Autosomal dominant polycystic kidney disease (ADPKD) is the most frequent monogenic kidney disease, alone responsible for over 10% of patients with end-stage renal disease, and with an important impact on public health. Tolvaptan (TOLV) has recently been approved in many European countries for its ability to slow disease progression in patients that are eligible for treatment. Nevertheless, the doctor’s choice to prescribe the drug and the patient’s compliance are strongly influenced by the aquaretic effect complications. In a cohort of patients pertaining to the Nephrology clinic of the AOU Federico II of Naples and  treated with TOLV, we assessed  not only the adherence to the treatment and the safety of the drug, but also the real feasibility of this therapy through specific questionnaires on sleep quality, abdominal-renal pain, quality of life and patients’ general satisfaction. Within the limits of preliminary data and on the basis of the responses of our population, followed for a period  of at least one year and administered the maximum titration dosage, it can be asserted that the doubts regarding the real compliance of the patients can be overcome.


Keywords: ADPKD, Tolvaptan, “real life” experience, quality of life

The advantages of remote patient monitoring in automated peritoneal dialysis

Gianpaolo Amici1, Antonina Lo Cicero1, Fabiana Presello1, Mery Zuccolo1, Dino Romanini1, Barbara Bellina1, Mariusz Janczar1, Enza Castenetto1, Consuelo Chiodarelli1, Francesca Katiana Martino2

1 Struttura Complessa di Nefrologia e Dialisi, AAS 3 “Alto Friuli-Collinare-Medio Friuli”, Ospedali di San Daniele del Friuli e Tolmezzo (UD), Italia
2 UO Nefrologia, Dialisi e Trapianto di rene. Ospedale San Bortolo, Vicenza e International Renal Research Institute, Vicenza, Italia

The follow-up automated peritoneal dialysis (APD) patients has been recently improved as data can be transmitted remotely to an internet cloud. The introduction of remote patient monitoring (RPM) technologies also allows a better clinical control and tailoring of dialysis treatment through a web-based software (Claria-Sharesource Baxter). The aim of the present study is to determine the impact of RPM in a single center, both in clinical and organizational terms, compared to traditional technologies. We studied 26 prevalent APD patients aged 69±13 years, observing them for a period of six months while using the traditional technology and then further six months using the new technology. The patients had been on dialysis for 9 months before the start of the study and a relevant portion of them lived in mountainous or hilly areas. Our study shows an increase in the number of proactive calls from the center to the patients, a reduction of anxiety in patients and caregivers, an earlier detection of clinical problems, a reduction of unscheduled (urgent) visits and finally a reduction of hospitalizations after the adoption of RPM software. In our experience, the RPM system showed a good performance and a simple interface, allowing for the precise assessment of daily APD. Furthermore, RPM system improved the interaction between patients and healthcare providers, with a significant benefit in terms of safety and of care quality.


Keywords: automated peritoneal dialysis, dialysis prescription, remote patient monitoring, telemedicine, hospitalization

Eculizumab as rescue therapy for lupus nephritis-related thrombotic microangiopathy

Filippo Maria Fani1, Annalisa Patera2, Marco Delsante2, Giovanni Maria Rossi2, Lucio Manenti2, Samuela Landini3, Giuseppe Regolisti2, Enrico Fiaccadori2

1 UO Nefrologia e Dialisi, Ospedale San Giovanni di Dio, Usl Toscana Centro
2 UO Nefrologia, AOU Parma, Azienda Ospedaliera-Universitaria Parma, Dipartimento Medicina e Chirurgia, Università di Parma
3 SOC Genetica Medica, Azienda Ospedaliera-Universitaria Meyer, Firenze, Dipartimento di Scienze Biomediche Sperimentali e Cliniche “Mario Serio”, Università degli studi di Firenze

Thrombotic microangiopathy (TMA) is a frequent and severe complication in systemic lupus erythematosus (SLE). It is reported in almost 20-25% of renal biopsies of patients with lupus nephritis (LN) and is associated with a poor renal prognosis. We report the case of a patient suffering from an aggressive form of proliferative LN in association with thrombotic microangiopathy (TMA-LN), who was resistant to standard combined immunosuppressive treatment with corticosteroids and cyclophosphamide, as well as to plasma exchange (PEX). Eculizumab was given as a rescue therapy with an optimal clinical response. We performed a systematic review of the literature and identified 11 papers, published between 2011 and 2018, with a total of 20 patients, in which eculizumab was used, always as rescue therapy, to treat TMA-LN. All reported cases showed a positive clinical response to eculizumab with a high rate of remission. Even if sparse, available clinical cases and case series support the use of eculizumab in highly selected cases as rescue treatment for LN-TMA resistant to conventional combined immunosuppressive treatment.

Keywords: lupus nephritis, systemic lupus erythematosus, Thrombotic microangiopathy, eculizumab

Book review: ‘Nefrologia medica’ by Claudio Ronco (Piccin-Nuova Libraria, 2019)

A cura di Gaetano La Manna

Extracorporeal renal replacement therapies in lithium intoxication

Rosa Giunta1,2, Francesca Di Mario1, Paolo Greco1, Tommaso Di Motta1, Caterina Maccari1, Elisabetta Parenti1, Giovanni Maria Rossi1, Santo Morabito3, Valentina Pistolesi3, Giuseppe Regolisti1, Enrico Fiaccadori1

1 Unità Operativa Complessa di Nefrologia, Azienda Ospedaliera Universitaria Parma e Scuola di Specializzazione in Nefrologia, Dipartimento di Medicina e Chirurgia, Università degli Studi di Parma
2 Sezione di Nefrologia, Dipartimento di Medicina Clinica e Sperimentale, Policlinico Universitario e Scuola di Specializzazione in Nefrologia, Università degli Studi di Catania
3 UOSD Dialisi, Dipartimento Medicina Interna e Specialità Mediche, AOU Policlinico Umberto I, Roma

Drug poisoning is a significant source of morbidity, mortality and health care expenditure worldwide. Lithium, methanol, ethylene glycol and salicylates are the most important ones, included in the list of poisons, that may require extracorporeal depuration. Lithium is the cornerstone of treatment for bipolar disorders, but it has a narrow therapeutic window. The therapeutic range is 0.6-1.2 mEq/L and toxicity manifestations begin to appear as soon as serum levels exceed 1.5 mEq/L. Severe toxicity can be observed when plasma levels are more than 3.5 mEq/L. Lithium poisoning can be life threatening and extracorporeal renal replacement therapies can reverse toxic symptoms. Currently, conventional intermittent hemodialysis (IHD) is the preferred extracorporeal treatment modality. Preliminary data with prolonged intermittent renal replacement (PIRRT) therapies – hybrid forms of renal replacement therapy (RRT) such as sustained low efficiency dialysis (SLED) – seem to justify their role as potential alternative to conventional IHD. Indeed, SLED allows rapid and effective lithium removal with resolution of symptoms, also minimizing rebound phenomenon.


Keywords: lithium, drug toxicity, dialysis, sustained low efficiency dialysis (SLED)

Inflammation in kidney diseases

Michelangelo Nigro1, Davide Viggiano2,3,4, Pierluigi D’Angiò1, Ermanno Guarino1, Giovambattista Capasso3,4, Giuseppe Gigliotti1

1 UOC Nefrologia e dialisi, Ospedale Civile di Eboli “MM.SS. Addolorata”, Eboli, Italia
2 Dip. Medicina e Scienze della Salute, Univ. Molise, Campobasso, Italia
3 Dip. Scienze Mediche Traslazionali, Univ. della Campania “L.Vanvitelli”, Napoli, Italia
4 BIOGEM, Ariano Irpino, Italia

The term “inflammation” is certainly one of the oldest medical terms still in use. However, its meaning has changed over the centuries. This work gives a historical and critical review of the concept of inflammation, with special reference to kidney diseases. Over time the definition of inflammation has shifted from a pure collection of symptoms to a histopathological definition, characterized by the tissue “inflammatory infiltrates” and different subcategories according to the cell type involved. The advantages of this classification are the generally good response to corticosteroids (with only a few exceptions) and the availability of specific drugs for each inflammatory infiltrate. Finally, a “molecular” definition of inflammation has arisen, where the inflammatory infiltrates make room to a plethora of plasma mediators. The authors show that the use of plasma biomarkers as a tool to define inflammatory state leads to net inflation of the number of “inflammatory” diseases – an effect that shows clearly in the field of nephrology.


Keywords: inflammation, acute phase proteins, nephritis, immune suppressors

Preliminary report on the Covid-19 outbreak in Valle d’Aosta dialysis centers

Massimo Manes1, Elisabetta Radin1, Valentina Pellù1, Andrea Molino1, Danila Gabrielli1, Giuseppe Paternoster1, Emanuele Parodi1, Laura Priante1, Alberto Catania2, Giulio Doveri3.

1 SC Nefrologia e Dialisi. Ospedale Regionale “U.Parini”. Aosta
2 SSD Malattie infettive. Ospedale Regionale “U.Parini”. Aosta
3 SC Medicina interna e Dipartimento Discipline Mediche. Ospedale Regionale “U.Parini”. Aosta

Valle d’Aosta, Italy’s smallest region, faced a Covid-19 epidemic trend of absolute relevance. In line with data concerning the local general population, the predominance of the illness among uremic patients has been high. The authors report here preliminary data on the spread of this disease within the region and on the clinical trend of the infected patients who needed to be hospitalised.

Keywords: Covid-19, outbreak, dialysis

The appropriateness of cannulation devices in the management AVF

Matteo Daniele Nardinocchi1, Katia Manocchi2, Tiziana Traini3

1 Infermiere Infermiere, Clinica Privata “Villa San Giuseppe” delle Suore Ospedaliere, Ascoli Piceno
2 Infermiera Coordinatrice, unità Clinica Ematologia e Trapianti, Ospedale Civile “C e G Mazzoni”, Ascoli Piceno
3 Infermiera Tutor di Tirocinio, Cdl Infermieristica UNIVPM, polo didattico di Ascoli Piceno

Hemodialysis cannulation is often done with a notoriously harmful device that also exposes operators to a high risk of accidental puncture. It is very interesting to look at the Japanese experience, that has introduced, with an excellent success rate, a new device for the cannulation of FAV: a plastic cannula.

The aim of this review is to verify if the literature describes any advantages in the use of the plastic cannula in hemodialysis compared to the traditional metal needle, in relation to mechanical and hemodynamic vascular trauma, treatment adequacy, patient comfort and operator safety. The study has been conducted by researching, reviewing and selecting scientific articles through search engines and specialized journals.

The peculiarities of the device’s design allow to expand the current possibilities in the practice of cannulation, producing positive outcomes for the patient and the operator. There is a need, however, for further studies and an update of device’s features.

Keywords: hemodialysis plastic cannula, vascular access cannulation, arteriovenous fistula

Standard procedures in dialysis during the Covid-19 epidemic

Michela Ippolito1, Giovannni Battista Di Tria1, Cinzia Aldrigo1, Mariangela Ricci1, Ulisse Zoni1, Antonino Giordano1, Mario Cozzolino1,2

1 SC Nefrologia e Dialisi, ASST Santi Paolo e Carlo, Milano
2 Dipartimento di Scienze della Salute, Università di Milano


The aim of this document has been to define standard procedures for dealing with dialysis patients once the first cases of novel Coronavirus 2019-nCoV (Covid-19) were confirmed among the Italian population.


These procedures, that refer exclusively to the hospital’s dialysis rooms, are currently implemented at the ASST Santi Paolo e Carlo in Milan and two smaller centers in the Milan area.


We describe the preemptive measures adopted by the staff at our dialysis unit since 24/02/2020, in order to slow down the transmission of Covid-19. They have allowed us to adopt a uniform approach towards all patients, streamlining the way we identify and deal with suspected, likely and confirmed Coronavirus infections. To start with, all patients coming to the hospital for their dialytic session have been treated as potentially infectious and everybody has been following closely the standard protocols regarding personal protective equipment (PPE).


Keywords: Covid-19-positive, dialysis, prevention, personal protective equipment

A life devoted to nephrology

Mauro Sasdelli1, Giovanni B. Fogazzi 2

1 Già Direttore del Dipartimento di Area Critica e di Nefrologia, Ospedale S. Donato, Arezzo, Italia
2 U.O.C. di Nefrologia, Dialisi e Trapianto di Rene, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano, Italia

This paper by Mauro Sasdelli describes the dawn and the development of nephrology first in Bologna, where Sasdelli studied in the nineteen-sixties, and later in Arezzo; the author tells us of the dedication, the enthusiasm, the hard work of all involved, but also of their conflicts and banter. The paper describes the important contributions to nephrology made by prominent personalities such as Domenico Campanacci, Vittorio Bonomini and Pietro Zucchelli, not only at a local level but also more broadly. Finally, text and images of this “personal history” can also be read as the integration of an article published on this same journal in 2016, “The dawn of Nephrology and Dialysis in Bologna with Vittorio Bonomini and Pietro Zucchelli” (Giornale Italiano di Nefrologia, vol. 33, n. 4).


Keywords: history of nephrology, history of Italian nephrology, history of the Italian Society of Nephrology

Clinical and social advantages of remote patient monitoring in home dialysis

Massimo Morosetti1, Michelina Peccerillo1, Maria Iolanda Famà2

1 UOC di Nefrologia e Dialisi, Ospedale G.B. Grassi Roma, Italia
2 Vree Health Italia s.r.l., Roma, Italia

Introduction. Home dialysis (both extracorporeal and peritoneal) can improve the management and the quality of life of patients with chronic disease. In this study we evaluated the possible clinical and social advantages derived from remote patient monitoring using the Doctor Plus® Nephro program, as opposed to the standard of care. Methods. We included in our analysis the patients participating in the remote monitoring program of the Nephrology Center of ASL 3 in Rome from July 2017 to April 2019. Each patient was observed from a minimum of 4 months to a maximum of 22 months. Systolic and diastolic pressure, heart rate, weight and oximetry were monitored. An SF-12 questionnaire was also administered to evaluate the level of satisfaction with the program Doctor Plus® Nephro. Results. 16 patients (56,3% males, mean age 62 years) were observed as part of the analysis. During the program there was a reduction of systolic pressure in 69% of the patients and of diastolic pressure in 62,5%. Mean heart rate decreased from 69,4 bpm to 68,8 bpm (p<0,0046). The answers to the SF-12 questionnaire showed that the perceived health status of all patients had improved. Due to the closer clinical monitoring, the number of patients accessing emergency services also decreased. Conclusion. Doctor Plus® Nephro could improve access to home treatment; the results of this study in fact show it to be a useful tool for Nephrological Centers to monitor patients undergoing home dialysis.

 Keywords: remote patient monitoring, dialysis, home dialysis, blood pressure, quality of life

Management of hemodialysis patient subject to medical-nuclear investigation

Antonio Granata1, Concetto Sessa2, Fulvio Fiorini3, Salvatore Randone4, Pierpaolo Di Nicolò5, Luca Zanoli6, Salvatore Piranio7

1 U.O.C di Nefrologia, Azienda Ospedaliera per l’Emergenza “Cannizzaro” – Catania, Italia
2 U.O.C. Nefrologia e Dialisi, P.O. “Maggiore”, Modica (RG), Italia
3 U.O.C. Nefrologia e Dialisi, PO Santa Maria della Misericordia, Rovigo (RO), Italia
4 U.O.S. Nefrologia e Dialisi, PO G. Di Maria, Avola (SR), Italia
5 U.O.C. Nefrologia e Dialisi – P.O. “S. Maria della Scaletta”, Imola (BO), Italia
6 Dipartimento di Medicina Clinica e Sperimentale, Nefrologia, Università degli Studi di Catania (CT), Italia
7 Divisione di Fisica Medica – P.O. “San Giovanni di Dio”, Agrigento (AG), Italia

In recent years imaging techniques that use radionuclides have become more and more clinically relevant as they can provide functional information for specific anatomical districts. This has also involved nephrology, where radionuclides are used to study patients with different degrees of renal function failure up to terminal uremia. Although chronic kidney disease, and dialysis in particular, may affect the distribution and the elimination of radiopharmaceuticals, to date there are no consistent data on the risks associated with their use in this clinical context. In addition to the lack of data on the safety of radio-exposure in dialysis patients, there is also a shortage of information concerning the risk for healthcare staff involved in conducting the dialysis sessions performed after a nuclear test.

This study, performed on 29 uremic patients who underwent hemodialysis immediately after a scintigraphic examination, assessed the extent of radio-contamination of the staff and of hemodialysis devices such as monitor, kits and dialysate. The data collected has been used to quantify the radiological risk in dialysis after the exposure to the most common radionuclides.


Keywords: chronic kidney disease, imaging, radionuclides, hemodialysis, scintigraphy, radiological risk

Screening and management of HCV-positive CKD outpatients

Giuseppe Gernone1, Francesco Detomaso1, Francesca Partipilo1, Silvia Gernone2

1 UOSVD di Nefrologia e Dialisi ASL Bari. P.O. “S. Maria degli Angeli” Putignano e “S. Giacomo” Monopoli. Sede Direzionale Putignano
2 Corso di Formazione Specifica in Medicina Generale della Regione Puglia

Background: Hepatitis C Virus (HCV) disease, which is commonly underdiagnosed, in addition to the well-known effects on the liver is also a risk factor for Cronic Kidney Disease (CKD) and End Stage Renal Disease (ESRD). It worsens the outcome at every stage of CKD; around 400.000 people worldwide die from HCV-related causes each year. The KDIGO 2018 Guidelines recommend that all patients be evaluated for renal disease when HCV is diagnosed and be screened for HCV when CKD is diagnosed, as the prevalence may be higher than in the general population. Effective screening is therefore necessary in order to establish early treatment. Aims of the study: We ran a systematic program of screening and management of HCV in nephropathic outpatients in order to improve Sustained Virological Response 12 weeks after the end of treatment (SVR 12) and renal functions such as GFR and proteinuria. Materials and methods: We considered outpatients not in dialysis and older than 18. The systematic, prospective observational study of HCV infection run over a period of 18 months. Results: Of 2798 nephropathic outpatients that came to our attention during this period, we identified 108 HCV-positive patients (prevalence: 3.85%). The test for HCV-RNA resulted positive in 78 patients and, after hepatological evaluation and informed consent to treatment, 51 of them underwent therapy with the new direct-acting antivirals (DAAs). 34 patients concluded the treatment during the 18-month period, all of them with 100% SVR 12. The average pre-treatment GFR was 40.5 ml/m’; after treatment resulted equal to 45 ml/m’ (p=0.01). The average value of pre-treatment proteinuria was 1.18 g/24 h; it was reduced to 0.79 g/24 (p=0.015). The remaining 17 patients were still under treatment/evaluation at the end of the 18 months. Conclusions: Treatment with the new DAAs has been confirmed safe and effective and is associated with an improvement of renal functions. Systematic screening of nephropathic patients may therefore contribute to achieving the WHO target of eliminating HCV by 2030.

Keywords: Hepatitis C Virus, HCV, cronic kidney disease, CKD outpatients

Giant parathyroid adenoma: a rare cause of severe hypercalcemia

Rosa Giunta1, Silvia Ferrario1, Luca Zanoli1, Silvia Orlando2, Alessandro Conti2, Daniela Benintende2, Giacomo Castiglione2, Francesco Rapisarda1

1 Sezione di Nefrologia, Dipartimento di Medicina Clinica e Sperimentale, Policlinico Universitario & Scuola di Specializzazione in Nefrologia, Università di Catania, Catania, Italia
2 Unità di Terapia Intensiva, Ospedale Vittorio Emanuele, AOU Policlinico–Vittorio Emanuele, Catania, Italia

We report the case of a 37-year-old woman that developed severe hypercalcemia due to a parathyroid gland mass. After the initial medical treatment, only a minimal reduction of calcemia was observed and her clinical condition worsened; thus, she required continuous renal replacement therapy (CRRT) that resulted in the normalization of calcium serum level. She then underwent a left thyroid lobectomy with exeresis of the associated parathyroid glands; the histological diagnosis revealed a giant parathyroid adenoma (GPA). CRRT, initially recommended only in case of severe refractory hypercalcemia poorly responsive to pharmacological approaches, is now being evaluated in the first line treatment of life-threatening cases, with or without associated acute kidney injury (AKI).


Keywords: hypercalcemia, giant parathyroid adenoma, continuous venovenous hemodialysis (CVVHD)

Compound heterozygosis with novel AQP2 gene mutation in sisters affected by autosomal congenital nephrogenic diabetes insipidus

Dario Musone1, Valentina Nicosia1, Antonio Treglia1, Francesco Amoroso1, Paola de Gemmis2, Maria Vittoria Enzo2, Uros Hladnik2

1 UOC Nefrologia e Dialisi, PO Dono Svizzero, Formia, Latina, Italia
2 Unità di Genetica, Istituto per le Malattie Rare “Mauro Baschirotto” – Fondazione B.I.R.D., Vicenza, Italia

Congenital nephrogenic diabetes insipidus (CNDI) is a rare inherited disorder, mostly caused by antidiuretic hormone receptor type 2 (ADHR2) gene mutations, which are inherited as X-linked traits. Less than 10% of cases are due to mutations in the aquaporin-2 (AQP2) gene, inherited in autosomal recessive or dominant manner. We report the case of two adult sisters, of 30 and 27 years of age, diagnosed in early infancy with X-linked CNDI. The patients’ sex and family history did not fit in well with this diagnosis, so we sequenced the coding regions of the ADHR2 and AQP2 genes. As expected, no mutations were found in the ADHR2 gene, while we found a compound heterozygosis for two different mutations in the AQP2 gene. A missense mutation (c. 439G>A, p.Ala147Thr), an already known cause of CNDI, and a novel missense putative mutation of an adenine to cytosine at position 551 (c.551A>C), resulting in the substitution of asparagine with threonine at amino acid position 184 (p.Asn184Thr). This second mutation changes a fundamental extracellular Asn-Pro-Ala motif (NPA) of the AQP2 protein, inhibiting its function. Its pathogenicity has been confirmed by in silico predictions and is in line with comparable alterations to the intracellular NPA motif of the AQP2 protein.


Keywords: AQP2, AQP2 gene, congenital nephrogenic diabetes insipidus, genetic kidney disease

Diagnostic and prognostic markers of renal cell carcinoma

Federica Spadaccino1, Giuseppe Stefano Netti1, Maria Teresa Rocchetti1, Giuseppe Castellano2, Giovanni Stallone2, Elena Ranieri1

1 UO di Patologia Clinica e Centro di Medicina Molecolare, Policlinico “Ospedali Riuniti” di Foggia, Dipartimento di Scienze Mediche e Chirurgiche, Università degli Studi di Foggia, Foggia, Italia
2 UO Nefrologia Dialisi e Trapianti, Policlinico “Ospedali Riuniti” di Foggia, Dipartimento di Scienze Mediche e Chirurgiche, Università degli Studi di Foggia, Foggia, Italia

Renal cell carcinoma (RCC) is the deadliest of all urogenital tumors, whereas it is the third for incidence after prostate and bladder cancer. An early diagnosis of RCC allows patients affected to be promptly treated with effective therapies, significantly increasing their survival rate. In addition, an early and accurate diagnosis avoids inadequate treatment, helps predict disease progression and establish the most appropriate treatments. Unfortunately, small renal tumors are usually asymptomatic, which results in a late diagnosis and, therefore, a low efficacy of treatment. Sensitive biomarkers are thus essential for early detection of RCC and for monitoring its progression. This review summarizes recent discoveries relating to renal tumor biomarkers, their diagnostic and prognostic values, and clinical feasibility.


Keywords: biomarkers, renal cell carcinoma, RCC, precision medicine

Rhabdomyolysis: have you considered food poisoning from quails?

Carlo Basile1,2

1 Divisione di Nefrologia, Ospedale Miulli, Acquaviva delle Fonti, Bari, Italia
2 Associazione Nefrologica Gabriella Sebastio, Martina Franca, Taranto, Italia

Rhabdomyolysis (R) is a complex condition involving the rapid dissolution of damaged or injured skeletal muscle. This leads to the direct release of intracellular components, including myoglobin, creatine kinase, aldolase, and lactate dehydrogenase, as well as electrolytes, into the bloodstream and extracellular space. Clinically, R shows a triad of symptoms: myalgia, limb weakness, and myoglobinuria without hematuria, while myoglobin has been recognized as playing a part in the development of acute kidney injury.

Coturnism is a relatively rare disease, mostly found in the European countries bordering the Mediterranean Sea, characterized by acute R. It follows the consumption of Coturnix coturnix, a species of quails common in Europe, that have ingested the toxic substances (and especially coniine) present in the herbaceous plant called hemlock (Conium maculatum). Coniine may be lethal at a dose of 150 mg but it has neurotoxic effects at smaller doses, with acute R and acute kidney injury. Freezing and cooking the meat does not inactivate the alkaloids present in the birds’ flesh and digestive tract. The clinical course of coturnism includes neurotoxicosis, tremor, vomiting, muscle paralysis, respiratory paralysis/failure, R and acute kidney injury. In appropriate geographical and temporal settings, it should be considered when diagnosing patients with acute R. The genetic, biochemical and epidemiological characteristics of coturnism are not yet fully known, while we wait reliable data from experimental studies.


Keywords: hemlock, coniine, coturnism, acute kidney injury, quails, rhabdomyolisis

Covid-19 in patients on dialysis: infection prevention and control strategies

Elena Brioni1, Donato Leopaldi2, Cristiano Magnaghi3, Rosalia Franchetti2, Elisa Granellini2, Marisa Pegoraro4, Maria Cristina Gambirasio5, Paolo Mazzacani6, Maria Teresa Parisotto7

1 Università Vita-Salute San Raffaele, Milano, Italia
2 U.O Nefrologia e Dialisi, ASST Fatebenefratelli Sacco, Milano, Italia
3 U.O Nefrologia e Dialisi, IRCCS Ospedale San Raffaele, Milano, Italia
4 U.O Nefrologia e Dialisi, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italia
5 U.O Nefrologia e Dialisi, ASST Nord Milano, Cinisello Balsamo, Milano, Italia
6 Educazione e Prevenzione clinica, Fundacion Coen, Chinandega, Nicaragua
7 Board Member of European Specialist Nurses Organization (ESNO), Brussels, Belgio

Covid-19 is a disease caused by a new coronavirus presenting a variability of flu-like symptoms including fever, cough, myalgia and fatigue; in severe cases, patients develop pneumonia, acute respiratory distress syndrome, sepsis and septic shock, that can result in their death. This infection, which was declared a global epidemic by the World Health Organization, is particularly dangerous for dialysis patients, as they are frail and more vulnerable to infections due to the overlap of multiple pathologies. In patients with full-blown symptoms, there is a renal impairment of various degrees in 100% of the subjects observed. However, as Covid-19 is an emerging disease, more work is needed to improve prevention, diagnosis and treatment strategies. It is essential to avoid nosocomial spread; in order to control and reduce the rate of infections it is necessary to strengthen the management of medical and nursing personnel through the early diagnosis, isolation and treatment of patients undergoing dialysis treatment. We cover here a series of recommendations for the treatment of dialysis patients who are negative to the virus, and of those who are suspected or confirmed positive.

Keywords: Covid-19, hemodialysis, transmission, prevention

Covid-19 and its impact on nephropathic patients: the experience at Ospedale “Guglielmo da Saliceto” in Piacenza

Roberto Scarpioni, Alessandra Manini, Teresa Valsania, Sara De Amicis, Vittorio Albertazzi, Luigi Melfa, Marco Ricardi, Chiara Rocca

UOC Nefrologia Dialisi, Ospedale AUSL “Guglielmo da Saliceto” Piacenza, Italia

Roberto Scarpioni and colleagues recount their experience with the Covid-19 epidemic at the Nephrology and Dialysis Center of the “Guglielmo da Saliceto” Hospital in Piacenza, where everybody is still fighting to this moment to contain the spread of the disease and face an increasingly unsustainable clinical situation. Piacenza is only 15 km away from the main cluster of cases in the country (Codogno, in the Lodi province) and, after the closure of the Hospital in Codogno, saw an escalation in the number of patients testing positive to Covid-19.

The authors describe their efforts and the practices they adopted to contain the spread of the disease among inpatients visiting the hospital’s Hemodialysis Clinic. They also reflect on some of the data available on the 25/03/2020, such as the number of patients testing positive and the mortality rate, unfortunately very high. Their aim is to help all colleagues that have yet to face this epidemic in its full force.

Keywords: Covid-19, coronavirus, nephropatic patients, dialysis, kidneys, Piacenza, Emilia Romagna

An account of the first hours of the Covid-19 epidemic at the Nephrology Unit in Lodi (Lombardy)

Marco Farina, Francesco Barbisoni, Silvia Bertacchini, Ilaria Borettaz, Raffaella Bucci, Milena Maggio, Chiara Ronga

Struttura Complessa di Nefrologia e Dialisi, ASST di Lodi, Ospedale Maggiore di Lodi (LO)

Marco Farina and colleagues give us their account of the first days of the Covid-19 epidemic in the Nephrology Unit of the Ospedale Maggiore in Lodi. From the news trickling through from Codogno on the 20th of February to the hospitalization, the following day, of the first dialytic patient with signs of pneumonia, who later tested positive to the virus.

They tell us of how the hospital has been completely restructured in the wake of the epidemic, at remarkable speed and providing an example for others to follow, and the great sense self-sacrifice displayed by all medical personnel. After an overview of the clinical conditions of the 7 patients positive to the virus hospitalised in the following few days, they describe in some detail how symptomatic Covid+ patients are currently managed at the Ospedale Maggiore in Lodi.

Keywords: Covid-19, Ospedale Maggiore di Lodi, nephrology, dialysis

Managing patients in dialysis and with kidney transplant infected with Covid-19

Federico Alberici1,2, Elisa Del Barba2, Chiara Manenti2, Laura Econimo2, Francesca Valerio2, Alessandra Pola2, Camilla Maffei2, Stefano Possenti2, Paola Gaggia2, Ezio Movilli2, Sergio Bove3, Fabio Malberti4, Marco Farina5, Martina Bracchi6, Ester Maria Costantino7, Nicola Bossini2, Mario Gaggiotti2, Francesco Scolari1,2, a nome della “Brescia Renal Covid Task Force”

1 Università degli Studi di Brescia, Dipartimento di Specialità Medico-Chirurgiche, Scienze Radiologiche e Sanità Pubblica, Brescia, Italia
2 ASST Spedali Civili di Brescia, Unità Operativa di Nefrologia, Brescia, Italia
3 ASST Spedali Civili di Brescia, Unità Operativa di Nefrologia, Montichiari (BS), Italia
4 ASST Cremona, Unità Operativa di Nefrologia, Cremona, Italia
5 ASST Lodi, Unità Operativa di Nefrologia, Lodi, Italia
6 ASST Franciacorta, Unità Operativa di Nefrologia, Chiari (BS), Italia
7 ASST del Garda, Unità Operativa di Nefrologia, Manerbio (BS), Italia

We are in the midst of a health emergency that is totally new for us all and that requires a concerted effort, especially when it comes to safeguarding patients on hemodialysis, and kidney transplant recipients. Brescia is currently a very active cluster of infections (2918 cases on the 17/03/2020), second only to Bergamo. The way our structure is organised has allowed us to treat nephropathic patients directly within the Nephrology Unit, following of course a great deal of reshuffling; at the moment, we are treating 21 transplanted patients and 17 on hemodialysis. This has led us to adopt a systematic approach to handling this emergency, not only in managing inpatients, but also in researching the
new disease. Our approach is mirrored in the guidelines attached to this article, originally intended for internal use only but potentially very useful to our colleagues, as they face the same exact problems.
We have also started collecting data on our positive patients with the aim of understanding better the functioning of this disease and how best to manage it. If anyone is interested, we ask you to please get in touch with us, so we can coordinate our efforts.


Keywords: Covid-19, Brescia, nephrology, dialysis, transplants, guidelines

More questions than answers, and a way ahead

Gaetano La Manna, Editor in Chief Giornale Italiano di Nefrologia

Alma Mater Studiorum – Università di Bologna
Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale – DIMES
Unità di Nefrologia, Dialisi e Trapianto
Policlinico S. Orsola – Malpighi pad. 15
Via G. Massarenti 9 – 40138 Bologna

Come editore del giornale ho voluto dare spazio alle esperienze di chi ha affrontato le fasi iniziali della malattia con grande competenza scientifica ed organizzativa. Si tratta di uno spaccato di ciò che è avvenuto, fatto di linee guida e di orientamenti clinici, per la maggior parte condivisi successivamente tra tutti i centri. Questa sezione è dedicata a chi per primo ha dovuto affrontare l’esplosione del contagio in Italia e ha avviato percorsi terapeutici ed organizzativi che sono stati di grandissima utilità a tutti, affinché tutti potessimo organizzarci e provvedere a fronteggiare quell’onda che ha colpito, in misura più o meno severa, tutto il nostro territorio, e non solo.
Gaetano La Manna

Italian nephrology and the progress of dialysis from its dawn to the present day

Antonio Santoro

Scuola di Specializzazione in Nefrologia, Università degli Studi di Bologna, Policlinico S.Orsola-Malpighi

In Italy, over the last 50 years, dialysis has been the driving force of research in nephrology. The work of many Italian nephrologists has fueled progress in dialytic techniques worldwide, improving dramatically the quality of dialytic therapy. Our foreign colleagues unanimously agree that we have been the first to look into the complexities of dialysis, into the many differences between dialytic patients and how to best address this diversity. This has allowed us to adopt a holistic approach, deeply connected to technological innovation, with the aim of putting the patient center stage and creating a “precision dialysis”.

Keywords: hemodialysis, peritoneal dialysis, Italian nephrology, development of filtration techniques

Liability in medical-assisted suicide

Fabio Cembrani

Direttore U.O. di Medicina legale, Azienda provinciale per i Servizi sanitari di Trento

Summarizing the contents of the Constitutional Court’s judgment n. 242/2019 on the non-liability in medical-assisted suicide, the author looks at how the new scenarios thus opened might undermine the safety and dignity of the most fragile and vulnerable people. He voices his concerns on the shifting relationship between doctors and patients and on the delegitimization of medical ethics that must instead continue to illuminate, with its guiding principles, professional behavior.


Keywords: assisted suicide, self-determination, end of life, duties of the doctor, duties of public health sector, ethics.

Association between low serum magnesium levels and the extent of abdominal aortic calcification in renal transplant recipients

Carlo Massimetti1, Paolo Cardello2, Franco Brescia2, Gea Imperato1, Sandro Feriozzi1

1 Centro di Riferimento di Nefrologia e Dialisi, Ospedale Belcolle, Viterbo
2 Radiologia, Ospedale Belcolle, Viterbo

Introduction – In renal transplant recipients (RTRs) vascular calcifications has been associated with an increased risk of cardiovascular as well as all-cause mortality.  Recent experimental and clinical studies showed that magnesium (Mg) deficiency may be related to the progression of vascular calcification. Aim of this study was to determine the hypothetical association between Mg and vascular calcifications in RTRs. Methods – Seventy-one RTRs underwent a lateral X-ray of the lumbar spine to assess the presence of calcification of the abdominal aorta. Abdominal aortic calcium (AAC) content was graded with a score ranging from 0 to 24 points. At the same time were evaluated: carotid artery intima-media thickness (IMT);  left ventricular mass index (LVMi); sCa, sPO4, sMg, uMg, PTH, HDL, LDL, blood pressure (BP). Results – AAC was correlated with: age (r=0.601; P<0.001), dialysis vintage  (r=0.314; P<0.01), sMg (r=-0.438; P<0.001), PTH (r=0.322; P<0.01), SBP (r=0.539; P<0.001), IMT (r=0.706; P<0.001), LVMi  (r=0.326; P<0.01). Serum Mg was correlated with PTH (r= -0.304; P<0.01). IMT was correlated with LVMi and SBP (r=0.330, P<0.01; r=0.494, P <0.0001; respectively). Stepwise multiple regression analysis showed that the final model contained six predictor variables for AAC (IMT, sMg, age, SBP, proteinuria, and dialysis vintage; F5,64=31.7, P<0.001; Adjusted R2 =0.718). Patients in higher AAC thirtile (8-24) were older, with longer dialysis vintage, lower sMg, higher PTH, and higher IMT values. Conclusions – Our results suggest a hypothetical interrelationship between sMg  and ACC, and IMT in RTRs.

