Protected: A narrative review on arteriovenous fistula for hemodialysis


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

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Immunosuppressive therapy reduction and early post-infection graft function in kidney transplant recipients with COVID-19


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


Since SARS CoV-2 infection was first identified in December 2019, the pandemic spread quickly around the world, with a disruptive impact on social and economic life. This virus yielded several new challenges to our healthcare systems that had to cope with an increased rate of morbidity and mortality among the most vulnerable populations [1]. Kidney transplant (KT) recipients are a subset of the population at high risk of severe COVID-19 due to the high burden of comorbidities and the cumulative side effects of immunosuppressive therapy (IST) [2]. Data collected so far show that transplant recipients are extremely susceptible to the SARS-CoV-2 infection, much more than the general population [3, 4]. The causes are multiple, but principally revolve around the use of long-term IST.

Despite the great emphasis on early IST reduction to face the potentially lethal consequences of COVID-19, no confirming data supports its beneficial effect in terms of survival or clinical manifestations. Additional uncertainty arises from the recent literature reporting that a tempered immune response is thought to prevent COVID‐19–induced systemic inflammatory syndrome. To date, data regarding early graft outcomes after COVID-19 are scarce [5]. It is worth noting that graft survival may be threatened by non-reversible episodes of kidney injury [6, 7]. Lastly, a concerning issue may be the hyporesponsiveness to anti-SARS-CoV-2 vaccination [8, 9]. Numerous studies have confirmed that KT recipients have a blunted immune response to mRNA vaccines [10]. Only 48% of patients were able to develop a protective serologic response to SARS-CoV-2 [11]. Caillard et al [12] reported that about one-third of kidney transplant patients had severe manifestations, including a fatal outcome, despite COVID-19 vaccination. This group of patients is therefore expected to remain vulnerable to the severe complications of COVID-19 until new strategies will be implemented to reduce the susceptibility of these subjects.

Considering all the uncertainties in the management of KT recipients and the high risk of severe COVID-19 manifestations within this cohort of patients, we report our experience in managing KT recipients with COVID-19. In particular, we focus on the impact of early IST reduction, and early graft function after the resolution of the infection.


Material and methods

Kidney transplant outpatient clinic

This kidney transplant outpatient clinic follows more than 500 KT recipients, including combined liver and pancreas-kidney transplantation. Outpatient service was delivered by a senior nephrologist with experience in kidney transplantation, one fellow and three nurses. A 24-h, 7/7 days per week service was available for KT recipients in case of kidney-related pathologic processes (anuria, fluid overload) or infections. This service was also offered to the subjects transplanted in our Center but living far away from it.

During COVID-19 all the patients were instructed to call the clinic in case of COVID-19 symptoms. Despite the reduction of non-essential healthcare services, our outpatient clinic continued to deliver care to KT recipients, adopting all the containment measures (triage at entry, masking, social distancing and hands hygiene) to prevent COVID-19 diffusion. A telephonic triage was performed for all patients before reaching the hospital to intercept paucisymptomatic patients.

Patients with symptoms were invited to perform nasal swabs using RT-PCR and were visited in a dedicated room to assess vital parameters and clinical conditions. According to the severity of the symptoms, patients were sent home or to the emergency room. To reduce the workload of the emergency room, patients were managed as outpatients unless they developed severe symptoms that required hospital admission. The monitoring of noncritical patients was mostly performed via phone calls and emails.

According to our internal protocol and taking into account the opinions of European experts [13, 14], immunosuppression was modulated as follow:

  • for asymptomatic or mild COVID-19 patients (i.e., mild upper respiratory and/or gastrointestinal symptoms, temperature <38°C without dyspnea) in triple therapy (calcineurin-inhibitors [CNI] + mycophenolate acid [MPA]/azathioprine [AZA] + steroids), MPA or AZA was withdrawn, and a dual therapy (CNI + steroid) was continued. If the patients were on dual therapy (CNI + mammalian target of rapamycin inhibitor [mTOR-i] or CNI + MPA), MPA/mTOR was withdrawn and replaced with a low dose of steroids (i.e., methylprednisolone 4 or 8 mg once-daily).
  • for moderate (signs and symptoms of lower respiratory disease or saturation of oxygen [SpO2] ≥94% on room air at sea level) and severe COVID-19 (SpO2 <94% on room air at sea level, a ratio of arterial partial pressure of oxygen to fraction of inspired oxygen [PaO2/FiO2] <300 mm Hg, respiratory frequency >30 breaths per minute, or lung infiltrates >50%) all immunosuppressors, but steroids, were stopped. The prescription of anti-inflammatory and immunomodulant steroid therapy for symptomatic COVID-19 patients (dexamethasone at a dose of 6 mg once daily for up to 10 days) was not part of the anti-rejection therapy and was administered by COVID-19 experts.

