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Metabolic acidosis is frequently observed in clinical practice, especially among critically ill patients and/or in the course of renal failure. Complex mechanisms are involved, in most cases identifiable by medical history, pathophysiology-based diagnostic reasoning and measure of some key acid-base parameters that are easily available or calculable. On this basis the bedside differential diagnosis of metabolic acidosis should be started from the identification of the two main subtypes of metabolic acidosis: the high anion gap metabolic acidosis and the normal anion gap (or hyperchloremic) metabolic acidosis. Metabolic acidosis, especially in its acute forms with elevated anion gap such as is the case of lactic acidosis, diabetic and acute intoxications, may significantly affect metabolic body homeostasis and patients hemodynamic status, setting the stage for true medical emergencies. The therapeutic approach should be first aimed at early correction of concurrent clinical problems (e.g. fluids and hemodynamic optimization in case of shock, mechanical ventilation in case of concomitant respiratory failure, hemodialysis for acute intoxications etc.), in parallel to the formulation of a diagnosis. In case of severe acidosis, the administration of alkalizing agents should be carefully evaluated, taking into account the risk of side effects, as well as the potential need of renal replacement therapy.

Due to the scarce supply of deceased donor kidneys, living donor kidney transplantation is becoming an increasingly important resource of organs for patients with end-stage renal disease. Laparoscopic nephrectomy, now the most common form of surgical procedure, produces better cosmetic results, less pain, and shorter hospital stay compared to open surgery. Therefore it represents an incentive to improve rates of living kidney donation. Since surgery is scheduled in advance, living donor kidney transplantation offers an unique opportunity to overcome immunological barriers, such as ABO-incompatibility and HLA-incompatibility. Unfortunately, unlike ABO-incompatibility, HLA-incompatibility (i.e. kidney transplantation in a recipient with positive complement-dependent cytotoxic or flow-cytometric crossmatch against the donor) it still leaves many unresolved issues nowadays, concerning the long-term efficacy, safety, and costs of the current treatment protocols. Kidney paired donation represents the ideal solution to immunological barriers, since it avoids the costs and side effects associated with ABO- and HLA-incompatible kidney transplantation. Living donor kidney transplantation also represents the ideal condition for developing tolerance-induction protocols. Indeed, a dramatic progress in this line of research has recently been made with the publication of the results of an apparently safe and efficacious protocol inducing durable high-level hematopoietic chimerism in recipients of living donor kidney transplantation.

In patients with heart failure fluid overload is clinically evident as systemic and/or pulmonary congestion, and represents a key issue in the therapeutic approach to the syndrome. Ultrafiltration, obtained by dedicated machines or standard dialysis machines (isolated ultrafiltration), or by the use of the peritoneal membrane (peritoneal ultrafiltration), has been recently proposed for fluid overload correction. This review is aimed at illustrating the operative background, safety, efficacy and cost issues of the different ultrafiltration modalities in heart failure. We retrieved all full-text non-duplicated articles documenting clinical studies on ultrafiltration in heart failure and describing patient characteristics, ultrafiltration procedures, renal outcome and adverse effects, by searching MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials up to December 31, 2011, with the terms ''heart failure'' and ''ultrafiltration OR hemofiltration'' and ''heart failure'' and "peritoneal dialysis". Isolated ultrafiltration can be considered potentially safe for the heart and the kidney in heart failure, and is efficacious for fluid overload removal. However, the available evidence does not support its widespread use as a substitute for conventional diuretic therapy. Isolated ultrafiltration should be employed neither as a quicker way to achieve mechanical diuresis nor as a remedy for an apparently inadequate response to conventional diuretic therapy. Peritoneal ultrafiltration is a promising ultrafiltration procedure that can be safely and successfully performed in heart failure; however, also in this case larger-scale randomized controlled trials are needed. The available evidence supports the concept of reserving ultrafiltration modalities for selected patients with advanced heart failure and true diuretic resistance, as part of a more integrated strategy aimed at fluid overload control.

The AA. refear a case of massive necrosis of intrapancreatic biliary tract secondary to an acute necrotizing postoperative cephalopancreatitis. The high mortality lesion risk was successfully treated by many factors: surgicals and medicals. The AA. think that the wise use of Somatostatine was the most important factor.