Keywords: magnesium, vascular calcification, carotid artery intima-media thickness, renal transplantation

Monocentric experience of left atrial appendage occlusion among patients with advanced chronic kidney disease and non-valvular atrial fibrillation

Massimo Manes1, Elisabetta Radin1, Valentina Pellù1, Emanuele Parodi1, Donatella Caputo1, Danila Gabrielli1, Andrea Molino1, Giuseppe Paternoster1, Elisa Pelloni2, Francesco Pisano1

1 SC. Nefrologia e Dialisi. Ospedale “Umberto Parini”. Viale Ginevra 1. Aosta
2 SS Cardiologia Interventistica . Ospedale “Umberto Parini”. Viale Ginevra 1 Aosta

Atrial fibrillation is the most common cardiac disorder among chronic nephropathic patients. Possible therapeutic approaches include the use of anticoagulants, which are able to reduce the risk of thromboembolism but lead to an increasing bleeding risk, especially in this cohort of patients. Also, novel oral anticoagulant agents (NAO), due to their mainly renal clearance, are a relative contraindication in advanced renal disease. As an alternative to the oral anticoagulant therapy, left atrial appendage occlusion seems a promising opportunity in high risk, difficult to manage patients. Since there is limited evidence of LAAO in advanced chronic renal disease or dialysis patients, we report here a monocenter experience on 12 patients (6 of which in regular dialytic treatment) with a median clinical follow-up of fourteen months (3-22 months).


Keywords: left atrial appendage occlusion, LAAO, atrial fibrillation, NAO, advanced chronic kidney disease, dialysis

Peritoneal dialysis in the Lazio region: results from 2017 regional audit

Massimo Morosetti1, Anna Rachele Rocca2, Alessandro Domenici3, Silvia D’Alonzo4, Stella Caramiello5, Armando Filippini6, Alberto Santoboni7, Roberto Palumbo5, Paolo Menè3, Sandro Mazzaferro2, Loris Neri8

1 Ospedale GB Grassi-Roma, Italy
2 Azienda Ospedaliera Universitaria Policlinico Umberto I Roma, Italy
3 Azienda Ospedaliera Sant’Andrea Roma, Italy
4 Policlinico Universitario A. Gemelli, Roma Italy
5 Ospedale S Eugenio- Roma, Italy
6 Policlinico Casilino-Roma, Italy
7 Ospedale P. Delfino-Colleferro, Italy
8 Ospedale San Lazzaro Alba-Cuneo, Italy

In 2011, a first peritoneal dialysis audit was held in the Lazio region to analyze the problems hindering the spread of this method and to improve the quality of care through the sharing of best practices across Centers. A scientific board was therefore set up, representing all the Centers offering PD, in order to assess clinical effectiveness using KPIs (Key Performance Indicators) and to quantify the objectives to be achieved. The analysis made it possible to identify the main problems and take action, all the while monitoring progress through KPIs.

A second audit was carried out in 2017 and the collected data was analyzed and compared with the findings of the previous study. Overall, data showed an increase in prevalence, although the incidence showed a slight decrease. Indicators on the change of dialysis treatment, the dropout from domiciliary treatment and the incidence of late referral appeared stable over time. A slight improvement was observed in clinical data on peritonitis and on the length of hospitalization.

All participants in the audit declared that sharing and discussing clinical practices had been really useful. In addition, through the drafting of practical documents (guides for patients, guidance on informed consent, protocols of clinical follow-up), a number of tools have been provided to ensure a uniformly high level of care across the different regional Centers.


Keywords: audit, peritoneal dialysis, best practices, Key Performance Indicators (KPI), protocols

Double purse-string craft around the inner cuff: a new technique for an immediate start of CAPD

Antonio Scalamogna1, Luca Nardelli1,2, Piergiorgio Messa1,2

1 UOC di Nefrologia, Dialisi e Trapianti di Rene, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano
2 Scuola di Specializzazione in Nefrologia, Università degli Studi di Milano

Background: In order to minimize the risk of leakage and displacement, international guidelines recommend that catheter insertion should be performed at least 2 weeks before beginning CAPD. However, the optimal duration of the break-in period is not defined yet. 

Methods: From January 2011 to December 2018, 135 PD catheter insertions in 125 patients (90 men and 35 women, mean age 62,02 ± 16,7) were performed in our centre with the double purse-string technique. Seventy-seven straight double-cuffed Tenckhoff catheter were implanted semi-surgically on midline under umbilicus by a trocar and 58 were surgically implanted through rectus muscle. In all patients CAPD was started within 24 hours from catheter placement, without a break-in procedure. We recorded all mechanical and infective catheter-related complications during the 3 first months after initiation of CAPD and the catheter survival rates.

Results: During the first 3 months the overall incidence of peri-catheter leakages, catheter dislocations, peritonitis and exit-site infections was 2,96% (4/135), 1,48% (2/135), 10.3% (14/135) and 2.96% (4/135), respectively. No bleeding events, bowel perforations or hernia formations were reported. The catheter survival censored for deaths, kidney transplant, loss of ultrafiltration and inability was 74,7% at 48 months. There was no difference in the incidence of any mechanical or infectious complications and catheter survival between the semi-surgical and the surgical groups. 

Conclusions: Double purse-string technique allows an immediate start of CAPD both with semi-surgical and surgical catheter implantation. This technique is a safe and feasible approach in all patients who refer to peritoneal dialysis. 


Keywords: continuous ambulatory peritoneal dialysis, CAPD, peritoneal catheter, break-in time, infective catheter-related complications, double purse-string technique

Renal dysfunction in psoriatic patients

Valeria Grandinetti1, Olga Baraldi1, Giorgia Comai1, Valeria Corradetti1, Valeria Aiello1, Claudia Bini1, Vera Minerva1, Simona Barbuto 1, Benedetta Fabbrizio2, Gabriele Donati1, Gaetano La Manna1

1 UO Nefrologia, Dialisi e Trapianto, Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Azienza Ospedaliero-Universitaria Sant’Orsola-Malpighi, Alma Mater Studiorum Università di Bologna, Italy
2 Diagnostica istopatologia e molecolare degli organi solidi e del relativo trapianto – D’Errico SSD Azienza Ospedaliero-Universitaria Sant’Orsola-Malpighi, Alma Mater Studiorum Università di Bologna, Italy

Psoriasis is a common chronic inflammatory disease of the skin that is increasingly being considered as a systemic inflammatory disorder due to its association with cardiovascular, metabolic, pulmonary, renal, liver, and neurologic diseases. Renal involvement is rare but well documented and psoriasis is recognized as an independent factor for CKD and ESKD. A careful monitoring of the urinalysis and of renal function is recommended in psoriatic patients, especially those with moderate-to-severe disease. In case of pathologic findings, the execution of a renal biopsy appears necessary to make an accurate diagnosis and to establish the most appropriate therapeutic strategies to prevent the progression of kidney damage. The mechanisms of kidney involvement are different and not yet fully clarified. We present here two case reports of renal dysfunction during psoriasis. In one case, we diagnosed IgA nephropathy with particularly severe clinical presentation; in the other, an advanced kidney injury due to nephrotoxicity after prolonged CNI treatment.


Keywords: psoriasis, chronic inflammation, renal involvement, IgA nephropathy, drug nephrotoxicity

Primary hyperoxaluria: case report and therapeutic perspectives

Vincenzo Cuomo, Cesare Gerardo Riccio, Salvatore Coppola

UOSD Nefrologia e dialisi, P.O. Piedimonte Matese, Azienda Sanitaria Locale Caserta

Primary hyperoxaluria (PH) is a rare genetic disorder with autosomal recessive transmission, characterized by high endogenous production and markedly excessive urinary excretion of oxalate (Ox). It causes the accumulation of calcium oxide crystals in organs and tissues including bones, heart, arteries, skin and kidneys, where it may cause oxalo-calcic nephrolithiasis, nephrocalcinosis and chronic renal failure. Some forms are secondary to enteric diseases, drugs or dietetic substances, while three primitive forms, caused by various enzymatic defects, are currently known: PH1, PH2 and PH3.

An early diagnosis, with the aid of biochemical and genetic investigations, helps prevent complications and establish a therapeutic strategy that often includes liver and liver-kidney transplantation, improving the prognosis of these patients.

In this work we describe the clinical case of a patient with PH1 undergoing extracorporeal hemodialysis treatment and we report the latest research results that could change the life of patients with PH.


Keywords: primitive hyperoxaluria, PH, nephrocalcinosis, chronic renal failure

Native kidney ultrasound in obstructive uropathy

Fulvio Fiorini1,7,9, Antonio De Pascalis2, Alessandro D’Amelio3,9, Biagio Di Iorio4, Cataldo Abaterusso5, Antonio Granata6,8,9

1 UOC Nefrologia, Dialisi, AULSS5 Polesana, Rovigo
2 UOC Nefrologia e Dialisi, Lecce
3 UOS Dialisi, Gallipoli (LE)
4 UOC Nefrologia e Dialisi, Avellino
5 UOC Nefrologia, AULSS2 Marca Trevigiana, Asolo (TV)
6 UOC Nefrologia e Dialisi, A.O. “Cannizzaro”, Catania
7 Scuola Nazionale di Ecografia Nefrologica, Società Italiana di Ultrasonologia in Medicina e Chirurgia (SIUMB), Rovigo
8 Scuola Nazionale di Ecografia Nefrologica, società Italiana di Ultrasonologia in Medicina e Chirurgia (SIUMB), Catania
9 Commissione Didattica Iter Formativo in Ecografia Nefrologica Società Italiana di Nefrologia

The term “obstructive uropathy” refers to the complex structural and functional changes following the interruption of normal urinary runoff, which can occur at every level of the urinary tract. Depending on its origin, duration and severity, urinary tract obstructions can be acute or chronic, mono or bilateral, partial or complete. The obstruction can be localized or extended to the entire pielo-caliceal system and/or homolateral urethra. 

The term “hydronephrosis” indicates the dilation of the pelvis detected through imaging techniques. Among these, ultrasound is considered the gold standard in the diagnosis of obstructive uropathy: it allows to distinguish three degrees of urinary tract dilation, depending on the extent of the dilation itself and the thickness of the parenchyma. Nephrologists are confronted daily with patients who experience kidney failure and must be able to quickly distinguish between chronic and acute and, in the latter case, to discern between issues of nephrological or urological competence. This short review aims at helping them deal with this very common scenario, through the use of ultrasound.


Keywords: acute renal failure, chronic renal failure, obstructive uropathy, imaging, ultrasound

Vascular dysfunction in Cardiorenal Syndrome type 4

Concetto Sessa1, Antonio Granata2, Agostino Gaudio3, Anastasia Xourafa3, Lorenzo Malatino3, Paolo Lentini4, Pasquale Fatuzzo5, Francesco Rapisarda5, Pietro Castellino3, Luca Zanoli5

1 U.O.C Nefrologia e Dialisi, P.O. “Maggiore” di Modica, Ragusa
2 U.O.C di Nefrologia, Azienda Ospedaliera per l’Emergenza “Cannizzaro” – Catania.
3 Medicina Interna, Dipartimento di Medicina Clinica e Sperimentale, Università degli Studi di Catania, Catania
4 U.O.C Nefrologia, P.O “San Bassiano”, Bassano del Grappa, Vicenza
5 Nefrologia, Dipartimento di Medicina Clinica e Sperimentale, Università degli Studi di Catania, Catania

The Cardiorenal Syndrome type 4 (CRS-4) defines a pathological condition in which a primary chronic kidney disease (CKD) leads to a chronic impairment of cardiac function. The pathophysiology of CRS-4 and the role of arterial stiffness remain only in part understood. Several uremic toxins, such as uric acid, phosphates, advanced glycation end-products, asymmetric dimethylarginine, and endothelin-1, are also vascular toxins. Their effect on the arterial wall may be direct or mediated by chronic inflammation and oxidative stress. Uremic toxins lead to endothelial dysfunction, intima-media thickening and arterial stiffening. In patients with CRS-4, the increased aortic stiffness results in an increase of cardiac workload and left ventricular hypertrophy whereas the loss of elasticity results in decreased coronary artery perfusion pressure during diastole and increased risk of myocardial infarction. Since the reduction of arterial stiffness is associated with an increased survival in patients with CKD, the understanding of the mechanisms that lead to arterial stiffening in patients with CRS4 may be useful to select potential approaches to improve their outcome. In this review we aim at discussing current understanding of the pathways that link uremic toxins, arterial stiffening and impaired cardiac function in patients with CRS-4.


Keywords: arterial stiffness, cardiorenal syndrome, chronic kidney disease, inflammation, intima-media thickness, uremic toxins

Different methods to manage dry weight in hemodialysis patients

Alessandro Puntoni1, Domenico Giannese2, Enrico Varricchio1, Claudia D’Alessandro1, Maria Francesca Egidi2, Adamasco Cupisti1 

1 Dipartimento di Medicina Clinica e Sperimentale, Università di Pisa
2 U.O. Nefrologia Trapianti e Dialisi, AOUP, Pisa

Estimating the euvolemia and dry weight of hemodialysis patients still represents a challenge for the nephrologist, since both dehydration and hyperhydration are associated with intradialytic events and cardiovascular complications in the short and long term.

Despite the need for a precise and objective definition of the dry weight for the individual patient on dialysis, this is usually determined on a clinical basis. To obtain greater sensitivity the dosage of natriuretic peptides, Bioelectrical Impedance Analysis (BIA) and, more recently, Lung Ultra-Sound (LUS) can all be used. The BIA allows to estimate the subject’s body composition and, in particular, the distribution of body fluids. The presence of hyperhydration, as determined through the BIA, is predictive of an increased mortality in numerous observational studies.

In recent years, pulmonary ultrasound has taken on an increasingly important role not only within the cardiology and intensive care units, but also in a nephrology setting, especially in dialysis.

The purpose of this article is to analyze the advantages and limitations of the methods that can be used to assess the dry weight of patients undergoing hemodialysis treatment.


Keywords: hemodialysis, lung ultra-sound, bioelectrical impedance analysis, overhydration, dry weight



ADPKD treatment: Tolvaptan and Octreotide

Marco Galliani1, Silvana Chicca1, Elio Vitaliano1, Eleonora Moscaritolo1, Luca Calvaruso3, Francesco Iorio2, Antonio Paone1

1 UOC Nefrologia, Dialisi e Litotrissia, Ospedale Sandro Pertini Roma
2 UOC Diagnostica per Immagini, Ospedale Sandro Pertini Roma
3 U.O.C. Nefrologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, Italia

Autosomal Dominant Polycystic Kidney Disease (ADPKD) is the most frequent monogenic hereditary disease as well as the most studied inherited kidney disease. Two drugs have recently been authorized that can slow down the progression of the disease: Tolvaptan (vasopressin receptor antagonist) and Octreotide-LAR (long-acting somatostatin analogue); they both are able to reduce the activity of cyclic adenosine monophosphate (cAMP) and therefore have anti-proliferative and anti-secretory effects. This review analyzes the main trials published to date demonstrating the effects on disease progression in patients with ADPKD and illustrates the indications for identifying subjects eligible for therapy.

Keywords: ADPKD, Tolvaptan, Octreotide

Assessing the quality of life in patients with a vascular access

Carla Colturi1, Valeria Sala1, Marco Lombardi2, Alessandro Toccafondi3, Antonio Marciello4, Giacomo Forneris5
Per conto del Gruppo di Progetto degli Accessi Vascolari della Società Italiana di Nefrologia

1 UO Nefrologia e Dialisi, ASST Valtellina e Alto Lario, Sondrio, Italia
2 SOS Nefrologia e Dialisi Ospedale del Mugello della SOC Nefrologia e Dialisi Firenze 2 ASL Toscana Centro, Firenze
3 SOSD Psicologia Clinica in servizio presso SOC Nefrologia e Dialisi Firenze 2 ASL Toscana Centro, Firenze
4 SC Nefrologia e Dialisi ASLTO3 di Collegno Pinerolo, Presidio Ospedaliero “Edoardo Agnelli” Pinerolo
5 SC Universitaria di Nefrologia e Dialisi, Centro di Ricerche di Immunopatologia e Documentazione Malattia Rare, Ospedale Giovanni Bosco e Università di Torino

Patients undergoing haemodialytic treatment have a lower quality of life than the general population because of several factors. Their wellbeing can be assessed through a clinical evaluation or through the subjective point of view of the patients themselves: the perceived Health-Related Quality of Life (HRQoL) is an index calculated on the basis of the patients’ own perspective. A well-functioning vascular access (VA) and the absence of complications are certainly associated with better health in patients on dialysis but unfortunately VA-related perceived HRQoL has so far been a subject of little interesting literature, even though the choice of the most appropriate access in the individual patient is today increasingly articulate and difficult. Information about subjective perception of health is typically collected through generic or specific questionnaires. The most used reproducible questionnaires available are SF-36, EuroQoL5D, SONG-HD, WHOQoL-BREF, VAQ, although not all of them have been used for a targeted assessment of the issues concerning HRQoL and VA function. This review confirms that the VAQ questionnaire is currently the simplest and most reliable tool to assess patient satisfaction with their VA.

Keywords: Health-Related Quality of Life (HRQoL), questionnaires, vascular access

Positioning central venous catheters: how to prevent legal disputes

Fulvio Fiorini1, Antonio Granata2

1 UOC Nefrologia e Dialisi, AULSS 5 Polesana, Ospedale SM della Misericordia, Rovigo. Scuola Nazionale SIUMB di Ecografia Nefrologica, Rovigo.Coordinatore Commissione Affari legali e Giuridica della SIN.
2 UOC Nefrologia e Dialisi, Ospedale S. Giovanni di Dio, ASP1, Agrigento. Scuola Nazionale SIUMB di Ecografia Nefrologica, Agrigento

Central venous catheterization is a procedure frequently performed in daily clinical practice. The use of ultrasound during central venous catheter placement has significantly reduced the number of complications. However, while the outcome of the procedure has significantly improved, the number of legal disputes has increased. Despite the current legislation has repeatedly stressed the importance of adequately collecting informed consent, to date many legal cases show that this procedure is only superficially followed. The objective of the present work is to analyze the various phases of central venous catheterization, with the aim of making useful suggestions to avoid potential medical-legal problems. 

Keywords: central venous catheter, prevention, civil liability, legal issues in medicine

Endoplasmic Reticulum stress in chronic kidney disease. New molecular targets from bench to the bedside

Carlo Alberto Ricciardi, Luigi Gnudi

King’s College of London, Faculty of Life Sciences & Medicine, School of Cardiovascular Medicine & Sciences, Section Vascular Biology and Inflammation, British Heart Foundation Centre for Research Excellence.

The identification of new biomarkers/pharmacological targets for chronic kidney disease (CKD) is required for the development of more effective therapies. Several studies in vitro and in vivo have shown the importance of the endoplasmic reticulum (ER) (cellular organelle devolved to protein biosynthesis and maturation, and cellular detoxification processes) in the pathophysiology of CKD.

Hence, the synthesis and development of novel drugs against the different ER intracellular pathways is crucial in order to slow down the development and progression of renal diseases.

This review aims to dissect the role of the different ER branches (PERK, IRE1α, ATF6) and their function in CKD, providing potential insights for the development of new treatments.

Keywords: endoplasmic reticulum, chronic kidney disease, unfolded protein response, reticulon

Nephrologists’ role in a changing climate

Bianca Covella1, Luigi Rossi1, Piero Lisi1, Simone Corciulo1, Elisabetta Manno1, Carlo Lomonte1

1 U.O.C. di Nefrologia e Dialisi, Ente Ecclesiastico Ospedale “F.Miulli”, Acquaviva delle Fonti (Ba)

Human-induced climate changes represent an increasing concern in recent years. Among the medical specialties, Nephrology is the most interested in the negative effects of climate changes on human health. Kidneys in fact play a crucial role in blood volume regulation as well as in the extra- and intracellular osmolality that allow normal metabolism. Furthermore, urinary concentration minimizes fluid losses, while also insuring the excretion of nitrogenous wastes. The harmful effects of heat can lead to both acute and chronic kidney diseases, electrolyte abnormalities, kidney stone formation and urinary tract infections. As global warming increases, major efforts are required worldwide to assure adequate hydration and prevent overheating in vulnerable populations. While our activities make us responsible agents, there are also several opportunities to change the game, both individually and as a scientific society. This call to action intends to raise awareness on environmentally sustainable practices and encourage the nephrology community in Italy to participate in this important discussion.

Keywords: kidney injury, kidney disease, nephropathy, climate change, global heating

Anonymity of organ donors under discussion

Eva Oliver1, Gabriel Moreno1, Josep Maria Grinyo2

1 Organ Procurement Office and Transplant Coordination. Intensive Care Medicine. Hospital Universitari de Bellvitge. Barcelona
2 Professor of Medicine. Universitat de Barcelona. Nephrology Department. Barcelona

L’Organizzazione Mondiale della Sanità dichiara, nelle sue Guiding Principles on Human Cell, Tissue and Organ Transplantation, che la privacy e l’anonimato sia dei donatori che dei riceventi d’organo deve essere sempre protetta. Per questo motivo, la maggioranza dei programmi di trapianto europei proibisce qualsiasi contatto diretto tra la famiglia del donatore e il ricevente. L’anonimato infatti protegge entrambe le parti da possibili abusi, manipolazioni e pressioni di tipo economico.

Negli ultimi anni, tuttavia, si è riaperta la discussione su questo punto, specialmente in Italia dove il Comitato Nazionale di Bioetica ha recentemente adottato una posizione che favorisce gli incontri tra le famiglie dei donatori e i riceventi, nei casi in cui entrambe le parti lo desiderino. Molte famiglie di donatori sentono di voler “completare” la biografia del proprio parente deceduto, anche per far pace con la propria difficile scelta di donare; una proporzione considerevole di riceventi, d’altro canto, desidera riconoscere il ruolo svolto dal donatore e dalla sua famiglia e affrontare il fatto di dover la propria vita a qualcun altro, senza sensi di colpa. Pertanto, un modello basato sulla confidenzialità, l’autonomia e la libertà di fare scelte informate dovrebbe essere preso in considerazione nei paesi in cui le leggi riguardanti il trapianto d’organo sono attualmente soggette ad ampio dibattito.

Parole chiave: leggi sul trapianto d’organo, anonimato, famiglie dei donatori, riceventi

Organ donor families should be free to meet their recipients under controlled conditions if both sides wish, Italian National Committee for Bioethics says *

Carlo Petrini1 e Reginald Green2. Tradotto dall’inglese da Andrea Scarabelli.

1 Direttore dell’Unità di Bioetica, Istituto Superiore di Sanità, Roma, Italia
2 Presidente della “Nicholas Green Foundation”, La Canada, CA, USA

On 27 September 2018 the Italian Committee for Bioethics (ICB) adopted an opinion regarding the possibility of an exception to the anonymity obligation when both parties agree and have signed an appropriate informed consent form. According to the IBC any contact between the donor’s family and recipient must be managed by a third-party body pertaining to the National Health Service, established to guarantee strict control over the expression of consent in order to avoid any risk of inappropriate behaviour. The paper traces how Reg and Maggie Green, on holiday from California, donated the organs of their seven-year old son, Nicholas, to seven Italians after he had been shot in a carjacking on the Salerno-Reggio Calabria highway in 1994. Reluctant as a foreigner to propose a change in Italian law that effectively prevents the two sides from contacting each other, Reg Green held back for 22 years until, at age 87, he began a public campaign to voice his concern that the law was hurting transplant families rather than helping them.

Key words: ethics, healthcare legislation, organ donation, organ transplantation

Prototyping a new registry of vascular accesses for hemodialysis

Maria Luisa Lefons1, Salvatore Accoto2, Francesco Caccetta3, Adriano De Giorgi4, Virginia Greco5, Oronzo Lazzari6, Aldo Paolillo7, Francesco Giovanni Russo8, Giovanni Sandri9, Marcello Napoli1

1 U.O.C. Nefrologia-Dialisi e Trapianto Renale PO V. Fazzi Lecce
2 U.O.S. Nefrologia-Dialisi PO Casarano
3 U.O.C. Nefrologia-Dialisi PO Tricase
4 Centro Dialisi Clinica Città di Lecce
5 Centro Dialisi Diaverum Copertino
6 UOS Dialisi PO Gallipoli
7 Centro Dialisi Thourist H. Otranto
8 U.O.S Nefrologia-Dialisi PO Scorrano
9 U.O.S. Nefrologia-Dialisi PO Galatina

Allo scopo di migliorare il management degli Accessi Vascolari (AV) abbiamo sviluppato un nuovo sistema di registrazione degli AV dei pazienti della nostra ASL. Abbiamo registrato tutti gli AV dei pazienti prevalenti al 31/12/2017. Degli AV erano registrati tipologia, sede, vasi coinvolti, numero di accessi avuti dal paziente e tipo di anastomosi. Dei CVC, oltre la sede e le caratteristiche, era registrata la motivazione del posizionamento.

Risultati: I pazienti erano 726 (63% maschi), con età media 66+15 anni. Le fistole artero-venose con vasi nativi (FAV) erano 609 (84%), di cui il 65% localizzate al 1/3 distale dell’avambraccio (DF), il 10% al 1/3 medio (MF), il 5% al 1/3 prossimale dell’avambraccio (PF) e il 4% al braccio (AM). Le fistole protesiche (AVG) erano 12 (1.7%). I CVC erano invece 105 (14.5%). Nelle donne vi era un maggior numero di CVC (p<0.005) e di FAV al braccio (p<0.05). Gli over 75 avevano meno FAV al braccio (p<0.05) e Graft (P<0.05). I diabetici avevano un maggior numero di CVC (p<0.05) ma erano più vecchi rispetto al resto della popolazione (p<0.003). I pazienti rientrati in dialisi per perdita del trapianto renale avevano più FAV al braccio (p<0.001) e Graft (p<0.001) e meno FAV al DF (p<0.001). Il confronto dei dati tra il 2013 e il 2017 dimostra una stazionarietà della prevalenza degli AV.

Conclusioni: Il nuovo sistema di registrazione degli accessi vascolari ci ha permesso di evidenziare numerose informazioni rilevanti sia dal punto di vista clinico che epidemiologico.

Parole chiave: accessi vascolari, registro, sede delle FAV, emodialisi

Economic impact of kidney patients with sepsis in hospital setting

Yuri Battaglia1, Franco Guerzoni2, Manuel Gigante1, Marco Veronesi1, Chiara Oppi3, Elena Forini4, Ines Ullo5, Emidia Vagnoni3, Alda Storari1

1 UOC di Nefrologia e Dialisi, AOU “Sant’Anna”, Ferrara, Italia
2 Nucleo Aziendale Controlli, AOU “Sant’Anna”, Ferrara, Italia
3 Dipartimento di Economia e Management, Università di Ferrara, Italia
4 Ufficio Statistico, AOU “Sant’Anna”, Ferrara, Italia
5 UOC di Nefrologia e Dialisi, ASST Sette Laghi, Varese, Italia

Introduction: Over the last decades, sepsis has become a real medical emergency, with a high mortality rate and often requiring admission to an intensive care unit. An increasing number of CKD patients contracts sepsis due to several clinical risk factors (use of catheters, immunosuppressive therapy, comorbidity, etc.) and is treated in Nephrology wards, generating additional costs that are not covered by hospital Diagnosis Related Groups (DRG) reimbursement. The aim of the study is to evaluate the costs of sepsis in one Nephrology Unit and to detect the mortality rate of CKD patients with sepsis.

Methods: We conducted a retrospective study on a cohort of CKD patients admitted into one Nephrology Unit in 2017. CKD inpatients were divided in two groups: patients with sepsis (SP) and without (control group). Socio-demographic, clinical and therapeutic data, as well as routine biochemistry, were collected through a “sepsis form”. SP were identified thanks to hospital discharge records (HDR). The hospital-related costs of a SP were obtained by summing up: (1) the average cost of an inpatient day of care for the average length of stay in the Nephrology Unit; (2) the average cost of the antimicrobial therapy, as recorded on the clinical folder.

Results: Among the 408 CKD inpatients, 61 were septic. The overall average cost of a SP was 23.087,57 €; the average cost of the hospital stay and of the antimicrobial therapy was 19.364,98 € and 3.722,60 € respectively. The average length of stay in the Nephrology Unit was 16.7 days. The in-hospital mortality rate was 41.7%, with a 312% additional mortality rate.

Conclusions: SP had an overall average cost three times higher than CKD inpatients without sepsis (9.290,79 €). This additional cost was due to a longer hospital stay (8.7 days more on average) and a higher cost of antimicrobial therapy per case (€ 221,24). A national multi-centre study is needed to confirm our data and to promote an adjustment of reimbursement tariff for DRG-sepsis, which is now applicable only to an ICU setting. 

Keywords: sepsis, costs, kidney disease, hospital discharge register

The challenge of the peripheral Nephrological Center: an Italian story

Elena Belotti1, Doriana Polonioli1

1 UO Nefrologia e Dialisi, ASST Valcamonica – Esine (Brescia)

In small peripheral nephrological hospitals it can sometimes be difficult to obtain an early diagnosis and to ensure a state-of-the-art treatment. In the most complex cases, in fact, patients must be transferred to the closest Nephrological Referral Center in order to recover kidney function or improve the chance of survival. Other challenges are represented by the progressive ageing of the population and by the management of oncological patients developing kidney complications, for which it would be desirable to create dedicated clinics.

However, small hospitals also offer many advantages, such as better work management, the opportunity to attend many training initiatives and congresses, and the ability to better balance career with family needs. Cooperating in smaller teams and the harmony that develops with the other physicians and nurses allows us to offer the best healthcare to nephropathic patients who live far away from the major Referral Centers.

Each peripheral Center can also represent an essential resource for the major Center because it acts as the first point of contact with patients, taking care of identifying the situations that need the attention of the Referral Center and, subsequently, taking charge of the follow-up in conservative or replacement therapy.

Keywords: peripheral Nephrological Centers, Referral Centers, follow-up, point of contact, challenges.

The dawn of Parma’s nefrological school as told by one of its students

Rosario Maiorca1, Giovanni B. Fogazzi2

1 Già Direttore della Cattedra e della Scuola di Specializzazione di Nefrologia dell’Università di Brescia e Primario della Divisione di Nefrologia, Dialisi e Trapianti degli Spedali Civili di Brescia
2 U.O.C. di Nefrologia, Dialisi e Trapianto di Rene, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano

This paper, written by Professor Rosario Maiorca, describes the everyday professional life in the institutes of Clinica Medica and subsequently of Patologia Medica at Parma University in the second half of the fifties and in the first years of the sixties of the past century. Those institutes and that period, which have been very important for the birth of Nephrology in Italy, have already been described, from the historical standpoint, in an Italian monograph on the history of our specialty for the period 1957-2007. The present paper adds to that chapter an insight of “real life”, with a lively description of the wide and passionate clinical and scientific activities of the young doctors in training and of the personality, greatly stimulating and altruistic, of their “Masters”.

Keywords: history of nephrology, history of Italian nephrology, history of the Italian Society of Nephrology

Acute renal failure secondary to DRESS syndrome

Elnaz Rahbari1, Roberto Cardillo1, Lucia Dimora2, Rosaria Gangemi2, Patrizia Boemi2, Rosaria Saitta2, Alessandro Cardillo3, Giovanni Rapisarda2

1 Dipartimento di Medicina, sez di Nefrologia, Azienda Ospedalieri G.Rodolico, via Santa Sofia 86,95123 , Catania, Italia
2 Dipartimento di Medicina Interna, ospedale Santa Marta e Santa Venera, Via Caronia Acireale, Catania, Italia
3 Università degli studi di Catania

We report here the case of a 63-year-old man, diagnosed with rheumatoid arthritis, who presented fever, weakness, diarrhea, chest, limbs and face erythema 20 days after starting of therapy with salazopyrin; these symptoms only partially and temporarily subsided after early drug withdrawal. The subsequent intake of mesalazine during acute colitis, after 48 hours, determined a sever relapse characterized by high fever, general malaise, diffuse morbilliform rash on the trunk, face and limbs with visceral involvement (acute renal and hepatic injury). At this time the diagnosis of “Drug reaction with eosinophilia and systemic symptoms”, or DRESS, was done according to “Regiscar” criteria. Mesalazine was therefore suspended and steroid therapy begun, inducing a slow but complete remission within two months.

Keywords: rash, eosinophilia, lymphadenopathy, salazopyrin, mesalazine, acute renal injury

Vascular access survey in the Triveneto area: data analysis for the year 2017

Patrizia Veniero1, Diana Zarantonello1, Maurizio Axia2, Andrea Bandera3, Manuela Bosco4, Giuliano Boscutti5, Carlo Crepaldi6, Mauro Dugo7, Lucia Martimbianco8, Massimiliano Martone4, Giuseppe Scaparrotta9, Maria Grazia Tabbì10, Fabrizio Valente1, Fulvio Fiorini11

1 Ospedale S. Chiara di Trento, USC Nefrologia e Dialisi
2 Ospedale di Santorso, UO di Nefrologia e Dialisi
3 Ospedale di Feltre, USC Nefrologia e Dialisi
4 Ospedale di Gorizia, USC Nefrologia e Dialisi
5 Ospedale Santa Maria della Misericordia di Udine, UO di Nefrologia, Dialisi e Trapianto renale.
6 Ospedale San Bortolo di Vicenza UO di Nefrologia, Dialisi e Trapianto renale
7 Ospedale di Treviso USC Nefrologia e Dialisi
8 Ospedale di Palmanova, UO Nefrologia e Dialisi
9 UO di Nefrologia, Dialisi e Trapianto Azienda Ospedaliera-Universitaria di Padova.
10 Ospedale Provinciale di Bolzano- Divisione di Nefrologia e Dialisi
11 Ospedale di Rovigo, USC Nefrologia e Dialisi

In 2017 the Italian Society of Nephrology operating in the Triveneto area investigated through a questionnaire, distributed to the various nephrological centers in the regions of Friuli Venezia Giulia, Trentino Alto Adige and Veneto, the differences concerning organizational models, choice of dialysis, creation and management of vascular access. The results emerging from the analysis of the collected data are presented.

Keywords: questionnaire, Triveneto area, vascular access, data analysis

The accuracy of hospital discharge records and their use in identifying and staging chronic kidney disease

Dino Gibertoni1, Marcora Mandreoli2, Sara De Amicis3, Chiara Cantarelli4, Mattia Corradini5, Francesco Caruso6, Francesca Testa7, Lorenzo Gasperoni8, Catia Orrico9, Francesca Brancaleoni10, Davide Martelli11, Maria Laura Angelini12, Benedetta Ferri13, Marta Flachi14, Marica Iommi1, Antonio Santoro9

1 Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna
2 UO Nefrologia e Dialisi, Ospedale “S.Maria della Scaletta”, Imola
3 UO Nefrologia e Dialisi, Ospedale “Guglielmo da Saliceto”, Piacenza
4 SC Nefrologia, Ospedale Maggiore, Parma
5 UO Nefrologia e Dialisi, Arcispedale “S.Maria Nuova”, Reggio Emilia
6 UO Nefrologia e Dialisi, Ospedale “B. Ramazzini”, Carpi
7 SC Nefrologia e Dialisi, Policlinico di Modena
8 UO Nefrologia, Dialisi e Trapianto, Ospedale S.Orsola-Malpighi, Bologna
9 UO Nefrologia, Dialisi e Ipertensione, Ospedale S.Orsola-Malpighi, Bologna
10 UO Nefrologia e Dialisi, Arcispedale “S.Anna”, Ferrara
11 UO Nefrologia e Dialisi, Ospedale “S.Maria delle Croci”, Ravenna
12 UO Nefrologia e Dialisi, Ospedale “G.B.Morgagni-L.Pierantoni”, Forlì
13 UO Nefrologia e Dialisi, Ospedale “M.Bufalini”, Cesena
14 UO Nefrologia e Dialisi, Ospedale Infermi, Rimini

Administrative databases contain precious information that can support the identification of specific pathologies. Specifically, chronic kidney disease (CKD) patients could be identified using hospital discharge records (HDR); these should contain information on the CKD stage using subcategories of the ICD9-CM classification’s 585 code (subcategories can be expressed just by adding a fourth digit to this code). To verify the accuracy of HDR data regarding the coding of CKD collected in the Italian region Emilia-Romagna, we analyzed the HDR records of patients enrolled in the PIRP project, which could easily be matched with eGFR data obtained through laboratory examinations. The PIRP database was used as the gold standard because it contains data on CKD patients followed up since 2004 in thirteen regional nephrology units and includes data obtained from reliable and homogeneous laboratory measurement.

All HDR of PIRP patients enrolled between 2009 and 2017 were retrieved and matched with available laboratory data on eGFR, collected within 15 days before or after discharge. We analyzed 4.168 HDR, which were classified as: a) unreported CKD (n=1.848, 44.3%); b) unspecified CKD, when code 585.9 (CKD, not specified) or 586 was used (n=446, 10.7%); c) wrong CKD (n=833, 20.0%); d) correct CKD (n=1041, 25.0%). We noticed the proportion of unreported CKD growing from 32.9% in 2009 to 56.6% in 2017, and the correspondent proportion of correct CKDs decreasing from 25.4% to 22.3%. Across disciplines, Nephrology showed the highest concordance (69.1%) between the CKD stage specified in the HDRs and the stage reported in the matched laboratory exam, while none of the other disciplines, except for Geriatrics, reached 20% concordance. When the CKD stage was incorrectly coded, it was generally underestimated; among HDRs with unreported or unspecified CKD at least half of the discharges were matched with lab exams reporting CKD in stage 4 or 5.