COVID-19 population

The study population was comprised of kidney transplant recipients with COVID-19 with a complete follow-up, including death or discharge from hospital.

We retrospectively reviewed the electronic charts of all KT recipients with COVID-19 from March 7, 2020, to June 25, 2021. During this period we performed 144 nasopharyngeal swabs. The diagnosis of COVID-19 was performed through reverse transcriptase-polymerase chain reaction (RT-PCR) assay on a nasopharyngeal swab. We excluded patients aged <18 years. Kidney function was estimated by glomerular fraction rate (eGFR) using the CKD-EPI equation. Occasionally, some data were missing for patients admitted to a hospital located far from our Center.

This study has been authorized by the local Ethical Committee of Emilia Romagna (n. 839/2020). The study protocol complies with the guidelines for human studies and includes evidence that the research was conducted ethically in accordance with the World Medical Association Declaration of Helsinki.

Statistical analysis

Baseline characteristics were described using median (interquartile range [IQR]) or frequencies, as appropriate. The chi-square or Fisher’s test, and student’s t-test were used to compare categorical and continuous variables between groups, respectively. Univariate and multivariate logistic regressions were performed to test the association between mortality and baseline patient characteristics. Variables that were significant on univariate analysis (P=<0.05) were entered into the multivariate model to identify independent predictors. Results were expressed as odds ratios (OR) and 95% confidence intervals (CI). Univariate and multivariate logistic regression analysis determined risk factors for death. A P value of <0.05 was considered statistically significant. All statistical analyses were performed using SPSS® statistical software.



Characteristics of COVID-19 population

From the beginning of the COVID-19 pandemic in Italy, 45 KT recipients followed in our center contracted COVID-19. The demographic and clinical characteristics of these patients are detailed in Table I. This group of patients included two (4.4%) combined liver-kidney and one (2.2%) heart-kidney transplant recipient. Seven (15.5%) patients were hospitalized in another structure because they lived far from our Center.

Variable All patients
Reduced-dose IST
Full-dose IST
Age, year 56.1 (47.3-61.1) 55.9 (47.6-61.2) 56.1 (44.4-62) 0.85
Range 19.2-83.5 19.2-79.8 28.1-83.5
Males, n. (%) 29 (64.4) 18 (66.7) 110 (61.1) 0.75
Race/ethnicity 0.61
White, n. (%) 41 (91.1) 26 (92.6) 16 (88.9
Black, n. (%) 4 (8.9) 2 (7.4) 2 (11.1)
Transplant vintage, year 10.1 (2.7-16.01) 7.8 (2.4-15.2) 11.1 (4.7-21.1) 0.29
sCr pre-COVID-19, mg/dl 1.45 (1.18-1.84) 1.44 (1.18-1.81) 1.28 (1.14-1.82) 0.68
eGFR pre-COVID-19, ml/min 48.4 (36-64) 47.7 (35-64) 49.5 (38.6-67.9) 0.83
24-h proteinuria, mg/dl 87.4 (0.52-188.5) 72 (0.25-183) 145.5 (6.2-205) 0.69
Immunosuppressive therapy, n. (%)
CNI 39 (86.7) 24 (88.9) 15 (83.3) 0.67
mTOR-i 8 (17.8) 4 (14.8) 4 (22.2) 0.69
MPA 31 (68.9) 24 (88.9) 7 (38.9) 0.01
Steroid 36 (80) 23 (85.2) 13 (72.2) 0.44
IS regimen 0.001
Triple therapy 25 (55.6) 21 (77) 4 (22.2)
Double therapy 19 (42.2) 6 (22.2) 13 (72.2)
Monotherapy 1 (2.2) 0 (0) 1 (5.6)
Reduction IS therapy, n. (%) 27 (60) 27 (100) 0 (0) N/A
MPA withdrawal 24 (53.3) 24 (88.9) 0 (0) N/A
CNI or mTOR-i withdrawal 6 (13.3) 6 (22.2) 0 (0) N/A
Increase steroid 9 (5,4) 8 (29.6) 1 (5.6) 0.064
Comorbidities, n. (%)
HIV, HCV or HBV 6 (13.3) 3 (11.1) 3 (16.7) 0.65
Diabetes 5 (11.1) 4 (14.8) 1 (5.6) 0.63
Neoplasia 10 (22.2) 7 (25.9) 3 (16.7) 0.71
Graft rejection 4 (8.9) 1 (3.7) 3 (16.7) 0.13
CVD 12 (26.7) 7 (25.9) 4 (22.2) 77
Autoimmune disease 4 (8.9) 1 (3.7) 3 (16.7) 0.13
Previous severe infection 13 (28.9) 8 (29.6) 5 (27.7) 1
Symptomatic COVID-19, n. (%) 40 (88.9) 27 (100) 13 (72.2) 0.45
Hospitalization, n. (%) 19 (42.2) 14 (51.9) 5 (27.8) 0.13
Graft failure, n. (%) 1 (2.2) 1 (3.7) 0 (0) 1
ICU admission, n. (%) 9 (20) 4 (14.8) 5 (27.8) 0.28
Mortality, n (%) 8 (17.8) 4 (14.8) 4 (22.2) 0.69
Post-COVID-19 follow-up, day 70.5 (51-109) 76  (50.5-116.5) 69 (66-76) 0.57
Notes: eGFR denotes estimated glomerular filtration rate; CNI, calcineurin inhibitor; CVD, cardiovascular disease; HCV, hepatitis C; HBV, hepatitis B; IST, immunosuppressive therapy; MPA, mycophenolate acid; mTOR-I, mammalian target of rapamycin inhibitor; sCr, serum creatinine.
Table I:Demographics and clinical characteristics of KT recipients

The age of patients ranged from 19.2 to 83.5 years and the median was 56.1 (IQR, 47.3-61.1) years. COVID-19 was more prevalent in males than in females (64.4% vs 35.6%) and occurred after a median of 10.1 (2.7-16.01) years from transplantation.

Before the COVID-19 infection, serum creatine (sCr) was 1.45 (IQR 1.1-1.8) mg/dl corresponding to a median eGFR of 48.4 (IQR 36-64) ml/min. At the time of the COVID-19 diagnosis, more than half of the patients were in triple standard IST. Forty patients (88.9%) developed symptoms of COVID-19 and 19 of them (42.2%) required hospitalization. One patient returned to dialysis following acute kidney injury. Overall, nine patients (20%) were admitted to ICU for severe manifestations of COVID-91 and eight (17.8%) died.

Reduced- vs full-dose IST group

The entire population was subdivided into two groups: reduced-dose (n.=27; 60%) and full-dose IST (n.=18; 40%). There were no significative statistical differences in terms of demographic and clinical characteristics between the two groups. Statistical analysis detected significant differences in the prescription of IST. Patients who underwent reduction of immunosuppression (reduced-dose IST) were treated with a higher dose of IST before COVID-19; indeed, the rate of prescribed triple-drug IST was higher in this group than in full-dose IST patients (77% vs. 22.2%; P=<0.001).

In the reduced-dose IST group, MPA (88.8%) and CNI or mTOR-i (22.2%) were the most frequent discontinued agents. Conversely, the dose of steroids was increased in a third of patients and, in all of them, the administration of steroids changed from alternate days (methylprednisolone 2/0 or 4/0) to a daily regimen.

Hospitalization, ICU admission and death rate in patients who underwent IST reduction were 51.8%, 14.8% and 14.8%, respectively. However, despite IST reduction, hospitalization (P=0.13), ICU admission (P=0.28) and death (P=0.69) rates were not different from those of the full-dose IST group.

Outcomes of KT recipients with COVID-19

Univariate and multivariate logistic regression was performed to detect predictors of mortality (Table II). Multivariate analysis found that age (OR=1.19 [95%CI 1.01-1.39]; P=0.034) and years spent on immunosuppressive therapy (OR=1.17 [95%CI 1.01-1.35]; P=0.040) were associated with mortality in this group of patients.

Univariate Multivariate
Variable OR CI (95%) p-value OR CI (95%) p-value
Male 4.40 0.78 24.81 0.09  
Age (1-yr increase) 1.11 1.02 1.22 0.016 1.19 1.01 1.39 0.034
KT vintage (1-yr increase) 1.10 1.00 1.21 0.053 1.17 1.01 1.35 0.040
Steroid-based IST 1.93 0.21 18.08 0.56
Reduction IST 1.33 0.26 6.869 0.74
Increase of steroid 0.52 0.06 4.85 0.56
Triple IST 0.51 0.10 2.620 0.42
Double IST 1.96 0.38 10.026 0.42
GFR 0.99 0.95 1.026 0.57
GFR< 45ml/min 1.47 0.32 6.80 0.62
GFR 45-59 ml/min 0.68 0.15 3.16 0.62
sCr 1,33 0,26 6.87 0.73
Graft rejection 1.52 0.14 16.91 0.73
Autoimmune disease 0.00 0.00 0.99
HIV/HCV/HBV 2.58 0.38 17.43 0.33
Previous sever infection 0,73 0.13 4.19 0.72
Diabetes 1.11 0.11 11.49 0.93
Neoplasm 1.12 0.19 6.70 0.89
Cardiovascular disease 1.73 0.34 8.76 0.50
Notes: eGFR denotes estimated glomerular filtration rate; HCV, hepatitis C; HBV, hepatitis B; IST, immunosuppressive therapy; MPA, mycophenolate acid; mTOR-I, mammalian target of rapamycin inhibitor; sCr, serum creatinine.
Table II: Univariate and multivariate predictors of mortality through logistic regression analysis