We found that the quality of CKD stage coding in the HDR record database was very poor, and insufficient to identify CKD patients unknown to nephrologists. Moreover, the growing proportion of unreported CKD could have an adverse effect on patients’ timely referral to a nephrologist, since general practitioners might remain unaware of their patients’ illness. Actions aimed at improving the training of the operators in charge of HDRs compilation and, most of all, at allowing the exploitation of the informative potential of HDRs for epidemiological research are thus needed.


Keywords: chronic kidney disease, hospital discharge records, administrative databases, CKD stage, identification of CKD

Multifaceted approach to a rare clinical case of calciphylaxis in a renal transplant recipient

Carlo Massimetti1, Antonio Bellasi2, Antonio Modoni3, Vito Gomes4, Sandro Feriozzi1

1 Renal Division, Belcolle Hospital, Viterbo, Italy
2 Research, Innovation and Brand Reputation, ASST Papa Giovanni XXIII, Bergamo, Italy
3 Vascular Surgery, Belcolle Hospital, Viterbo, Italy
4 Division of Surgical Pathology, Belcolle Hospital, Viterbo, Italy

Calcific uremic arteriolopathy (CUA) is a highly morbid condition usually found in ESRD patients that has rarely been reported after renal transplantation and renal function restoration. Furthermore, little is known about the optimal management of CUA in this setting. Herein, we report on the clinical case of AB, a 70-year-old woman who developed CUA after renal transplantation and renal function restoration. However, other risk factors for CUA such as diabetes and warfarin treatment, due to mechanical aortic valve implantation, were present. Thirty-eight months after renal transplantation she developed erythema and livedo reticularis in both legs and a gradually enlarging skin ulcer in the right leg. A skin biopsy of the ulcer showed features compatible with the CUA, such as sub-intimal calcification and luminal obstruction of the small dermal arterioles, tissue ischemia and signs of adipocytes degeneration. A multidisciplinary approach was adopted, including medical and non-medical treatments such as surgical debridement and vacuum-assisted closure therapy. Medical treatments included a five weeks course of once a week intravenous infusion of pamidronate and intravenous sodium thiosulfate (STS) at increasing doses. Four months after beginning the therapy with STS, a complete healing of the ulcer on the right leg and the disappearance of the livedo reticularis on the left leg was noted. In conclusion, although rare CUA may develop also in renal transplanted patients, a timely and combined therapeutic approach is essential for its resolutive treatment. Sodium thiosulfate therapy has proven to be effective and tolerated.

Key words: calcific uremic arteriolopathy, calciphylaxis, renal transplantation, sodium thiosulfate

Leptospirosis and kidneys: a clinical case

Lorenzo D’Elia1,2, Maria Consiglio Barozzino2,3, Massimo Liberatori1,2, Nicola Panocchia 1,2

1 U.O.C. Nefrologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia
2 Università Cattolica del Sacro Cuore, Roma, Italia
3 U.O.C. Medicina Interna, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia

We describe here the case of a young patient, employed in agriculture, who entered the emergency room with fever, headache, hematuria and a worsening of renal function; we diagnosed leptospirosis with renal involvement. As the patient lamented very generic symptoms, the anamnesis was fundamental in leading us to suspect an infection, execute the right laboratory analysis, and correctly diagnose a pathology which is currently very rare in Italy.

Keywords: case report, leptospirosis, AKI

Effect of hyperkalemia and RAASi nonadherence on patients affected by heart failure or chronic kidney disease

Luca Degli Esposti1, Valentina Perrone1, Elisa Giacomini1, Diego Sangiorgi1, Davide Alessandrini1, Antonio Santoro2

1 CliCon S.r.l. Health, Economics & Outcomes Research
2 Scuola di Specializzazione in Nefrologia- Università degli studi di Bologna

The presence of hyperkalemia (HK) in patients with heart failure (HF)or chronic kidney disease (CKD) increases the risk of death. The aims of the present study have been: i) to evaluate if the risk of cardiovascular (CV) events and mortality increases in two cohorts of patients with heart failure (HF) or chronic kidney disease (CKD) affected by hyperkalemia (HK) and treated with renin-angiotensin-aldosterone system inhibitors (RAASi). We have also evaluated the risk of dialysis among CKD patients; ii) to provide an estimate of the increased risk of CV events and mortality caused among HK patients by a non-optimal adherence to RAASi therapy in both HF and CKD cohorts.

This is a retrospective study, based on the administrative databases of five Italian Local Health Units. All patients ≥18-year-old discharged from hospital with a diagnosis of HF (ICD-9-CM 428) or CKD (ICD-9-CM585) between January 2010 and December 2017 were enrolled. We defined as index date (ID) the date of first diagnosis during the enrolment period. Only patients that were prescribed RAASi therapy during the first three months after the ID were considered. Serum potassium level was tested in the three months before and after ID. The patients were considered as having HK if they presented a serum potassium level ≥5.5 mmol/l. Results show that patients with HK treated with RAASi were respectively 46% (HF) and 31% (CKD) more at risk of CV events and 88% (HF) and 72% (CKD) more at risk of dying. Moreover, the risk of dialysis in CKD patients increased by 458%. After the onset of HK, non-optimal adherence to RAASi in patients with HK was found to increase notably the risk of CV events (65% HF, 34% CKD) and mortality (127% HF, 122% CKD) in both cohorts.


Keywords: hyperkalemia, renin-angiotensin-aldosterone system inhibitor, chronic kidney disease, heart failure, drugs for hyperkalemia, real-world study

Bardoxolone: a new potential therapeutic agent in the treatment of autosomal dominant polycystic kidney disease?

Sonia Celentano1, Giovanna Capolongo1, Rosa Maria Pollastro1

1 Università degli studi della Campania “Luigi Vanvitelli”, U.O.C. di Nefrologia e Dialisi, Napoli, Italia

Autosomal dominant polycystic kidney disease (ADPKD) is the most common genetic cause of chronic renal failure. The natural history of ADPKD is characterized by development of multiple bilateral renal cysts that progressively destroy the architecture of the parenchyma and lead to an enlargement in the total kidney volume (TKV) and to the decline of the renal function. Cyst growth activates the immune system response causing interstitial inflammation and fibrosis that contribute to disease progression. In recent years, the therapeutic toolkit available to the nephrologist in the treatment of ADPKD has been enriched with new tools, and in this context bardoxolone is classified as a potential therapeutic agent. It is a semisynthetic derivative of triterpenoids, a family of compounds widely used in traditional Asian medicine for their multiple effects. Bardoxolone exerts antioxidant activity by promoting the activation of Nrf2 (Nuclear factor erythroid2-derivative – 2) and the downregulation of the proinflammatory NF-kB (Nuclear factor kappa-light-chain-enhancer of activated B cells) signaling. Several pieces of evidence support the use of bardoxolone in the treatment of chronic kidney disease (CKD) documenting an effect on the increase of glomerular filtration rate (GFR). However, its use is limited to patients at risk of heart failure. The FALCON study will clarify the efficacy and safety of bardoxolone in the treatment of ADPKD.

polycystic kidney disease, inflammation, bardoxolone, glomerular filtration

Non erythropoietic effects of Erythropoietin

Chiara Guglielmo1,2, Chiara Cantarelli1,3, Andrea Angeletti1,2, Paola Todeschini2, Paolo Cravedi1

1 Icahn School of Medicine at Mount Sinai, New York, NY, USA
2 Dipartimento Unità Sperimentale di Medicina Specialistica, Diagnostica, Nefrologia, Dialisi e Trapianto Renale, Ospedale Universitario S. Orsola, Bologna, Italy
3 Dipartimento di Medicina e Chirurgia (Università di Parma), UO Nefrologia (Azienda Ospedaliera-Universitaria Parma), Parma, Italy

Over the past two decades it has emerged that, in addition to erythropoietic activity, erythropoietin (EPO) has numerous other functions, including neuro-protective, anti-apoptotic, antioxidant, angiogenetic and immunomodulatory ones. EPO interacts with two different forms of its receptor (EPOR): a homodimer receptor, responsible for the erythropoietic effects, and a heterodimer receptor, responsible for the non-erythropoietic effects. The effects on the heterodimer receptor are responsible for EPO-induced prolongation of organ transplant survival in mice and humans.

The development of new molecules that selectively target the heterodimer EPOR is allowing to test the effect of long-term treatments, without the possible complications related to the increased hematocrit.


Keywords: erythropoietin, EPO, ARA290, EPOR

Conflicts in healthcare: a communication issue

Fulvio Fiorini1, Antonio Granata2

1 UOC Nefrologia e Dialisi, AULSS 5 Polesana, Ospedale SM della Misericordia, Rovigo
2 UOC Nefrologia e Dialisi, Ospedale S. Giovanni di Dio, ASP1, Agrigento

Conflicts are situations in which two or more people come into disagreement: they are an integral part of social life caused by the inability to find a solution to a dispute. Conflicts are constantly present within families and in all social organizations; in the health sector, they are part of the daily routine. The most common causes of conflict are the lack of resources and the divergence in objectives. All conflicts can quickly escalate, so it is essential to recognize them in order to defuse them as soon as possible. Doctors, as managers, must recognize the early signs of latent conflict in order to better manage them and possibly use them in order to stimulate change in the organization.

Keywords: conflict, resources, communication, change

From scientific evidence to clinical recommendations: outlooks and challenges for the SIN (Italian Society of Nephrology)

Domenico Santoro1,2, Emanuele Torri3,4, Marta Rigoni3,5, Giandomenico Nollo3,5, Holger J. Schünemann6,7, Giuliano Brunori2,8

1 Dipartimento di Medicina Clinica e Sperimentale, Università di Messina, Messina
2 Società Italiana di Nefrologia, Roma
3 Innovazione e Ricerca Clinica e Sanitaria – HTA, Fondazione Bruno Kessler, Trento
4 Dipartimento Salute e Politiche Sociali, provincia Autonoma di Trento, Trento
5 Dipartimento di Ingegneria Industriale, Università di Trento, Trento
6 Department of Health Research Methods, Evidence, and & Impact; McMaster University, HSC-2C16; 1280 Main Street West; Hamilton, ON, Canada L8N 3Z5, Canada
7 Department of Medicine; McMaster University, HSC-2C16; 1280 Main Street West; Hamilton, ON, Canada L8N 3Z5, Canada
8 Unità Operativa di Nefrologia, Ospedale S. Chiara, Trento

According to the new Clinical Guidelines National Plan, Scientific Societies take on a key role in creating and implementing guidelines within the National Health System. We chart the efforts of our Society in creating the right kind of expertise and closing the gap with Scientific Societies abroad.


Keywords: Clinical Practice Guidelines, National Plan, GRADE method, Italian Society of Nephrology

60 years of the SIN (Italian Society of Nephrology)

Giuliano Brunori

Corrispondenza a:
Giuliano Brunori
Presidente della Società Italiana di Nefrologia
Ospedale Santa Chiara
UO Nefrologia e Dialisi
Largo Medaglie d’Oro, 9

We celebrate this year the 60th National Congress of our Scientific Society. This important accomplishment encourages us to reflect back on the long history of Italian Nephrology and the progress done so far.

Malattie renali ereditarie con fenotipo cistico ad espressione in età adulta: non solo ADPKD2

Elisa Delbarba1, Nadia Dallera2, Francesco Scolari1, Claudia Izzi3

1 Nefrologia, Università di Brescia
2 Nefrologia ASST Spedali Civili, Brescia
3 Nefrologia e Diagnosi Prenatale, Ostetricia e Ginecoloiga, ASST Spedali Civili, Brescia

In recent years, the etiologies of many kidney diseases have been revealed as single-gene defects, due to the use of novel molecular genetic techniques. It is now clear that molecular diagnostics of kidney diseases plays a key role not only in the pediatric field, but also in adult nephrology. Recent data suggest that inherited disorders may account for approximately 10% of ESRD cases presenting in adulthood. Among hereditary kidney diseases, the most common are cystic diseases.

Here we describe five cases of adult-onset renal genetic disease with cystic phenotype, encountered in daily clinical practice. In particular, we discuss two cases of Polycystic Kidney Disease (PKD) and three cases of Autosomal Dominant Tubulointerstitial Kidney Disease (ADTKD). Molecular analysis was performed using Next Generation Sequencing (NGS) with a 7-gene panel for cystic kidney disease (PKD2, PKHD1, TSC1, TSC2, UMOD, HNF1B, REN).

Drugs and kidney in the elderly patient

Silvana Savoldi, Andrea Serra

S.C. Nefrologia e dialisi, ASL TO4, Ospedali di Cirié, Chivasso, Ivrea

With aging, different factors contribute to change the pharmacokinetics and pharmacodynamics of drugs and therefore can cause variable and unpredictable clinical outcomes.

As we age, the body composition changes, liver and kidney blood flow decreases resulting in reduced function of both organs and therefore decreased metabolism and insufficient elimination of drugs. On the other hand, the elderly are at greater risk in the use of drugs both for the reasons listed above and for the presence of diseases that determine the intake of numerous drugs that can interact with each other. The lower physiological reserves and the conditions related to fragility contribute to the occurrence of toxicity or adverse events related to therapy. To these causes are added factors related to the health system such as the fragmentation of care with multiple prescribers and inadequate training in treating the elderly patient. The need for correct reconnaissance and pharmacological reconciliation is therefore of fundamental importance.

The frequency of adverse drug reactions is about three to ten times higher in the elderly patient and clinically the adverse reactions are more severe. Furthermore, there is a close relationship between the incidence of adverse reactions and renal function which is in turn responsible for changes in the pharmacokinetics and pharmacodynamics of drugs and the kidney is very often the target organ of adverse drug reactions.


Keywords: Drugs, kidney, adverse drugs reactions, drugs toxicity

L’insufficienza renale acuta nell’anziano

Antonio Santoro

Scuola di Specializzazione in Nefrologia, Università degli Studi di Bologna, Policlinico S.Orsola-Malpighi

L’insufficienza renale acuta (IRA), definita anche come danno renale acuto, è una patologia che sta ricevendo una crescente attenzione negli ultimi anni, vista la sua incidenza, i danni che causa al paziente ed i costi che sono necessari per il suo trattamento. Il soggetto anziano, spesso gravato da numerose pluri-patologie e con una riduzione funzionale para-fisiologica dell’attività renale, risulta essere maggiormente a rischio di sviluppo di un danno renale acuto. La comparsa di IRA è infatti insieme alle sepsi una delle complicanze più frequenti nell’anziano ricoverato in ambiente ospedaliero. Vi sono delle strategie comportamentali che si sono dimostrate efficaci nella prevenzione del danno renale in molte situazioni, come l’idratazione prima dell’utilizzo dei mezzi di contrasto iodati, l’attenzione ai farmaci nefrotossici, la modulazione di concomitanti terapie che impattano sul sistema cardio-vascolare (inibitori del SRA, betabloccanti, ecc.).

Il sovraccarico di liquidi, la riduzione delle masse muscolari, gli stati settici, che si verificano molto più facilmente e rapidamente nel soggetto anziano, possono mascherare l’innalzamento della creatinina plasmatica. Pertanto, nel contesto anziano, modelli previsionali e diagnostici quali i criteri KDIGO, AKIN e RIFLE vanno presi in considerazione con una certa cautela e ripensati. L’IRA nell’anziano ha specifiche peculiarità che la rendono difficoltosa, sia sotto il profilo diagnostico che terapeutico. Le cose si complicano ulteriormente quando sono necessari interventi, come quelli dialitici, che di per sé hanno una loro un-physiology che può risultare destabilizzante in soggetti fragili e con labile compenso emodinamico.

Parole chiave: insufficienza renale acuta, anziani, co-morbidità, deterioramento danno renale acuto, dialisi


Enrico E. Minetti

S.C. Nefrologia, ASST Grande Ospedale Metropolitano  Niguarda, Milano

The increasing number of patients waiting for a kidney transplant is mainly due to the increase in the number of patients over 65 year old.

Kidney transplantation from cadaveric or living donors confer benefits in terms of improved patient survival in suitably selected elderly recipients. The net gain in survival becomes evident two years after transplantation.

The old for old allocation strategy aims to ensure an appropriate match of kidney and patient life expectancy, simultaneously providing a more immunogenic graft to a less immune-responsive recipient.

The entity of life expectancy gain after transplantation should be evaluated taking into account the improvement in dialysis life expectancy that has been observed in the last years, especially in the elderly patients.

By recognizing who the frail patients are, and by measuring their frailty, we can improve our ability to select older patients for transplantation.

The mostly adopted immunosuppressive regimens for older recipients are not different from those adopted in other patients, at least in the induction phase. The maintenance therapy is kept to the lower limits of standard immunosuppression.

Due to the unfavorable effect of a long dialysis vintage on graft and patient survival, it is important to lead older patients to transplantation with no delays.

It has been demonstrated that kidney transplantation from expanded criteria donor in patients 60 years or older is associated with higher survival rates than remaining on dialysis, whereas living donor renal transplantation is superior to all other options.


Keywords: Kidney transplantation, aging, immunosuppressive agents, frailty

Kidney transplantation from older living donors

Silvio Sandrini, Francesca Valerio

U.O. di Nefrologia, ASST Spedali Civili di Brescia

Recently, living donor kidney transplantation has become a suitable therapeutic option for many elderly patients with ESRD. In this setting, the living donor will often be an equally elderly subject. This entails a process of selection that is complex and not always well codified.

Elderly donors (EDs) are aged between 65 and 80. In EDs, the minimum glomerular filtration rate (GFR) acceptable for donation decreases with increasing age, but according to the KDIGO guidelines it should never be less than 60 ml / min / 1.73m2. However, the United Kingdom Guidelines also accept slightly lower values.

After donation, also in the elderly there is an increase in the volume of the residual kidney and an increase in GFR of about 20% (mainly due to increased renal plasma flow). This allows maintaining a stable GFR over time, without an increased risk of ESRD.

For GFR evaluation, the suggested formulas are CKD-EPI or MDRD. However, creatinine clearance, although little considered by the guidelines, in the elderly may be reliable, and is still widely used.

Graft survival from EDs may be lower to those from younger donors but as high as those from standard deceased donors

The selection of the donor requires many other investigations. In the elderly, unlike in the young, it may be difficult to distinguish between a pathological or a para-physiological result. In order to correctly interpret these conditions, it is necessary to have great experience and expertise that only transplant centers with a high volume of activity can guarantee


Keywords: living donor, elderly donor, kidney transplantation

Aging e rene – Il trapianto renale con donatore deceduto anziano

Maria Messina, Davide Diena, Fabrizio Fop, Luigi Biancone

Unità Trapianto Renale, Divisione di Nefrologia, Dialisi e Trapianto, Università di Torino e A.O.U. Città della Salute e della Scienza di Torino

Con l’incremento dei pazienti in attesa di trapianto renale senza un concomitante aumento del numero di donatori disponibili si è reso necessario di allargare progressivamente in criteri di accettazione del donatore deceduto sia in termini di età che di caratteristiche cliniche con ovvie conseguenze in termini di qualità dei reni a disposizione. Infatti con l’età vi è una riduzione del filtrato glomerulare a cui si aggiungono ulteriori “danni” a carico dell’organo di varia natura sia pre-esistenti che al momento del trapianto. Il donatore anziano è pertanto da tempo definito come marginale o subottimale con criteri di allocazione ben definiti che si sono modificati nel corso del tempo a partire dalla prima definizione del 1999 (cosiddetti criteri di Crystal City) fino ai più recenti algoritmi (KDRI/KDPI).

Per ridurre il tasso di scarto di tali organi ed al tempo stesso assicurare buoni tassi di sopravvivenza per i riceventi sono state utilizzate differenti strategie a partire dalla valutazione del donatore (includendo l’analisi istologica pre-trapianto), alla gestione del prelievo e del trapianto e al follow up dei riceventi. Nel presente articolo si analizzano tali strategie nel dettaglio e per ognuna si pone l’accento su punti di forza e criticità nonché su come siano state utilizzate nelle differenti realtà trapiantologiche. Un capitolo peculiare è dedicato al doppio trapianto renale ed alla sua evoluzione nel tempo. Nella parte finale si mette in evidenza l’esperienza del centro Torinese nella gestione dell’allocazione dei reni marginali con riferimento anche all’andamento del ricevente nel lungo termine.

In conclusione gli autori confermano la tesi sostenuta da molti autori che propongono il trapianto di rene da donatore deceduto anziano come un’alternativa valida per utilizzare al meglio il pool di organi disponibili riducendo la “discard rate” e assicurando accettabili tassi di sopravvivenza per i riceventi (seppure come ovvio inferiori a quelli ottenibili con donatori standard). L’ottenimento di tali risultati non può prescindere da strategie dedicate e da un approccio multidisciplinare oltre che dal costante aggiornamento dei clinici coinvolti.

Parole chiave: trapianto renale, donatore deceduto anziano, criteri di allocazione, doppio trapianto.

La sospensione della dialisi e le cure palliative: da un caso clinico una riflessione generale

Marazzi F1, Serra I1, Manazza A2, Marengo M1, Tamagnone M1, Pino C1, Bottaro C1, Falconi D1, Gherzi M1, Tattoli F1, Formica M1

1 S.C.Nefrologia e Dialisi ASL Cuneo1.
2 S.S Cure Palliative ASL Cuneo1.

La sospensione della dialisi è un evento che spesso si verifica precocemente. È comunque un possibile indicatore di scelte inadeguate in un panorama di difficile decifrazione caratterizzato da comorbilità, fragilità e disabilità.

Sono stati sviluppati strumenti sensibili per la conoscenza della prognosi a breve e medio termine e per la conoscenza multidimensionale del paziente che pongono la qualità di vita alla base delle decisioni.

Al pensiero medico attuale si richiede di integrare elementi clinici e fisiopatologici con una forma di intelligenza filosofica “totale” fondata su valori e modalità operative che consentano una comunicazione efficace con il paziente e i famigliari per un percorso di scelta condivisa.

La prassi clinica deve poter contare su un quadro normativo certo e la preparazione specifica nella disciplina delle Cure Palliative.

È inoltre indispensabile che in tutto il percorso di assistenza al fine vita si realizzi l’integrazione tra la competenza specialistica clinica e fisiopatologica con la competenza delle Cure Palliative, per la corretta comprensione dei sintomi e la loro appropriata gestione.

La visione della dialisi rimodulata o palliativa, comprese opzioni di trattamento estemporaneo dopo la sospensione, e il principio di intervento mirato al sollievo dei sintomi con ogni mezzo, devono essere perseguiti fino al momento della morte.

Il “buon uso” della dialisi nella terminalità presuppone un sistema logistico coerente stabile e dedicato a questa tipologia di paziente.

La domiciliarità è setting ideale in cui si può attuare una gestione integrata simultanea del “fine vita” da parte di Nefrologo e Palliativista.

Parole chiave: Sospensione dialisi, età anziana, comorbilità, fragilità, fine vita, rimodulazione trattamento

La cardio-nefropatia avanzata nel paziente anziano. Quale approccio?

Bertoli Silvio Volmer1, Nava Elisa2, Guastoni Carlo Maria3, Traversi Lara1, Bigatti Giada1, Ciurlino Daniele1

1 Nefrologia e Dialisi IRCCS Multimedica Sesto San Giovanni
2 Università degli Studi di Milano Bicocca
3 UOC Nefrologia e dialisi ASST Ovest Milanese

La gestione della emodialisi nel paziente anziano

Filippo Aucella1, Antonio Gesuete1, Antonio Cicchella1,  Giuseppe Lucio Valente1, Mimmo Vigilante2, Giuseppe Gatta1, Michele Prencipe1

1 Struttura Complessa di Nefrologia e Dialisi, Istituto di Ricovero e Cura a Carattere Scientifico “Casa Sollievo della Sofferenza”, San Giovanni Rotondo (FG)
2 Unità Dialitica, Ospedale di Lucera ASL FG (FG).

Nowadays individuals > 65 years of age comprise the fastest growing subset of patients with ESRD in developed world. Although dialysis may be a life-extending treatment for patients of all ages, one-year mortality for older dialysis starts is very high. Moreover, in addition to limited life expectancy, many older adults experience functional decline and increased episodes of hospitalization after starting dialysis. In the elderly, a significant burden of harm may arise from the delivery of conventional haemodialysis, with frequent episodes of hypotension   having deleterious effects on both cardiac  and cerebral function.

This poor outcome is mainly due to frailty, a condition characterized by weakness, motility and balance issues, and a declined ability to resist stressors, leading to increased risks of adverse health outcomes a poor quality of life. Determination of the degree of frailty enables the clinician to evolve a holistic treatment plan with better outcome.


Key Words: haemodialysis, elderly, geriatric nephrology, frailty, palliative care.

Kidney Transplant from donors after cardiac death (DCD): monocentric experience and literature review

Marco Busutti1, Vera Minerva1, Andrea Angeletti1, Valeria Corradetti1, Chiara Zanfi2, Matteo Ravaioli2, Giorgia Comai1, Gaetano La Manna1

1 UO Nefrologia, Dialisi e Trapianto, Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Azienza Ospedaliero-Universitaria Sant’Orsola-Malpighi, Alma Mater Studiorum Università di Bologna, Italy

2 UO Chirurgia Generale e dei Trapianti, Dipartimento delle insufficienze d’Organo e dei Trapianti, Azienza Ospedaliero-Universitaria Sant’Orsola-Malpighi, Alma Mater Studiorum Università di Bologna, Italy

Kidney transplant from donor after circulatory death (DCD) represents a valid choice to increase the incidence of renal transplantation, presenting recipients’ and grafts’ survival rates comparable to those from brain dead donors (DBD). In January 2016, the Transplant Referral Center in the Emilia Romagna region has started a DCD program. In the present study we report on the first 30 months of the program as far as our own Center in Bologna is concerned, and we provide a comparison with DBD transplants performed over the same period. From January 2016 to September 2018, 16 kidney transplants from 10 DCD donors (5 SCD-DCD and 5 ECD-DCD) have been performed, with two graft-loss at 12 months of follow-up, both due to renal artery rupture caused by infectious arteritis with consequent transplantectomy. Two patients died due to sepsis. Seven (44%) delay graft function (DGF) have been reported. No differences have been found between DCD and DBD in terms of kidney function (serum creatinine and eGFR evaluated at discharge, 12 and 24 months of follow-up). Kidney from marginal donors (ECD-DCD or KDPI >65%) were associated with a higher rate of DGF and worst graft function at discharge. All the predicting factors that have been analysed, including Karpinsky Score, failed to show an association with serum creatinine and eGFR at 12 and 24 months of follow up.

Keywords: DCD, transplant, kidney, perfusion, outcomes, asystole

La dialisi peritoneale nell’anziano

Giusto Viglino, Loris Neri, Barbieri Sara, Catia Tortone

SC Nefrologia e Dialisi – Ospedale San Lazzaro – Alba

In questo lavoro abbiamo analizzato l’utilizzo della dialisi peritoneale (DP) nei pazienti anziani relativamente ai seguenti aspetti: risultati della metodica, barriere alla DP e DP assistita.

La DP, salvo poche eccezioni, a livello nazionale o di centro, è utilizzata meno negli anziani. Rispetto all’emodialisi (HD), i dati di registro evidenziano una sopravvivenza uguale o superiore nei pazienti giovani in DP, uguale o inferiore negli anziani. Più del 50% degli studi riporta una sopravvivenza della tecnica peggiore in DP con l’aumento dell’età; nei rimanenti studi essa è uguale o migliore. Il rischio di peritonite non è maggiore negli anziani, in cui tuttavia questa complicanza può avere un decorso più grave. Diversi studi, infine, non evidenziano differenze significative nella Qualità di Vita tra DP ed HD, nei pazienti che hanno potuto scegliere tra le due metodiche.

All’aumentare dell’età aumentano le comorbilità e si riduce l’autonomia; per tale ragione negli anziani sono presenti un maggior numero di barriere sociali, fisiche, cognitive e psicologiche all’autogestione della DP. La DP assistita consente di superare in modo efficace queste barriere, con risultati adeguati in termini di giorni di ricovero, mortalità, sopravvivenza della tecnica ed incidenza di peritoniti.

Nella nostra esperienza, la videodialisi (VD) è un sistema di telemedicina affidabile, sicuro e facilmente utilizzabile da utenti senza alcuna conoscenza tecnologica per realizzare un “caregiver virtuale” che consente d’iniziare o continuare la DP quando sono presenti barriere. Essa è anche in grado di favorire l’empowerment del paziente, evitando il ricorso a forme assistenziali a più elevato costo sociale ed economico.

Parole chiave: Dialisi Peritoneale, Dialisi Peritoneale assistita, Pazienti anziani, Barriere all’autogestione, Videodialisi

Gammopatie monoclonali di interesse renale nell’anziano: diagnosi e terapia

Francesco Iannuzzella1,  Elisa Gnappi 1, Mariacristina Gregorini1, Sonia Pasquali1

1 SC di Nefrologia e Dialisi, IRCCS Arcispedale S. Maria Nuova, Reggio Emilia

Le gammopatie monoclonali di significato indeterminato (MGUS) sono di comune riscontro nella popolazione generale e particolarmente frequenti tra gli anziani. Il termine “gammopatia monoclonale di significato renale (MGRS)” indica la presenza di una lesione renale direttamente attribuibile a una gammopatia monoclonale nell’ambito di un disordine proliferativo linfocitario o plasmacellulare che non soddisfa i criteri per il mieloma multiplo, la malattia di Waldenström, la leucemia linfatica cronica  o un linfoma. L’associazione fra MGUS e malattia renale nel paziente anziano è comune, ma solo raramente si tratta di MGRS. Nei casi sospetti la diagnosi richiede l’esecuzione di una biopsia renale per definire il tipo di lesione e una serie di esami ematologici per indentificare la componente monoclonale responsabile. A seconda del ruolo svolto dalla componente monoclonale, i meccanismi coinvolti nella patogenesi del danno renale possono essere schematicamente suddivisi in diretti e indiretti. Le lesioni sono inoltre classificate in base alla microscopia elettronica. Il trattamento, diretto all’eliminazione del clone sottostante, è indicato per evitare la progressione del danno renale e ridurre il rischio di recidiva nei pazienti candidati a trapianto.

Parole chiave: gammopatia monoclonale di significato renale (MGRS), proliferazione linfo-plasmacellulare, catene leggere, biopsia renale.

Glomerulonefriti e vasculiti nel paziente anziano: diagnosi e terapia

Antonello Pani, M.D.

Division of Nephrology and Dialysis, Azienda Ospedaliera G. Brotzu, Cagliari, Italy

La biopsia renale nell’anziano

Carlo Manno, Anna Maria Di Palma, Elisabetta Manno, Michele Rossini, Loreto Gesualdo

U.O.C. Nefrologia, Dialisi, Trapianto
Dipartimento Emergenza e Trapianti d’Organo
Università Aldo Moro di Bari, Bari

La biopsia renale e l’esame istologico permettono una corretta diagnosi  e un adeguato trattamento di numerose malattie renali acute e croniche. Sebbene la tecnica della biopsia renale percutanea  sia stata migliorata dall’utilizzo di guida ecografica e di aghi automatici, essa resta ancora sottoutilizzata soprattutto nella popolazione anziana e nelle patologie associate quale il diabete mellito. Le indicazioni più frequenti nei vari studi su pazienti anziani sono rappresentate dal danno renale acuto e dalla sindrome nefrosica; le diagnosi più frequenti sono patologie suscettibili di terapie specifiche e mirate, quali  vasculiti, amiloidosi e nefropatia membranosa. Per quanto concerne il diabete mellito, non sempre la diagnosi istologica è rappresentata dalla tipica nefropatia diabetica, ma spesso possono essere presenti quadri di glomerulonefrite che possono giovarsi di terapie immunosoppressive. La stessa nefropatia diabetica presenta varie classi che hanno un forte impatto sull’outcome clinico della insufficienza renale terminale. Sebbene la biopsia renale non sia totalmente scevra di pericoli, alcune revisioni  sistematiche e studi di registro hanno mostrato che le complicanze emorragiche maggiori, quali macroematuria e necessità di emotrasfusione, sono rare e che l’età anagrafica non costituisce un fattore predittivo del rischio emorragico.


PAROLE CHIAVE: Biopsia renale, anziano, complicanze emorragiche.

Epidemiologia delle malattie renali nell’anziano

Aurelio Limido

Segretario del Registro Italiano Dialisi e Trapianto, Società Italiana di Nefrologia

L’allungamento dell’aspettativa di vita e la ridotta natalità nella maggior parte dei paesi sviluppati o in via di sviluppo ha determinato un significativo invecchiamento della popolazione, con aumento progressivo delle classi di età più anziane anche se la tradizionale definizione su base anagrafica (> 65 anni) di “soggetto anziano” sembra attualmente limitante.  L’Italia rappresenta una delle nazioni a più alto indice di invecchiamento.

I cambiamenti in termini demografici hanno comportato anche una transizione di carattere epidemiologico, con riduzione delle patologie infettive e acute e progressivo aumento di quelle cronico-degenerative come l’ipertensione, il diabete, la malattia cardiovascolare e, in quanto strettamente correlata, la malattia renale cronica (CKD) nei suoi vari stadi fino all’uremia (ESRD) e al trattamento sostitutivo.

Le casistiche nazionali e internazionali confermano come CKD ed ESRD siano più frequenti nella popolazione anziana, spesso associate a fragilità o ad altre comorbilità.

La prevalenza globale di CKD in Italia resta comunque relativamente bassa, se confrontata ad altri paesi, soprattutto per gli stadi più avanzati, nonostante la maggior percentuale di popolazione anziana a livello nazionale.

Oltre la metà dei nuovi ingressi in trattamento sostitutivo per ESRD in Italia è rappresentato da pazienti con 65 o più anni e l’età avanzata rappresenta per questi soggetti un fattore prognostico negativo, gravando la terapia dialitica di una elevata mortalità precoce nei primi tre mesi.

Lo sforzo attuale e nei prossimi anni in ambito nefrologico sarà quello di migliorare lo studio e il potere prognostico dei fattori di rischio di questa vasta ma verosimilmente eterogenea popolazione, non solo in termini di evoluzione della malattia renale o di sopravvivenza ma anche di qualità di vita.

PAROLE CHIAVE: Malattia renale cronica, Anziano, Epidemiologia, Demografia

Un mondo che invecchia: prospettive demografiche e medicina del futuro

Ketty Vaccaro

Responsabile Area salute e welfare
Fondazione Censis

L’invecchiamento, insieme alla denatalità, è un fenomeno demografico che caratterizza l’attuale assetto sociale del Paese e che si accentuerà ulteriormente nel futuro, con effetti ancor più dirompenti sotto il profilo epidemiologico. Una radicale revisione dell’attuale approccio della medicina e dell’assetto dei servizi sanitari e sociali appare pertanto fondamentale. Sarà prima di tutto imprescindibile sviluppare la prevenzione, per garantire elevati livelli di autosufficienza anche nelle fasi avanzate della terza età e, allo stesso tempo, appare necessario un ulteriore forte investimento per nuove soluzioni assistenziali efficaci e a basso costo, centrate sul domicilio e sul territorio e in grado di inglobare efficacemente le reti di sostegno informali.

Parole chiave: Invecchiamento, cronicità, dimensione soggettiva della terza età, prevenzione, innovazione dei modelli di cura e assistenza.

Minimal change disease during lithium therapy: case report

Graziani Romina1, Monti Mattia1, Sejdiu Brunilda1, Gozzetti Francesco1, Martelli Davide1, Tampieri Elena1, Isola Elisabetta1, Zanchelli Fulvia1, Briganti Mario1, Cenacchi Giovanna2, Fabbrizio Benedetta2, Buscaroli Andrea1

1 UO Nefrologia e Dialisi, Ospedale Santa Maria delle Croci, Ravenna, Ausl Romagna
2 SSD di Diagnostica Istopatologica e Molecolare degli Organi solidi e del relativo Trapianto Policlinico S. Orsola-Malpighi Bologna

Lithium is a largely used and effective therapy in the treatment of bipolar disorder. Its toxic effects on kidneys are mostly diabetes insipidus, hyperchloremic metabolic acidosis and tubulointerstitial nephritis. Also, a correlation between lithium and minimal change disease has sometimes been described.

We report here the case of a patient with severe bipolar disorder on lithium therapy who, without any pre-existing nephropathy, developed nephrotic syndrome and AKI with histopathologic findings pointing to minimal change disease.