Among the survivors (82.2%), one patient with a CKD stage 4 (GFR=20 ml/min) before SARS-CoV-2 infection developed irreversible graft failure requiring HD. One patient (2.7%) manifested de-novo proteinuria (4100 mg/die) after the resolution of COVID-19 and graft biopsy revealed IgA glomerulonephritis (the lack of data on the cause of CKD did not allow us to classify these histological findings as either de-novo or recurrent IgA glomerulonephritis). Lastly, one patient experienced symptomatic COVID-19 reinfection after the primary infection and another one following the SARS-CoV-2 mRNA vaccine. Early post-COVID-19 follow-up of 25 out of the 37 survivors showed that pre- and post-COVID variations of sCr, eGFR and 24-hour proteinuria were not statistically significant in outpatients after the resolution of COVID-19. A significantly lower sCr level (P=0.019) and eGFR (P=0.028) were measured after hospital discharge in hospitalized patients. No differences were noted in the level of daily proteinuria (Table III). The early follow-up of KT recipients after COVID-19 resolution did not show any new episodes of graft rejection.

Non-hospitalized patients Hospitalized patients
Pre-COVID-19 Post-COVID-19 p-value Pre-COVID-19 Post-COVID-19 p-value
sCr, mg/dl 1.31 (1.2-1.76) 1.33 (1.08- 1.7) 0.85 1.49 (1.1-1.8) 1.21 (0.9-2.1) 0.019
eGFR, ml/min 48.8 (40.5-62.1) 56.7 (41.5-67) 0.25 46.7 (36-64) 56.7 (41.5-67) 0.028
24-h proteinuria, mg/die 102 (6.2-205) 89.4 (37.2-246.4) 0.08 13(2.5-183) 44.7 (10.8-1141) 0.29
Notes: eGFR, estimated glomerular filtration rate; sCr, serum creatinine.
Table III: Early graft function post-COVID-19 in hospitalized and non-hospitalized KT recipients



Numerous reports have alerted the scientific community regarding the unfavorable outcome of COVID-19 in patients with a reduced immune response [1, 15]. The results of this study confirmed that COVID-19 poses KT recipients at high risk of severe consequences.

In our cohort of KT recipients, COVID-19 carried with it a higher rate of symptoms, hospitalization and mortality compared to the general population [16, 17]. We found that in this cohort (45 KT recipients with COVID-19, median age 56.1), 40% of patients developed severe symptoms requiring hospitalization. Overall mortality was 17.8%, higher than the mortality reported in the general population, which ranges between 0.1-19.2% around the world and accounts for about 2.02% globally [18].

In an attempt to reconstitute the immune system against SAR-CoV-2 infection, we minimized the burden of IST in these patients. All KT recipients who communicated their COVID-19 positivity to our center, were advised to discontinue the antimetabolite agents (i.e., MFA or AZA) (88.9%) and CNI or m-TOR-i (22.2%). In the hospitalized patients, IST was further reduced or suspended, according to the clinical conditions of the patient. Nevertheless, hospitalization and death rates in the reduced-dose IST group were not dissimilar from the full-dose IST group.

At first glance, these results show that the reduction of immunosuppression did not confer any advantage in terms of patient survival. However, some considerations should be considered before drawing firm conclusions. Most patients who underwent IST reduction carried a significantly higher burden of IST compared to KT recipients whose therapy was left unmodified. The higher prevalence of triple-drug immunosuppressive regimen in patients who underwent IST minimization (77% vs. 22.2%; P=<0.001) has probably increased the vulnerability to COVID-19. Conversely, patients with a full-dose IST spent more time (11.2 vs 7.8 years) on kidney transplantation compared to the reduced-dose IST group. Lastly, we believe that the slight increase of steroid therapy (from alternate days to a daily administration) in the reduced-dose IST group (P=0.064) was too small to mitigate the inflammatory response driven by COVID-19.

Although the reduction of IST did not lead to a favorable outcome, it is worth mentioning that the overall mortality in our cohort was tendentially lower than that reported in other studies, where this approached up to 32.5% [1926]. Our results are in line with the population-based data on 1013 KT recipients affected by COVID-19 collected by the French and Spanish national registries, which reported a 28-day mortality of 20% [27]. In Italy, Bossini et al. [24] reported a higher overall mortality rate (28%) during the first wave of COVID-19 in the city of Brescia. Similarly to our therapeutic strategy, they discontinued immunosuppression in all hospitalized patients and introduced or increased the dose of steroids. The causes underlying these different mortality rates are unknown. The different timing of enrollment made the two cohorts not perfectly comparable. All patients in the Brescia cohort were enrolled during the first wave of COVID-19 in Europe, in an overwhelmed and unprepared hospital setting, within a timespan characterized by a high rate of experimental regimens and relative side effects [28, 29]. Lastly, a lower median age (56.1 vs. 60 years) in our cohort of patients probably contributed to the better prognosis.

Multivariate analysis showed that the predictors of death were age and time elapsed on IST, in line with previous studies. Age is widely associated with COVID-19 severity and death in KT recipients [30, 31] as well as in the general population [32]. The Centers for Disease Control (CDC) claims that 8 out 10 COVID-19 deaths in the U.S. occurred in adults over 65 and that the risk of hospitalization and death increases enormously with age [33].

The effect of immunosuppression is still controversial in KT recipients [34]. Immunosuppression is known to dysregulate innate and adaptive immunity, exposing the patients to severe infections. On the other hand, severe COVID-19 infection has been associated with a dysregulated inflammatory response (IL-6, IL-1, and chemokines) leading to ARDS and sepsis. The new insights support a promising role of immunosuppressants (i.e., tocilizumab, steroid) in tempering the immune response of patients with severe manifestations of COVID-19 [35].

Lastly, we report a short-term good graft function in patients who survived COVID-19. These data indicate a stable early graft function (sCr and 24-hour proteinuria) in outpatients who were not hospitalized. Conversely, hospitalized KT recipients had a statistically significant improvement in renal function. As stated also by Dacina et al. [5], we speculate that lower sCr after SARS-CoV-2 is due to the minimization or withdrawn of CNI, a ‘drug holiday’ apparently without dire consequences in terms of graft rejection.

Finally, the limitations of the study should be enumerated. It is a retrospective study, with a small sample size and a short follow-up after COVID-19. The small number of patients and the short observation period may have reduced the probability to observe an underlying difference between these two groups. Long-term follow-up is required to verify if the early improvement of kidney function after COVID-19 is maintained in the survivors. Furthermore, we cannot exclude that, in some cases, the reduction of IST occurred with a short delay after the diagnosis of COVID-19; however, all patients with symptoms underwent nasopharyngeal swabs as fast as possible in an ambulatory setting.



In our cohort of patients, the reduction of immunosuppression did not decrease the risk of severe COVID-19 or death. COVID-19 was associated with hospitalization (42%), graft failure (2.2%), IgA glomerulonephritis (2.2%) and death (17.8%). Age and time elapsed from kidney transplantation were independent predictors of death in our patients. Short-term follow-up after COVID-19 showed an excellent graft function in most survivors. Primary infection or vaccination did not exclude the risk of SARS-CoV-2 infection in KT recipients.


Authorship credit

Conception: Gaetano Alfano and Francesca Damiano

Collection of data: Camilla Ferri, Francesco Giaroni, Andrea Melluso, Martina Montani, Niccolò Morisi, Lorenzo Tei, Jessica Plessi

Analysis and interpretation of data: Gaetano Alfano, Francesco Giaroni, Francesca Damiano

Drafting the article: Gaetano Alfano, Francesco Fontana, Silvia Giovanella, Giulia Ligabue, Giacomo Mori

Intellectual Contribution: Francesco Fontana Gianni Cappelli, Giovanni Guaraldi

Revising the article: Gianni Cappelli, Giovanni Guaraldi

Approval of the version to be published: all authors



Special thanks are due to Marco Ballestri, Elisabetta Ascione, Roberto Pulizzi and Francesca Facchini, skilled and experienced nephrologists involved in the “Kidney Transplant Program”, and to Laura Bonaretti and all nurses of the “Kidney Transplantation Outpatient Clinic” at the University Hospital of Modena for their precious support in managing KT recipients.