The patient was treated with symptomatic therapy; the discontinuation of lithium therapy resulted in the remission of AKI and of the nephrotic syndrome, thus suggesting a close relationship between lithium and minimal change disease.


Keywords: minimal change disease, lithium, nephrotic syndrome

Peripheral hypoperfusion syndrome and monomielic syndrome: from diagnosis to treatment. Case report with review of the literature

Marina Cornacchiari1, Anna Mudoni2, Pierpaolo Di Nicolò3, Marco Mereghetti4, Barbara Gidaro1, Antonia Stasi1, Anna Lisa Neri1, Carlo Guastoni1

1 Unità di Nefrologia e Dialisi, ASST OVEST MILANESE, Italia
2 Unità di Nefrologia e Dialisi Pia Fondazione Cardinale G.Panico Tricase (Le)
3 Unità di Nefrologia e Dialisi Ospedale S. Maria della Scaletta, Imola-Bologna
4 Unità di Medicina ASST OVEST MILANESE, Italia

Arteriovenous access ischemic steal is a fairly uncommon complication associated with the creation of a vascular access for hemodialysis, which can sometimes cause potentially devastating complications, with permanent disability. Several old names for this syndrome have now been replaced by two new denominations: Hemodialysis Access-Induced Distal Ischemia (HAIDI) and Distal Hypoperfusion Ischemic Syndrome (DHIS).

Clinically, we distinguish between the Peripheral Hypoperfusion Syndrome, which can cause gangrene of the fingers, and the Monomelic Syndrome, characterized by low incidence and by the presence of neurological dysfunctions. Risk factors include diabetes mellitus, atherosclerotic vascular disease, old age, female gender, tobacco use and hypertension.

We report the case of a patient with HAIDI in order to increase awareness on this syndrome’s early diagnosis and proper management. After describing the case, we also include a literature review.


Keywords: hand Ischemia, vascular access, echocolordoppler, hemodialysis

Acute kidney failure in differentiation syndrome: a possible complication during therapy with differentiating agents for acute promyelocytic leukemia. A case report

Lucia Di Micco1, Francesco Mirenghi2, Emanuela Morelli3, Emanuele De Simone4

1 UOC Nefrologia e Dialisi, Ospedale Del Mare, ASL Napoli 1 Centro, Napoli, Italia
2 UOC Nefrologia, Azienda Ospedaliera Dei Colli, Napoli, Italia
3 UOC Ematologia-Oncologia e Trapianto, Istituto nazionale Tumori -IRCCS- Fondazione G. Pascale, Napoli, Italia.
4 UOC Nefrologia e Dialisi, Ospedale San Giovanni Bosco, Torino, Italia

Differentiation syndrome (DS), previously known as retinoic acid syndrome or ATRA (all-trans retinoic acid) or ATO (arsenic trioxide) syndrome, is a life-threatening complication of the therapy with differentiating agents in patients with acute promyelocytic leukemia (APL). The latter is a rare subtype of acute myeloid leukemia and represents a hematological emergency. The clinical manifestations of DS, after induction therapy with differentiating agents, include unexplained fever, acute respiratory distress with interstitial pulmonary infiltrates, unexplained hypotension, peripheral edema, congestive heart failure and acute renal failure. The therapy is based on early intravenous administration of high-dose dexamethasone, in order to counteract the cytokine storm responsible for the DS. Among the supportive measures for the management of DS, furosemide (in 87% of patients) and dialysis (12% of patients) are used to manage acute renal failure, peripheral and pulmonary edema.

We describe a case of acute renal failure, treated with haemodialysis, in a young patient with APL and an early and severe DS after induction therapy. This is a rare condition, not well known among nephrologists, where early recognition and treatment are crucial for the prognosis.

Keywords: acute kidney failure, dialysis, acute promyelocytic leukemia, differentiation syndrome, all-trans retinoic acid, dexamethasone. 

Monoclonal gammopathy of renal significance and membranoproliferative glomerulonephritis: a complex relationship with promising therapeutic opportunities

Massimo Manes1, Elisabetta Radin1, Valentina Pellu’1, Andrea Molino A.1, Danila Gabrielli1, Emanuele Parodi1, Donatella Caputo1, Giuseppe Paternoster1, Antonella Barreca2, Maria Pagliaro3, Giacomo Quattrocchio4, Dario Roccatello4


1 S.C. Nefrologia e Dialisi. Ospedale “Umberto “Parini”, Viale Ginevra 1. Aosta
2 S.C.D.U. Anatomia e Istologia Patologica 1 U. AOU Città della Salute e della Scienza. Ospedale Molinette. Torino
3 S.S.D. Ematologia e Malattie Trombotiche, Ospedale San Giovanni Bosco, Piazza Donatore di Sangue 3. Torino
4 S.C.D.U. Nefrologia e Dialisi. CMID Ospedale San Giovanni Bosco, Piazza Donatore di Sangue 3 e Università di Torino. Torino

In the last few years, the increasing awareness of the complex interaction between monoclonal component and renal damage has determined not only a new classification of the associated disorders, called Monoclonal Gammopathy of Renal Significance (MGRS), but has also contributed to emphasize the importance of an early diagnosis of the renal involvement, which is often hard to detect but can evolve towards terminal uraemia; it has also pointed at the need to treat these disorders  with aggressive regimens, even if they are not strictly neoplastic.

The case described here presented urinary abnormalities and renal failure secondary to a membranoproliferative glomerulonephritis (MPGN), with intensively positive immunofluorescence (IF) for monoclonal k light chain and C3, and in the absence of a neoplastic lympho-proliferative disorder documented on bone marrow biopsy. After the final diagnosis of MGRS, the patient was treated with several cycles of a therapy including dexamethasone, cyclophosphamide and bortezomib, showing a good functional and clinical response.


Keywords: monoclonal gammopathy of renal significance, membranoproliferative glomerulonephritis, kidney biopsy

Peritoneal dialysis catheter infection with abscess of the abdominal wall in a ADPKD patient

Lucio Polese1, Silvio Borrelli1, Giuseppe Conte1, Luca De Nicola1, Roberto Minutolo1, Carlo Vita1, Nicola Peruzzu1, Antonella Netti1, Toni De Stefano1, Michele Provenzano2, Carlo Garofalo1

1 U.O. Nefrologia, Università degli Studi della Campania, “Luigi Vanvitelli”, Napoli, Italia
2 U.O. Nefrologia, Università “Magna Graecia”, Catanzaro, Italia

Infections to the peritoneal catheter are common in Peritoneal Dialysis (PD). We report the clinical case of a 49-year-old male patient in PD, who showed an atypical manifestation of tunnel infection caused by Staphylococcus aureus. The infection was characterized by a little abscess, on the left pararectal abdominal line, 6 cm far from exit-site of the peritoneal catheter. The diagnosis was made using ultrasonography (US), which showed a fistulous communication from subcutaneous cuff to the skin. We treated the infection conservatively by performing cuff-shaving and drainage of the abscess, associated to antibiotic therapy (teicoplanin). Due to the persistence of the infection, we added oral and topical rifampicin, and advanced medication with freez-dried collagen plant impregnated with extended-release gentamicin. The complete resolution of the infection allowed us to avoid removing the catheter.


KEY WORDS: Peritoneal Dialysis, peritoneal catheter infection, cuff-shaving

The Fabry nephropathy: new insight in diagnosis, monitoring and treatment

Renzo Mignani

UO Nefrologia e Dialisi, Ospedale Infermi, Rimini, Italia

Fabry disease is a rare inborn error of the enzyme α-galactosidase (Α-Gal) and results in lysosomal substrate accumulation in tissues with a wide range of clinical presentations. The disease has attracted a lot of interest over the last years and several issues has been discovered up to now leading to increasing knowledge and awareness of the disease. However, several aspects are still unclear and under investigation. Thus, the new challenges that physicians encounter are the discovering of the pathogenic mechanisms, the neutralising antibodies to ERT, the long-term efficacy of therapies.

In this article, we summarise and review the latest developments in the science community regarding diagnosis, management and monitoring of Fabry disease concerning in particular its physiopathology, novel biomarkers, antibodies development and novel treatment options.


Keywords: Fabry disease, nephropathy, α-galattosidase A, agalsidase

Osteoporosis and chronic kidney disease: review and new therapeutic strategies

Concetto Sessa1, Dario Galeano1, Ivana Alessandrello1, Giorgio Aprile1, Giulio Distefano2, Vincenzo Ficara1, Elisa Giglio1, Stella Musumeci1, Barbara Pocorobba1, Carmelo Zuppardo1, Salvatore Musso1, Antonio Granata3

1 U.O.C Nefrologia e Dialisi, P.O. “Maggiore” di Modica. Azienda Sanitaria Provinciale di Ragusa, Ragusa
2 U.O. Radiologia I, Dipartimento di Scienze Mediche, Chirurgiche e Tecnologie Avanzate “G.F. Ingrassia”, Università di Catania, Catania
3 U.O.C. Nefrologia e Dialisi – P.O. “San Giovanni di Dio”, Agrigento – Italia

Osteoporosis affects a segment of the population in which Chronic Kidney Disease is also greatly represented. Nephropathic patients may present peculiar biochemical abnormalities related to Chronic Kidney Disease, defining the Mineral and Bone Disorder. This kind of anomalies, in the worst scenarios, configure the typical histomorphology patterns of Renal Osteodystrophy. Scientific Societies of Endocrinology have established therapy guidelines for patients with osteoporosis only based on the glomerular filtration rate and recommend avoiding the use of some drugs for the more advanced classes of nephropathy. However, there is no clear therapeutic approach for patients with advanced nephropathy and bone abnormalities. In this paper we propose a systematic review of the literature and present our proposal for managing patients with advanced nephropathy, based on eGFR and on presence of Mineral and Bone Disorder.


Keywords: bisphosphonates, CKD-MBD, chronic kidney disease-mineral and bone disorder, uremic osteodystrophy, osteoporosis

Antifibrotic renal role of mineralcorticoid receptor antagonists

Alessandra Ocello1, Sandra La Rosa1, Fulvio Fiorini2, Salvatore Randone3, Rosario Maccarrone5, Giorgio Battaglia4, Antonio Granata5

1 UOS di Nefrologia e Dialisi, P.O. “Giovanni Paolo II”, Sciacca (AG), Italia
2 UOC Nefrologia – Dialisi e Dietologia, P.O. “S.M. della Misericordia”, Rovigo, Italia
3 UOC Nefrologia e Dialisi, P.O. “Umberto I”, Siracusa, Italia
4 UOC Nefrologia e Dialisi, P.O. “Santa Marta e Venera”, Acireale (CT), Italia
5 UOC Nefrologia e Dialisi, P.O. “San Giovanni di Dio”, Agrigento, Italia

Cardiovascular and renal diseases are one of the main health problems in all industrialized countries. Their incidence is constantly increasing due to the aging of the population and the greater prevalence of obesity and type 2 diabetes.

Clinical evidence suggests that aldosterone and the activation of mineralocorticoid receptors (MR) have a role in the pathophysiology of cardiovascular and renal diseases. Moreover, clinical studies demonstrate the benefits of mineralocorticoid receptor antagonists (MRAs) on mortality and progression of heart and kidney disease.

In addition to renal effects on body fluid homeostasis, aldosterone has multiple extrarenal effects including the induction of inflammation, vascular rigidity, collagen formation and stimulation of fibrosis.

Given the fundamental role of MR activation in renal and cardiac fibrosis, effective and selective blocking of the signal with MRAs can be used in the clinical practice to prevent or slow down the progression of heart and kidney diseases.

The aim of the present work is to review the role of MRAs in light of the new evidence as well as its potential use as an antifibrotic in chronic kidney disease (CKD). The initial clinical results suggest that MRAs are potentially useful in treating patients with chronic kidney disease, particularly in cases of diabetic nephropathy. We don’t yet have efficacy and safety data on the progression of kidney disease up to the end stage (ESRD) and filling this gap represents an important target for future trials.


Key words: mineralocorticoid receptor, aldosterone, kidney, cardiac, fibrosis

Psychology of the communication between doctors/nurses and patients in nephrology and dialysis

Valentina Paris1, Fulvio Fiorini2

1 Psicologa, già Infermiera di Nefrologia e Dialisi, Bergamo, già Presidente ANED
2 UOC Nefrologia e Dialisi, AULSS 5 Polesana, Ospedale SM della Misericordia, Rovigo

People with a chronic kidney condition can live with their disease for several years, during which the illness becomes “an integral aspect of life” and requires “an arduous and continuous process of adaptation at multiple levels: cognitive, emotional and physical”. Often, communicating with doctors is not helpful to these patients in understanding what is happening and reorganizing their lives, as ineffective communication strategies are employed. It is in fact necessary to overcome obstacles such as the use of incomprehensible technical language, ambiguity, the lack of communication training and the abundance of stressful situations.

Chronically ill patients have the right to be informed in a simple, clear and impartial way about their condition and its possible treatments; this information will help them manage their kidney disease, “accept” it and find the motivation to adhere to medical prescriptions over time.


Keywords: Communication, doctor, nurse, chronic patient


Massimo Cardillo1, Letizia Lombardini1, Vito Sparacino1, Pamela Fiaschetti1, Marzia Filippetti1

1 Centro Nazionale Trapianti

The main objective of the Italian National Transplant Center (CNT) is to increase the number, the quality and the safety of transplants by promoting special programs in cooperation with Italian Regions. Data show that the number of deceased subjects that are reported for organ or tissue donation is largely lower than it could potentially be, and that great variations exist among different Regions. In order to increase the number of performed transplants, the CNT is planning to move in three main directions: (1) promoting transplants from deceased donors, (2) promoting transplants from living donors and (3) optimising the way organs are stored, distributed and utilised across the country.


Keywords: Italian National Transplant Center, transplants from deceased donor, transplants from living donor, organ procurement

The new National Guidelines System in Italy: a first evaluation

Primiano Iannone, Daniela Coclite, Antonello Napoletano, Alice Fauci, Giuseppe Graziano, Laura Iacorossi, Daniela D’Angelo

Centro Nazionale Eccellenza Clinica, Qualità e Sicurezza delle Cure (CNEC),
Istituto Superiore di Sanità

The so-called Gelli-Bianco Law (L 24/2017) recognizes the central role of Guidelines as far as decision-making in the health sector is concerned and establishes the Italian National Guidelines System (SNLG) as a “safe harbor”, notwithstanding the specificities of each real-world case. The Italian National Center for Clinical Excellence, Quality and Security (CNEC) is responsible for the creation and the development of the SNLG.

After considering the many issues revolving around the creation of shared Guidelines, both on the national and international level, we present here the activities of the SNLG to date, together with an evaluation of how the new rules and practices around the creation of National Guidelines have been received. We also provide a series of recommendations for scientific societies on how best to produce Guidelines in their own field and how to submit them to the SNLG.


Keywords: Guidelines, scientific societies, Istituto Superiore di Sanità, best practices, evidence-based medicine

Data protection in healthcare

Filippo Lorè

Università degli Studi di Bari

The study of the personality of a potential case of samaritan donation

Concetta De Pasquale1, Maria Luisa Pistorio2, Massimiliano Veroux2, Provvidenza Marisa Cottone3, Valentina Martinelli4, Alessia Giaquinta5, Pierfrancesco Veroux5

1 SC Chirurgia Vascolare e Centro Trapianti, AOU Policlinico-Vittorio Emanuele di Catania, Dipartimento di Scienze della Formazione, Università di Catania, Italia
2 SC Chirurgia Vascolare e Centro Trapianti, AOU Policlinico-Vittorio Emanuele di Catania, Dipartimento di Chirurgia, Trapianti e Tecnologie Avanzate GF Ingrassia, Università di Catania, Italia.
3 CRT Sicilia, UOC Dipartimento Emergenza-Urgenza, ARNAS “Civico Di Cristina Benfratelli”, Palermo, Italia
4 Università di Pavia, Italia
5 Dipartimento di Chirurgia Generale e Specialità Medico-Chirurgiche, Università di Catania, Italia

The term Samaritan is used to indicate the choice of a living donor to offer its own organ to save the life of a patient with whom it has no parental or affective relation (article 1, Law of 26 June 1967). It is a gesture of great solidarity, one that promotes life. The purpose of this study has been to analyze a case of potential Samaritan donation.

The investigation consisted of six interviews, on a bi-weekly basis, for a total duration of three months. The clinical interviews allowed us to delve deeper into the motivations for the donation. The following tests were administered: the Rorschach projective test, the Millon Clinical Multiaxial Inventory Personality Test (MCMI-III) and the Symptom Checklist-90-Revised (SCL-90-R).

Some issues regarding age, self-confidence, emotional difficulties and maladjustment to social environment emerged. The analysis of the test results confirmed the “negative” indices that led the authors to decide against the psychological-psychiatric suitability for the Samaritan donation.

The Samaritan donation is a rare and precious donation and understanding in depth the motivations behind this choice is extremely important. The choice to donate, even if freely made, must not make one forget their responsibility towards themselves and towards the integrity of their own body.


Keywords: Samaritan donation, psychological evaluation, Rorschach projective test, Millon Clinical Multiaxial Inventory Personality Test (MCMI-III), Symptom Checklist-90-Revised (SCL-90-R)

Steroid and cyclosporine therapy in idiopathic membranous nephropathy: monocentric experience and literature review

Federica Zotta1, Enrico Di Stasio2,3, Andrea Manzione1, Nicola Pirozzi1, Antonella Stoppacciaro1, Paolo Menè1

1 UOC Nefrologia e Dialisi Sant’Andrea, Roma. Dipartimento di Medicina Clinica e Molecolare, Sapienza Università di Roma
2 Istituto di Biochimica e Biochimica Clinica, Università Cattolica del Sacro Cuore, Roma, Italia
3 Fondazione Policlinico Universitario A Gemelli IRCCS, Roma, Italia

Introduction: Immunosuppressive treatment of patients with idiopathic membranous nephropathy (IMN) is debated due to its possible side effects. The 2012 KDIGO guidelines suggest alkylating agents as first choice therapy. The aim of the study is to retrospectively evaluate the induction and maintenance of clinical remission in patients with histological diagnosis of IMN undergoing steroid and/or cyclosporine therapy at the Nephrology Unit of the Sant’Andrea Hospital in Rome.

Materials and methods: Therapy A (conservative) was reserved to low-risk patients. 8 medium and high risk patients were induced by Therapy B (Prednisone 1 mg / kg ≤12-16 weeks plus 8 weeks withdrawal); 6 patients by Therapy C (Prednisone 1 mg /kg ≥20-24 weeks plus 8 week withdrawal) and, finally, 6 steroid-resistent patients by Therapy D (steroid withdrawal + cyclosporine 3-5 mg / kg for 2 years).

Results: Complete remission was observed in 37.5% of patients in Therapy B, in 83.3% of patients in Therapy C and in 66.6% of patients in Therapy D. Patients in group B relapsed more frequently than patients in the other groups. Side effects were irrelevant.

Conclusions: In view of the potential cytotoxicity of alkylating agents, steroids are a valid alternative in inducing and maintaining clinical remission over time, when administered with a more aggressive induction scheme. In cases of steroid resistance or rapid relapse, cyclosporine is a valid alternative to alkylating agents.


Keywords: nephrotic syndrome, steroid therapy, cyclosporine, idiopathic membranous nephropathy

Efficacy of sodium thiosulphate in a case of calciphylaxis in a chronic nephropathic ninety-year-old patient on conservative therapy

Luca Piscitani1, Vittorio Sirolli1,2, Roberto Di Vito2, Patrizia Muscianese2, Uwe Florian Manfred Brummer2, Lorenzo Di Liberato2, Mario Bonomini1,2

1 Dipartimento di Medicina e Scienze dell’Invecchiamento, Università “G. d’Annunzio” di Chieti-Pescara
2 UOC Nefrologia e Dialisi, Ospedale SS. Annunziata, Chieti, Italia

Calcific uremic arteriolopathy, also known as calciphylaxis (CUA), is a rare and potentially fatal condition that occurs in 1-4% of the population with chronic renal failure, most often on dialysis treatment. The pathogenesis is not yet clear although several hypotheses have been advanced, most importantly the alteration of the calcium phosphorus metabolism. Administration of sodium thiosulfate (STS) is the emerging therapy. Below, we report the case of an elderly chronic kidney patient on conservative therapy suffering from CUA who has been successfully treated with STS.


KEYWORDS: calciphylaxis, sodium thiosulfate, chronic kidney disease

Ultrasonography in chronic lithium nephropathy: a case report

Carmela Iodice1, Carlo Garofalo1, Silvio Borrelli1, Giuseppe Conte1, Luca De Nicola1, Roberto Minutolo1, Arcangelo Di Cerbo2, Michele Provenzano3, Felice Nappi4

1 U.O. Nefrologia, Università degli Studi della Campania, “Luigi Vanvitelli”, Napoli, Italia
2 Dipartimento di Psichiatria, Università degli Studi della Campania, “Luigi Vanvitelli”, Napoli, Italia
3 U.O. Nefrologia, Università “Magna Graecia”, Catanzaro, Italia
4 U.O. Nefrologia, Ospedale Santa Maria della Pietà, Nola, Italia

Lithium has always been used as a first-choice therapy in bipolar disorders. However, its therapeutic index is restricted by placing patients at risk of potential nephrotoxic effects ranging from polyuria, to Insipid Nephrogenic Diabetes, to chronic kidney disease with a slow reduction of renal function over time. The Nephrologist has the role to diagnose chronic lithium nephropathy, monitoring its evolution and optimizing the management of risks associated with the treatment. In fact, the main objective, to be shared with the psychiatrist, is to encourage the maintenance of therapy even in the presence of nephropathy. Renal ultrasound, a safe, repeatable and low-cost technique, is essential to pursue this goal as it not only confirms the diagnosis of chronic lithium nephropathy hypothesized on the basis of the history and clinical picture, but is also helpful in monitoring its evolution. In this paper, we report a case of chronic lithium nephropathy in order to analyze the etiopathogenesis of renal damage, the clinical-laboratory and histological picture and, in particular, the fundamental role of ultrasound imaging.


KEYWORDS: lithium, Insipid Nephrogenic Diabetes, polyuria, nephropathy, renal ultrasound

Membranoproliferative glomerulonephritis with relapsing episodes of acute kidney injury in the Schnitzler syndrome

Luigi Rossi1, Francesco Casucci1, Annalisa Teutonico1, Pasquale Libutti1, Piero Lisi1, Carlo Lomonte1, Carlo Basile1,2, Raffaele Manna3

1 Divisione di Nefrologia, Ospedale Miulli, Acquaviva delle Fonti
2 Associazione Nefrologica Gabriella Sebastio, Martina Franca
3 Centro di Ricerca delle Malattie Rare e delle Febbri Periodiche, Fondazione Policlinico Gemelli, Università Cattolica, Roma

The Schnitzler syndrome (SS) is a rare and underdiagnosed entity that associates a chronic urticarial rash, monoclonal IgM (or sometimes IgG) gammopathy and signs and symptoms of systemic inflammation. During the past 45 years the SS has evolved from an elusive, little-known disorder to the paradigm of a late-onset auto-inflammatory acquired syndrome. Though there is no definite proof of its precise pathogenesis, it should be considered as an acquired disease involving abnormal stimulation of the innate immune system, which can be reversed by the interleukin 1 (IL-1) receptor antagonist anakinra. Here we describe the case of a 56-year-old male Caucasian patient affected by SS and hospitalized several times in our unit because of relapsing episodes of acute kidney injury. He underwent an ultrasound-guided percutaneous kidney biopsy in September 2012, which showed the histologic picture of type I membranoproliferative glomerulonephritis. He has undergone conventional therapies, including nonsteroidal anti-inflammatory drugs, steroids and immunosuppressive drugs; more recently, the IL-1 receptor antagonist anakinra has been prescribed, with striking clinical improvement. Although the literature regarding kidney involvement in the SS is lacking, it can however be so severe, as in the case reported here, to lead us to recommend the systematic search of nephropathy markers in the SS.


Keywords: Acute kidney injury, auto-inflammatory diseases, chronic urticarial rash, membranoproliferative glomerulonephritis, monoclonal IgM gammopathy, Schnitzler syndrome

Acute kidney injury in elderly patients

Antonio Santoro

Scuola di Specializzazione in Nefrologia, Università degli Studi di Bologna, Policlinico S.Orsola-Malpighi

In the last few years, more and more studies have been focusing on Acute Kidney Injury (AKI) because of its incidence, its effects on patients, and the costs associated to its treatment. Elderly patients are especially in danger of developing AKI given the para-physiological deterioration of their renal functions and the presence of several co-morbidities. Together with sepsis, AKI is in fact one of the most common complications occurring during hospitalization. However, some strategies have proved to help in preventing renal damage in the elderly.

Fluid overload, malnutrition and sepsis, which are far more common and momentous in older patients, can conceal or minimize rising creatinine levels. As such, it is not always possible to rely on the creatinine behaviour to diagnose AKI as proposed by KDIGO, AKIN e RIFLE guidelines. On the one hand, these and other peculiarities make AKI very difficult to diagnose and treat in elderly patients. On the other, the dialysis treatment, with its intrinsic “un-physiology”, further complicates matters and (if it is very aggressive in terms of efficiency and removal of fluids) can destabilize these fragile patients and their poor haemodynamic compensation.


Keywords: acute kidney injury, comorbidity, elderly patients, renal functional decline, dialysis

Role of Ambulatory Blood Pressure Monitoring (ABPM) in chronic kidney patients: a review

Antonella Netti1, Silvio Borrelli1, Nicola Peruzzu1, Lucio Polese1, Carlo Vita1, Toni De Stefano1, Giuseppe Conte1, Luca De Nicola1, Roberto Minutolo1, Michele Provenzano2, Carlo Garofalo1

1 U.O. Nefrologia, Università degli Studi della Campania, “Luigi Vanvitelli”, Napoli, Italia
2 U.O. Nefrologia, Università “Magna Graecia”, Catanzaro, Italia

About 90%of patients with chronic kidney disease (CKD) have arterial hypertension; the main international guidelines recommend maintaining blood pressure (BP) values below 130/80 mmHg to reduce the cardio-renal risk in this population. Twenty-four-hour Ambulatory Blood Pressure Monitoring (ABPM) is the golden standard for the identification of the BP profiles and patterns, as well as for the assessment of the circadian rhythm and BP variability. The correct interpretation of ABPM allows to optimize anti-hypertensive treatment and to reduce cardio-renal risk in CKD patient.

In fact, in patients with CKD, the ABPM has a greater role in terms of renal and cardio-vascular prognosis when compared to clinical BP measurements. Patients with ABPM in target present a low cardio-renal risk, regardless of clinical BP values; on the contrary, if the clinical PA is normal and the ABPM not in target, this risk increases significantly. Moreover, in the CKD population, non-dipping is associated with a higher risk of cardiovascular events and end stage renal disease (ESRD), making identifying nocturnal hypertension greatly important.

Therefore, ABPM is an instrument of primary importance in the diagnostic and therapeutic work-out of renal patients.


KEYWORDS: ABPM, CKD, blood pressure

Acetate-free Biofiltration: CO2-free treatment for hemodialysis patients with hypercapnia

Marco Marano1, Giuseppina Giordano1, Luigi Cosenza2

1 Servizio di Emodialisi. Casa di Cura Maria Rosaria. Pompei (NA)
2 Servizio di Pneumologia ed Allergologia Respiratoria. Casa di Cura Maria Rosaria. Pompei (NA)

In bicarbonate-dialysis the dialysate is acid, thus allowing salts to remain in their soluble form, as a result of the chemical reaction of bicarbonate with any acid that yields carbon dioxide (CO2). The residual anion, commonly acetate or more rarely citrate, reaches the patients’ bloodstream. CO2 also spreads to the patients and ventilation needs therefore to be increased to avoid hypercapnia. In addition, during on-line haemodiafiltration in post-dilution mode, the dialysate – in the form of infusate – carries CO2 (and acetate) to the patient, bypassing the filtering membrane. On the contrary, in Acetate-Free Biofiltration (AFB) the dialysate is free of acid and, uniquely, is also a CO2-free bath. Despite the infusion of bicarbonate in post-dilution mode, the blood coming back from the extracorporeal circuit does not carry any burden of CO2. As a result, AFB is the recommended renal replacement therapy for patients affected by lung disease and those with CO2 retention (respiratory acidosis). Patients with some degree of ventilatory dysfunction may in fact experience acute hypercapnia (acidosis by dialysate) at the beginning of the treatment if bicarbonate-dialysis or on-line HDF is performed (and regardless of whether acetate-containing or citrate-containing bath is employed). Acidosis by dialysate is characterized by respiratory symptoms first and by haemodynamic instability later, which make it look very similar to acetate intolerance. To discriminate between these two conditions, blood gas analysis is mandatory. The presence of hypercapnia can be revealed by using the Very Simple Formula (expected pCO2 = bicarbonate + 15), thus identifying those patients that may take the most advantage of AFB.


KEYWORDS: acetate-free biofiltration, carbon dioxide, hypercapnia

Interviewing Professor Enrico Malizia, one of the fathers of Italian nephrology

Giovanni B. Fogazzi1, Attilio Losito2, Salvatore Di Giulio3

1 U.O.C. di Nefrologia, Dialisi e Trapianto di Rene, Fondazione, IRCCS, Ca’ Granda Ospedale Maggiore Policlinico, Milano.
2 S.C. di Nefrologia e Dialisi, Ospedale Santa Maria della Misericordia, Perugia.
3 Registro di Dialisi e Trapianto, Regione Lazio

This article contains an interview to Professor Enrico Malizia (born in 1926), who played an important role in the birth of nephrology in Italy. On April 27th, 1957 Professor Malizia was in fact among the founders of the Italian Society of Nephrology, which he also served as secretary for some years, together with Professor Luigi Migone (1912-2002). In addition, he participated in the organization of the First International Congress of Nephrology, which took place in Geneva and Evian from September 1st to 4th, 1960. Professor Malizia devoted himself to nephrology for many years, both as clinician and as researcher, by publishing many original papers and monographs on different nephrological topics, a few of which are described in detail in the present article. In addition, his interest in renal diseases led him to frequent the institutions of eminent renal scientists of the period such as the physiologist Homer Smith (1895-1962) and the pathologist Jean Oliver (1889-1976) in the United States, and the clinician Jean Hamburger (1909-1992) in Paris.

Keywords: history of nephrology, history of the Italian Society of Nephrology, history of the International Society of Nephrology

Medicine, Nephrology and social networks

Vincenzo Montinaro1, Vincenza Colucci2, Giuseppina D’Ettorre2, Silvia Matino2, Adriano Montinaro2, Paolo Protopapa2, Paola Suavo-Bulzis2, Marco Taurisano2, Chiara Villani3

1 U.O. Nefrologia e Dialisi, Azienda Ospedaliero-Universitaria “Consorziale Policlinico”, Bari
2 U.O. Nefrologia e Scuola di Specializzazione in Nefrologia, Dipartimento dell’Emergenza e Trapianto di Organi, Azienda Ospedaliero-Universitaria “Consorziale Policlinico” e Università degli Studi “Aldo Moro” di Bari
3 Centro Dialisi “Santa Rita”, Gruppo CBH, Bari

Peritoneal Dialysis in Italy: the 6th GSDP-SIN census 2016

Loris Neri1, Giusto Viglino2, Giancarlo Marinangeli3, Annamaria D’Ostilio4, Massimo Matalone5, Antonio Ragusa6, Valerio Vizzardi7, Roberto Russo8, Gianfranca Cabiddu9, a nome del Gruppo di Studio Dialisi Peritoneale della Società Italiana di Nefrologia (on behalf of the Peritoneal Dialysis Study Group of the Italian Society of Nephrology)

1 Nefrologia e Dialisi, Ospedale San Lazzaro, Via Pierino Belli 26, Alba, Cuneo, Italy
2 Nefrologia e Dialisi, Ospedale San Lazzaro, Via Pierino Belli 26, Alba, Cuneo, Italy
3 Nefrologia e Dialisi, Ospedale Maria SS dello Splendore, Giulianova, Teramo, Italy
4 Nefrologia e Dialisi, Ospedale Maria SS dello Splendore, Giulianova, Teramo, Italy
5 Nefrologia e Dialisi, Azienda Ospedaliera Cannizzaro, Catania, Italy
6 Nefrologia e Dialisi, Ospedale San Vincenzo, Taormina, Italy
7 Nefrologia e Dialisi, Policlinico Università A. Moro, Bari, Italy
8 Nefrologia e Dialisi, Spedali Civili, Brescia, Italy
9 Nefrologia e Dialisi, Azienda Ospedaliera Brotzu, Cagliari, Italy

Objectives. We report here the results of the 6th National Census (Cs-16) of Peritoneal Dialysis in Italy, carried out in 2017-18 by the Italian Society of Nephrology’s Peritoneal Dialysis Study Group and relating to 2016.

Methods. The Census was conducted using an on-line questionnaire administered to the 237 non pediatric centers which did perform Peritoneal Dialysis (PD) in 2016. The results have been compared with the previous Censuses carried out since 2005.

Results. Incidence: In 2016, 1,595 patients (CAPD=56.1%) started on PD (1st treatment for ESRD) and 4,607 on hemodialysis (HD). PD was started incrementally by 32.5% in 144 Centers. 15.6% were late referrals, and 5.1% began within 48-72 hours of insertion. The catheter was positioned exclusively by a Nephrologist in 24.3% of cases. Prevalence: Patients on PD on 31/12/2016 were 4,607 (CAPD=46.6%), with 22.2% of prevalent patients on assisted PD (family member caregiver: 80.5%). Out: In 2016, PD dropout rate (ep/100 pt-yrs: 12.5 to HD; 11.8 death; 7.0 Tx) has not changed. The main cause of transfer to HD remains peritonitis (23.8%), although it is still decreasing (Cs-05: 37.9%). Peritonitis/EPS: The incidence of peritonitis in 2016 was 0.211 ep/pt-yr (939 episodes). The incidence of new cases of EPS in 2015-16 is diminishing too (16 cases=0.176 ep/100 pt-yrs). Other results: In 2016 the number of Centers using 3.86% for the peritoneal equilibration test (PET) (49.8%) increased, and the Centers carrying out home visits diminished (51.5%).

Conclusions. Cs-16 confirms that PD in Italy is having good results.

Keywords: Peritoneal Dialysis, technique failure, incremental Peritoneal Dialysis, peritonitis, home visits, peritoneal equilibration test (PET)

Il responsabile del trattamento

Filippo Lorè

Università degli Studi di Bari

Carnitin-Palmitoyl Transferase type 2 deficiency: a rare cause of acute renal failure due to rhabdomyolysis

Francesco Detomaso1, Vito Pepe1, Francesca Partipilo1, Giuseppe Gernone1

1 UOSVD di Nefrologia e Dialisi ASL Bari. Sede Direzionale: Osp. “S. Maria degli Angeli” Putignano

Fatty acid oxidation disorders are inborn errors of metabolism. One of the possible alterations involves the failure of the carnitin-based transport of long-chain fatty acids into the mitochondria, necessary for muscle metabolism in case of prolonged physical exertion. Three kinds of Carnitin-Palmitoyl Transferase type 2 (CPT2) deficiency have been described: a myopathic form, a severe infantile form and a neonatal form. The clinical picture is characterized by recurrent attacks of rhabdomyolysis, muscular pains and fatigue, secondary to a prolonged physical exercise and sometimes aggravated by intercurrent events. Rhabdomyolysis episodes are associated with a significant increase in creatine phosphokinase and myoglobinuria and may result in acute renal failure. Patients are usually asymptomatic during intercurrent periods. When acute renal failure from rhabdomyolysis arises after intense physical activity, it is therefore necessary to also investigate the presence of metabolic myopathies due to enzymatic deficiency.

Keywords: deficit CPT2, rhabdomyolysis, acute renal failure

Renal failure in the medicolegal evaluation of civil invalidity and social security disability (INPS)

Marcella Scaglione1, Vita Maria Agate2, Michele Sammicheli1

1 Medici specialisti in medicina legale, medici convenzionati esterni presso il Centro Medico Legale (CML) INPS di Siena.
2 Medico specialista in nefrologia, dirigente medico responsabile dell’UO di Nefrologia e Dialisi dell’ospedale di Barga – Val del Serchio (LU).

After a quick description of the anatomopathology and physiopathology of renal failure, the Authors delve into the problem of assessing its medicolegal aspects in the fields of civil invalidity and social security.

In Italy, civil invalidity involves protecting the psychological and physical welfare of the disabled, as sanctioned by law 118 of 1971; this law protects all citizens with a debilitating condition, including those who do not work or are not of working age. A disabled person is someone who, if of working age (between 18 and retirement) has a reduction of more than ⅓ (34%) of their general work capacity; if under or over the retirement age, they have a persistent difficulty in carrying out age-appropriate functions and tasks. In support of an application for being awarded civil invalidity, people can also refer to law no. 104 of 1992, which assesses social, relational and work disadvantages of a disabled person.

INPS (Italian Social Security Institute) protection, on the other hand, is a social security protection based on health requirements (having a capacity for work which is reduced by more than ⅓, as established by law no. 222 of 1984), as well as on the following administrative requirement: having paid, as a worker, at least 260 weekly contributions, equivalent to five years of contribution and insurance, of which 156, equal to three years of contribution and insurance, were made in the five-year period preceding the date of submitting the application. If this is the case, the protected person, thus insured, can enjoy protection for their illness by virtue of the stipulations for social security.


Keywords: Renal failure, civil invalidity, social security disability, Italian Social Security Institute (INPS)

Psychological Assessment of a sample of women with ADPKD: quality of life, body image, anxiety and depression

Giulia Bruna Delli Zotti1,6, Eleonora Sangiovanni1, Elena Brioni3, Maria Monica Ratti1,6, Maria Teresa Sciarrone Aliprandi2, Donatella Spotti2, Paolo Manunta4,6, Lucio Sarno5,6

1 Servizio di Psicologia Clinica e della Salute, IRCCS Ospedale San Raffaele, Milano, Italia
2 MD, U.O Nefrologia Dialisi e Ipertensione, IRCCS Ospedale San Raffaele, Milano, Italia
3 Infermiera di Ricerca, U.O Nefrologia Dialisi e Ipertensione, IRCCS Ospedale San Raffaele, Milano, Italia
4 Primario U.O Nefrologia Dialisi e Ipertensione, IRCCS Ospedale San Raffaele, Milano, Italia
5 Primario Servizio di Psicologia Clinica e della Salute, IRCCS Ospedale San Raffaele, Milano, Italia
6 Università Vita Salute San Raffale, Milano, Italia

Introduction: The Autosomal Dominant Polycystic Kidney Disease (ADPKD) is a chronic renal disease that has not yet been the subject of psychological research. There are only a few studies related to the consequences and complications of this pathology on female patients, although women affected by this disease present serious problems.

Aim: The purpose of this study is to perform a psychological assessment (quality of life, anxiety, depression, body image) on a sample of 37 women with ADPKD.

Materials and Methods: The assessment is based on ad hoc social and personal record, KDQOL-SF (to evaluate health-related quality of life), HADS (for anxiety and depression) and BUT (for perceived body image). This assessment is administrated in a specific outpatient clinic.

Results: Results show that kidney disease has a negative impact on health-related quality of life. Concerns about body image are linked to anxious and depressive symptomatology: an increase in these concerns is related to a worsening of anxiety and depressive symptoms in patients. Moreover, a higher psychological malaise emerges in hypertensive ADPKD patients, in terms of mood and quality of life, compared to those without this concomitant pathology. Finally, it is important to note that social support, real or perceived, is of paramount importance in maintaining psychological well-being.

Conclusions: The psychological evaluation of ADPKD patients can be used in clinical practice as a supplemental model in multidisciplinary Nephrology team.


Keywords: Quality of life, ADPKD, body image, psychological assessment, hypertension.

Waiting time on dialysis for active access to renal transplantation: a multicenter cross-sectional study in Lombardy

Mario Picozzi1, Federico Nicoli2, Gabriella Biffa3, Tullia Maria De Feo4, Renzo Pegoraro5, Giuseppe Piccolo6, Maria Antonella Piga7, Giuseppe Rossini8, Sergio Vesconi9, Aurelio Limido10

1 MD, PhD, Professore Associato di Medicina Legale, Direttore del Centro di Ricerca in Etica Clinica, Dipartimento di Biotecnologie e Scienze della Vita, Università degli Studi dell’Insubria, Varese, Italia.
2 PhD, membro del Centro di Ricerca in Etica Clinica, Dipartimento di Biotecnologie e Scienze della Vita, Università degli Studi dell’Insubria, Varese, Italia; referente del Servizio di Etica Clinica, Casa di cura Domus Salutis, Fondazione Teresa Camplani, Brescia, Italia.
3 U.O. di Psicologia Clinica e Psicoterapia, Ospedale Universitario San Martino, Genova, Italia.
4 MD, PhD, North Italy Transplant program, Fondazione IRCCS “Ca’ Granda Ospedale Maggiore Policlinico”, Milano, Italia.
5 MD, Cancelliere presso la Pontificia Accademia per la Vita, Città del Vaticano.
6 MD, Coordinatore regionale trapianti, North Italy Transplant program, Fondazione IRCCS “Ca’ Granda Ospedale Maggiore Policlinico”, Milano, Italia.
7 MD, Ricercatrice in Medicina Legale e del Lavoro, Università degli Studi di Milano, Italia.
8 North Italy Transplant program, Fondazione IRCCS “Ca’ Granda Ospedale Maggiore Policlinico”, Milano, Italia.
9 MD, membro del Comitato Esecutivo del Sistema Trapianti di Regione Lombardia, Milano, Italia.
10 MD, UO Nefrologia e Dialisi, ASST Fatebenefratelli e Oftalmico, Milano, Italia.

Background: The amount of time spent in dialysis waiting for a renal transplantation significantly affects its outcome. Hence, the timely planning of patients’ transplant evaluation is crucial. According to data from the Nord Italia Transplant program (NITp), the average waiting time between the beginning of dialysis and the admission to the regional transplant waiting list in Lombardy is 20.2 months.

Methods: A multicenter cross-sectional study was conducted in order to identify the causes of these delays and find solutions. Two questionnaires were administered to the directors of 47 Nephrology Units and to 106 patients undergoing dialysis in Lombardy respectively, during their first visit for admission to the transplant waiting list.

Results: The comparative analysis of the results revealed that both patients (52%) and directors (75%) consider the time required for registering to the waiting list too long. Patients judge information about the transplant to be insufficient, especially regarding the pre-emptive option (63% of patients declare that they had not been informed about this opportunity). Patients report a significantly longer time for the completion of pre-transplantation tests (more than 1 year in 23% of the cases) compared to that indicated by the directors.

Conclusions: The study confirmed the necessity of providing better and more timely information to patients regarding the different kidney transplantation options and highlighted the importance of creating target-oriented and dedicated pathways in all hospitals.


Keywords: Renal transplantation, waiting list, active access to renal transplantation, questionnaire, Lombardy region

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Infected hepatic cyst in ADPKD patient in peritoneal dialysis

Nicola Peruzzu1, Silvio Borrelli1, Antonella Netti1, Toni De Stefano1, Carlo Vita1, Maria Sabatino2, Michela Salzano2, Giuseppe Conte1, Luca De Nicola1, Roberto Minutolo1, Carlo Garofalo1

1 U.O. Nefrologia, Università degli Studi della Campania, “Luigi Vanvitelli”, Napoli, Italia
2 U.O. Radiologia, Ospedale Santa Maria del Popolo degli Incurabili, Napoli, Italia

Renal and hepatic cysts infections are among the most important infectious complications of ADPKD and often require hospitalization. Liver cysts are even more complex than renal cysts and their diagnosis and treatment are quite controversial.

We report the case of a 58-year-old patient with ADPKD undergoing peritoneal dialysis treatment. He presented fever and severe asthenia and was diagnosed with a hepatic cyst infection. Given the presence of the peritoneal catheter, and in order to facilitate the targeted treatment of the infection, we administered antibiotics (ceftazidime and teicoplanin) in the bags used for peritoneal dialysis exchanges for 4 weeks, obtaining the complete disappearance of symptoms and laboratory and ultrasound alterations.

Intraperitoneal antibiotics administration in the treatment of infected hepatic cysts represents an effective and safe therapeutic alternative, never described in literature so far.


Keywords: ADPKD, ESRD, Infected hepatic cyst, peritoneal dialysis

HELLP syndrome and hemolytic uremic syndrome during pregnancy: two disease entities, same causation. Case report and literature review

Andrea Mancini1, Gianluigi Ardissino2, Pernina Angelini1, Vincenzo Giancaspro1, Elvira La Raia1, Mariateresa Nisi1, Annarita Proscia1, Giuseppe Tarantino1, Ottavia Vitale1, Filomena D’elia2

1 S.C. di Nefrologia e Dialisi Ospedale Di Venere – BARI
2 Centro per la Cura e lo Studio della Sindrome Emolitico-Uremica. Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano


Thrombotic microangiopathies (TMA) are a group of diseases that can complicate pregnancy and threaten the lives of both the mother and the fetus. Several conditions can lead to TMA, including thrombotic thrombocytopenic purpura (TTP), HELLP syndrome and hemolytic uremic syndrome (HUS). We describe the case of a 39-year-old woman who presented a HELLP syndrome in the immediate postpartum period. The patient had acute kidney injury (AKI), increased LDH, unmeasurable haptoglobin levels and hypocomplementemia. Her ADAMTS13 value was normal, thus ruling out TTP. Shiga toxin tests were negative, so HUS associated with E. coli was also ruled out. HELLP syndrome and atypical hemolytic-uremic syndrome (aHUS) remained the most probable diagnosis. In the days following childbirth, the patient’s transaminase and bilirubin levels normalized while the anemia persisted, as did the AKI, resulting in the institution of dialysis treatment. A diagnosis of aHUS was made and therapy with eculizumab was started. The patient’s blood counts progressively improved, urine output was restored, her indices of renal function also concomitantly improved and dialysis was interrupted. A rash appeared after the third administration of eculizumab and the treatment was suspended. The patient is currently being followed up and has not relapsed. At thirteen months after delivery her renal function is normal as are her platelet counts, LDH, haptoglobin levels and proteinuria. Tests for mutations in the genes that regulate complement activity were negative. We believe that childbirth triggered the HELLP syndrome, which in turn brought about and sustained the HUS. In fact, the patient’s liver function improved right after delivery, while her kidney injury and hemolysis persisted, and she also had an excellent response to eculizumab. To our knowledge, no other cases of HELLP syndrome associated with haemolytic uremic syndrome during pregnancy have been reported in literature, nor have cases in which treatment with eculizumab was limited to only three administrations.

Keywords: HELLP syndrome, hemolytic uremic syndrome, pregnancy, eculizumab, thrombotic microangiopathy

POEMS Syndrome: Nosographic classification and considerations on a clinical case

Di Franco Sebastiano1, Reina Antonino2, De Luca Maurizio1, Sessa Concetto3

1 Servizio Nefrodialitico Tike, Siracusa
2 U.O.C. Nefrologia e Dialisi, Ospedale Umberto I Siracusa
3 U.O.C. di Nefrologia e Dialisi, Ospedale “Maggiore” Modica

POEMS syndrome is a rare multisystemic disease characterised by the coexistence of two main symptoms, polyneuropathy and monoclonal gammopathy, associated with minor symptoms such as organomegaly, endocrinopathy, and skin changes. We describe a patient who presented with symptoms and signs fulfilling the criteria of POEMS. We have carried out a literature review with particular emphasis on its demographic and polymorphic clinical features.


Keywords: POEMS, monoclonal gammopathy, calciphylaxis, Castleman’s disease, VEGF

The new frontier in endovascular treatment of arteriovenous fistula stenosis: the role of ultrasound-guided percutaneous transluminal angioplasty

Rosario Maccarrone1, Luca Zanoli2, Lillo Pace3, Giulio Di Stefano4, Antonio Basile4, Luca Di Lullo5, Francesco Pesce6, Fulvio Fiorini7, Giovanni Giorgio Battaglia8, Antonio Granata1

1 UOC di Nefrologia e Dialisi, P.O. “San Giovanni di Dio”, Agrigento, Italia
2 Dip. di Medicina Interna, AOU “Policlinico – V. Emanuele” Università di Catania, Catania, Italia
3 UOC di Radiologia, P.O. “San Giovanni di Dio”, Agrigento, Italia
4 Dip. di Radiologia, AOU “Policlinico – V. Emanuele” Università di Catania, Catania, Italia
5 UOC di Nefrologia e Dialisi, P.O. “L. Parodi – Delfino”, Colleferro, Roma, Italia
6 Dip. di Nefrologia, Dialisi e Trapianto, AOU “A. Moro” Università di Bari, Bari, Italia
7 UOC di Nefrologia e Dialisi, P.O. “Santa Maria della Misericordia”, Rovigo, Italia
8 U.O.C. Nefrologia e Dialisi, P.O. “S. Marta e S. Venera”, Acireale, Catania, Italia

Native arteriovenous fistula is the preferred vascular access because of it does not usually cause infections and seems to be closely related with prolonged patient survival, compared to prosthetic grafts and central venous catheters; it also is cost effective. Venous stenosis is one of the main causes of AVF failure. It is caused by a number of upstream and downstream events. The former group comprises hemodynamic and surgical stressors, inflammatory stimuli and uraemia, while downstream events involve the proliferation of smooth muscle cells and myofibroblasts and the development of neo-intimal hyperplasia. Percutaneous transluminal angioplasty is the gold standard for arteriovenous fistula stenosis. It allows the visualization of the whole vascular circuit and the immediate use of the vascular access for the next dialysis session. Ultrasound-guided percutaneous endovascular angioplasty is a feasible and safe alternative to conventional fluoroscopic technique: it is equally effective in treating arteriovenous fistula stenosis, but it presents the advantage of not using contrast media or ionizing radiation. The aim of this review is to report the latest evidence on cellular and molecular mechanisms that contribute to the development of neo-intimal hyperplasia, as well as the current and future therapeutic perspectives, especially concerning the use of anti-proliferative drugs, and the efficacy of the ultrasound-guided angioplasty in restoring and maintaining the vascular access patency over time.

Key words: Percutaneous angioplasty, ultrasound, arteriovenous fistula, hemodialysis, stenosis.

Temporal variation of Chronic Kidney Disease’s epidemiology

Michele Provenzano1, Cinzia Mancuso1, Carlo Garofalo2, Luca De Nicola2, Michele Andreucci1

1 Nephrology Unit of “Magna Graecia” University of Catanzaro, Italy
2 Nephrology Unit of University of Campania “L. Vanvitelli” – Naples, Italy

Chronic Kidney Disease (CKD) is a major risk factor for mortality and morbidity, as well as a growing public health problem. Several studies describe the epidemiology of CKD (i.e. prevalence, incidence) by examining short time intervals. Conversely, the trend of epidemiology over time has not been well investigated, although it may provide useful information on how to improve prevention measures and the allocation of economic resources. Our aim here is to describe the main aspects of the epidemiology of CKD by focusing on its temporal variation. The global incidence of CKD has increased by 89% in the last 27 years, primarily due to the improved socio-demographic index and life-expectancy. Prevalence has similarly increased by 87% over the same period. Mortality rate has however decreased over the last decades, both in the general and CKD populations, due to a reduction in cardiovascular and infectious disease mortality. It is important to emphasize that the upward trend of incidence and prevalence of CKD can be explained by the ageing of the population, as well as by the increase in the prevalence of comorbidities such as hypertension, diabetes and obesity. It seems hard to compare trends between Italy and other countries because of the different methods used to assess epidemiologic measures. The creation of specific CKD Registries in Italy appears therefore necessary to monitor the trend of CKD and its comorbidities over time.

Keywords: chronic kidney disease, CKD, epidemiology, registers, socio-demographic index

Doctor-Patient communication

Fulvio Fiorini1, Antonio Granata2

1 UOC Nefrologia e Dialisi, Ospedale Santa Maria della Misericordia, AULSS5 Polesana, Rovigo
2 UOC Nefrologia e Dialisi, Ospedale San Giovanni di Dio, Azienda Sanitaria, Agrigento

The Doctor-Patient relationship is of fundamental importance in the field of care and continues to undergo profound transformations. In ancient times the doctor was “authoritarian”: the patient was considered a passive element, incapable of understanding, knowing and acting for his own health. The doctor then became a “paternalistic” figure and it is only recently that the patient has become a responsible subject who interacts with the doctor in the definition and evaluation of every health intervention. The patient needs to be actively involved and informed, participating in the therapeutic process and in monitoring the positive and negative effects of the treatment. The doctor needs to communicate in a way that is simple and appropriate in order to avoid misunderstandings, which are very common as patients and doctors can often attribute different meanings to certain words. Doctors need to be aware that such a possibility exists and verify that the patient has understood the real meaning of his words. As good communication between doctors and patients is a strategic factor in care, communication courses should be included in any Medical Degree course.


Keywords: communication, doctor, humanisation, patient

Choice and management of anticoagulation during CRRT

Davide Ricci1, Laura Panicali1, Giuseppe Cavallari1, Maria Grazia Facchini1, Elena Mancini1

1U.O. Nefrologia Dialisi e Ipertensione, Policlinico S.Orsola-Malpighi, Bologna, Italia

Continuous renal replacement therapies (CRRT) are widely used in the treatment of acute kidney injury. Several causes, related to the treatment itself or to the patient’s condition, determine the coagulation of the extracorporeal circuit. These interruptions (or down-time) have a negative impact on the effectiveness of the treatment in terms of solute clearance and fluid balance. Historically, the choice of anticoagulant has fallen on unfractionated heparin because it is cheap and easy to use. Today, the use of citrate is recommended in most instances because of its high efficacy and safety. Several studies demonstrate the superiority of citrate in terms of filter survival. The reduction of down-time results in a reduction of the delta between the prescribed dialysis dose and the dose that is actually administered (ml/Kg/hour of collected effluent). The literature also agrees that there is a reduction in the incidence of major bleeding events when citrate is used instead of heparin, although there is no impact on mortality rates.

Some technical and clinical complexities, secondary to citrate action both as anticoagulant and buffer, still exist in the use of regional citrate anticoagulation. However, complications due to citrate use, such as acid-base balance disorders and hypocalcaemia, are rare and easily reversible.

There is not much data about the costs and benefits of using citrate instead of heparin; according to the experience within our own Unit, we have observed a reduction in costs when the data is normalized for 35 ml of effluent administered. Appropriate protocols, accurate surveillance and the automated management of regional citrate anticoagulation thanks to dedicated software make this technique safe and effective.

Keywords: anticoagulation, citrate, acute kidney injury, CRRT

Extracorporeal therapy in sepsis

Marco Pozzato1, Sergio Livigni2, Dario Roccatello1

1 Struttura Complessa Universitaria di Nefrologia e Dialisi – CMID, Ospedale San Giovanni Bosco, ASL Città di Torino, Torino
2 Struttura Complessa di Anestesia e Rianimazione, Ospedale San Giovanni Bosco, ASL Città di Torino, Torino

Acute renal injury (AKI) occurs in 19% of patients with sepsis, 23% of those with severe sepsis and up to 50% of patients with septic shock. AKI represents an independent prognostic factor of mortality (about 45%); epidemiological studies have pointed out that the onset of AKI in sepsis (S-AKI) correlates with an unfavourable outcome, reaching a mortality of 75%.

Over the years, efforts have been made to prevent and treat “low flow” hemodynamic damage resulting from shock by increasing renal blood flow, improving cardiac output and perfusion pressure. New experimental studies in S-AKI have shown that renal blood flow is maintained, and indeed increases, in the course of septic shock. Recently, a “single theory” has been proposed that defines acute renal injury as the final result of the interaction between inflammation, oxidative stress, apoptosis, microcirculatory dysfunction and the adaptive response of tubular epithelial cells to the septic insult.

The type of treatment, the dose and the starting time of RRT are of strategic importance in the recovery of AKI in septic patients.

The use of new anticoagulation strategies in critically ill patients with S-AKI has allowed treatments to be carried out for enough time to reach the correct dose of purification prescribed, minimizing down-time and bleeding risk.

The availability of new technologies allows to customize treatments more and more; the collaboration between nephrologists and intensivists must always increase in order to implement modern precision medicine in critical care.

Keywords: S-AKI, septic shock, CRRT, citrate, CPFA, adsorption

Differential diagnosis of acute kidney injury in critically ill patients: the nephrologist’s role in identifying the different causes of parenchymal damage

Paola Inguaggiato1, Giorgio Canepari1, Luca Besso1

1 SC Nefrologia e Dialisi, ASO S.Croce e Carle, Cuneo

The management of acute kidney injury in the critical area is complex and necessarily multidisciplinary, but the nephrologist should maintain a pivotal role, both in terms of diagnosis and of indication, prescription and management of extracorporeal replacement therapy.

The most frequent causes of AKI in the critically ill patients are correlated to sepsis and major surgery, but the incidence of different causes, of strict nephrological relevance, is probably higher than the estimate.

Nephrologists have the competence to evaluate data relating to renal functions, urinary electrolytes, urinary sediment, and to identify which specific examinations can be useful to define the cause of AKI. A nephrological consultation will therefore improve the clinical management of AKI by guiding and integrating the diagnostic path with traditional or more advanced assessments, useful for the identification of the different causes of acute kidney damage and consequently of the most appropriate therapy.

The etiological diagnosis of AKI will also be crucial in defining the renal prognosis and therefore an appropriate nephrological follow up.

Keywords: Acute kidney injury, differential diagnosis, critical care nephrology

The management of antibiotic therapy in critically ill patients with AKI: between underdosing and toxicity

Giorgio Canepari1, Paola Inguaggiato1, Luca Besso1

1 SC Nefrologia e Dialisi, ASO S.Croce e Carle, Cuneo

Changes in microbiology and dialysis techniques in intensive care have made the use of antibiotics on nephropathic patients more complex. Several recent studies have modified our knowledge about the use of antibiotics in the care of critically ill patients, highlighting the frequency of their inappropriate use: both underdosing, risking low efficacy, and overdosing, with an increase in toxicity. Kidneys, organs devoted to excretion and metabolism, are a potential target of pharmacological toxicity. Extracorporeal replacement therapy is also a possible drug elimination route. What we call nefropharmacology represents a complex, tangled and rapidly evolving subject of multi-specialist interest. We have reviewed here most of the recent literature dealing with the appropriateness of antibiotic use, focusing on the most interesting contributions from a nephrological perspective.

Keywords: AKI, antibiotics, CRRT, pharmacokinetic

Is apheresis still a useful tool in the treatment of nephrological diseases?

Antonio Santoro

Scuola di Specializzazione in Nefrologia, Università degli Studi di Bologna, Policlinico S.Orsola-Malpighi

Therapeutic apheresis is by now a century-old extracorporeal procedure, but it is still very much relevant thanks to advances in medical device technology. In addition to the classic plasma exchange, we now have double filtration techniques, plasma absorption, immunoadsorption, leuko and cyto-apheresis, LDL apheresis. The application of these highly selective techniques has opened up new perspectives in the treatment of various nephrological diseases. Unfortunately, renal diseases that can be treated with apheretic techniques are often relatively rare and this prevents us from carrying out extensive studies aimed at demonstrating the real benefits of these methods. Every three years, the American Society of Apheresis provides solid recommendations regarding the diseases that can be treated with apheresis. New immunosuppressants, immuno-modulating substances and monoclonal antibodies are becoming extremely selective and sophisticated weapons against diseases with a clearly identified causal agent. This does not exclude the fact that, due to economic reasons or even to minimize the side effects of these new drugs, apheretic techniques could still retain an important, if ancillary, role. 

Keywords: plasmapheresis, plasma exchange, immunoadsorption, LDL apheresis, cascade plasmapheresis, double filtration, cytoapheresis

Evaluating the impact of regulation 2016/679 of the European Parliament

Filippo Lorè

Università degli Studi di Bari

Relationships between Medicine and Spirituality

Simonetta Pulciani1, Emanuele Nutile2

1 Centro Nazionale Malattie Rare, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161, Roma, Italia.
2 Via Illiria 18, 00183, Roma, Italia. Già dirigente psicologo/psicoterapeuta DSM ASL Roma B.

This review aims at analysing the links between medicine and spirituality, two seemingly distant concepts. Medicine at its beginnings was imbued with rituals that invoked the intervention of supernatural powers, as man were unable to treat diseases and struggled to bear the suffering caused by them and the fragility of their own bodies. Today, in the post-genomic era, medicine has gained great benefits from new and extraordinary scientific and technological achievements, permitting sophisticated therapeutic and diagnostic approaches, which assure cures not previously possible. Even considering these great accomplishments in medicine and technology, it should be borne in mind that diseases not only induce bodily changes in sufferers, but also affect their emotional state and social interactions. Illness, especially when serious and in presence of a poor prognosis, raises profound questions around the meaning of life, affections, suffering and death. In the last few decades scientists, doctors, theologians, psychologists and others, in considering these questions, have emphasized the importance of spirituality as a relevant factor in the care of the sick and their illnesses.

Drawing from some thoughts expressed in the book, “When the Breath Becomes Air,” authored by the physician Paul Kalanithi, we claim that spirituality should be perceived as an important contributing factor in the therapeutic path. Our aim is to deepen the meaning of spirituality, differentiating it from religion, faith and mysticism, and to understand how it should be integrated with post-genomic medicine to enhance its positive aspects and effects.

Keywords: Spirituality, Medicine, communication, patients, physicians

After 103 years, is it time to cancel the Hasselbalch equation from textbooks?

Francesco Sgambato1, Sergio Prozzo1, Ester Sgambato2

1 U. O. C. di Medicina Interna – Ospedale Fatebenefratelli – Benevento
2 U. O. C. Medicina e Chirurgia di Accettazione e Urgenza – Osp. S. Eugenio – Roma

The equation called “Henderson-Hasselbalch Equation” was created in 1916 following the Henderson Equation published in 1908.

After analyzing the evolution from the simplicity of Henderson to the complexity of Hasselbalch, it is hoped that the acid-base balance can become a simpler and more exciting topic if approached and taught without using the Henderson-Hasselbalch equation, which includes 4 logarithms.

It is stated that the rationale underlying the understanding of acid-base equilibrium and its clinical application is already clearly inherent in the much simpler Henderson formula (without logarithms), which is sufficient, and very useful, for both teaching and learning in Medicine.

Key words: Hasselbalch, Henderson, [H+], pH

Narrative Medicine can reduce opposition to organ removal for transplantation

Rosa Maria De Santo1, Luca Salvatore De Santo2

1 Scuola di Psicoterapia Gestaltica Integrata – SiPGI, Torre Annunziata (NA)
2 Cattedra di Cardiochirurgia Università di Foggia

In Italy in 2017 out of 2738 assessments of death, there was a 28.7% of oppositions of family members to the removal of organs post-mortem. This opposition is a serious limitation to the development of transplantation programs. There is a need to increase the number of transplants since transplantation grants the highest quality of life, a longer survival and at a lower cost for the society. We propose the use of Narrative Medicine (MN) to reduce this opposition. “Narrative Medicine – as Charon says – fortifies clinical practice with the narrative competence to recognize, absorb, metabolize, interpret, and be moved by the stories of illness”. We have identified eight stories as having a particular echo: 1. That of Nicholas Green, the American child killed on the Salerno-Reggio Calabria highway and whose organs saved seven people. 2. The story of Ylenia, who learned solidarity from transplants. 3. That of Robin JA Eady, Dermatology Professor in London and the second person on dialysis from Scribner in Seattle. 4. The story of the organ donation of Liberato Venditti, a young man who loved life and climbs on a motorcycle. 5. That of the young football player Giuseppe Feola, remembered here by the Napoli player Gonzalo Higuaín. 6. The donation of the organs of Bruno Memoli, Professor of Nephrology in Naples. 7. The reflections of a heart surgeon. 8. The story written by Federico Finozzi about his own transplant.

“The stories” – as Greenhalgh writes – “have an ethical dimension. The person who reads or hears such a story incurs a duty to act so. Stories are open and subversive”.

Keywords: Narrative Medicine, organ donation, opposition to organ removal, lack of organs for transplantation, narrative organ donation

Correction of secondary hyperparathyroidism with paricalcitol in renal transplant improves left ventricular hypertrophy

Carlo Massimetti1, Gea Imperato1, Sandro Feriozzi1

1Centro di Riferimento di Nefrologia e Dialisi, Ospedale Belcolle, Viterbo

Background – Left ventricular hypertrophy (LVH) is common in renal transplant recipients (RTRs), and persistent secondary hyperparathyroidism (SHPT) is considered to be one of the main causes of its pathogenesis. In this study we evaluated if the control of SHPT with paricalcitol is associated with a reduction of LVH in RTRs. Methods – For this purpose we selected 24 RTRs with LVH and SHPT . Secondary hyperparathyroidism was defined as PTH levels 1.5 times higher than the high normal limits, while LVH was defined as a left ventricular mass index (LVMi) >95g/m2 in females, and >115g/m2 in males. Treatment with paricalcitol started at mean dose of 1µg/day and lasted 18 months. The dose of paricalcitol was reduced to 1µg on the other day when serum calcium was >10.5mg/dl and/or fractional excretion of calcium was >0.020%; administration was temporarily stopped when serum calcium was >11 mg/dl. Results – At follow-up PTH levels decreased from 198 ± 155 to 105 ± 43pg/ml (P < .01), and LVMi decreased from 134 ± 21 to 113 ± 29g/m2 (P < .01); the presence of LVH decreased from 100% at baseline to 54% at F-U. Serum calcium levels showed a modest and not significant increase. Renal function was stable in all patients. Conclusions – Secondary hyperparathyroidism seems to play an important role in the development and maintenance of LVH and its correction with paricalcitol has a favorable impact on its progression.

Keywords: left ventricular hypertrophy; parathormone; paricalcitol; renal transplantation; secondary hyperparathyroidism

Survey on the Prevalence of Rare Kidney Diseases in Sicily

Silvio Maringhini1, Rosa Cusumano2, Patrizia Miceli3, Santina Castellino4, Roberto Chimenz5, Gabriella Dardanoni3, Angelo Ferrantelli6, Antonio Granata7, Domenico Santoro8 e Salvatore Scondotto3

1 Dipartimento Pediatria, Istituto Mediterraneo dei Trapianti e Tecniche specialistiche (ISMETT), Palermo, Italia
2 UOC Nefrologia Pediatrica, PO “G. Di Cristina”, ARNAS Civico, Palermo, Italia
3 Dipartimento Attività Sanitarie Osservatorio Epidemiologico, Assessorato alla Salute, Regione Sicilia, Palermo, Italia
4 Università di Catania, Italia
5 UO Nefrologia e Reumatologia Pediatrica con Dialisi – AOU “G. Martino”, Messina, Italia
6 UOC di Nefrologia e Dialisi, PO ” V. Cervello”, Palermo, Italia
7 UOC di Nefrologia e Dialisi, PO ” San Giovanni di Dio”, Agrigento, Italia
8 UOC Nefrologia e Dialisi, di Medicina Clinica e Sperimentale, Università degli studi di Messina, Italia

Renal Diseases represent almost 6% of all Rare Diseases but are often misdiagnosed. In a survey made in Sicily in 2016, based on cases reported from all public hospitals according to a list of rare kidney diseases, we were able to collect 337 cases (199 males and 138 females). The highest prevalence was detected in children: 13.9 cases in 100.000 children; the mean age was 10, and the median 5 years, at the time of the diagnosis. Comparing our data with those available in the Sicilian Register of Rare Diseases we found that only 141 cases (54%) were present in the register. Promoting regional registries of rare kidney diseases in Italy may be useful for epidemiologic studies.

Keywords: renal disease, rare diseases, rare renal diseases

Cost analysis of haemodialysis catheter related bloodstream infection through the DRG system, “on behalf of Project Group of Vascular Access of Italian Society of Nephrology”

Salvatore Mandolfo1, Milena Maggio1, Giacomo Forneris2, Franco Galli3

1 UOC di Nefrologia e dialisi – Ospedale Maggiore Lodi
2 UOC di Nefrologia e Dialisi – Centro di Ricerche di Immunopatologia e Documentazione Malattie Rare – Ospedale San Giovanni Bosco e Università di Torino
3 BEL – Bioengineering  Laboratories Cantù

Catheter related bloodstream infections (CRBSI) represent a complication that often requires hospitalization and the use of economic resources. In Italy, there is no literature that considers the costs of CRBSI for tunneled catheters (CVCt).

The aim of this work is to evaluate the relative costs of CRBSI through the DRG system.

From 2012 to 2017 we examined 2.257 hospital discharge forms, 358 of which relating to haemodialysis patients. Patients with CVCt (167), compared to FAVs (157), on average stay in hospital longer (10 vs. 8 days), entail higher costs (+8.5%) and higher admissions rate for infections (+114%). The incidence of CRBSI was 0.67 episodes per 1000 CVCt/days. CRBSI accounts for 23% of the cases of hospitalization of patients with CVCt and 5.2% of total hospitalization costs. Complicated CRBSI involve a 9% increase in average costs compared to simple ones, with patients staying in hospital three times longer. The cost of a CRBSI varies from €4,080 up to €14,800, with an average cost of €5,575. The costs calculated here are less than a third of that reported in American literature but this can be explained by the different reimbursement rates systems. The methodology of CRBSI costs through DRGs appears simple, and its main limit is the correct compilation of the discharge form. This is a reminder that discharge forms are an integral part of the medical record and can become important in recognizing the cost of the medical services provided.

Keywords: hospital costs, CRBSI, central venous catheter

The unusual couple: a clinical case of coexistence between aHUS and Fabry’s disease

Salvatore Coppola1, Vincenzo Cuomo1, Cesare Gerardo Riccio1, Ludovica d’Apice2, Walter de Simone3, Giovambattista Capasso4

1UOSD Nefrologia e dialisi, PO Piedimonte Matese, ASL Caserta
2Già  Direttore UOC Nefrologia e dialisi AO Caserta
3Già  Direttore UOC Nefrologia e dialisi AO Avellino
4Professore Ordinario di Nefrologia, Università degli Studi della Campania, Luigi Vanvitelli

Atypical hemolytic-uremic syndrome (aHUS) is a rare, potentially lethal (14) systemic disorder, capable of affecting both adults and children, causing thrombotic microangiopathy (TMA) (5) that leads to the formation of thrombus within small blood vessels with multiple organ failure. The pathogenesis of the aHUS is part of a sort of chronic and uncontrolled activation of the complement system by genetic mutation of some proteins usually responsible for its self-regulation (6,7). Today, the rapid diagnosis of the disease and the timely start of treatment with eculizumab, improve outcomes of renal failure, stroke and heart attack (810).

Fabry disease is a rare tesaurismosis, X linked, due to the deficiency of the lysosomal enzyme alpha-galactosidase A (11-13), necessary for the physiological catabolism of glycosphingolipids. Multisystem clinical manifestations lead to a serious degenerative pathology. The diagnostic suspicion based on anamnesis and careful research of the symptoms and then confirmed by the enzymatic dosage of alpha galactosidase or by molecular analysis, allows the early treatment of the patient with enzyme replacement therapy, guaranteeing the resolution and/or slowing down the evolution of the disease, especially in the brain, heart and kidneys.

In this report, we describe the clinical case of a patient who is a carrier of both rare diseases.


Keywords: aHUS, eculizumab, Fabry’s disease, alpha galactosidase, enzyme replacement therapy

Diagnosis of Biliary Hamartomatosis in Kidney Transplant Recipient affected by ADPKD

Giuseppe Leonardi1, Mariadelina Simeoni1, Michele Bozzo1, Alfredo Caglioti 1, Giorgio Fuiano1

1 UO Nefrologia e Dialisi, Policlinico Germaneto, Catanzaro

Biliary hamartomas (BH) are rare benign lesions of the liver characterized by a dilation of a variable number of small biliary ducts, usually surrounded by abundant fibrotic tissue. These malformations are due to an aberrant remodelling of the ductal plate, that is the embryonic structure generating the normal biliary tree. BH are usually asymptomatic, but in rare cases they can be associated with jaundice, heartburn and fever. Evidences for a sharing of similar pathological pathways between BH and adult dominant polycystic kidney disease (ADPKD) are widely reported. These similarities induce an increased neoplastic risk transformation in both conditions. This risk is even greater in immunosuppressed patients. The diagnosis of BH by imaging is not easy, especially in the context of ADPKD. We present a clinical case of a 54-year-old kidney transplant recipient affected by ADPKD in which BH, previously undetected, was for the first time suspected on routine ultrasound scan and confirmed with MRI 4 years after renal transplantation. Demodulation of proliferative signals induced by immunosuppressive therapy, and particularly by calcineurin inhibitors, could cause an enlargement of AB and increase the risk of neoplastic transformation. Our case-report suggests a close imaging follow-up may be needed in ADPKD patients with BH, especially if transplanted. High sensitivity techniques, such as CEUS and MRI, should be preferred to conventional ultrasound.