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AKI in hospitalized patients with COVID-19: a single-center experience

Dear Editor,

since December 2019, the COVID-19 pandemic is straining hospitals and nephrology services worldwide. Although this disease manifests mostly with pneumonia, acute kidney injury (AKI) is recognized as a common complication in patients with severe manifestations of COVID-19. The pathogenesis of COVID-19 is still unclear but recent evidence supports a multifactorial etiology [1]. Generally, kidney involvement following SARS-CoV-2 infection is proportionate to the gravity of the infection and is commonly diagnosed in hospitalized patients with lung involvement [2]. As in another clinical scenarios, kidney injury is independently associated with morbidity and mortality in patients with SARS-CoV-2 infection [3,4].

The distribution of AKI in patients with COVID-19 is extremely variable across countries [5]. The first reports from China described a low prevalence of AKI in hospitalized patients [6] but subsequent evidence, coming from the USA and Europe, suggested a higher kidney involvement, especially in the intensive care setting [7] and among vulnerable patients [8]. Few studies have estimated the rate of AKI in hospitalized patients admitted to non-intensive care units in Italy. It ranges between 13.7-22.6% [911] and is similar to the prevalence detected in other European countries (4.5-22%) [1214]. In order to broaden the knowledge of this phenomenon, we report the data on the prevalence and clinical characteristics of AKI in COVID-19 patients.

We evaluated a cohort of 792 COVID-19 patients hospitalized at the University Hospital of Modena, Italy, between February 25 and December 14, 2020 for severe symptoms of COVID-19. The diagnosis of COVID-19 was performed through reverse transcriptase-polymerase chain reaction (RT-PCR). We excluded patients aged <18 years (n=2), patients on dialysis (n=5), and patients without serum creatinine on admission (n=19). The diagnosis of AKI was defined according to the Kidney Disease: Improving Global Outcomes (KDIGO) criteria [15], without considering the urine output criteria. Baseline serum creatinine (sCr) coincided with sCr at admission. All the enrolled patients were discharged or died at the end of the follow-up.

According to the Istituto Superiore di Sanità (ISS), the coronavirus pandemic in Italy can be subdivided in three waves during 2020: first wave (February-May), transitional period (June-August) and second wave (September- December) [16]. As a result, the study population was subdivided into three groups: wave-1 (n=389), transitional period (n=57) and wave-2 (n=346).

Data are expressed as mean ± standard deviation or a percentage (%). Statistical differences were tested using Student’s t-test or Chi-square as appropriate. Cox regression analysis evaluated the influence of AKI on the hazard of death. The study was approved by the regional ethical committee of Emilia Romagna (n. 0013376/20).

In a cohort of 792 hospitalized patients, 122  cases (15.4%) of AKI were diagnosed. Patients with AKI were older (77.4 vs 64.3 years; P=<0.001) and had a higher baseline sCr (1.37 vs 0.96 mg/dl; P=0.004) than non-AKI patients (Table I). As expected, patients with AKI showed increased levels of inflammatory markers (CRP; P=0.001), tissue damage (LDH; P=0.01) and hypoxia (PO2/Fi02;P=<0.001). We detected a higher burden of morbidity and comorbidity compared to non-AKI patients, as indicated by a higher SOFA (P=<0.001) and Charlson score (P=<0.001), respectively. In particular, AKI patients had a high rate of non-invasive ventilation (NIV; P=0.001), high flow nasal oxygen (HFNO; P=<0.001), mechanical ventilation (P=0.001) and, consequently, ICU admission (P=0.01). Given the burden of multiorgan dysfunction, AKI patients experienced a prolonged hospital stay (22.4 vs 13.2 days; P=0.008).

AKI stage 1 was the most frequent event (n=82; 67.2%) followed by AKI stage 2 (n=15; 12.2%) and AKI stage 3 (n=25; 20.4%). In this latter group, renal replacement therapy was necessary for 11 patients (44%).

The overall mortality rate was 19.1% and it increased up to 61.5% in patients with an acute worsening of kidney function (Figure 1). AKI was an independent risk factor for death after adjustment for age, sex, PO2/FiO2, baseline creatinine, BMI, LDH, CRP, diabetes and cardiovascular disease (HR, 3.39; CI95% 1.032-11.1; P=0.04). Of the survivors with AKI, 40.4% did not recover kidney function at discharge.

Variable All patients (n=792) No AKI (n=670) AKI patients (n=122) p-value
Age 66.3±16.1 64.3±16.18 77.4±10.92 0.012
Males (%) 511 (64.5) 425 (63.4) 86 (70.5) 0.15
White blood cells (cell/mm3) 8587±7170 7657.1±5696.6 9737.7±7380.5 0.053
Hemoglobin (gr/dl) 12.7±1.8 12.6±1.8 13.1±1.6 0.084
Platelets (103/mm3) 253.7±116.3 261.8±111.2 207.8±133.5 0.85
CRP (mg/dl) 8.9±8.2 8.3±7.89 12.3±9.6 0.001
LDH (U/L) 648.9±991.9 592±283.4 950±238.9 0.01
Baseline sCr (mg/dl) 1±0.71 0.96±0.25 1.37±0.08 0.004
sCr peak (mg/dl) 1.2±1.1 1.01±0.65 2.72±1.76 <0.001
sCr at discharge (mg/dl) 1±0.89 0.84±0.44 2.23±1.57 <0.001
MAP 90.3±13.2 88.8±12.2 95.5±14.2 0.12
PO2/FO2 250.6±105.2 261.11±101.3 184.87±106 <0.001
SOFA score 2±2 1.7±1.6 3.5±2.7 <0.001
Charston score 3.4±2.9 3 ±2.8 5.1±3.1 <0.001
Comorbidities§ (%)
COPD (%) 32 (14.5) 22 (12.1) 10 (26.3) 0.04
Diabetes (%) 75 (31.9) 61 (31.1) 14 (35.9) 0.576
Hypertension (%) 182 (65.9) 150 (64.7) 32 (72.6) 0.386
CVD (%) 50 (22.5) 30 (16.5) 20 (50) <0.001
CKD (%) 35 (15.8) 24 (13.1) 11 (28.9) 0.025
BMI>30 (%) 113 (32.2) 99 (33.6) 14 (25) 0.275
ACE inibitors (%) 102 (12.9) 90 (13.4) 12 (9.8) 0.307
FANS (%) 21 (2.7) 17 (2.5) 4 (3.3) 0.550
Nephrotoxic antibiotic (%) 20 (2.5) 15 (2.2) 5 (4.1) 0.216
Use of chonic diuretic therapy (pre-AKI) (%) 259 (32.7) 182 (27.2) 77 (63.1) 0.001
Antiviral (%) 253 (31.9) 215 (32.1) 38 (31.1) 0.91
IV hydratation with cystalloids pre-AKI (%) 233 (29.4) 189 (28.2) 44 (36.1) 0.085
Steroid (%) 287 (38.5) 232 (36.7) 55 (48.7) 0.021
Immunotherapy  (%) 326 (43.4) 275 (43.4) 326 (43.7) 0.758
O2 therapy (%) 537 (67.8) 454 (67.8) 83 (68) 1
HFNO (%) 101 (18.5) 71 (15.4) 30 (35.7) <0.001
NIV (%) 172 (31.3) 128 (27.8) 44 (49.4) 0.001
Mechanical ventilation (%) 91 (12.2) 59 (9.3) 32 (28.3) 0.001
ICU admission (%) 153 (20.5) 111 (7.5) 42 (37.2) 0.001
BMI 28.5±5.3 28.5±5.1 28.1±6.2 0.109
Time elapsed from admission to AKI (day) 11.8±9.34 NA 11.8±9.34 0.063
Hospitalization (day) 14.7±13.7 13.28±11.3 22.45±21.38 0.008
Death (%) 151 (19.1) 76 (11.3) 75 (61.5) <0.001
Legend: CRP, C-reactive protein; LDH, lactate dehydrogenase; MAP, mean arterial pressure; sCr, serum creatinine; SOFA, Sequential Organ Failure Assessment; COPD, chronic obstructive pulmonary disease; CVD, cardiovascular disease; CKD, chronic kidney disease; BMI, body mass index; HFNO, high-flow nasal oxygen; NIV, noninvasive ventilation; AKI, acute kidney injury; ICU, intensive care unit.
Table I: Demographics and clinical manifestation of COVID-19 patients
Figure 1: Kaplan Mayer curves showing survival of AKI and non-AKI patients with COVID-19
Figure 1: Kaplan Mayer curves showing survival of AKI and non-AKI patients with COVID-19

From an epidemiological point of view, the prevalence of AKI remained similar during the first (15.9%) and the second wave (14.7%) (P=0.89) (see Figure 2). The rate of ICU admission (P=0.42) was similar in these two groups but during the second wave AKI patients were more frequently treated with steroids (P=0.007), HFNO (P=0.001) and required less mechanical ventilation (P=0.019) compared to patients admitted during the first wave. Nevertheless, the mortality of AKI patients did not change between the first (59.7%) and the second (70.6%) wave of COVID-19 (P=0.243).