Keywords: Biliary Hamartomatosis, Kidney Transplant, ADPKD

A child with severe growth delay and renal cysts

Gianluca Vergine1, Elisa Ravaioli1, Viviana Palazzo2, Giovanni Gambaro3,  Sabrina Giglio2

1UO Pediatria, Ospedale Infermi Rimini, ASL Romagna
2UO Genetica Medica, Ospedale Meyer Firenze
3 UO Nefrologia, Policlinico Universitario A. Gemelli-Università Cattolica del Sacro Cuore, Roma

We describe the case of a 5-year-old who came to our attention for a growth delay. Among the investigations planned because of the child’s short stature, we performed an abdominal ultrasound showing normal-sized kidneys with signs of cortico-medullar de-differentiation, diffuse medullary hyperechogenicity with reduction of cortical thickness and cortical-medullary cysts. The ultrasound findings, also confirmed in MRI, led us to suspect a genetically determined cystic nephropathy of the nephronophthisis or medullary cystic disease type. No mutation was identified in NPHP1, HNFb1 and UMOD genes. Interestingly, laboratory investigations revealed a severe metabolic acidosis with normal renal function and hypokalemia. These findings are not characteristics of a nephronophthisis. We therefore also performed molecular analysis for distal tubular acidosis (dRTA) that showed the association of two genetic variants of ATP6V1B1 and SLC4A genes. These “double mutations” have been inherited from the mother, which however does not have the classic dRTA phenotype. These variants do not currently meet the criteria for a conclusive molecular diagnosis of dRTA but represent variants of uncertain clinical significance. However, considering the clinical and laboratory data one can reasonably conclude that the child has a “probable” diagnosis of distal tubular acidosis. The rapid recovery of staturo-ponderal growth after the start of alkalizing treatment supports our diagnostic hypothesis. The association between distal tubular acidosis and renal cysts is well described in the literature. The hypothesis is that chronic hypokalemia may play a possible role in the formation of renal cysts.

Keywords: growth delay, renal cysts, tubular acidosis, ipokalemia

Atrial fibrillation in severe and end stage renal disease: from oral anticoagulation therapy to percutaneous left atrial appendage occlusion

Pierluigi Merella1, Gavino Casu1, Patrizio Mazzone2, Giovanni Lorenzoni1, Giuseppe D’Angelo2, Simonetta Genovesi3.

1 Unità Operativa di Cardiologia, Ospedale San Francesco, Nuoro, Italia
CardiacPacing Unit, IRCCS Ospedale San Raffaele, Milano, Italy
3 Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
Nephrology Unit, San Gerardo Hospital, Monza, Italy

Non-valvular atrial fibrillation (AF) is the most frequent arrhythmia in the general population and its prevalence increases with age. The prevalence and incidence of AF is high in patients with chronic kidney failure (CKD). The most important complication associated with AF, both in the general population and in that with CKD, is thromboembolic stroke. For this reason, in patients with AF, the Guidelines indicate oral anticoagulant therapy (OAT) with vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs) for thromboembolic risk prevention. Patients with severe CKD and, in particular, with end stage renal disease (ESRD) undergoing renal replacement therapy, often have both a high thromboembolic and hemorrhagic risk and therefore present both an indication and a contraindication to OAT. In addition, patients with severe or ESRD were excluded from trials that showed the efficacy of different antithrombotic drugs in patients with AF. Thus there is no evidence of the effectiveness of OAT in this population. This review deals with the issues related to OAT in patients with severe or end stage CKD and the possible use of percutaneous closure of the left auricula (LAAO), recently proposed as an alternative in patients with an absolute contraindication of OAT in this population.

Key words

Atrial fibrillation; oral anticoagulant therapy; bleeding; severe chronic kidney disease; end stage renal disease; left atrial appendage occlusion.

Talking about medicine through mass media

Fulvio Fiorini, Antonio Granata1, Yuri Battaglia2, Michele A.A. Karaboue3

UOC Nefrologia e Dialisi, Aulss5 Polesana, Ospedale SM della Misericordia, Rovigo
1 UOC Nefrologia e Dialisi, Ospedale S. Giovanni di Dio, Agrigento
2 UOC Nefrologia e Dialisi, A.O.U. S.Anna, Ferrara
3 Sezione Medicina Legale, Dipartimento Medicina Sperimentale “L. Vanvitelli”, Università della Campania, Napoli

The ability to communicate is central to all professional activities and therefore being able to communicate effectively with mass media is essential. The medical doctor often needs to communicate not with a single patient or with a group of family members, but with “an important number of patients” through a microphone, a newspaper, a radio or a television. In this case it is not necessary to provide specific information on a single clinical case, but to provide simple, general information on a single pathology or a group of diseases to an interviewer or journalist, who will probably elaborate it at his own discretion making it usable to a diverse and unspecified audience. It is therefore important to be relevant to the question, clear in the presentation, but also synthetic to respect the time limits of interview.

KEY WORDS: communication, medicine, mass media, patients

Medicine, Nephrology and social networks

Vincenzo Montinaro1, Emanuela Cataldo2, Francesca Cianciotta2, Vincenza Colucci2, Giuseppina D’Ettorre2, Giulia Fontò2, Davide Gianfreda1, Marica Giliberti2, Enrica Gintoli2, Silvia Matino2, Adriano Montinaro2, Paolo Protopapa2, Paola Suavo-Bulzis2

1 U.O. Nefrologia e Dialisi, “Pia Fondazione Card. G. Panico”, Tricase (LE)

U.O. Nefrologia e Scuola di Specializzazione in Nefrologia, Dipartimento dell’Emergenza e Trapianto di Organi, Azienda Ospedaliero-Universitaria “Consorziale Policlinico” e Università degli Studi “Aldo Moro” di Bari

Investing on the journal of the Italian Society of Nephrology

Gaetano La Manna, Editor in Chief Giornale Italiano di Nefrologia

Alma Mater Studiorum – Università di Bologna
Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale – DIMES
Unità di Nefrologia, Dialisi e Trapianto
Policlinico S. Orsola – Malpighi pad. 15
Via G. Massarenti 9 – 40138 Bologna


Antonio Capasso

Dottore in giurisprudenza, Cultore della materia Università Federico II Napoli

The article deals with the regulatory and jurisprudential evolution of medical criminal responsibility from the 70s to the Gelli-Bianco law of 2017. Subsequently it winds through the contribution of the last important judgments of the subject up to the decisions of the Supreme Court with United Sections of 2018, finally to conclude with an economic analysis on the increasement of the legal disputes registered in recent years.

Keywords: medical criminal responsibility, Gelli-Bianco law, judgement Mariotti.


Salivary creatinine and urea in patients with end-stage chronic kidney disease could not be used as diagnostic biomarkers for the effectiveness of dialysis treatment

Anna Nenova Nogalcheva1, Desislava Konstantinova2, Petia Pechalova3

1 Department of Oral and Maxillofacial Surgery, Faculty of Dental medicine, Medical UniversityVarna, Bulgaria
2 Department of Prosthetic Dentistry, Faculty of Dental medicine, Medical University Varna, Bulgaria
3 Department of Oral Surgery, Faculty of Dental medicine, Medical University Plovdiv, Bulgaria

Introduction. End-stage chronic kidney disease (CKD) is characterized by kidney failure with the organ’s functions reduced or lost completely, where the kidneys are incapable of filtering excess fluids. Renal replacement therapy may be provided by peritoneal dialysis, hemodialysis or renal transplantation. Among the key indicators for tracking patients’ current status are urea and creatinine levels.

Aim. The study analyzed saliva as a medium to detect and measure urea and creatinine levels in end-stage CKD patients as well as to use it as criteria for the effectiveness of the dialysis treatment by comparing salivary urea and creatinine levels with their blood levels.

Material and methods. The study targeted 70 end-stage CKD patients from northeastern Bulgaria undergoing hemodialysis treatment. The urea in blood serum was carried out using the UV kinetic method. Creatinine levels were measured using Jaffe reaction colorimetric method without deproteinezation, adapted on an Olympus AU 400 automated biochemical analyzer (Beckman Coulter Inc., USA). Samples from whole unstimulated saliva were collected in a 15 ml sterile test tube as per Navazesh method. The qualitative determination of salivary urea was performed using the UV kinetic method. Creatinine levels in whole unstimulated saliva were measured using Jaffe reaction colorimetric method.

Results. There was a statistically significant reduction in blood urea levels (P=0.000) and in blood creatinine levels (P = 0.000) following hemodialysis. The results revealed that there was no statistically significant dependence between both, the urea levels (P=0.240) and the creatinine levels (P=0.065) in whole unstimulated saliva obtained prior to and after a hemodialysis.

Conclusion. Despite the parallel increase of the urea and creatinine levels in blood serum and in whole unstimulated saliva in end-stage CKD, salivary urea and creatinine levels could notbe used as diagnostic biomarkers for the effectiveness of dialysis treatment.


Key words: end-stage chronic kidney disease, dialysis, salivary urea, salivary creatinine

La Nefrologia nella Regione Sicilia

Avv. Ruggero Razza

Intervento a cura dell’Assessore alla Salute Regione Sicilia

Hemodialysis treatment as a trigger cause of cryoglobulinemic purpura: a case report

Lorenzo D’Elia1, Michi Recupero1, Porri Maria Grazia1, Alessandro Naticchia1 , Silvia D’Alonzo1

1 U.O.C. Nefrologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, ROMA

We describe the clinical case of a patient who developed mixed cryoglobulinemia syndrome after hemodialysis treatment with dialysate temperature lower than 36 °C despite the negativization of the viral genome for HCV after eradication therapy.

Keywords: case report, cryoglobulinemia, mixed cryoglobulinemic syndrome, dialysate temperature

Il Registro delle Operazioni di Trattamento

Dott. Filippo Lorè

Università degli Studi di Bari

Artificial intelligence for future MD

Gian Piero Sancipriano

UO Nefrologia e dialisi Ospedale Ciriè (dal 1977 al 2015) Torino, Italia

Health care workers need artificial intelligence.
Artificial intelligence is a set of studies and techniques that tend to the realization of machines, which solve complex problems automatically, simulating or emulating human intelligence activities.
Human intelligence is innate, creative, emotional, sporting, social in the collective and connected future.
Knowledge is the faculty, act, mode, effect of taking possession, intellectually or psychologically, with systematic activity of any certain aspect of reality.
The dates are given in the form of text, number, symbol, image, sounds that are used or stored in computers. Having many data or data does not mean having much information. Having a lot of information does not mean having a lot of knowledge.
Symbolic reasoning uses symbolic logic, logical connectives, expert systems, production rules, genetic algorithms, validation, explanation, justification, verification of inference, heuristic research. The knowledge of symbolic reasoning is deterministic.
Machine learning is the field of study that gives computers the ability to learn without being programmed to do so. Use algorithms for statistical and probability calculations, the learning phases may not be verifiable. They are mathematically structured human opinions, spoiled by the pre – understandings of those who design them, of those who want to look for something.
The association between symbolic reasoning and automatic learning is excellent.
The intelligence of health workers work connected and collective, develop knowledge bases to be subjected to symbolic reasoning, expert systems and rules to have deterministic knowledge.

The deterministic knowledge subsequently elaborated by artificial intelligence will be returned to human intelligences.

Keyword. Artificial intelligence. Automatic learning. Symbolic reasoning.

The Good Samaritan Donor Experience

Rosario Girgenti1, Marinella Buttafarro2

1 Psicologo Clinico e di Comunità, Psiconcologo, Psicoterapeuta Cognitivo Comportamentale, Responsabile dell’Unità Operativa di Psicologia Clinica Ismett, Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione – IRCCS, Palermo.
2 Psicologa Clinica, Psicoterapeuta Sistemico Relazionale IIPR, Psicologa Clinica Ismett, Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione – IRCCS, Palermo

The need for patients with a chronic kidney failure and on dialysis to embark on a kidney transplant process, poses the challenge to identify alternative and effective surgical strategies to overcome the insufficient number of deceased donors. The purpose is to allow the considerable number of patients on the kidney transplant waiting lists to receive appropriate treatment in time and under the most favorable clinical conditions. Living donation from a significant other is becoming increasingly widespread, on a national and international level. Furthermore, in the last years clinical experience is showing a special kind of kidney living donation: the Good Samaritan donation, i.e. when the donor has no emotional or blood bond with the recipient and decides to become a donor as a mere act of generosity, with no remuneration or reward in return. This article, after a brief analysis of the phenomenon through data obtained from recent international studies, shares the direct experience of the Clinical Psychology Service at IRCCS – ISMETT with regard to the psychological assessment and support throughout the clinical process of a Good Samaritan kidney donor. Sharing our experience and starting a discussion on this issue is the result of the need to define shared guidelines on the psychological approach to be used with potential Good Samaritan donors.


KEYWORDS: Kidney transplantation, living organ donation, good Samaritan donation, psychological assessment, altruism

Efficacy of SUPRA HFR in the treatment of acute renal damage during multiple myeloma

Germana Daidola1, Cesare Guarena2, Maddalena Brustia3, Gianluca Leonardi2, Federica N. Vigotti4, Antonio Marciello4, Simona Bianco2, Doriana Chiarinotti3, Marco Saltarelli4, Luca Besso1, Luigi Biancone2

1 S.C. Nefrologia e Dialisi AO S. Croce e Carle di Cuneo (CN), Italia
2 S.C. Nefrologia, Dialisi e Trapianto U. AOU Città della Salute e della Scienza di Torino (TO), Italia
3 S.S.D. Nefrologia e Dialisi, AOU Maggiore della Carità, Novara (NO), Italia
4 S.S. Nefrologia e Dialisi, Ospedale “E. Agnelli”, Pinerolo (TO), Italia

Acute Kidney Injury (AKI) is a frequent complication of multiple myeloma (MM) with unfavorable prognostic significance.

Light chains removal, combined with hematological therapy (CT) seems to offer significant benefits to renal function recovery (RFR).

The SUPRA HFR, through the combination of high cut-off membrane without albumin loss and adsorbent cartridge, represents one of the “emerging” light chain removal methods. We report our multicentric retrospective experience with SUPRA HFR in 7 MM patients.

At the end of the treatment with SUPRA HFR a significant reduction in serum free light chains compared to baseline was observed (min 24%; max 90%; median 74%). Despite a not always early start of the treatment, all patients recovered renal function with withdrawal from dialysis in 6/7 cases.

Our preliminary experience of a combination of SUPRA HFR treatment with CT in 7 MM patients with AKI showed a significative renale functional recovery, with favourable cost/benefit ratio and a simple treatment schedule. These encouraging data suggest to further extend such treatment option, waiting for larger studies in this field.



Acute Kidney Injury, haemodiafiltration, multiple myeloma

Acute kidney injury as a risk marker for hospital readmission: a single-center pilot study in the general population of the Parma area

Giuseppe Regolisti1, Luigi Gerra1, Francesca Di Mario2, Marco Delsante1, Giovani Piotti1, Chiara Cantarelli1, Santo Morabito3, Marco Brambilla4, Vincenzo Cantaluppi5, Umberto Maggiore1, Enrico Fiaccadori1, a nome del Gruppo di Progetto AKI e Terapie Extracorporee in Area Critica SIN

1 Unità di Fisiopatologia dell’Insufficienza Renale Acuta e Cronica – Dipartimento di Medicina e Chirurgia, Università degli Studi di Parma
2 Scuola di Specializzazione in Nefrologia, Università di Roma La Sapienza, Roma
3UOD Dialisi, Università di Roma La Sapienza, Roma
4Servizio Informativo Aziendale, Azienda Ospedaliera-Universitaria Parma, Parma
5Nefrologia, Dialisi e Trapianto, Ospedale Maggiore della Carità, Università del Piemonte Orientale, Novara

Acute Kidney Injury (AKI) is an important issue for the healthcare system, as it is associated with high mortality and increased risk of readmission, with consequent elevated healthcare resource utilization.

We investigated the incidence of AKI based on the examination of the discharge cards of all patients admitted between January 1 2011 and December 31 2015 at the Parma University Hospital, as well as the frequency and type of 30-day hospital readmission in the patients discharged with a first AKI diagnosis (index admission).

The mean pooled 5-year incidence of AKI was 2.4%. The mean frequency of 30-day readmission for any disease in patients discharged with a first AKI diagnosis in the selected time interval was 23.1%/year. The main four disease categories, as assessed by the Diagnosis Related Group (DRG) classification, responsible for patient 30-day readmission were a new AKI episode, heart failure, respiratory failure requiring or not requiring mechanical ventilation, and sepsis. The mean lenght of hospital stay of patients discharged with AKI as a principal or secondary diagnosis was 14.4 and 21.8 days, respectively.

Based on the evaluation of administrative data from all hospital admissions at the Parma University Hospital in the 2011-2015 5-year period, we conclude that AKI represents a serious challenge for the healthcare system, with high short-term morbidity and increased resource utilization due to frequent hospital readmissions.

Retroperitoneal renal hemorrhage: experience of our dialysis center

Marina Cornacchiari1, Anna Mudoni2, Antonia Stasi1, Bianca Visciano1, Francesco Cosa1, Valentina Martina1, Maria Giuseppina Ponticelli1, Carlo Giastoni1

1ASST-Ovest Milanese – Ospedale Magenta e Legnano, Milano
2 Unità di Nefrologia e Dialisi, Ospedale Cardinale G. Panico, Tricase, Lecce

The aging of the uremic population, the increasingly common use of anticoagulants, antiplatelet agents e heparin, during hemodialysis, can expose our patients to a greatest risk of bleeding. Spontaneous retroperitoneal hematomas are a fairly rare and potentially fatal condition.
We describe 5 clinical cases of retroperitoneal hemorrhage that we observed during 10 years in our department, focusing on modalities of symptom onset, clinical-laboratory picture and treatment modalities

Keywords: Retroperitoneal hemorrhage, hemodialysis

FSGS collapsing variant during anabolic steroid abuse: Case Report

Marta Flachi1, Viola Menghi1, 2, Maria Rita Moschella1, Paola De Giovanni1, Marcello Montevecchi1, Davide Cerretani1, Daniela Grimaldi1, Olga Baraldi3, Benedetta Fabbrizio4, Gaetano La Manna3 e Angelo Rigotti1

1 UO Nefrologia e Dialisi AUSL Romagna Ospedale Infermi Rimini
2 Medicina Interna ISS Repubblica di San Marino,
3 UO Nefrologia Dialisi e Trapianto Policlinico S. Orsola-Malpighi Bologna,
4 SSD di Diagnostica Istopatologica e Molecolare degli Organi solidi e del relativo Trapianto Policlinico S. Orsola-Malpighi Bologna

Anabolic Androgenic Steroids (AAS) is an hormone family whose use has considerably increased among body-builders during the last decades. The AAS abuse, especially associated with other drugs or nutritional supplements and protein loads, may cause a variety of pathologies to several organs with a mechanism related to dosage, timing and substance. The kidney is the main metabolizer of these drugs and it can be acutely or chronically damaged with ESKD. The literature reports some cases of Focal Segmental Glomerulosclerosis (FSGS) in body-builders who abused of AAS. However, the link is not well understood and limited to some case-studies.


In this paper, we report the case of a young body-builder who developed a FSGS collapsing variant with ESKD after prolonged abuse of AAS and a strongly hyperproteic diet and other dietary supplements. The patient underwent a genetic test because of the rapid and irreversibile onset of ESKD. The test showed a gene mutation of ACTN4, predisposing and causal of some genetic forms of FSGS.

It was a very complex case, caused by several factors. The mutant protein of ACTN4 gene makes most vulnerable the cytoskeleton of the podocytes to external disturbances. That would explain why in those patients where the mutation has occurred, only those patients subject to “unfavorable environmental conditions”, like the abuse of AAS, can develop a disease.


Key words: anabolic androgenic steroids (AAS), end stage kidney disease (ESKD), focal segmental glomerulosclerosis collapsing variant

The pathway of vasopressin as a pharmacological target in nephrology: a narrative review

Recupero Michi, Fulignati Pierluigi, Naticchia Alessandro, D’Alonzo Silvia, D’Ascenzo Francesca, Costanzi Stefano

ADH is a hormone secreted by neurohypophysis that plays different roles based on the target organ. At the renal level, this peptide is capable of causing electrolyte-free water absorption, thus playing a key role in the hydro-electrolytic balance. There are pathologies and disorders that jeopardize this balance and, in this field, ADH receptor inhibitors such as Vaptans could play a key role. By inhibiting the activation pathway of vasopressin, they are potentially useful in euvolemic and hypervolemic hypotonic hyponatremia. However, clinical trials in heart failure have not given favourable results on clinical outcomes. Even in SIADH, despite their wide use, there is no agreement by experts on their use.

Since vaptans inhibit the cAMP pathway in tubular cells, their use has been proposed to inhibit cystogenesis. A clinical trial has shown favourable effects on ADPKD progression.

Because vaptans have been shown to be effective in models of renal cysts disorders other than ADPKD, their use has been proposed in diseases such as nephronophthisis and recessive autosomal polycystic disease. Other possible uses of vaptans could be in kidney transplantation and cardiorenal syndrome.

Due to the activity of ADH in coagulation and haemostasis, ADH’s activation pathway by Desmopressin Acetate could be a useful strategy to reduce the risk of bleeding in biopsies in patients with haemorrhagic risk.


Keyword: vasopressin, vaptans, hyponatremia, ADPKD, biopsy


Fabio MANONI1, Gianluca GESSONI2, Giovanni Battista FOGAZZI3, Maria Grazia ALESSIO4, Alberta CALEFFI5, Giovanni GAMBARO6, Sandra SECCHIERO7, Barbara PIERETTI8, Cosimo OTTOMANO9, Anna LIVERANI1, Cettina DRAGO10, Fiamma BALBONI11, Maria Grazia EPIFANI7, Graziella SACCANI12, Giovanni DI RIENZO13, Sara VALVERDE2, Rudi RAVASIO4, Giuliano BRUNORI14, Loreto GESUALDO15, per il Gruppo Interdisciplinare Analisi delle Urine

1Dipartimento dei Servizi di Diagnosi e Cura Ospedali Riuniti Padova Sud “Madre Teresa di Calcutta” Monselice PD.
2Servizio di Medicina di Laboratorio, Ospedale Madonna della Navicella, Chioggia VE
3Laboratorio Clinico e di Ricerca sul Sedimento Urinario U.O. Di Nefrologia e Dialisi Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Milano.
4Laboratorio Analisi Chimico Cliniche. ASST Papa Giovanni XXIII Piazza OMS Bergamo.
5U.O Diagnostica Ematochimica, Dipartimento Diagnostico, Azienda Ospedaliero-Universitaria Parma.
6Cattedra di Nefrologia-Divisione di Nefrologia e Dialisi, Fondazione Policlinico A. Gemelli, Università Cattolica del Sacro Cuore, Roma.
7Centro di Ricerca Biomedica, U.O.C. Medicina di Laboratorio Azienda Ospedaliera-Università, Padova
8UOC Laboratorio Analisi Ospedale S. Croce Fano PU
9Centro Analisi Monza.
10Laboratorio di Analisi Cliniche e Microbiologiche del Centro Cuore Morgagni in Pedara
11Laboratorio Analisi IFCA Firenze
12Servizio di Medicina di Laboratorio Ospedale Orlandi Bussolengo VR
13UOC Patologia Clinica-Ospedale Altamura ASL BARI
14UOC Nefrologia e Dialisi, Ospedale Santa Chiara Trento
15Cattedra Nefrologia Università degli Studi di Bari- Azienda Ospedaliero-Universitaria Consorziale “Policlinico” di Bari

With these recommendations the Interdisciplinary Urinalysis Group (GIAU) aims to stimulate the following aspects:

  • improvement and standardization of the post analytical approach to physical, chemical and morphological urine examination (ECMU).
  • Emphasize the value added to ECMU by selection of clinically significant parameters, indication of analytical methods, of units of measurement, of reference values
  • Improvement of interpretation of dip stick urinalysis with particular regard to the reconsideration of the diagnostic significance of the evaluated parameters together with an increasing awareness of the limits of sensitivity and specificity of this analytical method. Accompanied by the skills to propose and carry out in-depth investigations with analytical methods that are more sensitive and specific.
  • Increase the awareness of the ‘importance of professional skills in the field of urinary morphology and their relationships with the clinicians. through the introduction, in the report, of descriptive and interpretative comments depending on the type of request, the complexity of the laboratory, the competence of the pathologist.
  • Implement a policy of evaluation of the analytical quality by using, in addition to traditional internal and external controls, a program for the evaluation of morphological competence.

The hope is to revalue the enormous potential diagnostic of ‘ECMU, implementing a urinalysis on personalized diagnostic needs that each patient brings with it.


Key Words: Recommendations, Post Analytical Phase, Urinalysis

Medicina e Nefrologia dai Social Networks

Vincenzo Montinaro1, Emanuela Cataldo2, Bianca Covella3, Giuseppina D’Ettorre2, Vincenzo Di Leo2, Giulia Fontò2, Pasquale Gallo2, Davide Gianfreda1, Silvia Matino2, Adriano Montinaro2, Paolo Protopapa2, Paola Suavo-Bulzis2, Marco Taurisano2

1 U.O. Nefrologia e Dialisi, “Pia Fondazione Card. G. Panico”, Tricase (LE)
2 U.O. Nefrologia e Scuola di Specializzazione in Nefrologia, Dipartimento dell’Emergenza e Trapianto di Organi, Azienda Ospedaliero-Universitaria “Consorziale Policlinico” e Università degli Studi “Aldo Moro” di Bari
3 U.O. Nefrologia e Dialisi, Ospedale “Miulli”, Acquaviva delle Fonti (BA)

Methodology for determining workforce in health nephrologic unit in ITALY. Update of lows

Gianfranco Carnevali1, Santina Castellino2, Pietro Claudio Giovanni Dattolo3, Giovanni Giorgio Battaglia4, Giuseppe Quintaliani5

1 Esperto in legislazione ed organizzazione sanitaria ed ex Direttore Generale di Aziende Sanitarie Locali ed Ospedaliere
2 Coordinatore tavolo permanente workforce della SIN
3 SOC Nefrologia e Dialisi Firenze AUSLTC
4 Direttore U.O.C. Nefrologia e Dialisi P.O. Acireale /Direttore Dipartimento Medicina Azienda Provinciale Sanitaria Catania
5 Membro del Direttivo SIN, esperto di organizzazione sanitaria, ex responsabile controllo di gestione ospedale di Perugia, ex coordinatore governo clinico SIN

Nephrology continues to be in transition. While rates of kidney diseases and injury continue to rise, changes in the general health care system and the delivery of kidney care make it unclear how increases in need will be translated into demand for nephrologists. The changes in the delivery system also raise questions as to the future roles and career paths for nephrologists. There a major interrelated workforce issues to be watched closely: How many nephrologists are needed? The supply of nephrologists does not reflect the distribution of patients with kidney diseases or the activity and job description related to end stage renal disease (ESRD) patients. Looking forward, more needs to be done to systematically measure need and access, and to identify clinical areas and activity of high need for nephrologists. This review examines the laws that govern the measure of work and the needs of personnel of the Italian state and in particular in health care. Therefore, once the method is accepted and established, it will be possible communicate those findings to policy makers and fellows and to involve the politicians.


Keywords: health workload legislation, workforce, workload

Laws regulating transplantation should express the contemporaneity. Questions to the constitutionalist Francesco Paolo Casavola and to the philosophers Remo Bodei and Aldo Masullo about the possibility deciding the destiny of one’s own organs at the time one decides on how to die and on contacts between donor families and recipients.

Natale G De Santo1, Franco Citterio2, Luca S De Santo3, Guglielmo Venditti4, Giusy De Rosa5, Biagio Di Iorio6, Giovambattista Capasso7

1Professore Emerito, Università della Campania Luigi Vanvitelli, Responsabile di Sopravvivere Non Basta;
2Unità di Trapianto Renale, Clinica Chirurgica, Università Cattolica del Sacro Cuore, Policlinico Gemelli, Roma;
3Cattedra di Cardiochirurgia, Università di Foggia;
4Nefrodialisi Ospedale Civile di Isernia, Consigliere Nazionale AIDO;
5Comitato Scientifico di Sopravvivere Non Basta, Istituto Comprensivo Ruggiero, Caserta;
6Unità Complessa di Nefrologia AORN Ospedale Cardarelli, Napoli;
7Dipartimento di Scienze Mediche Traslazionali, Università della Campania Luigi Vanvitelli, Napoli

Transplantation represents modernity thus the laws regulating the procedure should be continuously renovated and remodeled in order to take full advantage of progress. The debate is about Law no. 219, December 22, 2017 and on Law no. 222, April 1, 1999. The quests are a). about the possibility to modify the first so that people deciding on how they want to die, may also decide about their willingness to allow the removal of their organs for transplantation and b). the possibility for donor families and recipients to have contacts after transplantation in the case both sides agree. Questions were emailed to the constitutionalist Francesco Paolo Casavola, immediate Past President of the National Committee for Bioethics, and to the philosophers Remo Bodei and Aldo Masullo. Their answers received by September 16, support the idea a). to include in the Law no. 219, 2017 the possibility to decide not only on the modality one wants to die but also on the possibility to allow his own organs to be removed for transplantation and b). to liberalize contacts between donor families and recipients when both side agree. For both changes there is enough evidence of their feasibility-necessity. The answers related to contacts between donor families and recipients support the decision of the National Committee for Bioethics on September 27, 2018. Professor Casavola also suggests that contacts should organized and supervised by the ethical committees of the hospitals where the transplantation procedure is accomplished.

KEY WORDS: Laws on transplantation, Laws on transplantation and contemporaneity, Law on end of life care (no. 219, 2017), Law negating the possibility of contacts between donor families and organ recipients (no. 222, 1999)

Il Giornale Italiano di Nefrologia… sei anni dopo

Biagio Raffaele Di Iorio

Editor in Chief
Giornale Italiano di Nefrologia anni 2013 – 2018

Nutritional diet therapy in the management of the patient with Chronic Kidney Disease in advanced phase to delay the beginning and reduce the frequency of dialysis. An option also in the pre-emptive transplant program

Adamasco Cupisti1, Giuliano Brunori2, Biagio Raffaele Di Iorio3, Claudia D’Alessandro1 4, Franca Pasticci4 5, Carmela Cosola6, Vincenzo Bellizzi7, Piergiorgio Bolasco8, Alessandro Capitanini9, Anna Laura Fantuzzi10, Annalisa Gennari4 11, Giorgina Barbara Piccoli12, Giuseppe Quintaliani13, Mario Salomone14, Massimo Sandrini11, Domenico Santoro15, Patrizia Babini16, Enrico Fiaccadori17, Giovanni Gambaro18, Giacomo Garibotto19, Mariacristina Gregorini20, Marcora Mandreoli21, Roberto Minutolo22, Giovanni Cancarini11, Giuseppe Conte22, Francesco Locatelli23, Loreto Gesualdo6

1 Dipartimento di Medicina Clinica e Sperimentale, Università di Pisa, Italia
2 SC Multizonale di Nefrologia e Dialisi, APSS, Trento, Italia
3 UOC di Nefrologia, PO “A. Landolfi”, Solofra (AV), Italia
4 ANDID Associazione Nazionale Dietisti, Verona, Italia
5 Dipartimento di Medicina, USL Umbria 1, Italia
6 Dipartimento dell’Emergenza e dei Trapianti di Organi D.E.T.O. – Sezione di Nefrologia, Dialisi e Trapianti, Università di Bari, Italia
7 Divisione di Nefrologia, Dialisi e Trapianto Azienda Ospedaliera Universitaria “San Giovanni di Dio e Ruggi d’Aragona” Salerno, Italia
8 UOC Territoriale di Nefrologia e Dialisi, ASL Cagliari, Italia
9 SOS Nefrologia Pistoia, ASL Toscana Centro
10 UO Scienza dell’Alimentazione e Dietetica, Nuovo Ospedale S. Agostino-Estense, ASL Modena, Italia
11 UO Nefrologia, ASST Spedali Civili e Università di Brescia, Italia
12 Dipartimento di Scienze Cliniche e Biologiche, Università di Torino, Italia / Centre Hospitalier Le Mans, Le Mans, France
13 Nefrologia e Dialisi, Azienda Ospedaliera di Perugia; Italia
14 Nefrologia e Dialisi, ASL TO5, Chieri (TO), Italia
15 Dipartimento di Medicina Clinica e Sperimentale – UOC di Nefrologia e Dialisi, Università di Messina, Italia
16 ANED Onlus, Milano, Italia
17 Unità di Fisiopatologia Insufficienza Renale, Università di Parma, Italia
18 Dipartimento di Medicina, Università Cattolica del Sacro Cuore, Roma, Italia
19 Università degli Studi di Genova, DIMI and IRCCS AOU San Martino IST, Genova, Italia
20 SC Nefrologia e Dialisi Arcispedale S. Maria Nuova Azienda USL Reggio Emilia, Italia
21 Nefrologia e Dialisi, Ospedale S. Maria Scaletta, Azienda USL Imola, Italia
22 Divisione di Nefrologia, Università della Campania “Luigi Vanvitelli”, Napoli, Italia
23 Nefrologia e Dialisi, Ospedale Manzoni, Lecco, Italia

Con il patrocinio di:
Società Italiana Nefrologia (SIN), Associazione Nazionale Dietisti (ANDID), Associazione Nazionale Emodializzati Dialisi e Trapianti (ANED)

La SIN ringrazia Dr. Shär AG/SPA per contributo non condizionato

La presente pubblicazione rappresenta la versione italiana dell’articolo [ref. 168]  Cupisti A, Brunori G, Di Iorio BR et al. Nutritional treatment of advanced CKD: twenty consensus statements. J Nephrol. 2018 Aug;31(4):457-473

The Italian nephrology has a long tradition and experience in the field of dietetic-nutritional therapy (DNT), which is an important component in the conservative management of the patient suffering from a chronic kidney disease, which precedes and integrates the pharmacological therapies. The objectives of DNT include the maintenance of an optimal nutritional status, the prevention and / or correction of signs, symptoms and complications of chronic renal failure and, possibly, the delay in starting of dialysis.

The DNT includes modulation of protein intake, adequacy of caloric intake, control of sodium and potassium intake, and reduction of phosphorus intake. For all dietary-nutritional therapies, and in particular those aimed at the patient with chronic renal failure, the problem of patient adherence to the dietetic-nutritional scheme is a key element for the success and safety of the DNT and it can be favored by an interdisciplinary and multi-professional approach of information, education, dietary prescription and follow-up. This consensus document, which defines twenty (20) essential points of the nutritional approach to patients with advanced chronic renal failure, has been written, discussed and shared by the Italian nephrologists together with representatives of dietitians (ANDID) and patients (ANED).

Keywords: CKD, Nutritional treatment, diet, dialysis, kidney transplant, chronic renal failure.

Inapparent charges for the assistance to nephropathic patient on dialysis

Giuseppe Quintaliani1, Vincenzo Bellizzi2, Fulvio Fiorini3, Biagio R. Di Iorio4
On behalf of Dialysis and Procedures Study Group#

1 Nefrologo Segretario FIR, Commissione Governo Clinico SIN
2 Divisione di Nefrologia, Dialisi e Trapianto Azienda Ospedaliera Universitaria “San Giovanni di Dio e Ruggi d’Aragona” Salerno, Salerno, Italy
3 Nephrology and Dialysis Unit, “S. M. della Misericordia” Hospital, ASL 18, Rovigo, Italy
4 Nephrology, AORN “A. Cardarelli”, Naples, Italy

# La lista completa dei contributors è in appendice

The increasing technological effectiveness has undoubtedly produced an improvement in clinical parameters of dialysis patients, but this satisfactory therapeutic result did not follow an adequate improvement in mortality or in the perception of quality of life as per patients. Furthermore, dialysis treatment is often associated with “inapparent charges” that reduce the perception of well-being, independently of clinical changes.

Thirty years ago, we carried out a national survey on inapparent charges, which represent frustrating aspects that negatively affect patients’ perception of their quality of life.

Thirty years later, it seemed important for us to repeat the survey to understand if Italian legislative remodeling have introduced changes in procedures and social aspects of dialysis, as preservation of quality of life is an important aspect of the replacement treatment.

Keywords: dialysis, inapparent charges, public and private, geographical areas

Medicina e Nefrologia dai Social Networks

Vincenzo Montinaro1, Emanuela Cataldo2, Francesca Cianciotta2, Giuseppina D’Ettorre2, Alessandro Mascolo2, Silvia Matino2, Adriano Montinaro2, Francesco Paganelli2, Paolo Protopapa2, Marco Taurisano2, Chiara Villani2

1 U.O. Nefrologia e Dialisi, “Pia Fondazione Card. G. Panico”, Tricase (LE)
2 U.O. Nefrologia e Scuola di Specializzazione in Nefrologia, Dipartimento dell’Emergenza e Trapianto di Organi, Azienda Ospedaliero-Universitaria “Consorziale Policlinico” e Università degli Studi “Aldo Moro” di Bari

An alternative proposal for managing morphological examination of urinary sediment and increasing its appropriateness

Cristina Robbiano1, 2, Ilenia Infusino1, Federica Braga1, 2, Alberto Dolci1, Mauro Panteghini1, 2

1UOC Patologia Clinica, ASST Fatebenefratelli-Sacco, Milano
2Dipartimento di Scienze Biomediche e Cliniche ‘Luigi Sacco’, Università degli Studi, Milano

Background. The morphological examination of urinary sediment (MEUS) is traditionally associated with urinalysis (UA), with workload implications and the need for automation of its execution.

Methods. Considering MEUS as a test requiring specialized knowhow and skill for its execution, since 2005 in our laboratory it is performed for inpatients only upon specific request. Eleven years after, we have analyzed the long-term impact of this approach on the provided service. We evaluated results in the 2009-2016 period, in which our hospital did not undergo any change both in the number of beds and in the clinical case-mix.

Results. From 2009 to 2013 an average of 2264 MEUS and 10,204 UA per year were ordered, respectively, with an average ratio of 22.2%. Since 2014, a change on computerized order entry involving MEUS caused a further decrease of its requests (in average, 923 per year), which was not associated to a decrease in UA (in average, 9810 per year) (in average, MEUS/UA 9.4%). MEUS requests came mainly from Paediatrics (47.8%), Nephrology (20.9%) and Rheumatology (18.3%) wards. By filling a satisfaction survey, clinical wards evaluated the provided service as satisfactory, while highlighting some critical issues, mainly referred to preanalytical phase.

Conclusions. The alternative proposal for managing MEUS presented in this paper markedly reduces the number of requests and increases their appropriateness. This is achieved without any negative impact on patient care.

Keywords: Clinical governance, Patient safety, Urinalysis

Microbiological quality of hemodialysis water: what are the risk factors?

Gianmarco Troiano1, Gabriele Messina2, Elisabetta Zanieri3, Valeria Li Donni4, Nicola Nante5, Lea Magistri6, Maria Beatrice Pulci7, Fabrizio Niccolini8

1 Post Graduate School of Public Health, University of Siena, Italy
2Associate Professor, Post Graduate School of Public Health, University of Siena, Italy
3 Public Health Laboratory, Azienda Sanitaria Toscana centro, Florence, Italy
4 Public Health Laboratory , Azienda Sanitaria Toscana centro, Florence, Italy
5 Full Professor, Post Graduate School of Public Health, University of Siena, Italy
6 Director, Hygiene and Health Organization, Hospital “Careggi”, Florence, Italy
7 Nurse, Hygiene and Health organization, Hospital “Careggi”, Florence, Italy
8 Director, Hygiene and Health organization, Hospital “Careggi”, Florence, Italy

Background A dialyzed patient weekly gets in touch with a large amount of water (on average 350 liters) through the dialysis bath. It is therefore essential that this solution would have a high quality and purity. The aim of our study was to monitor the microbiological quality of the hemodialysis water in order to identify possible factors that could affect it.

Methods We conducted a cross-sectional study from January 2015 to October 2017 collecting the dialysis water in AOU Careggi. Samples were aseptically collected by specialized technicians and then transported under ice at 4 ° C to the Laboratory of Biological Hazards of USL Toscana Centro for laboratory analyses.

Results 126 water samples were collected. Coliforms, E. coli, Staphylococcus aureus, enterococci were not detected. Pseudomonas aeruginosa was found in only one sample. Both for CFU at 37 ° C and at 22 ° C, the type of device represented the only statistically significant risk factor (OR 15.21 and OR 10.25 respectively): SDS devices had a significantly higher risk of being positive for CFU at 37 ° C and 22 ° C.

Conclusions As our study demonstrated, the system producing dialysis water must be constantly monitored, especially in cases of SDS devices which may be subjected more frequently to a higher contamination, due to their discontinuous use.


Keywords: surveillance, hemodialysis, infections

Metabolic effects of Cholecalciferol supplementation in kidney stone formers with vitamin D deficiency

Corrado Vitale1, Alberto Tricerri1, Francesca Bermond1, Laura Fabbrini1, Cristina Guiotto2, Martino Marangella 3

1 S.C. Nefrologia e Dialisi, A.O. Ordine Mauriziano di Torino
2 S.C. Laboratorio Analisi Cliniche e Microbiologiche, A.O. Ordine Mauriziano di Torino
3 Fondazione Scientifica Mauriziana ONLUS

Introduction. In this paper we investigated whether cholecalciferol supplementation, prescribed to treat vitamin D deficiency in patients with nephrolithiasis, increased the risk of stone recurrence.

Methods. Calcium excretion and urine supersaturation with calcium oxalate (ßCaOx) and brushite (ßbsh) were evaluated in 33 kidney stone formers (aged 56±17; 12 males), both before and after therapy with cholecalciferol, prescribed as oral bolus of 100.000-200.000 UI, followed by maintenance doses, repeated every week (5.000-10.000 UI) or month (25.000-50.000 UI). During the study, patients followed a dietary regimen which included a daily calcium intake of about 800-1000 mg.

Results. Urinary nitrogen, sodium and ash-acid excretion did not significantly change during the study. After cholecalciferol supplementation, the main results were as follows: both serum calcium and phosphate did not vary significantly; 25(OH)VitD3 increased from 11,8±5,5 to 40,2±12,2 ng/mL (p<0,01); 1,25(OH)2 VitD3 increased from 41,6±17,6 to 54,0±16,0 pg/mL (p<0,01); PTH decreased from 75,0±27,2 to 56,7±21,1 pg/mL (p<0,01); daily urinary calcium increased from 2,7±1,5 to 3,6±1,6 mg/Kg b.w. (p<0,01), whereas fasting urinary calcium did not change significantly. After therapy, ßbsh increased from 0,9±0,7 to 1,3±1,3 (p=0,02) and ßCaOx did not vary significantly. Before cholecalciferol supplementation, 6/33 patients (18.2%) were hypercalciuric, whereas 13/33 patients (39,4%) showed hypercalciuria after supplementation (pX2=0,03).

Conclusions. Cholecalciferol supplementation for vitamin D deficiency may increase both urinary calcium and urine supersaturation in stone formers. If vitamin D supplements are needed in these patients, a careful monitoring of urine metabolic profile is warranted, in order to customize the metaphylaxis accordingly (hydration, potassium citrate, thiazides).


Keywords: Vitamin D deficiency, Cholecalciferol, Nephrolithiasis, Urolithiasis, Hypercalciuria

Challenges and results of the PIRP project (Prevenzione della Insufficienza Renale Progressiva) of the Emilia-Romagna Region

Antonio Santoro1, Dino Gibertoni2, Paola Rucci2, Elena Mancini1, Decenzio Bonucchi3, Andrea Buscaroli4, Anselmo Campagna5 Gianni Cappelli6, Salvatore David7, Maria Cristina Gregorini8, Gaetano La Manna9, Giovanni Mosconi10, Angelo Rigotti11, Roberto Scarpioni12, Alda Storari13, Marcora Mandreoli14

1 UO Nefrologia, Dialisi e Ipertensione, Policlinico S.Orsola-Malpighi, Bologna, Italia
2 Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Italia
3 SSD di Nefrologia e Dialisi, Ospedale Ramazzini, Carpi, Italia
4 UO Nefrologia e Dialisi, Ospedale S. Maria delle Croci, Ravenna, Italia
5 Assessorato alle Politiche della Salute, Regione Emilia-Romagna
6 UO Nefrologia e Dialisi, Ospedale Universitario di Modena, Italia
7 UO Nefrologia e Dialisi, Ospedale Maggiore, Parma, Italia
8 UO Nefrologia e Dialisi, Arcispedale S. Maria Nuova, Reggio Emilia, Italia
9 UO Nefrologia, Dialisi e Trapianto, Policlinico S.Orsola-Malpighi, Bologna Italia
10 UO Nefrologia e Dialisi, Ospedale Morgagni-Pierantoni, Forlì e Ospedale M.Bufalini, Cesena, Italia
11 UO Nefrologia e Dialisi, Ospedale degli Infermi, Rimini, Italia
12 UO Nefrologia e Dialisi, Ospedale “Guglielmo da Saliceto”, Piacenza, Italia
13 UO Nefrologia e Dialisi, Arcispedale S. Anna, Ferrara, Italia
14 UO Nefrologia e Dialisi, Ospedale S. Maria della Scaletta, Imola, Italia

The PIRP project was conceived in 2004; with the aim to face the increased prevalence of chronic kidney disease (CKD) associated with the aging and increased survival of the population. The first phase of the project consisted of training primary care physicians to identify people at risk of CKD and to implement intervention strategies that proved to be effective in preventing CKD it or delaying its progression once it is established. In the second phase of the project, dedicated ambulatories were opened in the nephrology units of Emilia-Romagna hospitals to provide an in-depth assessment and personalized care to CKD patients, following them up until renal failure or death or referring them back to general practitioners, according to the study protocol. A web-based registry was implemented to collect demographic and clinical data on PIRP patients. As of 30 June 2018, the registry included 26.211 CKD patients, with a median follow-up of 24.5 months. Over the 14 years of the PIRP the mean age of incident patients increased from 71.0 years to 74.2 years and the mean eGFR increased from 30.56 to 36.52 mL/min/1.73 m2, proving that the project was successful in recruiting older patients with a better renal function. At 5 years, the percentage of patients still active in the project was >45%.The implementation of the project has seen a reduction in the number of patients arriving every year to the dialysis treatment in E-R (about 100 units less from 2006 to 2016). The PIRP cohort is the largest in Italy and in Europe, which makes it ideal for research based on international comparisons and as a model for national registries.

Keywords: Renal insufficiency, CKD, GP, GFR, Proteinuria, Public Health Intervention

A case of severe metformin-associated lactic acidosis treated with CVVHDF and regional anticoagulation with sodium citrate

Matteo Ferrario, Antonio Apicella, Mauro Della Morte, Enrico Beretta

Unit of Anesthesia and Intensive Care, ASST Valtellina e Alto Lario, Ospedale E. Morelli, Sondalo, Italy.

Metformin is an antidiabetic drug; used to treat type II diabetes mellitus, metformin associated lactic acidosis has an incidence of 2-9 cases / 100,000 patients / year with high mortality (30%). We have had the case of a 75-year-old woman with metabolic acidosis as a result of metformin assumption, treated by renal replacement therapy (CRRT) with continuous veno-venous hemodiafiltration (CVVHDF). Results: after a short treatment period there was a reduction in Lactates (from 16.8 mmol/L to 12.6 mmol/L) and a progressive improvement of acidosis. In 72 hours the recovery of diuresis and subsequent suspension of CRRT was achieved. Conclusion: CRRT, in addition to ensuring support for renal failure and volume correction, allowed a rapid recovery from metformin-associated lactic acidosis.

Keywords: metformin, lactic acidosis, CRRT, CVVHDF.

Encrusted Pyelitis during a case of Thrombotic Thrombocytopenic Purpura

Michele Vergura1, Illuminato Carosi3, Giulia Ercolino2, Diego Palladino2, Michele Prencipe1, Antonio Scarlatella1 e  Filippo Aucella1

1 SC Nefrologia e Dialisi, IRCCS “Casa Sollievo della Sofferenza” San Giovanni Rotondo, Italia
2 SC Radiologia Diagnostica, IRCCS “Casa Sollievo della Sofferenza” San Giovanni Rotondo, Italia
3 SC Anatomia Patologica, IRCCS “Casa Sollievo della Sofferenza” San Giovanni Rotondo, Italia

Encrusted pyelitis is a chronic urinary tract infection associated with mucosal encrustation induced by urea splitting bacteria. More than 40 bacteria have been implicated but the most frequent is Corynebacterium group D2. Predisposing factors are debilitating chronic diseases and preexisting urological procedures. Immunosoppression is an important cofactor. For these reasons the disease is almost always nosocomially acquired and renal transplant recipients are at particular risk. The symptoms are not specific and long lasting: dysuria, flank pain and gross haematuria are the most frequent; fever is present in two-thirds. The demonstration of urine splitting bacteria in constantly alkaline urines and radiological evidence of extensive calcification of pelvicalyceal system, ureter and bladder at US or CT scan in a clinical context of predisposing factors are the mainstay of diagnosis. Treatment is based on adapted antibiotic therapy, acidification of urine and excision of plaques of calcified encrustation. The prognosis relies on timing of diagnosis; delay can be detrimental and result in patient’s death and graft loss. We describe a unique case of 69-year-old man with two contemporary diseases: autoimmune thrombotic thrombocytopenic purpura and encrusted pyelitis with a fatal evolution.

Keywords: encrusted pyelitis, thrombotic thrombocytopenic purpura, urea-splitting bacteria, encrustations, computed tomography

PD in Italy: the 5th GSDP-SIN Census 2014

Giancarlo Marinangeli1, Loris Neri2, Giusto Viglino3, Anna Rachele Rocca4, Alessandro Laudon5, Antonio Ragusa6, Gianfranca Cabiddu7. On behalf of Peritoneal Dialysis Study Group of Italian Society of Nephrology

1 Nefrologia e Dialisi, Ospedale Maria SS dello Splendore, Giulianova, Teramo, Italy.
2 Nefrologia e Dialisi, Ospedale San Lazzaro, Via Pierino Belli 26, Alba, Cuneo, Italy.
3 Nefrologia e Dialisi, Ospedale San Lazzaro, Via Pierino Belli 26, Alba, Cuneo, Italy.
4 Nefrologia e Dialisi, Policlinico Umberto I, Roma, Italy.
5 Nefrologia e Dialisi, Azienda Provinciale Servizi Sanitari, Trento, Italy.
6 Nefrologia e Dialisi, Ospedale San Vincenzo, Taormina, Italy.
7 Nefrologia e Dialisi, Azienda Ospedaliera Brotzu, Cagliari, Italy.


To know PD modalities and results in Italy.


The Census was carried out by means of an on-line questionnaire in ALL the 225 non-pediatric public centers which PERFORMED PD in 2014. The results were compared with those of previous Censuses (2005:Cs-05; 2008:Cs-08; 2010:Cs-10; 2012:Cs-12).


Incidence. In 2014 PD was begun (first treatment for ESRD) by 1,652 pts (CAPD: 57.2%) and HD by 4,442 pts (%PD-incidence= Cs-14: 27,1%; Cs-12: 23.4%; Cs-10: 23.3%; Cs-08: 22.8%; Cs-05: 24.2%). For the first time Incremental PD does not increase (Cs-14: 27,5%; Cs-12: 28,8%; Cs-10: 22,8%; Cs-08: 18,3%; Cs-05: 11,9%).

Prevalence. At 31/12/2014 there were 4,480 patients on PD (CAPD: 46.9%) (%PD-prevalence= Cs-14: Cs-12: 17.1%; Cs-10: 16.6%; Cs-08: 16.7%; Cs-05:16.8%; p=NS), 24.3% of whom were on assisted PD (family members: 83.6%; paid caregivers: 11.5%; nurses: 1.1%; NH: 2.8%).

Out. In 2014 there was no change in the PD drop-out rate (32.0 ep/100yrs-pt) (death: 502; transplant: 329; switch to HD: 528 pts). The main reason for transferring to HD remained peritonitis (24.8%). Choice (9.3%) and impossibility to continue PD (15.2%) are increasing.

Peritonitis. The peritonitis rate (953 episodes) was 0.224 ep/yrs-pt. The incidence of new cases of EPS in 2013-14 (39 cases=0.444 ep/100yrs-pt) is decreasing (2011-12= 0.505; 2009-10= 0.529; 2004-08= 0.701 ep/100-yrs-pt).

Other results. Compared to 2012, in 2014 the number of Centers using 3.86% for PET increased (41.3%) (Cs-12: 30.8%; Cs-10: 15.6%; p<0.001), while the number carrying out home visits (59.6%) remained unchanged (56.3% in 2012, 59.4% in 2010). CONCLUSIONS

Cs-14 confirms the extensive use, stability and good results of PD in Italy. Incremental PD and assisted PD are unchanged, peritonitis are decreased and EPS remains a rare event. PET-3.86% is increasingly used.

Keywords: Peritoneal Dialysis, Technique failure, Incremental peritoneal dialysis, assisted PD, peritonitis, home visit, PET (peritoneal equilibration test)

A case of Anderson-Fabry disease: a multidisciplinary approach for diagnosis and follow up

Zito Anna1, De Pascalis Antonio1, Armeni Annarita1, Ria Paolo1, Barbarini Leonardo2, Caggiula Marcella2, My Filomena2, Barbarini Silvia3, Trianni Giorgio2, Napoli Marcello1

1Unità Operativa Nefrologia e Dialisi, Ospedale “Vito Fazzi”, Lecce
2Unità Operativa Neurologia, Ospedale “Vito Fazzi”, Lecce
3Unità Operativa Nefrologia e dialisi, Fond. Pol. A. Gemelli, Roma

Fabry disease (also known as Anderson-Fabry disease, angiocheratoma corporis diffusum, diffuse angiocheratoma) is a rare tesaurismosis linked to the deficiency of the lysosomal enzyme alpha-galactosidase A, required for the physiological catabolism of glycosphingolipids.

The related clinical signs show a multisystemic feature and define a degenerative and disabling pathology, whose approach requires a close multidisciplinary specialist collaboration.

Currently, the renewed interest in the disease is aimed at the need to provide an early diagnosis, in order to early begin the enzyme replacement therapy and to slow down or avoid the establishment of irreparable organ damage. For this reason, the diagnostic suspicion becomes crucial and arises from the careful observation and research of the symptoms, together with the anamnesis and the overall clinical evaluation of the patient.

Keywords: Fabry disease, alpha-galactosidase, sphingolipids, enzymatic replacement therapy

Hyperkalemia treatment in chronic kidney disease patients: overview on new K binders and possible therapeutic approaches

Toni De Stefano, Silvio Borrelli, Carlo Garofalo, Michele Provenzano, Luca De Nicola, Roberto Minutolo, Giuseppe Conte

Affiliazione: Cattedra di Nefrologia-Università degli studi della Campania “Luigi Vanvitelli”; P.O. S.M.d.P. Incurabili, Napoli

Hyperkalaemia is a common complication in patients with nondialysis Chronic Kidney Disease (CKD). It is associated with weakness, paralysis, arrhythmias and increased mortality. Higher serum potassium levels refractory to treatment is one of the most frequent reasons to initiate immediately renal replacement treatment in advanced stages of CKD. Hyperkalaemia is also indirectly associated with the progression of CKD; in fact higher serum potassium levels may lead to withdrawal of renin-angiotensin-system inhibiting drugs that currently represent the most effective tools to postpone ESRD. It is therefore essential to identify patients at higher risk of increase of serum K and to implement therapeutic interventions aimed at preventing and treating hyperkalaemia, such as diet modifications and greater use of diuretics and potassium binders. Sodium and calcium-polystyrenesulfonate (SPS) are the resins currently available in Italy. However, few studies showed that SPS is efficacious to reduce serum K and is associated with increased risk of severe adverse effects. Patiromer and ZS-9 represent a significant pharmacological progress in the treatment of hyperkalemia. Indeed, recent studies showed that these novel binders are efficient to reduce serum levels of K with minor occurrence of side effects than polystyrensulfonates. Furthermore, Patiromer, sodium free agent, might have a further advantage in CKD patients, reducing the salt intake in these patients. In addition, ZS-9, being fast-acting drug, might be used also in the treatment of acute hyperkalaemia.

Keywords: Hyperkalaemia, L binder, SPS, CPS, Patiromer, ZS-9

Hyperphosphatemia in dialysis: which binder?

Carlo Alfieri1, Fabio Malberti2, Sandro Mazzaferro3, Maurizio Gallieni4, Domenico Russo5, Piergiorgio Messa1, Mario Cozzolino6

1 Fondazione IRCCS Ca’ Granda – Ospedale Maggiore Policlinico Milano & Università degli Studi di Milano
2 Divisione di Nefrologia e Dialisi, ASST Cremona
3 Sapienza Università di Roma & Ospedale Policlinico Umberto I
4 Presidio Ospedaliero San Carlo Borromeo, ASST Santi Paolo e Carlo, Milano & Università degli Studi di Milano
5 Dipartimento di Sanità Pubblica Università degli Studi Federico II. Napoli
6 Presidio Ospedaliero San Paolo, ASST Santi Paolo e Carlo, Milano & Università degli Studi di Milano

Several studies have evidenced the association between high serum phosphorus concentrations and adverse events especially in patients on dialysis.

Recent K-DIGO guidelines suggest lowering elevated phosphate levels toward the normal range. This goal should be achieved by combining dietary counseling, optimizing dialysis procedures and prescribing phosphate binders.

Despite the availability of several binders, the “ideal” phosphate binder that combines high efficacy, low pills burden, minimal side effects and low cost is still not available.
In clinical practice it is crucial to reach a high patient’s compliance to therapy. The pill burden is the most relevant factor contributing to low compliance. This is the case of phosphate binder therapy that represents almost 50% of total pills prescribed to patients on dialysis.
It has been evidenced an association between pills of phosphate binder and poor control of phosphorus and PTH.
In recent years sucroferric oxyhydroxide is available as a new phosphate binder. Its
peculiarity is an high phosphate binding capability that requires prescription of low number of pills per day. This characteristic has been confirmed by several randomized controlled trials. These trials have also evidenced that sucroferric oxyhydroxide may cause some gastrointestinal side effects. There is an ongoing study to confirm in “the real world” the incidence of side effects reported by controlled trials.

Key words: Phosphate; Binder; Secondary Hyperparathyroidism

Direct-acting antiviral agents, hepatitis C and dialysis: an update

Fabrizio Fabrizi1, Pietro Lampertico2, Piergiorgio Messa3

1Divisione Nefrologia, Ospedale Maggiore e Fondazione IRCCS, Milano, Italia
2 Divisione Gastroenterologia, Ospedale Maggiore e Fondazione IRCCS, e Università degli Studi di Milano, Italia
3 Divisione Nefrologia, Ospedale Maggiore e Fondazione IRCCS, e Università degli Studi di Milano, Italia

Hepatitis C virus infection is still common among patients with chronic kidney disease, particularly within Dialysis Units all over the world. Although the full extent of HCV transmission in dialysis units is unknown, outbreaks of HCV infection continue to occur all over the world. Evidence has been accumulated in the last decade suggesting that HCV plays consistent activity at hepatic and extra-hepatic level. A recent systematic review of the medical literature with a meta-analysis of clinical studies retrieved 15 longitudinal studies (n=2,299,134 patients); we found a significant relationship between anti-HCV positive serologic status and higher frequency of CKD; the summary estimate for adjusted hazard risk with HCV across the surveys, 1.54 (95% CI, 1.26; 1.87) (P<0.0001). The advent of direct-acting antiviral agents has revolutionized the therapy of HCV, including patients with advanced chronic kidney disease. Two regimens based on DAAs have been recently approved for the antiviral therapy of HCV in patients with CKD stage 4/5: elbasvir/grazoprevir and glecaprevir/pibrentasvir. Such regimens have been provided with high efficacy and safety, according to the results given by C-SURFER and EXPEDITION-4, respectively. Sofosbuvir, a non-structural 5B polymerase inhibitor, is the backbone of many anti-HCV drug regimens, and has significant renal excretion. As a result, the use of sofosbuvir is not recommended in patients with an eGFR <30 mL/min/1.73m2. In summary, recent studies have shown that several combinations of DAAs are currently available for CKD patients, including those with CKD stage 4/5. These drugs have reported high efficacy and satisfactory tolerability, regardless of HCV genotype or renal impairment. We need to improve the screening for HCV and the access to DAAs in patients with CKD stage 4/5.


Keywords: Chronic kidney disease; Dialysis; Direct-acting antiviral agents; Hepatitis C; Sustained virological response

Medicina e Nefrologia dai Social Networks

Vincenzo Montinaro1, Emanuela Cataldo2, Bianca Covella2, Giuseppina D’Ettorre2, Vincenzo Di Leo2, Marco Fiorentino2,3, Pasquale Gallo2, Anna Mudoni1, Adriano Montinaro2, Marco Taurisano2

1 U.O. Nefrologia e Dialisi, “Pia Fondazione Card. G. Panico”, Tricase (LE)
2 U.O. Nefrologia e Scuola di Specializzazione in Nefrologia, Dipartimento dell’Emergenza e Trapianto di Organi, Azienda Ospedaliero-Universitaria “Consorziale Policlinico” e Università degli Studi “Aldo Moro” di Bari
3 Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh PA

Privacy by Design in GDPR

Filippo Lorè

Università degli Studi di Bari

Proactive approach for the patient safety in the extracorporeal blood purification treatments in nephrology

Federico Nalesso1, Francesco Garzotto 2,3, Barbara Rossi 1, Leda Cattarin1, Francesca Simioni1, Giovanni Carretta4, Giuliano Brunori 5, Giovanni Gambaro6, Lorenzo A Calò 1

1 Dipartimento di Medicina, UOC Nefrologia 2, Università di Padova, Azienda Ospedaliera di Padova
2 Unità di Biostatistica, Epidemiologia e Salute pubblica, Dipartimento di Scienze Toraciche e Cardiovascolari, Università di Padova
3 UOC Health Technology Assessment, Regione Veneto, Azienda Zero, Padova
4 Direzione Medica, Azienda Ospedaliera di Padova
5 UOC di Nefrologia, Azienda Provinciale per i Servizi Sanitari, Provincia Autonoma di Trento, Trento
6 Division of Nephrology and Dialysis, Columbus-Gemelli University Hospital, Catholic University, School of  Medicine, Rome, Italy

Latent, systemic, organizational and clinical errors may impend on a single clinical reality that is considered safe. These errors may lead to the occurrence of a critical event with possible damage to the patient. The patients’ greater clinical complexity, in the field of AKI or CKD, requires a multidisciplinary approach that involves nephrologists and other specialists in the diagnostic-therapeutic-rehabilitative path requiring the administration of personalized extracorporeal blood purification treatments. In consideration of the comorbidities of these patients, and their increasing management complexity, the Patient Safety becomes a priority objective in these therapeutic pathways.  For all caregivers, it is therefore necessary to be able to acquire a series of tools suitable for the analysis of the clinical risk present in each individual nephrological realities in order to introduce a series of measures and tools for the analysis and prevention of possible errors that can determine an event. The aim of this paper is to introduce the problem of patient safety in the extracorporeal blood purification treatments for the initial analysis of local clinical risks, and the prevention of errors in the clinical practice in nephrology by introducing specific procedures and check lists. This work is addressed to all the caregivers involved in the Nephrology care.

Key words: patient safety, extracorporeal blood purification, event, error, check list, procedure.

mTOR inhibitors in kidney transplantation

Barbara Bonino, Ernesto Paoletti, Luigina Marsano, Antonella Sofia, Fabio Massarino, Abitha Murugavel, Diego Bellino, Daniela Verzola, Rodolfo Russo, Giacomo Garibotto

Clinica Nefrologica, Dialisi, Trapianto, Università di Genova e Ospedale Policlinico San Martino, Genova

A changing paradigm of treatment of kidney transplant recipients is a new, wider approach to immunosuppression, which should take into account both antiviral and anticancer effects, in addition to cardiovascular protection. Recent observations suggest that the early introduction of mammalian target of rapamycin inhibitors (mTORi) in association with low dose CNI may offer many of these effects. The present manuscript summarizes benefits and contraindications of combinations with mTORi in kidney transplant immunosuppressive strategies.

Key words: kidney transplantation, mTOR inhibitors, immunosuppressive therapy

Recensione “L’essere è colui che dà, dalla sua donazione vive chi riceve”, autore Battista Catania

Biagio Di Iorio

Editor in Chief del Giornale Italiano di Nefrologia

Minimal Change Relapse During Pregnancy

Fulvia Zanchelli, Elisabetta Isola, Lara Cicciarella, Romina Graziani, Mattia Monti, Davide Martelli, Elena Tampieri, Andrea Buscaroli

AUSL della Romagna – U.O. Nefrologia e Dialisi, Ospedale Santa Maria delle Croci, Ravenna, Italia

The appearance of nephrotic syndrome during pregnancy is considered an exceptional event, whose incidence is around 0.012-0.025% of all pregnancies, and it is even more rare when the cause is represented by minimal lesions glomerulonephritis. In this article we will describe the case of a patient with a histological diagnosis of glomerulonephritis with minimal lesions, tending to frequent relapses. She was in complete remission since 2013 after treatment with cyclosporine. suspended in May 2017. After few weeks she become pregnant, and the pregnancy was regular until the 23rd week. when a recurrence of nephrotic syndrome appears. She was treated with steroids bolus followed by oral steroid, and afterwards gave birth to a live fetus with spontaneous delivery at 37 weeksThe few data in the literature confirm that recurrence of glomerulonephritis due to minimal lesions in pregnancy should be treated rapidly with steroids, that can induce rapid remission and protect both the pregnant than the fetus from even serious damage.

Keywords: Minimal change nephropathy, pregnancy, nephrotic syndrome, steroid.

Between old and new targets: blood pressure control in hypertensive outpatients

Antonio Del Giudice1, Andrea Fontana2, Antonio Cicchella1, Claudio Carmine Guida1, Antonio Gesuete1, Rachele Grifa1, Antonio Mangiacotti1, Filomena Miscio1, Matteo Piemontese1, Michele Prencipe1, Michele Vergura1, Massimiliano Copetti2, Filippo Aucella1

1Dipartimento di Scienze Mediche, Struttura Complessa di Nefrologia e Dialisi e Centro per l’Ipertensione Arteriosa, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italia
2Unità di Biostatistica, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italia

Objective. In developed countries, blood pressure (BP) control has increased over the past few decades and is now approaching 70% of patients. Herewith we report the results of a cross-sectional study carried out on hypertensive outpatients.

Design and methods. In a cohort of 1,412 consecutive hypertensive outpatients (790 females, 622 males; mean age: 60.3±12.2 years) evaluated from January 2015 to December 2016, the following parameters were assessed: age, gender, body mass index (BMI), waist circumference (WC), smoking habits, BP in the sitting position, estimated glomerular filtration rate (eGFR), serum glucose, lipid profile, antihypertensive drugs prescribed. In agreement with the European guidelines, hypertension was defined as sitting BP ≥140/90 mmHg or use of antihypertensive drugs. Patients whose BP was <140/90 mmHg were considered as having achieved BP control. Furthermore, in compliance with the redefinition of hypertension suggested by the American College of Cardiology/American Heart Association (ACC/AHA), a second level of BP control (BP <130/80 mmHg) was evaluated.

Results. Overall, 75.7% of hypertensive patients achieved BP levels <140/90 mmHg, while 50.5% achieved BP levels <130/80 mmHg. In both contexts, compared with patients whose BP was not controlled, those achieving the BP targets were mainly younger and females with a lower prevalence of obesity, diabetes and chronic kidney disease. Furthermore, they also had a lower WC and a higher eGFR.

Conclusions. Nearly 76% of patients achieved the BP target of <140/90 mmHg, a result which is higher than the 70% achieved in Europe, and 50.6% achieved that of <130/80 mmHg, a result which is slightly higher than the 47% recently reported in USA.

Keywords: Blood pressure, blood pressure control, hypertension.

Posterior Reversible Encephalopathy Syndrome (PRES) induced by Rituximab in two patients with vasculitis, and treated by hemodialysis

Simone Vincenzo Saverio Verdesca1, Chiara Villani1, Michele Rossini2, Carlo Manno2, Loreto Gesualdo2, Vincenzo Montinaro2

1Scuola di specializzazione in Nefrologia, Università degli Studi “Aldo Moro” di Bari, Azienda Ospedaliero-Universitaria Policlinico-Bari
2U.O. Nefrologia Universitaria, Azienda Ospedaliero-Universitaria Policlinico e Università degli Studi “Aldo Moro” di Bari

Small and medium vessel vasculitides, either ANCA-associated or caused by anti-GBM antibodies, are multisystemic diseases with predominantly renal involvement that often require dialysis support; clinical remission can be induced with immunosuppressive therapies including apheretic treatments, high doses of steroids, and immune suppressants. In addition to the complications resulting from the primary pathological process, those associated with the immunosuppressive therapies are not negligible.

Reversible Posterior Encephalopathy Syndrome (PRES) is a clinical condition with a hyperacute onset, which can complicate the evolution of vasculitides while treated by immunosuppressive therapy. Relevant pathogenic factors are represented by alterations of the cerebral blood-brain barrier or vasogenic and/or brain edema phenomena, also related to uncontrolled hypertension.

We describe two cases of patients with systemic vasculitides, rapidly progressive renal failure (RPGN) requiring dialysis, and poor response to the initial immunosuppressive therapy who were treated subsequently with rituximab. PRES developed immediately after administration of the drug, which, however resulted effective on the course of the vasculitis in one case and not effective in the other.

In both cases, the subsequent radiological controls showed a total resolution of the encephalic alterations observed during the acute phase.

Keywords: PRES, Rituximab, ANCA-associated vasculitis, Anti-GBM Glomerulonephritis, Iatrogenic complications.

Management of the incidental renal masses

Anna Mudoni1, Marina Cornacchiari2, Amelia Liccardo3, Pierpaolo Di Nicolo’4, Luca Di Lullo5, Carlo Guastoni2, Marco Mereghetti6

1 Unità Operativa di Nefrologia e Dialisi Ospedale Cardinale G Panico Tricase (LE)
2 Unità Operativa di Nefrologia, ASST MILANO OVEST
3 Unità Operativa di Nefrologia e Dialisi Multimedica Presidio di Castellanza (VA)
4 Unità Operativa di Nefrologia e Dialisi S. Maria della Scaletta, Imola-Bologna
5 Unità Operativa Complessa di Nefrologia e Dialisi, Ospedale “L. Parodi – Delfino”, Colleferro (RM)
6 Unità Operativa di Medicina, ASST MILANO OVEST

The diagnosis of renal masses has increased in the last decades owing to the widespread use of imaging (ultrasound, computed tomography and magnetic resonance).

Majority of the renal masses are detected incidentally on routine ultrasound examination.

Solid masses detected on ultrasound require further imaging evaluation with CT and/or MRI for suitable characterization. US-guided renal biopsy is a safe, effective and accurate method for evaluating the small renal masses with ambiguous radiologic findings.

Navigation technology and multimodality image fusion represent an important development in interventional radiology, especially for performing difficult percutaneous biopsies and ablations of small renal masses.

Multidisciplinary approach is required which results from experience and knowledge and in hard cases the use of serial imaging can be helpful.


Keywords: renal masses, imaging, ultrasound, renal biopsy, active surveillance

Possible role of Lercanidipine in Chiloperitoneum occurrence in CAPD: a case-report

Ramona Nicotera, Salvatore Chiarella, Giordano Placida, Luciano De Paola, Giuseppina D’Onofrio, Maria Teresa Panzino, Antonio Panzino, Salvatore Mileti, Angela Rosa Pinciaroli, Giuseppe Coppolino

Nephrology and Dialysis Unit, “Pugliese-Ciaccio” Hospital of Catanzaro, Italy

Chylous ascites is rarely observed in patients undergoing peritoneal dialysis Here, we present the occurrence of chyloperitoneum in a peritoneal dialysis patient disappeared immediately after discontinuation of calcium-antagonist.

Keywords: chyloperitoneum, calcium-antagonist, Chylous ascites

Recurrent Kidney Stones in a patient with Malabsorption Syndrome

Matteo Bargagli, Pierluigi Fulignati, Silvia D’Alonzo, Alessandro Naticchia, Diego Galli, Pietro Manuel Ferraro

Nefrologia, Fondazione Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore (Roma)

Enteric hyperoxaluria is one of the most frequent complications of bariatric surgery. In this setting the prevalence of kidney stones is increased. Currently the treatment of enteric hyperoxaluria is based not only on the reduction of urinary oxalate but even controlling other lithogenic risk factors, like urinary volume and urinary citrate levels.

This case report suggests a possible benefit using magnesium citrate in addition to calcium supplementation, in the treatment of hyperoxaluria caused by enteric malabsorption.