Figure 2: AKI prevalence during the first wave, the trasitional period and the second wave
Figure 2: AKI prevalence during the first wave, the trasitional period and the second wave

The findings of this study provide new information on the epidemiology of AKI in COVID-19. We found that the overall rate of AKI in unvaccinated hospitalized patients with COVID-19 accounted for 15.4% and that the prevalence of AKI remained relatively steady (about 15%) during the three phases of the COVID-19 pandemic that hit Italy and Europe during 2020. These data are in line with the results of a recent metanalysis, reporting a comparable pooled incidence (15.4%) among 25,566 patients, enrolled in 39 studies [17]. However, the distribution of AKI is not homogeneous among the published studies, where prevalence ranged from 0.5%-60%. Multiple factors may have affected this epidemiological variability including the surge capacity of the healthcare system, how the care was delivered (publicly or privately) and the method of patients selection (e.g. criteria for hospital admission).

In our study, subjects with AKI showed different demographic and clinical characteristics compared to non-AKI patients. Kidney injury was indeed experienced by elder patients affected by a more severe disease than non-AKI patients. COVID-19 patients with kidney involvement had a higher rate of morbidity (lung involvement, ICU admission, length of stay) and a 3.4-fold increase in mortality than non-AKI patients. No clear differences were detected in terms of AKI prevalence between the first and second wave, despite some therapeutic improvements (steroids, remdesivir, immunomodulant) were made in the management of these patients.

Since AKI is an independent risk factor  in COVID-19, many efforts should be made to identify and correct predisposing factors for kidney injury. From a practical point of view, the prevention measures that we put in place were not different from those we follow for AKI from other causes in critically ill patients [15,16]. These were based mainly on surveillance of kidney function, maintenance of normovolemia and avoidance of nephrotoxic agents.

In conclusion, our study confirms that AKI is a common event (15.4%) in COVID-19 and its prevalence was stable through 2020. AKI was more common in older patients who experienced a severe COVID-19. The outcome of patients with AKI was poor, as more than half died at the end of the follow-up and 40% of survivors had not recovered kidney function at hospital discharge. The heterogeneity of COVID-19-associated AKI in terms of incidence and etiology presents many challenges to its prevention and management. Further studies are required to investigate the effects of new virulent SARS-CoV-2 variants on the development of AKI, the impact of vaccination in the prevention of kidney involvement and the long term consequences of AKI.



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  3. Cheng Y, Luo R, Wang K, et al. Kidney disease is associated with in-hospital death of patients with COVID-19. Kidney Int 2020; 97(5):829-38.
  4. Alfano G, Ferrari A, Fontana F, et al. Twenty-four-hour serum creatinine variation is associated with poor outcome in the novel coronavirus disease 2019 (COVID-19) patients. Kidney Res Clin Pract 2021; 40(2):231-40.
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  8. Fisher M, Neugarten J, Bellin E, et al. AKI in Hospitalized Patients with and without COVID-19: A Comparison Study. J Am Soc Nephrol 2020; 31(9):2145-57.
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Treating anaemia in patients with chronic kidney disease: what evidence for using ESAs, after a 30-year journey?


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

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Dalla pubblicazione dello storico lavoro di Eschbach più di 30 anni fa [1], il trattamento dell’anemia con i farmaci stimolanti l’eritropoiesi (Erythropoiesis Stimulating Agents, ESAs) ha rivoluzionato la qualità della vita dei pazienti con malattia renale cronica (Chronic Kidney Disease, CKD). In quegli anni i pazienti erano gravemente anemici e spesso sopravvivevano con livelli di emoglobina anche inferiori a 5 g/dL, ricorrendo a periodiche trasfusioni, con alto rischio di trasmissione di un’epatite allora sconosciuta, definita “non A-non B” (oggi chiamata C) e con conseguente accumulo di grandi quantità di ferro. Nei casi più gravi i nefrologi erano costretti ad intervenire con un trattamento chelante a base di desferriossamina, a sua volta gravato da serie complicanze come la mucoviscidosi. Improvvisamente, grazie all’utilizzo dell’eritropoietina, i pazienti ricominciarono a vivere. Tale era l’entusiasmo dei nefrologi nel poter finalmente correggere efficacemente la grave anemia dei loro pazienti cronici, che si fecero trascinare fino a una correzione troppo rapida dei valori di emoglobina, portando a complicanze come un aumento dei valori pressori sino a severe crisi ipertensive e, a volte, convulsioni. 

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