Keywords: kidney stones, hyperoxaluria, magnesium citrate

Practical approach to patient therapy affected by Autosomal Dominant Autosomic Polycystic Kidney Disease

Ciro Esposito, Vincenzo La Milia, Claudia Altobelli, Roberta Cerutti, Paolo Manunta, Nadia Dallera, Giovanni Piscopo, Riccardo Magistroni8

1 Nefrologia e Dialisi, ICS Maugeri S.p.A. SB, Università di Pavia, Pavia, Italia
2 Nefrologia e Dialisi, Ospedale di Lecco, Italia
3 Università degli Studi della Campania “Luigi Vanvitelli”, U.O.C. di Nefrologia e Dialisi, Napoli, Italia
4 Nefrologia e Dialisi della Fondazione IRCCS Policlinico, Mangiagalli, Regina Elena, Milano, Italia
5 Università Vita Salute San Raffaele, Istituto Scientifico San Raffale, Milano, Italia
6 Nefrologia e Dialisi, Presidio Ospedaliero Montichiari, Brescia, Italia
7 Azienda Ospedaliero-Universitaria “Consorziale Policlinico” e Università degli Studi “Aldo Moro” di Bari
8 Divisione di Nefrologia, Dialisi Azienda Ospedaliero Universitaria Policlinico di Modena, Dipartimento Chirurgico, Medico, Odontoiatrico e di Scienze Morfologiche con Interesse Trapiantologico, Oncologico e di Medicina Rigenerativa. Università di Modena e Reggio Emilia, Modena, Italia
ǂ Questi autori hanno contribuito in pari misura al manoscritto

The Autosomal Dominant Polycystic Kidney Disease(ADPKD) is the most frequent renal genetic condition and involves 7 to 10% of subjects undergoing renal replacement therapy. It is estimated that between 24,000 and 34,000 subjects in Italy are affected by this condition. For an illness that has long been neglected due to a lack of treatment options, an attractive treatment possibility is now available: tolvaptan has shown clinical efficacy regarding disease progression in two clinical trials (ADPKD patients with mild renal failure and ADPKD patients with advanced renal failure). The possible liver toxicity expressed in about 4% of the subjects exposed to the drug and an important aquaretic effect suggest prudence and attention in the use of this new molecule. Based on these critical points, some clinicians with direct experience in the use of the drug have briefly collected in the pages to follow the main clinical recommendations for the treatment of ADPKD patients. The recommendations concern the general approach to the patient affected by ADPKD but with particular attention to the aspects related to the new treatment. The delicate task of introducing the opportunities and limitations of the offered therapy to the patient will be deepened. Finally, the document wants to suggest how best to organize a clinic dedicated to this condition.

Keywords: Autosomal Dominant Polycystic Kidney Disease, Renal failure, Cyst, Aneurysm, tolvaptan

Esposizione al Comitato Nazionale di Bioetica

Reg Green

The Nicholas Green Foundation,
Los Angeles, USA
Email: rfdgreen@gmail com –

Identification of a new mutation of the NPHP1 gene

Antonella La Russa1, Rosa Anna Cifarelli2, Anna Perri1, Angelo Saracino3, Giovanni Santarsia3 e Renzo Bonofiglio1

1Centro di Ricerca “Rene e Trapianto” UOC Nefrologia e Dialisi abilitata al Trapianto, AO Cosenza, Italia
2Fondazione Basilicata – Ricerca Biomedica, Madonna delle Grazie, Matera, Italia
3Unità Operativa Complessa “Nefrologia Dialisi e CRT-Centro Regionale Trapianti”, Matera, Italia

Kidney cystic diseases are inherited disorders causing chronic renal failure. According to the genetic defect they are classified as diseases of the primary ciliary complex and uromodulin-associated diseases. Mutations in genes coding for ciliary proteins are the basis of a broad category of genetic diseases, called ciliopathies. To date, three important ciliopathies are known: the autosomal dominant form and the recessive shape of the polycystic kidney and the nephronophthisis (NPHP).

Juvenile Nephronophthisis (NPHP) is a progressive renal tubulo-interstitial disorder with a form of autosomal recessive inheritance that progresses inexorably towards terminal renal failure. Three different forms have been distinguished: juvenile (NPH1), infantile (NPH2) and adolescent (NPH3). Juvenile Nephronophthisis or nephronophthisis type 1 (NPH1), is the most frequent form. In most patients with a suspected diagnosis of NPHP, based primarily on clinical and radiological data, the deletion in homozygous NPHP1 is present in 20-40% of cases. Heterozygous deletions are found in 6% of patients, with concomitant mutation of the NPHP1 gene on the second allele.

In this study we subjected to genetic screening 6 patients with suspected NPHP causing chronic renal failure, belonging to 6 families. The genetic screening identified in 2/6 patients a deletion of exons 5-7-20 and in 4/6 patients an heterozygous deletion of exon 20 and an  heterozygous deletion on exon 17 not yet described in literature.

Our results suggest that genetic screening should be included in the diagnostic procedure of patients with suspected nephronophthisis and that it may be used alternatively to  renal biopsy.

Keywords: Nephronophthisis, NPHP1 gene, Ciliopathies.


Vincenzo Montinaro1, Francesca Cianciotta2, Vincenza Colucci2, Giuseppina D’Ettorre2, Pasquale Gallo2, Marica Giliberti2, Enrica Gintoli2, Silvia Matino2, Umberto Mercurio2, Adriano Montinaro2, Chiara Villani2

1 U.O. Nefrologia e Dialisi, “Pia Fondazione Card. G. Panico”, Tricase (LE)
2 U.O. Nefrologia e Scuola di Specializzazione in Nefrologia, Dipartimento dell’Emergenza e Trapianto di Organi, Azienda Ospedaliero-Universitaria “Consorziale Policlinico” e Università degli Studi “Aldo Moro” di Bari

Waiting for General Data Protection Regulation

Filippo Lorè

Università degli Studi di Bari

Renal Infarction: multicentric cases in Piedmont

Daria Motta1, Andrea Airoldi2, Serena Bainotti3, Manuel Burdese4, Andrea Campo5, Luigia Costantini6, Raffaella Cravero7, Paola Mesiano8, Giorgina B. Piccoli9, Olga Randone10, Andrea Serra11,  Patrizia Vio12, Roberto Boero1. Gruppo Piemontese di Nefrologia Clinica

S.C. Nefrologia e Dialisi, Ospedali:
1 Martini Torino,
2 Novara,
3 S. Croce e Carle Cuneo,
4 Città della Salute e della Scienza,
5 Alba,
6 Vercelli,
7 Biella,
8 San Giovanni Bosco Torino,
9 San Luigi Orbassano,
10 Asti,
11 Ciriè,
12 Verbania

We describe factors associated to renal infarction, clinical, instrumental and laboratoristic features, and therapeutic strategies too.

This is an observational, review and polycentric study of cases in Nephrologic Units in Piedmont during 2013-2015, with diagnosis of renal infarction by Computed Tomography Angiography (CTA).

We collected 48 cases (25 M, age 57±16i; 23 F age 70±18, p = 0.007), subdivided in 3 groups based on etiology: group 1: cardio-embolic (n=19) ; group 2: coagulation abnormalities (n= 9); group 3: other causes or idiopathic (n=20).

Median time from symptoms to diagnosis, known only in 38 cases, was 2 days (range 2 hours- 8 days). Symptoms of clinical presentation were: fever (67%), arterial hypertension (58%), abdominal o lumbar pain (54%), nausea/vomiting (58%), neurological symptoms (12%), gross hematuria (10%).

LDH were increased (>530 UI/ml) in 96% of cases (45 cases out of 47), PCR (>0.5 mg/dl) in 94% of cases (45 out of 48), and eGFR <60 ml/min in 56% of cases (27 out of 48). Comparison of the various characteristics of the three groups shows: significantly older age (p=0.0001) in group 1 (76±12 years) vs group 2 (54±17 years) and group 3 (56±17 years); significantly more frequent cigarette smoking (p = 0.01) in group 2 (67%; 5 cases out of 9) and group 3 (60%; 12 cases out of 20) than group 1 (17%). No case has been subjected to endovascular thrombolysis. In 40 out of 48 cases, anticoagulant therapy was performed after diagnosis: in 12 (32%) cases no treatment, in 12 cases (30%) heparin, in 8 cases (20%) low molecular weight heparin, in 4 cases (10%) oral anticoagulants, in 3 cases fondaparinux (7%), in 1 case (2%) dermatan sulfate. Conclusions: Although some characteristics may guide the diagnosis, latency between onset and diagnosis is still moderately high and is likely to affect timely therapy. Keywords: renal infarction, kidney failure, atrial fibrillation, coagulopathy

A young girl with recurrent calculosis and hypercalcemia

Federica Di Maio1, Matteo Vittori2, PierFrancesco Bassi2, Pierluigi Fulignati1, Silvia D’Alonzo1, Pietro Manuel Ferraro1

1UOC di Nefrologia Fondazione Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore (Roma)
2 UOC di Urologia, Fondazione Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore (Roma)

Mutations of the CYP24A1 gene are associated with alterations in the activity of the enzyme 25-OH-D-24-hydroxylase, resulting in dysfunction of the metabolism of vitamin D. This enzymatic deficiency may cause hypercalcemia, low parathyroid hormone levels, hypercalciuria, nephrolithiasis and nephrocalcinosis. The clinical case of a young woman with recurrent renal lithiasis, hypercalcemia and hypercalciuria is described. These features are linked to deficiency of the enzyme 25-OH-D-24-hydroxylase, therefore to a biallelic mutation of the CYP24A1 gene.


Keywords: nephrolithiasis, CYP24A1, 25-OH-D-24-hydroxylase, hypercalcemia

Steroid-resistant focal segmental glomerulosclerosis treated with cascade plasmafiltration and rituximab

Paola Tatangelo, Francesco Londrino, Giorgio Di Vasta, Giuliana Guido, Alessia Centi, Sara Dominijanni, Eleonora Bernabei, Maria Stella Caramiello, Damiano Di Franco, Roberto Palumbo

U.O.C di Nefrologia e Dialisi, Ospedale S. Eugenio, Roma, Italia

A 39-year man with primary steroid resistant focal segmental glomerulosclerosis (FSGS) was treated with mycophenolate mofetil and ACE-inhibitors. After six months a different therapeutics approach was mandatory due to the worsening of renal function and the relapse of proteinuria at the nephrotic range. The combination of cascade plasmafiltration and single dose of rituximab (375 mg/m²) achieved clinical remission and improved renal function in six months follow up. Cascade plasmafiltration in association with rituximab can be considered as a salvage method for primary steroid-resistant FSGS. Clinical trials should be carried out for protocol approval.

Keywords: focal segmental glomerular sclerosis, steroid-resistant focal segmental glomerular sclerosis, cascade plasmafiltration, rituximab


Nicola Mongera1, Vittorio Di Maso1, Elisabetta Ermacora1, Michele Carraro1, Cristina Bregant1, Martina Pian1, Umberto Savi1, Eric Lorenzon1, Boscutti Giuliano1

1 SC Nefrologia e Dialisi-ASUITs (Azienda Sanitaria Universitaria Integrata di Trieste)

Granulomatosis polyangiitis (GPA) is an ANCA-related vasculitis (AAV) whose clinical manifestations mainly concern the respiratory tract (upper and lower) and the kidney. The treatment of GPA (as well as other AAV) includes the use of immunosuppressive drugs with numerous side effects; the most frequent complications are infectious and neoplastic. GPA frequently relapses. Epstein Barr Virus (EBV) is a ubiquitous virus; it is estimated that about 90% of the world’s population has BEEN EXPOSED TO with this pathogen and has subsequently developed a latent infection. Under certain conditions including immunosuppression EBV may reactivate. We report the clinical case of a 67-year-old woman who presented with GPA involving the upper respiratory tract and renal failure with the need for hemodialysis treatment. The fourth month of induction therapy with cyclophosphamide and methylprednisone she presented with dyspnea and respiratory failure. After excluding pulmonary embolism and heart failure, a series of investigations including high resolution tomography and fibroscopy with broncoalveolar lavage (BAL) were performed which excluded recurrence of pulmonary vasculitis including alveolar haemorrhage A BAL demonstrated EBV-DNA. On this basis EBV pneumonia was diagnosed, and antiviral therapy with acyclovir was begun, followed by clinical and radiological improvement. In patients with GPA treated with immunosuppressive drugs pulmonary involvement may not only be due to the underlying vasculitis, but also to opportunistic agents, which must always be considered.

Keywords: EBV-associated pneumonia, granulomatosis with polyangiitis, acyclovir

An unusual presentation of Amyloidosis AL

Anna Zito, Antonio De Pascalis, Paolo Ria, Annarita Armeni, Alessandro D’Amelio, Marcello Napoli

Unità Operativa Nefrologia e Dialisi, Ospedale “Vito Fazzi”, Lecce

We describe the case of a 74-year-old man admitted to our Nephrology Unit with nephrotic syndrome and mild kidney disease. A complete panel of laboratoristic and instrumental tests did not provide useful information for diagnosis. No specific signs or symptoms suggested the presence of AL amyloidosis. As a matter of fact, diagnosis was reached thanks to the hystopathologic examination of renal tissue and bone marrow, since the associated B-cell lymphoproliferative disorder had not revealed itself through serum and urine electrophoresis and immunofixation. This recent case provides the opportunity to review about the disease and to revaluate the renal biopsy as a first line exam in a clinical context where laboratoristic and instrumental tests offer us poor information.

Keywords: AL amyloidosis, bortezomib, renal biopsy

Protein carbamylation: what it is and why it concerns nephrologists

Emanuele De Simone1, Lucia Di Micco1, Gaetano La Manna2, Biagio Raffaele Di Iorio3

1 UOC Nefrologia, Ospedale Moscati, Avellino
2 Cattedra di Nefrologia, Università Alma Mater Studiorum – Policlinico Sant’Orsola Bologna
3 UOC Nefrologia Ospedale Landolfi, Solofra (AV)

Abstract: Spontaneous urea dissociation in water solution is a prominent source of protein carbamylation in our body. Protein carbamylation is a well-known phenomenon since early seventies. Some years ago, much interest in the diagnostic power of carbamylated protein arouse. Recently the target of the researches focused on its potential cardiovascular pathogenicity. Some authors claimed that this could be a reason for higher cardiovascular mortality in uremic patients. Nutritional therapy, amino acids supplementation and intensive dialysis regimen are some of the therapeutic tools tested to lower the carbamylation burst in this population.


Keywords: protein carbamylation, urea, chronic kidney disease

Hyperkalemia as a limiting factor in the use of drugs that block the Renin Angiotensin Aldosterone System (RAAS)

Antonio Santoro1, Marcora Mandreoli2

1 Divisione di Nefrologia, Dialisi ed Ipertensione, Policlinico S.Orsola-Malpighi Azienda Ospedaliero-Universitaria di Bologna
2 UOC Nefrologia e Dialisi, Ospedale S. Maria della Scaletta, Imola

Angiotensin-converting enzyme (ACE-I) inhibitors and ARBs have shown real efficacy in reducing blood pressure, proteinuria, in slowing the progression of chronic kidney disease (MRC) and in clinical improvement. in patients with heart failure, diabetes mellitus and ischemic heart disease. However, their use is limited by some side effects such as the increase in serum potassium (K), which can be particularly severe in patients with renal insufficiency. In the 23,000 patients followed by the PIRP project of the Emilia-Romagna Region, hyperkalaemia at the first visit (K> 5.5 mEq / L) was present in about 7% of all patients. The prevalence of K values> 5.5 mEq / L increased in relation to the CKD stage, reaching 11% in patients in stage 4 and 5. Among patients with values ​​of K> 5.5 at baseline, 44.8% were in therapy with ACE-I / ARB inhibitors, 3.8% with anti-mineralcortoid and a further 3.9% concurrently taking SRAA-blocking agents and K-sparing diuretics. Counter-measures to avoid the onset of hyperkalemia during treatment with drugs that block the RAAS range from the low-K diet, to diuretics and finally to drugs that promote fecal elimination of K. Among these, polystyrene sulfonates, which have more than 50 years of life, exchange K with sodium or calcium. These drugs, however, in chronic use, can lead to sodium or calcium overload and cause dangerous intestinal necrosis. Recently two new highly promising drugs have been introduced on the market for the treatment of hyperkalemia, the patiromer and sodium zirconium cyclosilicate. The patiromer, which is a potassium-calcium exchanger, acts at the level of the colon where there is a higher concentration of K and where the drug is most ionized. Sodium zirconium cyclosilicate (ZS-9) is a resin with micropores of well-defined dimensions, placed in the crystalline structure of the zirconium silicate. The trapped K is exchanged with other protons and sodium. However, even these drugs will have to demonstrate their long-term efficacy and safety to be considered true partners of RAAS blockers in some categories of patients.

Key words: potassium, hyperkalemia, ARB, ace-inhibitors, renal failure, patiromer, sodium zieconium cyclosylate, ZS-9, kayexalate

New scenarios in secondary hyperparathyroidism: etelcalcetide. Position paper of Nephrologists form Lombardy

Antonio Bellasi1, Mario Cozzolino2, Fabio Malberti3, Giovanni Cancarini4, Ciro Esposito5, Augusto Genderini6, Carlo Maria Guastoni7, Patrizia Ondei8, Giuseppe Pontoriero9, Ugo Teatini10, Giuseppe Vezzoli11, Piergiorgio Messa12 e Francesco Locatelli13

1UOC di Nefrologia e Dialisi, Ospedale Sant’Anna, ASST-Lariana, Como
2UOC Nefrologia e Dialisi ASST Santi Paolo e Carlo, Presidio San Paolo, Milano
3Struttura Complessa di Nefrologia e Dialisi Istituti Ospedalieri di Cremona
4Dipartimento della Cronicità, ASST, Spedali Civili e Università di Brescia
5Struttura Complessa di Nefrologia e Dialisi Fondazione IRCCS S. Maugeri Pavia
6Ospedale Pubblico, Divisione di Nefrologia e Dialisi, Ospedale Caduti Bollatesi, Bollate
7UO Nefrologia ASST Ovest Milanese
8USS Emodialisi, Azienda Ospedaliera Ospedale Papa Giovanni XXIII, Bergamo
9Struttura Complessa Nefrologia e Dialisi, Ospedale A Manzoni, ASST Lecco
10Divisione Nefrologia e Dialisi. Ospedale Bollate
11Unità di Nefrologia e Dialisi, Istituto di Ricovero e cura a carattere scientifico San Raffaele, Milano
12Unità Operativa Complessa di Nefrologia e Dialisi, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano
13Ospedale “Alessandro Manzoni”, ASST, Lecco

Bone mineral abnormalities (defined as Chronic Kidney Disease Mineral Bone Disorder; CKD-MBD) are prevalent and associated with a substantial risk burden and poor prognosis in CKD population. Several lines of evidence support the notion that a large proportion of patients receiving maintenance dialysis experience a suboptimal biochemical control of CKD-MBD. Although no study has ever demonstrated conclusively that CKD-MBD control is associated with improved survival, an expanding therapeutic armamentarium is available to correct bone mineral abnormalities. In this position paper of Lombardy Nephrologists, a summary of the state of art of CKD-MBD as well as a summary of the unmet clinical needs will be provided. Furthermore, this position paper will focus on the potential and drawbacks of a new injectable calcimimetic, etelcalcetide, a drug available in Italy since few months ago.


Keywords: secondary hyperparathyroidism, etelcalcetide, cinacalcet, CKD-MBD, PTH

Bartter syndrome, severe rare orphan kidney disease: a step towards therapy through pharmacogenetic and epidemiological studies

Elena Conte, Paola Imbrici, Dalila Sahbani, Antonella Liantonio e Diana Conte

Dipartimento di Farmacia – Scienze del Farmaco, Università di Bari

Bartter syndromes (BS) types 1-5 are rare salt-losing tubulopathies presenting with overlapping clinical phenotypes including marked salt wasting and hypokalemia leading to polyuria, polydipsia, volume contraction, muscle weakness and growth retardation. These diseases are due to an impairment of sodium, potassium, chloride reabsorption caused by mutations in genes encoding for ion channel or transporters expressed in specific nephron tubule segments. Particularly, BS type 3 is a clinically heterogeneous form caused by mutations in CLCNKB gene which encodes the ClC-Kb chloride channel involved in NaCl reabsorption in the renal tubule. Specific therapy for BS is lacking and the only pharmacotherapy up today available is purely symptomatic and characterized by limiting side effects. The improvement of our understanding of the phenotype/genotype correlation and of the precise pathogenic mechanisms associated with BS type 3 as well as the pharmacological characterization of ClC-K chloride channels are fundamental to design therapies tailored upon patients’ mutation. This mini review focused on recent studies representing relevant forward steps in the field as well as noteworthy examples of how basic and clinical research can cooperate to gain insight into the pathophysiology of this renal channelopathy, paving the way for a personalized therapy.


Key words: Bartter syndrome, CLC-K chloride channels, pharmacogenetics, rare diseases

Update 2017 of the KDIGO guidelines on Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD). What are the real changes?

Marzia Pasquali, MD, PhD1; Antonio Bellasi, MD, PhD2; Giuseppe Cianciolo, MD3; Carlo Massimetti, MD4; Maria Cristina Mereu, MD5; Luigi Morrone, MD6; Vincenzo Panuccio, MD7
A nome del GdS Elementi Traccia e Metabolismo Minerale della Società Italiana di Nefrologia.

1 UOC Nefrologia, Azienda Ospedaliero-Universitaria Policlinico Umberto I di Roma, Italia;
2 Nephrology and Dialysis Unit, ASST- Lariana, Como, Italia;
3 UO di Nefrologia Dialisi e Trapianto, Azienda Ospedaliero-Universitaria di Bologna Policlinico S.Orsola-Malpighi, Italia;
4 Centro di Riferimento di Nefrologia e Dialisi, Ospedale Belcolle, Viterbo, Italia;
5 Ospedale N.S. di Bonaria, San Gavino Mon.le, Cagliari, Italia;
6 Struttura Complessa di Nefrologia e Dialisi – P.O.C. “S.S. Annunziata”, A.S.L. Taranto, Italia;
7 UOC di Nefrologia, Dialisi e Trapianto del GOM “BMM”, di Reggio Calabria, Italia;

Guidelines for the assessment, diagnosis and therapy of the alterations that characterize the CKD-MBD are an important support in the clinical practice of the nephrologist. Compared to the KDIGO guidelines published in 2009, the 2017 update made changes on some topics on which there was previously no strong evidence both in terms of diagnosis and therapy. The recommendations include the diagnosis of bone anomalies in CKD-MBD and the treatment of mineral metabolism abnormalities with particular regard to hyperphosphataemia, calcium levels, secondary hyperparathyroidism and anti-resorptive therapies. The Italian Study Group on Mineral Metabolism, in reviewing the 2017 recommendations, aimed to assess the weight of the evidence that led to this update. In fact, on some topics there has not been a substantial difference on the degree of evidence compared to the previous guidelines. The Italian Study Group emphasizes the points that may still reserve critical issues, including interpretation, and invites an evaluation that is articulated and personalized for each patient.


Key words: CKD-MBD, BMD, Bone Biopsy, Calcemia, Phosphorus, Secondary Hyperparathyroidism

Anxiety and depression in emodialysis

Anna Fuduli1, Angela Minutoli2, Elisabetta Privitera3, Biagio Ricciardi4

1 Psicologa c/o U.O.S. di Nefrologia e dialisi P.O. Patti
2 Psicologa c/o U.O.C. di Nefrologia e Dialisi P.O. Milazzo e C.A.D. di Nefrologia e dialisi P.O. Barcellona
3Dir. Psicologo Asp 5 Messina
U.O.C. di Nefrologia e Dialisi P.O. Milazzo/ Lipari/Nefrologia e Dialisi P.O. Barcellona

The patients in terminal uremia show anxiety and depression correlate with anagraphic and dialytic age, here evidenced trought  the Hospital Anxiety and Depression Scale (HADS).

In a cohort of 120 patients, only 100 have been selected, because of incompatibility (11.6%) or  refusal (5%). The pool composed of 100 patients (59 men, 41 women; mean age of 70.8±12.07 years; 30% mean age of 74.27±3.12 and  mean time on dialysis of 55.03±70.12 months, was treated with Bicarbonate High Flux, Hemodialysis Filtration (HDF), Hemofiltration Replacement (HFR), Acetate Free Hemofiltration (AFB),  in Ultrapure, 40% in dialysis <24 months.

Analyzing the data, the 58% (25% men, 33% women) presented  level of anxiety and depression of IV° Likert,  versus 16.6% of the general population.

The correlation of variables indicates that among the patients under HD, the increase of anagraphyc age correlates with an increase at IV° of anxiety and depression, seen in 36% of patients with a mean age of 78.61± 5.95 (19% men, 17% women) and in 22% of patients with a mean age of 59.22± 8.43 (7% men, 15% women).

Considering the dialytic time, the IV° itself correlates with patients under treatment <2 years, regardless for  age. In fact 22% of these patients (8% man, 14% women – mean age of 69.31± 8.40) present a level of anxiety and depression worst than the population in longer treatment (87.36± 16.36 months), who instead represent 10% of the sample (3% men, 7% women -mean age 72.2± 11.24). This data can be read as a psychosomatic adaptation, but anymore  as a consequence of the improvement of cenesthesy due to a personalized haemodialysis.


Keywords: anxiety, depression, time of dialysis.

Enhanced adsorption dialysis on acute kidney injury in micromolecular myeloma

Maria D’Amico, Luigi Campo, Gaspare Giorlando, Francesca Incalcaterra, Francesco Paolo Sieli, Vito Barraco

UOC Nefrologia e Dialisi, P.O. S. Antonio Abate, Trapani

Acute kidney  injury ( AKI) is one of the mean causes of morbidity and mortality in patients with multiple myeloma. Approximately ten per cent of patients with diagnosis of multiple myeloma is in need of dialysis owing to AKI from accumulation of monoclonal free light chains (FLC) both K and lambda.

In order to increasing their removal haemodialysis with protein-leaking dialyzers is necessary.

It is clear that the series of filters with Polimetilmethacrylate (PMMA BK-F) is particularly able to absorb the FLC. The absorption has the greatest efficacy in the first hours of the dialysis, whereas it is almost lacking in the second part of  dialysis, when the membrane is saturated.

The Enhanced adsorption dialysis (EAD), trough the use of a second dialyzer, PMMA BK-F and of a second haematic line, doubles the absorption capacity.

We describe the case of a 70 years old patient, that comes to our examination owing to AKI in anuria. The positive serum immunofixation through K chains and osteological lesions, marked by RX, at the backbone and at the braincase, arouse suspicions of micromolecular myeloma, so the patient underwent dialytic treatment in EAD with halving of FLC lambda values and a 33 per cent decrease, following recovery of diuresis and partial betterment of renal function parameters.

Key Words: Micromolecular Myeloma, free light chains, Enhanced Adsorbtion dialysis

Metformin and Diabetes: still has a sense of its use in paz. CKD stage II or is an additional risk factor?

Antonio Pontoriero1, Antonino Saporita1, Carlo Alberto Ricciardi2, Biagio R Ricciardi1

U.O.C. di Nefrologia e Dialisi P.O. Milazzo – ASP5 Messina
2 Scuola di Specializzazione in Nefrologia – Università di Messina

Pz woman of 62 years comes to P.S.G. for fatigue, low-grade fever, diuresis present. A history of hypertension refers to therapy for about five years, diabetes mellitus for about two years in therapy with Metformin 1gr x 3 gg / day.  Blood tests: BUN 195 mg / dL, creatinine 8.0 mg / dl, Ph 6877, HCO3 5.1 mmol / L BE -29.1 mmol / l. Rapid clinical deterioration with occurrence of arterial hypotension – 85/60 mmHg, stupor. Start therapy Bicarbonates ev, is positioned in Urgency CVC and it undergoes AFB with infusion of bicarbonates 2000 ml / h for 4 hours, blood flow rate 250 ml / min., the hemodynamics has been supported with dopamine infusion 200 mg: 2 vials in 250 cc of physiological vel 30 – 40 ml / h, The pc after undergoing three AFB, interrupted the dialysis for resumption of diuresis spontaneous and progressive improvement of renal function and blood pressure. Monitored, after discharge, the parameters of renal function decreased to within normal limits, clearance compatible with IRC II – III stage.

Conclusions: dehydration, fever, IRC II stadium, undiagnosed caused, in a very short time, an accumulation of metformin, which has been the cause of metabolic acidosis. The pc. saved thanks to the positioning of the CVC and to the AFB in the treatment with the infusion of large quantities of Bicarbonates e.v.

The use of metformin in pcs. > 50 years and / or creatinine clearance <60 ml / min., Must be subordinated to the preliminary study and periodic renal function.


Keywords: Metformin, Diabetes, IRA, metabolic acidosis

PET with C-methionine and hyperparathyroidism

Francesco Rapisarda1, Barbara Pocorobba1, Roberta Aliotta1, Sebastiano Cosentino2, Sara Baldari2, Gabriella Murè2, Pasquale Fatuzzo1, Massimo Ippolito2

Università di Catania. Scuola di Spec. Nefrologia, Dipartimento di Medicina Interna – Sez. Nefrologia
U.O.C. Medicina Nucleare Centro PET/TC Azienda Ospedaliera per l’Emergenza

Scintigraphy 99mTc-sestamibi, in association ultrasound of the neck, is currently the technique of choice for the location of parathyroid adenomas in patients with hyperparathyroidism then undergo parathyroidectomy (1).

After surgery, from 2% to 7% of patients continues to have a persistence of the disease. In this case, the sensitivity of scintigraphy with MIBI in locating ectopic parathyroid glands is limited and varies from 30% to 80% (2).

Thanks to the introduction of a new method radiological, PET with 11C-methionine, it is now possible to detect the possible presence of parathyroid adenomas in patients with MIBI scintigraphy been examined (3) and is also useful for false positives. PET with 11C-methionine is a diagnostic accurate in locating the parathyroid adenomas of the neck with a sensitivity of 91%, allowing you to run parathyroidectomy focused with a reduced invasiveness of surgery, with reduction of postoperative pain and better results aesthetic (4). In addition, a method is clinically useful in patients with secondary hyperparathyroidism and tertiary. The limits of this promising method are the poor availability of the tracer, the fact that it is executed in only four centers in Italy and the high cost.

We present the cases of two patients who are diagnosed with hyperparathyroidism. They are submitted in the first instance to MIBI parathyroid scintigraphy parathyroidectomy and after removal of pathological glands. Persisting high values of PTH, patients are executed before a new scintigraphy with MIBI which is however negative and then a PET with 11C-methionine which shows accumulation of tracer in a different place not detected by scintigraphy.

Key words: PET with C-methionine; proactive approach; hyperparathyroidism

Technical-Organizational and Welfare Aspects Of The First Home Hemodialysis Program in Campania

Stefania Brancaccio, Alfredo Capuano, Andea Memoli, Stefano Federico

Cattedra di Nefrologia, Dipartimento di Sanità Pubblica, Università di Napoli “Federico II”

To activate a program of home hemodialysis (HHD) and to ensure its sustainability and success, it is essential to provide a structured path with the realization of a programmatic document detailing the technological requirements and the type of organization and assistance in line with the regulations currently in force. The path must consider the following: (a) eligibility clinical criteria of the patient and the caregiver, (b) analysis of the most recent HHD literature and the reasons of the choice of the latest technology, (c) accurate information of the patient and the caregiver with their approval, (d) care coverage and hospital admission modalities (e) suitability of the rooms where the patient will perform the HHD treatment, (f) training program of the patient and the caregiver, home treatment start and patient follow-up. The implementation of this structured process has allowed us to launch a successful HHD program: this modus operandi has preventively defined the pathway care and analyzed the priorities of risk.We have analyzed the HHD process to identify the possible problems and predictable critical situations in home health care.The experience with the HHD is promising: the patients did not show any clinical problems and reported a better quality of life; this dialysis method can be considered as further treatment option to selected patients, according to the eligibility criteria.

Keywords: Home Hemodialysis, Short Daily Home Hemodialysis, Care Pathway, Risk Management.

DPP-4 inhibitors in nephropatics

Annamaria Bruzzese1, Maria Pasquale2, Carmela Aloisi1, Giuseppe Costantino1, Michele Buemi1

UOC di Nefrologia e Dialisi, Policlinico Universitario Gaetano Martino, Messina
SOC di Medicina Interna, P.O. “Santa Maria Degli Ungheresi”, Polistena (RC).

The use of glucose-lowering drugs in advanced stage diabetic nephropathic patients should be done very carefully. Some drugs are contraindicated or not recommended. The same insulin needs a dose reduction to avoid dangerous hypoglycemia. For some years the use of inhibitors of the DDP-4 has been approved in T2DM patients with CKD III and IV stage, proposing the use without limitations even in case of ESRD.

We conducted a prospective observational study of a cohort of 60 patients with T2DM and CKD stage IV, selecting a sample of 15 patients taking an inhibitor of DPP-4 and comparing it with those who took therapy “old” drugs, despite having similar characteristics of CKD.

In both groups, we found: 1) the effectiveness of therapy, through the assessment of glycated hemoglobin and glycemic profile; 2) the possible occurrence of “hypoglycemia”, “side effects”, accelerating the progression of CKD. No patients being treated with inhibitors of DPP-4 have experienced hypoglycemia, or adverse events, or adverse effects on the progression of CKD. The glycated hemoglobin, revealed more stability than the comparison group. Hypoglycaemic episodes were present only in the group receiving intensive insulin. Although kidneys and their dose, in case of high degree of CKD, primarily eliminate inhibitors of DPP-4, with some exceptions, should be reduced, in our experience they have proven beneficial drugs in diabetics with kidney disease, being effective and well tolerated in the case of ESRD, where the only treatment option was represented by insulin.

Keywords: diabetes, chronic kidney disease, drug, tollerability

Home Hemodialysis: Experience and Preliminary Results Of The First Center In Campania

Stefania Brancaccio, Alfredo Capuano, Andea Memoli, Livia Maria Sorrentino, Laura Pirro, Stefano Federico.

Cattedra di Nefrologia, Dipartimento di Sanità Pubblica, Università di Napoli “Federico II”

The Home Hemodialysis (HHD) is an uncommon dialytic option that can offer better clinical outcomes and a more satisfactory quality of life. The Health Plan of the Region Campania 2011-2013 states that” the system of home care for regional planning is particularly important”.

From August 2014 to March 2015 two patients, on standard dialysis (HD) as inpatients at Dialysis Centre of the University “Federico II” of Naples, started Short Daily Home Hemodialysis (SDHD) (4-6 dialysis treatments/week, 2.5 hours per session) using the portable cycler NxStage System One).

The data collected showed that the clinical benefits described in the literature were confirmed in patients enrolled in this HHD program. Shorter and more frequent hemodialysis sessions allowed a significant reduction in interdialytic weight gain and greater intradialytic hemodynamic stability. A significant reduction in blood pressure and anti-hypertensive drugs were obtained. The control of phosphorus appeared better and hemoglobin was to target with a lower dose of weekly erythropoetin. The patients reported a greater well-being and a reduction in post-dialytic asthenia. No problem has been reported in using the vascular access (CVC and FAV) by the patient/caregiver. The dialysis adequacy and efficiency were comparable between SDHD and HD. The experience with the HHD is encouraging as the patients achieved an adequate dialysis dose without any complications reporting an improving sense of well-being and a better quality of life.

Key Words: Home Hemodialysis, Short Daily Home Hemodialysis, Dialysis Adequacy, Quality of Life.

Atypical Hemolytic Uremic Syndrome: experience of a pediatric center

Rosa Cusumano, Maria Chiara Sapia, Ciro Corrado, Elisa La Barba, Maria Michela D’Alessandro, Giovanni Pavone, Silvio Maringhini

ARNAS Civico Palermo, UO Nefrologia Pediatrica

In the last two years we admitted in our Hospital  38 children with acute renal failure (ARF). Six of them were affected by hemolytic uremic syndrome (HUS) atypical. The aHUS is diagnosed in the presence of thrombotic microangiopathy (MAT), renal insufficiency (GFR 5%).

The clinical presentation of our children has been varied and so also its evolution. Patients observed were all male, aged 2 to 12 years, and no one had a family history of kidney disease. In four patients we documented alterations of complement factors (MCP deficiency and factor H and presence of anti factor H). Repeated blood transfusions were required in 4 patients and in 3 patients the platelet count was slightly reduced. In 5 patients we did plasmapheresis and in 3 patients dialysis (hemodialysis and peritoneal dialysis). In three patients in whom the diagnosis was not clear, renal biopsy was performed to confirm the diagnosis. Eculizumab was administered in 3 patients resistant to plasma exchange. We obtain a rapid response on MAT with normalization of platelet count. The effect on renal function was variable (complete remission in a patient, partial improvement in another, and unresponsiveness in the last). The last had on Kidney biopsy signs of severe impairment and we documented the presence of antibodies to eculizumab. HUS is a rare condition, but probably much more common than reported. In children with ARF and microangiopathic anemia is necessary evaluated  complement factors as early to obtain an improved clinical response to treatment with eculizumab.

Keywords: atypical hemolytic uremic syndrome, acute renal failure, pediatric, eculizumab.

Nephrocalcinosis in children

Maria Michela D’Alessandro1, Giovanni Pavone1, Maria Cristina Castiglione2, Anna Maria Tranchida2, Maria Chiara Sapia1, Rosa Cusumano1, Ciro Corrado1, Rosa Mongiovi1, Silvio Maringhini1

1U.O. Nefrologia Pediatrica – ARNAS Civico Palermo
Dipartimento di Scienze per la Promozione della Salute e Materno Infantile “G. D’Alessandro” – Policlinico di Palermo

Nephrocalcinosis (NC) is a renal disease characterized by  deposition of calcium salts into the renal medulla. There are several causes, organic, iatrogenic, hereditary and